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May 23, 2005
Catastrophic Non-Sequitur
I'm very confused by this Yglesias post. Here's his take on the rationale for health savings accounts:
Let's say the main problems with the US healthcare system really are overconsumption (i.e., third party payment encourages people to use health care services they don't really need) and overregulation (i.e., mandated features on insurance plans designed to make them better just price them out of the range of too many consumers) and that, therefore, HSAs are a good solution.
I don't think this really gets at the gist of the argument for HSAs. It's not simply that consumers consume too much medical care and we have to get them to consume less. (although that's probably true to some extent) It's that even for services they legitimately need, consumers have no incentive to pay attention to how much the services they get costs. They have no incentive to shop around or to ask whether there's a cheaper alternative.
And because consumers don't care about costs they aren't paying, producers have an incentive to charge the highest prices they know their customers' insurance companies will pay. They have a n incentive to recommend tests and procedures that are of only marginal importance.
I think people dramatically underestimate how insidious it is to have an entire industry operated on a principle of third-party payment for a half-century. It's not that health care providers or bureaucrats are greedy or unscrupulous. Most of them are wonderful people who want only the best for their patients. But when a distant third party is paying all the bills, no one bothers to think very hard about ways to save money. Because everyone is getting paid by the same insurance company cartel (or government program) as everyone else, price competition just isn't a way to get a leg up on your competitors.
This cost inflation from third-party payers trickles down through the whole system. Hospitals collect inflated payments from insurance providers, but then they must pay inflated salaries to doctors and inflated prices for equipment, supplies, and drugs. Even if one hospital shops wisely, prices are being bid up by all the others, so that eventually every hospital must pay inflated prices to get the supplies they need.
Now imagine this process goes on for 50 years. Every year, a few minor inefficiencies are introduced into the system, adding an extra percent or two to the cost of health care. Drug companies raise their rates at twice the rate of inflation. Doctors order start ordering a few extra tests just to be on the safe side. Hospitals tack another dollar onto the price of aspirin. Gradually, the entire health care industry expands on an ever-increasing spigot of government and insurance industry money. We've been seeing this happen steadily for decades, with health care now consuming close to 20% of our GDP.
Price competition would be the sunshine that flushes this kind of rot out of the system. Suddenly, bloated institutions would be forced to ask themselves "The hospital down the street just cut its prices! How can we cut our costs so we're not forced out of business?" Hospitals would start asking their equipment and drug suppliers to deliver cheaper equipment and giving their business to those that responded the quickest. Doctors would find that they could attract more customers if they lowered their rates.
HSAs are designed to bring about this kind of price competition. They're designed to get consumers to start asking "how much will that cost me?" and shop around if they don't like the answer. The elements of consumer choice and provider competition are the reason HSAs might effectively limit health care costs.
HSAs aren't a silver bullet. The LA Times article correctly points out that a lot of the costs are in catastrophic care that's paid for above the deductible, and those expenses wouldn't be subject to price competition. But still, HSAs are a step in the right direction. They help to bring a measure of fiscal discipline to a health care marketplace that's been getting blank checks for decades.
All of which leads me to the second half of Matt's blog post, where he bizarrely claims that Milton Friedman agrees with him. For the record, here's what Uncle Milty says:
The ideal way to do that would be to reverse past actions: repeal the tax exemption of employer-provided medical care; terminate Medicare and Medicaid; deregulate most insurance; and restrict the role of the government, preferably state and local rather than federal, to financing care for the hard cases.
You can sort of twist that to imply that a national catastrophic health insurance program would be better than the status quo, but that misses the entire point of Friedman's article. I'll certainly grant that there's nothing inherently incompatible between HSAs and a national catastrophic health insurance program. But I don't really get why he thinks the one follows from the other. It's just a non-sequitur. HSAs are good because they introduce price competition and consumer choice in health care. A national, high-deductible health insurance plan has a variety of advantages and disadvantages, but I don't think any of them really follow from the argument for HSAs.
Update: Matt writes to point out this quote in Friedman's article: "A more radical reform would, first, end both Medicare and Medicaid, at least for new entrants, and replace them by providing every family in the United States with catastrophic insurance - i.e., a major medical policy with a high deductible."
But the important point is the "end both Medicare and Medicaid" part. The purpose of the catastrophic policy would be to negate the rationale for other government interventions in the health care market (i.e. that otherwise, old and poor people might fall through the cracks). He's clearly not advocating government-run, catastrophic health care as a stand-alone policy.
Posted by Tim Lee at May 23, 2005 8:34 PM
Comments
In what way do HSAs get rid of third party payment?
Is this discussion about HSAs replacing private insurance, or as a supplment around the edges?
Posted by: theCoach at May 24, 2005 9:31 AM
HSAs are coupled with a high-deductible insurance plan. That means that the first few thousand dollars ($2250 in my case) is paid by the patient out-of-pocket (much of which is provided by the employer through the HSA), and only those with more than $2250 in medical expenses in a given year get covered by their insurance plans.
So HSAs don't get rid of third party payment entirely, but what it does is shift a lot of routine health care costs, like doctor's checkups and prescription drug expenses, out of third-party payment. There are lots of people who, most years, spend less than $2,000 on health expenses. For those people, all of their health care expenses would be paid for out of their HSAs, eliminating third party payment entirely.
Posted by: Tim at May 24, 2005 9:55 AM
I current advise my clients to insure only against catastrophic loss, and just plan for everything else. Insuring against routine medical care, like prescriptions and office visits, is just buying your medical care at retail plus a markup (you invariably get screwed). If you can predict things like office visits, so can the insurance company -- and they are actually better at it than you are.
Unfortunately, very few of my clients recognize the benefits of this approach. I still get folks that insist that if they don't have coverage for prescriptions and office visits, they don't want to bother with insurance at all. IOW, they are inviting the insurance company to screw them over, because they want to continue the myth that healthcare expense is something that should be taken care of by somebody else. Insurance has been improperly sold in the US for several decades now, and the result has been a fantastic increase in healthcare expense.
-- Howard Lee Harkness, http://www.hlhins.com
Posted by: Howard Lee Harkness at May 24, 2005 10:27 AM
I think one thing that has to be written in the sky when discussing HSAs is this: what money you don't spend from your savings account, you get to keep. Think of it like an IRA. You can roll it over, you can withdraw (with a tax penalty) or you can spend it on the designate type of expense (medical.)
As soon as patients have the opportunity to retain the money they *don't* spend on health care, they start price shopping. As it stands today, patients are actually encouraged to make sure they get their premiums' worth by spending as much of the insurance company's money as possible.
Posted by: Nathan T. Freeman at May 24, 2005 10:40 AM
HSAs are the single best investment vehicle currently available for non-politicians and non-wealthy individuals. It allows you to pay for all of your healthcare with pre-tax money, and it has some of the additional benefits of an annuity.
But I find that they are still very hard to sell, because (roughly speaking) absolutely nobody wants to buy a HDHP, because it doesn't 'cover' office visits. The insurance industry has succeeded in firmly planting a load of disinformation in the collective consciousness of Americans.
-- Howard Lee Harkness, http://www.hlhins.com
Posted by: Howard Lee Harkness at May 24, 2005 10:43 AM
This is a wonderful post and hits the nail on the head.
The problem, as you stated, is the fact that we have taken the third party payments for granted and are therefore not thinking everything through.
Posted by: michael at May 25, 2005 8:40 AM
Does anyone know of anyway to currently get involved in an HSA? I'm looking to go into business for myself in the near future, and would like to couple an HSA with a catastrophic plan.
If I could use pre-tax dollars to pay for my regular visits, I'd be on board.
Posted by: michael at May 25, 2005 8:43 AM
To answer michael, you can buy your own HSA/HDHP, *IF* you qualify. Or, if you have a company with more than about 5 w-2 employees, you can get a group plan -- but then you have the rather large hurdle of convincing at least 4 other people that they don't really want coverage for office visits.
Posted by: Howard Lee Harkness at May 26, 2005 8:55 PM
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Could someone describe to me their experience of shopping for these services and how they negotiated the price down?
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Actress and R&B singer Brandy was involved in a fatal, four-car accident on a Los Angeles freeway last month that started when her sports utility vehicle hit another car from behind, police said on Wednesday...
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