Tuesday, February 05, 2013

Interstate health insurance...  

And other free market tinkering for healthcare reform.

A commenter suggests other reforms would have been better than Obamacare:
"It seems absurd to me to say Obamacare will bring us toward a freer market. If we all recognize a free market with consumers being aware of real costs and allowed to make a decision on their own that would collectively drive the market, than why not recognize that the conservative position of eliminating interstate insurance purchases would have been a great first step to introduce market forces. The other aspect you ignore that has been well-documented in many studies is that the reason US health care is expensive is in large part the built in costs and extra testing associated with our lack of liability reform. That was purposely omitted from Obamacare. Many democrats said they would deal with that separately, but of course they've forgotten all about that given the huge donations they get from trial lawyers."
Let's take these two ideas in turn. First the idea that if competition is allowed it will occur. There is no evidence for this whatsoever.
Allowing insurance sales across state lines comes up perennially as a way to drive down the cost of health care.
Conservatives argue that allowing a plan from a state with relatively few benefit mandates – say, Wyoming – to sell its package in a mandate-heavy state (like New York) would give consumers access to options that are more affordable than what they get now. 

Liberals tend to argue this is a bad idea, contending that it would create a “race to the bottom,” where insurers compete to offer the skimpiest benefit packages
A new paper from Georgetown University researchers suggests a third possible outcome: Absolutely nothing at all will happen. They looked at the three states – Maine, Georgia and Wyoming – that have passed laws allowing insurers from other states to participate in their markets. All have done so within the past two years. 
So far, none of the three have seen out-of-state carriers come into their market or express interest in doing so. It seems to have nothing to do with state benefit mandates, and everything to do with the big challenge of setting up a network of providers that new subscribers could see. [More]
Avik Roy argues it will just take longer, but so far the results are: nada. This idea also would not touch the "uninsurable" problem, which grows with each new diagnostic test.

As for tort reform, I think the idea is obscured by an availability paradox. We read about multimillion dollar settlements and see the lawyer ads, but don't have a handy comparison to total health care costs. The CBO checked this claim.
Elmendorf wrote that newly available research prompted CBO to update "its analysis of the effects of tort reform." The agency's conclusion: A package of reforms that included a $250,000 cap on damages for pain and suffering and a $500,000 cap on punitive damages "would reduce total national health care spending by about 0.5 percent."
The federal government would reap a substantial portion of those savings, the CBO said, primarily through reduced Medicare costs.  [More]
Tort reform isn't chump change, but it doesn't really move the needle. At about $5B per year saved it's really not a biggy. (At least that's what we say when they want to reduce crop insurance by a similar amount.) Keep this number in mind: $3T. That is our total health care cost estimate for 2014. (I picked that year because it's a round-ish number.)

Another issue is, as economists of all stripes point out, when you are paid per procedure (Fee For Service), you tend to get more procedures, regardless of "defensive" medicine or not. Personally, I also think American consumers want something done or prescribed, rather than hear, "You'll survive, just outlive it." Most doctor visits are for self-limiting or chronic complaints. Think of the antibiotic overuse (especially in children) that farmers point to when feeding antibiotics is linked to resistance.

I support both ideas. But because Republicans refused to negotiate during the passage of the ACA the ideas never got looked at seriously. When obstruction is your primary goal, why should your ideas be included? Davis Frum agrees. Much of Obamacare, and certainly the mandate, was a conservative idea back when I was a mainstream conservative.
“Nobody was saying that it was creeping socialism or unconstitutional at the time. A lot of conservatives were for it,” former GOP senator Bob Bennett told me yesterday, looking back to the 1993 fight against “Hillarycare.”
The roadmap for what was then the signature Republican approach to health-care reform was provided by the once quintessentially Reaganaut think tank, the Heritage Foundation, which now denounces “the cancer of Obamacare.”  The offending document was written in 1989, at the dawn of the first Bush presidency, and its rationale for the individual mandate was as follows:
1989 Assuring Affordable Health Care for All Americans
There is no Republican plan for reforming our healthcare problem, and the two items listed above are good ideas, but hardly an answer. Besides, watch immigration reform. The right now has only one political skill/agenda: stop anything from happening.

1 comment:

someguy said...

using 2 states that only allowed interstate insurance purchases in the last 2 years is hardly representative of what might happen in a real marketplace. Why would insurance companies make an effort to take advantage of that change when they are overwhelmed with preparing for the plethora of regulations and changes that Obamacare is ushering into their business.
To me this effort to deny the obvious reality that we see in all marketplaces and the way competition works for the efficient delivery of services and goods when they are allowed to function is similar to the way we see everywhere in our world that anywhere people are serious about stopping the unauthorized movement of people - they build a fence. Prisons, private property, government property, borders, whatever...it's clear it works better than anything else. Yet because of the microphone of the media and their liberal friends, all we ever hear is that a fence at our border is a ridiculous idea that would never work, and only a troglodyte of some sort would entertain it. It's repeated over and over in the media unchallenged and eventually conservatives seem to give up fighting it aggressively. We see the same technique being employed with guns in schools. It's completely obvious that anytime we are serious about protecting something or someone, from Brinks armored trucks and banks to politicions and their families,that we use guards with guns. Yet, we are being told over and over that it's such a stupid suggestion that...that...well it's just unbelieveable that anyone would suggest we protect our schools with guards with guns.

With regard to the study on the potential savings of tort reform, I have read about too many studies that arrive at radically different conclusions to simply believe one CBO study that seems 'out of the mainstream' to me.