Topic: Health Care & Welfare

Mass Health Plan: I Told You So

Supporters of Governor Romney’s Massachusetts health care plan scoffed when I warned that it “opens the door to widespread regulation of the health care industry and political interference in personal health care decisions.  The result will be a slow but steady spiral downward toward a government-run, national health care system.”  Recent events, alas, suggest that I was right.

When the plan was passed I said, “special interests representing various health care providers and disease constituencies can certainly be expected to lobby for the inclusion of additional services or coverage under any mandated benefits package.”  Now it appears that my only mistake was in not realizing just how fast the special interests would move.  Already the state has been forced to delay implementation of some aspects of the plan because of a bitter battle over issues such as whether dental benefits should be included in the basic plan that residents must buy.

Fortunately, however, members of the State Health Care Connector, which is designing the plans, say that the legislature didn’t really mean it when it passed a law setting the deadline.  Of course, one might wonder what other aspects of the law they will feel free to ignore.

And, now the Boston Globe reports that Christian Scientists are lobbying hard to change the definition of health care under the law so as to include faith healers.  Such are the perils of having the government design the products you must buy.

I also warned that as costs increased there would be increased pressure to increase subsidies or cap insurance premiums.  This week, the Globe reported that State Senator Richard T. Moore, a key architect of the law, is complaining that health insurance premiums are too high.  He is demanding that either premiums or subsidies be adjusted so that no one earning less than 300 percent of the poverty level ($58,000 for a family of four) will have to pay more than 5 percent of their income for insurance.

The plan is less than five months old and already the wheels are coming off.  It would be sad if it had not all been so predictable.

Fear of Freedom in Health Care

Ezra Klein writes,

From there, we part. Kling’s other solution relies on a massive increase in the amount of health costs that come out of pocket. The “very poor” would be subsidized, as would the “very sick” (neither term is defined in his book), but everyone else would be paying for their own care. This makes sense in a very specific sort of world – one in which you believe consumers have the capacity to make rational health care decisions – and to a very specific sort of person – one who believes those who make mistakes with their health care should simply pay the costs, be they financial ruin or death.

I am not that sort of person, and I am highly dubious of that world. I see no evidence for the claim that a gas station manager in Bakersfield, California, will be able to second- or third-guess his cardiologist’s recommendation of an angioplasty. Will he have the money to get a second opinion? A fourth? Or will Kling’s system convince him to foolishly underestimate his risk? Economists, after all, have shown time and again that we overestimate the pain of financial loss – that, when it comes to money, we are not nearly so rational as one might hope.

In the simulation of my proposals in the chapter on matching funding to needs, I define poor as below the poverty line and I define very sick as having annual expenses over $5000 for the non-elderly and over $20,000 for the elderly.  I think that one can, and should, come up with better definitions, but the terms are not left undefined.

How should consumers make decisions about their health care? Let me define a “good” decision as one that is optimal in terms of expected benefits relative to expected costs. A different decision is a “mistake.”

I propose making more consumers more accountable for more of their own health care spending. Let me describe this as a system where consumers make their own mistakes.

What is the alternative to a system where consumers make their own mistakes? The opponents of consumer choice would have you believe that the alternative is a system where no mistakes are made, and instead we simply see good decisions. But that is not the alternative that we observe. In fact, no one would say that the medical decision-making process is mistake-free in America today.

The realistic alternative to having consumers make their own mistakes is to have mistakes made on their behalf by doctors, insurance companies, and government.

In my health care proposals, I envision doctors, insurance companies, and government still available to offer advice. In fact, I envision a much stronger advisory role in health care coming from a commission that studies costs and benefits of health care proposals.

What I propose is that consumers have the incentive to use information about costs and benefits. Any treatment that is proposed today, under the presumption that a third party will pay for it, would still be available under a system where consumers are allowed to make their own mistakes. It’s just that under the latter system, consumers would take costs into account.

I get the sense that the rhetorical attack on consumer choice in medicine is based primarily on the implicit assumption that the alternative to consumers making their own mistakes is consumers making no mistakes. Once you strip away that rhetorical support, the case for paternalism in medicine seems difficult to make.

When Generous People Stop Kidding Themselves

Over at Tapped, Ezra Klein is wrestling with my interpretation of the new estimates of poverty and health insurance coverage released yesterday by the Census Bureau. I observed that after the 1996 welfare reforms made federal cash assistance less “generous,” poverty went down. In contrast, federal health care spending grew ever more “generous,” and the number of uninsured went up. I humbly submitted that perhaps Congress should stop being so “generous” with health care.

Klein thinks that’s “crazy,” but he misfires on poverty rates:

  1. He suggests that economic growth of the late 1990s and the expansion of the Earned Income Tax Credit were responsible for the post-1996 reductions in poverty. (The EITC does not directly affect the poverty rate, but it does affect the decision to earn other income that does.) Certainly each played a part. But prior economic booms did not have as dramatic an effect on the poverty rate even when the EITC was present, and scholars like June O’Neill have estimated that welfare reform had larger effects than did the economy. Moreover, although the EITC encourages some people to work more, it reduces work overall by encouraging others – those in the phase-out range – to work less. That might lift some out of poverty, but it traps them and others on the lower rungs of the economic ladder.
  2. He notes that poverty has increased every year from 2000 to 2004. True, but he is being selective in order to avoid the larger point that poverty remains lower now than at any point in the 17 years leading up to welfare reform. (Also, FWIW, poverty dropped slightly in 2005.)
  3. He confuses the poverty rate for families (9.9 in 2005) with the overall poverty rate (12.6 percent in 2005).
  4. Finally, he notes that the family poverty rate was lower in 2005 than in 1996. Yet he somehow believes this to be evidence that federal cash assistance does not contribute to poverty.

The political Left has had a really hard time dealing with welfare reform. When Congress pared back cash assistance, the Left assumed that bad things would happen (increased poverty, starvation, etc.). Instead, good things happened. But that evidence doesn’t fit in the Left’s model. They just don’t know where to put it.

Klein is as confused about the health care side of the comparison.

  1. Klein writes: “I don’t know any health care wonks who think medical cost inflation is a product of government spending…” He should get out more. He should start by hanging out with Maryland’s Mark Duggan and Yale’s Fiona Scott Morton, who estimate that prescription drugs are 13 percent more expensive in the private sector thanks to Medicaid. He should read up on crowd-out of private health insurance, which isn’t likely to make private insurance markets any more robust. Many people think that cost-shifting from Medicaid increases the cost of private coverage. Personally, I’d call that crowd-out of another sort, but the effect is the same. Klein should read about how MIT’s Amy Finkelstein speculates that Medicare led to increased medical expenditures in the private sector as well. All of which affects insurance premiums.
  2. Klein dismisses the idea of reforming Medicaid as Congress reformed welfare – by cutting back assistance. But that’s exactly what Congress did when it cut off Medicaid for non-citizen immigrants in 1996. Do I need to tell you what the Left predicted? Do I need to tell you what actually happened? Klein should add to his reading list Harvard’s George Borjas, who found that coverage levels for non-citizen immigrants increased after they were cut from the Medicaid rolls – a result that, Borjas argues, cannot be explained by the robust economy.
  3. Finally, Klein writes that yours truly “[doesn’t] want Big Government to start pummeling the medical-industrial complex.” But as I argue elsewhere, so long as the government controls the money, the medical-industrial complex will never get the beating it deserves because producers will always have a disproportionate influence over political decisions that effect their incomes. We will not discipline the medical-industrial complex until we have patients on the side of restraining spending, and that will not happen until patients own the money that’s being spent. Libertarians would love to pummel the medical-industrial complex. It would be (marginally) easier to do so were Klein to get out of the way.

Klein’s post reminds me of the passage Charles Murray used to close his seminal work Losing Ground:

Most of us want to help. It makes us feel bad to think of neglected children and rat-infested slums, and we are happy to pay for the thought that people who are good at taking care of such things are out there. If the numbers of neglected children and the numbers of rats seem to be going up instead of down, it is understandable that we choose to focus on how much we put into the effort instead of what comes out. The tax checks we write buy us, for relatively little money and no effort at all, a quieted conscience. The more we pay, the more certain we can be that we have done our part, and it is essential that we feel that way regardless of what we accomplish…

To this extent, the barrier to radical reform of social policy is not the pain it would cause the intended beneficiaries of the present system, but the pain it would cause the donors. The real contest about the direction of social policy is not between people who want to cut budgets and people who want to help. When reforms finally do occur, they will happen not because stingy people have won, but because generous people have stopped kidding themselves.

New Uninsured Estimate, Same Old Story

Today, the Census Bureau reported that in 2005 the number of Americans without health insurance inched up yet again.  This annual ritual, repeated every August, gets old after a while. 

The Official Uninsured Estimate – now 46.6 million residents – comes from a survey that is not designed to measure insurance coverage.  The Official Uninsured Estimate includes people who are covered by Medicaid, who lack coverage today but will regain it tomorrow, and who make over $50,000 per year.  The Congressional Budget Office reports [.pdf] that the number of chronically uninsured (who lack coverage for a year or more) is more like 20-30 million – and still many of them are covered by Medicaid.

Part of this ritual is that Medicaid wins plaudits for “picking up the slack” when employment-based coverage falls.  Yet Medicaid encourages employers not to offer coverage, encourages workers to avoid private coverage, and makes private coverage more expensive for both employers and workers.  Medicaid doesn’t just catch people who fall off the economic ladder – it shakes the ladder.

Just about the only useful aspect of The Official Uninsured Estimate is the trend it displays over time.  When compared to the trend in the poverty rate (also released today), a stark contrast emerges.

  • Ten years ago, Congress reformed the welfare system.  It stopped the practice of just throwing more money at the problem of poverty.  What happened?  Poverty fell and remained lower in 2005 than at any point in the 17 years leading up to welfare reform. 
  • But Congress kept throwing more money at health care by expanding government programs (e.g., SCHIP).  The result?  Unlike the poverty rate, The Official Uninsured Estimate continues its steady climb.

Maybe we should stop throwing money at the problem?