You may have heard that the U.S. is about to plummet off of a fiscal cliff. Policymakers may disagree about how to bring the nation's finances into balance, but one thing they don't disagree about are the forces pushing us towards the abyss: in a word, runaway health care spending.
As former Obama OMB and CBO director Peter Orszag quipped in 2010, "it is no exaggeration to say that the United States' standing in the world depends on its success in constraining this health care cost explosion; unless it does, the country will eventually face a severe fiscal crisis of crippling inability to invest in other areas."

What is true at the federal level is also true at the state level. State Medicaid expenditures account for almost a quarter of state budgets today, second only to education funding. Medicaid expenditures are also projected to rise faster than state revenues, increasingly crowding out funding for other critical state priorities. Addressing the shortfall may require sharp tax increases, painful budget cuts, or both.
You'll also get little opposition from either side of the aisle that America isn't getting the best value for our outsized health care spending, currently at 18% percent of GDP and rising. According to a 2011 article in JAMA, "in just 6 categories of waste, over treatment, failure of care coordination, failures of execution of care processes, administrative complexity, pricing failures, and fraud and abuse, the sum of the lowest available estimates exceeds 20% of total health care expenditures." The same report estimated annual loses from fraud and abuse in Medicare and Medicaid at up to $98 billion annually.
There are two basic arguments about how to tackle the problem of rising costs, and they split largely (but not entirely) on ideological lines.
One, approach, generally favored on the left (and largely embraced in the Affordable Care Act), is to attack the problem on the supply side by increasing government's role in setting prices and defining insurance packages, along with driving delivery system reforms. Supply side reforms include bundled payments for Medicare and Medicaid; Medicare's new Independent Payment Advisory Board (IPAB); price controls on reimbursements for health care goods and services (Medicare's DRG pricing system; ACA cuts to provider reimbursements); stringent rate reviews for insurance carriers; and even heavier-handed market controls like bans on physician-owned hospitals, and requiring state pre-approval for new health care related facilities through certificate of need laws.
The other approach, generally favored on the right, is to focus on improving the functioning of health care markets on the demand side. This means increasing consumers' "skin in the game" for routine health care costs through consumer-directed health plans (CDHPs) and Health Savings Accounts (HSAs); capping or eliminating the tax exclusion of employer-provided insurance and replacing it with a standard deduction or tax credit for health insurance; and shifting other public programs, like Medicare, towards a defined contribution approach where seniors would shop from a competing menu of health care plans with a defined level of public support. Proponents of more consumer involvement in health care also support efforts to improve transparency on provider prices and quality, so that consumers can seek out the most effective and efficient providers (or in the case of insurance, the most efficient networks).
Whatever you may think about the Affordable Care Act, our recent election guaranteed that it is going to be implemented, more or less. The choice before the country now is how that implementation will be structured, and how to make that implementation sustainable given the massive cost explosion that the ACA - whatever its other merits - has done little to address. As we've argued elsewhere, many of its key provisions will likely make the health care cost problem worse, because it heavily subsidizes consumption of traditional, first-dollar insurance for families making up to about $92,000 a year, or four times the Federal Poverty Level.
But implementation, and America's mounting fiscal woes, also provides an opportunity for genuine dialogue and compromise. We're beginning to detect a growing acknowledgement on the
center-left that more consumer side reforms are needed and inevitable, particularly in the ACA and, on the right, that
mitigating the ACA's worst flaws could turn out to be both
good policy and good politics - especially for an electorate that is increasingly frustrated by Washington's inability to tackle America's most serious challenges.
That conversation should be helped by a thoughtful and balanced paper from Richard P. Nathan, a senior fellow at the Rockefeller Ins ute in New York. The paper,
How to Rein in Health Care Costs: Empower Consumers, is a concise tour de force in health economics and public choice theory that makes the case for incorporating more consumer-driven insurance choices into both public and private insurance programs, including the ACA.
First, Nathan recognizes that we'll need "at least one more round" of health care reform to truly tackle the cost problem.
Taken together, Medicare and Medicaid account for 25 percent of federal spending; they are projected to account for one-third in 2021. Medicaid also accounts for a huge and growing share of state budgets, and in some states local budgets as well. Focusing on Medicare, Jonathan Gruber estimates that in order
"to put the program on a solid footing for the foreseeable future would require imposing a 15 percent payroll tax. Every person in America would have to pay 15 percent of their wages to the government, basically doubling the tax burden on American families. ...
An analysis by Eugene Steuerle of the Urban Ins ute shows the share that Medicare taxes and premiums cover "of the care provided to the average recipient ranges from 51 to 58 percent over time." Steuerle says "[for] the rest we borrow from China and elsewhere, and we use up ever-larger shares of income tax revenue, leaving ever-smaller shares for the government functions. Bottom line: without reform, current workers would continue to shunt many of their Medicare costs onto younger generations."
Nathan is right on the mark. And to paraphrase Stein's law, if something can't keep going on forever, it won't.
While broadly supportive of the ACA, Nathan is skeptical that supply side reforms can adequately grapple with the endemic cost problems in American health care:
Provider-value social engineering shouldn't be the main line strategy for dealing with the fiscal imperative of fast-rising health care costs. Politicians are good at giving social benefits but not so good at taking them away. Likewise, leaders in government public health care programs tend to come to their jobs with a concern about and belief in the programs they are responsible for. Government
does not have the necessary penetration -- nor the leverage commitment, or clout needed-- to reform the huge health care industry.
This is a variation on Mancur Olson's famous theory of collective action. In a nuts , it's very hard for large groups of individuals to organize for broad social aims - even when that organization would produce large gains for society. On the other hand, small, highly motivated special interest groups have powerful incentives to organize and lobby government for wealth transfers. In the case of health care, this means that providers (hospitals, nursing homes, physicians, home health care workers, etc.), consumer groups (like the AARP), and public sector unions (like the SEIU) are well positioned to push for increases in health care spending, with politicians reaping the rewards from campaign contributions and energized voting blocks.
Although Democrats are more associated with the welfare state, both parties have facilitated the expansion of public funding for the medical-industrial complex from a mechanism to help the poor and disabled to get access to care, to an en lement program for the middle class and older (and more affluent) consumers. Republicans, after all, created the Part D Medicare drug benefit, and Republican governors, like George Pataki, in New York, have worked hard to leverage federal dollars to support local state Medicaid
providers.
Unsurpringly, when it comes to meaningful reforms of Medicare and Mediciad, the track record of the federal government has been mostly disappointing. (And when it comes to weeding out fraud and abuse in those programs, the record is downright
disgraceful.)
While supply side reforms are necessary, Nathan believes, "in the long run creating and managing compe ion in the health care marketplace is the better approach for achieving health care cost control by mobilizing price-consciousness in a way that at the same time protects consumers from having to pay the high costs of catastrophic care."