Category: Health Care

I had the opportunity to attend the recent New Mexico First event on health care. I was pleased to see so many concerned citizens take time out of their busy lives to get together and work out solutions to one of our state’s most pressing problems, but amazed at how complicated and convoluted the health care issue has become.

Much of the blame must be placed at the feet of Congress and the federal government that has created the misguided and bizarre incentives under which all states must operate. Health Savings Accounts, which give individuals greater control over their health care needs, were a necessary first step. But these somewhat complicated accounts would be unnecessary if Congress would heed President Bush’s call to offer to individuals the same tax incentives now given only to companies.

The fact that these tax incentives are given to employers is a historical anachronism that does nothing but place health insurance companies between health care consumers and their providers. Whereas socialized medicine and other “universal” models simply replace health care companies with government bureaucrats as our health care gatekeepers, giving individuals control over their health care dollars would restore that patient-doctor relationship. Unfortunately, corporate and union interests have teamed up to strangle this needed reform in the cradle.

Another change that Congress needs to make is to bring federalism to health care. One of the great strokes of genius made by the Founding Fathers, federalism forces states to compete with each other.

Unfortunately, in the area of health insurance, this concept has been lost as insurance companies have successfully walled off each state, thus protecting themselves from competition and subjecting consumers to costly mandates and regulations imposed by the individual states.

New Mexico, for example, has 45 mandates covering everything from alcoholism and acupuncture to TMJ Disorders. While such coverage may be nice to have, they add significantly to the cost of health insurance. The costs associated with New Mexico’s large number of mandates contribute to our having the second-highest rate of uninsured.

Legislation that would have allowed individuals to purchase insurance across state lines was proposed by Rep. John Shadegg, R-Ariz., and then-speaker Dennis Hastert, R-Ill., last year, but died. Absent congressional action, New Mexico can and should allow residents to purchase health insurance from out-of-state.

Any discussion of health care in New Mexico would be incomplete without an analysis of the perverse incentives created by Medicaid. Due in part to the generous federal subsidy the federal government gives New Mexico (a 3-1 match depending on the specific program), many of our elected leaders view Medicaid as a means of generating economic growth at the expense of taxpayers in other states.

This rationale was among the justifications for successful efforts to raise from $4,000 to $10,200, the earnings threshold for low-income adults under which they can still qualify for Medicaid. The change is expected to add an additional 18,000 adults to the program, costing the state “only” $11 million— and costing taxpayers in other states probably three times as much.

While the incentives are certainly there for New Mexico to expand Medicaid to the greatest extent possible, this is not going to lift the poor out of poverty or improve health care coverage. Instead, Gov. Bill Richardson and the Legislature should request that the federal government allow New Mexico to follow the successful welfare reform model developed in the 1990s by receiving its Medicaid money in the form of a block grant and developing unique, New Mexico-centric solutions to our health care mess.

Unfortunately, while each reform I have outlined above would simplify and restore some logic to the health care system we all know and despise, each faces strong opposition from certain entrenched interests. Nevertheless, there are sensible free-market solutions to our health care problems that will expand coverage dramatically while also enhancing the patient-doctor relationship and cutting costs.

It may seem easier to throw up our hands and demand “universal coverage” with the government in charge, but government policies created many of these problems in the first place. We should hardly expect the government, the insurance companies, and other special interests to give up their power under a “socialized” scheme.

Paul Gessing is president of the Rio Grande Foundation, a non-partisan, tax-exempt research and educational organization dedicated to promoting prosperity for New Mexico based on principles of limited government, economic freedom and individual responsibility.

Although Sen. Domenici’s role in the ongoing flap over the fired U.S. Attorneys has garnered New Mexico’s senior senator a good deal of unwanted attention recently, another more substantive policy matter should be of greater concern to conservatives. Polls indicate that health care is one of the most important issues on voters’ minds. To this end, the concept of making health care more affordable is a mantra that has been adopted by politicians of both parties.

Domenici — working in conjunction with the usually conservative Mike Enzi (R.-Wyo.) and the reliably left-wing Ted Kennedy (D.-Mass.) — is now leading an effort that would ultimately drive up the costs of health insurance and may even inflict harm on the very people the senators are trying to help.

The legislation, which has already passed out of one Senate committee, is known as the “Mental Health Parity Act.”

While the desire to help those with mental illness is noble, the senators’ proposal will inevitably, if inadvertently, harm both the mentally ill and the uninsured.

This bill would require health insurance policies that provide coverage for mental illness provide it in the same way that they provide benefits for other conditions. Thus, if the co-pay to see a family doctor is $20, then the co-pay to see a psychiatrist must also be $20.

In a free market, the decision of how to cover mental health benefits is left to the insurer and the insured. A mandate to require that mental health coverage be given parity eliminates that freedom. Proponents of the mandate claim that it adds little to no extra cost to health insurance. They point to a study showing that there was no costs increase in mental health benefits when mental health parity was enacted in the Federal Employee Health Benefits (FEHB) program.

The reason costs didn’t increase is that the use of mental health benefits didn’t increase either. Most of the plans in the FEHB used managed care organizations to manage the mental health benefits, suggesting that use didn’t increase because the insurance programs restricted access to benefits.

Other research, which examines programs that didn’t restrict access, suggests that mental health parity is one of the most costly of benefit mandates. Using actuarial data, the Council for Affordable Health Insurance, an insurance industry group, estimates that it can add between five and ten percent to the cost of a health insurance policy.

More expensive health insurance means that means more businesses will increase their insurance premiums or drop their insurance altogether, resulting in an increase in the number of uninsured. Another route that businesses might pursue is simply dropping their mental illness coverage from their insurance policies, meaning that employees will have less access to mental health benefits.

A reading of the Mental Health Parity Act suggests that its supporters recognize that it will lead to higher costs. The bill tries to shield small businesses from rising health insurance costs by exempting any business with fewer than fifty employees. It also exempts any business whose health insurance costs rise more than 2% due to the mental health parity mandate.

Attempts to ask any of the three Senators what they thought about the cost of the bill proved fruitless. All three Senate offices responded to our calls, made over a two-week period, by saying the staff members who could address our questions were out of the office.

Thus far, only four benefit mandates exist at federal level.

Unfortunately, benefit mandates are extremely common among the states, as most states have dozens, mandating everything from hair prostheses to massage therapists.  New Mexico, for example, has 45 such mandates while Maryland has the most in the nation with 60 and Idaho has the least with only 14.

State level mandates have become such a problem that one of the most promising — albeit unsuccessful — efforts to reform health care in recent years was led by then-House Speaker Dennis Hastert (R-IL) and Rep. John Shadegg (R-AZ), both of whom wanted to change federal law to allow individuals to purchase insurance across state lines. This effort essentially would have forced insurance companies to compete across state lines.  That, in turn, would have pressured states to tailor their health care regulations in order to compete against each other.

Costs aside, what makes federal mental health parity legislation so troubling is that it could start a trend that shifts mandates from the state to the federal level, thus closing off a potential route to reform and future cost reductions. Instead of creating new mandates, Congress should be working to cut health care costs by allowing consumers to purchase health insurance — including mental health insurance — across state lines.

Mr. Gessing is the president of the Rio Grande Foundation, a non-partisan, tax-exempt research and educational organization dedicated to promoting prosperity for New Mexico based on principles of limited government, economic freedom and individual responsibility.

Mr. Hogberg, formerly with Capital Research Center, is a senior policy analyst at the National Center for Public Policy Research.

Outside of the Iraq War, the debate over health care reform is one of the most contentious issues in politics today. With ongoing debate in Washington and a flurry of activity in the states, the need to make health care more affordable is a mantra being adopted by politicians of both parties.

Unfortunately, despite the high-minded rhetoric, political intervention more often results in higher medical costs. One of New Mexico’s own senators, Republican Senator Pete Domenici – in conjunction with Senators Mike Enzi (R-WY) and Ted Kennedy (D-MA) – is now leading an effort that would ultimately drive up the costs of health insurance and may even inflict harm on the very people the Senators are trying to help.

The legislation, which has already passed out of one Senate committee, is known as the “Mental Health Parity Act.”

Although, Domenici’s desire to help those with mental illness is noble, it has led him to support a proposal that inevitably, if inadvertently, will harm both the mentally ill and the uninsured.

This bill would require that health insurance policies that provide coverage for mental illness must provide it in the same way that they provide benefits for other conditions. Thus, if the co-pay to see a family doctor is $20, then the co-pay to see a psychiatrist must also be $20.

In a free market, the decision of how to cover mental health benefits is left to the insurer and the insured. A mandate to require that mental health coverage be given parity eliminates that freedom.  Furthermore, mental health parity is one of the most costly of benefit mandates. Using actuarial data, the Council for Affordable Health Insurance, an insurance industry group, estimates that it can add between five and ten percent to the cost of a health insurance policy.

Few of the likely consequences of imposing a mental health parity mandate are good for employees. Forcing insurance programs to cover mental health the same way they cover physical illnesses and conditions will result in more expensive health insurance. That means more businesses will increase their insurance premiums or drop their insurance altogether, resulting in an increase in the number of uninsured. Another route that businesses might pursue is simply dropping their mental illness coverage from their insurance policies, meaning that employees will have less access to mental health benefits.

A reading of the Mental Health Parity Act suggests that Domenici recognizes that it will lead to higher costs. The bill tries to shield small businesses from rising health insurance costs by exempting any business with fewer than fifty employees. It also exempts any business whose health insurance costs rise more than 2% due to the mental health parity mandate.

Attempts to ask any of the three Senators what they thought about the cost of the bill proved fruitless. All three Senate offices responded to our calls, made over a two-week period, by saying the staff members who could address our questions were out of the office.

Thus far, only four benefit mandates exist at federal level. Unfortunately, benefit mandates are extremely common among the states, as most states have dozens, mandating everything from hair prostheses to massage therapists.  New Mexico, for example, has 45 such mandates.

Health care mandates at the state level have become such a problem that one of the most promising – albeit unsuccessful – efforts to reform health care in recent years was led by then-House Speaker Dennis Hastert (R-IL) and Rep. John Shadegg (R-AZ), both of whom wanted to change federal law to allow individuals to purchase insurance across state lines. This effort essentially would have forced insurance companies to compete across state lines.  That, in turn, would have pressured states to tailor their health care regulations in order to compete against each other.

Aside from the inherent cost, what makes federal mental health parity legislation so troubling is that it could start a trend that shifts mandates from the state to the federal level, thus closing off a potential route to reform and future cost reductions. Instead of raising costs by creating new mandates, Domenici, Enzi, and Kennedy and others should be working to cut health care costs by allowing consumers to purchase health insurance –including mental health insurance – across state lines.

Paul Gessing is the president of the Rio Grande Foundation, a non-partisan, tax-exempt research and educational organization dedicated to promoting prosperity for New Mexico based on principles of limited government, economic freedom and individual responsibility.

David Hogberg is a Senior Policy Analyst for the National Center for Public Policy Research, a communications and research foundation supportive of a strong national defense and dedicated to providing free market solutions to today’s public policy problems.

Editor’s note: The following article appeared in the October, 2006 edition of Health Care News which is published by the Heartland Institute www.heartland.org. The publication is distributed to state legislators and policymakers in all 50 states.

In a clear sign that health care and the uninsured remain hot-button issues on which many politicians intend to be proactive, New Mexico Gov. Bill Richardson (D) on July 20 proposed significant changes to the state’s Medicaid system.

Depending on the findings of the commission he appointed to explore universal insurance coverage options, expected next year, New Mexico may embark on a scheme to provide universal health care by 2008.

“Uninsured New Mexicans are a tremendous risk, and the effect of uncompensated care on our health care system is profound,” Richardson told the Santa Fe New Mexican on July 21. “We can’t wait for the federal government to solve this issue.”
Master Plan

In addition to appointing the task force, Richardson’s proposal included four other major elements:

• Phasing in a requirement for companies doing business with the state to begin offering health insurance benefits to their New Mexico employees if they do not do so already.
• Determining the number of state government employees who lack health coverage. Currently, if an employee declines enrollment, the state doesn’t check to see if he or she has coverage through a spouse or other entity. This full accounting will help create an accurate picture of coverage gaps and help the state target outreach efforts to get as many state government employees covered as possible, the governor said.
• “Maximizing” Medicaid coverage. For fiscal year 2008, Richardson will seek funding to increase coverage for adults through a two-year, phased-in approach. The initiative will be specifically designed to help low-income adults earning up to 100 percent of the federal poverty level. “Medicaid currently covers only adults with children whose incomes are below 30 percent of the poverty level, or $4,700 per year for a family of three,” explained Pam Hyde, secretary of the state Department of Human Services. “Covering all adults to 100 percent of the poverty level, or $16,600 a year for an equivalent family, would bring another 42,000 people under Medicaid coverage. Phased in over two years, the program would cost $1,500 per person per year.”
• Expanding the State Coverage Insurance program to help more working adults and asking the federal government to raise the federal poverty requirement to 300 percent with cost-sharing based on income. Expanding this public/private partnership with small employers will help cover working New Mexicans who currently cannot afford insurance, Richardson said. Currently serving 5,000 adults with incomes up to twice the poverty level, the program would be expanded to three times the poverty level, described as a family of three with an income of $49,800.

Federal Largesse

According to the Kaiser Family Foundation, 22 percent of New Mexicans lack health care coverage–more than any other state but Texas.

If enacted in its entirety in the upcoming legislative session, Richardson’s plan is expected to insure 59,000 New Mexicans–approximately 15 percent of the population currently lacking health insurance. It would cost the state $77 million a year while significantly raising the amount New Mexico receives for Medicaid from the federal government.

“The plan is affordable, because it would leverage $250 million in additional federal Medicaid funds,” New Mexico House Speaker Ben Luján (D-Nambé) told the Santa Fe New Mexican on July 21. New Mexico currently receives nearly $3 from the federal government for every $1 it spends on Medicaid from state funds.
Split Opinion

Reaction to Richardson’s proposal among public policymakers and opinion leaders was split along ideological lines.

Sharon Kayne, communications director for New Mexico Voices for Children, a self-described progressive, nonpartisan organization, welcomed the plan, saying, “We are pleased that the five-point plan revealed today includes an expansion of Medicaid, which plays an important role in lowering health care costs for everyone.”

But Michael Cannon, director of health policy studies at the libertarian Cato Institute in Washington, DC, said the governor’s plan will “increase taxes, pull more New Mexicans down into poverty, and increase the cost of private health care and coverage.”

Cannon said Richardson should instead make “these programs less burdensome by recovering Medicaid costs from the estates of well-to-do seniors” and make health care more affordable and convenient by deregulating nurse practitioners and other providers. Cannon also suggested the state lower the cost of private health insurance “by letting New Mexico residents and employers purchase coverage from out of state.”

Some 15 percent of all Americans are without any medical insurance, but the uninsured are not left in the streets to bleed from a car crash, nor are they denied a heart surgery if needed. Emergency rooms must treat anyone regardless of ability to pay. Taxpayers and people who are insured subsidize those medical services.

Some, including myself, believe that while the state should leave medical care to the free market, it should worry about the minority of the genuinely poor (and chronically ill, etc.). For others, forcing employers to insure the uninsured is the inauguration of a road toward a government-run health care system a la Canada.

Massachusetts recently made a big splash by enacting a law forcing all its residents to buy health coverage. Gov. Bill Richardson, who is campaigning in the national arena, wants “every New Mexican insured by 2008, 2009.”

Let’s compare New Mexico with Massachusetts and see if, instead of mimicking Gov. Mitt Romney’s plan, we can do better by modifying New Mexico’s new health initiatives. But first note: According to the Statistical Abstract of the United States, in 2003 average personal income per capita in New Mexico was fourth from the bottom with $24,995; Massachusetts was fourth from the top with $39,504.

According to the U.S. Census Bureau (average 2002-2004) New Mexico was the state with the second highest rate for uninsured residents, 21.8 percent. Massachusetts with 11.2 percent uninsured was the 13th from the bottom.

In April, Romney grabbed national headlines when he persuaded the Massachusetts legislature to pass a universal-health plan characterized as “market friendly.” It isn’t, nor is it fiscally wise. It penalizes employers to the tune of $295 per year per uninsured employee— a crude interference in the marketplace; it offers the needy state-subsidized health insurance policy with a zero deductible that insulates the insured from the true cost of medical care and, consequently, it costs taxpayers a fortune.

So, can poor New Mexico, with one of the highest rates of uninsured, do better than rich Massachusetts with a relatively low rate of uninsured?

Medicaid in New Mexico, with a budget of $2.59 billion (about 72 percent federal) in state fiscal year 2006, is very generous to poor children, including medically fragile children, the disabled, the aged who require institutional care and a variety of other needy persons, such as the blind.

New Mexico is currently in the process of implementing the State Coverage Insurance (SCI) plan, which involves businesses that employ 50 or fewer: The employer pays $75 per month per employee. The employee pays $0-$35 per month along a sliding scale. The state and federal government through Medicaid cover the remainder, estimated at $260 per month.

SCI is offered only to adults 19 through 64 years of age, who earn no more than 200 percent of the federal poverty guidelines. As an illustration, 200 percent of the poverty level for a single mother with two children is currently $33,204 per annum.

The SCI’s paramount advantage over the Massachusetts plan is that it is not mandatory: An employer can take it or leave it without paying any penalty. But it is flawed as follows:

• It targets only a subgroup of needy employees who happened to work for small companies.
• SCI fails to accept the premise that in a competitive labor markets, particularly where small employers are present, there is a dollar-for-dollar trade-off between wages and health benefits. A genuinely poor employee who pays no income taxes would hate to trade off $75 per month of reduced wages for health insurance knowing that he can gain admittance to hospitals through emergency rooms.
• SCI offers the poor employee insurance with a $0, $5 or $7 co-payment, depending on income, for a physician/provider office visit. But the SCI has no deductibles. Even the needy should not be completely insulated from health-care costs in the real world. Moreover, the lack of deductibles results in a huge monthly premium of $355 ($20 75 260), or $4,260 per adult per annum.

Gov. Richardson wants to outdo Gov. Romney. But, to innovate and do better than Massachusetts, New Mexico should target all genuinely poor adults with income less than 200 percent of the poverty level, instead of focusing on small employers and raising the poverty threshold to a fiscally irresponsible level of 300 percent of the poverty level.

The requirement that employers pay $75 per month per employee should be rescinded. The no-deductible policy is bad. The health care policy for the poor should offer a deductible that increases with income along a sliding scale.

The state should leave small employers alone: They are neither poor nor little children and they can figure out for themselves how to band together to form insurance pools.

Finally, those who argue that the cost of expanding medical care to the uninsured non-poor balances out the cost of funding uncompensated care for providers are wrong: “Free care” is negligible for the uninsured with incomes greater than 200 percent of the poverty level.

The Land of Enchantment can do better than the Bay State by focusing on the genuinely poor, not the uninsured.

Micha Gisser is professor emeritus of economics and senior fellow at the Rio Grande Foundation, a research and educational organization dedicated to promoting prosperity for New Mexico based on principles of limited government, economic freedom and individual responsibility.

On Friday, December 8, the Rio Grande Foundation invited Michael Cannon, Director of Health Policy Studies at the Cato Institute to discuss several important issues in health care. At the event, Cannon presented his ideas on necessary changes to New Mexico’s health care system, specifically targeting Medicaid reform.

Click here to download the presentation in Adobe PDF format.

 

Those who advocate the nationalization of the American health-care system often cite the trend of rising national health expenditures as percentage of gross domestic product. From 1960 to 2000, health care’s share of GDP in the United States increased from 5.3 percent to 13.2 percent. Rising personal income, higher quality care and insurance that insulates individuals from health care’s real costs are the main factors behind this trend. From 1960 to 2000 real GDP per capita, has increased from $13,155 to $32,670 (expressed in 1996 prices). During the same period, real GDP per capita devoted to non-medical services increased from $12,458 to $28,3588. Put differently, the so-called explosion in medical-care expenditures reduced the average annual rate of growth of real GDP per capita devoted to non-medical goods from a potential 2.30 percent to 2.08 percent.

American consumers are wealthier than ever: The more than doubling over four decades of real GDP per capita excluding medical expenditures is reflected in real consumption. The “explosion” in medical-care expenditures ate a bite of our salad, but hardly the whole lunch. And for that increase in health spending, we receive better high-tech care that was not available at any price in 1960.

In that light, the present looks pretty good. The future looks even better, mainly due to the surge of American productivity and the Health Savings Account Act that President Bush signed into law in 2003.

Traditional medical insurance covers two dissimilar events: minor ailments and catastrophic illnesses. If a consumer faces a 5 percent probability that she will contact a catastrophic illness in a given year requiring $20,000 of medical care, she would be willing to purchase a policy for $1,000 (plus transaction costs). She will not use more of the heart-surgeon’s services just because her out of pocket spending is zero.

This consumer also faces some probability of suffering the run-of-the-mill headaches, sniffles, backaches etc. Assume that she would be willing to purchase a policy for additional $1,000 for sniffles, etc. Under the tax law she is allowed to exclude $2,000 from her taxable income. Her demand for care for minor illnesses is inversely related to price: At the true high price she would consult the medical encyclopedia and use over-the-counter drugs. At a low price- zero if her insurance pays the entire cost- she would consume much more care.

The problem with the prevailing medical insurance is that the third-party payment of health care bills insulates the consumer from the real costs of medical care services for non-catastrophic illnesses.

The new Health Savings Account law basically allows the consumer in our example to set aside $1,000 in an HSA that is tax exempt, and can be used for sniffles and headaches at her discretion. If this year she spent only $300, she can use the remaining $700 for next year’s sniffles, or save it for retirement.

HSAs thus eliminate “moral hazard” by separating catastrophic from minor illnesses and injuries. Additionally, it is designed to enhance competition by eliminating managed-care-third-party restrictions. It is also likely that availability of HSAs would induce many of the uninsured to insure.

Furthermore, under the HSA law, it behooves our individual to convert a high-cost-$2,000 premium, low-deductible policy into a low-cost-$1,000 premium, high-deductible policy. Before the HSA option was enacted, such a transition would have resulted in a loss; turning the $1,000 premium saving into taxable income would have resulted in a loss of roughly 40 percent (income and payroll taxes.) But now, the individual can use the sum of $1,000 to fund a health savings account, and the contribution to this account will be fully deductible, whether she itemizes deductions or not.

Because of the contribution of the new HSA law to competition and efficiency, the next four decades look even brighter than the previous four.

There are two additional legislative modifications that should be initiated at the federal level in order to further reduce the future costs of medical care:

• Congress should change the Medicaid formula for matching state funds to making block grants. With block grants, states will have stronger political incentives to distribute Medicaid money more efficiently.
• In July 2003, the U.S. Senate could not muster the 60 votes needed to pass the medical liability reform to cap medical malpractice damage awards. They should try again, because such a reform would go a long way to reduce the cost of physicians’ services all over the United States.

The New Mexico Legislature removed the gross-receipts tax on payments to physicians from commercial managed care companies. But, the gross-receipts tax will continue to be imposed on the kind of out-of-pocket medical expenditures that would be made from health savings accounts. The 2005 Legislature should remove that vestigial gross receipts tax, an act that will make HSAs more attractive to consumers and help attract more physicians to New Mexico.