We are pleased that Jason Furman responded to our proposal by recommending that the book (on which we base the proposal) should be “required reading by specialists and non-specialists alike” and noting that he “would be perfectly happy if [our] proposal were adopted.” Both comments are extremely gratifying to receive from a skilled and insightful economist, and particularly from someone who was involved—at the highest levels of the Obama Administration—in crafting national health care policy. We're tempted to stop our response here.
If only Furman had, too.
But in the remainder of his essay, Furman critiques our proposal… and also complains that it can never get enacted. This pairing reminds us of the old joke about people critiquing the culinary options at a resort: the food is terrible… and such small portions!
We offered a two-part proposal for U.S. health insurance policy: (i) universal, automatic, basic coverage that is free for the patient; and (ii) the option to buy supplemental coverage in a well-designed market. Furman appears to have only one substantive critique with this proposal, which is the lack of cost sharing in the basic plan. He asks why everything in the basic plan should be covered for free, given the substantial body of evidence that cost-sharing is a “proven tool for reducing costs without worsening outcomes.”
We have no disagreement with Furman's description of the evidence on the impacts of cost-sharing. But cost-sharing cannot serve its cost-reducing function if most people and/or most expenses end up exempted from it. And, as we describe in our original Point piece, this is what has happened in countries around the world that have tried to introduce cost-sharing in their basic plan.
Furman takes note of our answer but argues that “their discussions of the experience of other countries feels like adding a political constraint to their optimization exercise, something they eschew in developing their overall approach.” We certainly agree that it would be inconsistent—and unpalatable—to pick and choose only some political constraints to respect. But our argument is not that we shouldn't have cost-sharing in the basic plan because it's politically unsustainable. Rather, our argument is that cost-sharing in the universal basic plan is substantively in tension with the very purpose of the existence of universal basic coverage: to provide access to essential health care, regardless of resources. There are always going to be people who cannot—or may not—be able to afford even small copays. This is why—in order to accomplish the purpose of the universal basic coverage—countries have found themselves compelled to issue an enormous set of exemptions. As we say in our original piece, cost-sharing in the basic plan is on a collision course with itself.
Furman further counters that a better approach would be income-related cost-sharing as originally proposed by Feldstein (
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