Tag Archives: Planned Parenthood

Can Health Care Bill Get GOP Off the Schneid?

29 Thursday Jun 2017

Posted by in Health Insurance, Obamacare

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health insurer bailout

For those who are “woke” to Obamacare’s failures, the Senate GOP’s health insurance reform bill has plenty to hate and maybe some things to love. There are likely to be some changes in the bill before it goes to a vote, which now has been delayed until sometime after Congress’ July 4th recess. Known as the Better Care Reconciliation Act of 2017 (BCRA), the bill is another mixed bag of GOP health care reforms and non-reforms. It is the Senate Republicans’ effort to improve upon the bill passed by the House of Representatives in May. The non-reforms are tied to an inability to repeal all aspects of Obamacare (the Affordable Care Act, or ACA) within the context of budget reconciliation, a process which permits a simple majority for approval of changes linked in some way to the budget (the so-called Byrd rule). Yuval Levin offers an excellent discussion of the bill and the general motivations for the form it has taken:

“They are choosing to address discrete problems with Obamacare within the framework it created and to pursue some significant structural reforms to Medicaid beyond that, and they should want the merits of their proposal judged accordingly. Their premise is politically defensible — it is probably more so than my premise — and the proposal they have developed makes some sense in light of it.“

It’s necessary to get one thing out of the way at the outset: the CBO’s scoring of the Senate bill is flawed in a massive way, like the earlier score of the House bill. The estimate of lost coverage for 22 million individuals is based on the CBO’s errant predictions of Obamacare coverage levels. (See here and here, and see Avik Roy’s latest entry on this topic.) Does anyone believe that enrollment on the exchanges will decline by 15 million in 2018 due to the elimination of the individual mandate? That’s over 40% more than total enrollment in 2017, by the way. Even if we attribute the CBO’s prediction to the elimination of both the individual and employer mandates, it would be an incredible plunge, especially given the means-tested tax credits in the BCRA. Does anyone believe that coverage levels under Obamacare would increase by 18 – 19 million by 2026 (mostly on account of the individual mandate)? That is the baseline assumed by the CBO in its scoring of the BCRA, which is laughable. A more realistic estimate of lost coverage under the BCRA might be 2 to 3 million, but remember that many of those coverage losses would not be “forced” in any sense. Rather, they would be purposeful refusals to take coverage with the demise of the individual mandate. But they would tend to be the healthiest of the current, coerced enrollees.

A related point has to do with hysterical claims that the BCRA will “kill thousands of people”. Someone cooked-up this talking (screaming?) point to rally the ignorant left and perhaps frighten the ignorant right (including a few GOP Senators). As Ira Stoll explains, there are several reasons to dismiss these assertions, not least of which is its tradeoff-free conceit. More ugly detail on the basis of these claims can be found here.

Will the BCRA “gut” Medicaid, as Charles Schumer, Nancy Pelosi and other have claimed? Program spending would not decline by any means, only its growth rate. Enrollment would decline with tougher eligibility rules, but as noted above, tax credits more generous than the Medicaid savings (relative to Obamacare) would help replace lost Medicaid coverage with private insurance. Steve Chapman has contributed one of the most nitwitted commentaries on Medicaid reform that I have seen. Not only do critics consistently ignore the proposed tax credits for coverage at low incomes, but they never address the monumental waste in the program., something that would likely improve under the budgeting requirements and additional discretion given to states by the BCRA.

An even crazier scare story going around is that the Senate bill will cut Medicare benefits. That is not the case, though the bill repeals an Obamacare Medicare tax increase on the self-employed.

Getting back to the broader BCRA, here are some of the major provisions:

  • Medicaid reform to replace the budgetary disaster of federal matching with per capita caps or block grants, and state program control.
  • Means-tested tax credits for insurance purchases would extend to low-income individuals who might otherwise lose their expanded Medicaid eligibility. According to Levin, this group is heavily weighted toward the unmarried and childless.
  • Greater state authority over regulation of the individual insurance market. This is accomplished through the availability of state waivers from many Obamacare regulations, including essential health benefits.
  • Almost all Obamacare tax provisions would be repealed. One exception is the “Cadillac” tax on high-cost employer plans starting in 2026 (after a temporary hiatus). Many of these repeals would benefit individuals broadly as taxpayers, employees, business people, and patients.
  • Expanded allowable age rating to 5/1 from 3/1. This helps limit adverse selection by pricing more risk where it exists, and the means-tested credits would help offset higher premiums for older individuals with low incomes.
  • Provides about $130 billion in “stabilization” funds for insurers over a three-year period. This is an attempt to keep premiums down during a transition over which the GOP probably hopes to enact additional deregulatory measures. Is this a practical maneuver? Yes, but it also reflects a bit of “corporatism-when-it’s-convenient” hypocrisy.
  • Eliminates funding for Planned Parenthood. Presumably funding could be restored later were the organization to split off its abortion services into a financially distinct division, which the Hyde Amendment would seem to require.
  • Retains coverage for pre-existing conditions.
  • Elimination of the individual and employer mandates, including the tax penalty. However, individuals who go without coverage for two months would face a six-month waiting period before they could re-qualify for coverage.

Eliminating the mandates is great from a libertarian and an economic perspective. The coercion inherent in those requirements is bad enough. In practice, the individual mandate has proven less effective in encouraging enrollment than Obamacare’s architects had hoped, which makes the CBO’s conclusions all the more puzzling. The employer mandate gives firms an incentive to reduce hours and employment, so it has extremely undesirable labor-market implications.

Most criticism of the BCRA from the right has centered on its failure to fully repeal Obamacare insurance and health care regulations. The continuation of Obamacare community rating is a major shortcoming of the bill, as it distributes the financial risks of medical needs in ways that do not correspond to the actual distribution of health risks. The result is the very same adverse selection problem we have witnessed on the Obamacare exchanges. Unfortunately, this raises the specter that we’ll be stuck with some form of community rating in the long-term, along with employer-provided coverage and the ill-advised premium tax deductions, which tend to inflate premium levels.

Michael F. Cannon of the CATO Institute calls the BCRA an Obamacare rescue package. John C. Goodman is largely in agreement with Cannon, stating that Republicans have no real desire to repeal Obamacare. Peter Suderman at Reason has many of the same concerns. In addition to community rating, Cannan (and Senator Rand Paul) are unhappy that Medicaid spending continues to grow under the bill with a new program of subsidies (tax credits) to boot! They also condemn the so-called “stabilization” or “cost-sharing” subsidies that would be paid to insurers under the bill. While a broader range of plans would become available, there is little confidence that insurers will be able to  bring down premiums and/or deductibles substantially without the added subsidies.

Avik Roy has defended the Senate bill for its proposed reforms to Medicaid, replacement of Obama’s Medicaid expansion with tax credits for private coverage, and transitional tax credits to smooth jumps in premium levels as income rises from low levels. This is an improvement over the House bill. However, marginal tax rates would be high under the BCRA for individuals in the range of income over which the credits phase out, which is a legitimate “welfare trap” criticism.

David Harsanyi also believes the bill is a good start:

“If Republican leadership had told conservatives in 2013 that they could pass a bill that would eliminate the individual and employer mandates, phase out Obamacare’s Medicaid expansion, cut an array of taxes, and lay out the conditions for full repeal later, I imagine most would have said ‘Sign me up!’“

Naturally, most critics of Obamacare have strong misgivings about a bill that would leave major components of the ACA’s structure in place. That includes Obamacare’s regulation of health care delivery itself, not just health insurance coverage. The BCRA might incorporate signifiant changes before it goes to a vote, however. One can only hope! Rand Paul has suggested breaking the bill into two parts: repeal of the ACA and other spending provisions, though it’s not clear how a repeal bill would qualify under the Byrd rule. Either way, the GOP intends to follow-up with additional health care legislation and administrative changes. Were a bill enacted soon, there is some chance that additional legislation could garner limited bi-partisan support. Long-term stability of the health insurance and health care markets would be better-served by a stronger semblance of political equilibrium than we have seen in the years since Obama was elected.

 

 

The Vagina Subsidies

08 Wednesday Feb 2017

Posted by in Health Care, Subsidies

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Many believe that women are entitled to taxpayer subsidies by virtue of “reproductive rights”, or simply gender disparities in health care costs. Is this reasonable from an economic perspective? Is it fair? Some components of this claim on public resources are highly controversial. I discussed these issues last week in the following post, originally titled “Spite and the ‘Right’ To Subsidies”:

The Women’s March on Washington on January 21st was not precise in communicating its real objectives. But the costumes were cute, and some critics felt that more of the men in attendance should have worn them. Anyway, the leaders and organizers fell short in terms of articulating a coherent agenda. Unless, of course, you just “got it”. These women were angry, but it’s not as contagious as they think: a great many circumspect women recognize the unmatched freedoms, privileges, and prosperity enjoyed by women (and men) in the U.S. The inherent divisiveness of identity politics is simply not appealing to everyone.

There are a number of reasons why those marching unfortunates might feel put upon, and it must have felt cathartic to wail and gnash teeth. The dissatisfaction is mostly related to the fact that Donald Trump is the president, but if I had to guess, I’d say a quarter of the marchers weren’t registered to vote. Probably a third of the remainder did not vote, despite their registration.

All that aside, what sort of policy purpose did the marchers hope to achieve? For one thing, they do not want to lose federal funding and cross-subsidies for support of women’s health issues, including reproductive rights or family planning (terms of art for preventing pregnancies). That’s a passable translation of “stay away from my vagina!” There are several avenues through which the federal government arranges payments or subsidies for women’s health services such as childbirth, maternity care, and birth-prevention products and services:

  1. Medicaid reimbursements account for the bulk of direct federal funding for family planning services; states are responsible for a major share of reimbursements as well.
  2. Federal funding also occurs under Title X, the Public Health Service Act of 1970, which authorizes federal grants for family planning services.
  3. Indirect funding occurs through cross-subsidies inherent in the structure of the Affordable Care Act (ACA), or Obamacare:
    • The ACA requires health insurance to include a set of “essential benefits”. Premium payments from those for whom such benefits are superfluous subsidize those who require those benefits.
    • The ACA prohibits “gender rating”, so that men effectively subsidize the higher cost of care and coverage for women (up to roughly middle age).
  4. Those purchasing coverage on the Obamacare exchanges may be eligible for federal subsidies on their premium payments.

Both Medicaid and Title X grants are intended to serve the family-planning needs of low-income women. Likewise, the federal subsidies (#4) for insurance covering family planning services, including contraceptives, are designed to assist low-income women. The cross-subsidies inherent in the structure of Obamacare premia confer family planning benefits (and penalties) across a broad range of incomes.

Reproductive Rights and Family Planning

Many taxpayers object to the use of tax dollars to pay for contraceptive services on religious or moral grounds. This is unrelated to a woman’s right to use contraceptives; it has to do with coerced payment for anyone’s contraceptives. The Supreme Court’s Hobby Lobby decision relieved private employers of the obligation to pay for abortifacients on religious grounds, however.

Even more controversial is the idea that federal tax dollars might be used to fund abortions. In fact, that is outlawed by the Hyde Amendment, a temporary provision routinely attached to budget appropriation bills each year. This amendment restricts the use of federal and state funds for abortion to cases of rape, incest, and when the mother’s life is in danger. Elective abortions, however, are not eligible for taxpayer funding. Unfortunately, Hyde and a related executive order issued by President Obama have not been wholly effective at preventing premium cross-subsidies and taxpayer subsidies from paying for elective abortions. That’s because of the limited choices of insurance plans available in many states and the failure of insurers and public authorities to monitor compliance. Carl Anderson in National Review explained these issues in “Obamacare’s Taxpayer-Funded Abortions“. Anderson points to the findings of a 2014 report from the federal General Accounting Office (GAO):

“Twenty-eight states have a legal environment that allows insurance plans within these exchanges to cover abortion. Among these 28 states, they found that 1,036 plans include abortion coverage, including every plan in New Jersey, Connecticut, Vermont, Rhode Island, and Hawaii. More than 95 percent of the plans in Massachusetts, New York, and California also cover abortion.

… The GAO report makes clear that those who want to find a plan that does not cover abortion will have a very difficult time. In some cases, the information is available in the Summary of Benefits. In other cases, it is only available on the insurer’s website. In other cases, the information is available only by calling the insurer.”

The ACA also required insurers to account and bill separately for abortion coverage, but compliance is spotty:

“… the GAO found that, of the 18 insurers it investigated, none of them charged separately for abortion coverage, and none of them even itemized the coverage on their bills.”

Planned Parenthood

It’s also quite likely that Title X grants and even Medicaid are funding abortions, despite prohibition by the Hyde Amendment. Medicaid is rife with mismanagement, with tens of billions of dollars of improper payments each year. Title X grants, if not tied to specific procedures, are used to cover overhead costs, some of which undoubtedly support the abortion practices of certain health service providers. Planned Parenthood (PP) is the largest abortion practice in the country, in furtherance of Margaret Sanger’s eugenic vision. Abortions have been declining nationwide in recent years, but PP’s abortion count has been fairly stable. Between 2009 and 2014, several other prominent PP services declined by half to two-thirds, such as cancer screenings, breast exams/breast care, and pap smears, while PP’s total income grew.

PP has aborted more than 300,000 pregnancies every year since 2007, yet the organization claims that those procedures account for only 3% of its activity. The 3% figure is derived by treating an abortion as the equivalent of a pregnancy test, or an STD test, or a breast exam, a PAP smear, or any other “discrete clinical interaction”. This renders the 3% claim meaningless, or much worse, a deception. Abortion is a costly procedure relative to most of the other services counted by PP as equivalent. “Prenatal care” services can be complex, but the small count of such services delivered (about 19,000 annually) indicates that it does not account for a major part of PP’s budget.

It is difficult to find information on PP’s fee revenue by service; one analysis concluded that abortions accounted for about 52% of PP’s fee income in 2010. But it is impossible to know exactly how the organization allocates public funds. Of course, fees from some services might cross-subsidize others. But almost half of PP’s annual budget is funded by taxpayers. Therefore, at a minimum, PP should be required to provide more auditable information on the question of how it allocates taxpayer funds.

Gender Rating

Another major source of cross subsidies is the absence of gender rating in insurance coverage under Obamacare and other law. Health care costs are higher for women than men for a variety of reasons: First, of course, there is childbirth and maternity care. Women also tend to utilize clinical services at higher rates than men. Perhaps women are more careful about attending to their health needs, as they are more likely than men to have regular checkups. They tend to have more stress fractures and other musculo-skeletal injuries. And they live longer than men, creating higher costs in their senior years. In the past, gender rating by insurers in the individual market led to premium disparities between women and men of 25%-85%. Some states have prohibited or restricted gender rating for years, however, and employer plans nationally have been prohibited from gender rating since 1978.

Prohibitions against gender rating, like other forms of community rating, are ill-founded from an economic perspective. Hadley Heath put it well in 2013 in “Women Should Pay More for Health Insurance“:

“Pregnancy and childbearing aside, women seek preventive care and visit doctors more often. But these additional screenings cost money, and the person receiving the care should pay for it, not other members of her insurance pool (community-rated or not). After all, women may reap the benefits of this behavior by living longer lives; they should also take on the costs. …

A better, more equitable solution would be for both men and women to pay for more noncatastrophic health expenditures outside an insurance plan. This is the only way to ensure that individuals — not pools of people — pay for what they consume. … If our premiums don’t reflect our risk, our claims or our costs, then some people will be overcharged and others undercharged. The overcharged parties will underinsure, and the undercharged parties will overinsure, perpetuating the problems in our current system.”

Those who over-insure, or who have access to services at prices below cost by virtue of mandates and cross subsidies, will over-utilize scarce health care resources. Eliminating the prohibition on gender rating would not foreclose the opportunity to obtain reasonably-priced health care coverage, however. In fact, eliminating over-charges to men would give them an incentive to remain in the risk pool, which would restrain pricing in age ranges through which women experience higher costs. The elimination of cross subsidies to women would ease cost pressure in the delivery of services as well. And interstate competition among insurers would give women a better set of choices and prices. Heterosexual married couples would split the difference in gender-rated premium levels, of course, but lesbian couples would probably bear higher costs. In general, allowing choice in selecting coverage levels would focus costs on cost-causers, a requirement for economic efficiency. For example, to the extent that many pregnancies are intended, maternity care actually fails to meet the definition of an insurable risk. Requiring others to pay those costs creates an incredibly arbitrary and unfair burden, though insuring against complications is a different matter.

Assisting Low-Income Women

Again, much of the federal funding at issue is directed at low-income women. This includes Medicaid, Title X grants, and Obamacare subsidies on policies purchased through the state exchanges. Current discussions regarding an ACA replacement plan would subsidize low-income individuals via refundable tax credits, which are free of the nasty incentive effects of coverage mandates combined with cross subsidies. While some contend that Medicaid is under threat, the most “extreme” plans discussed thus far are limited to replacing current federal funding practices with block grants to the states, who manage the program. The grants might be frozen at current funding levels. In view of the Medicaid waste identified by the GAO, there is a need to create incentives for states to manage the program more effectively.

The rules prohibiting taxpayer-funded abortion payments are unlikely to change, though they might be given a more permanent form than by Hyde, and compliance efforts might be tightened. It is mistaken to argue in this context that denying funds to a poor woman for an abortion is the equivalent of burdening society with more dependency. One error is in thinking that somehow life is for sale by taxpayers. It is not. The second is in assigning a negative value to a person with untold potential. Those individuals should be thought of as sentient human assets to be nurtured under policies that promote family stability, effective educational institutions and incentives for self-reliance. The third mistake is in selling short the charitable motives of pro-lifers, most of whom know that true charity has nothing to do with the state.

Your Vagina, My Money

The marchers on the 21st of January were motivated in part by possible changes in the availability of federal tax money for women’s health care under the Trump Administration. There are several avenues through which that support is provided as aid to low-income women. The funding mechanisms and management of these programs must be improved, and they must be made more accountable to taxpayers. Moreover, subsidies to women are provided through the structure of premiums under Obamacare, which distort economic incentives, misallocate resources, and undermine the stability of health care costs and insurance premia. An end to “one-side-fits-all” insurance mandates and gender rating would go far in improving the efficiency and equity of health insurance.

The marchers’ concern also revolves around subsidized access to contraceptives and federal support for organizations that provide abortion services. Even complete removal of that support would have no bearing on fundamental “rights” in any true sense. It has nothing to do with the existence of a right to abort children, only the question of who pays. Ultimately, your reproductive decisions, and your non-reproductive decisions, should be your own financial responsibility, your insurer’s, or that of others who might wish to assist you. Private donors give many millions of dollars to Planned Parenthood every year, and presumably could give more. Don’t ask for taxpayers to be involved with your vagina in any way.

Spite and the “Right” to Subsidies

02 Thursday Feb 2017

Posted by in Health Care, Subsidies

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img_3898

The Women’s March on Washington on January 21st was not precise in communicating its real objectives. But the costumes were cute, and some critics felt that more of the men in attendance should have worn them. Anyway, the leaders and organizers fell short in terms of articulating a coherent agenda. Unless, of course, you just “got it”. These women were angry, but it’s not as contagious as they think: a great many circumspect women recognize the unmatched freedoms, privileges, and prosperity enjoyed by women (and men) in the U.S. And the inherent divisiveness of identity politics is simply not appealing to everyone.

There are a number of reasons why those marching unfortunates might feel put upon, and it must have felt cathartic to wail and gnash teeth. The dissatisfaction is mostly related to the fact that Donald Trump is the president. But if I had to guess, I’d say a quarter of the marchers weren’t registered to vote. Probably a third of the remainder did not vote, despite their registration.

All that aside, what sort of policy purpose did the marchers hope to achieve? For one thing, they do not want to lose federal funding and cross-subsidies for support of women’s health issues, including reproductive rights or family planning (terms of art for preventing pregnancies). That’s a passable translation of “stay away from my vagina!” There are several avenues through which the federal government arranges payments or subsidies for women’s health services such as childbirth, maternity care, and birth-prevention products and services:

  1. Medicaid reimbursements account for the bulk of direct federal funding for family planning services; states are responsible for a major share of reimbursements as well.
  2. Federal funding also occurs under Title X, the Public Health Service Act of 1970, which authorizes federal grants for family planning services.
  3. Indirect funding occurs through cross-subsidies inherent in the structure of the Affordable Care Act (ACA), or Obamacare:
    • The ACA requires health insurance to include a set of “essential benefits”. Premium payments from those for whom such benefits are superfluous subsidize those who require those benefits.
    • The ACA prohibits “gender rating”, so that men effectively subsidize the higher cost of care and coverage for women (up to roughly middle age).
  4. Those purchasing coverage on the Obamacare exchanges may be eligible for federal subsidies on their premium payments.

Both Medicaid and Title X grants are intended to serve the family-planning needs of low-income women. Likewise, the federal subsidies (#4) for insurance covering family planning services, including contraceptives, are designed to assist low-income women. The cross-subsidies inherent in the structure of Obamacare premia confer family planning benefits (and penalties) across a broad range of incomes.

Reproductive Rights and Family Planning

Many taxpayers object to the use of tax dollars to pay for contraceptive services on religious or moral grounds. This is unrelated to a woman’s right to use contraceptives; it has to do with coerced payment for anyone’s contraceptives. The Supreme Court’s Hobby Lobby decision relieved private employers of the obligation to pay for abortifacients on religious grounds, however.

Even more controversial is the idea that federal tax dollars might be used to fund abortions. In fact, that is outlawed by the Hyde Amendment, a temporary provision routinely attached to budget appropriation bills each year. This amendment restricts the use of federal and state funds for abortion to cases of rape, incest, and when the mother’s life is in danger. Elective abortions, however, are not eligible for taxpayer funding. Unfortunately, Hyde and a related executive order issued by President Obama have not been wholly effective at preventing premium cross-subsidies and taxpayer subsidies from paying for elective abortions. That’s because of the limited choices of insurance plans available in many states and the failure of insurers and public authorities to monitor compliance. Carl Anderson in National Review explained these issues in “Obamacare’s Taxpayer-Funded Abortions“. Anderson points to the findings of a 2014 report from the federal General Accounting Office (GAO):

“Twenty-eight states have a legal environment that allows insurance plans within these exchanges to cover abortion. Among these 28 states, they found that 1,036 plans include abortion coverage, including every plan in New Jersey, Connecticut, Vermont, Rhode Island, and Hawaii. More than 95 percent of the plans in Massachusetts, New York, and California also cover abortion.

… The GAO report makes clear that those who want to find a plan that does not cover abortion will have a very difficult time. In some cases, the information is available in the Summary of Benefits. In other cases, it is only available on the insurer’s website. In other cases, the information is available only by calling the insurer.”

The ACA also required insurers to account and bill separately for abortion coverage, but compliance is spotty:

“… the GAO found that, of the 18 insurers it investigated, none of them charged separately for abortion coverage, and none of them even itemized the coverage on their bills.”

Planned Parenthood

It’s also quite likely that Title X grants and even Medicaid are funding abortions, despite prohibition by the Hyde Amendment. Medicaid is rife with mismanagement, with tens of billions of dollars of improper payments each year. Title X grants, if not tied to specific procedures, are used to cover overhead costs, some of which undoubtedly support the abortion practices of certain health service providers. Planned Parenthood (PP) is the largest abortion practice in the country, in furtherance of Margaret Sanger’s eugenic vision. Abortions have been declining nationwide in recent years, but PP’s abortion count has been fairly stable. Between 2009 and 2014, several other prominent PP services declined by half to two-thirds, such as cancer screenings, breast exams/breast care, and pap smears, while PP’s total income grew.

PP has aborted more than 300,000 pregnancies every year since 2007, yet the organization claims that those procedures account for only 3% of its activity. The 3% figure is derived by treating an abortion as the equivalent of a pregnancy test, or an STD test, or a breast exam, a PAP smear, or any other “discrete clinical interaction”. This renders the 3% claim meaningless, or much worse, a deception. Abortion is a costly procedure relative to most of the other services counted by PP as equivalent. “Prenatal care” services can be complex, but the small count of such services delivered (about 19,000 annually) indicates that it does not account for a major part of PP’s budget.

It is difficult to find information on PP’s fee revenue by service; one analysis concluded that abortions accounted for about 52% of PP’s fee income in 2010. But it is impossible to know exactly how the organization allocates public funds. Of course, fees from some services might cross-subsidize others. But almost half of PP’s annual budget is funded by taxpayers. Therefore, at a minimum, PP should be required to provide more auditable information on the question of how it allocates taxpayer funds.

Gender Rating

Another major source of cross subsidies is the absence of gender rating in insurance coverage under Obamacare and other law. Health care costs are higher for women than men for a variety of reasons: First, of course, there is childbirth and maternity care. Women also tend to utilize clinical services at higher rates than men. Perhaps women are more careful about attending to their health needs, as they are more likely than men to have regular checkups. They tend to have more stress fractures and other musculo-skeletal injuries. And they live longer than men, creating higher costs in their senior years. In the past, gender rating by insurers in the individual market led to premium disparities between women and men of 25%-85%. Some states have prohibited or restricted gender rating for years, however, and employer plans nationally have been prohibited from gender rating since 1978.

Prohibitions against gender rating, like other forms of community rating, are ill-founded from an economic perspective. Hadley Heath put it well in 2013 in “Women Should Pay More for Health Insurance“:

“Pregnancy and childbearing aside, women seek preventive care and visit doctors more often. But these additional screenings cost money, and the person receiving the care should pay for it, not other members of her insurance pool (community-rated or not). After all, women may reap the benefits of this behavior by living longer lives; they should also take on the costs. …

A better, more equitable solution would be for both men and women to pay for more noncatastrophic health expenditures outside an insurance plan. This is the only way to ensure that individuals — not pools of people — pay for what they consume. … If our premiums don’t reflect our risk, our claims or our costs, then some people will be overcharged and others undercharged. The overcharged parties will underinsure, and the undercharged parties will overinsure, perpetuating the problems in our current system.”

Those who over-insure, or who have access to services at prices below cost by virtue of mandates and cross subsidies, will over-utilize scarce health care resources. Eliminating the prohibition on gender rating would not foreclose the opportunity to obtain reasonably-priced health care coverage, however. In fact, eliminating over-charges to men would give them an incentive to remain in the risk pool, which would restrain pricing in age ranges through which women experience higher costs. The elimination of cross subsidies to women would ease cost pressure in the delivery of services as well. And interstate competition among insurers would give women a better set of choices and prices. Heterosexual married couples would split the difference in gender-rated premium levels, of course, but lesbian couples would probably bear higher costs. In general, allowing choice in selecting coverage levels would focus costs on cost-causers, a requirement for economic efficiency. For example, to the extent that many pregnancies are intended, maternity care actually fails to meet the definition of an insurable risk. Requiring others to pay those costs creates an incredibly arbitrary and unfair burden, though insuring against complications is a different matter.

Assisting Low-Income Women

Again, much of the federal funding at issue is directed at low-income women. This includes Medicaid, Title X grants, and Obamacare subsidies on policies purchased through the state exchanges. Current discussions regarding an ACA replacement plan would subsidize low-income individuals via refundable tax credits, which are free of the nasty incentive effects of coverage mandates combined with cross subsidies. While some contend that Medicaid is under threat, the most “extreme” plans discussed thus far are limited to replacing current federal funding practices with block grants to the states, who manage the program. The grants might be frozen at current funding levels. In view of the Medicaid waste identified by the GAO, there is a need to create incentives for states to manage the program more effectively.

The rules prohibiting taxpayer-funded abortion payments are unlikely to change, though they might be given a more permanent form than by Hyde, and compliance efforts might be tightened. It is mistaken to argue in this context that denying funds to a poor woman for an abortion is the equivalent of burdening society with more dependency. One error is in thinking that somehow life is for sale by taxpayers. It is not. The second is in assigning a negative value to a person with untold potential. Those individuals should be thought of as sentient human assets to be nurtured under policies that promote family stability, effective educational institutions and incentives for self-reliance. The third mistake is in selling short the charitable motives of pro-lifers, most of whom know that true charity has nothing to do with the state.

Your Vagina, My Money

The marchers on the 21st of January were motivated in part by possible changes in the availability of federal tax money for women’s health care under the Trump Administration. There are several avenues through which that support is provided as aid to low-income women. The funding mechanisms and management of these programs must be improved, and they must be made more accountable to taxpayers. Moreover, subsidies to women are provided through the structure of premiums under Obamacare, which distort economic incentives, misallocate resources, and undermine the stability of health care costs and insurance premia. An end to “one-side-fits-all” insurance mandates and gender rating would go far in improving the efficiency and equity of health insurance.

The marchers’ concern also revolves around subsidized access to contraceptives and federal support for organizations that provide abortion services. Even complete removal of that support would have no bearing on fundamental “rights” in any true sense. It has nothing to do with the existence of a right to abort children, only the question of who pays. Ultimately, your reproductive decisions, and your non-reproductive decisions, should be your own financial responsibility, your insurer’s, or that of others who might wish to assist you. Private donors give many millions of dollars to Planned Parenthood every year, and presumably could give more. Don’t ask for taxpayers to be involved with your vagina in any way.

Rent Seeking For Social Justice At Mizzou

15 Sunday Nov 2015

Posted by in Education

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Mizzou

Pre-blog postscript: In the wake of the tumultuous week discussed below, tonight Mizzou’s football team, which has struggled on the field this year, defeated a very good squad from Brigham Young University. Despite my strong misgivings about the actions of team members last week, tonight I am very proud of Mizzou, white, black and gold. Go Tigers!

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There is weak justification at best for the uproar over supposed racism and social injustice at Mizzou (the University of Missouri’s main campus in Columbia, MO). A protest highlighted by a hunger strike by one graduate student, a boycott by football players, and the threat of a walkout by faculty in nine academic departments led to the resignation last week of the university system’s president and the Mizzou chancellor, who were accused of inadequate sensitivity to the grievances of African-American students. The broader context for the protest is a nationwide assault on free speech, especially on college campuses, with demands for “safe spaces” and “trigger warnings” to protect students from words and acts that they might find offensive. This sensitivity is unbounded, and there is no limit to the censorship and fascism it brings forth in its proponents. From such sentiments are book-burners made.

It is a shame to see a great university like Mizzou reduced to groveling at the feet of petulant children who, ostensibly, have come to be educated, and often with financial support from the school. Full disclosure: Mizzou is my alma mater, so I am especially saddened by these developments. At the end of this post, I provide details on incidents that occurred at Mizzou over nearly three months leading up to the protest. Several of the incidents involved unproven and even false claims by the protestors.

Like it or not, speech outside the classroom by students at public universities has broad protection under the First Amendment. According to Eugene Volokh:

“Most clearly, students generally may not be expelled, suspended, or otherwise disciplined for what they say in student newspapers, at demonstrations, in out-of-class conversations, and the like… even if it’s offensive, wrongheaded, racist, contemptuous, anti-government, or anti-administration. Of course, it’s not protected from university criticism. The university is itself free to publicly speak to condemn student statements that university officials find to be unsound or improper.“

There are exceptions to this protection in the case of “fighting words” and “incitement”, but that kind of offense must be proven before an individual can be punished. It is absurd to demand that a university engage in unconstitutional restrictions on speech. Even if that were legal, it is unreasonable to expect a university to effectively police all speech on campus.

The Mizzou administration did take action this semester in the only case in which an individual engaging in racist speech was identified. The offender was intoxicated and disrupted an organization’s private rehearsal (see below). Whether he used “fighting words” is unknown, but a “conduct process” is still underway in his case. In addition, mandatory diversity training for students and faculty was announced by the chancellor in early October. It appears that the president, responsible for four campuses, may have delegated responsibility for managing the controversies in Columbia to the chancellor, but the failure of the president to respond directly was taken as dismissive. But in fact, Mizzou already had processes in place to address diversity issues, and the chancellor was active in communicating the administration’s concerns and support to minority students via social media. Still, the protestors assert that they were ignored and that no action was taken, among other falsehoods (see below).

In addition to an apology and removal of the University System president for “inaction”, the protestors demanded that the University meet a number of other conditions. These included a “racial awareness and inclusion curriculum throughout all campus departments” to be vetted by “students, staff, and faculty of color.” The protesters also demanded: “an increase the percentage of black faculty and staff campus-wide to 10%“; a 10-year strategic plan to improve retention of “marginalized students“; increased funding “for the purpose of hiring additional mental health professionals — particularly those of color“; and increased “funding and personnel for the social justice centers on campus for the purpose of hiring additional professionals, particularly those of color…”

The demands of the student protestors (and their faculty supporters) represent an exercise in rent seeking. They are attempting to commandeer resources at the cost of academic and educational efforts not explicitly dedicated to the theme of diversity and inclusion. If all of the demands are met, damage will be sustained by nearly all fields of study at Mizzou.

One of my frequent complaints about the Left is their inability to understand that rewards in a market economy are not zero-sum. Instead, they are earned by creating new value to be used in trade and enjoyed by others. The rent-seeking process disrupts that flow of benefits by using the power of government to extract resources from others for one’s private benefit, which then yields a negative-sum outcome for society. However, the resources sought by the Mizzou protestors must come from a public educational system for which funding is scarce. Funds provided to Mizzou by the state of Missouri have fallen significantly over the years, yet state law prohibits tuition increases for undergraduate residents exceeding the growth in the CPI. While the protestors might view their demands as reparation for past and ongoing injustices, many are already subsidized by an institution of higher learning that is strapped, and one that is already at their disposal for purposes of building their human capital. They should avail themselves of that opportunity so they can use that capital later in positive sum activities.

I also think the protests at Mizzou are symptomatic of misplaced priorities on the Left. I highly recommend this excellent essay by Jason Whitlock, an African-American sports journalist who notes that the protests at Mizzou have been given rapt attention by the Left, while the far more serious problem of black-on-black violence receives proportionately little play.

Much like other demands for “social justice”, the Mizzou protestors do not recognize the counterproductive nature of their activities and the measures they advocate. Merit will always be relied upon as as a standard by which people judge others. In a market system, it is a fairly objective standard at that. To a truly neutral observer, diversity is fine, but it is beside the point, and forced diversity often leads to suspicions of unfair play and resentment.

I find the attitude of the protestors appalling on several levels: the lies and the rent-seeking behavior, the damage they will inflict on Mizzou and their fellow students, and their rejection of good-faith efforts to address their concerns. To cap it all off, please read the childish posts shown in this article, in which the Mizzou protestors selfishly complain that the terrorist attacks in Paris have taken attention away from them, going so far as to characterize as “racist” the relative balance of coverage. Simply disgusting!

Sadly, there have been threats of violence on campus in the wake of recent developments. This week, a white teen in Rolla, Missouri, 100 miles from Columbia, was arrested and is being held without bond for making posts on social media that threatened black students at Mizzou. At the same time, hostility and threats toward campus greeks led to a lock-down at fraternities and sororities. As to racism, there is no doubt that it exists, but Mizzou is not exceptional in that regard. On campus, I believe that more racial tension is borne out of agitation from protestors than by any racist sentiments held by others. When the protestors acknowledge examples of apparently neutral, non-racist behavior by others, they insist that the racism they are fighting at Mizzou is systemic. Appeasing these complainants requires a ongoing series of reparations in the form of financial support, control over hiring, quotas and mandatory indoctrination. But here’s a clue: the social justice rap will never win the rewards and respect that arise naturally from hard work.

MIZ – ZOU!

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Here are key events or claims that led up to the present brouhaha at Mizzou, along with my editorial comments:

August 14: The university announced that it would no longer offer direct subsidies to graduate assistants for the purchase of health insurance. The reason? Obamacare prohibits the kind of low-cost, “individual market” policies (per IRS interpretation) offered by many schools. Mizzou, however, promised to provide a one-time fellowship to cover the economic loss suffered by grad students in the fall semester. When students threatened a walk-out, the university reinstated the subsidies, but with the proviso that a later review would be necessary. This incident had nothing to do with racism, but it inflamed passions. An African-Americam grad student named Jonathan Butler was very upset, even though his family is quite affluent and more than capable of affording his coverage.

August – September 2015: Mizzou cancelled contracts with Planned Parenthood (PP) clinics in the wake of the release of videos showing PP officials discussing the sale of fetal “tissue”. There was pressure on the school’s administration to cut ties with PP and revoke the “refer and follow” privileges of an abortion surgeon from St. Louis. These developments were very upsetting to the campus Left, and while gender-equality activists probably thought they had a legitimate gripe, the action should not be conflated with racism. Nevertheless, Jonathan Butler listed this issue as one of his grievances, and it helped to broaden support for his cause among the student Left.

October 3: The President of the Missouri Student Association, Payton Head, claimed that several men riding in the back of a pickup truck screamed racial slurs as he walked across campus. That is awful, but unless he can identify the individuals or the truck, nothing can be done about that particular incident. It was featured in Butler’s grievance letter to the university. Presumably, the school needs to racially-sensitize anyone with access to campus.

October 6: A white student, apparently drunk, interrupts a rehearsal of the Royalty Court of the Legion of Black Collegians with racial epithets. The student was identified the next day and removed from campus by the Office of Student Conduct pending the outcome of an ongoing disciplinary procedure.

October 10: The Homecoming parade is interrupted when University System President Tim Wolfe’s car is surrounded by students from an organization called Concerned Student 1950. (1950 was the first year that black students were admitted to Mizzou.) Wolfe instructs his driver to back away from the students. With more space between the car and the protestors, the driver attempts to proceed slowly to the right around the group. In this video, Jonathan Butler can then be seen rushing toward the moving car and planting his knees into the bumper. He later accused Wolfe and his driver of running into him. As the narrator on the video states, if this were an insurance case, that sort of fraud might get Butler arrested. After a short blank segment on the video, a so-called “townie” and a few other Mizzou football fans step forward to act as a barrier between Wolfe’s car and the protesters. Ultimately, Wolfe asked police to remove the protestors from the parade route. That was characterized as evidence of neglect on Wolfe’s part. Andrew McCarthy notes the following about Jonathon Butler:

“By the way, the racism is apparently so bad at Mizzou that Mr. Butler has chosen to pursue his Master’s degree (in education) there after attending the university as an undergraduate. Now in his eighth year at Mizzou, he hopes, according to NBC News, ‘to become an advocate and ‘social entrepreneur.””

October 24, 2015: Human feces is discovered on the floor of a restroom in a university residence hall; it had been used to smear a swastika on the wall. This is now confirmed by a campus police report, though no photographs of the “poop swastika” have been produced. (Apparently, a one-year-old photo of similar graffiti was circulated by protestors). The “poopetrator” has not been identified. The act could have been inspired by anti-Semitism, white supremism, simple pranksterism (albeit viciously expressed) , or quite possibly fraudulent agitation meant to incite fears on campus. The incident really did incite fears when it was communicated on social media by Residence Halls Association President Billy Donley. The poop swastika was taken as additional evidence of a bad racial climate at Mizzou, though the affair is suspect.

November 3: Butler begins a hunger strike in an impromptu “tent city” on campus. A student boycott of classes is announced the next day. I have strong doubts about Butler’s credibility (see below) and whether the hunger strike was authentic. He did not look or act like a hungry man before he ate his first post-strike sandwich, but I could be wrong.

November 8: Black football players announce their support of Butler by refusing to practice or play until President Wolfe apologizes and resigns. The next day, Coach Gary Pinkel tweets his support for the black players, and the athletic director agrees. Many of the white players also express support for the player boycott by appearing in a group photo, but it has been reported that not all of them agreed. (I personally believe that the whole lot of the boycotters were played by Butler and his organization.) On November 13, Coach Pinkel resigns, effective December 31, but the reason is a recent diagnosis of non-Hodgkins lymphoma (non-fatal). Some things are simply more important than in-fighting at the university. Coach Pinkel’s announcement, as sad as it is, may well help to defuse the immediate tensions.

November 10: President Wolfe and Chancellor R. Bowen Loftin resign. Butler ends his hunger strike with a sandwich as his friends urge him on with the expression “Yay N—–“, an utterance that may strike some as hypocritical. The football player boycott ends the next day.

On the evening of November 10 at about 11 p.m., Payton Head, the student body president, posted the following on Facebook:

“Students please take precaution. Stay away from windows in residence halls. The KKK has been confirmed to be cited on campus. I’m working with the MUPD, the state trooper [sic], and the National Guard.“

The news spread quickly. Head deleted the post by 11:30 and later apologized and accepted blame for spreading false information. Good for his accountability. His advice at that time was to trust only the @MUalert system, which had posted: “There is no immediate threat to campus. Please do not spread rumors…” 19 minutes before Head’s KKK post.

Must Support For “Family Planning” Be Compelled?

05 Monday Oct 2015

Posted by in Big Government, Liberty, Presumptive rights, Property Rights

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Fund Me

Where do Libertarians stand on the issue of federal funding of Planned Parenthood? What sort of balance should be struck between the rights of conscientiously-objecting taxpayers and the rights of women to use Planned Parenthood (PP) services? The correct answer has nothing to do with abortion, an issue on which Libertarians lack unanimity. However, the existence of moral objections by any segment of society, whether considered valid by a majority or not, is an important consideration.

Do Individual Freedoms Require Taxpayer Support?

Sheldon Richman discusses the funding question on his Free Association blog in “Planned Parenthood, Social Peace and  the Libertarian approach“. He first makes a basic point: “… no one’s freedom is violated by lack of access to taxpayer money.” I agree, but this statement requires some context. For Libertarians, the baseline is a society in which individual liberty is a presumption. That cannot be the case if taxes and transfers dominate our economic lives. If we’re all busy picking each other’s pockets, then perhaps anyone can lay claim to a dollop of public funds to pay for any damn thing they want. But in a society that explicitly limits the powers of coercive government, private individuals cannot, on the public dime, lay claim to whatever they wish to compel from others. What they desire, after all, is almost always available privately. Therefore, the denial of public funding for PP does not constitute a denial of anyone’s rights.

Individual’s are free to exercise their reproductive or non-reproductive rights as they see fit, and to pay for related services themselves or by seeking a benefactor. Nothing is deprived to that individual other than an invalid claim on the belongings of others.

“Individual rights ultimately boil down to the single right to be free from aggression, that is, to self-ownership. Rights would be defined out of existence if they could be ignored whenever doing so would make someone else’s objectives easier to accomplish. Such an approach to “rights” would turn rights theory on its head by making us a mere means to other people’s ends rather than ends in ourselves.“

Consistent Application of Property Rights

Richman asserts that the right of ownership of one’s body applies equally to the right of individuals to the income they produce:

“Ironically, the right to choose abortion is defended as an application of the right of women to their bodies, that is, as a property right (self-ownership). Another implication of the right to one’s own body is the right to control the fruits of one’s labor (income). No coherent theory of rights can permit a clash of the right to one’s body with the right to the fruits of one’s labor. Thus implicit in the pro-choice case is an argument against tax funding of Planned Parenthood (and anything else), that is, against taxation itself.“

Leftist elites say that a denial of public funding for PP is tantamount to a denial of service to low-income women. Richman asks the elites to put up or shut up: if they believe the services in question are critical, they are free support PP financially, but they much prefer to extract resources from taxpayers without regard to possible moral objections.

Protection of Religious and Moral Principles

Richman adds the following thoughts on public funding of Planned Parenthood near the end of his post:

“Reasonable people of all persuasions should see that it is simply unreasonable to force people to finance an organization they find morally offensive. Thomas Jefferson famously said, ‘To compel a man to furnish contributions of money for the propagation of opinions which he disbelieves is sinful and tyrannical.’ Compelling men and women to furnish contributions for the performance of services they deem immoral (whether or not they are) is worse.“

Supporters of public PP funding have sought to deflect morality-based opposition with the contention that abortions represent only 3% of PP’s services, but Slate debunked that claim over two years ago. It was based on a count of tests and procedures performed, not on revenue. PP also claims that tax funds never pay for abortion, but as Richman points out, once available, the revenue is fungible and may be used to cover the cost of any procedure. In short, the argument is specious.

The Public Good Argument Is Weak

One more elephant in the PP funding debate concerns the appropriate functions of government. Does PP provide a truly “public” good, one having benefits that are nonexclusive to the primary user? Health services are sometimes assumed to confer public benefits; that is an easy argument in the case of infectious diseases and to some extent for medical research, but not for most health services. The benefits of individual health services are largely private, providing little justification for government funding of PP from a public finance perspective.

Collective Action Needs Strict Limits

Collective action should be confined to the provision of public goods, but even then it can be fraught with conflicts, such as the difficulty of accommodating pacifists during wartime. A truly liberal society will do all it can to accommodate diverse beliefs by allowing objectors to opt out, if possible, or avoiding the funding of private activities, especially those over which there is significant dissent. Under no circumstances should one be compelled to pay for private services that they find to be morally objectionable.

OTC Birth Control vs. State Control

09 Tuesday Jun 2015

Posted by in Big Government

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cartoon_dancing

Why would the Progressive Left oppose over-the-counter birth control? Let us count the reasons…

Senator Cory Gardner (R-CO) has proposed a bill to eliminate the federal requirement that a doctor’s prescription is needed to obtain birth control. According to Gardner,

“Most other drugs with such a long history of safe and routine use are available for purchase over the counter, and contraception should join them.”

Six other Republicans have signed-on as co-sponsors. The change is sensible on many levels, from improving access to birth control to reducing health care costs, yet the Left and some so-called women’s advocates have reacted with horror. Most of what follows is discussed in two articles, “Why Liberals Oppose Over-the-Counter Birth Control“, by Jillian Kay Melchior, and “Republicans Push For Over-The-Counter Birth Control, Liberals Immediately Oppose The Plan“, from Before It’s News (BIN).

  1. “Free” birth control was offered under Obamacare. The Left claims that the OTC proposal is a conspiracy to eliminate federal funding of birth control and shift the cost burden back to women. Yet the bill does not change the coverage requirement in any way.
  2. The Left claims that the change to OTC will increase the cost of birth control. On one level, this is the same as #1. However, some have argued that the change will actually drive up the cost of contraception, and that’s a whole different level of delusional economics. Filling prescriptions involves much greater use resources than OTC, particularly the time of the physician and staff, the pharmacist, and the buyer. OTC would also remove a barrier to competition in the provision of birth control, which would reduce costs.
  3. Some physicians require an examination and even tests before they’ll write a birth control prescription, which can run into hundreds of dollars. Naturally, many of them would like to retain this flow of business, yet according to Melchior, “…the World Health Organization and the American Congress of Obstetricians and Gynecologists have confirmed that doctors can safely prescribe the pill without a full examination.” Freeing women of the need for a doctor’s blessing would  improve access unambiguously.
  4. Melchior also reports that “Planned Parenthood alone makes around $1.2 billion each year from contraceptive services.” Naturally, Planned Parenthood would like to protect that flow of revenue, but the availability of OTC birth control would expose it to competition.

What nonsense people spout in defense of their political agenda, not to mention their rents! The proposal for OTC birth control should be a slam-dunk liberalization, one that no self-respecting Liberal or Libertarian should oppose. But apparently, for the Progressives, helping women is secondary to preserving state control and the “statist quo”.