In upholding the Affordable Care Act, the Supreme Court has allowed the president and Congress to put the country’s health policy on a path that will restrict individual choices, stifle innovation and sharply increase health-care costs. Now the only recourse is to repeal the law through the legislative process and replace it with policies that rely on the power of the markets.
The American health-care system’s principal strength is its ability to produce ever more impressive innovations. The U.S. has no equal in developing new medical technologies, surgical procedures and pharmaceuticals. These extraordinary advances are not the product of government direction but rather the efforts of scientists, investors and entrepreneurs pursuing their individual goals and aspirations in a competitive market system. The Affordable Care Act puts these strengths at risk.
The law also exacerbates the central problem of our health-care system: high costs without corresponding value. The “individual mandate” will require that people purchase health insurance with generous benefits and limited cost-sharing. This flawed conception of health insurance has created the bad incentives that have led us to where we are today.
The principal factual claims made by the individual mandate’s supporters are that the failure to purchase conventional health insurance causes harm to the uninsured person (in the form of worsened health) and to others (in the form of a shifting of the burden of the costs of care).
The evidence supporting each of these claims is weak at best. Peer-reviewed studies from the National Health Insurance Experiment and other data dating back to the 1980s have concluded that there is little or no causal relationship between health insurance and a person’s health outcomes.
What about the claim that the costs of caring for the uninsured are significantly shifted onto doctor and hospital bills, thereby raising insurance premiums? George Mason University Prof. Jack Hadley and John Holahan, Teresa Coughlin and Dawn Miller of the Urban Institute published a comprehensive, peer-reviewed study on this in Health Affairs in 2008. It concluded that “Private insurance premiums are at most 1.7 percent higher because of the shifting of the costs of the uninsured to private insurance.”
The problems with the U.S. health-care system are mainly the result of a handful of government policies that have prevented market forces from reducing costs and making services more widely available. So what to do?
• Fix the tax code. First and foremost is the federal tax code’s long-standing exclusion from taxation of employer-sponsored health insurance. The exclusion has created a tax advantage for purchasing health care through insurance rather than directly with out-of-pocket dollars. This, in turn, has caused consumers to overutilize health-care services as they and their physicians perceive that someone else is footing the bill. As a result, health-care costs have been driven upward.
Policy makers should make the tax treatment of health care neutral by allowing out-of-pocket expenses and individual insurance to be tax deductible. Alternately, neutrality could be achieved by eliminating the tax exclusion for employer-sponsored health insurance. The Affordable Care Act’s tax on high-cost health plans is a first step toward tax neutrality. Unfortunately, the act couples this policy with others that work at cross-purposes.
• Redesign Medicare and Medicaid. The Affordable Care Act includes numerous reforms to the way that Medicare pays health providers, some of which are on the right track. But in Medicare, the main problem is the nearly complete neglect of patient incentives. The Medicare Part B average copayment rate has fallen nearly in half during the past 35 years. One near-term solution is to allow beneficiaries to choose health plans that have lower premiums but higher deductibles, more coinsurance, or more tightly managed networks of providers than those in traditional Medicare. The long-term solution is to provide beneficiaries with a defined level of support to allow them to purchase a private insurance plan. Such an approach is modeled on today’s Medicare prescription drug coverage and is similar to one proposed by Rep. Paul Ryan (R., Wis.) and Sen. Ron Wyden (D., Ore.).
In Medicaid, the emphasis on access to health insurance, rather than access to health care, has stifled innovation in delivering care to the uninsured. The Affordable Care Act does little to change this. Medicaid should be converted to a block grant in which states are given a fixed sum of money and allowed greater flexibility to experiment with new approaches, such as delivering care through organizations that tailor available services to patient needs at reduced costs.
• Reform insurance markets. State price controls and the proliferation of state mandates that insurers cover particular medical services and providers have driven up the cost of insurance by as much as 15%, made it less portable, and increased the number of uninsured by as many as 10 million. Unfortunately, the Affordable Care Act enshrines many of these flawed policies in federal law.
The key objective of insurance regulation should be to increase the availability of low-cost, portable health insurance—insurance that delivers the benefits that people want, at a price they can afford. To this end, individuals should be allowed to purchase insurance across state lines or in a federal market that is free of insurance mandates.
The Affordable Care Act will expand the reach of government into our personal health-care choices, while exacerbating the problems with our current health-care system. Market forces, if allowed to work properly, are the best means for reducing the growth in health costs, encouraging continued innovation, and ensuring that consumers have access to quality health care.
Messrs. Cogan and Kessler are senior fellows at Stanford University’s Hoover Institution and, respectively, professors of public policy and business and law at Stanford. Mr. Hubbard, dean of Columbia Business School, was chairman of the Council of Economic Advisers under President George W. Bush and is an adviser to Mitt Romney. They are the authors of “Healthy, Wealthy, and Wise” (2nd ed., Hoover Institution and American Enterprise Institute, 2011).
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