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Jens 'n' Frens
Idle thoughts of a relatively libertarian Republican in Cambridge, MA, and whomever he invites. Mostly political.
"A strong conviction that something must be done is the parent of many bad measures."
-- Daniel Webster
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Saturday, September 29, 2012 :::
I've been meaning to comment on a point that pops up once in a while: the official growth rate of Medicare under the Ryan-Wyden plan (and of the similar Romney-Ryan plan) is the same as the official growth rate under Obama's law: GDP growth plus 1% per year, IIRC.
This is correct using the numbers that the CBO used to score the plans, but that doesn't mean the plans have the same effect on the budget. Ryan-Wyden uses competition to try to reduce the growth of Medicare (not to mention, to give its recipients more of what they want), which a recent estimate suggests would reduce costs by 9%, though, of course, it's not a perfect estimate. The CBO doesn't use estimates of dynamic effects, so to get a CBO score, Ryan and Wyden added a backstop that limits spending to the rate in existing law by making wealthy Medicare recipients pay more and cutting payments to medical providers in areas in which costs have grown the most. Existing law similarly limits growth by cutting payments to medical providers.
So the official rates are the same, and both systems enforce the limits by reducing the availability of service, but Ryan-Wyden could plausibly have a lower growth rate; even if it doesn't, senior choice will do some of the job of limiting cost growth in ways in which growth reductions don't reduce benefits received, so the broad-based cuts imposed from Washington should be less severe. The CBO-official growth rates are the same, but that's just because the CBO only recognizes the growth rates of the caps, and ignores the primary Ryan-Wyden (and, now, Romney) means of holding down cost growth.
Labels: Health Care
::: posted by Steven at 3:27 PM
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Saturday, March 24, 2012 :::
The Supreme Court will be hearing arguments next week that the federal individual mandate to buy health insurance is unconstitutional. David Bernstein has comments and I wish to pick a nit.
Bernstein asks -- as have lawyers before him -- whether the mandate can be squared with any limit on Congress's authority under the Interstate Commerce clause or whether upholding the mandate means upholding Congress's authority to "require everyone to eat broccoli?" But the clearer analogy is to a requirement that everyone buy broccoli.
Perhaps the logic being used to justify the mandate to buy a product would also apply to a mandate to use that product, but if the proponents of the law want to draw a distinction, it seems like there's one there. Besides, my (not partially uninformed) impression is that, until the late 1930s the clause in question gave Congress the power "To regulate Commerce... among the several States," that from 1942 until the mid-1990s it effectively gave Congress the power "to regulate," (or, if there was some constraint on the clause, perhaps "to regulate activity by people who either might some day be capable of engaging in commerce with other states or use the postal service") and that since Lopez and Morrison, Congress has had the power "to regulate economic activity".
I think the Lopez-Morrison-Raich line of cases could suggest a finding that Congress may require people to buy broccoli but must stop short of actually forcing it down people's throats. The power to make you eat broccoli would be left to the states and municipalities. If you live in Bloomberg's New York City, you should probably expect that power to be used.
Incidentally, a few weeks ago I saw another common version of this analogy, asking whether Congress could require that we buy GM cars. Someone responded (to the best of my recollection), "they did force us to buy GM cars. We just didn't get the cars."Labels: Health Care, IANAL
::: posted by Steven at 12:10 AM
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Saturday, March 03, 2012 :::
One of the key ideas behind Obamacare was that unlike people who select among insurance plans, the government would be able to reduce expenses by saying no to coverage of medical expenses that aren't important enough to justify their costs. There might be some political pressure to require coverage for more goods and services than are justified because each individual good/service has producers and consumers lobbying in its favor while the cost of each individual good/service would be dispersed, but a board of independent-minded bureaucrats would be able to make dispassionate decisions and the political branches of government would, ultimately, back them up.
Last month, HHS decided that all health insurance plans would have to cover contraception. Based on the numbers I've seen for how much this would save people, I assume the mandate is for the user's choice of contraception (Rush Limbaugh seems to assume that it just means going through a lot of condoms, but I don't think that's right). This week the Senate voted on a bill to provide a religious exemption from the mandate to a handful of insurance programs. One possible objection to such a bill is that this particular exemption shouldn't exist, but that the mandate shouldn't either, but that line of argument wasn't heavily used - I'm pretty sure the bill's opponents in the Senate all believe that providing everyone with whatever form of contraception they prefer without paying any of the cost (more precisely: any more of the cost than any other member of society) is too important to let anyone fall through the cracks - especially members of the oppressed classes of society, like Georgetown Law students. Those opponents constitute a majority - the bill failed.
So, is our political system going to provide everyone the best contraception money can buy but deny people risky and expensive but potentially life-saving procedures? Or will cost control be a farce? I'm not sure which answer I like less.
Extra thoughts- "Both" is perfectly reasonable answer.
- A lot of medical spending is on old people, who are politically active, which leads me to expect that, like LBJ's entitlements, this will cost a lot more than it is supposed to.
- Will providing free hormonal contraception cause promiscuous people to use fewer condoms and increase the spread of STDs? Or will it not matter, because people who are that irresponsible are already too irresponsible to use condoms?
Labels: Health Care
::: posted by Steven at 12:20 PM
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Monday, February 13, 2012 :::
Regarding the recent controversy over requiring that everyone have employer-provided health insurance that covers contraception, I've seen some twitter comments from both the left and the right that the real lesson is that having health insurance tied to employment is kind of nuts.
I thought we had agreed on that several years ago, and one side of the political spectrum offered several proposals to allow the individual insurance market to compete on a more even footing with employer-provided insurance. Then the other side of the political spectrum pushed through a federal law exacerbating the problem.
I assumed that meant the consensus had ended, and maybe it still has -- one tweet from the left doesn't mean that everyone on the left has come back around. But I hope we can move back toward a consensus that we shouldn't fine companies for paying their employees in just cash instead of a combination of cash and health insurance.
It would be even better if we could let people save money and adhere to their beliefs by allowing health insurance that doesn't cover, without copays, every malady with a powerful lobby -- maladies like fertility, for example. [The previous sentence was edited for comprehensibility after the original post -SJ] I would think people would be less eager to have the government dictate what health insurance must include if you could choose your health insurance and your job separately.
Incidentally, I recently re-encountered a piece by Peter Suderman noting that most of the major provisions of PPACA had already been tried in the states and had failed before the law was passed.Labels: Health Care
::: posted by Steven at 9:25 PM
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Sunday, May 15, 2011 :::
One of the assumptions made by many people in the ongoing debate about how far to socialize medicine is that health insurance coverage leads to better outcomes. From the Wall Street Journal: Medicaid is Worse Than No Coverage At All.Labels: Health Care
::: posted by Anonymous at 7:15 PM
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Friday, April 29, 2011 :::
Megan McArdle looks at why we don't have better birth control pills. Some of the reasons are technical, some are economic, and some are regulatory (and, of course, all are interrelated).
She notes that[w]hen I was younger, I thought of the pill as something nearly perfect--almost no side effects, almost 100% effective. I think a lot of young women view it the same way. Arthur C. Clarke once noted that "any sufficiently advanced technology is indistinguishable from magic." I think the biggest difference - especially in medicine - is that magic is simpler. Magic (at least what I've read about) generally does exactly what is expected, which is generally something easily explained. At worst, the spell simply fails. If it has unexpected side effects, they are usually unexpected consequences of the expected consequences (e.g., the monkey's paw).
Medical technology is wonderful, but it isn't magic. If an FDA-approved pill exists that is supposed to alleviate or cure a problem you have, it likely will, but it won't leave you otherwise unchanged as a magic pill would, and most of the unintended consequences will generally be unwelcome (though not necessarily all of them).
As a (mostly) conservative, I assume that if the obvious effects of a major piece of legislation are, on net, roughly neutral, the actual effects will be, in the aggregate, negative. Not all change should be rejected, but unless a proposal has enough to recommend it to offset the risks that major change automatically entails, it's better to leave the old laws in place along with the schemes that people will have devised out to deal with their deficiencies. I operate under a similar rubric as a drug consumer.Labels: Health Care
::: posted by Steven at 8:15 PM
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Saturday, January 29, 2011 :::
On a new HHS report on Obamacare:Then there are vague promises about legislative goodies that might help keep health insurance costs down. One of these is rate reviews, which I wrote about in December when it was announced. As I pointed out then, reviewing rates has very little to do with driving down the underlying cost of health care. If a hospital charges $1,500 for a night in a bed, heckling the insurer is unlikely to change that. Just like yelling at the U.S. Airways ticket agent is not going to get your plane to take off during a snowstorm. Screaming about rate increases is a softer version of price-fixing. And capping rates paid for services naturally leads to shortages of providers or thinner benefits. But since you can’t lower benefits because the legislation makes insurance one-XXL-size-fits-all, it will lead rapidly to Medicaid-for-all. That’s where people think they have insurance but they don’t because nobody takes it. Try finding a dermatologist in most counties who will accept $18 for an office visit. If you can it’s because they’re a Good Samaritan, not because it’s a long-term sustainable business.
Actually, it can be sustainable if only a fraction of your patients are on Medicaid; it's only when everyone is on Medicaid that doctors really can't accept Medicaid patients at below cost. Which isn't to say that I'd blame them for turning down any patients who they would have to subsidize.
Semi-related, I just saw this "tweet":Breaking: Mubarak crushes populace with oppressive law, exempting hundreds of his cronies. Oh, wait, that's ObamaCare. Labels: Health Care
::: posted by Steven at 12:13 PM
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Tuesday, January 11, 2011 :::
Blue Shield of California is raising its health "insurance" premiums by "as much as 59%", and cites a variety of reasons:But responding to this most recent increase the company said, "our individual market medical costs are rising rapidly due to higher provider prices, increased utilization, and the fact that healthier people are dropping coverage during a bad economy," the company said. That last point raises in my mind the question as to how much of the relevant adverse selection is due to natural informational constraints and how much is imposed by state and federal governments. According to Families USA, which I'm willing to trust on this question, California seems not to be among the states with its own community rating stipulations, though another website indicates a variety of federal regulations — I don't know how many of them are new since last March — that presumably contribute.
Another natural set of questions: How much would those healthier people be willing to pay for health insurance? How much would they be required to pay by an insurance company not subject to these regulations? Somewhat less interesting, How much are they being asked to pay for insurance under the actual system of constraints they face?Labels: Health Care
::: posted by dWj at 12:57 PM
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Tuesday, September 28, 2010 :::
I had a doctor appointment a week ago, and have some questions related to it.- I've been prescribed an epi-pen. (This is quite precautionary, though I kind of have the impression that they generally are.) These are generally expected to be self-administered. This means that they're for situations in which a patient is conscious of the fact that he is at a significant risk of death, and in which more adrenaline will ameliorate the situation. I would think that sort of thing would be self-limiting.
- I'm helping the doctor's office get some of my medical information from other practices. I had imagined that they would send a form to the other practice, and the other practice would send back all my medical data, but it seems they instead make more narrow requests. This seems strange and bad to me; I would think ideally my current doctor would have access to everything in his own systems. Is there a good reason for this? Is it a system that kind of evolved in a nonideal way, rather than being top-down, and it would be hard to switch? Or is this a consequence of excessive concerns for privacy? (I tend to strongly defend pro-privacy positions, but to be rather free with my own information; I'm a supporter of the principle that people should have privacy if they want it. I also think people should be able to forego privacy if they like, to the extent that it doesn't scare the horses. I kind of like some privacy, but I more want not to die. If this is a privacy concern someone has on my behalf, I'd very much like to waive it.)
Update: On one hand, I don't know that a parenthetical should take over a blog post, but, on the other, it wouldn't be outside of the norm for me. One of the things about privacy is that I'm often rather surprised about the things people are wary of having known by whom, and what things they aren't. People who talk about their sex lives at parties, i.e. around strangers, but worry that a computer somewhere has their Ikea purchases stored in a database. On some level I still wish them well with getting the privacy they want, insofar as it doesn't cost me much, but they're going to have a hard time getting me seriously worked up about it, or eliciting from me an intuitive sense that this latter offense is obviously egregious and that whoever built the database must be evil.Labels: Health Care
::: posted by dWj at 6:52 PM
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Thursday, September 16, 2010 :::
Last week, some health insurance companies announced that they were raising rates on some individual plans because of new guaranteed-issue mandates. A lot of bloggers on the left think this is an excuse for implicit collusion, but, as Megan McArdle explains, it obviously makes sense that a guaranteed-issue will increase costs. I think actual cost increases are the better explanation than implicit collusion, especially if the rate increases last.
HHS Secretary Sebelius apparently disagrees, writing that "there will be zero tolerance for this type of misinformation and unjustified rate increases" and including this threat:We will also keep track of insurers with a record of unjustified rate increases: Those plans may be excluded from health insurance Exchanges in 2014. Which would mean they couldn't sell insurance.
I don't know what discretion the law gives the HHS Secretary on this - whether she can simply choose which companies are allowed to operate depending on who displeases her, or whether she is following some relatively transparent guidelines - but I think this illustrates a good reason not to concentrate more power than necessary in the hands of government.Labels: Health Care
::: posted by Steven at 12:26 PM
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Tuesday, June 08, 2010 :::
This headline is a little odd:Health law could ban low-cost plans The health law in question is the one you'd expect, and we know it has some hidden, perhaps unintended consequences. But prohibiting low-cost health plans -- in fact, requiring that everyone get a high-cost health plan -- was its primary purpose, wasn't it?
The article is about a specific type of low-cost plan and the fact that it will be prohibited long before subsidies are available to help poor people transition into something pricier. In other words, the substance of the article isn't entirely as obvious as the headline could suggest. But the headline caught my attention and I would rather blog than study accounting.Labels: Health Care
::: posted by Steven at 12:15 PM
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Tuesday, May 11, 2010 :::
The NYTimes offers Greece advice:Another reform high on the list is removing the state from the marketplace in crucial sectors like health care.... Economists say that the liberalization of ... the health care industry would help bring down prices in these areas, which are among the highest in Europe. Click-through is encouraged.Labels: Health Care
::: posted by dWj at 11:10 AM
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Friday, May 07, 2010 :::
It's well known — in some circles, at least — that much of what's wrong with the US healthcare system is driven by the strong link between health insurance and employment. In light of that, Obamacare may have something to recommend it.Labels: Health Care, possibly unintented consequences
::: posted by dWj at 5:33 PM
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Wednesday, April 21, 2010 :::
Tyler Cowen notices a story buried in the New York Times:Fearing that health insurance premiums may shoot up in the next few years, Senate Democrats laid a foundation on Tuesday for federal regulation of rates, four weeks after President Obama signed a law intended to rein in soaring health costs. Incidentally, I think an important question for analyzing what health "insurance" will look like in 10 years (assuming the legislation stays as it is) is how well "insurance" companies are going to be able to make plans look unattractive to people with existing conditions. Can you offer a plan with very poor coverage of cancer treatments, for example, possibly offering another (much more expensive) plan with better coverage of cancer treatments?
Incidentally, note that someone attempting to game the system by not buying insurance until they're sick would likely not be able to buy insurance between contracting appendicitis (or being in a car accident) and incurring medical expenses. I'm a bit unsure, ex post, whether they would find themselves partially indemnified by some party or another.Labels: Health Care
::: posted by dWj at 1:56 PM
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Tuesday, April 20, 2010 :::
Rtwt.Labels: Health Care
::: posted by dWj at 11:52 AM
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Monday, April 19, 2010 :::
You know that dilemma where someone posts a blog post so pithy that you kind of want to quote it in its entirety, but that seems inappropriate? Here's one of those.Labels: Health Care, tea parties
::: posted by dWj at 4:12 PM
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Tuesday, April 13, 2010 :::
Likely consequences of the health care reform bill:A week ago, a good friend -- let's call him Anthony -- related a remarkable story about shopping for health insurance in two states, New York and Arizona.
For Anthony and millions of other consumers, New York represents the ultimate nightmare for finding affordable coverage, pairing outrageously high prices with a tiny roster of offerings. By contrast, Anthony found fabulous bargains and a rich variety of policies in Arizona's desert sun.
So it would be wonderful for folks like Anthony if the historic health-care reform law scuttled the rules that created the disaster in New York, and made America's insurance markets a lot more like Arizona's.
But amazingly, the bill imposes a New York-style regime on the rest of the nation, then makes a gigantic bet that the results won't mimic those of the Empire State. Many of us in New York had already noticed this. (Many others in New York perhaps had not.)Labels: Health Care
::: posted by dWj at 1:03 PM
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Monday, April 05, 2010 :::
Thousands of consumers are gaming Massachusetts’ 2006 health insurance law by buying insurance when they need to cover pricey medical care, such as fertility treatments and knee surgery, and then swiftly dropping coverage, a practice that insurance executives say is driving up costs for other people and small businesses.
...
The typical monthly premium for these short-term members was $400, but their average claims exceeded $2,200 per month. The federal law signed by Obama two weeks ago, of course, creates a similar rule nationwide. I think it could be a good fifteen years before it becomes a big problem nationally; people will embrace this strategy gradually, with most people becoming brazen only gradually.Labels: Health Care, possibly unintented consequences
::: posted by dWj at 4:03 PM
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Monday, March 22, 2010 :::
Some of the consequences of the health care bill that haven't gotten as much discussion as, e.g., the implicit marginal tax hikes, at least in the places I read.Labels: Health Care
::: posted by dWj at 2:24 PM
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Tuesday, March 02, 2010 :::
Taranto might put among his "bottom stories of the day" the announcement that a doctors' association opposes competition with its members: (both links in the blockquote are pdfs)clinics treated these patients at lower cost than traditional health providers, specifically, $50-$60 cheaper per treatment, and they serve a population that is currently underserved by primary care providers. Other studies, which I can’t find right now, have shown no difference in treatment quality between retail clinics and traditional caregivers. So if retail clinics are treating common illnesses, at lower cost, with the same quality, what is the problem? Labels: big labor, Health Care
::: posted by dWj at 12:37 PM
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