More on Health Care: Agreeing on the Questions
Since I wrote a blog post in early December on "The Effect of the Affordable Care Act on Medical Care Inflation," in which I lamented that "I haven't seen anything of note written about the probable effect of the implementation of the Affordable Care Act on Medical Care CPI," several things have come to my attention. This is a great example of one reason that I write these articles: to scare up other viewpoints to compare and contrast with my own views.
In this case, the question is not a trivial one. Personally, I approach the issue from the perspective of an inflation wonk,[¹] but the ham-handed rollout of the ACA has recently spawned greater introspection on the question for purely political reasons. This is awkward territory, because articles like that by Administration hack Jason Furman in Monday's Wall Street Journal do not further the search for actual truth about the topic. And this is a topic on which we should really care about a number of questions: how the ACA is affecting prices, how it is affecting health care utilization and availability, how it is affecting long-term economic growth, and so on. I will point out that none of these are questions that can be answered definitively today. My piece mentioned above speculated on possible effects, but we simply will not know for sure for a long time.
So, when Furman makes statements like "The 7.9 million private jobs added since the ACA became law are themselves enough to disprove claims that the ACA would cause the sky to fall," we should immediately be skeptical. It should be considered laughably implausible to suggest that Obamacare had a huge and distinguishable effect before it was even implemented. Not to mention that it is very bad science to take a few near-term data points, stretching only for a couple of years in a huge and ponderous part of the economy, to extrapolate trends (this is the error that Greenspan made in the 1990s when he heralded the rise in productivity growth that was eventually all revised away when the real data was in). Furman also conflates declines in the rate of increase of spending with decelerating inflation - but changes in health care spending include price changes (inflation) as well as changes in utilization. I will talk more about that in a minute, but suffice to say that the Furman piece is pure politics. (A good analysis of similar logical fallacies made by a well-known health care economist that Furman cites is available here by Forbes.)
I want to point you to another piece (which also has flaws and biases but is much more subtle about it), but before I do let's look at a long-term chart of medical care inflation and the spread of medical care inflation to headline inflation. One year is far too short a period to compare these two things, not least because one-time effects like pharmaceuticals losing patent protection or sequester-induced spending restraints can muddy the waters in the short run. The chart below (source: Enduring Investments) shows the rolling ten-year rise in medical care inflation and, in red, the difference between that and rolling ten-year headline inflation.
You can see from this picture that the decline in medical care inflation, and the tightening of the spread between medical care inflation and headline inflation, is nothing particularly new. Averaging through all of the year-to-year wiggles, the spread of medical care has been pretty stable since the turn of the century (which, since this is a 10-year average, means it has been pretty stable for a couple of decades). Maybe what we are seeing is actually the anticipation of HillaryCare? (Note: that is sarcasm.)
Now, the tightening relative to overall inflation is a little exaggerated in that picture, because for the last decade or so headline inflation has been somewhat above core inflation due to the persistent rise in energy prices throughout the '00s. So the chart below (source: Enduring Investments) shows the spread of medical care inflation over core inflation, which demonstrates even more stability and even less reason to think that something big and long-term has really changed. At least, not that we would already know about.
The other piece I mentioned, which is more worth reading (hat tip Dr. L) is "Health Care Spending - A Giant Slain or Sleeping?" in the New England Journal of Medicine. The authors here include David Cutler, whom Forbes suspected was tainting his views with politics (see link above), so we need to be somewhat cautious about the conclusions but in any event they are much more nuanced than in the Furman article and the article makes a number of good points. And, at the least, the authors distinguish between spending on health care and inflation in health care. A few snippets, and my remarks:
"Estimates suggest that about half the annual increase in U.S. health care spending has resulted from new technology. The role of technology itself partly reflects other underlying forces, including income and insurance. Richer countries can afford to devote more money to expensive innovations." This is an interesting observation that we ought to think carefully about when professing a desire to "bend the cost curve." If we are reining in inflation, that's a good thing. But is it a good thing to rein in innovation in health care? I don't think so.
The authors, though, clearly question the value of technological innovation. "The future of technological innovation is, of course, unknown. But most forecasts do not call for a large increase in the number of costly new treatments... some observers are concerned that a wave of costly new biologic agents (for which generic substitutes are scarce) will soon flood the market." Heaven forbid that we get new treatments! "The use of cardiac procedures has slowed as well." This is a good thing?
"Health spending has clearly been associated with health improvements, but analysts differ on whether the benefits justify the cost." Personally, it makes me uncomfortable to leave this question in the hands of the analysts. If the benefits don't justify the cost, and the market was free, then no one will pay for those improvements. It's only with a highly regulated market - replete with "analysts" doing their cost/benefit analysis on health care improvements - that this even comes up.
Some of the statistical argument is a little weak. "The recent reduction in health care spending appears to have been correlated with slower employment growth in the health care field; this suggests that such changes may continue." I'm not sure that the causality runs that way. Surely tighter limits on what health care workers can earn might cause slower employment growth? That's at least as plausible as the direction they are arguing.
That sounds very critical, but I point these things out mainly to make them obvious. Overall, the paper does a very good job of discussing the possible causes of the recent slowdown in health care inflation (although they focus inordinately on "the first 9 months of 2013", a period during which we know the sequester impacted health care prices), give plenty of credit to reforms instituted far before ACA implementation, correctly distinguish between utilization and prices, and highlight some of the promising trends in health care costs - and yes, there are some! The authors are clearly supportive of the ACA, which I am not, but by and large they raise the salient questions.
It matters less if we instantly agree on the solution than that we agree on the questions.
[¹] Actually, a little more than a generic inflation wonk in this case; I've also written about, presented on (and you can listen to my presentation while you walk through the slides) and consulted on the topic of hedging health care inflation, for example in post-employment benefit plans.