The Critics Are Wrong About the Future of Free-Market Health Care Reform
Earlier this week, the two of us—Douglas Holtz-Eakin and Avik Roy—published an op-ed for Reuters in which we outlined a market-based plan for entitlement reform and universal coverage that builds on a reformed version of Obamacare’s subsidized insurance exchanges. The piece generated a lot of media reaction, both positive and negative, so we felt obliged to respond to our critics. Is free-market reform a "surrender" to Obamacare? No. Are we ignorant of the policy issues associated with a Swiss-style regulated, subsidized insurance market? Hardly. Consider this piece our all-purpose rebuttal to Matthew Yglesias, Paul Krugman, et al.
The Swiss paradigm
As a reminder, the basic framework that we advocated—one that Avik has also discussed at National Review and Forbes—involves first making substantial reforms to Obamacare’s exchanges. We seek to reduce the cost of insurance on the exchanges, expand consumer options, and improve the exchanges’ fiscal sustainability. After we reform the exchanges, we can gradually migrate the Medicare and Medicaid populations onto the exchanges, by slowly raising the eligibility age for Medicare, and reducing the income threshold needed to gain eligibility for subsidized coverage.
The end result would be a health-care system that resembles a slightly less-regulated version of Switzerland’s. Swiss government entities spend 60 percent less on health care than American ones do, and yet Switzerland enjoys universal coverage, timely physician appointments, and broad access to the latest medical technologies. (For more on the Swiss health-care system, see Avik’s lengthy write-up from 2011 and this edited excerpt from Regina Herzlinger’s study of the system.)
Liberal gloating is premature
The first set of commentary about our op-ed wasn’t so much focused on the policy aspects of the proposal, but more a political celebration of our acknowledgment that Obamacare is here to stay. "Obamacare is winning," announces Ezra Klein. "Gone is the millennial struggle to preserve the dying embers of freedom," exults Jonathan Chait. "From me, no gloating, no ’I told you so,’ no smugness. Instead, I feel appreciation for common sense overtaking extremism and myopia," says John McDonough. "This isn’t an alternative to Obamacare," chortles Matthew Yglesias. "It’s a negotiated surrender."
It’s hardly that; Ed Kilgore is more on the mark in describing it as a "strategy…that sells itself as a reform of the post-ACA health care system instead of a restoration of the pre-ACA status quo ante."
Yglesias claims that in 2009, Democrats were open to something resembling our framework, and only Republican intransigence prevented such an outcome. (David Frum joins in to say "I told you so.") This is demonstrably false. Democrats would have never gone along with applying the exchanges to Medicaid—and especially Medicare—in exchange for Republican acceptance of Obamacare. Indeed, as John McDonough has documented, Democrats balked on accommodating modest Republican ideas because they would have cost 10 to 15 Democratic votes on the bill.
Yglesias says that Democrats should only go along with free-market reforms if they get something in return, like "introducing a reasonably strong public option" or "higher taxes." But his negotiating strategy ignores an important point: our free-market roadmap involves a substantial redistribution of wealth, because it takes subsidies that now go to wealthy retirees, and redirects them to the poor.
Remember that Obamacare doesn’t achieve universal coverage. Even after Obamacare is fully implemented, there will still be 30 million uninsured Americans. By contrast, the market-based approach that we propose would achieve truly universal coverage, while improving the health outcomes of the poor, by replacing Medicaid with a more generous form of health insurance.
If Democrats want to stand in the way of such a proposal out of partisan spite, that’s their choice. But it’s not a morally or politically riskless choice.
The extraneity of community rating
Paul Krugman thinks that he has found a "gotcha" moment in our proposal because we believe that Obamacare’s community rating provision should be replaced. Aha! says Krugman. "Switzerland has community rating…Maybe Holtz-Eakin doesn’t know anything about this—but wasn’t Roy supposed to be a conservative expert in this field? Are they really unaware of the basics here?"
Yes, we are aware. (A simple Google search might have helped Prof. Krugman look into this.) Community rating is an undesirable feature of both Obamacare and the Swiss system, and hardly essential to either, as any actuary will tell you. By forcing twenty-somethings to pay two to three times what they should pay for health coverage, community rating creates adverse selection. It encourages young people to drop out of the system, leaving only older and sicker people in the risk pool, and driving up the cost of insurance for everyone else.
There is an obvious alternative to community rating as practiced by Switzerland and Obamacare: require insurers to charge the same rates to those within a specific birth year, regardless of gender or prior health status. The vast majority of the variation in health risk is accounted for by age; eliminating age-based community rating would do much to counteract the incentives for adverse selection that are contained in the Obamacare exchanges. Remember that Obamacare’s individual mandate, the thing that is supposed to force young people to buy overly costly insurance, is quite weak.
In our approach, all 24-year-olds might pay the same rate for actuarially equivalent insurance. But that rate would be much lower than the rate that all 41-year-olds would pay, or that all 62-year-olds would pay. That’s a fairer, less expensive, and more economically sound system than what both Obamacare and Switzerland impose.
Krugman complains that Switzerland spends a lot on health care—which is perfectly normal for a wealthy country—and he confuses overall national health expenditures with public health expenditures. Conservatives are particularly concerned about the growth in government health spending, because we are committed to ensuring that America remains solvent. As I describe here, and in the chart below, Switzerland and Singapore are far ahead of the U.S. and western Europe on this score. In 2010, U.S. government entities spent $3,967 per capita on health care. Switzerland spent $1,628. In 2009, Singapore spent a mere $762.
And Krugman’s attack on the Swiss system is particularly hilarious, given that, as he acknowledges, in 2009 he wrote that "a Swiss-style system of universal coverage would be a vast improvement on what we have now. And we already know that such systems work."
No, Switzerland is not a libertarian utopia
In fairness to Paul Krugman, his post on our op-ed is, in effect, an uncritical regurgitation of ones by Josh Barro and Aaron Carroll that are similarly snarky—and similarly flawed.
Strangely, Aaron claims that private non-profit insurers in Switzerland are "closer to a ’public option’ than anything we have." No one who follows the insurance industry would agree.
Indeed, the United States has plenty of non-profit insurers—Blue Cross Blue Shield, most notably—and their conduct in the marketplace is far closer to that of the for-profit insurers than it is to government payors.
Aaron claims that "there is no ’public option’ here" in the United States, which ignores the fact that more than 100 million Americans will soon be enrolled in the "public option" systems of Medicare and Medicaid. A la Krugman, Aaron wonders if we are aware that Switzerland has an individual mandate and that Switzerland heavily regulates its insurance products. Indeed, as Avik has noted in the past, Switzerland is no libertarian utopia:
Finally, Aaron says that he would applaud anyone who offered exchange-based coverage to the Medicaid population; he implies our plan does not, when in fact that is one of its core features: a serious misrepresentation on his part.
Criticisms from the right
Finally, we should mention criticisms of our approach that come from the right. John Goodman, one of our favorite writers on free-market health care, puts it this way:
We agree with John’s view of the ideal system: universal health savings accounts combined with catastrophic coverage. He writes compellingly about South Africa’s system in this regard. Avik has written in the past about Singapore, which blows away Switzerland on cost-efficiency by instituting universal health savings accounts. But John is making a mistake if he holds out for universal HSAs, at the expense of more politically feasible, market-oriented reforms that expand coverage and reduce federal spending.
Otto von Bismarck once said: Die Politik ist die Lehre vom Möglichen. Politics is the art of the possible. A system with universal coverage, individual choice, and fiscal sustainability is within our reach. It would be far better than the system we have now. Isn’t it worth a try?
This piece originally appeared in Forbes
This piece originally appeared in Forbes