Grading the States on Health Care Costs

On the morning of February 26, the health committee of the National Governors Association met. According to The Washington Post, the goal was to come up with ideas to reduce state health care costs.

Temporarily putting aside deep divisions over the costly ObamaCare scheme, which faces attacks from Republicans on the presidential campaign trail as well as a Supreme Court challenge with arguments to be heard in March, there was a different emphasis. The Post reported that "both Obama's assistant health secretary, Howard Koh, and Iowa Gov. Terry Branstad, a major opponent who sued to block the law, focused Sunday on what they could agree on: cutting medical suffering and costs by encouraging disease prevention and healthier lifestyle choices."

Unfortunately, this is either political fluff, at best, or an expansion of government intrusiveness and busybody-ness, at worst.

A more substantive endeavor would start with a look at the SBE Council's "Health Care Policy Cost Index 2012," which ranks the 50 states and District of Columbia according to key public policies affecting health care costs and the costs of health insurance coverage.

For example, as noted in the report, the Kaiser Family Foundation/Health Research & Educational Trust reported, based on its "2011 Employer Health Benefits Survey," that the average annual premium for employer-sponsored family health coverage increased by 9 percent in 2011 to $15,073.

In terms of broader costs and spending, national health spending continued to rise, but at a slower rate in 2009 and 2010. The latest data from the Centers for Medicare & Medicaid Services noted that expenditures increased by 3.8 percent in 2009 and 3.9 percent in 2010. At the same time, though, government health care spending, and therefore taxpayer costs, have continued to rise rapidly - increasing by 9.7 percent in 2009 and 6.5 percent in 2010.

What drives health care costs higher? Part of the increase is positive, due to new and improved treatments and care. As for the negative aspects, though, costs are pushed higher due to third-party payments (e.g., when employer-provided insurance or a government program pays for treatment, neither the health care provider nor consumer needs to be concerned about costs, as a result prices and utilization increase); and more regulations and mandates, with government overruling the marketplace and forcing health insurers to extend coverage, or assess risk and price services based on political preferences.

The 2012 index ranks the states according to eight criteria. They include both negative measures, along with some positive reforms:

• Health Savings Accounts (HSAs). Health Savings Accounts provide much-needed choice, competition and consumer control in the health insurance marketplace. HSAs are tax-free savings accounts owned and controlled by individuals, with funds deposited tax free into the account by the employee, employer or both, and earnings accumulate tax free. The funds are used to cover regular, predictable medical expenses, and each HSA is tied to a traditional catastrophic insurance plan to cover large health care expenditures.

• Guaranteed Issue for Self-Employed Group of One and the Individual Market. Health insurance represents a significant cost for businesses. Taxes, mandates and regulations increase health care costs, increase the number of uninsured, and act as another disincentive to starting up or locating a business in a high-cost state. Guaranteed issue means that individuals may not be turned down for health insurance coverage no matter the condition of their health or risk status. So, incentives for people to purchase health insurance before they become ill are removed. A guaranteed issue mandate raises health care costs, in this case for the self-employed. The index looks at guaranteed issue for self-employed group of one and for the individual market.

• Community Rating for Small Group Market and the Individual Market. Community rating mandates that an insurer charge the same price for everyone in a defined region regardless of their varying health care risks. So, no matter what the risks involved, everybody pays the same price for insurance. That translates into higher costs across the board. The index includes community rating gauges for both the small group market and the individual market.

• High-Risk Pools. For individuals that cannot get health coverage due to pre-existing conditions, some states have set up high-risk pools. According to the Council for Affordable Health insurance, high-risk pools "provide a safety net for the ‘medically uninsurable' 1% to 2% of the population, who have been denied health insurance coverage because of a pre-existing health condition, or who can only access private coverage that is restricted or has extremely high rates." CAHI notes that "state high-risk pools are a much better alternative to providing coverage for the medically uninsurable than imposing guaranteed issue laws on insurers which eventually increase the cost of insurance for everyone."

• Number of Mandates. Beyond regulations like guaranteed issue and community rating, state laws impose a host of mandated benefits on insurers. These mandates, while often sounding reasonable, carry real and sometimes significant costs. Health care mandates are easy to impose, as politicians take credit for expanded benefits while denying the related costs.

• Per Capita Medicaid Spending. Taxes imposed on entrepreneurs, businesses and consumers are a reflection of the level of government spending. Medicaid spending is a significant cost for taxpayers, whether paid at the state or federal levels. For good measure, as government spends more on a service, in this case health care, the opportunities for waste, fraud, abuse, etc. increase, and spending accelerates faster than it otherwise might due to the incentives at work in government, which can best be summarized as elected officials and their appointees spending other people's money. In the end, as government spends more on health care services, the costs in those services accelerate.

According to these measures, the best 15 states in terms of state health care policies are: 1) South Carolina, 2) Iowa, 3t) Indiana, 3t) South Dakota, 5) Nebraska, 6) Utah, 7) Wyoming, 8) Montana, 9) Alabama, 10) Wisconsin, 11) North Dakota, 12) Oklahoma, 13) Kansas, 14) Alaska, and 15) Tennessee.

Meanwhile, the worst states are: 34t) Florida, 34t) Colorado, 34t) Maryland, 37) Michigan, 38) Pennsylvania, 39) Minnesota, 40t) Delaware, 40t) California, 42) Oregon, 43) District of Columbia, 44) Connecticut, 45) Washington, 46) New Jersey, 47) Vermont, 48) Rhode Island, 49) Massachusetts, 50) Maine, and 51) New York.

In the end, at the federal and state levels, three policy paths actually exist on health care. One is about political fluff and platitudes, which means the status quo. A second option is more government control and interference, and therefore increased costs and diminished care. And the third would mean pro-market reforms that expand choice and competition for consumers and businesses, and restraining the growth in negative costs. The choice is clear, but apparently many elected officials fail to see the obvious.


Raymond J. Keating is chief economist for the Small Business & Entrepreneurship Council. His new book is "Chuck" vs. the Business World: Business Tips on TV.