In a recent post over at Capital Gains and Games, Andrew Samwick makes an important point about the debate over health insurance reform. As Andrew notes, many proponents of a public plan (aka public option aka government-run plan) blame the quest for profits for the ills they see in the private health insurance market.
This is one of those claims that is both true and false. What’s true, again echoing Andrew, is that the search for profits can lead to bad outcomes (e.g., efforts to cover the healthy while avoiding the sick) in our current system. That’s because we haven’t adequately addressed some key problems — most notably adverse selection — that arise in health insurance markets.
But that fact does not, of itself, demonstrate that the profit motive is itself the problem. If we can establish rules of the road that limit adverse selection (e.g., by prohibiting exclusions for pre-existing conditions), we may be able to direct the profit motive in the direction we want: finding ways to deliver greater value (i.e., better service and lower costs) to Americans with health insurance.
In Andrew’s words:
The solution to the problems in our health care sector is to make it look more like the retail sector or any other sector in which being voracious and profit-driven drives down costs. The problems of adverse selection and moral hazard in insurance markets are well known — they are what stands in the way of extending the benefits of competition to health care. Addressing them should be the central features of the reform, with a risk-adjustment mechanism to address the former and high-deductible plans to address the latter. All of this discussion of Medicare-for-all in a public option is at best premature, since we have not seen whether a competitive, private system can function under the right form of regulation.
To drive this point home, let me offer the following (admittedly imperfect) analogy: it turns out that the profit motive causes thousands of companies to emit millions upon millions of tons of carbon dioxide and other pollutants. That’s a bad thing. But it doesn’t imply that the solution is a “public option” for electricity production and gasoline refining. The right response is to establish rules that address the market failure — in this case the pollution — and then let the firms do their thing.
That’s what we should do with health insurance.
If you prohibit exclusions for pre-existing conditions, how do you prevent customers from milking the system? If there is no exclusion for pre-existing conditions, why should I purchase health insurance before my doctor uncovers a serious illness? If I am in reasonably good health, it would be much cheaper to pay for an annual checkup and infrequent office visits out of pocket until I discover I have a serious illness. Then I scurry down to my nearest insurance company office and sign up for a “Cadillac” plan that will cover me until my illness is cured, at which time i drop my insurance again.
You are absolutely right. That’s why these proposals are usually paired with provisions to get people into the insurance pool. As an analytic matter, the most natural (and, judging by comments from readers, most controversial) way to do this is to include an individual mandate. One of the interestng political questions is whether Congress as the votes to both (a) reduce screening by insurance companies while (b) reducing selection by customers. We will see.
You and ROA both have great points.
But isn’t the problem here that–because tax incentives have tied insurance to employment–people lose their insurance when they lose their jobs and then can’t get covered if they have a pre-existing condition?
Wouldn’t the solution then be to decouple insurance from employment?
This should also increase competition and bring down prices.
“All of this discussion of Medicare-for-all in a public option is at best premature, since we have not seen whether a competitive, private system can function under the right form of regulation.”
All this discussion is “premature” only if we are holding out for a market solution for the sake of a market solution, as a matter of ideology.
In the empirical bumblebees-can-fly world, Medicare-for-seniors has already established “greater value (i.e., better service and lower costs)” than the free market. Why cast about for some postulated jury-rigged regulatory concoction for decades in the hope of chancing upon something that works, when there’s a perfectly good, proven, time-tested, and popular solution right here in front of our noses?
Markets fail. Deal with it.
#1. Greater value than WHAT free market? I don’t see one around here.
#2. Medicare is broke.
What is interesting is that at least 93 million Americans, or roughly 1/3 of the total population, currently get their health insurance from a non-profit. http://www.nonprofithealthcare.org/resources/BasicFactsAndFigures-NonprofitHealthPlans8.6.08.pdf
This should demonstrate the problem is not pursuit of profit, but something else.
My 5-step plan:
1. Eliminate tax incentives that tie insurance to employment (reduce taxes to compensate).
2. Crack down on fraud.
3. Allow competition across state lines.
4. Lower barriers to entry.
5. Set up an online database of insurance companies and plans where the public can compare plans and rate their experiences.