Tag: Welfare & Entitlements

A Response to Gruber on RomneyCare & Health Care Costs

I just came across this letter to the editor of the Wall Street Journal from MIT economist Jonathan Gruber.  I don’t know how to confine myself to just one of the letter’s many problems. So brace yourselves, here comes the fisk.

Joseph Rago’s article on Massachusetts health-care reform (“The Massachusetts Health-Care ‘Train Wreck’,” op-ed, July 7) is exactly the type of selectively misleading use of facts upon which opponents of health-care reform have been relying over the past year.

No comment, other than remember the phrase “selectively misleading use of facts.”

Health-care reform in Massachusetts has covered 60% of the state’s uninsured, has done so at roughly the cost projected before reform was enacted in 2006, and remains overwhelmingly popular with the residents of the state.

Regarding coverage gains, Massachusetts officials used to claim that RomneyCare reduced the share of uninsured residents from around 10 percent to 2.6 percent.  In a study released this year, Aaron Yelowitz (a former student and coauthor of Gruber’s) and I show why that figure is too low and why the actual figure is likely 5.1 percent or higher.  The study on which Gruber relies – like all other such studies – neither mentions nor attempts to measure the problem that Yelowitz and I identified: uninsured Massachusetts residents appear to be responding to the individual mandate by concealing their lack of insurance, which would inflate the coverage gains.  Since that study obtained results similar to our results for Massachusetts adults, that study’s estimate of a 60-percent reduction in the uninsured appears to be an upper-bound estimate, rather than a point estimate.

Regarding costs, I haven’t seen any updated numbers since the Massachusetts Taxpayers Foundation’s whitewash from May 2009.  I’d like to see an updated, non-whitewashed report on actual spending and how it compares to the original projections, especially considering that in 2006, the Kaiser Family Foundation reported that Massachusetts “anticipates that no additional funding will be needed beyond three years.“  Updated figures would also allow us to judge how much RomneyCare spent per newly insured resident.

The state has seen a decline in its nongroup premiums of more than 50% relative to national trends…It reduced the costs to individuals of purchasing insurance…[an] enormous reduction relative to pre-reform…

Here’s where Gruber engages in his own “selectively misleading use of facts.”  Yes, non-group premiums appear to have fallen for the 4 percent of residents in the non-group market – because RomneyCare shifted those costs to workers with job-based coverage.

It is true that reform has not slowed the growth of group health-insurance premiums, which have continued to rise at exactly the same rate as in the nation as a whole.

The first part of this sentence is an understatement; the second part is false.  This report from the left-wing Commonwealth Fund shows that premiums in Massachusetts are growing faster than anywhere else in the nation.  And the only study that has tried to isolate the effect of RomneyCare finds that it increased premiums for employment-based coverage by 6 percent (see cost-shifting, above).

Despite Gov. Mitt Romney’s claims, the Massachusetts reform was not designed to slow the growth of health-care cost growth.

It should be obvious by now that RomneyCare wasn’t designed that way.  But it sure was sold that way.  And so was ObamaCare.  Any bets on how long before we hear apologists for both claiming that ObamaCare wasn’t designed to slow cost growth?

The PPACA also includes a series of changes that represent the best thinking about how to control costs, such as an independent rate-setting board for Medicare, pilots of innovative medical reimbursement approaches, and an end to the open-ended tax subsidy to the highest cost health insurance plans in the U.S. None of these is guaranteed to slow the rate of cost growth. But each is better than doing nothing, which was the alternative.

So the, ahem, best thinking on how to contain health care costs is (1) price and exchange controls set by (2) an unelected and unaccountable rationing board, plus (3) taxing health insurance.  Bra-vo. Sure, Obama’s National Economic Council chairman Larry Summers says, “Price and exchange controls inevitably create harmful economic distortions. Both the distortions and the economic damage get worse with time.” But when the alternative is nothing – nothing! – that means the bar for “best thinking” isn’t very high.

In the end, it is impossible to control health-care costs without first bringing as many citizens as possible into our health-insurance system.

As I blogged earlier today, it does not speak well of the Left’s approach to health care that in order to reduce wasteful government spending – or at least pretend to – they must first create more wasteful government spending.

RomneyCare Advocates: We Swear, This Time Centralized Planning Will Work

You know things aren’t going well in Massachusetts when supporters of RomneyCare write “there’s some evidence that the reforms signed into law by Mitt Romney in 2006 are struggling.”  That’s how The Washington Post’s Ezra Klein puts it in a post defending RomneyCare.  The New Republic’s Jonathan Cohn offers a similar defense.

Klein mentions only a few of the difficulties confronting Massachusetts.  Here are a few more:

  • The Commonwealth Fund reports that even though Massachusetts already had the highest health insurance premiums in the nation, premiums rose faster post-RomneyCare than anywhere else; 21-46 percent faster than the national average.
  • A recent study estimates that RomneyCare has so far increased employer-sponsored health-insurance premiums by an average of 6 percent.
  • The success that Klein sees in Massachusetts’ individual market – which accounts for just 4 percent of the private market – is merely the product of shifting costs to workers with job-based coverage.
  • Contrary to Klein’s post hoc spin that RomneyCare “was never an attempt to control costs,” Romney himself promised that “the costs of health care will be reduced.”
  • Aaron Yelowitz and I find evidence suggesting that uninsured Massachusetts residents are responding to the individual mandate not by obtaining coverage but by concealing their insurance status.  Coverage gains may therefore be less than official estimates suggest.
  • Evidence is mounting that, despite stiffer penalties than ObamaCare will impose, increasing numbers of people are gaming the individual mandate by only purchasing health insurance when they need medical care. Such behavior could ultimately cause the “private” insurance market to collapse.

Nevertheless, the Klein/Cohn thesis is basically that costs have been climbing and employers have been dropping/curtailing health benefits for decades.  So you can’t blame that stuff on RomneyCare.  We should instead be thankful that Massachusetts enacted a new raft of government price controls, mandates, and subsidies to protect residents from those features of “the American health-care system.”

The only problem is that “the American health-care system” is the product of the old raft of government price & exchange controls, mandates, and subsidies.  The largest purchaser of medical care in the country (and the world) is MedicareMedicaid is second.  The Left complains so much about fee-for-service medicine fueling rising health care costs and reducing quality, you’d never know that their beloved Medicare program is the primary reason for its dominance.  Likewise, the reason why employers are dropping and curtailing coverage is that the government turned the private health insurance market into an unsustainable employment-based system that is doomed to unravel.  Cohn’s book documents the inhumanity of that system so well, you’d think it would sour him on the sort of centralized planning that created it.  I could go on…

RomneyCare and its progeny ObamaCare are attempts by the Left’s central planners to clean up their own mess.  If Klein and Cohn want to defend those laws, pointing to the damage already caused by their economic policies won’t do the trick.  They need to explain why government price & exchange controls, mandates, and subsidies will produce something other than what they have always produced.

ObamaCare Still Unpopular, Especially among Voters

As of mid-July, it appears the American public still opposes ObamaCare, with the opposition strongest among those most likely to vote.

Judging by the latest data at the poll-aggregating site Pollster.com, a solid plurality of adults continues to oppose ObamaCare (46.8 vs. 40.1 percent):

The trendlines don’t look so good for supporters of the law.  (The public isn’t so hot about President Obama’s handling of health care, either.) Yet the above graph includes (polls that include) adults who are neither registered nor likely to vote.

If you want to know how public opinion about ObamaCare will influence the November elections, you’ll want to look at polls of likely voters. Those suggest a majority opposes the law (51.3 vs 42.9 percent):

It’s hard to know what to make of the trendlines, since the last poll of likely voters was in April and Pollster.com’s trend estimates can be skewed if the most recent poll is aberrant.

Polls of registered voters (which include both likely and unlikely registered voters) again show that a majority opposes ObamaCare (50.7 vs. 42.7 percent). Compared to the graph of likely-voter-only polls, the “oppose” trendline appears flatter, while the “support” line appears to have the same slope:

Yet the “support” trend-estimate among registered voters started from a lower base, so that the July point estimate (42.7 percent) is roughly the same as that for likely voters in April (42.9 percent).  And the most recent spread between opponents and supporters is roughly the same in the two graphs (8.4 vs. 8.0 percentage points).

Combining polls of likely voters and registered voters produces a higher ratio of likely-to-unlikely voters than looking at just registered voters.  It also shows that a majority oppose ObamaCare (50.7 vs. 41.2 percent), with a persistent gap of about 9 percentage points:

(NB: The figures I cite in this post are the figures that appeared on these graphs on July 17.  Since these graphs are embedded from Pollster.com, the figures in the graphs will change as as Pollster.com adds new polling data to their graphs.)

Dear Health Care Journos, There’s Nothing Free about ObamaCare

The Obama administration announced yesterday its plans for implementing ObamaCare’s mandate that consumers purchase first-dollar coverage for preventive services.  The press release reads (emphasis added):

Administration Announces Regulations Requiring New Health Insurance Plans to Provide Free Preventive Care

Of course the administration would emphasize that consumers will pay nothing for these services at the moment of service, and elide the fact that this mandate will increase their health insurance premiums. The administration’s use of the word “free” is what we call spin.

What’s surprising–and more than a little disappointing–is that journalists and headline writers at major media organizations would repeat the administration’s spin, as if the government really is giving away free stuff:

  • New York Times: “Health Plans Must Provide Some Tests at No Cost…free coverage…free screenings…free preventive services…”
  • Los Angeles Times: “Healthcare law offers preventive care at no cost”
  • Politico: “New rules: Free preventive care…free under new federal guidelines.”
  • Reuters: “Healthcare overhaul mandates free preventive care…no extra cost to consumers…Medicare patients will have access to free prevention services…”
  • Wall Street Journal: “White House Unveils Free Preventative Services…services that will be free to consumers…free preventive care…free preventive care…”

Each use of “free” and “no cost” in these excerpts is false, even within its original context.  There’s no such thing as a free lunch. Everything has a cost.  No government can change that.  Mandating that insurers cover certain services does not magically make them free.  Consumers still pay, just in the form of higher health insurance premiums and lower wages.

The Wall Street Journal (in paragraph six), The New York Times (paragraph seven), Reuters (paragraph 16), and the Los Angeles Times (paragraph 19 or so) do mention that consumers will pay for this mandate in the form of higher premiums–but that doesn’t make the untrue stuff true.  It just makes the article internally inconsistent.  Moreover, the Los Angeles Times incorrectly suggests that the higher premiums would be offset by lower out-of-pocket spending.  (The change in premiums will be larger due to moral hazard and administrative costs.)  And Reuters mentions higher premiums only vaguely, and as if insurers would bear that cost.  Each article also repeats the administration’s spin that spending more on preventive care would reduce health care costs, without mentioning that the Congressional Budget Office and other health care researchers dispute that claim.

Journalists need to be very careful with terms like “free” and “no cost.”

Restore Free Markets to Health Care

Eline van den Broek probably is not happy today since she was in South Africa watching her team lose a high-scoring (by soccer standards) battle with Spain, but she should be very proud of the new video she narrated that urges the repeal of Obamacare – and also points out some of the other reforms that are needed to restore a free market to the US health care system.

Her comments on how the American health care system was a mess even before Obamacare are particularly important and echo many of the points made by Mike Tanner and Michael Cannon.

The Recess Appointment of Donald Berwick

Late last week, President Obama made a recess appointment of Dr. Donald Berwick to head the Center for Medicare and Medicaid Services (formerly the Health Care Financing Administration). This has provided a good chunk of the week and weekend’s polititainment.

I know little about Berwick or his merits as an administrator of the government health care system, but in an April Cato@Liberty post I reviewed an article of his on “patient-centered health care.” If you’re interested, take a look at my comment, “A Little Less Poetry, a Little More Economics.”

Health Care Rights and Wrongs

Michael Cannon’s post about this ridiculous New York Times article nearly made me fall off my chair. The article, entitled “A Poor Nation, With a Health Plan,” favorably compares the health care system in Rwanda with that in the United States. That’s right: because we don’t have state-provided universal health care coverage, Americans are worse off than residents of one of the poorest countries in the world.  (This is a new article, by the way, not Frank Rich’s column in the Sunday paper.)

Here’s how it begins:

The maternity ward in the Mayange district health center is nothing fancy.

It has no running water, and the delivery room is little more than a pair of padded benches with stirrups. But the blue paint on the walls is fairly fresh, and the labor room beds have mosquito nets.

Inside, three generations of the Yankulije family are relaxing on one bed: Rachel, 53, her daughter Chantal Mujawimana, 22, and Chantal’s baby boy, too recently arrived in this world to have a name yet.

The little prince is the first in his line to be delivered in a clinic rather than on the floor of a mud hut. But he is not the first with health insurance. Both his mother and grandmother have it, which is why he was born here.

In other words, it’s not that the cost of modern medicine has declined in relative terms (thanks to American technological development) and the economy has grown (ours and theirs) such that more people can be medically trained and the tax base can support more public hospitals, but the insurance genie has come and sprinkled fairy dust on misbegotten villagers. (Read the whole thing for some more eye-popping lines – Rwanda has less obesity than the United States, for example.)

Now, I’m just a lawyer – about the only thing I know about health policy is that Obamacare is unconstitutional – but it seems to me that there are at least two basic definitional problems with the inferences the article invites the reader to make even beyond the detailed technical analysis Michael provides.

First, there’s a difference between health care and health insurance.  Nobody in the United States is denied health care.  Between Medicaid and federal law requiring emergency rooms to treat all comers, we simply do not have children dying in the street (like in, say, Rwanda, where, according to the Times, the most common causes of death are “diarrhea, pneumonia, malaria, malnutrition, infected cuts”).  As Michael says, “Yes, the poorer nation has a higher levels of health insurance coverage.  But the wealthier nation does a better job of providing medical care to everyone, insured and uninsured alike.”  That is, you can (and often do) have universal health insurance that provides universally bad care – except for the political elites, who pay extra for proper Western care.  Is there any American who would have better health living in Rwanda or any number of countries where the government provides universal health insurance?

Second, and relatedly, health care is not and cannot be a “right” – because rights are things that inhere in human beings by virtue of their being human.  As the Declaration of Independence says, we are “endowed by [our] Creator with certain unalienable Rights.”  These “natural” rights are things we enjoy without burdening the rights of others: freedom of speech and belief, the right to earn an honest living, freedom of movement, the right to acquire and possess private property, the right to decide what we do every day … all the way down to the right to get out of bed on the left or right side (or to stay in bed all day) – and the right to defend ourselves against those who would take away these rights.  Once you start making “rights” out of things that somebody has to provide you – food, shelter, health care, employment – then you’ve violated everyone’s natural rights and reduced their inherent liberty.

And that’s no less true in countries where the constitutions guarantee all sorts of things (e.g., article 24 of the UN Declaration of Human Rights guarantees the right to a paid vacation.  Those countries have the added misfortune of having a devalued constitution, whose promises are wholly aspirational at best.   Indeed, I’m often amused in foreign travels to be asked why the U.S. Bill of Rights doesn’t include health care (among other things).  I mean, if the best constitutions were the grandest ones, I could draw one up that guaranteed the right to immortality, the mandate that all streets be paved in gold, and the provision that everyone have above-average intelligence.  Also, two chickens in every pot and a flying car in every garage.

There is no magic genie to public health or national development:  it takes the rule of law – including restraining political elites from meddling in the economy – and years of entrepreneurship and hard work.  Indeed, there are plenty of ways in which the United States can improve its health care system but universal health insurance is beside the point. A cautionary note, though: It wasn’t that long ago, in relative human terms, that America was at Rwanda’s level of development – and it won’t take long to destroy, in the name of “fairness” or “human rights,” all we’ve created.