Tag Archives: single-payer

“Problem Solvers’” Obamacare Solution: Single Payer

On Monday, a bipartisan Problem Solvers Caucus in the House released their list of “solutions” regarding Obamacare. Developed over the past several months, the list can easily be summed up in a single phrase: Single payer.

The lawmakers didn’t come out and say as much, of course, but that would be the net result. In funding more bailout spending for insurers, the proposal clearly states that Obamacare is “too big to fail”—that no amount of taxpayer funding is too great to keep insurers offering coverage on the health exchanges. Enacting that government backstop would create a de facto single-payer health-care system—only with many more well-priced insurer lobbyists around to demand more crony capitalist payments from government to their industry.

Cost-Sharing Reductions

Suppose for a minute that a burglar comes into your house late at night and tries to steal your belongings. Upon apprehending the suspect, the burglar tells you that he only stole your property because he’s hungry and struggling to provide for his family.

In this scenario, how likely would you be just to give the burglar your property, so he could have the resources he needs? Probably not very. On the one hand, that would solve the burglar’s immediate problem, but the burglar broke the law—and ignoring that offense will only encourage future law-breaking.

That’s essentially the scenario facing Obamacare’s cost-sharing reduction payments, meant to subsidize discounted co-payments and deductibles for certain low-income individuals. Obamacare didn’t include an actual appropriation for the payments, so Barack Obama just made one up that didn’t exist. In essence, he stole both the constitutional spending power of Congress and taxpayer funds—recall that spending money without an appropriation is not just a civil, but a criminal, offense—to get Obamacare started.

Yet Congress seems far more worried about propping up Obamacare than holding President Obama to account—focusing solely on the outcomes to individuals, while caring not a whit for the effects on the rule of law. The Problem Solvers Caucus plan includes cost-sharing reduction payments with no accountability for the Obama sdministration’s flagrant violation of the Constitution.

Ironically, Tom Reed (R-NY) and other Republican members of the Problem Solvers Caucus voted in 2014 to authorize the lawsuit that declared the cost-sharing payments unconstitutional last year. But do Reed and his other colleagues actually want to do anything to enforce that lawsuit, and preserve the Constitution that they swore to uphold? Not a chance.

Reinsurance

The Problem Solvers Caucus plan also includes “stability fund” dollars designed to subsidize insurers for covering high-cost Obamacare enrollees. But here again, the proposal throws good money after bad at insurers, creating a new government program after non-partisan auditors concluded that insurers illegally received billions of dollars from the last federal bailout.

Last September, the Government Accountability Office (GAO) concluded that the Obama administration illegally funneled billions of dollars in reinsurance funds to health insurers rather than the U.S. Treasury. After taking in “assessments” (read: taxes) from employers, the text of Obamacare itself requires the government to repay $5 billion to the Treasury (to offset the cost of another Obamacare program) before paying health insurers reinsurance funds.

But when employer “assessments” generated less money than originally contemplated, the Obama administration put insurers’ needs for bailout funds over the law—and taxpayers’ interests. GAO found the Obama administration’s actions violated the law, costing taxpayers billions in the process.

As with the cost-sharing reduction payments, the Problem Solvers Caucus would give insurers even more money, while ignoring the prior illegal—and unconstitutional—acts that benefited health insurers under the Obama regime. In so doing, the Problem Solvers proposal would create another big problem, by incentivizing future presidents to keep breaking the law to advance their political agenda.

Throwing Money at Problems

In general, the Problem Solvers Caucus attempts to solve problems by throwing money at them, by paying tens of billions of dollars (at minimum) to insurers. But as Margaret Thatcher pointed out four decades ago, socialism always runs out of other people’s money—a problem that the proposal wouldn’t solve, but worsen.

The Problem Solvers Caucus proposal amounts to little more than an Obamacare TARP—that’s Turning Against Repeal Promises (or Taking Away Repeal Promises, if you prefer). In abandoning the repeal cause, and setting up a federal backstop for the entire health-care system, the plan would create a de facto single-payer health-care system. Bernie Sanders would be proud.

This post was originally published at The Federalist.

John Cornyn Illustrates Republicans’ Obamacare Problem in One Tweet

As the Senate’s second-ranking Republican, John Cornyn holds significant sway in policy-making circles. In his third term, and serving on both the judiciary and finance committees—the latter of which has jurisdiction over Medicare and Medicaid—Cornyn should have a good working knowledge of health policy.

All of that makes this tweet, sent Friday from his account, so surprising:

How can advocates tout Obamacare a success when, among many other flaws, it leaves 30 million people uninsured?

The tweet essentially complains that Obamacare wreaked massive havoc on the health care system, while leaving 30 million uninsured. It’s similar to the Catskills joke cited by Woody Allen in “Annie Hall”: “The food at this place is really terrible—and such small portions!”

Observers on Twitter noted the irony. Some asked Cornyn to support more government spending on subsidies; some asked him to have his home state of Texas expand Medicaid; some asked for a single-payer system that would “end” the problem of uninsurance entirely.

For that matter, increasing the mandate tax to thousands of dollars, or putting people in jail if they do not purchase coverage, would also reduce the number of uninsured. Does that mean Cornyn would support those efforts?

It’s the Costs, Stupid!

There are many reasons conservatives should not remain fixated on the number of people with health insurance when designing an Obamacare alternative.

Insurance Does Not Equal Access: The narrow networks and high deductibles plaguing Obamacare exchange plans—imposed because federally mandated benefits force insurers to find other ways to cut costs—impede access to care, making finding an in-network physician both more difficult and more costly.

Similarly for Medicaid—the prime source of Obamacare’s coverage expansions—beneficiaries themselves don’t even consider a Medicaid card “real insurance,” because they cannot find a physician who will treat them: “You feel so helpless thinking, something’s wrong with this child and I can’t even get her into a doctor….When we had real insurance, we would call and come in at the drop of a hat.”

Insurance Does Not Equal Better Health: The Oregon Health Insurance Experiment compared a group of individuals selected from a random lottery to enroll in Medicaid with similarly situated individuals who did not win the lottery and did not enroll in coverage. It found that Medicaid coverage brought no measurable improvement in physical health outcomes. Likewise, prior studies have suggested that, for health outcomes Medicaid coverage may be worse than having no health insurance at all.

Beneficiaries Do Not Value Health Insurance: Another study from the Oregon Health Insurance Experiment released last year found that most Medicaid beneficiaries valued their health insurance at between 20 and 40 cents on the dollar. In other words, if given a hypothetical choice between a Medicaid insurance policy valued at $3,000, and cash in the amount of $1,500, most beneficiaries would choose the cash.

Obama Promised to Lower Costs—And Failed to Deliver: During his 2008 campaign, Barack Obama didn’t promise to reduce the number of uninsured by a certain amount. He did, however, promise to cut the average family’s health insurance costs and premiums by an average of $2,500 per year. On that count, his health law failed miserably. Since the law passed, employer-sponsored coverage has risen by more than $4,300 per family. Exchange policies spiked dramatically in 2014, when the law’s mandated benefits took effect, and are set to rise again this coming year.

Voters Care Most About Costs: Prior polling data indicates that, by a more than two-to-one margin, voters prioritize the cost of health care (45 percent) over the lack of universal coverage (19 percent). Likewise, voters prefer a health plan that would lower costs without guaranteeing universal coverage to a plan that would create universal coverage while increasing costs by a 13-point margin.

Buying into a Liberal Shibboleth

The responses from liberals to Cornyn’s tweet indicate the extent to which health coverage has become a shibboleth on the Left. There are few things liberals will not do—from spending more money on subsidies, to creating a single-payer system, to expanding coverage to illegal immigrants—to ensure everyone has a health insurance card. (Some liberals might object to putting people in jail for not buying health coverage. Might.)

The liberal fixation—some would call it an obsession—over the number of people with health insurance comes despite evidence suggesting insurance coverage does not necessarily equate with access or improved health outcomes. Over the past 40 years, 90 percent of the growth in safety net spending has come in the form of higher spending on health programs. That spending could have been more effective in alleviating poverty by improving the education system, changing transportation patterns, or enhancing nutritional options in poor communities, all of which also could foster better health outcomes. But because liberals remain singularly focused on the number of Americans with insurance cards, that’s where they want to focus all the federal government’s time and energy.

So, apparently, does John Cornyn. Rather than pledging to lower health costs—Americans’ top health care goal—or questioning the effectiveness of Democrats’ focus on health insurance above all else, his tweet looks like pure kvetching about a problem he has no interest in solving. If one wants to understand Republicans’ problems on health care—both their poor messaging, and their single-minded policy focus on replicating liberal solutions in a slightly-less-costly manner—they need look no further than this one tweet.

This post was originally published at The Federalist.

How Bailing Out Health Insurers Will Lead to Single Payer Health Care

The bad news for Obamacare keeps on coming. Major health carriers are leaving insurance exchanges, and other insurance co-operatives the law created continue to fail, leaving tens of thousands without health coverage. Those on exchanges who somehow manage to hold on to their insurance will face a set of massive premium increases—which will hit millions of Americans weeks before the election.

Many on the Right believe Obamacare was deliberately designed to fail, and fear that we’re on a slippery slope toward single-payer. On the other side of the spectrum, the Left hopes conservatives’ fears—and liberals’ dreams—will be answered. But is either side right?

The reality is more nuanced than the rhetoric would suggest. Whether government runs all of health care is less material than whether government pays for all of health care. The latter will, sooner or later, lead to the former. That’s why the debate over bailing out Obamacare is so important. Ostensibly “private” health insurers want tens of billions of dollars in taxpayer-funded subsidies—because they claim these subsidies are the only thing standing between a government-run “public option” or a single-payer system.

But the action insurers argue will prevent a government-run system will in reality create one. If insurers get their way, and establish the principle that both they and Obamacare are too big to fail, we will have created a de facto government-run insurance system. Whether such system is run through a handful of heavily regulated, crony capitalist “private” insurers or government bureaucrats represents a comparatively trifling detail.

The Biggest Wolf Is Not the Closest

In considering the likelihood of single-payer health care, one analogy lies in the axiom that one should shoot the wolf outside one’s front door. Single-payer health care obviously represents the biggest wolf—but not the closest. While liberals no doubt want to create a single-payer health care system—Barack Obama has repeatedly said as much—they face a navigational problem: Can you get there from here?

The answer is no—at least not in one fell swoop. Creating a single-payer system would throw 177.5 million Americans off their employer-provided health insurance. That level of disruption would be orders of magnitude greater than the cancellation notices associated with the 2013 “like your plan” fiasco, which itself prompted President Obama to beat a hasty, albeit temporary, retreat from Obamacare’s mandates. Recall too that the high taxes needed to fund a statewide single-payer effort prompted Vermont—Vermont—to abandon its efforts two years ago.

Understanding the political obstacles associated with throwing half of Americans off their current health insurance, liberals’ next strategy has focused on creating a government-run health plan to “compete” with private insurers. Hillary Clinton endorsed this approach, and Democratic senators made a new push on the issue this month. When stories of premium spikes and plan cancellations hit the fan next month, liberals will inevitably claim that a government-run plan will solve all of Obamacare’s woes (although even some liberal analysts admit the law’s real problem is a product healthy people don’t want to buy).

Can the Left succeed at creating a government-run health plan? Probably not at the federal level. Liberals have noted that only one Democratic Senate candidate running this year references the so-called “public option” on his website. Thirteen Senate Democrats have yet to co-sponsor a resolution by Sen. Jeff Merkley (D-Oregon) calling for a government-run plan. Such legislation faces a certain dead-end as long as Republicans control at least one chamber of Congress. Given the failure to enact a government-run plan with a 60-vote majority in 2009, an uncertain future even under complete Democratic control.

What About Single-Payer Inside States?

What then of state efforts to create a government-run health plan? The Wall Street Journal featured a recent op-ed by Scott Gottlieb on this subject. Gottlieb notes that Section 1332 of Obamacare allows for states to create and submit innovation waivers—waivers that a Hillary Clinton administration would no doubt eagerly approve from states wanting to create government-run plans. He also rightly observes that the Obama administration has abused its authority to approve costly Medicaid waivers despite supposed requirements that these waivers not increase the deficit; a Clinton administration can be counted on to do the same.

But another element of the state innovation waiver program limits the Left’s ability to generate 50 government-run health plans. Section 1332(b)(2) requires states to enact a law “that provides for state actions under a waiver.” The requirement that legislation must accompany a state waiver application will likely limit a so-called “public option” to those states with unified Democratic control. Because Obamacare, and the 2010 and 2014 wave elections it helped spark, decimated the Democratic Party, Democrats currently hold unified control in only seven states.

Even at the state level, liberals will be hard-pressed to find many states in which to create their socialist experiment of a government-run health plan. In those few targets, health insurers and medical providers—remember that government-run health plans can only “lower” costs by arbitrarily restricting payments to doctors and hospitals—will make a powerful coalition for the Left to try and overcome. Also, in the largest state, California, the initiative process means that voters—and the television ads health-care interests will use to influence them—could ultimately decide the issue, one way or the other.

So if single-payer represents the biggest wolf, but not the one closest to the door, and government-run plans represent a closer wolf, but only a limited threat at present, what does represent the wolf at the door? Simple: the wolf in sheep’s clothing.

Too Big To Fail, Redux

The wolf in sheep’s clothing comes in the form of insurance industry lobbyists, who have been arguing to Republican staff that only making the insurance exchanges work will fend off calls for a government-run plan—or, worse, single-payer. They claim that extending and expanding the law’s current bailouts—specifically, risk corridors and reinsurance—can stabilize the market, and prevent further government intrusion.

Well, they would say that, wouldn’t they. But examining the logic reveals its hollowness: If Republicans pass bad policy now, they can fend off even worse policy later. There is of course another heretofore unknown concept of conservative Republicans choosing not to pass bad policy at all.

That’s why comments suggesting that at least some Republicans believe Obamacare must be fixed no matter who is elected president on November 8 are so damaging. That premise that Congress must do something because Obamacare and its exchanges are “too big to fail” means health insurers are likewise “too big to fail.” If this construct prevails, Congress will do whatever it takes for the insurers to stay in the marketplace; if that means turning on the bailout taps again, so be it.

But once health insurers have a clear backstop from the federal government, they will take additional risk. Insurers have said so themselves. In documents provided to Congress, carriers admitted they under-priced premiums in the law’s first three years precisely because they believed they had an unlimited tap on the federal fisc to cushion their losses. Republican efforts in Congress to rein in that bailout spigot have met furious lobbying by health insurers—and attempts by the Obama administration to strike a corrupt bargain circumventing Congress’ restrictions.

Efforts to end the bailouts and claw back as much money as possible to taxpayers would shoot the wolf at the door. Giving insurers more by way of bailout funds—socializing their risk—will only encourage them to take additional risk, exacerbating a boom-and-bust cycle that will inevitably result in a federal takeover of all that risk. When the federal government provides the risk backstop, you have a government-run system, regardless of who administers it.

While the insurance industry may view more bailouts as their salvation, Obamacare’s version of TARP looks more like a TRAP. By socializing losses, purportedly to prevent single-payer health care, creating a permanent insurer bailout fund will effectively create one. While remaining mindful of the other wolves lurking, Congress should focus foremost on eliminating the one at its threshold: Undo the Obamacare bailouts, and prove this law is not too big to fail.

This post was originally published at The Federalist.

The Republican Party Split That Donald Trump’s Nomination Won’t Resolve

The general election campaign has not begun, but preliminary polling suggests that Donald Trump is a decided underdog against Hillary Clinton. For the Republican Party, there is an issue beyond the Election Day outcome–and one that, at least right now, looks unlikely to be resolved no matter who wins in November.

More so than reports of John Kasich suspending his campaign, it was Sen. Ted Cruz‘s withdrawal from the Republican primary race Tuesday night that sparked reactions from Republicans ranging from begrudging acceptance to continued hostility. Mr. Trump’s ascendance illustrates a split within the Republican Party, between the “establishment” and the “tea party” lanes, that has been widening for years. It is likely to persist, as both factions disagree on the elements that led to Mr. Trump’s meteoric rise.

A core point in the internal GOP dispute is whether political confrontation or ideological conservatism most motivates voters, including the party’s base. Steve Schmidt, a consultant to John McCain‘s presidential campaign in 2008, said on MSNBC Tuesday night that Mr. Trump’s rise was fueled by voter frustration stoked by the tea-party wing. He and other establishment figures view anger as a poor substitute for substantive policy solutions and a dead-end political strategy in general.

On the other hand, those aligned with tea-partyers view the Trump phenomenon as rising from discontent with an insufficiently conservative leadership. They see voters’ frustration and anger rooted in an establishment that overpromised and underdelivered, for example by promising to fight President Barack Obama’s executive orders on immigration “tooth and nail” in November 2014 but, just a few months later, ruling out a partial government shutdown over the issue as “not an option.”

A Cruz nomination would have left little doubt about the party’s ideological direction. Mr. Cruz often echoed Ronald Reagan’s desire to speak “in bold colors, not pale pastels,” and relying on motivated conservatives to help drive general election turnout. A Cruz-Clinton match-up would have made clear the potential, and potential limits, of a “base strategy.”

Conversely, Trump’s ideological heterodoxies—on health careabortion and even about Hillary Clinton herself—reshuffle the political landscape. Mr. Trump falls outside the “establishment” and “tea party” labels, as neither side fully embraced his ascent. Mr. Trump said Wednesday that “As far as the Republican Party coming together, it will, maybe not 100%, but it’ll come together 99% and the 1% I don’t want and it won’t have any impact.” What shape the GOP takes as some elements rally behind him and others consider different directions will definitely have an impact on the Republican Party as we have known it.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Obamacare Increasing Government Bureaucracy

Even as federal regulators take steps to constrain administrative spending by private health insurers, government overhead on health coverage has soared.

In a Health Affairs blogpost published Wednesday, David Himmelstein and Steffie Woolhandler use actuarial estimates from the Centers for Medicare and Medicaid Services to project that between 2014 and 2022, national spending on private insurance overhead and government administration will rise by $273.6 billion related to the health-care overhaul.

The authors both favor single-payer health insurance; Mr. Himmelstein co-founded Physicians for a National Health Program, an advocacy organization directed to that end. They close their piece by saying that “In health care, public insurance gives much more bang for each buck.”

Yet overhead in the public sector is growing much faster than in the private sector.

Mr. Himmelstein and Ms. Woolhandler combine two categories of spending—government administration and the net cost of private insurance (i.e., overhead)—to reach their estimates of administrative costs. Combining the two categories masks significant differences. While private insurance overhead is projected to rise at an average annual rate of 8.2% between 2014 and 2022, government administration is projected to rise at a 22.7% annual rate—nearly three times as fast. That’s consistent with my 2012 analysis, which noted that federal actuaries projected double-digit increases in spending on government administration for three of the first four years of Obamacare implementation (2011, 2012, and 2014).

This week federal regulators proposed extending medical-loss ratio requirements—a price control on overhead spending—to Medicaid managed-care plans. Meanwhile, several state-run insurance exchanges face financial difficulties, with structural challenges to their ability to attain self-sufficiency while limiting their charges on consumers to only a small share of premiums. The growing spending on bureaucracy reported in Health Affairs suggests that regulators should perhaps focus first on increasing efficiency and reducing government’s own costs before issuing more requirements on the private sector—such as the 653-page regulations issued Wednesday—that attempt to pass them on to consumers.

This post was originally published at the Wall Street Journal’s Think Tank blog.

Single-Payer Dystopia

Late last week, Los Angeles Times columnist David Lazarus wrote an article about an impending piece of legislation to be introduced by Rep. Jim McDermott. According to the column, the bill would allow states to receive federal Medicare and Medicaid funds to establish state-based single-payer health insurance systems.  The article provides background on California’s numerous prior attempts to establish single-payer health care in the state, and quotes liberal advocates as saying the McDermott legislation could finally result in the single-payer dreams becoming reality.

Unfortunately, there are a few flaws in this logic. Such as California’s $16 billion budget deficit, which has prompted Gov. Jerry Brown to ask voters to approve massive tax increases. And there’s also this unwelcome element: “A draft of McDermott’s bill says that to receive federal funds, states would have to offer a health care plan with the same benefits as the most popular plan available to federal government employees.” That plan would be the Blue Cross Blue Shield standard option plan, which in 2010 cost a whopping $6,458.88 for a single person annually –34% more than the average single premium for employer-provided health insurance in California that year.

To sum up: At a time when California still faces double-digit unemployment and massive budget shortfalls, liberals think the state can use existing federal dollars to cover 7 million uninsured, provide 34% richer benefits to those with insurance, and save the state money in the process. Some might argue that position is taking “California Dreamin‘” to an extreme. Because given economic malaise, budget constraints, and a platinum-plated package of mandated benefits, the single-payer health utopia liberals seek would, for millions of California residents, quickly turn into a dystopia. Or even a Fruitopia.

Liberals’ Silly Contortions over Premium Support

Earlier this week the Center for American Progress released a paper, and former Obama Administration official Zeke Emanuel wrote a blog post, attacking the Ryan-Wyden premium support model.  The gist of both documents is their assertion that government-run Medicare would attract sicker beneficiaries than private plans, and in so doing fatally undermine the government-run program.  From the CAP report:

“No version of premium support fully prevents private health insurance plans from attracting healthier beneficiaries, driving up premiums for those who remain in traditional Medicare.  In addition, no version of premium support creates a level playing field between private plans and traditional Medicare.  As a result of these two factors, more and more beneficiaries would gradually shift to private plans over time.”

Compare the above position to the (in)famous quote from a Congressional Democrat two years ago, in which she said that a government-run plan for those under age 65 would eradicate private insurance:

“Next to me was a guy from the insurance company, who then argued against the public health insurance option, saying it wouldn’t let private insurance compete – that a public option will put the private insurance industry out of business and lead to single payer [loud cheering]. My single payer friends: He was right. The man was right.”

So the liberal groups who once claimed that a government-run plan “will put the private insurance industry out of business and lead to single payer” NOW believe that government-run Medicare CANNOT compete on a “level playing field” against the private sector.  Why didn’t they tell us this two years ago…?

There are three possible explanations for this abrupt U-turn by the left:

  • Liberals believe that risk adjustment to adjust for beneficiaries’ health status will not work effectively, and that allowing plans to offer benefits actuarially equivalent to, but not exact replicas of, government-run Medicare will attract healthier beneficiaries.  In this case, the left is admitting Obamacare will fail – because Obamacare includes provisions allowing for actuarially equivalent plans (Section 1302(d)) and a risk adjustment program (Section 1343).
  • Liberals believe that unlike the above-65 population in Medicare, everyone below age 65 has identical health status, rendering concerns about certain plans attracting sicker-than-average beneficiaries moot.
  • Liberals will say one thing when it comes to expanding government control, and another when it comes to giving individuals more private choices.

Feel free to decide amongst yourselves which option you find most accurate…

Donald Berwick, Transparency, and Rationing

In his first interview since leaving government service over the weekend, Donald Berwick made a series of revealing comments that reinforced just how and why Republicans and Democrats disagree on health care.  Asked by MSNBC’s Chris Hayes about his infamous “rationing with our eyes open” quote, Berwick talked about his daughter’s experience being denied a lab test by her insurer:

I called them and I said what do you mean, it’s not covered?  Who’s accountable?  Who made that decision, that that test is rationed to her, and you can’t even get a number or a name.  And what I said is, we need the lights on – we need that kind of decision-making to be done in daylight….So the quotes are nearly totally out of context.

Berwick’s television comments echo a print quote given to the New York Times, in which he said the point of his rationing comments was “that someone, like your health insurance company, is going to limit what you can get.  That’s the way it’s set up.  The government, unlike many private health insurance plans, is working in the daylight.  That’s a strength.”  So essentially, Berwick’s position is that someone has to tell a patient “No,” and that a government agency is better to serve this function than a private insurer, because the former is more transparent than the letter.  There are several problems with that line of thinking:

  • First is that when several private insurers participate in a marketplace, patients have choices – if they don’t like one carrier’s policies, they can buy a policy with another insurer.  (True, portability among insurers currently has some gaps, but some Republicans support solutions that could remedy this problem.)  Under a government-run system, individuals have no other place to turn if they don’t like the government’s decision-making processes.  And lest there be any doubt, Berwick didn’t just write about a single-payer system in Britain – his famous “Triple Aim” journal article said that a single-payer system in the United States was the best way to achieve his stated goals.
  • Second, Obamacare actually DECREASES transparency and accountability within the government-run health system.  Most notably, its new IPAB board of unelected bureaucrats, established in Section 3403 of the statute, will have the power to make binding rulings regarding Medicare policy.  And Obamacare includes NO requirement for public comment prior to IPAB issuing its recommendations.  Moreover, IPAB is definitely NOT accountable – unlike insurers, whom customers can sue for denying covered treatments, the decisions of IPAB’s unelected bureaucrats are not subject to judicial review.  So this new IPAB – which will make many of the key choices regarding Medicare – is neither open nor accountable to the American people.

It’s telling that Donald Berwick claimed that government can be a transparent arbiter – if not explicit rationer – of health care resources, even as he admitted in the very same interview that he couldn’t be transparent about his viewpoints and writings while serving in the Obama Administration.  If that’s not an indictment of Berwick’s own philosophy, I don’t know what is.

Premium Support and True Competition in Medicare

The ongoing discussion about entitlement reform has sparked a debate about some of the details of the current Medicare program, and how it might change under various reform proposals.  At the Incidental Economist blog, Boston University professor Austin Frakt wrote a post last week arguing that under premium support, traditional government-run Medicare might actually thrive.  Much of his post was based on the fact that Medicare pays providers much less than private insurers – a difference that will accelerate if provisions of Obamacare are implemented as scheduled – although he did admit that access in traditional Medicare might become constricted if 40 percent of providers become unprofitable from taking Medicare patients, as the program’s actuary has suggested.

Frakt went on to re-state a popular syllogism that falls short:

“Why are so many seeming to lack confidence that the program can compete?  After all, look at what’s going on today.  Private plans are at a tremendous advantage and have been for many years.  They receive per beneficiary subsidies way above the average cost of traditional Medicare.  They offer many additional benefits and many plans offer lower premiums and cost sharing relative to traditional Medicare.  Still, traditional Medicare retains 75% of the market.  Competitive bidding would reduce the overpayments to Medicare Advantage plans, reducing the advantage they have in the market today.”

The “overpayment” argument misses the point, for several reasons:

  1. Why does Medicare retain 75% of market share?  Because new enrollees in Medicare are enrolled not in the cheapest plan, or the best-rated plan, or the plan with the broadest provider network, or the plan with the best benefits.  Instead, beneficiaries are automatically enrolled in the government-run plan.
  2. Other studies of plan switching strongly suggest that seniors do NOT switch plans on a regular basis.  The Medicare Payment Advisory Commission (MedPAC) found earlier this year that “only about 6 percent of Part D enrollees have switched plans voluntarily each year.”  So once people enroll in a plan, they’re likely to stay in that plan – meaning that because government-run Medicare has a structural monopoly on enrollment, many seniors are not likely even to think about switching to a Medicare Advantage private plan.
  3. Because Medicare beneficiaries must make an affirmative choice to enroll in Medicare Advantage – and because Medicare Advantage plans CANNOT take away government-run Medicare’s structural enrollment monopoly by undercutting the government-run plan on price – they MUST use better benefits to attract seniors.

Former CBO Director Alice Rivlin acknowledged the structural deficiencies in the current program in her testimony before the Deficit Reduction Committee earlier this month:  “If a private healthcare plan currently has lower costs than FFS Medicare in its area, it cannot offer a rebate to enrollees as an incentive to sign up. Instead, it must increase benefits – which in and of itself increases Medicare spending.  Therefore, beneficiaries in areas with high FFS Medicare costs who enroll in private plans receive a host of free supplementary benefits, financed by the government.”  Rivlin again illustrates that Medicare Advantage plans have little incentive to under-bid Medicare on price – they must offer more benefits in order to attract seniors to enrollIn other words, the supposed “overpayments” are actually a symptom of a larger disease – the disease being the structural obstacles in the way of Medicare Advantage plans obtaining larger market share by offering a better deal to beneficiaries than government-run Medicare.

One easy way to solve this problem would be to automatically enroll new beneficiaries in the lowest-cost plan, whether that plan is a private Medicare Advantage plan or government-run Medicare.  Ironically enough, MedPAC – which spent years attacking “overpayments” in Medicare Advantage – has remained strangely silent about the structural bias in favor of government-run Medicare that caused this problem in the first place.  Unfortunately, this deafening silence may mean that neither MedPAC’s ostensibly non-partisan “experts,” nor liberal advocates fixated on a single-payer health care system, have an interest in putting private health plans on equal footing – both financial AND structural – with government-run Medicare.

Democrat Plans Rationing With Open Eyes

From Montana this week comes word that its Governor, Brian Schweitzer, wants to establish a government-run health care plan in his state.  The governor said he “has completely different plans for the Medicare and Medicaid money the federal government gives the state,” and that he wants to “create a state-run system that borrows from the program used in Saskatchewan.”  He then went on to explain how his government-run system might keep taxpayer spending on health care low:

[Schweitzer] said the Canadian province [i.e., Saskatchewan] controls cost by negotiating drug prices and limiting non-emergency procedures such as MRIs.

A simple web search about waiting times in Saskatchewan yields information about the types of “non-emergency procedures” subject to rationing in the province; for instance, the list of “Wait List FAQs” from the Saskatchewan Cancer Agency includes this helpful guidance for cancer patients:

What are you doing to ensure that I get an appointment in a timely way?

Currently we have a shortage of medical oncologists that is impacting our wait times.  We are also actively recruiting to fill our vacant positions throughout our facilities and are working to bring in locums to help address wait times….

Can I get care sooner if I go somewhere else?

You will find that wait times exist in the healthcare system throughout Canada and in other countries as well….

And when it comes to the MRI example Governor Schweitzer referenced, rationing occurs there as well – unless you’re politically connected.  Saskatchewan Rough Riders – i.e., players in the Canadian Football League – have been able to jump the long queues for MRIs in the province by paying for their own treatment; other people can wait for as long as three months.

Details on how Governor Schweitzer intends to turn Montana into a Canadian-style health care system are not yet known.  However, given that Schweitzer’s application will be reviewed by the Centers for Medicare and Medicaid Services – whose head, Donald Berwick, has spoken of rationing with our eyes open – it’s quite possible the application will be approved.  In that scenario, those who can afford to get to the head of the queue – millionaires and billionaires who can fund the entire cost of their treatment, and pro athletes like Michael Vick – will receive in a prompt fashion the MRIs and cancer care they need to maintain or regain their health.  Everyone else, perhaps not.