Thursday, January 5, 2012

Aligning incentives

Economist rock star Brad DeLong writes here about how healthcare companies essentially waste tons of money in the provision of healthcare services, all in the name of "free market efficiencies". Those familiar with the healthcare debate probably already know that approximately 25% of all healthcare costs are administrative - that billions of dollars are wasted in the U.S. healthcare system filing paperwork, contesting coverage, and shuffling responsibilities between different providers and insurance companies. DeLong doesn't offer a lot of new information, though he does cite some important data provided by Blue Cross. Instead, his more substantiative contribution is the insight that vast healthcare spending on adminstrative costs is the theoretical equivalent of lighting money on fire, at least as far as healthcare provision is concerned.

Now God knows I've made my fair share of poor political prognostications. And I will continue to do so! One such prediction, which I even went as far as to lecture my students on several years ago, was that I believed we would have universal healthcare in this country within 10 years because, ultimately, the Walmarts, and the Best Buys, and the Verizons, would realize that they are wasting billions in the healthcare provision business when they could cut their costs substantially, and increase profits radically, if the government took over these responsibilities. Why should Ford be in the healthcare provision business? Why should Exxon? Why should they need to employ an army of human resource employees to navigate our byzantine healthcare insurance system? But companies have not aligned themselves in battle to reform U.S. healthcare, for reasons, to be honest, I still don't fully understand. And given the last healthcare battle, which only marginally expanded healthcare access in this country and in no way whatsoever introduced a "socialization" of healthcare [I suspect 90-95% of both public citizens and elected officials could not accurately define "socialization"], they seem very unlikely to do so. So I seemed destined to blow yet another prediction. Again, I could not say why. I have no idea why doctors oppose healthcare reform - do they really enjoy the administrative headaches associated with filing insurance claims? Do they enjoy paying the extra salaries needed to file all of this paperwork? And what about the larger corporations - those Walmarts and Verizons I mentioned previously? How come they are not on the reform bandwagon? It is to my bewilderment that the Chamber of Commerce opposes federal government reform that would improve the bottom lines of 90% of their member organizations, but there you have it.

DeLong links to an article in the Washington Post which breaks down how our healthcare dollars are spent.  He finds:
The thing to focus on is the $0.13 of every dollar that Blue Shield spends on "administrative costs"--i.e., trying to make sure that they don't pay for sick people.
To which I would add - well, how do we convince the insurance companies themselves that there is real money to be saved and presumably (har, har) passed on to the rest of us by reducing these administrative costs? I mean, why does Blue Cross BlueShield want to spend $0.13 of every dollar on administrative costs? Why does Wellpoint? Clearly there is money to be saved here! Clearly there are opportunities for efficiencies! There is no money to be profited when Unitedhealth tells the Kaiser Foundation, who tells Aetna, who tells the doctors, who tells the pharmacist, who tells the pharmaceutical companies, who tells the X-ray technician, what will be covered and who will be covering it - these inefficiencies are deadweight losses! Isn't there some kind of political agreement to be forged whereby the government and the insurance companies agree to find ways to substantially reduce those 13 cents? Even if only 2 cents goes back to the consumer, and 8 cents goes back to the insurance companies, isn't that a win for all of us. Why can't we bring these groups together? Our interests would appear to be aligned.

I think I know the answers to some of these questions. 1) I think insurance companies (perhaps rightly) suspect that any government sponsored healthcare reform is really a ploy to begin the process of nationalized healthcare provision. This suspicion is probably not too crazy, but the healthcare industry has proven itself powerful enough in the past to grab subsidies and tax credits for themselves without losing too much political and regulatory control. 2) I think this is an ideology question. The Chamber of Commerce in particular has proven itself to be a greater slave to ideology rather than the bottom line. Because if it cared about the bottom line, it would support Democratic candidates. As I've posted previously, and Larry Bartels has demonstrated in "Unequal Democracy", the economy always does better under Democratic administrations, for rich and poor alike. 3) The "masters of the universe", perhaps blinded by ideology, really don't know what's best for themselves. Again, this is perhaps a function of ideology, but CEOs, bankers and Chicago-based economists almost seem to presume that the status quo is at its profit-maximizing optimization point, merely by virtue of being at that point.  Believing in a "perfect market", rational decision-making, and full information, our Randian overlords are not allowed to believe that markets can be inefficient. If Exxon could have made more money, Exxon believes they already would have made more money! The fact that they didn't make more money is evidence, ipso facto, that they are operating at full profitability. Clearly this is delusional thinking, but I don't think it's difficult to find individuals in high-ranking positions that act and believe this way.

I'm not sure how to overcome these barriers. I don't think, believe it or not, they are impossible. However, I do think it will take some kind of grand CEO to be elected president to grant the other financial and political elites the ideological space needed to overcome these biases. What I mean is that eventually we are going to need a "Nixon goes to China" moment. We will need to elect some unimpeachably brilliant CEO President (don't worry, it won't be Mitt Romney) who will come forward (Bloomberg maybe???) and say, "well of course, businesess can save a shitload of money if we reform healthcare. Of course the government and the taxpayers could save a lot of money if we blow up the current system!" Will this happen within my 10 year timeline? Er, probably not. Will it happen in my lifetime? Well, I'm still betting on that...

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