Medical care cost control requires both demand and supply management

Vijay K. Mathur

Published in Standard-Examiner, April 14, 2013, Ogden, Utah

It is well known that the price people pay for medical care either directly or indirectly is increasing at a rapid rate. In 2011 the national expenditure for health care was $2.7 trillion, a 92 percent increase since 2000. If the medical care market is competitive, the interaction of demand and supply would determine its price, and that price will be efficient and welfare maximizing.  However, despite the usual rhetoric of politicians and free market ideologues, the medical care market suffers from what economists call market failure. Competition in the medical care market, for example, requires a large number of buyers and independent providers of services, a relatively small size of providers to avoid dominance, full information about quality and prices of services.

On the demand side, competition works when consumers are well informed about the quality of medical care services and prices actually paid by them so that they can shop for services. Usually though, patients depend upon their doctors for information about medical procedures, need for those procedures, drugs, and hospitals’ quality.

Physicians are the agents who look after patients’ interests. However, when doctors are either employed by hospitals or have privileges in using hospital services, their loyalty is split between patients and hospitals.

Doctors have incentive to overuse medical services, because their own compensation is based upon the amount billed to insurance companies and/or to government programs such as Medicare and Medicaid. Third-party payment systems encourage doctors to create demand for hospitalization and/or medical services.  For example, a Rand Corporation study, “ Health Insurance Experiment” in 1982, found that when patients shared in the cost of medical care in an HMO, their use of all medical services was much less than those who had free care, without affecting quality of care and health outcomes.

Most of the discussion about medical care costs centers around demand and not much attention is paid to the supply side (cost). There is no doubt that something has to be done on the demand side, such as, increasing means tested and capped co-pays as a percent of the total bill of services as opposed to flat amounts. This will make consumers aware of their costs in relation to prices charged.  In 2011, those 65 years old and over constituted 13 percent of the total population while federal spending on Medicare and Medicaid was 30 percent of the total health care spending. Per capita spending on older people in 2011 was close to $14,000.

On the supply side, hospitals operate in a non-competitive market. The March 4, issue of Time magazine presents an in-depth investigation by Steven Brill on hospitals’ pricing strategy. He finds that hospital pricing cannot be explained by costs of medical services and procedures. It resembles monopolistic pricing strategy, in which hospitals dictate prices as opposed to being subjected to market prices. Steven Brill states, “ No hospital’s Chargemaster prices are consistent with those of any other hospital, nor do they seem to be based on anything objective — like cost — that any hospital executive spoke with was able to explain.” Chargemaster prices are prices most hospitals use in their billings, however they are discounted for insurance companies and Medicare. Even with discounts hospitals earn abnormal profits, unlike other businesses.

Contrary to other industries, improved technology in medical care, has led to an increase in costs. This is partly due to more ease in conducting various tests, fee for service pricing and efforts to ward off complaints.  The evidence does show increase in costly tests and medical procedures, a result of lack of attention to preventive care. 

Tests have increased by extending the population group, e.g., screening younger groups for breast cancer (extensive margin), and by increasing the number of tests on the same population group, e.g., more frequent colonoscopies (intensive margin). This has increased cost as well as profits of hospitals and physicians’ compensation.

Since evidence-based tests and treatments have not been extensively implemented either in hospitals or physicians’ clinics, we find a great variation in tests, procedures and hence, cost of medical care. In addition, since physicians are not sole agents of patients, they have no incentive to shop around for best prices on behalf of their patients. Also, control of prices due to monopoly power puts no pressure on hospitals to restrain abnormal compensation packages for administrators, physicians and other personnel, hence escalating total costs of care.

It is ironic that we regulate gas and electricity prices but not prices of medical care services, even though this market is monopolistic. It is only through Medicare, Medicaid and to a certain extent through insurance system that the cost of medical care for most consumers is kept below Chargemaster price level. The Affordable Care Act also contains provisions to contain costs of medical services (e.g., payments based on treatment outcomes) and insurance premiums.  However, a single-payer Medicare system for all, with a means tested increase in Medicare tax and supplemented by private insurance system, would be more cost effective than the mish-mash system we have now.

Mathur is former chairman and professor of economics and now professor emeritus, Department of Economics, Cleveland State University, Cleveland, Ohio. His articles also appear in mathursblogonomics.blogs.com. He also writes a blog for the Standard-Examiner at http://blogs.standard.net/economics,etc.

Misunderstanding on budget deficits and debts

Vijay K. Mathur

Published in Standard-Examiner, February 10, 2013, Ogden, Utah

Many Americans, including politicians and media pundits, are not well informed about federal budget deficits and debt and their role in fiscal policy. Most equate it with consumer debt. They also believe that state and local governments and consumers balance their budgets, and hence by implication have no debts. They assume that debt is burdensome on our children, without realizing that children also inherit substantial federal assets. However, the view that federal government should follow the example of states and consumers to balance its budget and reduce debt is not based on sound economic reasoning.

  

Budget deficit occurs when consumers’ spending exceeds income received in any given year. Borrowing, on credit cards or from other sources, must finance budget deficits. Debt in any given year is accumulated deficits over a period of time. Data shows that consumers in general are not debt-free in any given year, as many tend to assume. For example, New York Fed reports that in September 2012, total consumer debt, including mortgage debt, was $11.31 trillion, almost the same as federal debt held by the public in 2012. Consumers willingly tolerate debt if they have enough disposable income to service their debt. However, as opposed to governments at all levels, consumers do not have the power to tax or issue securities to finance their obligations. Individually, they also do not have the power to regulate business cycles or promote economic growth and development.

State and local governments also have debts in any given year. According to state government finances, total debt (excluding pension obligations) across all states was $1.132 trillion in 2011, and Utah was no exception. Federal government, as opposed to state and local governments, uses deficits and debt as a tool of fiscal policy to fine-tune the economy and build and accumulate national assets. In addition, the federal government has the constitutional obligation to provide national security against enemies and may have to incur deficits and debt to finance those obligations. 

In recessions, private consumption spending and private investment tend to decline. If exports are not increasing to offset imports, as is the case for the U.S. since 1976, the only component that can increase gross domestic product (GDP), a measure of a nation’s income, is to increase federal spending and hence deficits. In recessions tax revenues also decline. However increasing taxes, on all Americans at all income levels, in recessions is counter productive. Therefore, the only option to finance budget deficits is to issue Treasury securities (debt obligations). In 2011 the deficit was $1.3 trillion (8.7 percent of the GDP), decreasing 0.11 trillion from its recessionary peak in 2009.

No one is forced to buy Treasury securities. Individuals, businesses, foreign governments, pension funds and other investors and institutions buy these securities as a safe investment. As long as the federal government is able to service its debt and meet its obligations given its capacity to pay, the problem of default does not arise. Note, there is a distinction between “total debt” ($14.7 trillion in 2011) and “debt held by the public” ($10.1 trillion in 2011). In addition to “debt held by the public,” “total debt” includes obligations for entitlements such as Social Security, Medicare and other intra-government debt obligations. However, a significant part of “total debt” burden can be ameliorated, while at the same time assuring future benefits, by increasing income limit for Social Security and Medicare tax on higher income people. 

“Debt held by the public” includes debt to domestic and international investors, state and local governments and the Federal Reserve. The Congressional Budget Office (CBO) estimates that this debt was 77.8 percent with net interest cost of only 1.4 percent of the GDP in 2012; it is expected to decline to 58.5 percent of the GDP in 2022 with slight increase in interest cost. Federal debt poses no threat to inflation and crowding out private investment, since interest rates and inflation rates have been so low for quite some time. 

Americans should also know that total foreign debt is close to 48 percent of the “debt held by the public” and mainland China holds only 10 percent of our debt obligations in 2012-Q3. Moreover, no one is forcing China to buy U.S. Treasury securities. Given the economic conditions elsewhere in the world and China’s stake in the U.S. as an export market, it considers our securities a safe investment. Moreover, debt to foreigners should be viewed in terms of their substantial debt to us.

   

It should be understood that we cannot keep on piling up debt beyond our capacity to service and meet other debt obligations, but recessions are not the time for spending cuts. 

Taxes and spending should be tailored to stimulate investment in research and development, private and public physical capital, and human capital. All eyes should be focused on policies that stimulate growth now, and on deficit and debt reductions when the economy picks up robust growth.

Mathur is former chair and professor of economics and now professor emeritus, Department of Economics, Cleveland State University, Cleveland, Ohio. He also writes blogs for the Standard-Examiner at http://blogs.standard.net/economics,etc.

Incentivizing poor and low-income persons to work and save more

Vijay K. Mathur

Published in Standard-Examiner, October 28, 2012, Ogden, Utah

Means-tested anti-poverty programs determine eligibility based on income and assets. If benefits to able-bodied low income and poor persons are cut in larger proportions of their increasing earnings and assets, it provides a disincentive to earn and save more. Benefit cuts are like a tax on work earnings.

The study by John Karl Scholz, Robert Moffitt and Benjamin Cowan (SMC), Discussion Paper no. 1350-08, September 2008 (www.irp.wisc.edu), cites a study of low-wage single-parent families in New York where benefit cuts were such that their extra dollar earnings, from working between 8 to 35 hours per week, would increase their take home by only 15 cents per dollar earned (a 85 percent cut in income). However, there is also an upside of anti-poverty programs. SMC study investigates the role of social insurance programs and means-tested transfers, including entitlements, in reducing poverty. Assuming no behavioral response, they show these programs do reduce percentage of poor across different family types between 35 percent to 86 percent. The investigators did not want to confound the effect of anti-poverty programs on poverty rates by including behavioral responses. Even though anti-poverty programs have substantially reduced poverty rates, there is still a significant fraction of poor people in the country.

It appears that a large proportion of post transfers residual poverty rates must be due to behavioral responses to programs’ benefit policies. Program benefit cuts are an increasingly larger proportion of increasing earnings and assets, as the above study for New York shows. In addition, more benefits are guided to single parent as opposed to two parent families, thus encouraging formation of single parent families and/or encouraging divorces. The data show that single parent families headed by females have a much higher poverty rate than two parent families.

Since benefits and Earned Income Tax Credit (EITC) increase with family size, they tend to encourage more children in a single-parent family. Large family size is another source of hardship for poor families. However EITC, one of the fastest growing means tested program after Medicaid, is a pro-work program. Mr. Romney once remarked that the 47 percent of Americans who do not pay federal income taxes claim victimhood and expect the government to provide these transfers. It includes all those low-income people and poor who receive EITC. The credit provides incentive to work. Therefore, if the credit is taken away, poverty roles will further increase. In fact all means tested poverty programs for able-bodied persons, including food stamps, TANF (Temporary Assistance to Needy Families), housing subsidies and supplemental nutrition program (WIC), should be tailored around the theme of work incentives.

If we are serious about reducing poverty, benefits should increase when able-bodied poor and low-income families earn and save more, until income reaches a threshold level equal to "Basic Needs Budget" (BNB) proposed by National Center for Children in Poverty (NCCP) at Columbia University (www. Nccp.org). NCCP’s budget based income thresholds are higher than the poverty income thresholds defined by the Census Bureau, and vary from high-cost to low-cost cities and types of families. For example, Kinsey Dinan of NCCP (March, 2009) proposed annual income need of $41,000 for a single-parent family with two children in moderate-cost city, Des Moines, Iowa. It is 233 percent of the federal poverty level.

There is another beneficial side effect of pro-work EITC. The study by Gordon Dahl and Lance Lochner (DL), American Economic Review, August 2012, investigates scholastic achievement of children five years old and over due to EITC. They use a data set of 4,500 children from the National Longitudinal Survey of Youth and sample period (1987-2000) and measure family income as total net income, including EITC net of federal and state taxes and transfers. Test scores on PIAT (Peabody Individual Achievement Tests) measure scholastic performance of children. These standardized scores measure ability in mathematics, oral reading, reading comprehension and ability to derive meaning from printed words.

They find that increase in current income due to EITC significantly increases a child’s math and reading scores. Increase in scores is larger for younger children growing up in poor disadvantaged families, such as unmarried households, minority families, families with low-educated mothers. The effects are also more pronounced for boys. These findings are predictive of a better future for poor children and economic well-being of poor families.

Evidence indicates that means tested anti-poverty programs would provide incentives for work if a smaller proportion of benefits were reduced with increase in earned income. Census Bureau’s measures of poverty income are inadequate and hence should be modified along the lines of BNB. Also, benefits should promote education and skills and asset accumulation to put poor families on a sustainable path to economic self-sufficiency and replace programs that subsidize employers such as Work Opportunity Tax Credit. These subsidies do not help fill the skill gap emerging in the labor market due to the changing structure of the economy.

This is the second part of a two-column series by Mathur, who wrote on Oct. 21 about a renewed focus on poverty and entitlements. Mathur is former chair and professor of economics and now professor emeritus, Department of Economics, Cleveland State University, Cleveland, Ohio. He also writes blogs for the Standard-Examiner at http://blogs.standard.net/economics,etc.

Renewed focus on poverty and entitlements

Vijay K. Mathur

Published in Standard-Examiner October 19, Ogden, Utah

Election times in slow-growth economy bring attention to poverty and safety net programs to alleviate poverty. In the first presidential debate, Mitt Romney blamed President Barack Obama for the increase in the poverty rate. He promised to create 12 million jobs. Such a statement on jobs recognizes that increase in poverty is due to lack of job opportunities. However, this statement contradicts his remarks at the private fundraiser that 47 percent of Americans, who do not pay federal income taxes, consider themselves as victims and are dependent on government for entitlements.

Perhaps Mr. Romney’s views on 47 percent of Americans also fit his tax and spending agenda. Cutting income tax rates by 20 percent across all income brackets and other tax cuts, on top of Bush tax cuts, primarily benefit the rich. He also intends to increase defense spending and reduce the budget deficit. His claim, that he can accomplish his goal by reducing tax loopholes and deductions and increase the level of economic growth, is far fetched at best. Therefore, in all likelihood, Mr. Romney has to dip into Social Security, Medicare, Medicaid and other entitlements, which would be extremely burdensome to low-income and poor households and even to many middle-income households.

Let us look at some facts about poverty and then examine how much difference safety-net programs make in the lives of the poor. Census Bureau defines a family as poor if its annual pretax money income falls below the poverty threshold. Thresholds vary with the size of family.

For example, in 2011 poverty thresholds were $11,484 for one person with no children, $15,504 for two-person household under 65 years of age with one child, $18,106 and $18,123 for three person households with one child and with two children respectively, and $10,788 for those 65 years old and over with no children.

Census Bureau data shows that in 1959 poverty rate for all people in the U.S. was 23 percent of the population. It declined throughout 1960s, reaching a low point of 11.1 percent in 1973. This decline was partly due to the passage of The Economic Opportunity Act in 1964 during President Johnson’s administration. The poverty rate has increased to 15.9 percent in 2011. Among children 18 and under it has always been higher than for all people since 1973, and in 2011 it was a scandalous rate of 27 percent. The elderly poverty rate in 1959 was 35 percent, but in 2011 it was close to 12 percent, due mainly to social insurance programs. I am sure deep recession of 2007 worsened these rates.

The question is, how much difference is made in reducing poverty by social insurance programs (SIP), and Means-tested Transfers (MTT), including entitlements. SIP has dedicated funding and provide benefits to those who have made contributions to the programs. MTT are financed by general tax revenues, and provide benefits to eligible persons and families based on income and assets.

A major study by Professors John Karl Scholz, Robert Moffitt and Benjamin Cowan (SMC), Discussion Paper no. 1350-08, September 2008 at http://www.irp.wisc.edu, is instructive in gauging the effectiveness of these programs. They investigate SIP (Social Security, Medicare, unemployment insurance, workers’ compensation and disability insurance) and MTT. MTT includes three types of programs: 1) Medicaid and Supplemental Security Income for the aged, blind and disabled, 2) cash transfers, for example, Temporary Assistance for Needy Families that replaced AFDC (Aid to Families with Dependent Children) in 1996, Earned Income Tax Credit, and 3) in-kind transfers, for example, food stamps, housing assistance, head start, school lunches, and nutrition programs for women, infants, and children,

SMC analysis includes 1984, 1993 and 2004, but I report here their findings for only 2004. They assume away behavioral responses to the anti-poverty programs that may provide work disincentives and hence may increase the poverty rate. They find that in 2004 all transfers (including SIP, all cash transfers, all in-kind transfers, all MTT except child care credit and foster child payments) reduced percentage of poor families and individuals from 30.3 percent with no transfers to 12 percent after transfers.

In 2004 for different family types, the transfer system was very effective as well. For example, from pre-transfers to post-transfers, percentage of single-parent and two-parent poor families decreased 71 percent and 66 percent respectively, the percentage of employed poor decreased 51 percent and the percentage of elderly families and individuals decreased 86 percent.

Using SMC data I find that in 2005 spending on MTT (including Medicaid) was 53 percent of spending on SIP. The evidence suggests that safety-net programs with minimum disincentives for work would be very effective in reducing poverty. SMC cite past evidence that reducing entitlement benefits had imposed a heavy indirect tax on the poor for working.

Therefore, any trimming of these programs to offset tax cuts for the rich must be done with careful thought and not be guided by ideology. The character of a nation and its people is determined by how its most vulnerable people are treated.

This is the first part of a two-column series by Mathur. Next week he will write about incentivizing poor and low-income persons to work and save more. Mathur is former chair and professor of economics and now professor emeritus, Department of Economics, Cleveland Sate University, Cleveland, Ohio. He also writes blogs for the Standard-Examiner at http://blogs.standard.net/economics,etc.

Ryan’s muddled thoughts are of Rand, Hayek

Vijay K. Mathur

Published in Standard-Examiner September 9, 2012  

Let me first briefly give you some background on both of these thinkers, who, according to media reports, have shaped Rep. Paul Ryan’s thinking on government and free markets. For more details on their views, you could read their books, "The Fountainhead" and "Atlas Shrugged," by Ayn Rand and "The Road to Serfdom," (1994), first published in 1944 by late Austrian economist and Nobel laureate Friedrich A. Hayek.

 Ayn Rand was born in Russia in 1905 and developed intense dislike of the Bolsheviks and communism. In 1926 she migrated to the U.S. Her two fictional novels contain some of her views about government’s role in society and on economic policies. NPR site (www.npr.org) presents an interview of Rand by late "60 Minutes" journalist Mike Wallace, in which she expressed her concept of "objectivism." She says this concept is a system of morality that is "not based on faith ... but on reason." She was totally against all forms of controls, including taxes, and a firm believer in laissez-faire with no government regulation. The economic concept of laissez-faire was first proposed by a group of French writers called physiocrats during 17th and 18th centuries.

Ayn Rand was completely opposed to any general welfare programs such as Social Security, Welfare, Medicare, Medicaid, and unemployment compensation. This ideology contradicts the U.S. Constitution, since Article I, Section 8 specifies that the Congress provide for national defence and general welfare. The idea of laissez-faire advocated by Rand, was a critical response to mercantilism during 17th and 18th centuries’ Europe, whereby the merchant class persuaded states to regulate the economy to serve their own self interests. It seems that they believed in individual rights and property rights but only so long as their interests were served.

Hayek admits that his controversial book is a political book. He severely criticized socialism, where means of production are controlled by government. According to him, socialism works against individual freedom and it "…means abolition of private enterprise, of private ownership of the means of production, and the creation of a system of planned economy in which entrepreneurs working for profit are replaced by a central planning body." He supported competitive markets and criticized planning. Hayek was as critical of conservatives as he was of liberals who advocated or sympathized with socialism. He states, "A conservative movement by its very nature, is bound to be a defender of established privilege and to lean on the power of government for the protection of privilege." This comment exactly fits what current GOP and Romney/Ryan have on their agenda.

The U.S. and democracies of Western Europe have neither laissez-faire nor socialism, as defined by Hayek. These are mixed economies where governments’ role in markets is complementary in nature rather than a substitute for private enterprise. Even China, India and many Eastern European countries are gradually moving away from socialism as Hayek envisioned. Rand’s and Hayek’s fears of socialism and ultimately totalitarianism are not based on reality of markets in the U.S. and other countries of Western Europe. Rep. Ryan’s notion of free markets and regulation is outmoded and indicative of muddled thinking on the role of markets and government. Research, since the days of Rand and Hayek, has shown that markets in some areas of the economy, without government assistance and/or intervention, do not work efficiently due to market failure problems.

Environmental quality, national defense, human capital accumulation (education), research and development and space exploration are some of the examples of sectors where markets break down. For example, if an oil refinery pollutes, it violates homeowners’ property rights when they suffer health problems or property damages. Therefore, unless government intervenes to force the refinery to internalize its cost of pollution in the price of oil, the refinery has no incentive to do so. One may argue that individuals could sue the refinery. That is a very inefficient way to solve the problem. A cost effective strategy requires the government to own property rights for air-sheds on behalf Americans and hence enforce those rights by pollution taxation or by creating a market for pollution rights.

Another example of market failure arises when there is a very high risk in providing a product or service, such as infrastructure development, space exploration, basic R&D and other public goods. The U.S. government role is also called for in providing services for the general welfare of its citizens, as the Constitution specifies.

Mr. Ryan must understand that Hayek’s ideas and especially Rand’s ideas on free markets must be tampered with economic reality of markets. It is the government that had to come to the rescue of markets in the Great Depression of 1930s and again in the great recession of 2007-08; regulations had to be implemented to restore the integrity of the financial system plagued by scandals.

Mathur is former chair and professor of economics and now professor emeritus, Department of Economics, Cleveland State University, Cleveland, Ohio.  He also writes blogs for the Standard-Examiner at http://blog.standard.net/economics,etc.

Here we go again on the Affordable Care Act

Vijay K. Mathur

Published in Standard-Examiner, July 21, 2012, Ogden, Utah

The decision by the Supreme Court on the Affordable Care Act has not satisfied the right wing of the Republican Party in the Congress and their sympathizers. The congressional attempt to repeal ACA is a fruitless and unproductive exercise. If there is any iota of common sense left in this Congress, it is advisable to make constructive changes in the law that will benefit all Americans.

Professors John F. Cogan, Glen Hubbard (Mitt Romney’s adviser) and Daniel Kessler (CHK) in their op-ed in The Wall Street Journal, June 6, present the usual conservative point of view about ACA while lacking some facts, and espousing blind faith in market forces to fix the health care problem. Let me briefly summarize some of their arguments against the ACA below.

CHK claim that ACA will stifle innovations and increase health care cost without creating more value, and the mandate to buy insurance will not result in better health outcomes. CHK cite the 2008 study by Prof. Jack Hadley, et al in Health Affairs, to support their contention of weak evidence of cost-shifting by uninsured onto insured. They blame government policies for preventing market forces from reducing cost and improving access to health care. However, arguments for fixing the tax code, redesigning Medicare and Medicaid and changing states’ insurance regulations to improve the health care system have some merit.

CHK are unaware that ACA creates the Patient-Centered Outcomes Research Institute to promote innovations. Bloomberg Business Week, Spring 2012, reports that this institute, funded by $3 billion over 10 years, will provide grants to medical researchers to test drugs and a host of other treatments. In addition, $1 billion has been distributed as grants to approximately 3,000 small biotechnology companies, and funds are allocated for research in public health. The ACA also creates the Center for Medicare and Medicaid Innovation, which works with the private sector to promote innovations to lower cost and improve quality of care. This public-private partnership is the hallmark of R&D in many other industries, and hence health care is no exception.

On the cost side, Ezra Klein (www.washingtonpost.com/blogs) reports that CBO estimates show that the insurance coverage provisions of the ACA will have a net cost of just under $1.1 trillion during 2012-2021 period — about $50 billion less than its March 2011 estimate. Furthermore, this is only the outlay side and not the revenue side of the ACA.

CHK ignore the adverse selection problem, when insurance companies are saddled mainly with high cost users of medical care. This is part of the reason for the mandate. The 2012 Rand Corporation study (www.rand.org) estimates that by 2016 ACA with mandates will result "in coverage for 91 percent of the nonelderly population" as opposed to only 81 percent without mandates. Rand study also shows that under individual exchange plans, average premium per enrollee will increase 9.3 percent without the mandate in the ACA by 2016. However, the estimated premium increases, generated by the CBO, range from 15 percent to 27 percent without the mandate.

Cost-shifting by the uninsured could take many different forms. For example, it may cause premiums of insured to rise, may lead to absorption of losses by hospitals and/or doctors, may affect the quality of care, and may increase the cost of Medicaid and Medicare. There are numerous studies on cost-shifting with varied conclusions and estimates. Most studies, however, conclude that there is cost-shifting and hence an increase in premiums of insured persons.

The 2005 study by Families USA found that nationally uncompensated health care costs exceeded $43 billion. Two thirds of that was shifted to the privately insured (close to $922 for family and $314 for individuals). The study in Health Affairs, January/February 2006, by Allen Dobson, Joan DaVanzo and Namrata Sen, comes to the conclusion that, "states with low public payments relative to costs and high degree of charity care are associated with higher private payment-to-cost ratio." Their data show that aggregate hospital payment-to-cost ratio for Medicare and Medicaid are declining and for private payers increasing since early 2000.

CHK’s reliance on market forces to solve health care problems ignores market failure problems associated with asymmetric information, adverse selection, moral hazard, and spillovers across medical care services and across insurers over time. In addition, studies by R. Cebul. J. Rebitzer. L. Taylor and M. Votruba, in The American Economic Review, August 2011, and by L. Dafny in The American Economic Review, September 2010, found that medical insurance markets are monopolistic. In fact, CRTV present a very cogent argument for including public option in the ACA.

It seems CHK are espousing the usual conservative viewpoint, with some meritorious arguments for simplifying rules, regulations and tax laws, without recognizing fundamental features of ACA and issues in the provision of medical care and health insurance to all Americans. As surgeon and researcher Atul Gawande comments in his New Yorker article on ACA, "The rhetoric of intransigence favors extreme predictions, which are seldom borne out."

Mathur is former chair and professor of economics and now professor emeritus, Department of Economics, Cleveland State University, Cleveland, Ohio. He also blogs for the Standard-Examiner at http://blogs.standard.net/economics, etc.