Alain Enthoven, pioneer of "managed competition" and esteemed
authority on health-care economics, has an excellent column on Ryan's
premium support plan (What Paul Ryan's critics don't know about health economics).
Echoing arguments made by Alice Rivlin and Henry Aaron, he argues that
the premium support approach would encourage the spread of accountable
care organisations, and that these could make a big contribution to
improving efficiency and lowering costs. Ryan's indexation formula is
too severe, Enthoven says, but the basic idea is sound.
At the root of the waste and excess is Medicare's
open-ended fee-for-service system, which pays health-care providers for
doing more and more costly services, whether or not they're in the
patients' best interests. Last year's health-care reform legislation
acknowledged that fundamental change is needed from the traditional
fee-for-service model to a system in which doctors and hospitals team
up to offer coordinated care and are held accountable for per-capita
cost and quality. Hospitals and suppliers may participate in this
Shared Savings Program by creating or joining an Accountable Care
Organization (ACO).
Unfortunately, the incentives to form ACOs and to dramatically cut
costs are far too weak and the regulations far too complicated...
A better way to encourage accountable care is the "premium-support"
model proposed by House Budget Committee Chairman Paul Ryan, among
others. This is a managed competition model in which government would
make a defined contribution and beneficiaries would have a choice from
a variety of health plans with no discrimination based on health
status. Standard coverage contracts would make comparisons possible for
ordinary people. Competition would drive health plans to innovate in
ways that cut waste and improve quality. And the use of exchanges would
drastically reduce marketing costs, so insurance companies would not be
taking 20% off the top, as is currently the norm.
This is not "the end of Medicare," as some would have you believe.
One thing I don't understand is why Enthoven, like Ryan, takes such
exception to the use of the term "voucher" in describing the premium
support approach. Premium support is, to all intents and purposes, a
voucher. What's wrong with calling it that?