Public plan advocates, read this...

According to the Heritage Foundation's Robert A. Book, it's a myth that Medicare controls costs better than private insurers. The slower growth in Medicare spending is due mainly Medicare shifting more costs onto patients and their other insurance sources:

Medicare's share of total spending on health care services for non-institutionalized Medicare enrollees fell from 72.2 percent in 1997 to 50.8 percent in 2005.[27] The remaining 49.2 percent was covered by a combination of private insurance, including employer-sponsored insurance (for employees and retirees) and individually purchased Medigap plans (21.4 percent); beneficiaries' out-of-pocket spending (15.7 percent); and other public plans, including TRICARE, Veterans Health Administration, and Medicaid (12.0 percent). Total spending per capita in 2005 was $12,157, including $6,180 paid by Medicare and $2,603 paid by private insurance.[28]

Over time, Medicare's share of health care spending for Medicare beneficiaries has fallen, while private insurance's share has risen. In 1997, Medicare's share was 72.2 percent, and the private-insurance share was 12.2 percent. Total spending per capita in 1997 was $5,438, including $3,925 from Medicare and $662 from private insurance.[29]

While total per-capita health care spending for Medicare enrollees increased by 124 percent from 1997 to 2005 (an average of 10.6 percent per year), spending by the Medicare program increased by only 57.5 percent (5.8 percent per year). Meanwhile, private insurance spending on Medicare beneficiaries increased by 294 percent (18.7 percent per year), and out-of-pocket spending by Medicare beneficiaries increased by 205 percent (15.0 percent per year).

Book also claims that Medicare does not have lower administrative costs than private plans, that it does not use superior bargaining power to reduce costs, and that it is not more innovative than the private sector.

Book takes on Jacob Hacker and Paul Krugman, amongst others. I'd be interested to see a detailed rebuttal.

Hacker urges Obama to shift risk back

Jacob S. Hacker, the economist who best described the erosion of economic security for the middle class over the past thirty years in The Great Risk Shift, makes a tightly argued case that an all-out push toward universal health insurance is at once the best short-term stimulus and the best long-term investment Obama can make right now.

First, the short-term argument: Hacker lays out the extent to which out-of-pocket healthcare costs are eating into the income of the middle class as well as the poor, the underinsured as well as the uninsured:

Today, however, the health care deduction is big and getting bigger. Despite widespread complaints about "overinsurance," the amount people pay for health care out of their own pocket has risen substantially as a share of personal income over the last generation, and especially in the last decade. The Commonwealth Fund recently completed two massive surveys showing that the proportion of adults younger than 65 with health insurance who spent more than 10 percent of their income on health care out of pocket (5 percent for low-income adults) skyrocketed from 13.8 million in 2003 to 21.8 million in 2007, as health plans hiked deductibles and co-payments, denied claims more aggressively, jacked up costs for out-of-network care, and so on. What's more, almost all of the increase occurred among families with higher incomes--meaning that high health care costs have become a standard deduction for the middle class.

The problem is, of course, far worse for those who lack health insurance. Indeed, if you add the ranks of the uninsured to those without adequate coverage, you have more than 40 percent of the working-age population in an immediate economic bind because of medical costs. About half these people--slightly more of the uninsured than the underinsured, but not much more--report severe problems paying their medical bills. These are the families accounting for the 40 percent to 50 percent of people in bankruptcy or foreclosure who say health care is the number one reason for their plight.

So fixing health care isn't just a recipe for better access to medical care. It's an immediate economic lifeline for working families, giving them back part of their income to use on other things. It's also a rescue package for state and local governments burdened by Medicaid and S-CHIP, for doctors and hospitals who treat the uninsured and inadequately insured, for community institutions that help people in distress--in short, for all the rapidly fraying threads of our health care safety net. Put simply, most of the money we spend upgrading coverage and spreading it to the uninsured is going to go directly into the pockets of people who need help now.

And then, the long-term: controlling healthcare costs is the most important known variable in the nation's long-term fiscal prospects:

The faster everyone is in the system, the faster money flows into people's pockets, and the sooner reformers start reaping the political rewards.

And the faster all that happens, the better situated we are to start the difficult but essential task of controlling long-term health spending. Without runaway health spending, as Henry Aaron of the Brookings Institution has shown, the future fiscal picture of the federal government looks surprisingly rosy, even if taxes stay right where they are as a share of the economy. With runaway health spending, it looks catastrophic. Plus, as bad as the federal picture looks, it's prettier than what businesses and workers are facing. According to Sarah Axeen and Elizabeth Carpenter of the New America Foundation, if employer-sponsored insurance premiums and family income rise at the same rate they have for the past decade, an average family health plan will cost more than 45 percent of a typical family's income by 2016.

Will Obama risk his huge store of political capital -- and the nation's long-term fiscal health -- on trying to effect an immediate major investment in healthcare? No question. As he put it in his Dec. 11 press conference introducing his healthcare team: “Some may ask how at this moment of economic challenge we can afford to invest in reforming our health care system. And I ask a different question. I ask, how can we afford not to?”

Indeed, Obama's long campaign was in large part an extended argument for a sustained national investment in rolling back the shift of risk from institutions to individuals that Hacker so thoroughly documented -- through higher taxes on the wealthy that would enable new investments in healthcare, alternative energy and education. To shift risk to the public sector is not to eliminate it. Obama's writings show that he is aware of the dangers -- of large deficits, of taxes raised to the point of crimping economic growth, of bloated and unaccountable government offering ineffective services.

In The Audacity of Hope, he acknowledges those underpinnnings of the Reagan revolution. His argument in the campaign was not that there is no legitimacy to conservative concerns about big government, but that the pendulum has swung too far the other way -- that tax cuts for wealthy have hollowed out programs that sustain opportunity and social insurance. As he put it in Janeville, Wisconsin last February:

when opportunity is uneven or unequal - it is our responsibility to restore balance, and fairness, and keep that promise alive for the next generation. That is the responsibility we face right now, and that is the responsibility I intend to meet as President of the United States.

The genius of his campaign was a bid to move the center back to the left - to cast new social investment as a restoration of balance, fairness, commitment to commonwealth. Now, he cannot afford not to.

Clive Crook hazards a false moral on healthcare

Scouting the Obama healthcare plan for leaving employer based health insurance intact, Clive Crook succumbs to a Republican "ownership society" shibboleth. He'd have us believe that the runup in healthcare costs is driven mainly by consumers:

The real problem is slowing the remorseless trend of future growth. Until healthcare consumers are made to think about costs, that may be impossible. Consumers resist constraint because they think employers are paying for their health insurance; in fact, of course, workers are paying through lower wages.

In fact, the runup in healthcare costs is mainly driven by the incentive structure for doctors, who are paid by the procedure and have financial incentives to order costly tests and treatments (and the negative incentive of defensive medicine, thanks to our litigiousness); by drug companies, which deploy multiple means of bribing doctors to prescribe expensive (and often unproven) new medications, and who have lobbied their way to nearly unchecked pricing power; by insurers, who waste half of doctors' time with insanely arcane claims procedures and cherry-pick the healthiest patients; by the legions of uninsured, whose uncompensated care adds nearly a thousand dollars to the average family healthcare premium; and by the massive failure of our swiss cheese system to deliver preventive care.

It is counterproductive and immoral to induce people to access less healthcare by creating strong financial incentives to eschew treatment. In fact that's just what we do: there are tens of millions of people in this country halving their medication doses, going years without dental care, and avoiding visits to specialists they can ill-afford. You can't have adequate preventive care when every visit demands a consequential financial outlay.

Far from overconsuming healthcare, even Americans with insurance are increasingly underinsured. As reported by Jacob S. Hacker in The Great Risk Shift (2006):

Among insured Americans, 51 million spend more than 10 percent of their income on medical care. One out of six working-age adults are carrying medical debt,and 70 percent had insurance when they incurred it...nearly six in ten of the underinsured postponed needed medical care because of the cost, nearly four in ten had to put off home or car maintenance or repairs due to medical expenses, a third had to dig deep into their savings to pay for medical care, and more than one in five made job-related decisions based mainly on their health care needs. Strikingly, the median family income of the underinsured was $58,000--almost exactly the same as the median income of those with adequate coverage.

Crook has fallen victim to the Republican fallacy that adequate, affordable care creates "moral hazard" -- that patients will gorge themselves on on an open medical buffet if every item is not a la carte. In our healthcare system, the players morally at hazard are doctors who earn more if they prescribe more services, insurers who earn more by cherry-picking customers, and drug companies that earn more by turning doctors into shills. In the U.S., patients' hazard is physical and financial, not moral.

Belief among healthcare economists and policymakers that freedom from paying substantial fee-for-service sums leads patients to inefficiently overuse healthcare services rests largely on the famous RAND Health Insurance Experiment (HIE), a study of consumers provided with varying forms of health insurance over an extended period of time. The RAND HIE, begun in 1974 with results published in 1987 and 1993, purported to find that those in plans where they paid no fees for individual services used more healthcare than those in fee-for-service plans but did not enjoy any measurable health benefits as a result. In other words, the additional care accessed by those for whom services were "free" was effectively wasted.

This conclusion was effectively debunked in an analysis by John A. Nyman, published in October 2007 in the Journal of Health Policy, Politics and Law. Noting that all participants in HIE had the option of dropping out at will and returning to the health plan they held prior to the experiment, Nyman reported that sixteen times as many participants dropped out of the fee-for-service plans as out of the free plans. Since participants were given a financial incentive to remain in the experiment, the inescapable conclusion is that those who dropped out of the fee-for-service plans did so because they became seriously ill or were injured badly enough to need expensive care. In Nyman's analysis, "moral hazard" is exposed as essentially another word for "risk sharing." Those who need expensive healthcare access it if it is not financially prohibitive; those who don't need expensive procedures subsidize those who do. That's what insurance is for.