Minor Thoughts from me to you

Today’s New York Times features an opinion piece by J.D. Kleinke of the conservative American Enterprise Institute. Kleinke’s thesis is that ObamaCare’s conservative opponents should stop complaining. “ObamaCare is based on conservative, not liberal, ideas.”

If one defines conservative ideas as those that emphasize free markets and personal responsibility, there is zero truth to this claim.

Michael Cannon goes on to elaborate and then concludes with:

Even if one adopts the more forgiving definition that conservative ideas are whatever ideas conservatives advocate, there still isn’t enough truth to sustain Kleinke’s point. Yes, the conservative Heritage Foundation trumpeted ObamaCare’s regulatory scheme from 1989 until around the time a Democratic president endorsed it. But as National Review‘s Ramesh Ponnuru writes, accurately, “The think tankers were divided, with the Heritage Foundation an outlier. It was an outlier, too, in the broader right-of-center intellectual world.”

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John Goodman talks about how HSA's help customers save money and help lower costs for the overall healthcare system. Too bad the Obama administration, through Obamacare, wants to get rid of HSAs.

Megan Johnson, a self-employed single mother in Dallas, had severe pains in her side and back, just below the ribs. Her doctor said it was possibly kidney stones, but a CT scan would be necessary to confirm the diagnosis. Megan's doctor gave her the name of an outpatient radiology department near her home. A call to the hospital revealed her share of the cost would be more than $2,800. Because Megan's health insurance had a $5,000 deductible, she decided to ask some questions: Do I really need this? Is it less expensive anywhere else?

A quick search of HealthcareBlueBook.com confirmed a reasonable price for an abdominal CT scan was about $800 - not $2,800. More online research identified dozens of medical imaging centers - including one next to the doctor's office. The insurance company negotiated price was $407 - a fraction of the initial price the hospital quoted. Megan was able to save nearly $2,400 by simply doing a little research online.

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Former "car czar" Steven Rattner, fresh off of "rescuing" GM, is in favor of healthcare rationing by government bureaucrat.

We need death panels.

Well, maybe not death panels, exactly, but unless we start allocating health care resources more prudently — rationing, by its proper name — the exploding cost of Medicare will swamp the federal budget.

This is the inevitable result of third-party payment: some paper pusher will arbitrarily cut off care once you've "had enough". Or we can move back to buying healthcare like we buy everything else in life: paying for healthcare out of a mix of savings and insurance, shopping for the lowest price, and taking responsibility for deciding what is and isn't necessary. There is no middle ground here.

I know which way I want to go and it's not through rationing by a board of government "specialists".

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John Goodman writes about something that will be a big problem, as medical knowledge increases. We're increasingly finding out that different people respond differently to the same treatment, depending on their genetics and the DNA of whatever is attacking them. As our knowledge about these differences increases, we will increasingly have individualized treatments.

Everything about ObamaCare — from its emphasis on pilot programs and demonstration projects to its faith in “evidence-based care” — is all about standardization. It’s about treating all patients with the same condition the same way. It’s about herd medicine. It’s about cookbook medicine. It’s about assembly line medicine. It’s as different from personalized care as different can be.

Unless we make large scale reforms to our existing regulations, we will increasingly end up knowing how to treat someone's condition yet it will illegal for the doctor to deviate from the standardized treatment in order to apply the personalized care that the patient needs.

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Here is a brief review of the literature: Robert Book discovered that reported Medicare’s administrative costs per patient (not as a percentage of the bills) were actually higher than private insurance. A Milliman study concluded that when all costs are considered (including the cost of tax collection) Medicare’s cost as a percent of total spending is 66% higher than private insurance. Ben Zycher concludes that a government run system would have higher administrative costs than a private system. And Tom Saving and I showed (based on CBO numbers) that Medicare has not been more successful that the private section in holding down costs — as Krugman, Robert Reich and others have claimed.

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Veronique de Rugy is worried that Romney / Ryan's talk about "protecting Medicare" means that they won't really push to reform it.

The only way to ensure that Medicare is there “for my generation, and for my kids and yours,” reform it. If when Representative Ryan says “protect” and “strengthen” he means “reform Medicare,” great. Reform can take many forms, obviously. But, then we can believe Ryan when he says “ladies and gentlemen, our nation needs this debate. We want this debate. We will win this debate.”

She lays out all of the reasons why Medicare desperately needs to be reformed, if it's to survive at all. It's worth a read, especially if you're not convinced about the necessity of reforming Medicare.

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Yuval Levin fact checks a Paul Krugman column about Paul Ryan's speech and about Medicare reform. Yuval demonstrates (with copious links to evidence) all of the ways in which Paul Krugman is wrong about Medicare, wrong about Ryan's plan. It's the best single summary of everything wrong with Medicare that I've seen yet—and it explodes quite a few myths about Medicare's affordability, sustainability, and efficiency.

Here's a small taste.

To begin with, many of Medicare’s most significant administrative costs are just covered by other federal agencies, and so don’t appear on Medicare’s particular budget, but are still huge costs of the program. The IRS collects the taxes that fund the program; Social Security collects many of the premiums paid by beneficiaries; HHS pays for a great deal of what you would think of as basic overhead, but doesn’t put it on the Medicare program’s budget. Obviously private insurers have to pay for such things themselves. Medicare’s administration is also exempt from taxes, while insurers pay an excise tax on premiums (which is counted as overhead). And private insurers also spend a great deal of money fighting fraud, while Medicare doesn’t. That might reduce the program’s administrative costs, but it greatly increases its overall costs. Some administrative costs save money, after all: The GAO has estimated that a $1 investment in pre-payment review of claims, for instance, would save $21 in improper Medicare payments.

It's worth reading the entire thing. Especially if you think Medicare doesn't need to be changed.

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Austin Frakt, at The Incidental Economist, leads his readers through an exercise demonstrating that total employee compensation is a mix of salary and healthcare benefits. He demonstrates that if healthcare costs went away, employers would have to offer a higher salary.

Of course, the reverse is also true: if health insurance gets more expensive, employers will offer a lower salary (or just postpone raises indefinitely). Salary stagnation, then, is an artifact of increasing health insurance costs, not a sign of a poor economy.

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One issue that does not get enough attention is the prosaic act of shopping.   I spend my own money, and I care about price.  I spend someone else's money, I don't give a rip.  Josh Cothran did a visualization of who is spending health care money.  Just look at the 1960 and 2012 charts, and pay particular attention to the orange "out-of-pocket" number.  Another way to rewrite these charts is to say consumers care about prices for spending in the orange band only.

Also, healthcare providers only care about your happiness to the extent that you're paying them. If you're not paying out of pocket, they don't care whether or not you're happy with your healthcare.

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John Goodman talks about what irritates him, in healthcare policy discussions.

It’s impossible to have a rational discussion about health policy when one side of the argument is irretrievably deceitful. Here are some things I find irritating, to say the least:

• A White House that claims the way to control health care costs is to follow “evidence-based” guidelines, doing only procedures that are cost effective.
• A White House that then uses taxpayer dollars to promote procedures that are not evidence-based or cost effective for blatantly political reasons.
• A sycophantic press corps and fellow-traveling health policy bloggers who either remain silent or actually apologize for this hypocrisy.

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On Saturday, the Obama campaign released this ad attacking the Romney Medicare proposal. The ad doesn’t walk some sort of narrow line between misleading and deceiving, it’s just simply a pack of lies from top to bottom.

Yuval Levin provides his own analysis of a recent Obama campaign ad, related to Medicare reform.

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on Saturday, the Obama campaign came out with a new ad, approved by the President, claiming that Mitt Romney’s Medicare plan could require seniors to pay $6,400 more a year for health insurance. That claim is not only false, but brazenly and incontrovertibly so. Indeed, almost everything in the ad is wrong except for the phrase “I’m Barack Obama, and I approved this message.”

Democrats making things up about Republican reform plans? I'm shocked, simply shocked!

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During his first run for president, Barack Obama made one very specific promise to voters: He would cut health insurance premiums for families by $2,500, and do so in his first term.

But it turns out that family premiums have increased by more than $3,000 since Obama's vow, according to the latest annual Kaiser Family Foundation employee health benefits survey.

I must say, that's a totally unexpected result after increasing government regulations.

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David Autor of MIT talks with EconTalk host Russ Roberts about the Social Security Disability Insurance (SSDI) program. SSDI has grown dramatically in recent years and now costs about $200 billion a year. Autor explains how the program works, why the growth has been so dramatic, and the consequences for the stability of the program in the future. This is an illuminated look at the interaction between politics and economics and reveals an activity of government that is relatively ignored today but will not be able to be ignored in the future.

Some interesting facts.

• Disability insurance includes both a monthly cash payment as well as access to Medicare.
• The disability rolls have more than doubled in in the last 13 years, from 1.2 million people to 2.9 million people.
• Divided by the number of U.S. households, we're spending more than $1500 per U.S. household, on disability insurance.
• By law, the program is biased on favor of people making disability claims. It's comparatively easy to get disability and very, very hard to prove that someone either no longer needs disability or that they made a fraudulent claim in the first place.
• Law firms helping people get disability are entitled to 25% of the disability back benefits. Each year, the Social Security Administration pays out more than $1 billion to these law firms.
• In 1984, SSDI consumed 5% of all Social Security revenues. In 2004, SSDI consumed 10% of all Social Security revenues. It now consumes all of the dedicated SSDI revenue and is cutting into the general Social Security revenue. At the current rate of expenditure, the SSDI trust fund will be exhausted within 5 years.

It looks like SSDI is something that we need to start thinking about reforming as well, as it grows increasingly more expensive to maintain.

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Avik Roy dives into the recent history of healthcare reform and details the bipartisan plan that the Democrats killed, in order to pass a partisan plan of their own.

Hence, a bipartisan health-care agenda at the federal level will necessarily look quite different than one at the state level. If liberals had bothered to ask, they could easily have elicited bipartisan support for a proposal that did the following: (1) set up the Obamacare exchanges for those under 400% of FPL; (2) applied the Ryan reforms to Medicare and Medicaid (or, alternatively, folded in Medicare and Medicaid acute-care into the PPACA exchanges); (3) equalized the tax treatment of employer-sponsored and individually-purchased insurance; and (4) not increase taxes or the deficit.

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I like the way Sheldon Richman explains the difference between freedom and compulsion, between negative liberty and positive liberty.

Here's the bottom line.

What we have in this debate is a clash not between two liberty interests, but rather between two rights-claims – one negative (genuine), the other positive (counterfeit). All that is required for the exercise of a negative right (to self-ownership and, redundantly, liberty and one’s legitimately acquired belongings) is other people’s noninterference. (“When we say that one has the right to do certain things we mean this and only this, that it would be immoral for another, alone or in combination, to stop him from doing this by the use of physical force or the threat thereof,” writes James A. Sadowsky, S.J.) But the fulfillment of positive rights requires that other people act affirmatively even if they don’t want to — say, by providing products or paying the bills. If one person’s freedom depends on the infringement of someone else’s freedom, the first claim is illegitimate. To hold otherwise is to reject the principle of equality.

This controversy is not about contraception. It’s about freedom versus compulsion.

And here's the part that's been driving me nuts for two weeks now. There are too many smart people repeating this line. Are they really that dumb? Or do they just think that everyone else is?

How exactly was the liberty to use contraception jeopardized by the Catholic exemption? In no way would a woman’s freedom in this respect be infringed simply because her employer was free to choose not to pay for her contraceptive products and services.

Yet advocates of Obamacare insist on conflating these issues. They repeatedly portray opposition to forced financing of contraception as opposition to contraception itself. (Alas, some conservatives have encouraged this conflation.) Must the difference really be spelled out?

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In 1986, Congress passed EMTALA, making it a federal crime to transfer a patient from one hospital/emergency room to another for financial reasons. It compels hospitals to render care, even without any compensation.

... But EMTALA did more. It killed the voluntary nature of the Medicaid system.

... Today, if Arizona decided to leave Medicaid and resume its pre-Medicaid system, it couldn’t do so. EMTALA would prevent it from functioning. EMTALA specifically bans any hospital from transferring patients for financial reasons. Arizona’s pre-Medicaid system depended upon the transfer of indigent patients from private centers into its indigent health system, thus relieving private hospitals and providers from the burden of constantly providing uncompensated care.

States should be free to design their own systems and innovate, instead of all being forced into the same rigid mold.

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A. Barton Hinkle examines the Virginia state budget and determines that increased Medicaid spending is the big reason that the state government has had to cut the budget in recent years.

To hear some folks tell it, budget cuts in Virginia over the past three to four years have been so savage it’s a miracle there’s any state government left. We long ago cut out all the fat and hacked through the muscle; now we’re sawing deep into bone. Localities are scared stiff that the state will stiff them come January. And it’s only going to get worse. Gov. Bob McDonnell has had state agencies prepare plans cutting 2 percent, 4 percent, and 6 percent from their budgets. The stories have grown numbingly familiar.

Still: The general fund has grown roughly $1 billion from last fiscal year to this one. That represents about a 6 percent hike. So why is the governor asking agencies to plan for cuts?

… For example: From fiscal 2008 to fiscal 2012, general-fund outlays for the Department of Medical Assistance Services (that’s the one responsible for administering Medicaid and the state’s Children’s Health Insurance Program) have grown 35 percent. General-fund revenue hasn’t grown anything like that, so the difference has to come from the pockets of other programs.

Huh. Maybe we really should talk about reforming Medicaid.

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Education used to make up a bigger share of state spending. When the association first began compiling the report in 1987, elementary and secondary education made up the biggest share of state spending, and higher education the second-biggest share. Medicaid surpassed higher education as the second-biggest state program in 1990, and in 2003 it became largest state program for the first time. Since then it has vied with schools for the biggest share of state spending, but for the past three years it has been in the lead, with an increasing margin.

Maybe it's time to consider reforming Medicaid? Before it eats up state budgets completely? And maybe we could do it without demonizing the one party that's willing to talk about it? (Hello, Congressman Paul Ryan.)

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Some health plans require you to fill your prescriptions through mail order pharmacies. Some patients don't like that requirement. In New York State, that requirement will soon be a thing of the past.

The bill barred insurers or employers from forcing patients to use mail-order plans for prescription drugs, except for plans negotiated by unions. Instead, consumers would be guaranteed the choice of having their prescriptions filled either through mail-order or at the local drugstore, without any added copayments or fees.

So, at a time when health plans are under tremendous pressure to cut premiums (or at least to raise them as little as possible), the Governor is going to raise health plans' costs? Not exactly.

But the governor signed both bills late Monday on the condition that the Legislature would retroactively amend them to require retail pharmacies to accept the same reimbursement rates for drugs as mail-order pharmacies.

Oh, okay. The Governor is going to force small mom-and-pop stores to lose money on every prescription that they fill. Yeah, that's going to work out well.

There's absolutely no good way to fulfill this requirement without raising somebody's costs. The patient's preference for locally filled prescriptions is more expensive. By rights, patients should pay for that preference. Instead, the Governor is looking to make someone else pay instead. That's always a bad idea and this is going to end up back-firing.

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