Suppose we require people to buy private health insurance, subsidizing those who can't otherwise afford it. This gets us close to universal coverage and makes it possible to forbid insurance companies from discriminating against people with pre-existing conditions or capping benefits. But it is very costly, particularly because the health insurance industry is so concentrated. As this
AMA study shows, 96 percent of metropolitan areas in the U.S. have "highly concentrated" health insurance markets. For example, at least one insurer controls 30 percent or more of the HMO/PPO market in 96 percent of the MSAs and 50 percent or more in 64 percent of MSAs. Concentration allows insurers to charge excessive rates for health insurance, increasing the cost of reform. In addition, legislation that would force millions of Americans to buy insurance from local monopolies might prove unpopular. So it's imperative that Congress find some way to increase competition in local health insurance markets.
I'm no health economist, but let me take a crack at this anyway. Insurance companies are an intermediary between health care customers (you and me) and health care providers (doctors and hospitals). To enter a local health insurance market, an insurance company has to recruit customers and providers into its network. If the company has a large number of customers providers will want to join the network and the company will be able to negotiate low reimbursement rates for services. If the company has low reimbursement rates, it can charge lower premiums than the competition and get more customers. This basic feature of the industry gives existing firms an advantage in local markets. Say Highmark Blue Shield is the dominant firm in south central Pennsylvania. Now Aetna wants to crack the market. Aetna goes to the hospitals in the area to negotiate reimbursement rates. Since Aetna has few customers it has little bargaining power over the hospitals and therefore has to agree to high reimbursement rates. HBS, meanwhile, is able to use its market power to force lower reimbursement rates. But Aetna signs the deal. Now it tries to recruit customers from companies like Gettysburg College. The Human Resources people at Gettysburg look at the competing plans and rates and see that Aetna, because it pays higher rates for hospital services, charges higher premiums. Gettysburg therefore chooses HBS, and Aetna is out in the cold. Aetna is in a catch-22: it can't recruit customers unless it can negotiate low reimbursement rates, but it can't negotiate low reimbursement rates unless it has a lot of customers. Aetna can't crack the market, and HBS retains its monopoly position.
The problem is, health insurance companies have natural monopolies because of "network effects" or the "first-mover advantage." How do the reform packages currently on the table confront this problem? The health insurance exchanges make it easier for outside companies to recruit large numbers of customers: instead of recruiting people one-by-one, the company can form a pool that attracts a large number of customers at once. Conceivably this could help break the Catch-22, but I don't see the chance for much effect. Insurance companies already have the ability to attract people in big groups by pitching their services to large employers, but this has not been enough to solve the problem.
The public option would take a sledgehammer to insurance companies' monopoly power. It would be fairly easy for a public program modeled on Medicare to get hospitals to sign on at Medicare rates (or something close to it), which would allow it to pull customers away from the insurance companies. This might be a very effective way to force competition on the insurance companies. Unfortunately, the actual public program we are likely to get out of this round of reform is likely to be too modest to change the nature of the game entirely. And there might be some legitimate reasons to worry about a large Medicare-type program with the power to set rates below what hospitals can afford.
Suppose we wanted to increase competition in the health insurance industry without a public option. How could we do this? Well, let's rule out one approach off the bat: eliminating state regulatory requirements on insurance policies, as Republicans propose, is not going to do much if anything. The problem is not that Aetna doesn't have the resources to devise a policy that satisfies Pennsylvania's regulatory requirements; the problem is network effects that give HBS a natural monopoly.
One way we have dealt with natural monopolies in the past is regulation. The problem with a monopoly is it can charge prices above its long run average cost, thereby earning excess profits at the expense of its customers. If a state or federal commission set insurance rates the way many states set utility rates, it could force the companies to charge prices equal to average costs. This could work for health insurance, but again there may be benefits to having a truly competitive market rather than a regulated monopolistic one.
Here's something we could do to open markets to competition. We could require hospitals and doctors to accept any and all private insurance plans that were certified by the state or federal government. To prevent providers from being swamped with paperwork from hundreds of different insurers, we could require uniform reimbursement forms. In other words, hospitals and doctors would be required to operate as "common carriers" in the manner of transportation or telecom companies. In addition, hospitals and doctors could be subject to the equivalent of "most favored nation" requirements. A hospital would be prohibited from charging one insurance company higher reimbursement rates than the lowest reimbursement rates it accepts from other companies. Under this proposal every health insurance company pays hospitals the same rates; every hospital accepts every health insurance policy offered; and health insurance companies compete for customers by offering different types of policies, better service, or lower premiums.
Since insurers are the source of the problem, it might seem odd for a plan to restrict the activities of health care providers rather than insurers. But restrictions on the ability of providers to bargain actually strengthens their position relative to insurers because dominant insurers would no longer be able to force hospitals to accept lower reimbursement rates.
This plan seems to me to offer the best chance of promoting competition in the health insurance industry, thereby lowering the costs of reform in the long run. I would think it would be acceptable to Republicans who are hostile to the idea of a public plan. Though liberals probably would prefer a robust public plan, this plan might be preferable to a weak and ineffective public option. I wonder if anyone has thought of this before.
Labels: health reform, industrial organization, monopoly