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Rio Grande Foundation
P.O. Box 2015 Tijeras, NM 87059
505-286-2030

THREE ESSAYS ON HEALTH IN NEW MEXICO

Reprinted from the Albuquerque Journal

by Micha Gisser

Essay One: Medicare Needs a More Logical Formula
December 11, 2003.

The number of physicians per capita is a major indicator of quality and quantity of health care services available in New Mexico, or anywhere. This ratio is a function of money available to pay physicians.

• A: The short run. The only provision in the (recent) tax bill proposals that makes economic sense is to rescind the gross receipts tax (GRT) paid by medical care providers. The report by the New Mexico Health Policy Commission, "Physician Supply in New Mexico: 2002," concluded that the main factor contributing to physicians leaving New Mexico is GRT. Consider a physician who grossed $350,000 a year, of which $100,000 from Medicare and Medicaid is not subject to GRT. After paying all expenses, the physician nets $150,000 income before taxes. Rescinding the GRT (5.8125 percent) would net the physician an additional $14,531- almost 10 percent of net income before taxes. Obviously, the relief from abolishing GRT on medical providers will be shared by both doctors and patients, but the lion's share will benefit the doctors. The GRT is a good tax, and except for the doctors' and hospitals' bills it should be retained. In particular, grocery tax on food should be retained.

• B: The long run. According to the U.S. Census Bureau, in 1998 the average number of physicians per 100,000 resident population in the United States was 251. For New Mexico this figure was 212. Is the physician shortage in New Mexico severe? The ratio for Massachusetts was 412. If we sort the 51 states (including D.C.) by a descending order, New Mexico is No. 32. Idaho, with a ratio of 154, has the most severe shortage.
Calculations based on the Census Bureau reports show that in 2000 the average Medicare expenditures per enrollee nationwide was $5,578. The highest level was $10,316 in D.C. The second highest was Louisiana with $7,342, and the lowest figure was $3,053 in Iowa. In New Mexico, the fourth state from the bottom, the average Medicare expenditures per enrollee amounted to only $3,729.

Getting New Mexico a little closer to the national average, say by increasing its Medicare allocation by 20 percent, roughly to $4,500 per enrollee, would increase the number of physicians by 17- from 212 to 229 physicians per 100,000 residents.

Obviously, the archaic formula used in the process of allocating Medicare money is senseless and disadvantageous to New Mexico. A basic economic principle tells us that, on average, in a free labor market, incomes of physicians (and nurses, etc.) across the U.S. would be proportional to the cost of living. For example, if the cost of living in California is 10 percent higher than in New Mexico, we should expect neurosurgeons to earn 10 percent more (in nominal terms) in California relative to New Mexico.

To illustrate the arbitrariness of the federal allocation of Medicare money, I compare two states, Texas and New Mexico. The accompanying comparison illustrates my point:
Texas and New Mexico: A Comparison Based on ACCRA

• Medicare expenditures per enrollee: 2000
$3,729 in New Mexico
$6,540 in Texas

• ACCRA cost of living: 2002, four-quarter average
103.7 in Albuquerque
91.9 in Houston

The cost of living in Albuquerque is 10 percent higher than in Houston. Yet, in 2000, Texas was allocated 75 percent more Medicare money per enrollee than New Mexico. This is ludicrous. States like Iowa, Vermont, Maine and New Mexico that come up on the short end of the stick should band together and form a political coalition for the purpose of revamping the allocation of Medicare money. To this end they must have a cross-sectional price index that would calculate the cost of living for each of the 51 states. There is no reason why the experienced Bureau of Labor Statistics could not undertake to perform this task.

Our congressional delegation should lead the battle for a logical distribution of Medicare money by first convincing their colleagues to legislate the creation of a cross-sectional Consumer Price Index. The distribution of Medicare money to enrollees should be determined solely by a cross-sectional price index.

We should note that New Mexico legislators deserve credit where the U.S. Senate failed. New Mexico law caps punitive and economic damages at $600,000. (See "Better Than Most" by Winthrop Quigley, Business Outlook, Albuquerque Journal, June 26, 2003). However, the fact that New Mexico offers physicians cheaper malpractice insurance than most of the country is not enough to overcome physician shortages.

Essay Two: Health Savings Accounts Cure Patients of Blind Consumption
April 23, 2004.

Those who advocate the nationalization of the American health-care system often cite the trend of rising national health expenditures as percentage of gross domestic product.
From 1960 to 2000, health care's share of GDP in the United States increased from 5.3 percent to 13.2 percent. Rising personal income, higher quality care and insurance that insulates individuals from health care's real costs are the main factors behind this trend.
From 1960 to 2000 real GDP per capita, has increased from $13,155 to $32,670 (expressed in 1996 prices). During the same period, real GDP per capita devoted to non-medical services increased from $12,458 to $28,3588. Put differently, the so-called explosion in medical-care expenditures reduced the average annual rate of growth of real GDP per capita devoted to non-medical goods from a potential 2.30 percent to 2.08 percent.

American consumers are wealthier than ever: The more than doubling over four decades of real GDP per capita excluding medical expenditures is reflected in real consumption. The "explosion" in medical-care expenditures ate a bite of our salad, but hardly the whole lunch. And for that increase in health spending, we receive better high-tech care that was not available at any price in 1960.

In that light, the present looks pretty good. The future looks even better, mainly due to the surge of American productivity and the Health Savings Account Act that President Bush signed into law in 2003.

Traditional medical insurance covers two dissimilar events: minor ailments and catastrophic illnesses. If a consumer faces a 5 percent probability that she will contact a catastrophic illness in a given year requiring $20,000 of medical care, she would be willing to purchase a policy for $1,000 (plus transaction costs). She will not use more of the heart-surgeon's services just because her out of pocket spending is zero.

This consumer also faces some probability of suffering the run-of-the-mill headaches, sniffles, backaches etc. Assume that she would be willing to purchase a policy for additional $1,000 for sniffles, etc. Under the tax law she is allowed to exclude $2,000 from her taxable income.
Her demand for care for minor illnesses is inversely related to price: At the true high price she would consult the medical encyclopedia and use over-the-counter drugs. At a low price- zero if her insurance pays the entire cost- she would consume much more care.

The problem with the prevailing medical insurance is that the third-party payment of health care bills insulates the consumer from the real costs of medical care services for non-catastrophic illnesses.

The new Health Savings Account law basically allows the consumer in our example to set aside $1,000 in an HSA that is tax exempt, and can be used for sniffles and headaches at her discretion. If this year she spent only $300, she can use the remaining $700 for next year's sniffles, or save it for retirement.

HSAs thus eliminate "moral hazard" by separating catastrophic from minor illnesses and injuries. Additionally, it is designed to enhance competition by eliminating managed-care-third-party restrictions. It is also likely that availability of HSAs would induce many of the uninsured to insure.

Furthermore, under the HSA law, it behooves our individual to convert a high-cost-$2,000 premium, low-deductible policy into a low-cost-$1,000 premium, high-deductible policy.
Before the HSA option was enacted, such a transition would have resulted in a loss; turning the $1,000 premium saving into taxable income would have resulted in a loss of roughly 40 percent (income and payroll taxes.) But now, the individual can use the sum of $1,000 to fund a health savings account, and the contribution to this account will be fully deductible, whether she itemizes deductions or not.

Because of the contribution of the new HSA law to competition and efficiency, the next four decades look even brighter than the previous four.

There are two additional legislative modifications that should be initiated at the federal level in order to further reduce the future costs of medical care:

• Congress should change the Medicaid formula for matching state funds to making block grants. With block grants, states will have stronger political incentives to distribute Medicaid money more efficiently.

• In July 2003, the U.S. Senate could not muster the 60 votes needed to pass the medical liability reform to cap medical malpractice damage awards. They should try again, because such a reform would go a long way to reduce the cost of physicians' services all over the United States.

The New Mexico Legislature removed the gross-receipts tax on payments to physicians from commercial managed care companies. But, the gross-receipts tax will continue to be imposed on the kind of out-of-pocket medical expenditures that would be made from health savings accounts. The 2005 Legislature should remove that vestigial gross receipts tax, an act that will make HSAs more attractive to consumers and help attract more physicians to New Mexico.

Essay Three: State Plan Should Include the Uninsured
June 3, 2004

Gov. Bill Richardson promises to try again in 2005 his plan to put some 600,000 public employees and retirees into a single health-insurance purchasing pool. While this plan would create a huge state institution that will not do much, if anything at all, for state and public employees, it does not address some of the serious health care problems we face in New Mexico.

The aims of any down-to-earth health care policy for New Mexico should be first to attract more physicians and other care providers to New Mexico; second to remove the vestigial gross receipt tax on out-of-pocket medical expenditures; and, third, examine the issue of the high rate of the uninsured in New Mexico.

The national rate of uninsured steadily, but slowly, increased from 12.9 percent in 1987 to 16.3 percent in 1998. Then it made a sharp turn and moved downward to 14.2 percent in 2000 and upward to 15.2 percent in 2002. The apparent cycle in recent years is mainly in response to changes in unemployment and health care costs. In the near future, when the unemployment rate will continue to decline, the national rate of uninsured will change course and turn southward. It is too early to make predictions about the long-run trend. In what follows I focus on interstate insurance comparisons.

The proportion of persons without medical insurance in New Mexico is one of the highest in the United States. Indeed, according to the U.S. Census Bureau, 14.6 percent of all Americans were without any insurance in 2001. Iowa , with 7.5 percent, had the lowest rate; Texas, with 23.5 percent had the highest rate; New Mexico, with 20.7 percent was the second highest.

I applied statistical procedures using Census 1999 and 2000 data for all the states for estimating the impact of economic and social variables on the rate of uninsured. First, I found that an increase of average personal income by $1,000 is expected to reduce the rate of the uninsured by 0.45 of one percentage point. Second, a one percentage point increase in the number of Hispanics is expected to result in a rise of one-third of one percentage point of uninsured persons. Third, a one percentage point increase in the ratio of blacks in total population is expected to result in only one-tenth of one percentage point increase in uninsured persons.

Why Hispanics are less likely than non-Hispanic whites to be covered by health insurance is a puzzle. New Mexico should support a study to explore this issue. Additionally, policy-makers should focus on the uninsured who are extremely poor, chronically ill or disabled. For starters, not all uninsured persons deserve subsidized medical care even when they earn low incomes. Consider young adults who just graduated from college. In general, these young adults are relatively more likely to contract HIV, suffer violent injuries in car accidents, and, if they are females, become pregnant. But, between their feeling of invincibility and small bank accounts, graduates shun inexpensive short-term plans.

Or, consider adults who are temporarily unemployed or in job transition and being aware of the de facto subsidized health care for the uninsured, fail to continue insurance by COBRA (Consolidated Omnibus Budget Reconciliation Act). Or, how about those who retire before qualifying for Medicare but decide not to buy an individual health plan because it is surprisingly more expensive than they imagined.

Finally, there are the risk lovers for whom gambling, no matter in what form, is fun. It is likely that the availability of Health Saving Accounts (HSA) signed into law by President Bush in 2003 will induce some of the above to insure themselves: HSA will give them the same tax advantages now granted to mostly all other groups.

But we cannot ignore the truly needy. Medicaid in New Mexico is very generous to children, including medically fragile children, the disabled, the aged who require institutional care and a variety of other needy persons, such as the blind. There is a subgroup, however, of extremely poor, chronically ill, or a combination of the above, adults who are uninsured and do not qualify for Medicaid. As an illustration, consider a single parent- a mother with two children- earning $20,000, or a married couple earning $20,000 in which one spouse is chronically ill.
Instead of rushing to embrace a grandiose plan creating a huge pool for state and local government employees, our elected leaders should focus on the extremely poor and chronically ill. We need a solid economic study, based on a fresh survey of uninsured persons in New Mexico. Such a survey should sort the uninsured not only by the traditional explanatory factors- income, ethnicity, age and education- but also by Medicaid eligibility, unemployment status, job transition, recent graduation from college, being chronically ill and so on. The order of magnitude of the number of the truly needy among the uninsured is essential before any sound policy regarding the medically uninsured can be considered.

Appendix

A Statistical Estimate of the Average Number of Physicians per 100,000 Residents in 1998 as a Linear Function of Personal Income, Medicare Expenditures per Enrollee and Medicaid Expenditures Per Recipient and per Capita

A Statistical Estimate of the Percentage Uninsured as a Linear Function of Personal Income, Hispanic and Black as Percents of Total Population, Educational Attainment and age

The Data are for 51 States