Topic: General

No Need for a Mandate

Much of the justification for an individual health insurance mandate, like that pushed by Massachusetts Governor Mitt Romney and the Heritage Foundation, is that people who lack insurance in the current system still receive medical treatment when needed.  The cost of treating these “free riders” is shifted to the insured and the taxpayer.  In particular, it is suggested that these uninsured individuals will end up at hospital emergency rooms.  Advocates of universal single-payer systems often make similar arguments.

But a new study in Health Affairs shows that that there is no significant difference in emergency room use between insured and uninsured populations.  The study concludes that increases in the number of uninsured are not likely to lead to an increase in emergency room visits.  However, the study does show that Medicaid beneficiaries use emergency rooms more than either the insured or the uninsured.  This may result both from the difficulty that Medicaid patients have in finding primary-care physicians willing to treat them at Medicaid’s low reimbursement rates, and from the fact that emergency room visits are essentially free for the Medicaid patient.

One other finding is worth noting as well.  Contrary to public perception, noncitizen immigrants actually use emergency rooms less than citizens.  Emergency rooms are not being overrun by illegal immigrants.

Downside of Disclosure

The Washington Post reports today about the emergence of the Democratic Alliance, a group vetting organizations for wealthy, liberal contributors. The group has an interesting rule:

The alliance has required organizations that receive its endorsement to sign agreements shielding the identity of donors…The group requires nondisclosure agreements because many donors prefer anonymity…Some donors expressed concern about being attacked on the Web or elsewhere for their political stance; others did not want to be targeted by fundraisers.

Of course, the United States has a long tradition of anonymous speech and political activity, including The Federalist Papers. The donors to the Democratic Alliance continue in that tradition. Their desire for anonymity proves that mandatory disclosure of money in politics imposes costs on participation.

Those same costs affect donors to political campaigns who do not have a right to anonymous speech. In fact, a donor who gives to a challenger threatening an incumbent member of Congress faces a greater risk than that confronted by the donors to the Democracy Alliance.

Given their experience with the downside of disclosure, perhaps the donors to the Democratic Alliance (or the organizations they fund) will lead the way toward liberalizing or eliminating mandatory disclosure of campaign contributions.

Entangled in Iraq until 2016?

The Washington Times reports that U.S. military commanders believe American forces will be needed in Iraq until at least 2016.

There often are bad ideas in the arena of foreign policy. Sometimes there are very bad ideas. Occasionally, there are even monumentally bad ideas. Staying in the Iraqi snake pit for another decade belongs in the third category. As Cato scholars explain here, here, here and here, the Bush administration needs to adopt a strategy for a prompt exit from this unnessary and ill-conceived mission.

We need to have our forces out of Iraq in a matter of months, not years. And no reasonable person should want to keep our troops in harm’s way for another decade. Given the casualty rates during the first three years of this war, staying until 2016 would mean another 8,000 dead Americans. At that point, U.S. fatalities in Iraq would exceed the number the Soviet Union suffered during its ill-fated intervention in Afghanistan during the 1980s.

Remaining in Iraq for another decade while the country descends into sectarian civil war is a policy that should appeal only to masochists.

Broadband Bad News Is Good News … but It’s Bad News

Headlines are meant to draw readers in, and this one did me: Broadband’s Double-Digit Growth Coming to an End.

Something’s gone wrong with broadband! Quick! To the BroadbandMobile!

In the next instant, I realized that something had actually gone right. You see, double-digit change in percentage-based figures can’t keep going forever. In fact, it can’t last more than about ten time-periods. (Because then you’d have 110% of something, which only makes sense in rock ‘n’ roll, where the loudest speakers go to 11.)

Adoption of broadband is slowing as people who want it have already got it and people who don’t want it persist in not having it. (Bizarrely to people who live every minute of every day online, some people live no minute of every day online - ever. That is perfectly acceptable.)

There is undoubtedly a tiny margin of poor people who can’t afford broadband. But “can’t afford” is subjective. Many prioritize things other than broadband to buy with their limited resources (which is fine - remember, sans broadband is an acceptable way to live).

But the news report says this is all bad news:

One of the goals of US public policy when it comes to broadband is to ensure all US residents have access to broadband. President Bush said in 2004 that he wanted universal access to broadband in 2007, an achievement that appears unlikely at this point.

But, but … if people who want it are getting it, and people who don’t are not, isn’t that universal access to broadband? Apparently not. Affordability has been added to the metric, moving the goal posts so that federal subsidies for telecommunications seem important once again. Our news report continues:

The Democrats think it’s a great idea too—one plank in their platform for the 2006 mid-term elections is universal access. The telecom law rewrite which may or may not emerge from Congress this year intends to further that goal by funding broadband in areas currently unserved via the Universal Service Fund.

That’s the Universal Service Fund about which Daniel Berninger asks: What have we gotten for our $50 billion dollars?

In the end, this report amounts to an argument that satiation is a basis for subsidy.

Huh.

Premium Medicine vs. Watchful Waiting

In a response to my defense of health savings accounts, Dr. Hébert makes a thoughtful case for the value added by primary care physicians. One way that PCPs add value is through “watchful waiting”:

It used to be that observation was one of the mainstays of medicine. Now everything is scanned, biopsied, and aggressively worked up because specialists find it easier to bill for expensive procedures than for recurring office visits. This shift away from observation towards aggression runs the risk of hurting patients, and is one of the casualties of the microspecialist system.

The (over-) use of such “premium medicine” is one of the main themes of Crisis of Abundance, a new book by Cato adjunct scholar Arnold Kling. As an illustration, Kling writes about a blogger named Quixote who received intensive treatment for her swollen eye:

My guess is that 30 years ago, a patient with similar symptoms would have been treated “empirically,” a term doctors use to describe a situation for which they do not have a precise diagnosis and treatment, so that instead they must use guesswork. A layman’s synonym for treated empirically would be “trial and error.” In this case, the patient might have been sent home with an antibiotic and perhaps a prescription for Prednisone, a steroid used to reduce inflammation. There would have been nothing else to do. In 1975, computerized medical imaging technology was new and exotic, with limited applications.

In contrast, in 2005, over the course of a few days Quixote was given a computed tomography (CT) scan, referred to a specialist, sent to a different hospital, referred to a specialty clinic, seen by a battery of specialists there, and given yet another CT scan. Ultimately, however, she was sent home, as she might have been 30 years ago, with an antibiotic, Prednisone, and no firm diagnosis.

Compared with 30 years ago, Quixote received more services, in the form of specialist consultations and high-tech diagnostics. However, the ultimate treatment and outcome were no different. This does not mean that medicine is no better today than it was a generation ago. The CT scans and specialist consultations could have turned out differently. They might have been critically important, depending on her actual condition. Under some circumstances, treating Quixote empirically with an antibiotic and Prednisone could have been a mistake, perhaps costing some or all of her sight in one eye.

Such is modern medicine in the United States. Doctors are able to take extra precautions. They can use more specialized knowledge and better technology to try to pin down the diagnosis. They can perform tests to rule out improbable but dangerous conditions. But only in a minority of cases does the outcome deviate from what would have been the case 30 years ago.

That’s from chapter one. The remaining chapters wrestle with the question of when we should make use of premium medicine.

(The Cato Institute will host a book forum for Crisis of Abundance from 12-2pm at Cato on Tuesday, August 29. Kling will present, and the Washington Post’s Sebastian Mallaby and NYU’s Jason Furman will comment on the book. Keep watching www.cato.org for more details.)

“Pelosi Promises Fiscal Restraint If Democrats Win”

That’s the headline House Minority Leader Nancy Pelosi managed to get the Wall Street Journal to run after an exclusive interview. She told the Journal’s reporters that if Democrats take control of the House next year and raise taxes, they would use the money to reduce the federal deficit. And she promised to reduce the use of earmarks: “Personally, myself, I’d get rid of all of them,” she said. “None of them is worth the skepticism, the cynicism the public has… and the fiscal irresponsibility of it.”

If Republicans are going to spend like Democrats, it would be nice to think that Democrats might save like Republicans. But let’s take a reality check.

According to the National Taxpayers Union, in the first seven months of this Congress Nancy Pelosi introduced 22 bills that would increase spending and only one that would cut spending. Admittedly a better record than some Democrats: Rep. Charles Rangel (D-NY), who would be chairman of the Ways and Means Committee in a Pelosi-led Congress, introduced 80 spending bills and three cuts, for a net budget impact of $1.6 trillion. Even the misnamed Rep. Adam Smith (D-WA) introduced 44 spending bills and one cut. Another NTU report showed that Pelosi voted in the interests of taxpayers only 11 percent of the time on tax and budget votes. And her fiscal conservatism has been declining the longer she has been in Congress. In her early years in the House she sometimes voted for taxpayers as much as 25 percent of the time. But not recently.

For taxpayers, it looks like the fall election will be a choice between the devil we know … and another devil we know.