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Cleaving the Health Care Knot… Or Not

18 Saturday Mar 2017

Posted by pnoetx in Health Care, Obamacare

≈ 2 Comments

Tags

AHCA, American Health Care Act, Avik Roy, Budget Reconciliation, CBO, Community Rating, Congressional Budget Office, John C. Goodman, Medicaid Reform, Michael Cannon, Michael Tanner, Obamacare, Patient Freedom Act, Rand Paul, Refundable Tax Credits, Rep. Pete Sessions, Se. Bill Cassidy, Universal Basic Income, Yuval Levin

IMG_3957

Republican leadership has succeeded in making their health care reform plans in 2017 even more confusing than the ill-fated reforms enacted by Congress and signed by President Obama in 2010. A three-phase process has been outlined by Republican leaders in both houses after the initial rollout of the American Health Care Act (AHCA), now billed as “Phase 1”. The AHCA was greeted with little enthusiasm by the GOP faithful, however.

As a strictly political matter, there is a certain logic to the intent of “three-phase plan”: limiting the provisions of the AHCA to issues having an impact on the federal budget. That would allow the bill to be addressed under “budget reconciliation” rules requiring only 51 votes for passage in the Senate. Phase 2 would involve regulatory rule-making, or rule-rescinding, as the case may be. The putative Phase 3 would require additional legislation to address such unfinished business as allowing health insurance competition across state lines, eliminating anti-trust protection for insurers, and medical tort reform. How the sponsors will get 60 Senate votes for Phase 3 reforms is an unanswered question.

Legislative Priorities

Yuval Levin wrote a great analysis of the AHCA last week In which he described the structure of the House bill as a paranoid reaction to the demands of an “imaginary parliamentarian”. By that he means that the reforms in the bill conform to a rigid and potentially flawed interpretation of Senate budget reconciliation rules. Levin’s view is that the House should not twist itself up over what might be negotiated prior to a Senate vote. In other words, the House should concern itself at this stage with passing a bill that at least makes sense as reform, without bowing to any of the awful legacy provisions in Obamacare.

Medicaid reform is one piece of the proposed legislation and is reasonably straightforward. It imposes caps on federal funding to states after 2020, but it grants more flexibility to the states in managing the program. It also involves a tradeoff by allowing Medicaid funding to increase over the first few years, in line with the expansion under Obamacare, in exchange for capped growth later. The expectation is that long-term costs of the program will be reduced through a combination of the caps and better management at the state level.

The more complex aspects of the AHCA attempt to effect changes in the individual market. Levin offers a good perspective on these measures. First, he describes the general character of earlier Republican reform proposals from which the AHCA descends:

“Those various proposals all involved bringing premium costs down by enabling insurers to sell catastrophic coverage plans (along with more comprehensive plans) and enabling everyone in the individual market to afford at least those catastrophic coverage plans. This would enable far greater competition and let anyone not otherwise covered by insurance enter the individual market as a consumer.  …

The House proposal bears a clear resemblance to this approach. It involves some deregulation from Obamacare, it includes a refundable tax credit for coverage, it gestures toward incentives for continuous coverage. But it is also fundamentally different from this approach, because it functions within the core insurance rules established by Obamacare, which means it can’t really achieve most of the key aims of the conservative reforms it is modeled on.”

The rules established by Obamacare to which Levin refers include the form of community rating, which is merely loosened somewhat by the AHCA. However, the AHCA would impose a 30% penalty for those who fail to enroll while still healthy. This is a poorly designed incentive meant to substitute for Obamacare’s individual mandate, and it is likely to backfire. Levin is clear that this feature could have been avoided by scrapping the old rules and introducing a new form of community rating available only to the continuously insured.

The AHCA also fails to cap the tax benefits of employer-provided coverage, which retains a potential imbalance between the incentives for employer versus individual coverage. Levin believes, however, that some of these shortcomings can be fixed through a negotiation process in either the House or the Senate, if and when the bill goes there.

The CBO’s Report

As it is, the bill was “scored” by the Congressional Budget Office (CBO) with results that are widely viewed as unsatisfactory. The CBO’s report states that the AHCA would reduce the federal budget deficit, but the ugly headline is that relative to Obamacare, it woud cause 24 million people to lose their coverage by 2024. That number is drastically inflated, as Avik Roy demonstrated in his Forbes column this week. Here are the issues laid out by Roy:

  1. The CBO has repeatedly erred by a large margin in its forecasts of Obamacare exchange enrollment, overestimating 2016 enrollment by over 100% as recently as 2014.
  2. The AHCA changes relative to Obamacare are taken from CBO’s 2016 forecast, which still appears to over-predict Obamacare enrollment substantially. Roy estimates that this difference alone would shave at least 7 million off the 24 million loss of coverage quoted by the CBO.
  3. The CBO also assumes that all states will opt to participate in expanded Medicaid going forward. That is highly unlikely, and it inflates CBO’s estimate of the AHCA’s negative impact on coverage by another 3 million individuals, according to Roy.
  4. Going forward, the CBO expects the Obamacare individual mandate to encourage millions more to opt for insurance than would under the AHCA. Roy estimates that this assumptions adds as much as 9 million to the CBO’s estimate of lost coverage across the individual and employer markets, as well as Medicaid.

Thus, Roy believes the CBO’s estimate of lost coverage for 24 million individuals is too high by about 19 million! And remember, these hypothetical losses are voluntary to the extent that individuals refuse to avail themselves of AHCA tax credits to purchase catastrophic coverage, or to enroll in Medicaid. The latter will be no less generous under the AHCA than it is today. The tax credits are refundable, which means that you qualify regardless of your pre-credit tax liability.

Fixes

Despite Roy’s initial skepticism about the AHCA, he thinks it can be fixed, in part by means-testing the tax credits, rather than the flat credit in the bill. He also believes the transition away from the individual mandate should be more gradual, allowing more time for markets to being premiums down, but I find this position rather puzzling given Roy’s skepticism that the mandate has a strong impact on enrollment. Perhaps gradualism would convince the CBO to score the bill more favorably, but that’s a bad reason to make such a change.

It’s impossible to say how the bill will evolve, but certainly improvements can be made. It is also impossible to know whether Phases 2 and 3 will ultimately bring a more complete set of cost-reducing regulatory and competitive reforms. Phase 3, of course, is a political wild card.

Michael Tanner notes a few other advantages to the AHCA. Even the CBO says the cost of health insurance would fall, and the AHCA will bring greater choice to the individual market. It also promises over $1 trillion in tax cuts and lower federal deficits.

Alternatives

The GOP faced alternatives that should have received more consideration, but those alternatives might not be politically viable at this point. Some of them contain features that might be negotiated into the final legislation. Rand Paul’s plan has not attracted many advocates. Paul took the courageous position that there should be no entitlements in a reform plan (i.e., subsidies); instead, he insisted, with liberalized market forces, premium costs would decline sufficiently to allow affordable coverage to be purchased by a broad cross-section of Americans. Paul is obviously unhappy about the widespread support in the GOP for refundable tax credits as a replacement for existing Obamacare subsidies.

John C. Goodman has advocated a much simpler solution: take every federal penny now dedicated to health care and insurance subsidies, including every penny of taxes now avoided via tax deductions on employer-provided coverage, and pay it out to households as a tax credit contingent on the purchase of health insurance or health care expenses. This is essentially the plan put forward by Rep. Pete Sessions and Sen. Bill Cassidy in the Patient Freedom Act, described here. While I admire the simplicity of one program to replace the existing complexities in the federal funding of health care coverage, my objection is that a health care “dividend” of this nature resembles the flat tax credit in the AHCA. Neither is means-tested, amounting to a “Universal Basic Health Insurance Benefit”. Regular readers will recall my recent criticism of the Universal Basic Income, which is the sort of program that smacks of “universal state dependency”. But let’s face it: we’re already in a state of federal health care dependency. In this case, there is no incremental cost to taxpayers because the credit would replace existing outlays and tax expenditures. In that sense, it would eliminate many of the distortions currently embedded in federal health care policy.

A more drastic approach, at this point, is to simply repeal Obamacare, perhaps with a lengthy phase-out, and attempt to replace it later in the hope that support will coalesce around a reasonable set of measures leveraging market forces, and with accommodations for high-risk individuals and the economically disadvantaged. Michael Cannon writes that CBO estimated a simple repeal would increase the number of uninsured by 23 million over ten years, slightly less than the 24 million estimate for the AHCA! Of course, neither of these estimates is likely to be remotely accurate, as both are distorted by the CBO’s rosy assumptions about the future of Obamacare.

Where To Go?

Tanner reminds us that the real alternative to Republican legislation, whatever form it might take, is not a health care utopia. It is Obamacare, and it is collapsing. That plan cannot be effectively reformed with additional subsidies for insurers and consumers, or we’d find ourselves in a continuing premium spiral. The needed reforms to Obamacare would resemble changes contemplated in some of the GOP proposals. While I cannot endorse that AHCA legislation in its current form, or as a standalone reform, I believe it can be improved, and the later phases of reform we are told to anticipate might ultimately vindicate the approach taken by GOP leadership. I am most skeptical about the promise of subsequent legislation in Phase 3. I’ll have to keep my fingers crossed that by then, the path to additional reforms will be more attractive to democrats.

The Greening-Carbon Nexus

17 Saturday Dec 2016

Posted by pnoetx in Environment, Global Warming

≈ 2 Comments

Tags

Atmospheric Carbon Concentration, Climate Change, Climate Consensus, David Henderson, Global Greening, global warming, Harrison H. Schmitt, Matt Ridley, Pollution, Rand Paul, Rodney W. Nichols, Roy Spencer, Thomas Malthus

carbon_sequestration

Satellite records show that our world is experiencing a remarkable “greening” in the 21st century, to the seeming chagrin of the environmental left. There is now more vegetation than two decades ago, and greener vegetation, across as much as 50% of the Earth’s vegetated surface area. That area is expanding as well, and the creeping greenery has improved soil moisture levels in some drylands. This bodes well for agricultural productivity, putting another nail in Malthus’ coffin. The satellite studies have concluded that most of the enhanced vegetation is attributable to greater concentration of CO2 in the atmosphere, as opposed to warming or other possible causes. An interesting feedback is that the enhanced vegetation increases natural absorption of CO2, providing an enhanced carbon sink. This, in turn, has caused a pause in the growth of atmospheric carbon cencentration.

The environmental left knows these developments tend to undermine their preferred narrative that human emissions of CO2 must be reduced — at any cost. In fact, already there are warnings that global greening will “outgrow its benefit” as the greater volume of plants begins to decay, releasing carbon. You just can’t make some people happy! But not all of the carbon release from plant decay adds to atmospheric carbon — some is soil-bound — so the greening should provide a fairly durable carbon sink.

Global greening was one of the major motifs in Matt Ridley’s 2016 Global Warming Policy Foundation Lecture. Ridley covered various evidence of greening, but he also discussed the failure of a large contingent of climate researchers to follow a legitimate scientific approach to the study of climate change. Instead, they have politicized their field of study, committing a few noteworthy frauds along the way:

“It is irresponsible not to challenge the evidence properly, especially if the policies pursued in its name are causing suffering. Increasingly, many people would like to outlaw, suppress, prosecute and censor all discussion of what they call ‘the science’ rather than engage in debate. …

No wonder that I talk frequently to scientists who are skeptical, but dare not say so openly. That is a ridiculous state of affairs. We’re told that it’s impertinent to question “the science” and that we must think as we are told. But arguments from authority are the refuge of priests. Thomas Henry Huxley put it this way: ‘The improver of natural knowledge absolutely refuses to acknowledge authority, as such. For him, scepticism is the highest of duties; blind faith the one unpardonable sin’. 

What keeps science honest, what stops it from succumbing entirely to confirmation bias, is that it is decentralized, allowing one lab to challenge another.“

It is all too true that policies advanced in the interests of curbing a slight warming trend cause real suffering, and the pain is heavily concentrated on the most impoverished. The presumed benefits of activist climate-change policies are speculative, at best. They have little chance of reversing atmospheric carbon concentration on their own.

Ridley makes note of the substantial evidence that sensitivity of the climate to airborne carbon concentration is low. This has become increasingly evident with the unfolding of a consistent record of over-forecasts of global temperatures by climate forcing models. Roy Spencer provides insights about these models in a recent discussion of global warming and “dodgy science” on his blog.

There is a widespread myth that 97 percent of climate scientists believe human activity is the main cause of global warming. In fact, that claim was based on a paper counting citations, not scientists; the methods used in the study and the citations themselves were also questionable. I have reviewed that evidence here on Sacred Cow Chips. David Henderson reviewed it here. A large number of studies find fault with so-called “consensus” pronouncements. They should always be viewed with suspicion.

There is also a lively debate underway over whether CO2 should be considered a pollutant! I exhale, therefore I pollute? To the extent that fecal matter is considered a pollutant, is it fair that to say that CO2 is, too? After all, both are anthropogenic. No, they are not even close in terms of an immediate threat to human health. As a philosophical matter, the idea that anything done by man is “unnatural” denies the fact that we are a very part of nature. Obviously, CO2 is not in the same class as pollutants like sulfur dioxide, ammonia, carbon monoxide or toxic metals. Today, these pollutants are very common in many parts of the world, and they are very threatening to human life. Effective mitigation technologies are available, but instead, in the developed West, we fixate on an increase in CO2 concentration of 100 parts per million over many decades, the climate implications of which are de minimis.

Rand Paul’s Facebook page has an ungated link to a WSJ.com commentary by Rodney W. Nichols and Harrison H. Schmitt on “The Phony War Against CO2”. Their commentary provokes questions as to the motives of the environmental left, and certain members of the research community, in shilling for the cause. That we would fight the greening of the globe, and the potential agricultural benefit it could bring, is bizarre. To devote enormous resources to an endeavor that is largely futile is a waste and a tragedy.

 

Trump Tower of Babble

09 Sunday Aug 2015

Posted by pnoetx in Big Government, Marketplace of Ideas, Obamacare

≈ 2 Comments

Tags

Andrew Popkin, Bankruptcy, Brett Baier, crony capitalism, Donald Trump, eminent domain, GOP Debate, Hillary Clinton, Megyn Kelly, Obamacare, Peter Suderman, Rand Paul, single-payer plan, Vox

Presidential candidate, Donald Trump, has been critical of fellow Replubicans including Sen. John McCain. Some voters are curious about his "daffy" behavior.

Here’s a post-debate follow-up on Donald Trump the Shape Shifter: I’m surprised to hear anyone praising his performance after that debacle. He came off as a dick, and that’s really The Donald. I thought so before I heard that he suggested Megyn Kelly was menstruating that evening. Megan was tough, but please…. Trump is a loud-mouthed, offensive, and often incoherent bully.

Two Trump moments that I thought were amazing were his exchange with Brett Baier about political donations and his dust-up with Rand Paul over a single-payer health care system.

On donations, Trump seemed to take satisfaction in the fact that Hillary Clinton “had no choice” but to attend his wedding after he gave to her Senate campaign. He then made the following statement, which made me laugh:

“I will tell you that our system is broken. I gave to many people. Before this, before two months ago, I was a businessman. I give to everybody. When they call, I give. And you know what? When I need something from them, two years later, three years later, I call them. They are there for me. And that’s a broken system.“

Should I love him or hate him for that statement? He admits with no shame that he participates in crony capitalism, and he realizes that it’s corrupt. Andrew Popkin at Vox has a good analysis:

“Something Trump identifies that doesn’t always get mentioned is the way transactional politics transcend partisanship and ideology. Trump gave to Democrats and he gave to Republicans. He didn’t care what they believed. He cared what they could do for him. He wasn’t supporting them — he was buying them, and that’s completely different.“

It’s convenient for Trump to brag that he doesn’t need donations from others when campaigning. When he’s on the other side of the table, he’s happy to participate in the corruption. Did Trump buy the politicians who helped him arrange eminent domain actions against property owners who were in the way of his developments? He’s also quite proud of his use of bankruptcy laws allowing him to stiff lenders and investors in his enterprises. By the way, in comparing his four corporate bankruptcies to the many “deals” he’s executed over the years, he’d have you believe that the “deal” is always the relevant unit for a bankruptcy proceeding. That’s loose and misleading jargon.

I have said that Trump’s supporters really don’t know what their getting. Perhaps he won’t tell anyone because he’d lose “leverage”. A prime example of Trump’s shiftiness was his response to the following question on single-payer health care systems, including his attempt to embarrass Rand Paul:

Baier: “Now, 15 years ago, you called yourself a liberal on health care. You were for a single-payer system, a Canadian-style system. Why were you for that then and why aren’t you for it now?“

As Peter Suderman noted, Trump’s response to this question about health care began with his views on the war in Iraq. Donald’s rules…. But eventually, he addressed the health care question with a stream of words that thinking people might have been tempted to process logically in order to divine a coherent “Trump” position on the issue, but that would have been a mistake:

“As far as single payer, it works in Canada. It works incredibly well in Scotland. It could have worked in a different age, which is the age you’re talking about here.

What I’d like to see is a private system without the artificial lines around every state. I have a big company with thousands and thousands of employees. And if I’m negotiating in New York or in New Jersey or in California, I have like one bidder. Nobody can bid. You know why? Because the insurance companies are making a fortune because they have control of the politicians, of course, with the exception of the politicians on this stage. But they have total control of the politicians. They’re making a fortune.“

This is not a great moment of clarity for Trump. We still don’t know what he has in mind. He demonstrates that he doesn’t quite understand the inherent flaws in single-payer. If his complaint is with consolidation of the health insurance industry, single-payer would imply an even greater consolidation, indeed, a monopoly. A “private system” does not rule out single-payer. While the insurance companies have undoubtedly influenced politicians, just as Trump has, why is he complaining about a lack of choice, having just asserted that single-payer could work so well? And artificial lines have to do with non-price rationing, a typical feature of government intervention in markets. Thus far, the profits of under-pricing insurers have been protected by so-called “risk corridors” built into Obamacare. Would Trump allow health care providers and insurers to reprice in order to eliminate “artificial lines”? Trump’s words did not settle any questions about his position.

The end of Trump’s response is this:

“And then we have to take care of the people that can’t take care of themselves. And I will do that through a different system.“

So… was Trump still talking about single-payer or not? I forgive Rand Paul for imagining that he was. It was the only solid statement that one could cling to in Trump’s ramble.

Here is Suderman’s summary of Trump’s response with an account of the exchange with Rand Paul that followed:

“What matters is that [Trump] would be different. Different how? So very, very different—and definitely not a moron/loser/dummy/incompetent (pick one) like this other guy.

This is how Trump responds to almost everything: By not answering the question, by babbling out some at-best semi-relevant references, by promising to somehow be different and better without explaining how or why, and then by lobbing an insult.

An insult is how Trump finishes the Obamacare exchange as well. After Trump finishes answering the question, Sen. Rand Paul cuts in, saying, ‘News flash, the Republican Party’s been fighting against a single-payer system for a decade. So I think you’re on the wrong side of this if you’re still arguing for a single-payer system.’ [SCC’s bolding]

Trump’s comeback: ‘I’m not—I’m not are—I don’t think you heard me. You’re having a hard time tonight.’

The gist, as always, is that someone else—indeed, practically everyone else—is a dummy, a loser, a politician. Trump is the only one who really gets it, whatever it is.“

While I thought Rand Paul’s interjectory approach to debating was unwise, his comment to Trump was on-target, and he even qualified it. Trump responded with snark. Trump has yet to take a real position on health care in this campaign, but he has supported single-payer in the past. He doesn’t want to go to the trouble of deciding or revealing a specific plan just yet. Perhaps he’s “maintaining leverage”, keeping his options open, because he’s such a smart businessman. If you want to treat politics like a business deal, fine, but smart voters should be your partners, and they will expect you to reveal your terms.

Heal, You Dogs!

26 Tuesday May 2015

Posted by pnoetx in Obamacare, Shortage, The Road To Serfdom

≈ Leave a comment

Tags

Band the cost curve, Classical Values, Death Spiral, federal subsidies, Joel Winberg, King v. Burwell, Medicaid reimbursement, Obamacare, Rand Paul, Risk corridors, SCOTUS, Shortage

Doctor-shortage

In bondage to the State: The Classical Values blog has this interesting quote from Dr. Rand Paul:

“With regard to the idea of whether or not you have a right to healthcare, you have to realize what that implies….I’m a physician, that means you have a right to come to my house and conscript me, it means you believe in slavery. It means you’re going to enslave not only me, but the janitor at my hospital, the assistants, the nurses…There’s an implied threat of force, do you have a right to beat down my door with the police, escort me away, and force me to take care of you? That’s is ultimately what the right to free healthcare would be.”

It would be “free” only in nominal terms to the patient, and greatly degraded. The gap between the need for health care and the available supply cannot be solved via “conscription” of providers. And caring for the sick is one thing, but granting a “right” to well-care or health maintenance makes the gap much larger. Inadequate compensation to providers is an important subtext here, and it goes to the heart of the conflict. Basic economics tells us that the gap in access will expand if buyers are subsidized and providers are penalized by artificially low prices. The expanded eligibility for Medicaid in many states under Obamacare only exacerbates shortages, as physician reimbursements remain generally low.

Obamacare may have improved access to health care for a small minority of individuals, but only at the expense of penalizing many others, including providers. The program has fallen far short of its goal of covering the uninsured and has failed to “bend the cost curve” (despite false claims to the contrary, which attempt to take credit away from the Great Recession for slowing costs). Obamacare still looks to be unsustainable, as many have predicted. Insurers are now seeking large rate increases in many states, and going forward, they will not have the cushion of government-funded “risk corridors” when premiums fail to cover claims.

A Supreme Court ruling in the King v. Burwell case is due next month. The case has been discussed on this blog twice this spring. The plaintiffs have challenged federal subsidies in states relying on federal insurance exchanges in direct contradiction to the “plain language of the law”. The subsidies were intended to be an inducement to states to set up their own exchanges, but a number of states chose not to do so. A ruling for the plaintiffs would severely damage the Obamacare program, since the subsidies are key to making the relatively extravagant mandated coverage affordable to low-income individuals. However, Joel Zinberg insists that ending federal subsidies will not cause a death spiral.

Still, such a ruling would seem to give Congress and the Republicans an opportunity to craft legislation to replace Obamacare with a more viable program. Republicans seem have been unable to craft a strategy for dealing with this contingency, but their best strategy might be to wait, pass an extension of subsidies until 2017, and dare Obama not to sign it into law.

Court Strength In The Constitution

30 Friday Jan 2015

Posted by pnoetx in Judicial Branch

≈ 1 Comment

Tags

Boston Globe, Constitutional rights, Damon Root, Judicial Activism, Judicial Restraint, Original Intent, Rand Paul, Randy Barnett, Reason Magazine

santorumandi

An important function of the judicial branch of government is to defend the U.S. Constitution and the constitutional rights of individuals. In my view, deference on the part of courts to legislative decisions or to court precedent should be viewed with skepticism. The plain text of the Constitution should always come first. Beyond that, however, judges should not interject their personal opinions into decisions. Does this position support so-called “judicial activism”, or “judicial restraint”? Many legal thinkers reject that dichotomy because it embodies contradictions, failing to reliably categorize my position combining constitutional precedence with a rejection of political preference in jurisprudence. The pairing seems natural enough to me.

“Judicial activism” is often used as a pejorative, as Randy Barnett says at the link above, quoting a Boston Globe article that quotes him:

” ‘Most people who use the term don’t provide a coherent definition of it. It typically means judicial opinions with which they disagree,’ says Randy E. Barnett, a law professor at Boston University who considers himself a libertarian and a defender of ‘original intent’ in Constitutional matters. [He should have written ‘original meaning’ not “original intent” –RB.]”

According to Reason‘s Damon Root, Rand Paul calls himself a judicial activist. It would be interesting to hear exactly how he defines it, but he also purports to be something of a strict constitutionalist. In “Why Rand Paul’s Case for ‘Judicial Activism’ Scares Both Liberals and Conservatives“, Root discusses the interesting coincidence that contrary to Paul, both traditional conservatives and progressives seem to believe in judicial restraint. His explanation:

“What these two views share in common is that they each support what amounts to virtually unchecked majoritarian rule over certain aspects of American life. For conservatives, judicial deference means that lawmakers get the last word when it comes to banning birth control and prohibiting ‘homosexual conduct.’ For liberals, judicial deference means that lawmakers get the last word when it comes to bulldozing private property in the name of eminent domain. Each approach demands judicial passivity in the face of its preferred forms of government action.”

Of course, there are lovers of government power on both the left and the right. Rand Paul wants to distance himself from their kind, but many libertarians do not believe he will stick to principles of limited government as he campaigns for the GOP nomination.

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