Last night in the State of the Union address, President Obama stated that “the only way to tackle our deficit is to cut excessive spending wherever we find it—in domestic spending, defense spending, health care spending, and spending through tax breaks and loopholes. This means further reducing health care costs, including programs like Medicare and Medicaid, which are the single biggest contributor to our long-term deficit. Health insurance reform will slow these rising costs.”
Is it possible that the President has already forgotten that the health care law included a massive expansion of the broken Medicaid entitlement? According to projected national health expenditures from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS), Medicaid spending in 2019 will be $896.2 billion. Without the health care law, CMS projects that the amount would have been $802.4 billion.
This means that the President’s health care law will increase Medicaid spending by 12 percent or about $100 billion annually. The extra spending comes from the additional 18 million or so individuals—mostly non-disabled and non-elderly adults without children—who will now have taxpayers paying their health care bills through the Medicaid program.
Two central components of the law expand eligibility to the government-run Medicaid program and offer costly subsidies to an estimated 20 million individuals to purchase health insurance. With an increasing amount of health care subsidization, taxes will increase, but so will the demand for health care services. This problem is exacerbated because there is very limited out-of-pocket payment for Medicaid. The subsidies and the increased third-party payment will cause health spending to grow, not slow.
Medicaid is a broken program for many reasons. First, national spending on Medicaid has more than quintupled over the past two decades, and about 16 percent of the population is currently enrolled. A primary reason state budgets are out of whack is this explosive Medicaid growth and states’ responsibility to finance a portion of its programs costs.
Despite the massive increase in spending, many physicians fail to participate in the program because of low payment rates and a frustrating amount of paperwork. This causes many Medicaid beneficiaries to receive basic care services in the emergency room.
There is evidence that Medicaid provides beneficiaries with a low quality of care. A recent study from the University of Virginia found that Medicaid patients have worse surgical outcomes than individuals without insurance, even controlling for a multitude of personal characteristics.
Instead of doubling down on Medicaid and its existing structure, Washington should consider major structural reform for this troubled program. To start, the open-ended federal reimbursement of state Medicaid spending, which creates perverse incentives for states to grow their programs unsustainably, must be reformed. Then, taxpayer-financed assistance should be targeted to truly deserving individuals using market-based principles that better align incentives of providers, recipients, states, and taxpayers. This is the path to put Medicaid spending on a more sustainable course.
The President should re-read his law if he believes its passage either improved Medicaid for those on it or reduced Medicaid spending growth.
By Douglas K. Smith, Member, Board of Directors, SeaChange Capital Partners
Social impact bonds, a useful experiment underway in England, is gaining attention on this side of the pond, including from the Obama administration. We are glad to see this at SeaChange (a non-profit group seeking innovative ways to bring capital to the non-profit sector). What is deeply concerning, though, is how some elites are packaging and promoting social impact bonds as yet one more example of everything the market does is good while everything government does is bad. Moreover, these same elites betray a stunningly superficial grasp about how markets actually work.
This is lamentable. Think for a moment about a common method among athletic coaches. Whether its tennis, golf, baseball, or any other sport, coaches know that athletes might get the right or wrong results by doing things the right or wrong way. You might win a tennis match with a sloppy forehand – and, ultimately, if you’re to improve your game, you need to win matches hitting forehands correctly. My skepticism, then, is less about using and learning from social impact bonds than about the ‘right result, wrong way’ advocacy that links them to ideological ‘givens’ about always good markets and always bad government. Moreover, this same overly simplistic positioning threatens to create ‘wrong result, wrong way’ outcomes by too easily producing misuses of social impact bonds in ways that cause them to fail.
For those who’ve not heard of them, let’s answer the Times’ David Leonhardt’s question, “What are social impact bonds?”
The short answer: a vehicle offering investors bond-like returns for taking equity-like risks on investing in potential solutions to socio-economic challenges. The key to success lies in the performance results achieved by the social service providers. If yes, investors gain bond-like returns sourced from cash linked to that performance. If the providers fall short, however, investors suffer equity-like losses. A group called Social Finance is experimenting with social impact bonds aimed at reducing recidivism among inmates in a UK prison. If they lower the recidivism rate by 10% greater than comparable prisons, investors gain between 7.5% to 13.5% returns. If the social service providers fail to do this, investors lose their money.
Let’s first look at the ‘right result, wrong way’ chorus on how social impact bonds derive from the wonderfulness of markets. Leonhardt does this. So does Harvard Professor Jeffrey Liebman in a Center for American Progress white paper on the subject.
Both are enthusiastic about how social impact bonds can bring much needed to capital to serious social ills. Terrific! Maybe we’ll get the ‘right result’. But why must each slide into the all-too-predictable ‘either/or-ism’ that bedevils our search for creative solutions to real problems. Not only do they premise support for social impact bonds on the monotonously dumb meme of ‘markets good/government bad’; but, they do so in ways that threaten to add the phrase ‘market discipline’ to ‘free markets’ and ‘shareholder value’ as yet one more entry in the mindless lexicon of the status quo.
Discipline is not a phenomenon uniquely linked only to markets – a point ignored by Liebman and Leonhardt. We can and do speak just as much about organizational disciplines, network disciplines and personal disciplines. What ‘market’, e.g., explains the discipline used by weekend tennis players to hit forehands correctly? Organizations, too, choose the disciplines used to achieve their purposes. Yes, sometimes those choices are influenced by markets – but not always and certainly not always in ways so ideologically implied by Liebman and Leonhardt.
Liebman notes that too many government programs have disciplines that focus more on defining activities than results. But it does not follow logically or empirically that ‘market discipline’ is the only cure when such an activity-focus has ill effects. (I say “when” because, while there are ill effects to address, Liebman’s ‘either/or-ism’ ignores the good effects of an activity-focus in governmental contexts; namely, the means and ends demanded by notions of fairness and due process inherent in some versions of the rule of law.) Most private sector organizations, by the way, also have various forms of activity-driven disciplines that arise from the operations of their hierarchies, management processes and shared values – patterns that emerge notwithstanding the effects of the disciplines imposed by the markets in which they compete. Consider only the long, sad history of American automakers over much of the last three to four decades. For them, activity-driven organizational disciplines trumped ‘market discipline’.
But the flip side is also in evidence. That is, in addition to observable private sector activity disciplines trumping market discipline, we also see plenty of examples of organizational performance disciplines instead of activity disciplines in the absence of any market. Over the past few years, for example, a range of Georgia state government leaders with whom I’ve worked have shifted their agencies toward performance disciplines for services ranging from driver’s license renewals to job preparedness to prison reform to education to highway maintenance and more. Millions of dollars have been put to more productive use, and dozens of innovations plus much better customer service and new capabilities have been spawned – and all in the absence of any discipline derived from any market.
Both/and. Not either/or. The bottom line: markets might impose performance disciplines on organizations. But, contrary to the ‘markets good/governments bad’ trope, there’s neither any guarantee that the existence of a market equates with a disciplined focus on performance nor the inevitability that the absence of a market prevents as much. Why then is there this deep-felt need by elites to hew their conversations to the ideological line of ‘markets good/governments bad’?
The absence of ‘market discipline’, then, does not prevent any agency at any level of government from a shift to performance: it’s a question of leadership and will. Might social impact bonds help? Yes. But it’s not the kind of sine qua non requirement suggested by Liebman’s and Leonhardt’s all-or-nothing use of a phrase like ‘market discipline’.
Next, the ideological use of ‘market discipline’ clothed in ‘market good/government bad’ rhetoric is, well, unreal. Liebman and Leonhardt are smart and accomplished individuals. They’ve been around. So, why the thundering silence about ‘market discipline’ and, ahem, you know, events of the past decade? How did this ideologically pure ‘market discipline’ work out in financial, residential and commercial real estate, health care, and other markets? Leonhardt points to the wasting of ‘billions of dollars’ in government programs. How about the trillions of dollars of value destruction in these arenas subject to ‘market discipline’?
The concept that market discipline guarantees efficiency and effectiveness is fallacious. Nearly four years ago, for example, it was clear that the performance disciplines used by the best non-profit housing groups far outstripped the performance disciplines used by the private sector in terms of delinquencies and foreclosures. Yet, the private sector got all the capital. So much for ‘market discipline’. What happened there? Was there no market discipline? Was there no link between capital markets and competitive performance?
No. Actually, the reverse. Capital market discipline combined with organizational and managerial disciplines to promote a peculiar kind of performance on private sector players. We all know the nice sounding words that were (and are) used for this: earnings, returns, ‘shareholder value’. It’s just that these melodious sounds became ever more narrowly and loudly linked to unsustainable and even criminal greed through the precincts of the shorter-term, the quicker buck, the larger bonus, and the faster, more untraceable shifting of risk to others. Yes, ‘market discipline’ focused all of the various players on performance – banks, mortgage brokers, real estate brokers, hedge funds, ratings agencies, lawyers, accountants and more. But instead of efficiency and effectiveness that maniacal performance focus gave us control fraud, speculation, looting and managerial–and-casino capitalism.
Does that make ‘market discipline’ evil and bad? No. Remember: both/and, not either/or. Liebman and Leonhardt would recoil at anyone who condemned ‘market discipline’ to be banished from human experience based on these gargantuan failures of the past decade. Why, then, do they crow so loudly in favor of market discipline as a panacea for government and social sector ills? Again, why only a reference to the billions wasted by (some) government efforts and not the trillions destroyed by (some) markets?
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