It’s the Prices, Stupid.

By Richard Kirsch /New Deal 2.0
MAy 13, 2011

   Republican plans that shift costs to consumers completely misunderstand the United States’ health care system.

   Yesterday, Speaker Boehner issued what Robert Bob Borosage of Campaign for America’s Future correctly labeled extortion: “Give us trillions in cuts in Medicare and Medicaid or we blow up the economy.” Boehner’s threat to tie the lifting of the debt ceiling to trillions of cuts in spending would force huge cuts in Medicare and Medicaid.

   Actually, there are no health care cost savings in the Ryan-Boehner budget, just cost shifts. The Ryan budget cuts Medicare by shifting more than $6,000 a year to each senior who benefits from it. It shifts Medicaid costs to state taxpayers by cutting federal funding to states for the program.

   While the extremes of the Ryan-Boehner budget have been widely decried, the underlying assumption behind their Medicare privatization plan is too often accepted by a broad array of health policy advisers. The Ryan budget assumes that the problem with health costs is that consumers don’t pay enough out of pocket for care and that plans are too generous. Unfortunately, that’s also been the view of some Democratic health policy advisers. White House officials backed the taxation of higher cost health plans in the Affordable Care Act (ACA), and others like former Clinton OMB Director Alice Rivlin support a less draconian version of Medicare privatization.

   But the reason that health care costs so much in the United States is not that we consume too much health care; it’s that we pay too much for what we consume.* As Uwe Reinhardt and three other health economists summarized succinctly after comparing the prices we pay and the amount of health care we use in the United States with other developed countries, “It’s the prices, stupid.”

   For example, we make one-third fewer doctor visits a year than people in other countries but we pay an average of $59 for an office visit, compared with $31 in France. Our doctors make a lot more money than their colleagues in other countries. Adjusting pay across countries by purchasing power, U.S. doctors get paid about two times as much as in others. A Congressional Research Service analysis found that specialists in the United States are paid about $50,000 a year more than would be predicted, even considering the higher level of wealth in the United States.

   We go to the hospital a lot less, too, and when we’re there we don’t stay as long. But we pay a lot more. The average hospital stay costs us $3,181, compared with $837 in Canada. We do get a lot more MRIs in the United States, more than twice as much as other countries, and we also pay a lot more for each scan: an average of $1,200 compared to $839 in Germany. And as everyone knows, the price of brand-name prescription drugs is much higher in the United States than other countries.

   Why do we pay so much more for the same product? The biggest reason is that other countries understand that health care is a public good, not a commodity. Markets can’t control health care prices, since it is health care providers who decide what care is delivered. When providers determine both demand and supply, market economics don’t apply.

   Even in the United States, with all the political pressure from the doctor, hospital, and drug lobbies, we can see how a public insurance entity does a better job of controlling prices than private insurance. Medicare sets prices and pays $500 for an MRI, less than half the $1,200 U.S. average. Even with its older patients, Medicare pays $2,200 for an average hospital stay, almost 50% less than the U.S. average.

   Private insurance companies not only fail to control prices, they add costs. The private insurance companies that Ryan wants to hand Medicare over to are the primary reason that we spend more than four times as much on administrative and insurance costs in the United States as other countries.

   Which brings us to another market-driven argument that underlies the Ryan proposal and other conservative nostrums for controlling health care costs: that because Americans have insurance they are not prudent purchasers of health coverage. Again, the international comparison should put this to rest, as in all those other countries with much lower health spending everyone is fully covered. In these countries, the only prudent purchaser is the government, which is responsible for getting lower prices. As it is, the amount that Americans pay out-of-pocket for health care is already a lot more than consumers in other developed countries, even accounting for our higher incomes.

   The Obama budget plan begins to address the root causes of high health care costs by increasing the authority of a new public entity designed to control what Medicare pays for health care. The President contrasted his budget approach with that of the Republican budget in his April 13th budget address at George Washington University, saying: “Their plan essentially lowers the government’s health care bills by asking seniors and poor families to pay them instead. Our approach lowers the government’s health care bills by reducing the cost of health care itself.”

   The centerpiece of Obama’s plan to control Medicare costs is to add additional powers to a new body established under the ACA called the Independent Payment Advisory Board (IPAB). The IBAP will function as a kind of military base closing commission for Medicare. If the growth in Medicare costs exceeds a target amount, then it would institute cost control measures that would go into effect unless Congress intervened. Since cutting eligibility and benefits are not part of the IPAB mandate, cost savings would have to come from the actual drivers of cost: the prices paid for services and the way health care services are delivered.

   Obama’s budget proposal would strengthen the IPAB’s current authority, although the details of how to do that have not yet been specified. As you can imagine, it is already a target of attack from health care providers who are finding a sympathetic ear among both Republicans and Democrats in Congress. It’s also a favorite target of the right, which calls it “Obama’s death panel.”

   The battle being fought over Medicare is, like every other economic issue that faces the nation, a matter of power and a test of our democracy. We can control health care costs and improve the quality of care by addressing the root causes: our market-driven health care system pays too much for care and rewards quantity over quality. But changing the way we finance and pay for health care will mean putting the interest of consumers over the power of the industry lobby. For the doctors, hospitals, drug companies, medical device manufacturers and insurance companies, a dollar saved is a dollar lost in revenue.

   The firestorm of popular opposition to the Ryan Medicare plan is because he chose to side with industry over seniors. But with Boehner threatening to hold the economy hostage, and a health industry that has enormous lobbying clout, the future of our nation’s national health insurance system for seniors and the disabled remains in grave doubt.

Richard Kirsch is a Senior Fellow at the Roosevelt Institute, whose book on the campaign to win reform will be published in 2012. He was National Campaign Manager of Health Care for America Now during the legislative battle to pass reform.

*In 2000 the United States spent considerably more on health care than any other country, whether measured per capita or as a percentage of GDP. At the same time, most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. But U.S. policymakers need to reflect on what Americans are getting for their greater health spending. They could conclude: It’s the prices, stupid. ~ HealthAffairs.org