[Economic Report of the President (2008)]
[Administration of George W. Bush]
[Online through the Government Printing Office, www.gpo.gov]

 
CHAPTER 4

The Importance of Health and Health Care



The American health care system is an engine for innovation that develops
and broadly disseminates advanced, life-enhancing treatments and offers
a wide set of choices for consumers of health care. The current health
care system provides enormous benefits, but there are substantial
opportunities for reforms that would reduce costs, increase access,
enhance quality, and improve the health of Americans.

An individual's health can be maintained or improved in many ways,
including through changes in personal behavior and through the
appropriate consumption of health care services. While there is
substantial health care spending in the United States, the importance
of health does provide a strong rationale for this level of spending.
But because health care financing and delivery are often inefficient,
there are opportunities to advance health and access to health care
services without further growth in spending. To improve the efficiency
of health care financing and delivery, the Administration has pursued
policies that would increase incentives for individuals to purchase
consumer-directed health insurance plans. The Administration has also
worked to link provider payments to performance, thus rewarding
efficient delivery of health care. In the President's State of the
Union Address, he proposed changing the tax treatment of health
insurance, offering all Americans a standard deduction for buying health
insurance. Such a change could play an important role in increasing the
efficiency of the American health care system and expanding health
insurance coverage.

The key points in this chapter are:

Health can be improved not only through the consumption of
health care services, but also through individual behavior
and lifestyle choices such as quitting smoking, eating more
nutritious foods, and getting more exercise.

Health care has enhanced the health of our population;
greater efficiency in the health care syst
em, however,
could yield even greater health for Americans without
increasing health care spending.

Rapid growth in health care costs and limited access to
health insurance continue to present challenges to the
health care system.

Administration policies focus on reducing cost growth,
improving quality, and expanding access to health insurance
through an emphasis on private sector and market-based
solutions.


Health and the Demand for Health Care


The demand for health care is unlike the demand for most consumer
products and services because while the desire for consumer products
and services comes from direct consumption, the desire for health care
is not derived directly from the consumption of the medical procedures
themselves; rather, it comes from the direct value of improved health
that is produced by health care. For example, demand for an MP3 player
is based on the enjoyment that an MP3 player brings to a consumer, but
few would choose to get a laparoscopic cholecystectomy for the same
reason. Rather, a consumer's desire to have her gallbladder removed is
directly related to the positive impact the operation is likely to have
on her health. Understanding how health is produced, demanded, and
valued is a useful starting point for evaluating the health care system
and health care policy.


Demand for Health

People demand health because of its role in facilitating and providing
happiness. Health can be defined along two dimensions: the length of
life (longevity) and the quality of life. A person derives value from
the quality of life directly and indirectly: directly because one's
level of health affects the enjoyment of goods and leisure and
indirectly because one's level of health enhances productivity
(Box 4-1). Enhanced productivity can be rewarded in the labor market
through higher wages. The indirect effect of health on produc
tivity
suggests that health is an important component of human capital
investment. Consistent with the basic principle of our economic system,
consumers exercise choice in purchasing health care and other goods and
services.


The Production of Health

Health care is only one of the factors that determine health. Other
factors include individual behaviors, environmental factors, social
factors, education, income, and genetics. If we think of an individual
as a producer of health, the key production inputs are the time and
money spent on health-improving activities and health care. Health-
improving activities can include individual choices regarding exercise,
nutrition, and lifestyle. Health care can include hospital care,
outpatient visits to medical providers, nursing home care, and
medication. Because health can deteriorate from accidents, sudden
disease, and the effects of aging, health care inputs are needed not
only to maintain current levels of health but also possibly to restore
health following an illness or injury.

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Box 4-1: Health Effects on Job Productivity

Health can affect job productivity through absenteeism and presenteeism.
Absenteeism, not being present at the place of work as a result
of injury or illness, prevents an individual from contributing to output,
and may also affect the ability of coworkers to be productive when tasks
require collaboration. Presenteeism is the loss of at-work productivity
caused by a lack of physical or mental energy needed to complete
tasks, increased workplace accidents, and the possible spread of illness
to fellow employees. There is evidence that both of these factors are
costly. According to the Current Population Survey (CPS), 2.3 percent of
workers will have an absence from work during a typical week due to
injury or illness. Several studies estimating the extent to which
presenteeism affects productivity indicate that, on average, the
productivity loss caused b
y some of the most common conditions (such as
allergies, depression, musculoskeletal pain, and respiratory disorders)
is between
5 and 18 percent.

Investment in improving and managing health offers opportunities
to mitigate some of these costs. An increasing number of employers
are instituting at-work wellness programs that provide targeted health
management. These programs range from monetary penalties for those
with unhealthy lifestyles (such as smoking or uncontrolled diabetes) to
subsidizing access to exercise facilities. The benefits are shared by the
worker (higher earnings, better quality of life) and the employer
(enhanced productivity and decreased health care expenditures). Evidence
of the success of these programs, while incomplete and variable, suggests
that at-work wellness programs can improve worker health outcomes
and provide a positive return to employers. One long-term study of a
particularly comprehensive wellness program shows that health care
expenditures fell by an average of $225 per employee per year (mostly
due to fewer doctor visits and hospital stays), but it took several years
to realize these benefits.
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Studies of trends in health-improving activities show a mixed picture
on whether Americans are investing more in their health. A recent study
finds that Americans are smoking less and controlling their cholesterol
and blood pressure better (through a combination of health-improving
activities and medical inputs). In contrast, there has been a dramatic
increase in obesity in the United States in both adults and children
during the past few decades. Obesity has more than doubled since the
late 1970s, from 15 percent to 34 percent among adults. Among children
ages 6 to 19, the incidence of being overweight has tripled. Obesity is
an indicator of unhealthy behavior because it often reflects a lack of
exercise and overconsumption of unhealthy foods. Also, obesity is
associated with a high
er risk of many diseases and health conditions,
including hypertension, Type 2 diabetes, coronary heart disease, and
some cancers.


Trends in Health Spending

Americans are investing more in their health as measured by health
care expenditure. In 2006, Americans spent over $7,000 per capita on
health care, up from $2,400 in 1980 and $800 in 1960 (all in 2006
dollars). National health care spending has grown more rapidly than the
economy as a whole, so health care accounts for an increasing share of
the overall economy (Chart 4-1). National health care spending now
accounts for about 16 percent of gross domestic product (GDP), up
from 9.1 percent in 1980 and only 5.2 percent in 1960.

The primary factor that tends to drive health care expenditure growth
is the development and diffusion of new technologies. Knowledge about
health and health care conditions continues to expand over time,
generating an expanding inventory of new or improved products,
techniques, and services. Medical technology may account for about
one-half or more of real long-term





health care spending growth. Rising incomes are a second important
factor because as income increases, a greater proportion of income is
typically spent on health care. The aging of the population and
increasing disease prevalence is a third important factor contributing
to expenditure growth in the United States. Other cited factors include
more rapid wage growth in the health sector, greater insurance coverage
supported by large government subsidies through both government-sponsored
programs and tax subsidies, and the low share of health expenses paid
out-of-pocket by health consumers.


Trends in Life Expectancy

Life expectancy is only one of many outcome measures for health, but
because it has been reliably and consistently measured over time, it
offers a unique historical view of trends in health. United States life
expectancy trends since 1900 both from birth and from age 65 are shown
in Ch
art 4-2. In the two panels of this chart, we see life expectancy
gains throughout the century. Progress in life expectancy at birth was
rapid in the first half of the century, growing from 48 to 68 years.
Between 1950 and 1970, life expectancy at birth grew gradually, reaching
only 71 by 1970. Progress picked up in the 1970s, with life expectancy
reaching age 78 by 2004. There is a contrasting pattern for the life
expectancy among those who live to age 65. Life expectancy at age





65 showed little progress until the 1930s; in the subsequent 4 decades,
life expectancy at 65 rose 3 years to 15 (meaning that in 1930 a person
who was 65 could expect to live to age 77, while in 1970 a 65-year-old
person could expect to live to age 80). Starting in the 1970s, the pace
of improvement accelerated. By 2004, life expectancy at age 65 was 18.5
additional years; a gain of 3.5 years of life over the past 3.5 decades.

Innovations in health and health care can explain the patterns in
longevity. Changes in the first half of the 20th century came largely
through progress in reducing malnutrition, improving sanitation, and
containing infection through improved public health measures and the
use of antibiotic agents such as penicillin. After about 20 years of
gradual improvement in life expectancy, the rising longevity from 1970
reflects progress in treating life-threatening ailments prevalent among
those over 50. As shown in Table 4-1, the largest single contributor to
increased longevity has been reduced mortality from heart disease (3.6
years); reduced mortality from strokes added another 1.3 years to life
expectancy. Reduced mortality from those two conditions has thus added
nearly 5 years to the life expectancy of Americans.
Research suggests that the lower mortality from heart disease and
strokes is primarily attributable to advances in intensive medical
therapies, non-acute medications to manage high blood pressure and high
cholesterol, and changes in indi
vidual behavior to reduce risk factors
such as smoking and high-fat diets. Improvements in medical treatments
alone are believed to account for at least 3 of the 5 years of the life
expectancy gain that is attributable to reduced mortality from heart
diseases and strokes.

To put these substantial benefits of extending life into a
perspective that accounts for the increased spending on health care,
it is useful to assess the tradeoff between the cost of the treatments
and the benefits of longer life. An influential study has done this
and found the benefits of increased spending on cardiovascular
treatments to be about four times as large as the costs.




While the study focused on spending on cardiovascular disease, the
basic conclusion-aggregate health-spending increases have provided
positive returns-is true more broadly. Using the same framework, the
total increase in health care spending since 1950 can be justified, in
monetary terms, by the life expectancy gains from cardiovascular
treatment and neonatal care alone. Gains from other treatment advances
(not to mention benefits other than life extension, such as a higher
quality of life) thus imply that, over the past half-century, the
benefits from greater health care spending in the United States have
exceeded their costs. However, the benefits of greater health care
spending in relation to costs have not been as favorable since 1980,
suggesting potentially diminishing returns from health care spending.


Trends in Health Insurance Coverage

Health insurance helps shield families from the financial risk of the
unanticipated health expenses of serious illness or injury, and
facilitates access to the health care system, thereby improving health
outcomes. Given those benefits, it is a major concern that at any given
time, 16 percent of Americans report that they lack health insurance.
The primary driver of declining enrollment in private insurance has
been the increasing cost of health care a
nd this decline contributes to
the rising proportion of uninsured (Chart 4-3).




Addressing Challenges in the
Health Care System

The trends in the U.S. health care system suggest that the rapid
growth in health care costs will persist. Health care costs will pose
an increasing challenge for consumers of health care and health
insurance as expenditures in this sector make up a greater share of
household consumption. Taxpayers will also face an increasing
challenge as the budgetary burden of Federal and State health care
programs continues to expand. (See Box 4-2 for an overview of
government health care programs.) Reducing health care cost growth and
increasing access while improving health care quality are the goals of
Federal health care policy. The Administration's objective has been to
develop market-oriented policies to meet these goals by fostering the
innovation, flexibility, and choice that are the best aspects of the
American health care system. Market-oriented policies must address
potential market failures that are at the root of the challenges in
the health care system. These problems include insufficient
information available to patients, health providers, and insurers;
access barriers for lower-income or disadvantaged Americans; and two
specific market failures that arise in insurance markets: moral hazard
and adverse selection. Moral hazard is the tendency for individuals to
overuse certain types of health care when insurance covers a sizable
fraction of the costs; adverse selection is the tendency for insurance
to be purchased by those persons who are most likely to need it (and
who thus have higher costs). Policies aimed at mitigating these
problems can enhance the ability of our market-oriented health care
system to achieve the goals of controlled cost growth, improved
access to health insurance coverage, and high-quality health care.

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-----------------------
Box 4-2: Government Health Care Programs

About 46 percent of health care spending is funded by Federal and
State Governments through various health programs. The main government-
funded health programs are designed to serve specific populations
and include Medicare, Medicaid, the State Children's Health Insurance
Program (SCHIP), and the Veterans Health Administration (VHA).

Medicare was enacted in 1965 and covers nearly all individuals aged
65 and older (as well as some younger individuals with disabilities or
specific illnesses). Medicare today consists of three basic parts.
Part A is hospital insurance, which covers stays in hospitals and
nursing facilities. Part A is primarily funded by a 2.9 percent
payroll tax (1.45 percent each for workers and employers). Part
A is generally provided automatically and without premiums for
persons age 65 and older who are eligible for Social Security or
Railroad Retirement benefits. Part B is supplementary medical
insurance which covers doctor visits and other outpatient services.
Part B is voluntary and enrollees pay a monthly premium, yet 94 percent
of those eligible elect to enroll. Part D, Medicare's prescription drug
benefit which started in 2006, is available on a voluntary basis
to individuals who qualify for Medicare Part A, and requires a monthly
premium for those beneficiaries who do not qualify for the low-income
subsidy. Unlike other parts of Medicare, Part D is administered by a
partnership between private insurers and Medicare officials to provide
choice of prescription drug plans to beneficiaries and to allow for price
competition. Part B and Part D are funded by a combination of premiums
from beneficiaries and government revenues (Part D also receives some
resources from the States). In 2007, there were 43.4 million
beneficiaries enrolled in Part A, 40.6 million in Part B, and 24.4
million in Part D.

Under Fee-for-Service Medicare, health care providers are reimbursed
by the Federal Government at pred
etermined rates for services
provided. However, Medicare beneficiaries can opt to enroll in a private
Medicare plan under Medicare Advantage through local coordinated
care plans offered mostly by local health maintenance organizations
(HMOs) and preferred provider organizations (PPOs), regional PPOs, and
private fee-for-service providers. Local coordinated care plans make up
72 percent, regional PPO plans 3 percent, and private fee-for-service
plans 21 percent of Medicare Advantage plans.

Medicaid was also established in 1965 as a health care program for
low-income individuals, in particular those with children. Medicaid
is administered by the States, and is funded by both the Federal
Government and the States. Like traditional Medicare, Medicaid also
reimburses private providers for services at predetermined rates and
allows recipients to enroll in Medicaid managed care plans in many
States. However, unlike Medicare, these predetermined rates are
determined at the State level. In 2006, there were 45.7 million
enrollees in Medicaid, of whom 65 percent were in managed care plans.
The State Children's Health Insurance Program (SCHIP) was created in
1997 to cover children from low-income families who do not qualify for
Medicaid. SCHIP is also administered by the States and funded by both
Federal and State Governments, but the Federal contribution towards
spending is higher for SCHIP than for Medicaid. In 2006, there were
6.6 million enrollees in SCHIP.

While Medicare, Medicaid, and SCHIP are publicly funded programs,
most health care services are delivered by private providers not
employed by the government. In contrast, the Veterans Health
Administration (VHA) delivers health care to veterans through a
system that is run by the Department of Veterans Affairs. The VHA
is a truly public health care system in the sense that the Federal
Government owns the VHA hospitals and employs the health care
providers.

Rising health care costs are creating budget pressures for government
healt
h care programs. Currently, Federal spending on Medicare and
Medicaid totals about 4 percent of GDP, or about 20 percent of the
Federal budget. Rising health care costs, however, will likely raise
those figures in coming decades. If spending grows 1 percent per year
faster than GDP (which is somewhat slower than the historical rate of
growth over the past 40 years), for example, the Office of Management
and Budget projects that in 25 years, spending on these two programs
alone could reach 8 percent of GDP. Such spending growth, if it came
to pass, would require either unprecedented levels of taxation or
dramatic reductions in other government activities.
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Moral Hazard and Cost Control


In most markets, consumers decide what to purchase by comparing the
benefit of a good or service relative to its cost. In the health care
sector, however, consumers often do not learn the prices of goods and
services until bills are received weeks or months later. Because
health insurance polices cover most health care costs, including the
costs of routine, predictable health care services, consumers have
little incentive to try to access and act on price information. This
moral hazard effect encourages overuse of certain types of heath
care, gives little incentive for consumers to consider costs in their
search for a provider, and distorts incentives for technological
change.

Overuse of health care can occur when the perceived cost of a service
is less than the actual cost and, as a result, the service may be used
even when its value is less than its cost. This happens, for example,
with health insurance coverage that shields consumers from the true
cost of a service by having them pay none or only a portion of its
cost. To illustrate, consider a consumer's decision to purchase a
migraine therapy that costs $100 to produce. If the symptoms are
serious enough and would be relieved by the therapy, the consumer
might be willing to p
ay more than $100 for the therapy. The consumer
would thus purchase the therapy regardless of how much of the $100
cost was covered by insurance, and the purchase would not be
overconsumption. If the customer had milder symptoms, however,
insurance may induce overconsumption. Suppose, for example, that the
consumer would only be willing to pay $25 to relieve the symptoms. If
insurance covered the entire $100 cost, the consumer would purchase the
therapy since the $25 benefit exceeds the consumer's effective price of
zero. Even if a $10 copayment was required by the insurance benefit,
the purchase would still take place. Because the social cost of $100
exceeds the $25 benefit, this purchase would not be socially
beneficial and would therefore be considered overconsumption.

Because consumers are less sensitive to the prices of the health care
services they consume, the competitive forces that typically keep prices
down are weakened. Imagine two hospitals that provide the same service,
but hospital A charges $1,000 and is located in an older facility, while
hospital B charges $2,000 but is located in an updated facility with a
wide array of amenities and equipment on site. Given these choices, a
consumer facing the actual price may prefer hospital A, but in a world
where few costs are shared with the patient, most people would choose
hospital B. This gives hospital B few incentives to control costs given
that convenience or amenities have a greater influence on consumer
choice than price.

New technological innovations enter a market in which consumers rarely
pay more than 10 to 20 percent of the market price out-of-pocket. This
influences the value of the innovations that are developed and marketed.
If a new product is only slightly more effective than an existing
product, for example, it may be highly demanded even if it is priced
well above existing alternatives. Because there is a market for new
technology with little additional benefit over existing treatments,
innovators have suf
ficient incentive to create new technologies with
little marginal value.

Health insurers and their sponsors (employers) recognize that
insurance reduces consumer incentives to be responsive to costs.
Insurers use a variety of cost-control mechanisms such as utilization
review, pre-approval, and drug formularies to attempt to manage costs
and, in part, counteract the lack of cost consciousness by consumers.
But those mechanisms can only partly offset the problem. In addition,
insurance benefits are designed to limit moral hazard by sharing the
costs of services received with the beneficiary. Design features to
accomplish this goal include deductibles, copayments, and coinsurance.
Deductibles, the dollar amount that a consumer will have to pay before
the insurer pays for any medical expenses, are often less than $500.
Copayments are a fixed fee paid per visit or per prescription.
Coinsurance is a percentage of the cost of the service that is the
responsibility of the consumer.

These cost sharing mechanisms are underutilized because of a bias
created by the tax code. The health insurance premium of employees paid
by employers is exempt from income and payroll taxes, but individual
spending through deductibles, copayments, and coinsurance is taxable.
As a result, there is a tax incentive for employers to compensate
employees through generous health insurance plans that limit cost
sharing. Thus, the tax code reduces the incentive for optimal health
insurance design and ultimately encourages individuals to purchase more
health care services than they would otherwise. Health Savings Accounts
(HSAs), enacted into law by this Administration in 2004, and the
standard deduction for health insurance first proposed by this
Administration in 2007, both provide a mechanism for eliminating the
tax bias against greater cost sharing. These policies are intended to
offer the private sector more opportunities to control costs through
greater consumer awareness of the cost of health insurance premiums
and
health care services.

Health Savings Accounts

Health Savings Accounts are savings accounts of pre-tax dollars,
funded by individual or employer contributions, that can be used toward
current and future out-of-pocket medical expenses. HSAs are designed to
be used in conjunction with high-deductible health plans, reducing
reliance on insurance for routine health expenses. The funds in the HSA
can be used to pay these routine health expenses directly. Because
unspent funds belong to the individual and can accumulate over time,
HSAs lead the individual to play a more active role as a health care
consumer. In January 2007, HSAs covered 4.5 million people, which is an
increase of 1.3 million since January 2006, and 3.5 million since
March 2005.

As the consumer plays a greater role and becomes more aware of
routine health expenses, provision of inefficient care should be
reduced; incentives for providers to adopt cost-effective therapies
should increase; and possibly, some health care prices may decline,
which may even benefit consumers in traditional insurance plans. Yet
the benefit of moving to a high-deductible policy with an HSA will
vary in that chronically ill individuals with persistently high
spending may find these policies less desirable because their
out-of-pocket spending would be consistently high. Consumers in lower
tax brackets will derive a smaller tax benefit from HSAs because the
value of tax exemption depends on a consumer's marginal tax rate (the
tax paid on the next dollar a worker earns).


A Standard Deduction for Health Insurance to Replace the
Tax Exemption

The lack of consumer sensitivity to health care prices occurs not
just through the consumption of health care services, but through the
consumption of health insurance as well. The tax exemption of
employer-sponsored health insurance premiums is inefficient because,
by providing a larger tax break to families with more-generous
employer-sponsored health insurance policies, there is an incentive
for hea
lth insurance to cover more services than employees would
otherwise demand. This occurs because employees can increase after-tax
compensation by accepting more of their compensation in the form of
health insurance.

The President has proposed to replace the current open-ended tax
exclusion for employment-based health insurance with a flat $15,000
standard deduction for health insurance to all families (or $7,500 for
individuals), whether that insurance was obtained through their
employer or on their own. The amount of this standard deduction would
be independent of the actual amount spent on the premium, so families
who obtain insurance policies for less than $15,000 (but whose policy
satisfies a set of minimum requirements for catastrophic coverage) would
still have an exemption for the full $15,000 of compensation from
income and payroll taxes. The annual increase in the standard deduction
for health insurance would be linked to inflation as measured by the
Consumer Price Index.

This policy has two key effects: 1) It would reduce the inefficiency
of the current tax treatment of employment-based health insurance and
would allow individual consumers to benefit from reducing the cost of
their insurance; and 2) it would provide for equitable tax treatment
for health insurance purchased inside and outside of employment. The
first effect can be shown in the following example. Consider a family
of four with an annual income of $50,000 and a health insurance policy
worth $10,000 that is sponsored by an employer. Because the marginal
tax rate of this family is roughly 30 percent, the current tax
exemption for the cost of this insurance policy provides a $3,000 tax
break to the family. Another family with the same income and an
employer-sponsored health insurance policy worth $20,000 currently
receives a tax break of $6,000. One advantage of the proposed standard
deduction is that it provides the same tax treatment to all types of
health insurance plans. Under the proposed plan, both famil
ies would
qualify for the flat $15,000 standard deduction and receive the same
tax savings of $4,500. The flat tax break provides a strong incentive
to obtain health insurance coverage, and it would allow families to
reap the tax benefits of health insurance policies with optimal cost-
sharing features. Because the tax break is not more generous for those
who choose expensive health insurance plans (unlike the tax exemption),
consumers will become more conscious of cost when purchasing health
insurance and health care.

Health insurance purchases by families and individuals with or
without access to employment-based health insurance would receive the
same tax benefits under this policy. Currently, tax treatment of health
insurance premiums is inequitable because it does not offer the same
tax break to families and individuals without access to employment-based
insurance, who must instead purchase a private plan in the individual
health insurance market. The family considered above with an annual
income of $50,000 receives a $3,000 tax break for a health insurance
policy worth $10,000 sponsored by an employer, but no tax break for a
similar health insurance policy purchased through the individual
insurance market. Under the Administration's proposal, those who are
currently insured in the individual health insurance market would see
a reduction in taxes commensurate with those insured in the group
market. As a result, those who are currently uninsured because they have
no access to employment-based insurance, would be given a strong
incentive to purchase coverage. An uninsured family of four earning
$50,000, for example, would receive a tax benefit of $4,500 if they
purchased health insurance in the individual market (the value of the
$15,000 standard deduction if the family faces a 30 percent marginal t
ax rate). That tax break would cover nearly half the cost of a family
health insurance plan costing $10,000.

The availability of a tax deduction for the purchase of health
insurance
for individuals and families who are not offered employer-
sponsored coverage will make health insurance more affordable for
millions of Americans. The Administration estimates that the standard
deduction would provide 3 to 5 million individuals with health
insurance who did not have it previously. Even with a standard
deduction, challenges for affordable coverage remain for individuals
with low incomes or with substantial risk of high health expenditures.
The Administration's Affordable Choices Initiative addresses these
remaining challenges. The initiative facilitates State efforts to make
health insurance more affordable for individuals with persistently high
medical expenses or limited incomes. Currently, subsidies and payments
from the Federal Government are funneled through providers; the
objective is to redirect funding toward individuals.


Controlling Costs Through Competitive
Insurance Markets

The effective functioning of a competitive marketplace for health
insurance requires addressing adverse selection. Adverse selection
arises when insurance is most attractive to those persons most likely
to need it. If the premium is based on the population average and the
policy disproportionately attracts those who spend more than the
average, the policy will lose money for the insurer. The policy will
then either increase in price or not last in the market. In the
extreme, some consumers do not purchase insurance because the only
policy available to them is priced for the most expensive consumers.

The problems can be most severe in insurance markets involving small
firms and individuals without access to group coverage, because large
risk pools mitigate many of the forces that can lead to adverse
selection. (However, adverse selection can arise in broad risk pools
when competing health plan choices are made available.) To varying
degrees, States can minimize adverse selection by permitting providers
in the market for individual insurance to rate each individual on the
basis of his
or her medical risk and past health care expenditure. As
a consequence, individuals with chronic illnesses have to pay higher
premiums, be denied coverage altogether, or be denied coverage for the
condition which is making them ill.

To reduce the extent to which high-risk individuals face higher
premiums and to improve the availability of certain health insurance
benefits, States have imposed a range of restrictions on insurance
underwriting practices as well as coverage mandates on nongroup (and in
many cases on group) health insurance plans. These regulations generally
include guaranteed issue laws that require insurers to issue insurance
to any eligible applicant without regard to current health status or other
factors, and community rating laws that prohibit insurers from varying
premium rates based on health status and restrict the amount by which
insurers are allowed to vary rates based on characteristics such as age
or gender. Although these regulations tend to reduce insurance premiums
for high-risk individuals, they also increase premiums for lower risk
individuals. Those premium increases can have the unintended consequence
of encouraging people to wait until they have a health problem before
enrolling. If such adverse selection reduces participation of healthier
people, premiums will increase and the voluntary insurance market may
cease to operate effectively. The result may be less insurance coverage
and only limited premium reductions for those who are chronically ill,
as those who are healthier choose to forgo coverage entirely rather than
pay higher premiums.

The approach of the Administration is one that encourages lower
premiums particularly in the individual and small group markets, where
adverse selection poses the greatest challenges for competitive
insurance markets. The Administration supports a national market for
health insurance rather than State-specific markets. This would
effectively make insurance available to individuals and small groups
under conditi
ons that resemble those now available to employees of many
large corporations, which, by self-insuring, are exempt from State
insurance regulations and instead operate under the Federal insurance law
provisions of the Employee Retirement and Income Security Act (ERISA).
Health insurance policies with lower premiums would be more readily
available because health insurance policies would not be subject to
costly State mandates and regulations. The Administration also supports
Association Health Plans-plans that allow small groups to band together
to purchase insurance subject to Federal rather than State regulations-
because they would reduce adverse selection problems encountered by
small employers, achieve economies of scale in negotiating lower rates
with participating insurers, and allow for greater participation in a
competitive choice system of health insurance plans.


Improving Quality and Costs Through Information
and Reimbursement

Because of the complexities of medicine, patients must often rely on
experts to determine their diagnosis and select treatments. If the
incentives for the expert are different from those that would produce
the greatest benefit for the patient, however, the services delivered
by the expert may not always be of the greatest benefit to the
patient. For example, doctors may have incentives to overstate the
value of expensive tests, and most patients lack the expertise to
assess these claims.

Physicians determine needed services for patients. Because these
decisions are in part subjective, diagnoses and treatments often
differ across physicians, sometimes in ways that are not in the
patient's or society's best interest. For example, the frequency of
spinal surgery is almost eight times higher in some parts of the
United States than in others, even though the percentage of people
who have back problems does not vary widely between regions. These
types of geographic variations in quantity of care exist across a
wide range of treatments, yet few differenc
es in outcomes can be
detected. Overuse of health care services is one problem, and underuse
is another. A classic study evaluated the rate at which clinicians
followed processes of care widely recommended through national
guidelines and the medical literature. When averaged across all phases
of care for the most common or lethal conditions, it was determined that
nearly half of patients who met conditions for effective clinical care
failed to receive appropriate care.

There is great potential to improve quality and/or reduce costs
through reforms that improve information on quality and costs, and
align provider payments so that providers are rewarded for the health
outcomes of the patients rather than just for the services they perform.

Information on Effectiveness

One of the key impediments to more effective health care delivery is a
lack of relevant information-for patients, providers, and payers-on the
comparative effectiveness and efficiency of health care options. Such
information would be particularly useful for services that are in common
practice, generate high costs, employ rapidly changing technologies for
which multiple alternative therapies exist, and are in areas with
substantial uncertainty. The wide geographic variations in the use of
procedures suggest that better information on the effectiveness of
different styles of medical practice could result in substantial cost
savings.

Health Information Technology

Health information technology (health IT) allows comprehensive
management of medical information and the secure exchange of medical
information between health care consumers and providers. Broad use of
health IT has the potential to help dramatically transform the
delivery of health care, making it safer, more effective, and more
efficient. While a number of large health care organizations have
realized some of these gains through the implementation of
multifunctional, interoperable health IT systems, to date, experimental
evidence supporting the broad benefi
ts from health IT is more limited.
The Administration supports broad adoption of health IT as a normal
cost of doing business, including policies that will encourage
physicians and others to adopt electronic health records and through
furthering technologies for safe, secure health information exchange.

Value-based Purchasing

Pay for performance or value-based purchasing is a payment model that
encourages health care providers to meet certain performance measures
for quality and efficiency. A recent example is eliminating payments
for negative consequences of care. The Centers for Medicare and
Medicaid Services (CMS) implemented a provision of the Deficit Reduction
Act of 2005, which prevents Medicare from giving hospitals higher
payment for the additional costs of treating certain "hospital-acquired
conditions"-conditions that result from medical errors or improper care
and that can reasonably be expected to be averted. Now big insurers are
following Medicare's lead and are moving to ban payments for care
resulting from grave mistakes. These changes remove a perverse incentive
for hospitals: improving patient safety could reduce revenues and
profits. As a result, these reforms should trigger safety improvements
and enhance the efficiency of the health care system.

Transparency of Price and Quality Information

Transparency of information on price and quality has been a priority
of this Administration. Medicare has provided incentives to providers to
submit performance information to CMS and many of these performance
measures have been made available on the CMS website so that consumers
can compare the quality of providers as they seek care. The
administrators and sponsors of Medicare and other Federal health
insurance programs have been directed to share with beneficiaries
information about prices paid to health care providers and the quality
of the services they deliver. The commitment is to transform Medicare
by always seeking to improve the connection between expenditures and
positive health outcomes without increasing Medicare spending.


Promoting Healthy Behavior

Encouraging healthy behaviors, such as exercising more, eating
better, controlling weight gain, and quitting smoking, may be a cost-
effective alternative to increased spending on health care. One way
to encourage healthy behavior is through health education. For example,
much of the beneficial effect of prenatal care is simply related to
education about healthy behavior while pregnant. A better understanding
of the risks of high cholesterol and blood pressure (and how to reduce
those risks through healthy behavior) is credited with being a very
highly efficient way to improve health outcomes. Administration
policies that aim to increase consumer sensitivity to health care costs
have a positive indirect consequence in that they may induce an increase
in healthy behaviors.


Conclusion


The health care system in the United States has helped improve the
health and well-being of Americans. As health care costs continue to
rise, enormous opportunities exist to increase the value of health care
and improve health insurance coverage. Addressing these fundamental
problems and fulfilling the potential of our health care system will
require innovative polices to help Americans get the care that best
meets their needs, and to create an environment that rewards high-
quality, efficient care. While Federally sponsored health insurance
for the most vulnerable Americans through Medicare, Medicaid, and
SCHIP remains a priority, private markets offer the best opportunities
for controlling costs and providing innovative policies to enhance
efficiency, quality, and access. Efficiency of health spending would
be improved if tax code reforms were enacted. Reforms could level the
playing field between employer-provided and individual health
insurance, thus boosting insurance coverage. At the same time, reforms
could reward consumers for purchases of higher deductible plans with
re
asonable copayments that provide insurance for costly medical
necessities, but do not encourage unwarranted procedures. By addressing
concerns of adverse selection, insurance markets can become more
competitive, thereby promoting innovation, choice, access, and
efficiency. Finally, health care quality can be addressed by improving
the transparency of health care information and by tying reimbursement
to the performance of providers.