The Health Care Crisis and What to Do About ItWord文档下载推荐.docx
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The Health Care Crisis and What to Do About ItWord文档下载推荐.docx
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byHenryJ.AaronandWilliamB.Schwartz,withMelissaCox
BrookingsInstitution,199pp.,$44.95;
$18.95(paper)
TheHealthCareMess:
HowWeGotintoItandWhatItWillTaketoGetOut
byJuliusRichmondandRashiFein
HarvardUniversityPress,320pp.,$26.95
Healthy,Wealthy,andWise:
FiveStepstoaBetterHealthCareSystem
byJohnF.Cogan,R.GlennHubbard,andDanielP.Kessler
AmericanEnterpriseInstitute/HooverInstitution,130pp.,$18.00
ThegoodnewsisthatweknowmoreabouttheeconomicsofhealthcarethanwedidwhenClintontriedandfailedtoremakethesystem.There’snowalargebodyofevidenceonwhatworksandwhatdoesn’tworkinhealthcare,andit’snothardtoseehowtomakedramaticimprovementsinUSpractice.Aswe’llsee,theevidenceclearlyshowsthatthekeyproblemwiththeUShealthcaresystemisitsfragmentation.Ahistoryoffailedattemptstointroduceuniversalhealthinsurancehasleftuswithasysteminwhichthegovernmentpaysdirectlyorindirectlyformorethanhalfofthenation’shealthcare,buttheactualdeliverybothofinsuranceandofcareisundertakenbyacrazyquiltofprivateinsurers,for-profithospitals,andotherplayerswhoaddcostwithoutaddingvalue.ACanadian-stylesingle-payersystem,inwhichthegovernmentdirectlyprovidesinsurance,wouldalmostsurelybebothcheaperandmoreeffectivethanwhatwenowhave.Andwecoulddoevenbetterifwelearnedfrom“integrated”systems,liketheVeteransAdministration,thatdirectlyprovidesomehealthcareaswellasmedicalinsurance.
ThebadnewsisthatWashingtoncurrentlyseemsincapableofacceptingwhattheevidenceonhealthcaresays.Inparticular,theBushadministrationisundertheinfluenceofbothindustrylobbyists,especiallythoserepresentingthedrugcompanies,andafree-marketideologythatiswhollyinappropriatetohealthcareissues.Asaresult,itseemsdeterminedtopursuepoliciesthatwillincreasethefragmentationofoursystemandswelltheranksoftheuninsured.
Beforewetalkaboutreform,however,let’stalkaboutthecurrentstateoftheUShealthcaresystem.Letusbeginbyaskingaseeminglynaivequestion:
What’swrongwithspendingevermoreonhealthcare?
1.
Ishealthcarespendingaproblem?
In1960theUnitedStatesspentonly5.2percentofGDPonhealthcare.By2004thatnumberhadrisento16percent.AtthispointAmericaspendsmoreonhealthcarethanitdoesonfood.Butwhat’swrongwiththat?
Thestartingpointforanydiscussionofrisinghealthcarecostshastobetherealizationthattheserisingcostsare,inanimportantsense,asignofprogress.Here’showtheCongressionalBudgetOfficeputsit,inthelatesteditionofitsannualpublicationTheLong-TermBudgetOutlook:
Growthinhealthcarespendinghasoutstrippedeconomicgrowthregardlessofthesourceofitsfunding….Themajorfactorassociatedwiththatgrowthhasbeenthedevelopmentandincreasinguseofnewmedicaltechnology….Inthehealthcarefield,unlikeinmanysectorsoftheeconomy,technologicaladvanceshavegenerallyraisedcostsratherthanloweredthem.
Noticethethreepointsinthatquote.First,healthcarespendingisrisingrapidly“regardlessofthesourceofitsfunding.”Translation:
althoughmuchhealthcareispaidforbythegovernment,thisisn’tasimplecaseofrunawaygovernmentspending,becauseprivatespendingisrisingatacomparablyfastclip.“Comparingcommonbenefits,”saystheKaiserFamilyFoundation,
changesinMedicarespendinginthelastthreedecadeshaslargelytrackedthegrowthrateinprivatehealthinsurancepremiums.Typically,Medicareincreaseshavebeenlowerthanthoseofprivatehealthinsurance.
Second,“newmedicaltechnology”isthemajorfactorinrisingspending:
wespendmoreonmedicinebecausethere’smorethatmedicinecando.Third,inmedicalcare,“technologicaladvanceshavegenerallyraisedcostsratherthanloweredthem”:
althoughnewtechnologysurelyproducescostsavingsinmedicine,aselsewhere,theadditionalspendingthattakesplaceasaresultoftheexpansionofmedicalpossibilitiesoutweighsthosesavings.
Sofar,thissoundslikeahappystory.We’vefoundnewwaystohelppeople,andarespendingmoretotakeadvantageoftheopportunity.Whynotviewrisingmedicalspending,likerisingspendingon,say,homeentertainmentsystems,simplyasarationalresponsetoexpandedchoice?
Wewouldsuggesttwoanswers.
ThefirstisthattheUShealthcaresystemisextremelyinefficient,andthisinefficiencybecomesmorecostlyasthehealthcaresectorbecomesalargerfractionoftheeconomy.Suppose,forexample,thatwebelievethat30percentofUShealthcarespendingiswasted,andalwayshasbeen.In1960,whenhealthcarewasonly5.2percentofGDP,thatmeantwasteequaltoonly1.5percentofGDP.Nowthattheshareofhealthcareintheeconomyhasmorethantripled,sohasthewaste.
Thisinefficiencyisabadthinginitself.WhatmakesitliterallyfataltothousandsofAmericanseachyearisthattheinefficiencyofourhealthcaresystemexacerbatesasecondproblem:
ourhealthcaresystemoftenmakesirrationalchoices,andrisingcostsexacerbatethoseirrationalities.Specifically,Americanhealthcaretendstodividethepopulationintoinsidersandoutsiders.Insiders,whohavegoodinsurance,receiveeverythingmodernmedicinecanprovide,nomatterhowexpensive.Outsiders,whohavepoorinsuranceornoneatall,receiveverylittle.Totakejustoneexample,onestudyfoundthatamongAmericansdiagnosedwithcolorectalcancer,thosewithoutinsurancewere70percentmorelikelythanthosewithinsurancetodieoverthenextthreeyears.
Inresponsetonewmedicaltechnology,thesystemspendsevenmoreoninsiders.Butitcompensatesforhigherspendingoninsiders,inpart,byconsigningmorepeopletooutsiderstatus—robbingPeterofbasiccareinordertopayforPaul’sstate-of-the-arttreatment.ThuswehavethecruelparadoxthatmedicalprogressisbadformanyAmericans’health.
Thisdescriptionofourhealthcareproblemsmaysoundabstract.Butwecanmakeitconcretebylookingatthecrisisnowafflictingemployer-basedhealthinsurance.
2.
Theunravelingofemployer-basedinsurance
In2003only16percentofhealthcarespendingconsistedofout-of-pocketexpendituresbyconsumers.Therestwaspaidforbyinsurance,publicorprivate.Aswe’llsee,thisheavyrelianceoninsurancedisturbssomeeconomists,whobelievethatdoctorsandpatientsfailtomakerationaldecisionsaboutspendingbecausethirdpartiesbearthecostsofmedicaltreatment.Butit’snousewishingthathealthcareweresoldlikeordinaryconsumergoods,withindividualspayingoutofpocketforwhattheyneed.Byitsverynature,mosthealthspendingmustbecoveredbyinsurance.
Thereasonissimple:
inanygivenyear,mostpeoplehavesmallmedicalbills,whileafewpeoplehaveverylargebills.In2003,healthspendingroughlyfollowedthe“80–20rule”:
20percentofthepopulationaccountedfor80percentofexpenses.Halfthepopulationhadvirtuallynomedicalexpenses;
amere1percentofthepopulationaccountedfor22percentofexpenses.
Here’showHenryAaronandhiscoauthorssummarizetheimplicationofthesenumbersintheirbookCanWeSayNo?
:
“Mosthealthcostsareincurredbyasmallproportionofthepopulationwhoseexpensesgreatlyexceedplausiblelimitsonout-of-pocketspending.”Inotherwords,ifpeoplehadtopayformedicalcarethewaytheypayforgroceries,theywouldhavetoforegomostofwhatmodernmedicinehastooffer,becausetheywouldquicklyrunoutoffundsinthefaceofmedicalemergencies.
Sotheonlywaymodernmedicalcarecanbemadeavailabletoanyoneotherthantheveryrichisthroughhealthinsurance.Yetit’sverydifficultfortheprivatesectortoprovidesuchinsurance,becausehealthinsurancesuffersfromaparticularlyacutecaseofawell-knowneconomicproblemknownasadverseselection.Here’showitworks:
imagineaninsurerwhoofferedpoliciestoanyone,withtheannualpremiumsettocovertheaverageperson’shealthcareexpenses,plustheadministrativecostsofrunningtheinsurancecompany.Whowouldsignup?
Theanswer,unfortunately,isthattheinsurer’scustomerswouldn’tbearepresentativesampleofthepopulation.Healthypeople,withlittlereasontoexpecthighmedicalbills,wouldprobablyshunpoliciespricedtoreflecttheaverageperson’shealthcosts.Ontheotherhand,unhealthypeoplewouldfindthepoliciesveryattractive.
Youcanseewherethisisgoing.Theinsurancecompanywouldquicklyfindthatbecauseitsclientelewastiltedtowardthosewithhighmedicalcosts,itsactualcostspercustomerweremuchhigherthanthoseoftheaveragememberofthepopulation.Soitwouldhavetoraisepremiumstocoverthosehighercosts.However,thiswoulddisproportionatelydriveoffitshealthiercustomers,leavingitwithanevenlesshealthycustomerbase,requiringafurtherriseinpremiums,andsoon.
Insurancecompaniesdealwiththeseproblems,tosomeextent,bycarefullyscreeningapplicantstoidentifythosewithahighriskofneedingexpensivetreatment,andeitherrejectingsuchapplicantsorchargingthemhigherpremiums.Butsuchscreeningisitselfexpensive.Furthermore,ittendstoscreenoutexactlythosewhomostneedinsurance.
Mostadvancedcountrieshave
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