Vermont Falls

I am Hal’s total lack of surprise:

Vermonters will not be part of a single-payer healthcare system.

Gov. Peter Shumlin had hoped to create the first state-based single-payer system in 2017, but skepticism from both state lawmakers and constituents has halted the idea.

“This is not the right time” for enacting single payer, Shumlin said in a statement.

Shumlin cited the big increases in taxes Vermonters would see that would be required to pay for the plan.

“These are simply not tax rates that I can responsibly support or urge the Legislature to pass,” the governor said. “In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”

Federal funds available were also $150 million less than expected, Shumlin added.

Note that Jonathan Gruber was involved in this, just in case you might be wondering what his overall intentions for Obamacare were.

I’m sure this will be blamed on the “greed” of Vermont voters, wanting to keep more of their money. But Megan McArdle called this months ago. The plan was slated to cost $2 billion, requiring Vermont to raise taxes by 75% at least.

Especially when you consider that estimates for this plan’s cost are likely to err on the optimistic side, because, well, people drawing up proposed budgets for their pet ideas tend to be a little optimistic. Yes, yes, there may be fabulous cost savings from using the government’s monopoly buying power to bargain prices down with providers. But Vermont is already the beneficiary of significant monopoly buying power: One insurer has 74 percent of the state’s small-group business. It’s a Blue Cross/Blue Shield, so don’t count on fabulous savings from squeezing out profits. The large group market is even more concentrated, though on a for-profit insurer.

Nor can you get much administrative saving at the provider level, because they still have to deal with out-of-state insurers quite a bit. And the once-vaunted fabulous savings from preventative care have mostly turned out not to exist.

So this is going to be expensive. So expensive that I doubt Vermont is actually going to go forward with it.

Supporters of single-payer healthcare tell us constantly that such a system would be massively more efficient than what we have now. They base this partially on bogus claims that Medicare and Medicaid have low overhead costs. They base this partially, as McArdle points out, on comparisons to a healthcare system that is already, in many states, a monopsony, one that Democrats have fiercely resisted challenging by allowing insurance to be sold across state lines.

But, in the end, it’s mainly wishful thinking. We’re supposed to believe that socialized medicine magically keeps costs down. But the cost curve in the evil capitalist US system has basically matched that of socialized systems for the last twenty years. Most of the explosion of medical costs occurred in the 1970’s and 80’s and is baked into the system we have.

Vermont has now shown that switching to a single-payer system would be expensive and intrusive. Can’t we try anything else before we go there?


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 Bill Comes Due

Remember all that talk about how Obamacare was going to save us all this money? Evil uncaring heretics like me pointed out that this was impossible. You can not insure more people and you can not outlaw cheap insurance without increasing healthcare costs. Romneycare saw costs soar after implementation because … funny story … when people have insurance they see the doctor more often. Even the dreaded ER visits went up.

But no, we just didn’t understand. We were letting our hatred of poor people cloud our vision. Why the cost curve bent down in 2009-2013, which was proof that Obamacare was keeping costs down even before it was implemented!

Um … oops:

As I reported earlier this month, there were already signs of growing health care spending in the fourth quarter of 2013, when it jumped 5.6 percent, which had been the fastest clip since 2004.

But the 9.9 percent jump (on an annualized basis) came in the quarter from January through March, which was the first three months in which individuals who gaining coverage through the law were able to use it. That was the fastest rate recorded since health care spending grew at a 10 percent rate in the third quarter of 1980.

The data released on Wednesday, as part of the government’s report on gross domestic product, is preliminary and subject to revision in the coming months.

Note that first quarter GDP growth came in at 0.1%, so the non-healthcare section of the economy shrank by 1% last quarter.

So … are the Obamacare supporters admitting that they were wrong? Uh, not exactly:

But let’s be very clear about what’s happening here: an improving economy is allowing Americans to now spend more on health care, while people who have previously been uninsured are finally getting insurance and are using their care. In the meantime, health care prices are still continuing to grow at low rates, reducing Americans’ health costs.

ThinkRegress goes on to say that, in the long run, healthcare costs will come down because the IPAB will force changes in healthcare reimbursement. Therefore we should be celebrating because the first half of the CBO’s prediction — healthcare costs will rise — has come true!

There are many many problems with this. The biggest is history. IPAB is not the first effort by the government to reign in healthcare spending. There is a whole alphabet soup of programs — RBRVS, GRH, SGR, etc. — that have completely failed in this regard. And that leads to the bigger point. Those of you who have followed the budget debates for the last twenty years know how this plays out: we get spending increases today with the promise of spending cuts tomorrow to balance them out. And those spending cuts never happen. Because tomorrow we are told that spending needs to go up because of the economy, the uninsured, the homeless or Venus being in Taurus.

So what will the Democrats and their apologists say when health care costs continue to rise? Well, besides blaming Republicans, I expect they will claim that this “proves” how much we need single-payer. To prepare for that, read McArdle today. Over the last twenty years, uber-controlled monopsony single-payer healthcare systems have restrained their spending growth to … about what we’ve had in the United States. The big growth in US healthcare spending occurred forty years ago and is now baked into the system. So … no, Virginia, socialized medicine will not cure what ails us.

Buckle your seat belts, friends. The ride’s only going to get bumpier.

The Triumph of Obamacare

I think it’s time for us on the blog to finally admit that Obamacare has been a roaring success, far in excess of what even the most optimistic supporters projected. I mean, just check out the numbers:

  • At least six million people have signed up for insurance on the exchanges, close to the seven million Obama hoped for. Now granted, only two million of those were previously uninsured; the rest were people who were already insured but had their plans — some of which they really liked and were much cheaper — cancelled because they weren’t compliant. And, granted, nine million previously insured people have bought policies by ignoring the marketplaces and dealing with insurance companies directly (which was a fairly typical number prior to Obamacare). But two million people! All we need is 24 more Obamacares and there will be no uninsured!
  • Actually, Obamacare is even better than that. About 4.5 million people have been swept into Medicaid. Now granted, Medicaid is not a very good insurance system. Many of the best doctors refuse to see Medicaid patients and Medicaid-intensive hospitals are some of the worst in the country. But still, that means only nine more Obamacares and we’ve got this uninsured problem licked!
  • Something less than a million people are uninsured right now because their insurance was cancelled by Obamacare regs. Meh. Serves them right for having jobs.
  • The CBO projected in February that 13 million more people would have insurance thanks to Obamacare. And here we are, two months later, and it’s looking we may actually have a whole third of that! A third! And almost all of that is by expanding the glorious Medicaid system!
  • We’ve gotten all this for the bargain basement price of, depending on who you believe, somewhere between $1 trillion and all the money in the world plus all the money on other planets that will be discovered by the James Webb Telescope. Now, granted, for that price, we could probably have bought high-deductible plans for all of the newly insured and given them a $5000 HSA to cover the deductible. That wouldn’t have disrupted anyone else’ insurance either. But then what would the poor bureaucrats do?
  • I think we all know the conclusion to draw from this: we need to now move to single payer. The success of Obamacare tells us that we need single payer. And the failure of Obamacare tells us that we need single payer. The canceling of perfectly legitimate insurance plans tells us we need single payer. The massive premium increases tells us we need single payer. Actually, when Venus is in the house of the ram, it tells us that we need single payer. When the sun rises in the east, we need single payer.

    We just need single payer dammit ‘cuz REASONS!

    Obamacare: How We Got Here

    In the fight over the debt ceiling and shutdown, it’s important to remember that Obamacare was brought to us and is still supported by a string of deceptions and obfuscations. You should really read Megan McArdle’s breakdown of 11 pieces of conventional wisdom about Obamacare. Here’s an example:

    4.Emergency room use will decline.

    Unfortunately, it doesn’t actually seem to be true. In Massachusetts, ER visits actually rose post-Romneycare. It turns out that people use the ER for non-emergency care for a number of reasons — sometimes a painful-but-not-life-threatening condition like a urinary tract infection arises on a Saturday morning, and sometimes people who work for hourly wages don’t feel that they can afford to take off work to go to a doctor’s office. Or sometimes they have a primary care physician, but can’t get a timely appointment — a situation that got worse in Massachusetts after Romneycare passed.

    McCardle leaves out some other things, such as the idea that preventative care will save us money (it won’t) or that electronic medical records will (they won’t). Both might save lives but they won’t save money.

    But I’d like to focus on three particular lies that I consider the most egregious. The stuff McCardle talks about is wonky stuff that it hard to predict and about which there is some legitimate debate. But there are three claims about Obamacare that are not only false but were known to be false when they were uttered.

    First, the initial promise of Obamacare was that it would save $2500 a year for every family. This was the claim that Obama made during his initial presidential campaign. It was recycled, without the specific number, to get it passed through Congress. In light of spiking insurance rates, this claim now seems laughable. HS has been reduced to touting that premiums will be “lower than expected” which sounds good, but actually means, they aren’t quite as bad as had been feared.

    The claim that healthcare reform would immediately slice insurance rates was obvious garbage when Obama said it. Maybe, in the long run, healthcare reform will cut costs. But you simply can not expand insurance to millions of people and have costs go down. Reality doesn’t work that way. Maybe insuring those people is a good social goal; but that’s not how it was sold to us.

    It gets worse. Last week, we found out that the whole “save money” thing was just a throwaway line in an Obama speech:

    Soon-to-be-candidate Obama, then an Illinois senator, was thinking about turning down an invitation to speak at a big health care conference sponsored by the progressive group Families USA [in January 2007], when two aides, Robert Gibbs and Jon Favreau, hit on an idea that would make him appear more prepared and committed than he actually was at the moment.

    Why not just announce his intention to pass universal health care by the end of his first term?…

    “We needed something to say,” recalled one of the advisers involved in the discussion. “I can’t tell you how little thought was given to that thought other than it sounded good. So they just kind of hatched it on their own. It just happened. It wasn’t like a deep strategic conversation.”…

    The candidate jumped at it. He probably wasn’t going to get elected anyway, the team concluded. Why not go big?

    It was months later that Obama became even passingly familiar with healthcare policy. Dan McLaughlin was right when he called this the most Obama thing ever.

    The second falsehood we knew about was “if you like your insurance, you can keep it”. We’ve been over this before, so no point in rehashing it again. But it is worth remembering the changes to existing insurance policies was known when Obamacare was being debated. They knew this was incorrect; they knew it outlaws certain insurance policies. And they said it anyway.

    This third lie, however, is the one I want to really talk about. When Obamacare was being debated, conservatives were pilloried (and labelled liars by fact-checkers) for claiming this was a government takeover of healthcare and a step toward socialized medicine. Liberal wags joked that if we thought Obamacare was socialism, we didn’t know what socialism was. We were outmoded hysterics. Even when we unearthed video of Obama bragging that single payer was the goal, we were bashed for taking him out of context or something.

    But I’ve noticed something in the last few days. Suddenly, all the liberals who said we were crazy for thinking this would lead to single payer are … claiming this will lead to single payer. Their claim is that the fierce opposition to Obamacare is because conservatives are afraid the public will like it and demand single payer. Here‘s Bill Maher, in an awful op-ed I plan to fisk later today. Here is Harry Reid. Check out the comments of every liberal blog out there. The claim that was once dismissed as conservative hysteria is now being touted as the major reason for Obamacare’s awesomeness.

    So … let’s sum up. We claimed that Obamacare would be expensive, would change insurance and would be a step toward socialism. We were branded liars and hysterics by people who knew everything we said was right. And now they’ve turned those memes around to support Obamacare.

    And they think we’re dishonest.