OECD: Health Care Reform in the United States
Economic Department Working Paper No. 665: Health Care Reform in the United States
By David Carey, Bradley Herring and Patrick Lenain
OECD (Organisation for Economic Co-operation and Development)
February 6, 2009
Abstract
In spite of improvements, on various measures of health outcomes the United States appears to rank relatively poorly among OECD countries. Health expenditures, in contrast, are significantly higher than in any other OECD country. While there are factors beyond the health-care system itself that contribute to this gap in performance, there is also likely to be scope to improve the health of Americans while reducing, or at least not increasing spending. This paper focuses on two factors that contribute to this discrepancy between health outcomes and health expenditures in the United States: inequitable access to medical services and subsidized private insurance policies; and inefficiencies in public health insurance. It then suggests two sets of reforms likely to improve the US health-care system. The first is a package of reforms to achieve close to universal health insurance coverage. The second set of reforms relates to payment methods and coverage decisions within the Medicare programme to realign incentives and increase the extent of economic evaluation of different medical procedures.
http://lysander.sourceoecd.org/vl=16683430/cl=20/nw=1/rpsv/cgi-bin/wppdf?file=5ksnw5ghd45c.pdf
Comment:
By Don McCanne, MD
OECD reports are important not only because of their credible studies of economic conditions throughout the world, but also because they are used for policy decisions in the thirty member nations (including the U.S.) plus more than one hundred other countries and economies. Thus it is important to understand this new OECD report, “Health Care Reform in the United States,” especially at this time when intensive reform efforts are taking place in Washington.
The thirty member nations are “countries committed to democracy and the market economy.” Although the data provided by OECD can be very helpful in addressing each nation’s economic problems, the recommendations offered must be evaluated with a recognition that there is a bias toward market solutions, with governments being relegated to a supportive role in improving the functioning of markets.
As expected, this report describes well the poor performance of our health care system in spite of the very high level of spending - by far the highest of all nations. Special attention is directed to the increasing proportion of both the uninsured and the underinsured, and the failures of the private insurance market and current government policies to correct these deficiencies.
The most serious problem with this report is that their recommendations are primarily limited to those that would improve the functioning of private insurance markets, with a government role limited to refining policies that would enable improvements in the private markets (plus minor changes in Medicare design that might have a minimal impact in improving value, but with some policy tradeoffs). Although they parenthetically hint that single payer policies in other nations have been effective in achieving some of the reform goals, at no time do they suggest that a single payer approach might benefit the United States; in fact, they specifically reject it as “radical.”
Considerable attention is directed to the work of Jonathan Gruber and his efforts to use private insurance plans as a foundation for reform, including the real-life experience of the Massachusetts plan. Although the authors of this report echo some of his suggestions, their recommendations fall short of an optimal program of social insurance based on private health plans (a model that we believe is inadequate anyway). Except for tweaks to Medicare, they remain silent on public insurance programs. Last week we provided a critique of the Massachusetts plan, explaining why it is an unsatisfactory model for reform in the United States. (http://www.pnhp.org/news/2009/february/massachusetts_plan_.php)
Just one example of the inadequacies of their recommendations is the inconsistency between their discussion of the financial hardships faced by the underinsured, and their recommendation to “decrease the generosity of supplemental Medicare insurance designs for beneficiaries without chronic conditions to reduce moral hazard risks, which supplemental insurance accentuates by insulating Medicare beneficiaries from Medicare’s cost-sharing provisions.” Again, they provide good data on problems with our system (underinsurance), but they provide a terrible recommendation for policy changes (prevent “moral hazard” by expanding underinsurance) based on market theory instead of social solidarity.
In sum, OECD’s credibility as an important resource on economic data does not extend to credibility for its recommendations that are based on pro-market ideology. This report is valuable for its data showing how poorly our health care financing system is functioning, but it is almost worthless as a guide for policies on how to repair our system since it reinforces the obsolete model of private health plans and ignores the more efficient and effective model of a single payer national health program.