Healthcare Reform Paper Fall1994

ealth care reform: a free market perspective JEfTREY

S.

FLIER, MD, AND ELEFTHERIA MAR/\TOS-FUloR, MD

Problems with the U.S. health care system have been topics o[ discussion for many years. Escalating expenditurc~ on health and increased numbers of uninsured individuals are generally accepted as the major symptoms of these defects. Health care reform became paramount among social policy issues during the presidential campaign oflll91, and in early IlI!)3, Hillary Rodham Clinton was appointed to head a task force charge I With preparing legislative proposals designed to resolve the crisis. The task force met mostly in secret [or months, and in September 1993 the White House released proposals for unprecedented change in the trillion-dollar health care industry. The dominant theme of this complex legislation involved increased regulation and control of the medical and insurance industries. The next year witnessed intense and broad-based discussions of the nature of the problem and the merits of the specific legislation, as well as alternative approaches. The initial debate focused on both cost and access; however, over time the focus shifted to assuring universal cover­ age. The dominant theme of proposed legislation was to introduce sweeping new regulations and taxes. Cost estimates of the proposed plans were disputed, and no consensus could be reached regarding basic aspects of the legislation. The attempt to produce legislation in 1994 has largely been abandoned, and the focus has narrowed to incremental reform. However, the basic premise of leading proponcnts of refurm, that improvements in the health care system can be accomplisheJ by govern­ ment regulation, remains unchanged. We present this paper from an alternative perspective that vicws symptoms of cost and access as resulting to a substantial degree from decades of flawed public policy, rather than government inaction. How­ ever well intentioned, prior policies have caused economic distortions that raised the cost of medical care and reduced the availability of affordable insurance for a majority of the population. hom this perspec­ tive, further regulation is likely to exacerbate more problems than it will solve, bringing relief to some individuals while reducing availability to From tl1e Department or Medicine U.S.F.). Beth lSI el Hospital. Boston. the Department or Meel,clnc (E.M.·F.). Brigham & Women's Hospital nd Res arch Division. Joslin Dt betes C nler. Boston: and tl1e Departnlcnl of MediCine (JS.F. and E.M.·F.), Harvard Medical SchOol. SoslDn. M ~s<'Cnus~ells Address correspondence and rep"nt requests to Jeffrey S. Filer. MD, 6eth Isro I Hospital. 3::10 Brookline Ave .. 80';ton. MA 0221­

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DIABETES REVIEWS, Volume 2, Number 4, Fall 1994

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Problems with inflation of medical costs and inCI'eased numbers of uninsured individuals have resulted in widespread calls for reform of the U.S. health care system. Proposed refor'ms have generally emphasized increased regulation of the medical and insurance industries, but disputes over the cost and consequences of these proposal has so far prevented legislation fmID being passed. This paper' is pr'esentcd from an alternative perspective that views the current symptoms on cost and access as the results of decades of Hawed public policy, rather than govemment inaclion. Wc lrace the origins of dysfunclional hcalth carc markcts in prior public policy, and outline an approach to healing the heallh care system based on a new dedication to frec market principles and individual choice.

TI18 free market and IlealUl care rcrarnl

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many others of the healtl1 care they desire, This p
IS A FREE MARKET FOR MEDICINE POSSIBLE? A free milrket is chM
mill'ke't ,ldapliltlllllS to imperfect information have evulved over thc past .Ill yeMs, enelJuraging increaseJ p,llicnt ,lutO!lOl11y ,llld Cl1l1sensual doctor-patient re­ Lltll1l1slnps, These illclude publiC diseussil1n l1ll11edi­ Gil Inl1lw,llions, Incrcdsillg expectations regarding illlol'l11ed ((Inselll. ilnd increased scrutiny 01 physlci,ln services by 11C,lllh m,lintellailec organizations (I HvlUs) dl1ll Illsurers, These adapt'ltiolls l'lluld be strell,illhclled in ,I more ulll1pellllve allcJ decentralized l11<1rkelpl,lcL'
DIABETES REVIEWS, Volume 2, Numb", :\. Fall 1994

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SOME HISTORICAL ROOTS OF THE PROBLEMS OF COST AND ACCESS It is frequently asserted that the U.S he,tlth care system spends an excessive fraction of gmss domestic product (CJDP) on health. Although thc I IS. spends ,I greater fraction of GOP on health than any other country, the unaceepwbility of the 14 r/r, of GT P spent on heallh care is not self-evident. People in ,lmuellt societies will spend more for innovative and etfeetive diagnostics and therapies. An a, mg population ,tlso IllereaSes hCC1lth expenditures. M,lny other factms have been discussed (13). While the fact th,lt medie
Cost-Plus Cost-plus hospital reimnursement (full cost plus a small additional payment). initially en
,I

DIABETES REVIEWS, Volume 2, Number 4, Fall 19 4

cost-plus system through regulations like ccrtilicatL:s llf need (14,J(J) and IJhysicialls' Standards Review Organizations (PSROs), designed to eliminate "un­ nL:cess
First Dollar Coverage In the early 20th centurv, health Insurance covered Glt,lstrophie ami chn)nic Illness (:)). Routine care was p'\Il1 out of pocket. Since the !040s puhlle policy stimulated health insurance to evolve toward
Consumers vs. Payers The incentives discusseu above resulted in a f,llling fraction of health carl' expenditures paid for dlreCllv

-.1~

The free market and health carE: reforrn

by patients as opposed to llmd party payers. Dissoci­ ation of cost and service is sometimes eJcslrablc, allowing patients to avoid thc stress of flnancial dccisions whcn ill. fIowcver, in the absencc of cost consideration, utilization increases, some of it in the category of medically unnecessary utilization (21). Palients will more likely seck medical ({lrc for minor problems, and may accept low-risk (but cxpensive) diagnostic procedures wherc pathology IS unlikely. In hopeless situations, patients {lnd physicians morc often grnsp at experimental or useless treatments. We tind no moral fault in individuals seeking care, even exceeding that which mcdical authuritic's find appropriate, especially if spending their own re­ sources seeking hcalth and peace of mind. IlowevCl, we belicve that globally incrclsed demand for care without cost consciousness is Iitcrelily ullsustalIlable. Itimately spending will either be limited hy IIHlivid­ uals acting in their own interest (i.e., choosing to usc their resources on somethlIlg other than he,lIth care) or by bureaucracies reacting to global budget,lrv concerns. The transfer of such Important personal decisions to bureaucracies wi II encou rage the poli ti­ ciLiltion of health ,mel will dcprivc individmds of ~lLItonolllY in a critical sphere of their lives.

Mandated Coverage Mandated benefits requiring insurance to cover spe­ cific diseases, disabilities, and scrvices make Insur­ ance expensive (j 5,23). Most states mandate coverage for specific therapies, including pastoral counseling, hairpieces, in vitro fertilization, and Hcupuncture. The number of such laws increased frum 40 10 nearly 1,000 between 1970 and 1991 (I."i,n). TypiGdly, peu­ pic view such mandates as addressing specific needs, and they typically enter thc law quietly, through special interest pleading, without much public debate. Unfortunately, the unintended adverse consequences of such mandates arc rarely scrutinized, as th~' victims arc less readily identified than the bcneflciaries. [n addition to raising the costs of Insurance, these re­ quirements only apply to a minority of th' ropulation, because Medicare, Medicaid, most HMOs, and sell·­ insured companies (70% of largc corporations), Me exempt (J5.23). lience, those individuctls for whom high deductible, low cost catastrophic insurancc is most appropriate, i.e., the self-employed clnd employ­ ces of small husi nesses that do not otle r I nsu rance, are cJeprived of that choice through government-lIlduced cost inJlation, and as it result. the Itk~'lihood th;lt these individuals will be uninsured increases.

Government Responsibility for the Uninsured The problem of unmsured Americans has been brought to wide attention through thc storics of tragically ill individuals who suffered as a result of heing uninsured because of preexisting conditions, inability to afford policies, or loss of employer-based Insurance hecause of Joh loss. It is therefore impor­ tant to undcrst;lnd the nature and causes of thiS problem. [t is estimated tllat :17,000,000 people arc unillsured at any roint in time, and about half of them rcmain chronically uninsured. However, of the 2[)(l,()()() rcople who become uninsured in any given month, SWlr, arc uninsured for less lhan 5 months and only 15% lack insurance continuously for morc than 2 years (24). Many h,lve recently elwngecJ employment S[,ltUS, and so a Illajor part of this vexing problem results from lack of portability of employer-provided insurance. Most uninsured individuals, whether em­ ployed (about 50%) or not, are young (50% below ,1ge 34) and healthy (25). Many fmego expensive Insurance ,It it tllne when they (correctly) view major illness as unlikcly Less than I % of the population below ,\ge (15 is both uninsured and uninsurablc because of a preexist i ng condl tlon (26). t lnforlunately, our government tax policy penal­ Izes those I/ldividuals who are least able to afford insurance At present only 25'); of premiums are deductible by self-employed individuals (after deduct­ II1g 7% of adlusted gross income), while those em­ ployed by small businesses or the temporarily unempl~)yt'd get no tax break. Thus, while health costs rise because of the policies described above, tax treatment t·hat would make Insurance more afford­ able is unfitirly and selectively denied to the self­ employed, many cmployees of small businesses, and the unemployed. Government further contributes to the insurance deficit by reql1lring hospitals to bear the cost of 'i~'lvices to tvIedicare and Medicaid patients. despitc the decision of government to explicitly un­ dcrfund these programs (27). These governmenl­ m,lndated but unfunded costs are shifted to those with cOllventlonal Insurance who are often Icast able to pay.

THE RIGHT TO HEALTH CARE I' health care a right" While many have argued that there is a "righl to health care" (28) only limited attempts have been made [0 define the nature of this right. Unlike negative rights that establish boundaries that others must respect. "need confers rights only when what is needed is recognizable as a need by the one who is lu meet it" (2li). Should health care bc considered a "right," a system of defining medical

DIABETES REVIEWS, Volume 2, Number 4, Fall 1994

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needs would therefore be necessary. LJltim,ltely need would be determined by the political process and enforced by the state. Since everyone must have equal acccss to things that arc viewed as rights, fair distri­ bution is important. Individuals may find that In the Interest of "fairness," it would not be russlble to pursue, even with their own funds, hcalth Glre that they want. A "right to health care mcly actually diminish what is available

THE ROLE OF THE PHYSICIAN IN HEALTH CARE REFORM Increased g.overnment involvement thre,llens what wc view as several valuable dttributes of thc mcdical pro!'ession, including the Independence or' rractitlo­ ners and the ccntral view that physicians must serve as advoC
,I

DIABETES REVIEWS, Volulne 2, Numt.Jer 4. Fall 1994

~lnd

rhyslcians would he rressured to lilminish their rolc as patient advocatcs. Both advocates of markets and of governmellt-funded single-r'lyer solutions (32) arc concerncd about this outcomc.

POLITICAL SOLUTIONS: THE BROADER CONTEXT Politicians arc excessively attuncd to short-term promises ,Ind ,Ire tyricaily reluctant to !
GOALS OF AN IDEAL MARKET-BASED SYSTEM Policics claiming to rrovide health security through governmcnl-assurnj access to comprehensive health care of e,lch person's choice, achieved simultaneously With cost control and hudget caps, cannot, in our view, succeed, although, like most utopian notions, thcy arc arrcahng al first !-,-Iance Altempts to legislate such pollcics would, we believe, lead to accelerating costs, rcduced ,ICCCSS to care through rationing for mallY people, or, pcrhars most likely, an uIlaprcaling eom­ hination of both. Our objectlvc is to establish ,In efficienl IllL~dical mclrketrlaee that would increase the access to insurance and care of many individuals now unable to ohtdin these dnd to SII1lu.ltaneously reduce cost inRatioIl. These goals would hc supplemented by financial empowerment of those who remain In need of help. Although eschewing regulation and bureau­ crdey, our rdorm
,I

The free market and health care reform

or government would slow or be reversed. Third, Ihe trend toward hospitals being agents tm the Interests of physicians and insurers would end, and hospilals would increasingly compete for ratlents by impmvlng quality and lowering prices. Fourth, health insurance companies would be in the business of insuring against risk, rather than buying, managing, and 1',1­ tioning health care, Fifth, employers, would
Tax Equity Tax equity regarding health expCllses mLlst bc achieved, with hcalth expenditures heing equally de­ ductible reg<Jrdless of employmcnt. There h
Medisave Accounts MediS

Licensure Licensure, supported as a mcans to cnsure physician competence ,lIld prcvent Iraud, has been an dlcctivc means for the profession to reslrict Ils numhers ,ll1d limit competition from alternative, often lower cost. providers (7.-'i(1). CertitiC
DIABETES REVIEWS, Volume 2, Number 4, Fall 1994

Filer and Maratos-Flier

well, whik authorizing lncre(lsed services Irom an "rray or Ilon-MD practitioners (37).

Regulatory Barriers Numerous federal and state regulations are barriers to efficient medical services. Examples ,lrC pullcic" thal discriminate ,lg,lInst rural heaJth care facilities (Ji'UlJ). Medicare/Ml:dicaid regulations un Icvcb 01 sl"ll1ng "nd other dctails ot' service are hard to meet in rural economic environment, thus limiting care avail,1ble to ruraJ residents. Other examples arc tax laws and antitrust provisions that impede cost-saving (Illiances between institutions and physicl,lns ,Ind mandated benetit laws that raise costs of catastrophic Insurance. Since many qualitied applicants to U.S. medical schools are turned away, while thousands 01 foreign school graduates gain licensure through ex­ amination, it seems logical that new modes of lower cost mcdlcal education should hc allowed to develop In this country.

Aid for Those in Need A free market ror medicine wilJ remove many ,utili­ ci,t! impedimcnts to affordable insurance and care, but some individuals will remain unahle, throu~h misfortune, poor planning, or irresponsihility, to ,If­ rord the medical care they need. AlthouiJ,11 we view the position that medical care should be considered a right as inconsistent with a proper conception of h,1sic rights (10), thoughtful means for providing assistance arc hroadly desired. However, reasofl(lble efforts to fulfill this need do not require regulation, fT]Jndalcs, price controls, or outright government takeovcr, any more than efforts to house the homeless or ked the hungry require government control of the markets 101 rOOlI and shelter. The uninsured and uninsurahle can he given vouchers or tax credits enabling purchase of insur­ dIKe (40) ano [unding of medical IRAs. This ap­ proach acknowledges that Individuals, even when needy, have diverse desires reg,lrding health ,mel avoids unnecessarily regulating and homogenizing care for dll !\mericans. FI,iWS in the dcsign and funding of Medicare and Medicaid have fueled the current Crisis of cost and access, and keeping these programs fiscally sound over the next two decades will require fundamental reform. It is frequently noted that, despite the threat that Medicare will have a fiscal crisis within the next lO years, this program is popular with its beneficiaries and the public at large, and is beyond reform for politiCid rcasons. To the cxtent that this is true:. It identifies the real threat imposed by "entitlemcnts"

DIABETES REVIEWS, Volume 2. Number 4. Fall 1994

on a vast scale that, oncc enacted, are ditlicult to 11l0dily or limit. And it may be the case that the political Impossibility of modifying Medicare will change at the point at which the next generation begins to doubt that, despite ever-increasing taxes, they will nevcr receive henefits compdl'ahle to those of the current elders. A complete discussion of short­ edlcdl'e prohlem and long-term solutions to the exceeds the scope of this paper. Ilowcver, onc ap­ proach to a long-term solution would involve creatlrlg incentives ror individuals to save [or future health needs through Medisavc ,lecounts, since the present system encoura 'es dependence on benefits th(lt may be tiscally insupportable in 10 to 20 years. This is neither sound poliCy nor ethical. After tr'lnsition to d Medisave approach, clderly individuals with insuJli­ cient lunds could be given mt':ans-tested vouchers for the purchase of health insurance. Regarding Medic­ aiel, Introduction of markct principles inlo the proVI­ SllH1 of medical services to the indigent through vouchers andlncentivL's to managed care would move in the right direction. Private options for long-tcrm care should be enhanced by ,dlowing usc or rRAs for this purpose LIS well as changing the tax status or insur,lnce premiums for long-term care.

IMPLICATIONS OF HEALTH CARE REFORM FOR DIABETES CARE As discussed edl'ller, the original Clinton ,ldministra­ tlon health care plan and the follow-up plans for health carc reform 11,IVC sought to l'ind a me,lns for providing universal dccess [0 comprehensive bent':fits while sirnultdncuusly controlllf1g he,llth [(Ire costs. Although these plans now aprear to be stalled in congress, future attempts al health care Idorm are certain. Prolessionals concerned with diabetes care must therefore wonder whether efforts to attain both or these goals through government regulation, if cver enacted, would actually permit most people with diabetes to have access to the I-ange of options Cor diabetes managemcnt thdt they now have, including the high intensity of diabetes care currently recom­ mended for optim,11 therapy of their disorder. We think nol, for severdl reasons. It is Important to recognize that therapy necessary to limit complications is expensive initially, and that SdVlrlgS brought about through reduced morbidity are likelv to be recognizcd only in the long term (after close to two decades of treatment). It is diQicult to believe lhat in environmcnts such as HMOs, pre­ krred-providcr organiz,ltions, or other capitatecl sys­ tems, where toral dollars are limited on a day-to-day hdSis, or In the prescne' of govell1f11cnt-enrmced

The free market and health care reform

premium caps, maximal emphasis would bc placed on funding expensive therapies of chronic dise(lscs where benefits accrue over a long terrn. AdditJOnally, with increased government involvement in distribution of health carc dollars, decisions on funding for specific programs or benefhs will become Irlcreasingly subject to special interest politics. and the allocation of resources will be unpredictable. Finally, most reformers emphasiz.e the necessity, if cost control is to result from capitated plans, of having primary C8re physicians as providers, with limitations on the access of patients to specialists. Discouraging or prohibiting specialists Irl chronic diseases such as diabctes or rheumatoid arthritiS from serving the role of primary carc giver has also heen discussed. It is difficult to be optimistic about this focus from the perspective of the patient or the health professional interested in diabetes. Primary carc phy­ sicians do not typically have either the training, the resources, or the time to implement the therapeutic regimens required for optimal diabetes control (4 \). The original I !ealth Security Act as proposed by the Clinton administr8tion placed particular empha­ sis on the role of primary earc providers acting as '·gatekeepers." In such a paradigm for medical care, self-referral by patients to specialIsts woulu he .... x­ pected to be extremely difficult. P8r'I<.!oxlc
- - - - - - - - - - - - - - -----rrincip,t1s are unique in recogniz.ing the values of divcrsity and the dcsir8billty of choice in the highly personal realm of medic81 decision making.. Freed of rervcrsc incentives and regulatory o!lst'lcles, includ­ ing those that woulu be exacerbated by much of' the recently proposed reform legislation, markets In med­ icine, as in other areas, will outperform politics in making desirable health care avatlable to Americans.

ACKNOWLEDGEMENTS We gratefully acknowledge our many colleagues and friends who read and commented on various drafts of this manuscript including C. Ronald Kahn, Peter Sherllne, William isk8nen, Loren Lomasky, Ross Levattcr, Johanna Pallotta, Alan loses, and Marie Vrabel. We would e\peeially like to thank Gerald IV! Phillips for both his insightful comments and editorial assistClnce

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CONCLUSION The health policy community has paid insufficient attention to the role of past policies in accelerating costs and diminishing access to Insurance and has been too quick to recommend solutions based un optimistic projections of new rcgul;ltory dforrs. Re­ form ;InU aid to those in need based on free market

(';1111­

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