Top-Scoring Governor Moving to Florida

Maine Governor Paul LePage announced that he will be moving to Florida at the end of his term.

LePage is a staunch fiscal conservative and has received an “A” on the past three Cato fiscal policy report cards. He fought for spending and tax cuts throughout his tenure, and he often decried the negative effects of big government.

Why is LePage moving to Florida? One of the reasons is that Florida has lower taxes than Maine:

I’ll tell you very, very simply: I have a house in Florida. I will pay no income tax and the house in Florida’s property taxes are $2,000 less than we were paying in Boothbay … At my age, why wouldn’t you conserve your resources and spend it on family (rather) than spend it on taxes?

Why indeed.

Florida has the most net in-migration of any state in the nation, as discussed in this study. It has no income or estate tax. Its state and local tax burden is much lower than the burdens in the Northeast. Maine is high-tax state, but New York is even worse. I wonder whether Governor Andrew Cuomo is considering Florida when he retires?

Relative to personal income, Florida runs its government at just half the cost of New York’s. Half the cost! That is like a Honda dealer trying to sell the Accord for $50,000 while the Toyota dealer across the street has the Camry for $25,000. It wouldn’t make any sense.

Perhaps the 2017 Tax Cuts and Jobs Act is on Paul LePage’s mind. Because of the law, millions of households will become more sensitive to tax differences between the states. That may prompt an increased outflow of people from higher-tax to lower-tax states.

How should high-tax states respond to the outflows? It’s straightforward. They should run leaner governments with more efficient services to give taxpayers more value for their money. The Accord may have some features that the Camry doesn’t, but that would not double the cost.

N.Y. Proposal: Social Media Checks Before Gun Purchases

WCBS NewsRadio New York reports

Two New York lawmakers are working to draft a bill that would propose a social media check before a gun purchase.

Brooklyn Borough President Eric Adams and state Sen. Kevin Palmer’s proposal would allow authorities to review three years of social media history and one year of internet search history of any person seeking to purchase a firearm.

True, “free speech and gun rights complaints are likely to come up” – no kidding! – but Adams says it’s a way to identify persons who “not suitable to hold and possess a firearm.” 

The two are hoping to identify any hate speech on social media profiles, which are often revealed only after someone is arrested in a mass shooting.

The only way to make this proposal better – by which I mean worse – would be to arrange for New York to quarter troops on the homes of applicants with especially bad social media postings. That way the sponsors could achieve a straight flush of Bill of Rights violations.

Poll: The ACA’s Pre-existing Condition Regulations Lose Support When the Public Learns the Cost

Days before the 2018 midterms, 68% of voters say that health care is very or extremely important to how they plan to vote in this year’s elections, according to a new Cato 2018 Health Care Survey of 2,498 Americans. These numbers are driven primarily by Democratic voters with 86% who say this issue is especially important to them—in fact, 56% say the issue is “extremely important” to them. Independent (33%) and Republican voters (21%) are far less likely to say this is an “extremely” crucial issue for their vote this Tuesday.

 FIND FULL POLL RESULTS HERE

These results are consistent with analysis of 2018 campaign ads, which finds Democrats have made healthcare the centerpiece of their case to voters. About half of Democratic ads have featured health care issues compared to less than a third of Republican ads. At the core of the debate is what to do with pre-existing condition regulations embedded in the Affordable Care Act (ACA) that prevent health insurers from denying coverage or charging higher premiums to people with pre-existing conditions. Much of the public debate centered on pre-existing condition protections assume that these regulations enjoy widespread public support. However, these protections lose public support when voters learn about their costs, finds the Cato 2018 Health Care Survey.

The survey first replicated the results from myriad other surveys finding a majority (65%) of Americans favor regulations that prohibit insurance companies from refusing to cover, or charging higher premiums to, people with pre-existing conditions, while 32% oppose. However, support plummets when Americans are faced with likely consequences of these regulations. 

Support drops 20 points to 44% in favor and 51% opposed if pre-existing condition protections limited people’s access to medical tests and treatments. Similarly, 44% would favor and 50% would oppose if these regulations harmed the delivery of high-quality health care. Support drops 18 points to 47% in favor and 48% opposed if these regulations limited people’s access to top-rated medical facilities and treatment centers. Some may dismiss these potential costs as improbable; however, research finds these are likely consequences from the incentives these regulations create for the health care industry. It is for this reason that we investigate how the public evaluates these costs.

Compared to quality reductions, Americans are more prepared to pay higher taxes or premiums in exchange for keeping regulations that prevent insurers from denying coverage or charger higher premiums to people with pre-existing conditions. About half (51%) would favor and 44% oppose if these regulations raised taxes and 49% would favor and 47% would oppose if they drove up premiums. 

These results follow a familiar pattern identified in the Cato 2017 Health Care Survey that asked about each of these pre-existing condition protections separately. However, in this year’s survey we improve the desirability of these regulations by offering them as a bundle. Even still, when faced with the realistic costs of these mandates, public support plummets. 

Taking a look among partisans, we find that without any mention of costs, 83% of Democrats, 55% of independents, and 52% of Republicans initially support pre-existing condition protections. However, independents and Republicans turn against these regulations if they increase the cost of health insurance (66%, 55%), reduce access to medical tests and treatments (59%, 58%), harm the quality of health care people receive (57%, 55%), reduce access to top-rated medical facilities and treatment centers (57%, 55%), or increase taxes (57%, 57%). Democrats are less swayed by these trade-offs; however, they are least willing to sacrifice the quality of health care in exchange for keeping the pre-existing condition regulations (42%). Instead, majorities of Democrats are willing to have less access to medical tests (57%), or top-rated medical facilities (61%), or pay higher premiums (67%) or taxes (72%). Some differences in how partisans answer these questions may depend, perhaps, on how believable these costs seem to respondents rather than how acceptable they are. For instance, since Democrats are most enthusiastic about these regulations, they may be less likely to believe that they could harm the quality of care.

Higher-income Americans are more willing than low-income Americans to make trade-offs, such as shouldering higher premiums or having less access to top-rated medical facilities, to keep the pre-existing condition regulations. For instance, 61% of Americans earning more than $80,000 a year say they’d pay higher premiums to keep these regulations. In contrast, about a third (38%) of Americans earning less than $40,000 a year agree; instead, 56% oppose paying higher premiums for this reason. Nearly 6 in 10 (57%) of people earning more than $80,000 a year say they’d accept having less access to top-rated medical facilities compared to 35% of Americans earning less than $20,000 a year.

Short Term Plans

The survey also asked Americans about new federal rules that allow consumers to purchase alternative health insurance plans that don’t comply with ACA-mandates. The survey finds that majorities support new federal rules that allow consumers to purchase alternative plans, like short-term plans, even when confronted with likely trade-offs.

First, the survey presented respondents with only the anticipated benefits of the new federal rules. Doing so finds that 77% of Americans support new federal rules that allow consumers to purchase health insurance plans that cost 50% less and offer greater choices of hospitals and doctors than current plans and would cover 2 million more uninsured people. 

Support drops to 64% in favor and 31% opposed if these rules meant that some people would purchase insurance policies that cover fewer services than current plans. For instance, these new plans would not be required to cover services like mental health and prescription drugs. 

One reason why such plans have lower premiums is they do not have to comply with ACA pre-existing condition regulations and thus may exclude people, or offer limited services to people, with expensive medical conditions. These lower premiums could draw people who use fewer medical services out of the ACA-compliant plans and thus increase premiums for those who remain in those plans and are not eligible for subsidies. Nevertheless, the survey finds that 59% would continue to favor while 35% would oppose these new rules if they caused premiums to rise for some people who purchase insurance plans in the individual market.

These rule changes are popular among partisans with 77% of Democrats and 86% of Republicans in support. Majorities of Democrats and Republicans continue to favor allowing people to purchase non-ACA compliant plans even if doing so means people would not have as many services covered (58% and 71%) or if doing so increased premiums for unsubsidized people in the individual market (63% and 65%).

The Path Forward

The survey also asked Americans how they felt policymakers should approach health care reform going forward. A majority (55%) of Americans believe that the “better way” to sustainably provide high-quality affordable health care is through expanding free-market competition among insurance companies, doctors, and hospitals. Thirty-nine percent (39%) think that more government regulation of insurance companies, doctors, and hospitals is more likely to provide affordable coverage. These numbers are virtually unchanged from last year’s health care survey.

Independents (54%) and Republicans (79%) agree that more free-market competition rather than more government management of health care is more likely to lead to affordable coverage. However, a majority (60%) of Democrats think more government management is the key. Despite these partisan differences, majorities or slim majorities of whites (58%), African Americans (53%) and Hispanics (51%) believe more free market competition can better provide affordable health care than more government control.

Implications

These results do not support the widespread misperception among the political punditry that pre-existing condition regulations are necessarily and universally supported by voters across the political spectrum. Voters like benefits but not costs. And some costs are more acceptable to voters than others. Democratic accountability demands that we understand if voters are willing to bear the necessary trade-offs and costs in exchange for establishing a new policy, regulatory protection, or social program. But first, pollsters have to ask.

 
 
The Cato Institute 2018 Health Care Survey was designed and conducted by the Cato Institute in collaboration with YouGov. YouGov collected responses online October 26-30, 2018 from a representative national sample of 2,498 Americans 18 years of age and older. The margin of error for the survey is +/- 2.66 percentage points at the 95% level of confidence.

 

As If We Needed It, More Evidence Emerges Showing That The Government Has Changed The Opioid Crisis Into a Fentanyl Crisis

Speaking last week at a National Opioid Summit in Washington, DC, Attorney General Jeff Sessions reported opioid prescriptions fell another 12 percent during the first eight months of 2018, saying ‘We now have the lowest opioid prescription rates in 18 years.” Some of this was no doubt the result of the chilling effect that prescription surveillance boards have had on the prescribing patterns of physicians. For example, Sessions announced the Trump administration has charged 226 doctors and 221 medical personnel with “opioid-related crimes,” and this has not gone unnoticed by health care practitioners.

Sessions also pledged to meet the goal of a 44 percent overall reduction in the production of opioids permitted by the Drug Enforcement Administration. The DEA, which sets quotas on the production of opioids by US manufacturers, began the process with a 25 percent reduction in 2016 and another 20 percent reduction in 2017. This has led to shortages of injectable opioids in many hospitals, affecting the delivery and quality of care.

Meanwhile, the DEA reported in a Joint Intelligence Report that overdoses in Pennsylvania continued to rise, with 5,456 fatal overdoses in 2017, a 65 percent increase over 2015. Only 20 percent of those overdoses involved prescription opioids, with most deaths involving multiple drugs in combination—usually fentanyl, heroin and cocaine, as well as counterfeit prescription opioids (usually made of illicit fentanyl and heroin pressed into pills). The report stated heroin and fentanyl were found in 97 percent of Pennsylvania’s counties.

Prescription opioids were also responsible for just 20 percent of the fatal overdoses in Massachusetts in 2015, where researchers at Boston University reported last week in the American Journal of Public Health that Opioid Use Disorder among people over age 11 grew to 4.6 percent of the population that year. 

The Massachusetts Department of Public Health reports a modest tapering in the fatal overdose rate, from 2,154 in 2016 to 2,069 in 2017, and estimates up to 1,053 have occurred in the first 6 months of 2018. During the first quarter of 2018, 90 percent of those deaths involved fentanyl, 43 percent involved cocaine, 34 percent involved heroin, and 20 percent involved prescription opioids. Fentanyl is responsible for sustaining the death rate in Massachusetts at near-record levels.

What jumps out of these numbers is the fact that efforts to get doctors to curtail their treatment of pain have not meaningfully reduced the overdose rate. They have just caused non-medical users of opioids to migrate over to more dangerous heroin and fentanyl. Fentanyl and heroin—not prescription opioids—are now the principal drugs behind the gruesome mortality statistics. 

Addressing the overdose crisis by focusing on doctors treating patients aims at the wrong target. And patients are suffering—often desperately— in the process. The cause has been drug prohibition from the get-go. If policymakers can’t muster the courage to admit and address that fact, then they should at least put the lion’s share of reform efforts into mitigating the harmful unintended consequences of prohibition. I wrote about this here.

DEFENSE DOWNLOAD: Week of 11/1

Welcome to the Defense Download! This new round-up is intended to highlight what we at the Cato Institute are keeping tabs on in the world of defense politics every week. The three-to-five trending stories will vary depending on the news cycle, what policymakers are talking about, and will pull from all sides of the political spectrum. If you would like to recieve more frequent updates on what I’m reading, writing, and listening to—you can follow me on Twitter via @CDDorminey

  1. Bolton Calls National Debt ‘Economic Threat’ to US,” Toluse Olorunnipa. Hot off the presses! National Security Advisor John Bolton calls for significant cuts to discretionary spending in order to get the country back on the path of fiscal sustainability. The new trajectory? Bolton, and the President himself, have called for defense spending to be cut or levelled off in the short-term—a radical change from the administration’s previous two budgets. 
  2. In The Shadow of Reagan’s Legacy, Trump Is Failing,” Alexandra Bell. This article talks about why Reagan negotiated the INF treaty that President Trump is trying to dismantle and juxtaposes Reagan’s belief in arms control as a stabilizing force against the current administration’s actions. 
  3. The Nation Needs A 400-Ship Navy,” Thomas Callender. In the interest of showing the true breadth of this field, I’ve included this new report by the Heritage Foundation that calls for an increase over the adminstration’s current 355-ship plan for the Navy. Building to a 400-ship Navy will require $4-6 billion more annually than is already allocated, during a time of competing priorities and sky-high debt (see first article). 
  4. Mattis wants to boost fighter readiness. Here’s how industry could help,” Valerie Insinna. Last month, Secretary Mattis said that he’d like to get fighter readiness up to 80 percent—this would include all the F-35, F-22, F-16, and F/A-18 fighter jets. Readiness has been a rallying cry from the Pentagon for several years, but if Mattis intends to put his money where his mouth is, that could mean fewer dollars for new procurement projects in favor of upgrading and sustaining current platforms. 

Proposition 10: Rent Control in California

Proposition 10 on the California ballot would empower local governments around the Golden State to institute more and stricter rent control. Rent control laws infringe on landlords’ rights of property and contract; as critics point out, they also have a long history of making housing shortages worse, discouraging both the construction of new rental units and maintenance of the old while making it harder for newcomers to find a place to live. 

Though once favored in voter surveys, Proposition 10 has sagged lately, well behind in one poll and ahead in a second by only 41-38 with 21 percent undecided.  But advocates of liberty (and all who prize the lessons of Economics 101) shouldn’t get complacent.  Aside from the imponderables of turnout and momentum – first-time voters still lean toward the proposition, which has been endorsed by Bernie Sanders and the DSA – even a defeat for 10 could still leave the door open to future legislation in Sacramento working some of the same changes. Gubernatorial front-runner Gavin Newsom, for example, declares himself a supporter of rent control in principle and might preside over the passage using the conventional legislative process of what could get billed as a compromise measure with supposedly less radical provisions. 

It’s true that many California localities, the Bay Area especially, are experiencing skyrocketing housing costs. That has a lot to do with intense demand to live and work in places like Silicon Valley and San Francisco, and even more to do with the tight regulatory lid on new residential construction that artificially suppresses the supply of dwellings in the state generally and especially in desirable communities and near the coast. By shifting the blame for the resulting situation to owners of existing rental units, rent control would make it even less likely that Bay Area and coastal governments will take the one measure that would be effective against spiraling housing costs, namely legalizing much more new construction. 

As a classic instance of an infringement on economic liberty that often results in dire practical consequences over the long term, rent control has been a subject of interest to Cato from the institute’s earliest years and ever since then, in output ranging from multiple legal briefs, through a classroom treatment (at Libertarianism.org, by Howard Baetjer), to Ryan Bourne’s recent piece on Jeremy Corbyn’s plans to reimpose rent control in Britain.  Two papers from recent years:  

* “The Effects of Rent Control Expansion on Tenants, Landlords, and Inequality: Evidence from San Francisco” (Research Briefs in Economic Policy no. 109, April), by Rebecca Diamond, Timothy McQuade, and Franklin Qian of Stanford University. To quote the summary in Cato Policy Report this summer, the authors “study the effects of a 1994 San Francisco ballot initiative that provided rent control for small multifamily housing built before 1980. They find that any benefits to tenants of rent-controlled properties were counterbalanced by landlords reducing the supply of housing in response to the law.”

* “Housing Market Spillovers: Evidence from the End of Rent Control in Cambridge, Massachusetts” (Research Briefs in Economic Policy no. 9, 2014), by David H. Autor, Christopher J. Palmer, and Parag A. Pathak (“Our bottom line estimate is that the end of rent control added $2 billion to the value of the Cambridge residential housing stock over the ensuing decade following rent-control removal.”)

By the way, the chief group pushing Proposition 10 has been a Los Angeles-based nonprofit called the AIDS Healthcare Foundation. If you wonder what the rent control issue has to do with AIDS or healthcare, let that serve as a reminder to be extra-careful with your charitable giving, no matter how commendable or uncontroversial a group’s name or mission may sound.

The Migrant Caravan, Central America, and Vaccination Rates

Many commentators have recently written and said that members of the migrant caravan and Central American immigrants in general are diseased.  Former Immigration and Customs Enforcement agent David Ward claimed that the migrants are “coming in with diseases such as smallpox,” a disease that the World Health Organization (WHO) certified as being eradicated in 1980.  One hopes Mr. Ward was more careful in enforcing American immigration law than in spreading rumors that migrants are carrying one of the deadliest diseases in human history nearly 40 years after it was eradicated from the human population.  But even on other diseases, Ward and others do not have a compelling argument.

WHO has national estimates of vaccination coverage rates by country and type of vaccine.  It’s unclear whether vaccination coverage rates include immigrants, but they definitely include those born in each country as of 2017.  Vaccination coverage rates for the United States were unavailable for Tuberculosis and one of the polio vaccines (IPV1) while the IPV1 vaccine coverage rate is also unavailable for Costa Rica.  We shouldn’t expect vaccination rates to be the same in all countries for at least two reasons.  First, some diseases are more prevalent in certain climates so the requirement for vaccination there can be lower or higher.  Second, vaccines have a positive externality so there is less of an individual incentive to become vaccinated as all of the benefits are not internalized to the individual who receives the shot.  I expect the first reason to be more important than the second as enough benefits are internalized for the net-benefit of a vaccine to be positive (yes, vaccines are great) while many of the governments in these countries strongly encourage or mandate vaccination. 

Figure 1 shows that average vaccination rates for Tuberculosis (BCG), Diphtheria, Pertussis, & Tetanus (DTP1), Diphtheria, Pertussis, & Tetanus (DTP3), Hepatitis B (HepB_BD), Hepatitis B (HepB3), Haemophilus Influenzae (Hib3), Polio (IPV1), Measles 1st Dose (MCV1), Measles 2nd Dose (MCV2), Streptococcus Pneumoniae (PCV3), Polio (Pol3), Rubella (RCV1), and Rotavirus (RotaC).  The United States is in the middle of the pack with an 89 percent average vaccination coverage rate.

Figure 1 Average Vaccination Coverage Rates

The following figures all show the vaccination coverage rates for different vaccines in Central American countries relative to the United States.  In some figures, some countries are excluded because there are no WHO estimates of their vaccination rates.  The United States does not have the highest vaccination coverage rate for any vaccine reported below.  Perhaps members of the migrant caravan have lower vaccination rates than their fellow countrymen or they are carrying other serious contagions that cannot be vaccinated against.  But for most of these illnesses below, you have more to fear from your fellow Americans than from Central Americans.

Figure 2 Tuberculosis (BCG) Vaccination Coverage Rates
Figure 3 Diphtheria, Pertussis, & Tetanus (DTP1) Vaccination Coverage Rates
Figure 4 Diphtheria, Pertussis, & Tetanus (DTP3) Vaccination Coverage Rates
Figure 5 Hepatitis B (HepB_BD) Vaccination Coverage Rates
Figure 6 Hepatitis B (HepB3) Vaccination Coverage Rates
Figure 7 Haemophilus Influenzae (Hib3) Vaccination Coverage Rates
Figure 8 Polio (IPV1) Vaccination Coverage Rates
Figure 9 Measles 1st Dose (MCV1) Vaccination Coverage Rates
Figure 10 Measles 2nd Dose (MCV2) Vaccination Coverage Rates
Figure 11 Streptococcus Pneumoniae (PCV3) Vaccination Coverage Rates
Figure 12 Polio (Pol3) Vaccination Coverage Rates
Figure 13 Rubella (RCV1) Vaccination Coverage Rates
Figure 14 Rotavirus (RotaC) Vaccination Coverage Rates