Health care reform must address problems

Published in Standard-Examiner, June 30,2009, Ogden, UT

VIJAY K. MATHUR

The vigorous debate in the U.S. Congress and in the public arena seems to indicate that there are good chances of passage of a health care reform bill this year. I hope President Obama, before signing the bill, makes sure that the final bill represents reform not in name only, but as a fundamental change from the status-quo.

According to the most recent published data for 2000-2006, unadjusted for price changes, growth rate in total national health care expenditure has averaged 8 percent per year as opposed to 5 percent average growth rate of Gross Domestic Product (GDP); public expenditure grew at the rate of 8.6 percent per year. In relation to our capacity to pay, total expenditure increased from 13.8 percent to 16 percent of GDP. A report issued by the Council of Economic Advisors (CEA) on June, 2009 states that if health care cost keeps rising at historical rates, its share of GDP will reach 34 percent by 2040, an obviously unsustainable burden on the economy. Hence President Obama has stated two main goals of health care reform, 1) cost containment and 2) covering all uninsured people.

Health care faces four different market-inefficiency problems which require government intervention. Those who are fearful of encroaching socialism lack understanding of these problems. The first is "free-rider problem" where those who do not buy insurance get a free ride on emergency health care either in hospitals or in free clinics. It results in higher premiums for the insured and requires more tax revenue to support other medical care institutions supported by Medicaid funds.

Free rider problem could be mitigated if all people are required to buy insurance, the so-called mandate. Even low income household should be required to pay for insurance according to their ability to pay and the difference between the market price for insurance and their payment could be subsidized. This could ultimately eliminate the need for the Medicaid program. This universal insurance program would also ameliorate costs imposed by uninsured on insured when they spread infectious diseases.

Two other market failure problems in health care are "adverse selection" and "moral hazard." Insurance premiums increase due to adverse selection when an insurance company ends up with people in the pool who require more than average medical care. In other words, the health risk is not diversified with an appropriate mix of young and old people. Data show that during 2005-06, the highest percentage of uninsured Americans were 18 to 34 years old. On average, young people do not require more frequent medical care as do those above the age of 60. Hence, young people lack incentive to buy insurance, not only due to high cost of insurance but also because they can free ride on emergency care. A broader mix of people in the insurance pool will reduce risk and insurance premiums.

Moral hazard also contributes to higher insurance cost. If the insurance coverage is generous relative to premiums, insured people have a tendency to engage in risky behavior resulting in adverse health outcomes, e.g., smoking, obesity. If the insurance coverage is less relative to premiums, insured people will bear most of the health risk and hence will opt out of the insurance market. Thus, we will face increasing ranks of uninsured and less than efficient level of coverage for insured. Insurance companies in general pass costs of risky behavior by increasing deductibles and co-pays.

Besides deductibles and co-pays in insurance contracts, any reform proposal must relax laws so that insurance companies are encouraged to provide more positive incentives to the insured to make lifestyle changes, e.g., to reduce the incidence of cardiovascular diseases, obesity, diabetes. Even under current laws, self-insured Safeway Inc. is successful in implementing such an incentive program and reducing cost of medical care.

The last problem source is the "principal-agent" problem. A physician is supposed to be the agent of his or her patient (principal), representing the patient's interests in dispensing quality care at least cost. However, the fee-for-service compensation structure creates divergence of interests between patients and doctors, thus resulting in high cost without significant changes in the quality of medical care.

The principal-agent problem is more acute when physicians have commercial interests in clinics, hospitals and pharmaceutical companies. Evidence-based medicine, doctors on salaries, fixed payment for a bundle of services, capitated payments over a specified period of time and payments based upon health outcomes are attempts to minimize this problem and control cost. This problem also occurs when employer is the sponsor of a health insurance plan and employees have little choice in picking an insurance plan which suits their needs.

The health-exchange proposal should provide choice to all, including employers, between private and public insurance, with the added feature of portability within and across state lines. If private health insurance industry is more efficient in its service they need not fear public insurance and if they are not, they should become more efficient.

Congress must take the bold step in solving this lingering health care problem which is gradually eating away our material and human wealth.

Mathur is former chair of the economics department and professor emeritus of economics at Cleveland State University, Cleveland, Ohio. He is also an adjunct professor of economics at Weber State University, Ogden, UT. He resides in Ogden, UT.