That’s what Sherry Glied (Columbia University’s Mailman School of Public Health), Len Nichols (New America Foundation) and I discuss with Larry Levitt in this Kaiser Family Foundation webcast.
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Health Care
The Anti-Universal Coverage Club: One Big Tent
A new poll by the Kaiser Family Foundation and the Harvard School of Public Health asked likely Republican and Democratic primary voters their views on health care reform. In particular, the poll asked whether respondents would prefer that a presidential candidate propose:
- “A new health plan that would make a major effort to provide health insurance for all or nearly all of the uninsured BUT would involve a substantial increase in spending
- “A new health plan that is more limited and would cover only some of the uninsured BUT would involve less new spending [or]
- “Keeping things basically as they are”
(“Don’t know” and “Refused” were also options.)
Nearly 70 percent of likely Republican primary voters rejected the universal coverage option (#1). Forty-two percent said they preferred the more moderate, less universal option (#2), while 27 percent said they preferred to keep things as they are (#3).
Interestingly, nearly one-third of likely Democratic primary voters also rejected the universal coverage option: 22 percent said they would prefer the more moderate option, while 8 percent preferred the status quo.
Looks like there are candidates for the Anti-Universal Coverage Club on both sides of the political aisle.
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Sometimes Medicine Helps, Sometimes It Hurts
This week’s Health section in The Washington Post has one, two, three illuminating articles showing how aggressive medicine can either hurt or help:
- Often helpful, often unhelpful, sometimes harmful medicine: “Brenner and his colleagues estimate that CT scans may be responsible for perhaps 2 percent of all cancers in the United States. The ECRI Institute estimated the scans may be causing 6,000 extra cancers each year, half of them fatal … While there are scant hard data about how often CT scans are done needlessly, several experts estimated that perhaps one-third could be eliminated.”
- Outright harmful medicine: “One of the most horrifying medical treatments of the 20th century was carried out not clandestinely, but with the approval of the medical establishment, the media and the public. Known as the transorbital or “ice pick” lobotomy, the crude and destructive brain-scrambling operation performed on thousands of psychiatric patients between the 1930s and 1960s was touted as a cure for mental illness.”
- Unexpectedly helpful medicine: “Scans of my bones, pelvis and abdomen were all clear — suggesting the prostate cancer hadn’t metastasized. But the stomach scan caught a couple of inches of my right lung in the picture — and it wasn’t pretty. A suspicious nodule was growing in the lung’s lobe, apparently unrelated to my prostate cancer. A PET scan ‘lit up’ the nodule, confirming it was a live growth … My experience puts me in a select group of people lucky to have received an accidental lifesaving diagnosis.”
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Catching Flak for RomneyCare
Over at The Corner, Jonathan Adler is discussing the health care reforms Mitt Romney signed into law while governor of Massachusetts with an advisor to Romney’s presidential campaign.
The Romney advisor claims: “The fact is that since healthcare reform was passed just over a year ago, the number of uninsured and the price of the average individual market health insurance policy in MA have decreased substantially.” He may be right about the uninsured, but that’s a terrible measure of success. Health insurance does not equal access to medicine, and access to medicine does not equal health. Regarding the second claim, here’s what I wrote in September:
The Boston Globe truth-squads a similar claim and finds the reduction in premiums came from factors like political pressure, restrictions on access to providers, and greater pooling — not deregulation. Moreover, political pressure cannot last, while pooling raises someone else’s premiums to compensate. Overall, premiums under the Massachusetts law came in at more than projected. And premiums in Massachusetts are growing at 8–12 percent per year, compared to 6–8 percent for the rest of the country. Romney may not be responsible for that trend, but does anyone but Romney claim he has done anything to temper it?
Looking back on that, it occurs to me that the restrictions on access to providers part probably was deregulation. The Romney plan did repeal the Commonwealth’s any-willing-provider law. On balance, however, the plan increased regulation. The rest of that paragraph stands.
The Romney advisor writes: “Critics like Mr. Tanner [my Cato colleague] want to condemn the reforms as a failure just three days after the individual mandate has gone into effect.” Actually, all Tanner has done is make a few predictions about the ill effects of the plan, plus predict that the plan would fail to achieve Romney’s stated goal of universal coverage. Last time I checked, all of Tanner’s predictions had come true.
Finally, the advisor rather cynically argues: “bear in mind that any implementation hiccups are primarily the responsibility of the current (Patrick) Administration. If there are cost overruns, inefficiencies, etc., it’s very hard to blame someone who’s not in power to do anything about it anymore.” And if a bank security guard dynamites the safe, it’s very hard to blame him for the looting that occurs after his shift is over.
Adler responds ably: “If a government program is only good when controlled by the ‘right’ people, then it is not a good government program.”
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Cringe-Inducing Confusion at TNR
Over at The New Republic, Josh Patashnik responds to my post on Gov. Arnold Schwarzenegger’s (R‑CA) universal coverage plan. Over at Washington Monthly, Kevin Drum gave Patashnik Tuesday’s quote of the day.
It would be an understatement to say Patashnik and I don’t see eye to eye. I don’t even think we speak the same language. For example…
Market-friendly reforms? Patashnik describes the Schwarzenegger plan as a collection of “market-friendly” health care reforms. Really.
The plan would banish market prices for health insurance. It would override market allocations of wages and benefits. It would let the state, rather than the market, decide what share of health insurance premiums will be spent on administrative costs vs. claims. It would expand government coverage at the expense of private markets. Every plank of Schwarzenegger’s plan would reduce the number of decisions made by the market and increase the number of decisions made by government.
Certainly some insurance companies and employers would benefit, because the plan would cripple their competitors. But that makes the plan anti-competitive, special-interest legislation — not market-friendly.
Patashnik claims the plan contains a “variety” of market-friendly reforms. If he can find even one, I’ll buy him lunch.
Libertarians = conservatives? Patashnik writes:
I can’t say I’m surprised Cato doesn’t like [Schwarzenegger’s plan], though. The conservative health care strategy works like this…
Patashnik perhaps believes that conservatives and libertarians are the same thing, or that the latter are a subset of the former. This is a source of irritation for libertarians (and probably conservatives too), for the same reasons it would irritate TNR staff to be called communists: not only is it dismissive, it’s just plain inaccurate.
…endorse subsidies in theory, since it would seem unacceptably heartless to simply say that people who can’t afford medical care shouldn’t get it.…
Libertarians endorse voluntary subsidies, in the abstract and the concrete, for those who cannot afford medical care. This is not because “it would seem unacceptably heartless to simply say that people who can’t afford medical care shouldn’t get it,” but because that is unacceptably heartless.
Libertarians oppose coerced subsidies, such as the Medicaid program that Schwarzenegger proposes to defraud, because it is immoral to put someone in jail if he doesn’t want to contribute to Medicaid. Coerced subsidies are also counter-productive. (Need evidence? Look around.)
Mind you, we don’t think these things because we’re libertarians; we’re libertarians because we think these things.
Patashnik continues:
…Then, whenever anybody proposes a plan to actually implement subsidies, vehemently oppose it without offering any alternative plan to expand coverage.
Three things: First, a libertarian who opposes coerced subsidies is being entirely consistent. Second, libertarians have no obligation to offer an alternative plan to expand coverage, because libertarians reject that as a legitimate role for government. Third, were Patashnik to peruse the offerings of Cato health policy scholars, he would notice that most of our proposals nevertheless would expand coverage — simply because more people would have health insurance if government got out of the way.
State experimentation Patashnik concludes:
…In other words, let states experiment — except when they actually do.
Yeah — if libertarians (or conservatives?) prefer state-level economic regulation to federal regulation, why do they complain about it when they see it? Two responses:
First, one might believe that gay marriage is an issue for the states rather than Congress, but still oppose a particular state’s proposal to suppress that freedom. My guess is that Patashnik sees hypocrisy only because he does not value the freedom to choose his health insurance or how to provide charitable care as much as he values the freedom to marry someone of the same sex.
Second, Schwarzenegger is experimenting with the money of non-Californians. By law, half of California’s Medicaid budget comes from the feds. So the non-Californians funding his grand designs have every right to object. Moreover, Schwarzenegger proposes — in broad daylight — to further pick the pockets of non-Californians by defrauding Medicaid.
I wonder, does that bother Patashnik? I’m interested to know the answer.
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Unfunded State Health Costs: Still $1.4 Trillion
The New York Times and Washington Post report today on a new study by the Pew Center on the States regarding unfunded state and local pension and health costs for retirees.
Let’s just look at the health costs. Pew finds that state governments have promised their workers $370 billion of retiree health care that they have not put money aside for. Unless those benefits are cut, that figure represents the looming hit on future taxpayers.
But Pew only looks at state governments, which employ 4.3 million people, according to Census data. Local governments employ 11.8 million people. If the local health care problem is as big as the state problem, the total state/local unfunded amount would be $1.4 trillion.
Interestingly, that is precisely the figure that Jagadeesh Gokhale and I came up with when we looked at this problem last year. We estimated that state and local governments have racked up about $1.4 trillion in unfunded retiree health costs.
Our study and the Pew study highlight two fundamental problems. First, governments have been irresponsible in making huge promises to workers regarding future benefits, but then not funding them as private benefit plans would.
Second, “public sector employees are far more likely to receive retirement benefits [than private sector employees] and the gulf between private and public sectors continues to grow,” according to Pew. For example, 82 percent of government workers receive retiree health benefits, compared to just 33 percent of private sector workers.
The solution is to cut back sharply on the gold-plated benefits received by government workers, while privatizing as many state and local activities as possible.
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Universal Coverage Is the Health of the State
California’s health care sector is as bloated and inefficient as the rest of the country’s, meaning that it already bleeds the taxpayers dry. But that’s just not good enough for Gov. Arnold Schwarzenegger (R).
He and Assembly Speaker Fabian Nuñez (D) have cobbled — and the state Assembly has approved — a package of health care reforms that would further kneecap the taxpayers, march them down to Death Valley, and bury them up to their necks to be eaten alive by special-interest fire ants. But perhaps I understate.
Unless the Senate or the voters stop the plan, it will carve up taxpayers by regulating health insurance to protect favored insurers from competition; regulating employee benefits to protect favored employers from competition; imposing enormous taxes on young and healthy Californians; creating taxes and subsidies that seem deliberately designed to keep low-income Californians poor; imposing on all Californians the sort of punitive mandates that never have achieved universal coverage and never will; and fraudulently foisting part of the cost onto taxpayers in other states. And all in the face of a $14 billion deficit.
Just goes to show what Republicans and Democrats can do when they work together toward a common disaster like universal coverage.