Health Care

Op-Ed: America's Healthy Path to Fiscal Health

Project Syndicate | April 30, 2013

Over the last five years, the growth of health-care spending in the United States has slowed dramatically – to the lowest rate in the past 50 years. The slowdown is not a surprise. It is a predictable result of the recession and slow recovery that have left millions of Americans without health insurance and dampened household spending.

But the size of the slowdown is surprising, as is the fact that it started several years before the 2008 recession – and not only in the private insurance system, but also in Medicare and Medicaid, the two major government health programs. (Medicare provides health coverage for retirees, and Medicaid provides coverage for low-income Americans and their children and those with disabilities.)

What explains this slowdown in health-care spending? How much of it is attributable to the weak economy, and how much is the result of changes in provider and consumer behavior?

Two recent studies offer different answers, but both predict that at least some of the slowdown will persist even after the economy recovers. That would be good news for the US economy, which currently devotes nearly 18% of GDP to health care, by far the largest share among developed countries. It would also be good news for America’s fiscal position, because Medicare and Medicaid are the two largest contributors to the long-term federal budget deficit.

The growth of health-care spending declined or remained unchanged in real (inflation-adjusted) terms each year between 2002 and 2011, falling to 3-3.1% in 2009-2011, the lowest rates on record since reporting began in 1960. Recent data indicate that after a slight acceleration in 2012, the growth of real health-care spending in 2013 has fallen back to its 2009-2011 average.

As a result of the recession and lagging recovery, health-care spending has also slowed significantly since 2009 throughout the OECD. Indeed, for the first time on record, real health-care spending stalled on average in the OECD in 2010, as developed countries, reeling from budgetary constraints, clamped down on health programs. Growth in health-care spending was slower in every OECD country in that year, with the exception of Germany.

A new study by Drew Altman, a respected health-care expert and President of the Henry J. Kaiser Family Foundation, concludes that slower growth in real GDP, along with a lower inflation rate, accounts for more than three-quarters of the slowdown in health-care spending in the US after 2001. The weak economy has caused people to postpone consumption of health-care services and has encouraged states and employers to restrain their spending on health.

But important cost-containing changes in the private health-care system, including more cost-sharing in private insurance plans and tighter controls in managed care, have also contributed to the slowdown. Altman conjectures that, overall, the growth in health-care spending between 2008 and 2012 was about one percentage point lower than predicted by deteriorating macroeconomic conditions alone. If this reduction continues after the economy recovers – as seems likely, given the cost-containment incentives in the Affordable Care Act (commonly known as Obamacare) – the US stands to spend $2 trillion less on health care over the coming decade.

Based on the relationship between changes in real per capita health-care spending and changes in unemployment rates at the state level, the recent Economic Report of the President concludes that the recession and lackluster recovery account for less than 20% of the slowdown in health-care spending since 2007 – and for an even smaller share of the slowdown that began in 2002. And difficult macroeconomic conditions explain little (if any) of the slowdown in Medicare spending per enrollee since 2001.

That is not unexpected, because the largely retired Medicare population is less vulnerable to macroeconomic fluctuations than is the working-age population. The Council of Economic Advisers, whose members write the president’s report, surmise that structural changes – including stronger incentives for efficiency by hospitals and providers, more cost-sharing in insurance policies, and the substitution of generic drugs for branded drugs – explain most of the deceleration in per capita spending growth. They also suggest that payment reforms contributed to the slowdown in Medicare’s spending growth after 2001, and that early responses to new Medicare regulations in the Affordable Care Act may have caused a further decline after 2010.

The long-term effect on the federal budget implied by a sustained reduction in the growth of Medicare and Medicaid spending to the rates of the last several years would be profound. These programs currently claim 21% of the budget, with Medicare accounting for two-thirds of that amount. Even a small reduction in the growth of these programs would save billions of dollars. Based on the unexpected slowdown in spending growth during the last few years, the Congressional Budget Office recently cut its ten-year projections for these programs by 3.5%, reducing the ten-year deficit by $382 billion.

In 2011, Medicare spending accounted for 3.7% of GDP. Based on current policies, the government forecasts that Medicare spending per beneficiary will grow at an average annual rate of 4.3% and will rise to 6.7% of GDP over the next 75 years. If, instead, Medicare spending per beneficiary grew by only 3.6% a year, the average rate of the last five years, Medicare’s share of GDP would remain unchanged. This would narrow the fiscal gap, a widely used measure of long-term budgetary imbalance, by almost one-third.

Trends in the US budget reflect an inconvenient truth: If the growth of spending on health-care programs cannot be slowed, stabilizing the federal debt at a sustainable level will require deep cuts in spending on other priorities and increases in taxes on the middle class. The recent slowdown in the growth of health-care spending is a promising sign that America’s budgetary tradeoffs may turn out to be less difficult than expected.

Op-Ed: An Extremely Mucked Up Medicare Debate

Government We Deserve | October 29, 2012

Medicare is taking on a primary role in the presidential race. The discussion often turns to whether the program should continue in its current form, with more direct government controls over costs, or shift its emphasis to vouchers or premium support plans. Let’s try to set the record straight.

Lowering Medicare spending growth over the next 10 years from, say, an additional $500 billion to an additional $400 billion means spending $100 billion less on covered services. It doesn’t matter for budget purposes the source of the saving. It is a benefit reduction.

Both presidential candidates claim to save money on Medicare without cutting benefits. President Obama says his reforms “will save Medicare money by getting rid of wasteful spending…that won’t touch your guaranteed Medicare benefits. Not by a single dime.” Meanwhile, Governor Romney promises that his “premium support” plan will save money while still providing “coverage and service at least as good as what today’s seniors receive.”

But politicians aren’t the only ones dispensing that free-lunch rhetoric. Even highly respected journalists and researchers get pulled into it.

Consider two New York Times stories. After the first presidential debate, Michael Cooper, Jackie Calmes, Annie Lowrey, Robert Pear and John M. Broder said that President Obama “DID NOT CUT BENEFITS by $716 billion over 10 years as part of his 2010 health care law; rather, he reduced Medicare reimbursements to health care providers.” A few days later, David Brooks cited an AMA study of a premium support plan put forward by vice presidential candidate Paul Ryan and Democratic Senator Ron Wyden, saying that “costs might have come down by around 9 percent with NO REDUCTION IN BENEFITS” [cap emphases mine].

Can you see what is going on? Politicians, reporters, and experts all recognize that cost growth must be brought under control. But they also want to suggest that benefits won’t be reduced—if only we go with a particular approach.

It’s one thing to say that we can spend $100 billion less on health care so we can use the money better for education or tax cuts or paying off our debt. But it’s another thing to pretend that we can get $100 billion more in educational benefits or money in our pockets and absolutely the same quality of health care.

We know from personal experience that certain medical procedures, at the end of the day, are worthless or worse. But there’s no budget line called “worthless health care” that our elected officials can bravely vote to reduce.

Instead, we are left with blunt instruments to control costs. A Medicare board may recommend or members of Congress may elect to cut payments to providers, as they have done many times in the past. One can argue such cutting may not produce a great loss in services, depending upon how providers and consumers react. But no loss whatsoever? Come on! Try lowering government payments for anything—rental vouchers, school lunches, highways—and see if the same services are provided.

Similarly, suppose that Congress puts more Medicare recipients into a premium support system, like Medicare Advantage–type plans run by health maintenance and similar organizations. The system then limits the growth rate of payments to those groups. Again, there’s less money to go around.

Both the regulatory and voucher approaches have a precise accounting correspondence. If the government spends $100 billion less, then it purchases $100 billion less in services and makes $100 billion fewer payments to providers.

Back to the presidential and vice presidential debates. Directly trying to control prices for individual services may not have the same effect as trying to control the total amount paid for all services under a premium, and vice versa. But no candidate can deny that he favors benefit cuts relative to today’s unsustainable promises.

To add to the confusion, each side talks as if some idealized system of cost control or premium support exists. Almost inevitably, we will be taking ideas from both approaches.  We’ll cut back on high reimbursement rates when we believe the effect on actual services would be moderate and, at the same time, use limited budgets to encourage providers to operate more efficiently. For instance, we might lower the payment rates for many operations faster and simultaneously induce more Medicare recipients to opt into groups like Kaiser-Permanente that make many allocation decisions within a fixed budget.

Ferreting out the truth in this Medicare debate also requires looking beyond health care. Benefit losses in health care must be contrasted with benefit gains elsewhere. Yet even health care will likely be much worse if we continue to borrow hundreds of billions of dollars more from unfriendly nations and let excessive debt inhibit economic growth.

Bottom line: both parties favor cutting Medicare benefits, or, more accurately, slowing down the rate of benefit growth. The issue isn’t whether but how this can best be done.

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