Tag: Health insurance

Insurance is Not Healthcare

For a long time, conservatives and libertarians have been pointing out that Obamacare has come at a steep price for the insured. Not only are health insurance premiums rising, but the new plans cover less, demand healthcare within ever-shifting networks of approved providers and foist larger out-of-pocket expenses on patients.

Well, looks like the New York Times finally figured this out:

A study by the Commonwealth Fund this month found that the rise in health insurance premiums in employer-based plans had slowed in 31 states since the passage of the Affordable Care Act (good news, right?). But premiums were still rising faster than median incomes (hmm). More important, perhaps, the researchers found that patients were paying more in health care expenses than ever before, during a time of stagnant wages (not so great). In fact, nearly 10 percent of median household income now goes to pay premiums and deductibles, the study found. And that does not include other kinds of health payments that patients now encounter, such as co-pays and uncovered drugs or services.

A recent New York Times/CBS poll found that 46 percent of Americans said they had trouble affording health care, up 10 percentage points in just one year. Some of the cost problems may ease as patients — now known as health care consumers — learn what to expect and how to choose and navigate their plans.

In other words, premiums slowed down … but only because out-of-pocket expenses increased. On balance, that might not be such a bad thing. I’ve long advocated high-deductible plans as a way to bring the healthcare consumer back into the picture. David Goldhill once pointed out that if we replaced Medicaid with a high-deductible plan, we’d save enough money to give every poor person a voucher to cover their deductible.

But this isn’t the high-deductible idea. This is creating a hyper-regulated marketplace in which insurers are expected to provide “reasonably priced” health insurance to everyone, no matter how sick they may be. So doctors flit in and out of approved networks. Out-of-state clinics come to be preferred over in-state ones. And all of this is enforced with the threats of massive bills if you don’t do the insurance company’s bidding. And if you do their bidding, you’re still facing far larger healthcare bills than you were dealing with before Obamacare.

All of this was predictable of course. You simply can not expand health care coverage to ten million people — many of whom couldn’t get coverage because of expensive medical conditions — and not have it make insurance more expensive. We warned people about this for years. We had concrete examples of this in places like New York and Massachusetts. And yet everyone is acting all surprised when they discover that healthcare isn’t free.

Note one thing the story leaves out: the increasing number of doctors who are refusing to see Medicaid patients. Medicaid expansion is a big reason the Obama Administration can claim that they’ve insured ten million people. Only a couple of million have gotten private insurance thanks to Obamacare; most are in the Medicaid gulag.

Given the media’s lag, I expect we’ll start seeing stories about that in about 2019, at which point it will be blamed on President Walker.

Addendum: You may remember that a big pillar of Obamacare was that it would be paid for, in part by the savings from Electronic Healthcare Records. Yeah, that’s not working out either. Again, this was predicted. The one thing we all knew going into this was that EHRs are very expensive.

Day After Thoughts on Hobby Lobby

So I’ve had a few days to digest the Hobby Lobby decision and wanted to put up some further thoughts.

First, a lot of Leftists are claiming that this decision “proves” that we need single payer to make all these issues go away. Of course, the Left saw yesterday’s World Cup game as proof we need single payer. But the argument from the Hobby Lobby case is so poor that even Ezra Klein sees right through it:

At the core of the case is the fact that Obamacare had to decide which health-care services absolutely needed to be covered and which services didn’t. One of the services Obamacare deemed essential was contraception. That’s what led to the Hobby Lobby case: prior to Obamacare, there was no federal law forcing employers who offered insurance to cover contraceptive care, and so no need for employers to seek exemptions to that law.

A single-payer system heightens the stakes on this kind of decision. The assumption behind some of the Hobby Lobby-based arguments for single payer is that a single-payer system would cover contraception and that would mean everyone’s insurance covers contraception. But a Republican-led government could decide that taxpayer dollars shouldn’t be going to cover contraception at all, and then a single-payer system means no one’s insurance covers contraception.

An example comes from one America’s current single-payer systems: Medicaid. While Medicaid does cover contraception, Congress decreed years ago that it can’t, under any circumstances, pay for abortions. So while people buying private insurance can choose a plan that covers abortion if they want (and, in fact, about two-thirds of private health-insurance plans cover abortions), people in the Medicaid system have no option to choose a plan that covers abortion.

Ding! It boggles my mind that people can claim single payer will “take the politics” out of healthcare decisions. I have to believe that the “this supports single payer” claimants really mean something else: with single payer, Obama will be able to force a liberal vision of health insurance on the rest of the nation. That’s fine … as long as he’s President. But what will they say when President Santorum strips out birth control coverage and mandates coverage for gay conversion therapy? This is what conservatives and libertarians warned about from day one: the further you involve the government in healthcare, the more politicized healthcare decisions will become.

I oppose encroachments of government power. I oppose them even when I like the guy in office. The reason, as Lee pointed out endlessly, is because I know that he will not be in office forever. Eventually, someone I don’t like will be in. And he’ll have all the power we gave the last guy and take even more. See: Obama, Barack and Surveillance State.

Second, I am amazed at just how silly some of the commentary has gotten. Many commentators have clearly not read the decision or even vaguely familiar with its contents. Megan McArdle deals with some of the silliest talking points here. Eugene Volokh explains the narrowness of the ruling and why it was a statutory not Constitutional decision here. I’m hoping Ann Althouse, who has read the entire decision and is an expert on Constitutional Law and religion, will do some more blog posts on it. One of her first posts is this one, taking on the talking point that businesses can now do anything if they say it’s in the name of religion:

Under the Religious Freedom Restoration Act, when the federal government imposes a substantial burden on the exercise of religion, it must justify that burden by showing that it is the least restrictive means of achieving a compelling governmental interest. In Hobby Lobby, the compelling governmental interest is comprehensive preventive health care for women, and the majority said that requiring the employer to include coverage of all FDA-approved contraceptives in its health care plan was not the least restrictive way to to serve that interest. There are other ways the government could get the cost of contraceptives covered, ways that wouldn’t rope in the employer.

So the government’s interest could be served without imposing the burden on religion.

But when the government bans race discrimination, it is serving a compelling interest in banning race discrimination and there is no alternative way to achieve that end.

Exactly. The RFRA is designed to apply a common-sense limitation on government action where religion is concerned. It’s not a blanket that can allow human sacrifice or a refusal to pay taxes. In this particular case, the Court decided that the government can make sure women have access to birth control without requiring religious people to compromise their beliefs. And that was all it could rule on at this time.

Importantly, the Court did not decree that “corporations are people” or give them First Amendment rights (although they do have First Amendment rights in the context of free speech). They ruled that the people running closely-held businesses have First Amendment rights and that the RFRA requires the government to respect that. Don’t like it? All you have to do is revise the RFRA. Good luck with that.

Third, what’s amazing about the commentary is the number of catch-22’s the liberal intelligentsia places the Court in. When the Court ruled that birth control coverage could be refused for religious reasons, they started screaming, “Well, what about blood transfusions! What about psychiatry? What about gelatin? Huh? Huh? Huh?” But when the Court declined to specifically address those issues — because they can’t — the liberals then accused the Court of foisting their own religion on the country and ignoring everyone else’s.

They accused the Court of scientific illiteracy when they ruled on the methods Hobby Lobby believes are abortifacients (although, having poked around, I don’t the case that they aren’t is as ironclad as claimed). But when the Court clarified that coverage for all methods of contraception could be declined, they went ape again that the ruling was overly broad.

(I also must keep harping on this point: insurance-provided birth control is not “free”. You pay for it with your work. And you pay for it specifically with money your boss gives to the insurance company instead of you. Mother Jones — always a good source of mathematical garbage — put up a calculator showing how much birth control will cost a woman over her reproductive life. But she’s going to pay that price whether she is insured or not. In fact, there are good reasons to believe she will pay more by getting it through her insurance. What happens is that people get birth control through their employer’s insurance … and then wonder why their insurance premiums went up $50 a month.)

The one idea I keep returning to, however, is this: the Left should not be angry. Miffed a bit, sure. But they shouldn’t really be angry.

They should be ecstatic.

We now live in a country where insurance coverage of contraception is mandated by law for all but a small segment of employers. And those will almost certainly be covered when Obama expands the compromise that the Court gave their assent to (although he will probably let women swing in the wind until after the election). The conservative wing of the Court did not dispute that the government can provide birth control coverage. Nor did they dispute that insuring women have access to birth control was a compelling interest of the government. Griswold is in no danger of being repealed. A slight wrinkle has been thrown out in how birth control is paid for. And there are some states where Republicans are attacking programs that help pay for birth control for poor women. But overall, women are in a far better position with respect to controlling their reproductive systems than they have ever been.

I know people want to see this in terms of absolutes: that women have an absolute right to birth control. But living in a country of 300 million people means none of us get everything we want. There are no absolute policies that will work for the entire country.

And yet, with a near complete victory — the provision of almost “free” birth control; a goal they have wanted for decades — they are in hysterics because it wasn’t a complete victory. They are angry because a compromise was reached for people who have a moral objection to certain types of birth control. They are angry because they didn’t get everything they wanted. 85% of employers covered birth control before Obamacare. Nearly 100% will now and the remainder will get it through some kind of compromise. You can be a bit disappointed that it’s not 100%. But proclaiming that SCOTUS has now imposed Sharia Law and made women second-class citizens? Seriously?

Damon Linker:

Where once the religious right sought to inject a unified ideology of traditionalist Judeo-Christianity into the nation’s politics, now it seeks merely to protect itself against a newly aggressive form of secular social liberalism. Sometimes that liberalism takes the relatively benign and amorphous form of an irreverent, sex-obsessed popular culture and public opinion that is unsympathetic to claims of religious truth. But at other times, it comes backed up by the coercive powers of government.

That’s how the Hobby Lobby case needs to be understood: as a defensive response to the government attempting to regulate areas of life that it never previously sought to control. Like, for instance, the precise range of health insurance benefits a business must provide to its employees under penalty of law. Hobby Lobby doesn’t oppose contraception as such, as some Catholic businesses do. It merely opposes four out of 20 forms of contraception that the Obama administration wants to force them to cover — because its owners believe those four to be abortifacients.

From advancing an ideological project to transform America into an explicitly Catholic-Christian nation to asking that a business run by devout Christians be given a partial exemption from a government regulation that would force it to violate its beliefs — that’s what the religious right has been reduced to in just 10 years.

Exactly. The Left Wing has been running up victory after victory in the Culture War. Gay marriage just became legal in fricking Kentucky. Colleges are so eager to make birth control available, they’ll shove it down throat if you sleep with your mouth open. Marijuana is legal in two states and the edifice of criminalization is imploding. Public prayer has been reduced to few non-denominational utterances. Their only conservative “wins” have been a few recent restrictions on abortion and public funding for birth control, policy changes that are likely to be short-lived.

For a long time the Left has claimed that they are the side that wants to compromise and it is conservatives who are intransigent. Yet what is this but rejecting a compromise? What is this but going to tired “war on women” rhetoric at the slightest provocation? No one is being denied birth control. No one’s boss is interfering with their birth control. This is ultimate result of the Hobby Lobby decision: the Federal government will have to make a deal to provide birth control coverage for employees of a small fraction of businesses..

That’s a War on Women? That’s treating corporations like people and women like second-class citizens?

I humbly suggest the rhetoric over this decision needs to be toned down. Because if the Left shout down the heavens for something like this, who’s going to be listening when a state tries to outlaw abortion? Or repeal sexual discrimination laws? Or place heavy restrictions on birth control?

When it comes to long political struggles, you have to choose your battlefields. As much as I oppose much of what the religious right is doing right now, this isn’t the field on which the banners should be unfurled. Accept the near complete victory and move on.

The Big Shoes Drop

Two 5-4 decisions from SCOTUS today. The first was on forcing non-union employees to pay union dues. The Court decided they can not be forced to. The second was on mandated contraception coverage. The Court ruled narrowly that closely-held corporations can get a religious exemption. But it kept the door open for the government to provide such coverage.

I think the Court ruled correctly in both cases but expect very ugly commentary, especially on Hobby Lobby. There is a huge problem in the Left Wing in understanding the difference between something being a good idea (employer insurance should cover birth control) and something being mandated by law (employer insurance should be forced to cover birth control). So expect lots of commentary about how women’s rights have been set back (all the way to yesterday), how the court was mansplaining, how none of the female justices rules in favor of Hobby Lobby, etc., etc.

Just remember this. At the end of the day, women have no less access to birth control than they did last week. If you really want to make a difference in access to birth control, push the FDA to make it available over the counter. That will do a lot more good than forcing corporations to pay for it.

Update: A very important point from McArdle. The net result of this decision will almost certainly be that Obama will extend the deal he made with religious non-profits — where insurance companies agree to pay for contraception — to closely-held for-profits. And this compromise could have been made years ago.

As I see it, this case should never have made it to the court; the Barack Obama administration should have pre-empted the issue by quietly allowing exemptions for nonprofits and closely held corporations that had clear and deep religious beliefs that existed outside of the desire not to pay for contraception. (Hobby Lobby, for example, is closed on Sundays in observation of the Sabbath, even though this costs them sales; I think we can all agree that the Little Sisters of the Poor have demonstrated a fair amount of commitment to demanding religious principles.)

Instead, the administration chose to pick this fight — and got a definitive ruling that will probably have much broader impacts than quiet exceptions. Nor is this surprising; it was pretty predictable from earlier rulings like Citizens United, in which the court also held that people don’t lose their First Amendment rights simply because they have come together in a group or legally organized that group as a corporation.

Presumably, the administration hates this ruling — but at the same time, it has to love the passion that it has engendered. This is going to be fundraising gold for Democrats for the next two years. In a politics that cares more about symbolism than substance, that too was predictable. And it’s hard to avoid the conclusion that this was the prediction that mattered more. Politics may not be rational, but it still has its own remorseless logic.

Look at Twitter. Look at Facebook. Look at the liberal blogs. They are exploding with rage over a decision that will ultimately have almost no impact on women at all. Women will get contraception coverage; just through a different financial means. So the Obama Administration has riled up their base over next to nothing.

This is how they operate, people. Let’s not act surprised.

Shifting the Numbers

We’ve gotten used to the numbers game this Administration plays with Obamacare. It was going to ensure thirty million. No twenty million. No ten million. We have seven million signed up! Well, they haven’t all paid. And five million previously had insurance. And insurance rates are going down! Well, they’re actually going up. And the number of uninsured is the lowest in five years! Well, that just brings us back to pre-recession levels — a level that meant people were dying in the streets when Bush was President but means progress now that Obama is.

Still, even with all that, this is pretty blatant:

The Census Bureau, the authoritative source of health insurance data for more than three decades, is changing its annual survey so thoroughly that it will be difficult to measure the effects of President Obama’s health care law in the next report, due this fall, census officials said.

The changes are intended to improve the accuracy of the survey, being conducted this month in interviews with tens of thousands of households around the country. But the new questions are so different that the findings will not be comparable, the officials said.

An internal Census Bureau document said that the new questionnaire included a “total revision to health insurance questions” and, in a test last year, produced lower estimates of the uninsured. Thus, officials said, it will be difficult to say how much of any change is attributable to the Affordable Care Act and how much to the use of a new survey instrument.

The Census Bureau estimates this will reduce the number of estimated uninsured by two percentage points — from 12.5% to 10.6%. That’s basically six million people — which is about two-thirds of what Obamacare is supposed to accomplish. In other words, a real decline in the uninsured of 9 million could look like 15 million or even more simply because the changes in the way the Census does things.

To be fair, these changes have been needed for a while and are driven by technical experts at the Census Bureau, not the Administration. Conservatives have long complained that the methodology overestimates the number of uninsured. But to quote Megan McArdle, it doesn’t matter if these changes are coming from elves at the north pole. It would be well within the President’s authority to delay the changes so we can get a clear read on the effects of PPACA.

Do you think any liberal pundits will take note of this? A few years ago, both the NCVS and FBI changed their methodology when calculating rape statistics. This didn’t stop feminists from jumping on the “shocking rise” in rape rates.

If the Obama Administration were confident in their program, they wouldn’t be tinkering with the definition of uninsured. If they were even curious about how well their program was working, they’d delay this. What does it tell you that they’re happy to let the waters get muddied like this?

Sebelius v. Hobby Lobby

The Supreme Court heard oral arguments yesterday in the case of Sebelius v. Hobby Lobby. This case concerns whether the federal government can force an employer to provide birth control to their employees. Hobby Lobby is claiming it violates their Freedom of Religion and the Religious Freedom Restoration Act to force them to pay for a service they have a moral objection to.

You can read some legal analysis from Mataconis and a series of posts from Stephen Bainbridge. It looks like the Court is leaning in favor of Hobby Lobby, perhaps with a narrow ruling that only addresses this particular issue.

There are two things I wanted to note about this, however.

First, I tend to side with Hobby Lobby on this one. My support has little to do with birth control and everything to do with opposing coverage mandates. Coverage mandates drive up insurance costs and provoke these kind of bitter arguments. It’s bad enough that the government is forcing people to provide or buy insurance. Why must it insist on specifying what the insurance will cover?

The potential for abuse is very high here. What’s to prevent some moonbeam President from mandating coverage for pseudo-scientific gibberish like therapeutic touch or aromatherapy (as indeed, some Senators tried to do and some states actually do)? What’s to prevent a future President from forbidding birth control coverage, especially given the precedent this President has established for ad hoc rewriting of the law? It’s bad enough that employers can control our healthcare. Many employers are now mandating “wellness” programs and the like. Must we let the politicians do it too?

Frankly, I’d prefer the Court strike down coverage mandates in general but they are not going to make such a broad ruling.

But second, this is another reminder that although I side with the Left on a number of culture issues, I am never very happy about the company I keep. The Left Wing, with the sympathetic media in lockstep, has responded to the Hobby Lobby case with a barrage of lies about the case, the law and birth control that is really despicable. They are desperate to pretend that, if Hobby Lobby wins, this means the end of birth control. But it does not:

The New York Times’ Adam Liptak puts it right there in the first sentence: “The Supreme Court on Tuesday will hear arguments in a case that pits religious liberty against women’s rights.” This could not be further from the truth. Women will have the same constitutional rights to acquire and use contraception regardless of whether Hobby Lobby wins or loses. More than that, they’ll have the exact same rights as they had before the contraception mandate was a gleam in Sec. Sebelius’ eye. What women won’t have is the right to force other people to pay for their contraception, but that has never been a right recognized by the Supreme Court.

In the Bizarro World of the newspapers, not paying for someone else’s contraception is the same thing as prohibiting them from purchasing and using them themselves. This is an obviously false equivalence, but one that leftists are bent on telling themselves. No matter how many times you point out that the business owners in these cases aren’t preventing their employees from purchasing and using contraception, a smug leftist will smile and say “but women’s rights, you see,” as if these magic words excuse the lie.

Opponents of Hobby Lobby say that, if the Court decides in their favor, this will allow employers to “impose their morality” on their employees. But there is no such imposition. Hobby Lobby can not stop their employees from buying birth control. They can’t stop them from having sex. They can’t stop them from having gay abortions while smoking pot and watching Girls.

So why is having to pay for your own birth control oppression? Because the Left Wing has convinced itself that healthcare is a right, that health insurance is a right and therefore, if your employer refuses to pay for any healthcare service, they have deprived you of that right.

I find this view absurdly childish. This isn’t heart surgery we’re talking about; this is birth control, which is available for a few hundred bucks a year for most women and can be replaced cheaply with condoms or withdrawal or abstinence. Claiming that you have been “deprived” of birth control because someone else won’t pay for it is no different than claiming you’ve been deprived of electricity because you have to pay your own electric bills (which are, incidentally, usually more expensive than birth control).

If the Democrats are so passionate about birth control, why don’t they create a government program to provide it? I would oppose such a program, but it would likely be constitutional. Of course, they could never get such a program through the legislature. So they have to resort to the back door of forcing other people to pay for it.

Let me be clear. If I ran a business, I would choose insurance that included birth control coverage. I think employers should include it, although bringing birth control into the insurance sphere will likely drive up the cost of it for everyone. But there is a distinction between thinking something should be done and decreeing that it must be done, a distinction that seems lost on the Left Wing.

I would also point out that the “employer imposing their morality” argument only applies in this case. As Bainbridge points out, corporations debate morality all the time — whether to do business with sweat shops, whether to go green, whether to provide daycare, how much maternity leave to provide, whether to divest their funds from nefarious foreign countries.

Large corporations are already faced with choices over whether to pursue social justice, civil rights, and environmental concerns, and with disputes over the interests of majority shareholders, proxy questions, and the like. Corporate law has extensive mechanisms in place for dealing with these scenarios. Religion as one motive among many does not change the landscape.

In fact, religion is already part of that landscape, since state law allows corporations to pursue it among all lawful purposes. There are no practical or theoretical grounds for specifically excluding religion as a permissible basis for corporate decision- making—indeed, it would be a clear violation of the First Amendment to even try. See Emp’t Div., Dep’t of Human Res. of Or. v. Smith, 494 U.S. 872, 877 (1990) (noting that the government cannot ban “acts or abstentions only when they are engaged in for religious reasons”). Yet businesses infrequently choose to pursue religious ends.

As a practical matter, it is hard to demonstrate any interest shown by large, publicly-traded corporations in exercising religion. Market forces tend to push such firms far away from religious controversy. It is no accident that this case and related litigation involve corporations that are closely held.

Is Chick-Fil-A “imposing their religion” by being closed on Sundays? What if Apple announced that they would provide cars to their employees … but only if those cars were electric or hybrid cars. Would the Left Wing start screaming about Apple “imposing their morality” on their employees? What if a university were to ban Apple computers because they don’t like the work conditions in Apple’s factories? There would be some vigorous debate — I would oppose it. But would people think the federal government should step and force the university to use Apples? What distinguishes these moral decisions from a moral decision about what kind of health insurance to provide?

If Hobby Lobby — an ostensibly non-religious organization — were forbidding their employees from obtaining or using birth control pills, I’d be on the side of their opponents. But all they are asking for is to not have to pay for it.

In fact, the Left Wing’s arguments are so disingenuous, I think we are seeing a degree of hysteria. I think they are scared because if the Court strikes this down, it will endanger all coverage mandates. Their ability to dictate every detail of our insurance coverage — to effectively create single payer through mandates and restrictions — will be badly damaged.

But I also think there’s a more concrete motive. The Democrats are pushing this issue and lying about it because, as I pointed yesterday, the polls are not looking good for them. They are worried they are going to lose the election in 2014 and possibly in 2016. And so they are dragging the “War on Women” back out.

Am I too cynical? I don’t think so. This issue has reached a fever pitch at almost the same moment that pundits are projecting a Republican Senate in the fall. The attempts to stuff what is ultimately a business issues into a “War on Women”-shaped hole has almost exactly paralleled the rising unpopularity of Obama and Obamacare. And frankly the Democrats have a long and ugly history of trying to terrify the populace — especially the distaff part of it — with scary stories about how Republicans, if elected, will take away their Medicare, their Social Security, their Obamacare, their birth control, their abortion, their education and their dental fillings if they fall asleep.

So, in the the end, this really isn’t about birth control. If the Democrats really cared about access to birth control, they’d be talking about the solution many libertarians favor — make birth control available over the counter. That would do far more to make birth control available to women than a coverage mandate. No, this about politicizing the hell out of women’s reproductive systems in the hope of holding off electoral defeat.

The Republicans may or not be fighting a “war on women”. But the Democrats are using them as vehicles for their own political gain. I don’t see that that’s any better.

Home for the Holidays

Busy day, but I thought you’d get a kick out of this. Barack Obama is encouraging people to take some time during the holidays to talk to their families about Obamacare.

This holiday season, millions of Americans have a chance to get quality, affordable health insurance—many for the first time. If you have family members who are uninsured, you can play a big part in helping them find coverage that works for them. It might not always seem like it, but your family listens to you. So have the talk.

Because nothing says “Merry Christmas” like drunken arguments over Obamacare.

The site a step-by-step guide to “having the conversation” with your family and includes such items as:

Don’t wait until the last minute—be sure to start the conversation early!: “Thanks for picking up from the airport, dad. Have you thought about getting Obamacare? Waddya mean I can take the bus home?”

Be honest about your feelings and why this is important to you.: “If you’re going to get in a car accident, for God’s sake do it on the government’s dime.”

Tell them: The marketplace gives you an easy way to find plans, compare them and sign up for the one that’s right for you. You don’t have to complete the process all in one sitting, and you can do it over the phone, online, or in person.: “Here, you bring up the healthcare website and wait for it to work. I’ll cover you at work for the next three months.”

I realize that, to Obama, this sounds pretty reasonable. It’s now easy to get cheap insurance (theoretically, at least) so we should spread the word to our uninsured family members so they’ll sign up. But the website has a creepifying propaganda vibe that’s hard to ignore.

(I’ll also note the site seems a bit confused about whether you are signing up family members or yourself. It instructs you in signing up family members. But at the beginning, it tells you to make sure you have your social security number, budget, etc.)


Once that conversation is over perhaps you could bring up reproductive rights, immigration reform, and judicial filibusters. They’re all important subjects of national concern. Why not set aside some time on Thanksgiving Day to discuss them too? Maybe just pick up the remote, turn off the football game, and ask everyone if you could have their attention while you explain how progressive public policy can improve their lives if only they do their part. They’ll appreciate it!

My family members range from stark raving liberal to rock-ribbed conservative. I have absolutely no intention of bringing up Obamacare at any family event. Because while I like my mother’s turkey stuffing, I have no desire to end up wearing it. Those members of my family who need individual insurance policies know about it already. And if they didn’t and I wanted them to, my iPhone is never more than a few feet away.

We Should Hope This Works

As the insurance exchange debacle drags on into its fourth week, the Democrats and the Obama Administration continue to dodge questions, obfuscate and try to find ways to blame Republicans. Yesterday’s hearing featured Democrat Frank Pallone calling the hearing a “monkey court” because Republicans have the temerity to wonder what the hell is going on with an overhaul of one-fifth of our economy. The Democrats’ media dog-washers are trying to silence liberal critics of the system using the “under no circumstances ever agree with conservatives, especially when they’re right” doctrine.

But they can’t keep up the facade. Conservatives, libertarians and honest liberals are detailing the many flaws this system has and the significant hurdles it faces getting online. Those critics are not passe about this; they are livid. And they should be.

One of the memes that is emerging among the Obamacare defenders is that Republicans and other opponents of Obamacare have no right to criticize the utter complete failure of the federal exchanges because we opposed it reform the first place. Since we opposed Obamacare, how can we complain about it? You’ll remember, of course, how that logic was applied to the Iraq War. Those who opposed the war never complained about how the war was executed or what happened in the aftermath of it.


But as an opponent of Obamacare myself, I am highly critical of the rollout because … I actually want the insurance exchanges to work. Everyone — conservative, liberal, libertarian or monarchist — should want the exchanges to work for three very important reasons.

First, the exchanges are one of the few good ideas that got into Obamacare. One of the things that drives up insurance costs is the lack of competition. The exchanges force open competition between the insurance companies, which is a good thing. They’re not perfect, of course or even particularly good. A better exchange system would have cheaper entry-level insurance, allow insurance to be sold across state lines and have fewer coverage mandates (it would also, you know, work). But compared to subsidies, coverage mandates, purchase mandates, Medicaid expansion and the IPAB, the exchanges are almost smart.

Second and more far more important is that if the insurance exchanges don’t work for a long time or if the purchase mandate is delayed, the result could be the complete destruction of the individual insurance market.

A lot of people don’t appreciate how much Obamacare is like a house of cards. Insurance companies can no longer deny coverage and have priced insurance on the exchanges based on the idea that people will be “taxed” for not buying insurance. This only works, however, if people are actually forced to buy insurance. Otherwise, they will wait until they are sick to insure themselves. If people can’t buy insurance or aren’t made to, the result is a death spiral where insurance gets more and more expensive and more and more people wait until they are sick to buy it.

This isn’t some theoretical possibility. It happened in New York:

New York state’s guaranteed issue and community rating rules—the two regulations that limit how insurers can charge based on health history and require them to sell policies to all comers—took effect in 1994. At the time, there were about 752,000 policyholders in the state’s individual market, or about 4.7 percent of the non-Medicare population. But by 2009, according to a Manhattan Institute report by Stephen Parente and Tarren Bragdon, the state’s individual market had practically disappeared, leaving just 34,000 participants, or about 0.2 percent of the non-elderly population. Individual insurance premiums, meanwhile, were among the highest in the nation—about $388 on average in 2007, compared with just $151 in California, another big Democratic-leaning state. In New York City, the annualized premium cost for individuals was more than $9,300 and more than $26,400 for a family.

The result, in other words, was a combination of sky-high premiums and far fewer insured individuals.

The individual markets only survived at all because insurance companies could make up the losses from less stupid states. But Obamacare is national; there is no other state to make money off of.

If people can’t buy insurance, the result will be the complete meltdown of the individual insurance market and millions of Americans becoming uninsured. In fact, many have already lost their insurance as companies cancel individual policies in anticipation of the Obamacare exchanges.

Now maybe you think that’s acceptable. Obamcare will implode, the Democrats will be blamed and Republicans will sweep back into power (assuming they don’t screw it up). But look beyond the politics. Millions of Americans will be cast into an insurance purgatory that they may never get out of. The individual insurance market works because of people being good citizens — buying insurance when they don’t need it so that the market can support those that do. If that culture is destroyed, if Americans get into the habit of waiting until they are sick to buy insurance, they may never get out of it. A good example of this is the Israeli Daycare Study where daycare centers imposed a fine on people for picking up their kids late. The result? More parents showed up late because they could now buy off their guilt. And when the fine was rescinded, the parents kept showing up late because the social norm of being on time had been effectively destroyed.

Once the individual market collapses, we may never be able to rebuild it. We may be in a situation where your insurance choices are either through your employer or through Medicaid. That is an extremely high price to pay for making Obama look bad and maybe winning an election.

(It has been suggested, here and on other blogs, that this sabotage is deliberate; that Obama is deliberately crippling the individual market to lead us toward single payer. I’m open to the possibility of a subconscious desire to wreck the private market. But I have a hard time believing in any conspiracy with this administration. It’s not that they wouldn’t try. It’s that these guys are so incompetent that if they actually tried to sabotage the exchanges, the result would be a perfectly functioning exchange system.)

Now my second point may cause many liberals — who see Obamacare as a stepping stone to single payer — to quietly rejoice. Already, many are blaming this on the private sector. Who will be the first to say this “proves” we should trash private insurance and go with single payer? Who will be the first to say we should just expand Medicaid to everyone who isn’t insured by an employer?

But this idea is mind-bogglingly stupid. If the Democrats destroy the individual insurance market and increase the number of uninsured, Americans will not thank them for it. We are not going to rise up in a mass and say, “Oh, you great ones who took away our insurance. Tell us what to do next!”

And frankly, if anyone thinks Medicaid is the future of health insurance (oh, wait, here’s Krugtron the Ever-Wrong making the case) they need to spend a few weeks working in a hospital that only takes Medicaid. Medicaid is only marginally preferable to no insurance at all, providing a consistently lousy quality of service. That’s how it keeps costs down. In fact, Krugman’s defense of Medicaid is made entirely in terms of costs. His only acknowledgement of the downside of consigning millions to the Medicaid gulag is this:

But the problems of access, such as they are, would largely go away if most of the health insurance system were run like Medicaid, since doctors wouldn’t have so many patients able and willing to pay more.

Yes. I’m sure those doctors will take massive pay cuts rather than leave the field. Let’s apply Krugman’s logic to academia, another industry afflicted with runaway costs. We could cut those costs by turning the entire shebang to the community college model. And the problem of finding good professors for those colleges would disappear if they no longer had universities like Princeton able and willing to pay more.

(My apologies to community colleges, who are far better at teaching than Medicaid is at insuring.)

Obamacare is a bad law. It ignores everything we’ve learned about healthcare reform over the last decade and applies a model that at least twenty years old. But the situation with Obamacare could get far, far worse and could do permanent damage to the healthcare system if the exchanges don’t start working. Everyone should hope that they do because this isn’t a political game: this is the healthcare of millions of people. We will never be able to truly reform the system if there’s nothing left to reform.

When You’ve Lost the Unions…

Maybe this will persuade some of the few holdouts that Obamacare is in deep trouble:

The leaders of three major U.S. unions, including the highly influential Teamsters, have sent a scathing open letter to Democratic leaders in Congress, warning that unless changes are made, President Obama’s health care reform plan will “destroy the foundation of the 40 hour work week that is the backbone of the American middle class.”

If that’s not bad enough, the Affordable Care Act, if not modified, will “destroy the very health and wellbeing of our members along with millions of other hardworking Americans,” the letter says.

The letter is at the link. And it rehashes a lot of the arguments we’ve been having. It turns out — surprise! — that unions don’t like paying more for insurance and don’t like having part-time jobs instead of full-time ones.

First, the law creates an incentive for employers to keep employees’ work hours below 30 hours a week. Numerous employers have begun to cut workers’ hours to avoid this obligation, and many of them are doing so openly. The impact is two-fold: fewer hours means less pay while also losing our current health benefits.

Second, millions of Americans are covered by non-profit health insurance plans like the ones in which most of our members participate. These non-profit plans are governed jointly by unions and companies under the Taft-Hartley Act. Our health plans have been built over decades by working men and women. Under the ACA as interpreted by the Administration, our employees will treated differently and not be eligible for subsidies afforded other citizens. As such, many employees will be relegated to second-class status and shut out of the help the law offers to for-profit insurance plans.

And finally, even though non-profit plans like ours won’t receive the same subsidies as for-profit plans, they’ll be taxed to pay for those subsidies. Taken together, these restrictions will make non-profit plans like ours unsustainable, and will undermine the health-care market of viable alternatives to the big health insurance companies.

You may remember during the PPACA debate that Obama tried to get union plans exempted from various aspects of Obamacare. Gee, I wonder why?

So, now I become curious. Business hates Obamacare. Consumers don’t like it. Unions don’t like it. Who, apart from the Obamabots, does like it? What exactly is being accomplished by not either fixing or repealing this bill, other than saving face for a lame duck President?

Is Krugman Stupid, A Troll Or A Stupid Troll?

Paul Krugman — fresh off his I’m smarter than you post (I have a few tasty comments in that thread that riled the libs something fierce), says this today in response to the Oregon study:

Fire Insurance Is Worthless!

After all, there’s no evidence that it prevents fires.

But strange to say (as Mark Thoma points out in correspondence), people seem to think it’s a good idea anyway.

I leave the relevance of this thought to the Medicaid discussion as an exercise for readers.

This is the most common defense being dragged out in response to the Oregon study: that maybe health insurance doesn’t actually improve health. But it saves people from being financially ruined by a health crisis! Isn’t that good?

Let’s put aside that the liberals have spent the last four decades insisting that a lack of insurance kills tens of thousands of Americans every year. Let’s put aside that they will drag that bogus stat back out from behind the barn if the next Oregon study shows health gains from Medicaid (and probably even if it doesn’t). No, let’s concentrate on this:

This is what conservatives and libertarians have been saying for a very very long time.

This what is David Goldhill said in his excellent essay four fucking years ago. This is what I have said many many many times. I have specifically asked people to imagine how much car insurance would cost if it paid for every gasup (and how efficient our cars would be). I have specifically pointed out how expensive fire insurance would be if it covered every burnt meal. A number of us have called specifically for catastrophic health insurance that is more modelled after fire insurance than our current “first dollar coverage” model, at least on the government side. For that, we have been mocked as heartless and clueless. We’ve been told that health insurance is fundamentally different from other forms of insurance (which it is, when you consider it a handout).

Now the liberals want to pretend that this is a novel argument? They want to pretend they have discovered that the real benefit of health insurance is risk mitigation, not magical health fairies? Seriously?

I suppose I should be happy. This is progress in liberal thinking, after all. But no, I’m not happy. Because they have turned to this explanation as an excuse for why the Oregon study hasn’t yet shown the huge benefits they thought Medicaid expansion would produce. The minute the wind turns, the minute the next study shows even minimal health gains, they will tack and suddenly start saying that insurance is the only thing that keeps people from dropping dead in the street.

Piling On

Apropos to Alex’s post below, the huge news in the last day is a study from Oregon that looked at the effects of expanding Medicaid. As McCardle points out, the study was done under near ideal circumstances. Oregon could not expand Medicaid to everyone who wanted it, so they created a lottery. Sociologists swooped in and recruited. The result was a study of 6000 people with Medicaid and almost 6000 without. One of the authors was an Obamacare architect. This is the kind of diverse randomly-selected sample that sociologists dream about.

The result is …. not much:

Utilization went up, out-of-pocket expenditure went down, and the freqency of depression diagnoses was lower. But on the three important health measures they checked that we can measure objectively–glycated hemoglobin, a measure of blood sugar levels [and diabetes indicator]; blood pressure; and cholesterol levels–there was no significant improvement.

It’s one of two major RCTs that have ever been done on insurance. And like the first one, it doesn’t show a signficiant effect. That is huge news. Not good news–obviously, it’s much nicer if giving people money to pay for health care makes them obviously much healthier. But big.

And it’s actually bigger, and more important than Obamacare. We should all be revising our priors about how much health insurance–or at least Medicaid–really promotes health. What this really tells us is how little we know about health care, and making people healthy–and how often data can confound even our most powerful intuitions.

In other words, insuring people resulted in more spending by the government, but not necessarily improved health. Gee, I think I’ve heard that before.

As you can imagine, the liberals are spinning as fast as they can. And, to be fair, they have a point. The study covers only of a couple of years and it might take a while for long-term effects to show up. But you know that if the study showed even the slightest improvement in health, they would be shouting it from the rooftops. They have, after all, spent years citing dubious studies that claim that the lack of universal healthcare kills, if I remember the Obamcare rhetoric correctly, at least 17.4 billion Americans every year. And, in fact, when the first Oregon study came out and showed that people weren’t healthier, per se, but felt better, the liberals crowed about it.

The new study is much more difficult to twist abut that’s not stopping their attempts. One thing they have harped on is that the insurance is preventing people from being financially destroyed by a health crisis. But Avik Roy is all over that in a must-read response to liberal excuse making:

Medicaid reduced financial hardship for the poor, by protecting them against catastrophic health risks. Wonderful, but we could have achieved the same outcome for a fraction of the price, by adopting the plan proposed by Florida’s Will Weatherford and Richard Corcoran: Offering low-income Americans a subsidy with which to purchase catastrophic coverage on the open market. That plan was foiled by people—including Republicans—who insisted on expanding Medicaid instead.

Ross Douthat is on the same page:

But what if we lived in a world in which the Republican Party had fully embraced the views of many right-of-center health policy writers (and some G.O.P. politicians, including the John McCain of 2008) and supported an alternative to Medicaid expansion, which would change the tax treatment of health insurance to free up money to create a universal tax credit or voucher designed to spur the purchase of catastrophic health insurance plans? What if the choice, in other words, weren’t between the current health care law and a repeal-plus-nothing G.O.P., but between the current health care law and the best conservative thinking on the issue?

This is, in fact, what most libertarians have advocated for years, including me.

I remind you that this isn’t a trivial question. Obamacare gambles some $750 billion on the idea that Medicaid will improve health outcomes, boost the economy, reunite the surviving Beatles and help us all lose ten pounds with diet and exercise. If the gain from that huge investment is this marginal, it is not worth it. I’m sorry to be cruel, but it not worth $750 billion to save only a few lives.

I do want to repeat my earlier caution that it would be odd to conclude that health insurance has no health benefit. We may not know for a while. But I do think it’s becoming clear that Medicaid expansion is not going to be the miracle breakthrough that so much of the Left has claimed it would be. If lack of insurance really were killing as many people as the Left insists it is, the Oregon data would show it. You might even already see a difference in mortality rates.

I know it surprises some people, but improving our nation’s health is not as simple as simply throwing lots of money around.