Tag: Medicare

We Need a Debate about the Size of Government, but It Helps to Understand Basic Fiscal Facts

Self awareness is supposed to be a good thing, so I’m going to openly acknowledge that I have an unusual fixation on the size of government.

I don’t lose a wink of sleep thinking about deficits, but I toss and turn all night fretting about the overall burden of government spending.

My peculiar focus on the size and scope of government can be seen in this video, which explains that spending is the disease and deficits are just a symptom.

Moreover, my Golden Rule explicitly targets the spending side of the budget. And I also came up with a “Bob Dole Award” to mock those who mistakenly dwell on deficits.

With all this as background, you’ll understand why I got excited when I started reading Robert Samuelson’s column in today’s Washington Post.

Well, there’s a presidential whopper. Obama is right that the role of the federal government deserves an important debate, but he is wrong when he says that we’ve had that debate. Just the opposite: The White House and Congress have spent the past five years evading the debate. They’ve argued over federal budget deficits without addressing the underlying issues of what the government should do, what programs are unneeded, whether some beneficiaries are undeserving… The avoidance is entirely bipartisan. Congressional Republicans have been just as allergic to genuine debate as the White House and its Democratic congressional allies.

You’ve Come a Long Way, Baby: Barack Obama on Health Care Fraud

Last week, President Obama approved a one-year, unilateral (and thus illegalrepeal of ObamaCare’s requirements that the federal government verify the incomes and insurance options of people applying for the law’s new subsidies—a move that eviscerated the law’s anti-fraud protections. Rescinding anti-fraud protections is nothing new (or defensible). There is a very powerful fraud lobby in Washington, D.C. Normally, such steps just mean an increase in fraudulent and improper payments from the federal treasury, and a few more ignored reports from the Government Accountability Office and HHS Inspector General. Obama’s move, however, is so sweeping that he effectively expanded the eligibility criteria for ObamaCare’s new entitlements without so much as consulting Congress. Indeed, the law Obama is implementing did not and could not have passed Congress.

Barack Obama wasn’t always part of the health-care fraud lobby. Oh, no: time was, he railed against health care fraud. When he pleaded for his health care plan before a joint session of Congress in 2009, he promised that with his plan:

We will root out the waste and fraud and abuse in our Medicare program that doesn’t make our seniors any healthier…I’ve appointed a proven and aggressive inspector general to ferret out any and all cases of waste and fraud.

Any and all cases! So inspiring. And in his final push for ObamaCare’s passage, he promised the law would reduce fraud and improper payments. Here are excerpts from a strident speech he gave in Missouri on March 10, 2010:

I believe that in everything government does, we’ve got a special responsibility to be wise stewards about how Americans’ hard-earned tax dollars are spent. And I know you agree with that, too. Doesn’t matter whether you’re a Democrat or a Republican, you don’t like seeing your money wasted — or an independent, don’t like seeing your money wasted.

That’s a responsibility my administration is seeking to fulfill every single day…

Washington is a place where tax dollars are often treated like Monopoly money — they’re bartered and traded, and they’re divvied up among lobbyists and special interests, and where waste — even billions of dollars of waste — is accepted as the price of doing business…

The health care system has billions of dollars that should go to patient care and they’re lost each and every year to fraud, to abuse, to massive subsidies that line the pockets of the insurance industry.

Let me just give you one example — this is a long recognized but long tolerated problem called “improper payments.” That’s what they call them. Washington always has a name for these things. “Improper payments.” And as is often the case in Washington, the more innocuous the name, the more worried you should be. So these are payments mostly made through Medicare and Medicaid that are sent to the wrong person, sent for the wrong reason, sent in the wrong amount. Sometimes they’re innocent errors. Sometimes they’re because nobody is bothering to check to see where the money is going and they’re abused by scam artists and fly-by-night operations…

If we created a “Department of Improper Payments” it would be one of the largest agencies in our government…

Now, for the past few years, there has actually been a pilot program that uses a system of tough audits to recover some of this lost money. And even though these audits, they were just operating mainly in three states, they already found a billion dollars in improper payments. So these results were both disturbing and encouraging. They’re disturbing because it shows you how much waste there is out there in the health care system. But it’s encouraging because we can do something about it.

So earlier today, with [U.S. Sen.] Claire [McCaskill, D-Mo.] looking over my shoulder — one of our auditors-in-chief — I signed an order calling on all federal agencies to launch these kinds of audits all across the country. All across the country. (Applause.) So agencies would hire auditors to scour the books, go through things line by line. Auditors are paid based on how many abuses or errors they uncover. So it’s a win-win. The auditor, if they do a good job they get a small percentage as a reward. And the taxpayer wins by getting huge sums of money that would otherwise be lost that we can then spend to provide care to people who really need it, or we can use to reduce the deficit.

Now, through this effort, we expect to more than double the amounts we would’ve otherwise recovered — a couple of billion dollars over the next few years. And I’m announcing my support for the Improper Payments Elimination and Recovery Act — that’s a mouthful — but this is a bipartisan bill — (applause) — is a bipartisan bill to expand our ability to do these audits, so we can prevent even more fraud and abuse and waste.

Now, the reason I’m bringing all this stuff up is because there’s been a lot of talk about health care lately. And look, I’ll be honest, a lot of people, they’re confused, they’re saying, well, how can you help people get insurance who don’t have it without it adding to our deficit? It’s a legitimate question.

Well, the reason is, is because so much of the money currently in our health care system is being misspent.

Barack Obama used to oppose health care fraud—up until the moment that opposing fraud conflicted with his goal of preserving ObamaCare.

And why not? It’s just other people’s money.

How to Tell If the Government Has Taken over Health Care

From the Washington Post:

Hedge fund executives and other investors are increasingly interested in the timing and nature of health-policy decisions in Washington because they directly affect the profits and stock prices of pharmaceutical, insurance, hospital and managed-care companies…

[Former Centers for Medicare & Medicaid Services] director Thomas Scully, who served during the Bush administration…said he thought that it was useful for CMS officials to have more communication with Wall Street investors as a way for regulators to learn and “explain what an $800-billion-a-year agency” does with its money.

So long as someone is still making a buck, it’s not socialized medicine…right?

Roy: “The Arkansas-Obamacare Medicaid Deal: Far Less Than It First Appeared”

At Forbes.com’s Apothecary blog, the Manhattan Institute’s Avik Roy is cool to the idea of states implementing ObamaCare’s Medicaid expansion by putting those new enrollees in ObamaCare’s health insurance “exchanges”: 

When Arkansas Gov. Mike Beebe (D.) first announced that he had reached a deal with the Obama administration to use the Affordable Care Act’s private insurance exchanges to expand coverage to poor Arkansans, it seemed like an important, and potentially transformative, development. The myriad ways in which the traditional Medicaid program harms the poor have been well-documented, and it looked like Beebe had come up with an attractive—albeit expensive—way to provide the poor with higher-quality private insurance. A Good Friday memo from the U.S. Department of Health and Human Services, however, splashes cold water on that aspiration. It’s now clear that the Beebe-HHS deal applies a kind of private-sector window dressing on the dysfunctional Medicaid program, and it’s not obvious that the Arkansas legislature should go along.

The first reason states should not pursue the Beebe plan is that, like a straight Medicaid expansion, it would inhibit the pursuit of low-cost health care for the poor. 

The second reason is that it would cost even more than putting those new enrollees in the traditional Medicaid program. Economist Jagadeesh Gokhale, who advises the Social Security program on how to make these sorts of projections, estimates a straight Medicaid expansion would cost Florida, Illinois, and Texas about $20 billion in the first 10 years. And that’s in the wildly unrealistic event that the feds honor their committment to cover 90 percent of the cost. President Obama has already proposed abandoning that committment. Congressional Budget Office projections suggest the “Beebe plan” would increase the cost of the expansion by 50 percent. That too should be enough reason to reject the Beebe plan. Neither the state nor the federal government have the money to expand Medicaid at all. Volunteering to make the expansion even more expensive is lunacy. 

The Beebe administration is trying to make its plan seem no more expensive than a straight Medicaid expansion. How? By simply assuming state officials would voluntarily make a straight Medicaid expansion so expensive that the Beebe plan wouldn’t cost a penny extra. The illogic goes like this. If Arkansas were to expand traditional Medicaid, the state would likely need to increase Medicaid payments to doctors and hospitals in order to secure adequate access to care for new enrollees. That would make a straight Medicaid expansion so expensive that the Beebe plan would be no more costly, and might even cost less. 

It’s true, states that implement ObamaCare’s Medicaid expansion would have to increase provider payments to give new eligibles decent access to care. The problem is that Medicaid never does that. Medicaid is notorious for paying providers so little that it access to care is lousy. Medicaid does so year after year, even if people sometimes die as a result. The Beebe administration simply assumed that state officials would magically change such behavior, increase Medicaid’s provider payments to the same levels private insurers pay, and thereby volunteer to make an already-expensive Medicaid expansion even more unaffordable. In that fantasy world, the Beebe plan would be no more expensive. As an indication of how implausible that assumption is, no one had been talking about combining a straight Medicaid expansion with higher provider payments until the Beebe administration needed to make the governor’s plan seem slightly less unaffordable. 

Roy has soured on Beebe-style plans since reading some of the terms and conditions the Obama administration issued on Friday. Yet he still imagines there might be free-market-friendly ways to implement a massive expansion of the entitlement state. Thus he counsels states only to expand Medicaid in exchange for real reforms. We’ve heard that song and dance before. Republicans said the State Children’s Health Insurance Program and Medicare Part D – two Republican initiatives – would lead to Medicaid and Medicare reform. Instead, government got bigger and reform went nowhere. Lucy is going to pull the football here, too. If it is Medicaid reform you seek, the only free-market Medicaid reforms are Medicaid cuts. Roy’s criticisms of the Beebe plan are welcome, though it’s odd to find him to the left of officials in the 15 or more states that are flatly rejecting the expansion.

Holman Jenkins: ObamaCare Is Part of the Insanity, Not Its Cure

I’m a week late on this, but Holman Jenkins has an excellent discussion of why health care costs and pricing (not the same thing!) are insane, and why ObamaCare will only make it worse:

Duke University’s Clark Havighurst [wrote] a brilliant 2002 article that describes the regulatory, legal and tax subsidies that deprive consumers of both the incentive and opportunity to demand value from medical providers. Americans end up with a “Hobson’s choice: either coverage for ‘Cadillac’ care or no health coverage at all.”

“The market failure most responsible for economic inefficiency in the health-care sector is not consumers’ ignorance about the quality of care,” Mr. Havighurst writes, “but rather their ignorance of the cost of care, which ensures that neither the choices they make in the marketplace nor the opinions they express in the political process reveal their true preferences.”

You might turn next to an equally fabulous 2001 article by Berkeley economist James C. Robinson, who shows how the “pernicious” doctrine that health care is different—that consumers must shut up, do as they’re told and be prepared to write a blank check—is used to “justify every inefficiency, idiosyncrasy, and interest-serving institution in the health care industry.”

Hospitals, insurers and other institutions involved in health care may battle over available dollars, but they also share an interest in increasing the nation’s resources being diverted into health care—which is exactly what happens when costs are hidden from those who pay them.

Put aside whether President Obama could have pushed real reform if he wanted to. ObamaCare as it emerged from Congress fulfills the insight that any highly regulated system ends up benefiting those with influence, i.e., health-care providers and high-end customers, not those of modest means.

What are ObamaCare’s mandates on individuals and employers except an attempt to force back into the insurance market those who have been priced out by previous “reforms” so their money can be used to prop up a system of gold-plated coverage that mostly benefits those in the highest tax brackets? What are ObamaCare’s minimum coverage standards except a requirement that these customers buy more costly coverage than they would choose for themselves so their money can be used for somebody else?

I include a lengthy excerpt from Robinson’s excellent article in my chapter for the Encyclopedia of Libertarianism.

Majority of Americans Now Oppose ‘Universal Coverage’

I launched the Anti-Universal Coverage Club on the Cato@Liberty blog in 2007. The Club is “a list of scholars and citizens who reject the idea that government should ensure that all individuals have health insurance.”

Well, that list just got longer. A whole lot longer. I’ll let the folks at Gallup take it from here:

In U.S., Majority Now Against Gov’t Healthcare Guarantee

For the first time in Gallup trends since 2000, a majority of Americans say it is not the federal government’s responsibility to make sure all Americans have healthcare coverage. Prior to 2009, a majority always felt the government should ensure healthcare coverage for all, though Americans’ views have become more divided in recent years…

The shift away from the view that the government should ensure healthcare coverage for all began shortly after President Barack Obama’s election and has continued the past several years during the discussions and ultimate passage of the Affordable Care Act in March 2010.

The split is 54-44 percent, well outside the poll’s margin of error. Below the jump are the results in chart form:

Now all we need is for 54 percent of the public to “like” the Anti-Universal Coverage Club’s Facebook page.

The shift was bipartisan:

Republicans, including Republican-leaning independents, are mostly responsible for the drop since 2007 in Americans’ support for government ensuring universal health coverage. In 2007, 38% of Republicans thought the government should do so; now, 12% do. Among Democrats and Democratic leaners there has been a much smaller drop, from 81% saying the government should make sure all Americans are covered in 2007 to 71% now.

Yet another indication that ObamaCare remains quite vulnerable.

Pages