Category Archive for: Health Care [Return to Main]

Monday, May 23, 2016

Why Obamacare's "Cadillac Tax" is so Contentious

I have a new article at CBS MoneyWatch:

Why Obamacare's "Cadillac tax" is so contentious: President Obama's signature health care law is called the Affordable Care Act... One of its provisions that aimed at chipping away health care's high costs is a tax that attempts to remove a hidden subsidy for the most expensive employer-paid health insurance plans.
The highly controversial 40 percent surcharge on these plans quickly became known as the "Cadillac tax," but its implementation has been anything but quick: Congress has delayed its effective date from 2018 to 2020, given the misgivings many lawmakers have about its wisdom -- and possible effects. Indeed, it's not at all clear that the provision will ever become effective.
The Republican opposition is based upon the party's overwhelming aversion to everything about Obamacare, and the Democrats' resistance arises from concerns over how the tax will affect employee benefits. Unions are also concerned that health insurance benefit increases they've bargained for in lieu of wage increases will be lost.
Of course, economists have opinions on this topic as well, with a recent poll of economists finding strong support for the Cadillac tax on high-price employer-provided health plans.
The tax was intended to raise revenues to help fund Obamacare and, because it provides an incentive for employers to reduce their spending on health care, function as a cost-control measure. ...

Thursday, April 28, 2016

High-Risk Pools Don't Work, Have Never Worked, and Won't Work in the Future

 Kevin Drum:

High-Risk Pools Don't Work, Have Never Worked, and Won't Work in the Future: Even among conservative voters, Obamacare's protection of people with pre-existing conditions has always been popular. ... But popular or not, Paul Ryan wants nothing to do with it:

..."Less than 10 percent of people under 65 are what we call people with pre-existing conditions, who are really kind of uninsurable," Ryan, a Wisconsin Republican, told a student audience at Georgetown University. "Let's fund risk pools at the state level to subsidize their coverage, so that they can get affordable coverage," he said. "You dramatically lower the price for everybody else. You make health insurance so much more affordable, so much more competitive and open up competition."

It's true that the cost of covering sick people raises the price of insurance for healthy people. That's how insurance works. But there's no magic here. It costs the same to treat sick people whether you do it through Obamacare or through a high-risk pool—and it doesn't matter whether you fund it via taxes for Obamacare or taxes for something else. However, there are some differences:

  • Handling everyone through a single system is more efficient and more convenient.
  • High-risk pools have a lousy history. They just don't work.
  • Implementing them at the state level guarantees a race to the bottom, since no state wants to attract lots of sick people into its program.
  • Ryan's promise to fund high-risk pools is empty. He will never support the taxes it would take to do it properly, and he knows it.

This is just more hand waving. Everyone with even a passing knowledge of the health care business knows that high-risk pools are a disaster, but Republicans like Ryan keep pitching them anyway as some kind of bold, new, free-market alternative to Obamacare. They aren't. They've been around forever and everyone knows they don't work.

See also Shorter Paul Ryan to Cancer Patients: Die Quickly from Charles Gaba.

Sorry, that's really the only headline which came to mind when I read this story...

The magic solution to the problem, according to Ryan and the GOP, is "high risk pools", which simply means separating out the sickest, most expensive people in the country and dumping them into a separate program.

With the "bad apples" (ie, human beings with terrible medical problems) safely tucked out of the way, the average cost of treating everyone else supposedly suddenly becomes less pricey.

This is the exact opposite of the entire point of health insurance in the first place...spreading the risk. In addition, as Jean P. Hall notes in this Commonwealth Fund analysis, it doesn't actually save anyone a dime...

Harold Pollack put it far more succinctly for the Twitter age:

@charlesornstein @LenMNichols @Reuters_Health high risk pools are among the very worst ideas in health policy.

— Harold Pollack (@haroldpollack) April 28, 2016

Tuesday, April 19, 2016

Debunking Republican Health Care Myths

From the NY Times editorial board:

Debunking Republican Health Care Myths: “Disaster.” “Incredible economic burden.” “The biggest job-killer in this country.”
Central to the presidential campaigns of Donald Trump and Ted Cruz has been the claim that the Affordable Care Act has been a complete failure, and that the only way to save the country from this scourge is to replace it with something they design.
It’s worth examining the big myths they are peddling about the Affordable Care Act and also their ill-conceived plans of what might replace it. ...
In inventing problems that don’t exist and proposing solutions that won’t help, Donald Trump and Ted Cruz show that they don’t care about helping Americans get health care, which has never been their interest. They want to trash the Affordable Care Act, and they’re willing to mislead the public any way they can.

Thursday, March 24, 2016

Why Is the CBO Concocting a Phony Debt Crisis?

Lifted from Brad DeLong at Equitablog:

Why Is the CBO Concocting a Phony Debt Crisis?: Must-Read: Ari Rabin-Havt: Why Is the CBO Concocting a Phony Debt Crisis?: “The CBO assumes that Social Security and Medicare Part A will draw on the general fund of the US Treasury…
…to cover benefit shortfalls following the depletion of their trust funds, which at the current rate will occur in 2034. That would obviously lead to an exploding debt, but it’s a scenario prohibited by law. In the case of both programs, benefits must be paid either from revenue collected via payroll taxes or from accumulated savings in the programs’ trust funds. When those funds run out, full benefits will simply not be paid. ‘Because there is no borrowing authority, there is really a hard stop,’ said Goss.
Congress could pass a law saying that Social Security and Medicare Part A would begin drawing on the US Treasury general fund after 2034. Or, Congress could preemptively pass laws to avert the situation before the deadline; it could take the approach favored by progressives and increase revenue to the programs by lifting the payroll tax cap, or alternatively raise the retirement age and lower benefits. But the bottom line is the CBO projections disregard the actual law and assume a worst-case legislative scenario—and one that is politically unlikely, to boot…

Friday, February 05, 2016

Paul Krugman: Who Hates Obamacare?

The left's attack on Obamacare could be harmful:

Who Hates Obamacare?, by Paul Krugman, Commentary, NY Times: ...the Affordable Care Act is already doing enormous good. ... Why, then, do we hear not just conservatives but also many progressives trashing President Obama’s biggest policy achievement?
Part of the answer is that Bernie Sanders has chosen to make re-litigating reform, and trying for single-payer, a centerpiece of his presidential campaign. So some Sanders supporters have taken to attacking Obamacare as a failed system. ... And some of these critiques have merit. Others don’t.
Let’s start with the good critiques...
The number of uninsured Americans has dropped sharply... But millions are still uncovered, and in some cases high deductibles make coverage less useful than it should be.
This isn’t inherent in a non-single-payer system: Other countries with Obamacare-type systems, like the Netherlands and Switzerland, do have near-universal coverage even though they rely on private insurers. But Obamacare as currently constituted doesn’t seem likely to get there, perhaps because it’s somewhat underfunded.
Meanwhile, although cost control is looking better than even reform advocates expected, America’s health care remains much more expensive than anyone else’s.
So yes, there are real issues with Obamacare. The question is how to address those issues in a politically feasible way.
But a lot of what I hear from the left is not so much a complaint about how the reform falls short as outrage that private insurers get to play any role. The idea seems to be that any role for the profit motive taints the whole effort.
That is, however, a really bad critique..., the fact that some insurers are making money from reform (and their profits are not ... all that large) isn’t a reason to oppose that reform. The point is to help the uninsured, not to punish or demonize insurance companies.
And speaking of demonization: One unpleasant, ugly side of this debate has been the tendency of some Sanders supporters, and sometimes the campaign itself, to suggest that anyone raising questions about the senator’s proposals must be a corrupt tool of vested interests. ...
And let’s be clear: This kind of thing can do real harm. The truth is that whomever the Democrats nominate, the general election is mainly going to be a referendum on whether we preserve the real if incomplete progress we’ve made on health, financial reform and the environment. The last thing progressives should be doing is trash-talking that progress and impugning the motives of people who are fundamentally on their side.

Monday, January 18, 2016

'Paul Krugman, Bernie Sanders, and Medicare for All'

Dean Baker (this was posted at Econospeak instead of CEPR due to website troubles -- assuming CPER's Creative Commons license still applies):

Paul Krugman, Bernie Sanders, and Medicare for All: Paul Krugman weighs in this morning on the debate between Bernie Sanders and Hillary Clinton as to whether we should be trying to get universal Medicare or whether the best route forward is to try to extend and improve the Affordable Care Act. Krugman comes down clearly on the side of Hillary Clinton, arguing that it is implausible that we could get the sort of political force necessary to implement a universal Medicare system.
Getting universal Medicare would require overcoming opposition not only from insurers and drug companies, but doctors and hospital administrators, both of whom are paid at levels two to three times higher than their counterparts in other wealthy countries. There would also be opposition from a massive web of health-related industries, including everything from manufacturers of medical equipment and diagnostic tools to pharmacy benefit managers who survive by intermediating between insurers and drug companies.  
Krugman is largely right, but I would make two major qualifications to his argument. The first is that it is necessary to keep reminding the public that we are getting ripped off by the health care industry in order to make any progress at all. The lobbyists for the industry are always there. Money is at stake if they can get higher prices for their drugs, larger compensation packages for doctors or hospitals, or weaker regulation on insurers.
The public doesn’t have lobbyists to work the other side. The best we can hope is that groups that have a general interest in lower health care costs, like AARP, labor unions, and various consumer groups can put some pressure on politicians to counter the industry groups. In this context, Bernie Sanders’ push for universal Medicare can play an important role in energizing the public and keeping the pressure on.
Those who think this sounds like stardust and fairy tales should read the column by Krugman’s fellow NYT columnist, health economist Austin Frakt. Frakt reports on a new study that finds evidence that public debate on drug prices and measures to constrain the industry had the effect of slowing the growth of drug prices. In short getting out the pitchforks has a real impact on the industry’s behavior.
The implication is that we need people like Senator Sanders to constantly push the envelope. Even if this may not get us to universal Medicare in one big leap, it will create a political environment in which we can move forward rather than backward.
The other point has to do with an issue that Krugman raises in his blogpost on the topic. He argues that part of the story of lower health care costs in Canada and other countries involves saying “no,” by which he means refusing to pay for various drugs and treatments that are considered too expensive for the benefit they provide.
While there is some truth to this story, it is important to step back for a moment. In the vast majority of cases, the drugs in question are not actually expensive to manufacture. The way the drug industry justifies high prices is that they must recover their research costs. While the industry does in fact spend a considerable amount of money on research (although they likely exaggerate this figure), at the point the drug is being administered this is a sunk cost. In other words, the resources devoted to this research have already been used; the economy doesn’t somehow get back the researchers’ time and the capital expended if fewer people take a drug that is developed from their work.
Ordinarily economists treat it as an absolute article of faith that we want all goods and services to sell at their marginal cost without interference from the government, like a trade tariff or quota. However in the case of prescription drugs, economists seem content to ignore the patent monopolies granted to the industry, which allow it to charge prices that are often ten or even a hundred times the free market price. (The hepatitis C drug Sovaldi has a list price in the United States of $84,000. High quality generic versions are available in India for a few hundred dollars per treatment.) In this case, we are effectively looking at a tariff that is not the 10-20 percent that we might see in trade policy, but rather 1,000 percent or even 10,000 percent.
This sort of gap between price and marginal cost leads to exactly the sort of distortions that economists predict when the government intervenes in a market with trade tariffs, except the distortions are hugely larger with drugs. Companies have incentive to engage in massive marketing efforts, they push their drugs for conditions for which they may not be appropriate, and they conceal evidence suggesting their drugs may be less effective than advertised, or possibly even harmful. They also lobby politicians for ever longer and stronger patent protection, and they use the legal system to harass potential competitors, both generic and brand. Even research is distorted by this incentive structure, with large portions of the industry’s budget being devoted to developing copycat drugs to gain a share of a competitor’s patent rents.
Perhaps the worst part of this story is that the patent monopolies put us in a situation where we might have to say no. The industry’s monopoly allows it to say that it will not turn over a life-saving drug for less than $100,000, $200,000, or whatever price tag it chooses. However, if there was no patent monopoly, we would be looking at buying this drug at its cost of production. That will rarely be more than $1,000 and generally much less. At those prices, it will rarely make sense to say no. (The same issue arises with most medical equipment – once we have the technology, producing an MRI is relatively cheap, as would be the cost of an individual screening.)
We do have to pay for the research, but the way we are now doing it is incredibly backward. It is like paying the firefighters when they show up at the burning house with our family inside. Of course we would pay them millions to save our family (if we had the money), but it is nutty to design a system that puts us in this situation.
We should be looking for a system that pays for the research upfront. There are various mechanisms to accomplish this goal. (Here’s my plan for a system of publicly funded clinical trials.) Obviously overhauling our system for financing drug research is not something that is done overnight, but it is an issue that needs attention. The current system is incredibly wasteful and it needlessly puts in a situation where we have to say no in contexts where the costs to society of administering treatment are actually very low.
This doesn’t mean that we would pay for everything for everybody. There are some procedures that actually are very expensive, for example surgeries requiring many hours of the time of highly skilled surgeons. But we should be trying to design a system that minimizes these sorts of situations, rather than making them an everyday occurrence.

Paul Krugman: Health Reform Realities

Would it be worth it to try to enact single-payer health care system?:

Health Reform Realities, by Paul Krugman, Commentary, NY Times: ... Obamacare is ... a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
My answer ... is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues...
If we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone. But single-payer wasn’t a politically feasible goal in America, for three big reasons...
First, like it or not, incumbent players have a lot of power. ...
Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class...
Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. ...
What this means, as the health policy expert Harold Pollack points out, is that a simple, straightforward single-payer system just isn’t going to happen. ...
Which brings me to the Affordable Care Act, which was designed to bypass these obstacles. ... Even so, achieving this reform was a close-run thing: Democrats barely got it through during the brief period when they controlled Congress. Is there any realistic prospect that a drastic overhaul could be enacted any time soon — say, in the next eight years? No.
You might say that it’s still worth trying. But politics, like life, involves trade-offs.
There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. ...
So progressives must set some priorities. And it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years.

Tuesday, December 29, 2015

'Mandate Memories'

Paul Krugman:

Mandate Memories: Sarah Kliff notes that the individual mandate in Obamacare is turning out to be essential — and it’s working, with the risk pool improving as the penalties kick in. What I wrote back in 2007, when Obama was campaigning against the mandate.
Fortunately, once in office he was a stronger advocate for health reform than I feared — including for necessary pieces he opposed in the primary; what we actually ended up with was, strictly speaking, Hillarycare.

Kevin Drum:

Chart of the Day: The Uninsured Rate in America Just Keeps Dropping:

I forgot to blog about this when the numbers came out, but the CDC has now updated their survey of the uninsured through the second quarter of 2015. ...
The number of uninsured adults under 65 continues to decline...

Tuesday, November 24, 2015

'Is the ACA in Trouble?'

Henry Aaron at Brookings:

Is the ACA in trouble?: United Health Care’s surprise announcement that it is considering whether to stop selling health insurance through the Affordable Care Act’s health exchanges in 2017 and is also pulling marketing and broker commissions in 2016 has health policy analysts scratching their heads. ...
Is United’s announcement seriously bad news for Obamacare, as many commentators have asserted? Is United seeking concessions in another area and using this announcement as a bargaining chip? Or, is something else going on? The answer, I believe, is that the announcement, while a bit of all of these things, is less significant than many suppose. ...
What seems to have happened—one can’t be sure...—is that the company, which mostly delayed its participation in the individual exchanges until 2015, incurred substantial start-up costs, enrolled few customers who turned out to be sicker than anticipated, and experienced more-than-anticipated attrition. Other insurers, including Blue-Cross/Blue-Shield plans nation-wide which hold a dominant position in individual markets in many states, did well... But minor players in the individual market, such as United, may have concluded that the costs of developing that market are too high for the expected pay-off. ...
What this means is that United’s announcement is regrettable news for those states from which they may decide to withdraw, as its departure would reduce competition. United might also use the threat of departure to negotiate favorable terms with states and the Administration. ... But it would be a mistake to treat United’s announcement, presumably made for good and sufficient business reasons, as a portentous omen of an ACA crisis.

Monday, November 23, 2015

Paul Krugman: Health Reform Lives!

The recent "bad, or at least not-great news about health reform" is won't derail Obamacare:

Health Reform Lives!, by Paul Krugman, Commentary, NY Times: To the right’s dismay, scare tactics — remember death panels? — and spurious legal challenges failed to protect the nation from the scourge of guaranteed health coverage. Still, Obamacare’s opponents insisted that it would implode in a “death spiral” of low enrollment and rising costs.
But the law’s first two years ... went remarkably well. The number of uninsured Americans dropped sharply,... while costs came in well below expectations. ...
I mention all of this to give you some perspective on recent developments that mark a break in the string of positive surprises. Yes, Obamacare has hit a few rough patches lately. But they’re much less significant than a lot of the reporting, let alone the right-wing reaction, would have you believe. Health reform is still a huge success story. ...
First, premiums are going up for next year, because insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected. There’s a lot of variation across states, but the average increase will be around 11 percent. That’s a slight disappointment, but it’s not shocking, given both the good news of the previous two years and the long-term tendency of insurance premiums to rise 5-10 percent a year.
Second, some Americans who bought low-cost insurance plans have been unpleasantly surprised by high deductibles. This is a real issue, but it shouldn’t be exaggerated. All allowed plans cover preventive services without a deductible, and many plans cover other health services as well. Furthermore, additional financial aid is available to lower-income families... Some people may not know about these mitigating factors ... but awareness should improve over time. ...
Oh, and official projections now say that fewer people will enroll in those exchanges than previously predicted. But the main reason is that surprisingly few employers are dropping coverage; overall projections for the number of uninsured Americans still look pretty good.
So where does that leave us? Without question, the run of unexpectedly good news for Obamacare has come to an end, as all such runs must. ... There were bound to be some bobbles along the way.
But are we looking at the beginnings of a death spiral? Some people are indeed saying that, but as far as I can tell, they’re all people who have been predicting disaster every step of the way...
The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working.

Tuesday, November 10, 2015

'To Understand Climbing Death Rates Among Whites, Look To Women Of Childbearing Age'

From an email suggestion:

To Understand Climbing Death Rates Among Whites, Look To Women Of Childbearing Age, by Laudan Aron, Lisa Dubay, Elaine Waxman, and Steven Martin, Health Affairs: The news that mortality is increasing among middle-aged white Americans spread like wildfire last week ... thanks to a study by Anne Case and Angus Deaton... Unfortunately, there are a couple of pieces of the puzzle ... the ... study missed.
By not looking at men and women separately, Case and Deaton failed to see that rising mortality is especially pronounced among women...., in the decade between 1992-96 and 2002-06, female mortality rates increased in 42.8 percent of US counties. Only 3.4 percent of counties, by comparison, saw an increase in male mortality rates. ...

Urban-womens-survival-age-50

Furthermore, our own analysis of the same data used by Case and Deaton shows that ... between 1999 and 2013, age-specific mortality rates for US white women age 45-54 increased by 26.8 deaths per 100,000 population, while the corresponding increase for men was 7.7 deaths.

By lumping women and men together, the study also missed the important point that the increases in mortality are affecting women of reproductive and childrearing ages...

Accidental poisonings ... explain only half of the total increase in deaths among white women... In addition to suicide, obesity- and smoking-related diseases are driving these mortality increases. Our findings clearly point to the need for a stronger public health focus on the misuse of prescription opioid drugs, as well as more prevention and treatment of tobacco, alcohol, and other drug use; mental illness; and obesity-related illnesses. ...

Friday, November 06, 2015

'Health Inequality'

Health inequality is large and consequential:

Health Inequality, by Giacomo De Giorgi and Maxim Pinkovskiy, Libery Street Economics: However important income inequality is, it is only a partial representation of the inequality in well-being among individuals, households, counties, and other communities. At a minimum, we need to consider other crucial measures such as consumption, leisure, and health. ...

It seems rather obvious that health is a fundamental component of welfare, yet more work needs to be done on analyzing the evolution of health inequality and its relationship with income inequality in a consistent framework that would allow us to draw welfare conclusions, as we do later in this blog.

First, we document, and map below, a large dispersion in life expectancy across counties.

Average Life Expectancy by County in 2007

...From the map’s legend, we can immediately notice a very large dispersion: the top 20 percent of life expectancy is about a decade longer than the bottom 20 percent. Looking at the map also immediately tells us that the Southeast has a substantially lower life expectancy. We note that this is partly owing to differences in demography and income across counties. ...
Welfare Analysis How important are these large health inequalities for welfare? ...

We ... conclude that raising life expectancy out of the lower tail would be a much more welfare-improving intervention than fully equalizing consumption. (We get analogous results if we ask by how much the decision maker would need to have all consumption levels raised in order to be indifferent between the current consumption and life expectancy distribution and the proposed intervention).


Health is a Key Component of Inequality
In terms of welfare (under standard assumptions on the welfare function), the elimination of the left tail of mortality would have a beneficial impact that is about 60 percent larger than full consumption equalization.

What are the policies that might eliminate the lower tail of the life-expectancy distribution? This remains a topic for further discussion. However, we observe that the increase in life expectancy that we need to achieve the elimination of the lower tail is not unprecedented. Over a span of twenty years, life expectancy increased on average by three years across U.S. counties, which would be sufficient to raise the lower tail substantially.

Monday, October 26, 2015

Paul Krugman: Free Mitt Romney!

Mitt can't win:

Free Mitt Romney!, by Paul Krugman, Commentary, NY Times: Sometimes I find myself feeling sorry for Mitt Romney. No, seriously. In another time and place, he might have been respected as an effective technocrat ... for his ability to get things done. In fact, that’s kind of how it worked when he was governor of Massachusetts...
But now it’s 2015 in America, and Mr. Romney’s party doesn’t want people who get things done. On the contrary, it actively hates government programs that improve American lives, especially if they help Those People. And this means that Mr. Romney can’t celebrate his signature achievement in public life, the Massachusetts health reform that served as a template for Obamacare.
This has to hurt. Indeed, a few days ago Mr. Romney couldn’t help himself: he boasted to the Boston Globe that “Without Romneycare, we wouldn’t have had Obamacare” and that as a result “a lot of people wouldn’t have health insurance.” And it’s true!
But such truths aren’t welcome in the G.O.P. ... Not surprisingly, then, Mr. Romney quickly tried to walk his comments back, claiming that Obamacare is very different from Romneycare, which it isn’t, and that it has failed.
But you know, it hasn’t. On the contrary, the Affordable Care Act has been a remarkable success, especially considering the scorched-earth opposition it has faced. ...
In short, President Obama, Nancy Pelosi and Harry Reid, who pushed the Affordable Care Act through despite total opposition from the G.O.P., have a lot to be proud of. And so does Mr. Romney, who helped lay the foundation. Instead, however, he’s trashing the best thing he’s ever done.
You have to wonder: Does Mr. Romney really think that his party would look more favorably on Obamacare if it worked even better than it has, if it cost no money at all? If so, he’s delusional. After all, the great majority of Republican-controlled states have turned down free money, refusing to let the federal government expand Medicaid...
The point is that from the point of view of the Republican base, covering the uninsured, or helping the unlucky in general, isn’t a feature, it’s a bug...: the base is actually willing to lose money in order to perpetuate suffering. ...
Maybe Mr. Romney ... just can’t bring himself to admit that he picked the wrong group of people to hang out with. Either way, one hopes for his sake that he eventually gives up his illusions. Trust me, Mitt: it will be a liberating experience.

Saturday, October 24, 2015

'Uniting Behind the Divisive ‘Cadillac’ Tax on Health Plans'

Summers and Mankiw:

Uniting Behind the Divisive ‘Cadillac’ Tax on Health Plans: One of us, a former member of the Obama administration, remains a fan of the president. The other, not so much. But we agree on one thing: The excise tax on high-cost health care plans, the so-called Cadillac tax, is good policy. Congress should side with President Obama and resist calls to scrap it. ...

To some, the Cadillac tax is unpopular because unions oppose it, having negotiated especially generous health plans. But legislators should not let special interests stand in the way of a more rational health care system for all Americans.

To some, the Cadillac tax is unpopular because it was passed as part of the Affordable Care Act, a.k.a. Obamacare. But the Cadillac tax can be evaluated as a stand-alone measure. Both fans and critics of Obamacare should see the merits in a more level playing field between alternative forms of compensation.

One of us worked for President Obama when the Affordable Care Act was passed. One of us worked for President George W. Bush and supported John McCain and Mitt Romney in their attempts to defeat Mr. Obama. We disagree on many things, but we agree that health policy is too important to treat as if it were nothing more than another political battlefield.

Some policies deserve bipartisan support. The Cadillac tax is one of them.

Thursday, September 24, 2015

'Rational Drug Pricing'

Should we rationally expect rational drug pricing?:

Rational Drug Pricing, by Jeff Sachs: Drug pricing has taken center stage in U.S. politics, and it's high time that it should. ...
Drug pricing is not like the pricing of apples and oranges, clothing, or furniture that well and good should be left to the marketplace. There are two major reasons. First, the main cost of drug production is not the cost of manufacturing the tablet but the cost of producing the knowledge embedded in the tablet. Second, there is often a life-and-death stake in access to the drug, so society should take steps to ensure that the drug is affordable and accessible.
To ensure that financial resources flow to scientists to produce the knowledge embedded in the tablet, the government does two things. First, the government pays directly for a substantial part of the research and development (R&D). ... Second, the government grants patent rights for drug discovery. ...
It's a basic insight of economics that patent rights are a "second-best" solution to drug pricing, not an optimal solution. A patent creates an artificial monopoly to incentivize R&D. Yet it also reduces access to the product, perhaps with unacceptable and immoral life-and-death consequences. Rational drug pricing would get the best of the patent system but ensure that it is compatible with access to the life-saving drugs.
Unfortunately, the current rules of the game in the U.S. pharmaceutical sector do not compensate for the weaknesses of patents. They amplify them. ... What should be done? Here are three key principles.
First, private R&D should certainly be protected by patents but only enough to elicit the needed R&D, not to produce outlandish profits. ...
Second, when the U.S. government pays for much of the R&D, it should share in the property rights. This should be a no-brainer, but in fact the NIH simply gives away most or all the intellectual property that it has financed, so the taxpayer pays part of the R&D bills but the returns are fully captured by private companies.
Third, when companies ... make profits from their U.S.-based research and U.S.-based production and sales, they should certainly pay U.S. taxes on their profits. The fact that the IRS lets them hide their profits in overseas tax havens is scandalous and without any logical justification whatsoever.

Wednesday, September 16, 2015

'Bernie Sanders Wants to Spend $18 Trillion: So What?'

James Kwak (Dean Baker makes the same point):

Bernie Sanders Wants to Spend $18 Trillion: So What?: The front page of yesterday’s Wall Street Journal featured an article claiming that Bernie Sanders wants to increase federal government spending by $18 trillion over the next ten years—an increase of about one-third over that time period. This was apparently supposed to raise some kind of alarm—what kind of maniac is this?—and I’m sure both Republicans and Hillary Clinton are happy the Journal is doing their work for them.
The problem is that a spending figure, even one as big as $18 trillion, is meaningless on its own.
Most of that money—$15 trillion—is the expansion of Medicare to cover all Americans. Yes, that’s a lot of money. But we are already spending a ton of money on  health care—with embarrassingly poor results. In 2013,... Americans ... paid ... $1.4 trillion... Project that out for ten years, add health care inflation, and you’re talking about a lot more than $15 trillion.
At the end of the day, what matters isn’t the amount of money that the federal government spends for health care. What matters is the amount of money that the American people spend for health care. The government is just a device that we use to provide certain services that are better handled collectively than individually. If the government can provide equivalent service at lower prices, then the gross dollar amount involved doesn’t matter. ...
Now the big issue, I admit, is whether the government can provide equivalent service at lower prices. For the vast majority of consumer goods and services, it can’t. ... But real economists have known for more than half a century that health care doesn’t behave like ordinary consumer goods. ...
If you don’t want to read economics papers, the best evidence that health care is different comes from comparing the United States to other rich countries, which all have something closer to a single payer model for health insurance. As is well known, we spend a lot more money and have comparable or worse aggregate health outcomes. There is a huge ongoing adebate about why this is, which I’m not going to try to settle here.
The main point, however, is that if you want to argue against the Bernie Sanders health care plan, you have to make the case that Medicare for all will actually produce worse outcomes or higher costs than our current system. The fact that it costs a lot of money is beside the point.

Tuesday, September 15, 2015

'Market Power in Healthcare'

Via Austin Frakt at The Incidental Economist (I shortened the summaries):

Market Power: Recent NBER publications by Laurence Baker, M. Kate Bundorf, and Daniel Kessler:

1) “The Effect of Hospital/Physician Integration on Hospital Choice“:

We find that a hospital’s ownership of an admitting physician dramatically increases the probability that the physician’s patients will choose the owning hospital. We also find that ownership of an admitting physician has large effects on how the hospital’s cost and quality affect patients’ hospital choice. Patients whose admitting physician is not owned by a hospital are more likely to choose facilities that are low cost and high quality. ... We conclude that hospital/physician integration affects patients’ hospital choices in a way that is inconsistent with their best interests.

2) “Does Health Plan Generosity Enhance Hospital Market Power?” :

To what extent does the generosity of health insurance coverage facilitate the exercise of market power by producers of health services?  […]

We find a statistically significant and economically important effect of plan generosity on hospital prices in uncompetitive markets. ...

Thursday, July 30, 2015

'Dentists and Skin in the Game'

Paul Krugman:

Dentists and Skin in the Game: Wonkblog has a post inspired by the dentist who paid a lot of money to shoot Cecil the lion, asking why he — and dentists in general — make so much money. Interesting stuff; I’ve never really thought about the economics of dental care.

But once you do focus on that issue, it turns out to have an important implication — namely, that the ruling theory behind conservative notions of health reform is completely wrong.

For many years conservatives have insisted that the problem with health costs is that we don’t treat health care like an ordinary consumer good; people have insurance, which means that they don’t have “skin in the game” that gives them an incentive to watch costs. So what we need is “consumer-driven” health care, in which insurers no longer pay for routine expenses like visits to the doctor’s office, and in which everyone shops around for the best deals. ...

As it turns out, many fewer people have dental insurance than have general medical insurance; even where there is insurance, it typically leaves a lot of skin in the game. But dental costs have risen just as fast as overall health spending...

Monday, July 27, 2015

Paul Krugman: Zombies Against Medicare

Despite what you might hear from conservatives, Medicare is "eminently sustainable":

Zombies Against Medicare, by Paul Krugman, Commentary, NY Times: Medicare turns 50 this week, and it has been a very good half-century. Before the program went into effect, Ronald Reagan warned that it would destroy American freedom; it didn’t, as far as anyone can tell. What it did do was provide a huge improvement in financial security for seniors and their families, and in many cases it has literally been a lifesaver as well.
But the right has never abandoned its dream of killing the program. So it’s really no surprise that Jeb Bush recently declared that while he wants to let those already on Medicare keep their benefits, “We need to figure out a way to phase out this program for others.” ...
The ... reason conservatives want to do away with Medicare has always been political: It’s the very idea of the government providing a universal safety net that they hate, and they hate it even more when such programs are successful. But ... they usually shy away from making their real case...
What Medicare’s would-be killers usually argue, instead, is that the program as we know it is unaffordable — that we must destroy the system in order to save it... And the new system they usually advocate is ... vouchers that can be applied to the purchase of private insurance.
The underlying premise here is that Medicare as we know it is incapable of controlling costs, that only the only way to keep health care affordable going forward is to rely on the magic of privatization.
Now, this was always a dubious claim. .... In fact, Medicare costs per beneficiary have consistently grown more slowly than private insurance premiums... Indeed, Medicare spending keeps coming in ever further below expectations...
Right now is, in other words, a very odd time to be going on about the impossibility of preserving Medicare, a program whose finances will be strained by an aging population but no longer look disastrous. One can only guess that Mr. Bush is unaware of all this, that he’s living inside the conservative information bubble, whose impervious shield blocks all positive news about health reform.
Meanwhile, what the rest of us need to know is that Medicare at 50 still looks very good. It needs to keep working on costs, it will need some additional resources, but it looks eminently sustainable. The only real threat it faces is that of attack by right-wing zombies.

Friday, May 08, 2015

'Childhood Medicaid Coverage Improves Adult Earning and Health'

I highlighted the second article below, and many others reaching similar conclusions, in my last column:

Childhood Medicaid Coverage Improves Adult Earning and Health, NBER Digest: Medicaid today covers more Americans than any other public health insurance program. Introduced in 1965, its coverage was expanded substantially, particularly to low-income children, during the 1980s and the early 1990s.
Throughout Medicaid's history, there has been debate over whether the program improves health outcomes. Two new NBER studies exploit variation in children's eligibility for Medicaid, across birth cohorts and across states with different Medicaid programs, along with rich longitudinal data on health care utilization and earnings, to estimate the long-run effects of Medicaid eligibility on health, earnings, and transfer program participation.
In Childhood Medicaid Coverage and Later Life Health Care Utilization (NBER Working Paper No. 20929), Laura R. Wherry, Sarah Miller, Robert Kaestner, and Bruce D. Meyer find that among individuals who grew up in low-income families, rates of hospitalizations and emergency department visits in adulthood are negatively related to the number of years of Medicaid eligibility in childhood. The authors exploit the fact that one of the substantial expansions of Medicaid eligibility applied only to children who were born after September 30, 1983. This resulted in a large discontinuity in the lifetime years of Medicaid eligibility for children born before and after this birthdate cutoff. Children in families with incomes between 75 and 100 percent of the poverty line experienced about 4.5 more years of Medicaid eligibility if they were born just after the September 1983 cutoff than if they were born just before, with the gain occurring between the ages of 8 and 14. The authors compare children who they estimate were in low-income families, and otherwise similar circumstances, who were born just before or just after this date, to determine how the number of years of childhood Medicaid eligibility is related to health in early adulthood. Their finding of reduced health care utilization among adults who had more years of childhood Medicaid eligibility is concentrated among African Americans, those with chronic illness conditions, and those living in low-income zip codes. The authors calculate that reduced health care utilization during one year in adulthood offsets between 3 and 5 percent of the costs of extending Medicaid coverage to a child.
In Medicaid as an Investment in Children: What is the Long-Term Impact on Tax Receipts? (NBER Working Paper No. 20835), David W. Brown, Amanda E. Kowalski, and Ithai Z. Lurie conclude that each additional year of childhood Medicaid eligibility increases cumulative federal tax payments by age 28 by $247 for women, and $127 for men. Their empirical strategy for evaluating the impact of Medicaid relies on variation in program eligibility during childhood that is associated with both birth cohort and state of residence. The authors study longitudinal data on actual tax payments until individuals are in their late 20s, and they extrapolate this information to make projections for these individuals at older ages. When they compare the incremental discounted value of lifetime tax payments with the cost of additional Medicaid coverage, they conclude that "the government will recoup 56 cents of each dollar spent on childhood Medicaid by the time these children reach age 60." This calculation is based on federal tax receipts alone, and does not consider state tax receipts or potential reductions in the use of transfer payments in adulthood.
Both studies use large databases of administrative records to analyze the long-term effects of Medicaid. The first study measures health utilization using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases for Arizona, Iowa, New York, Oregon, and Wisconsin in 1999, and those states plus Maryland and New Jersey in 2009. State hospital discharge data were also available from Texas and California. Data on all outpatient emergency department visits were available for six states in 2009. The second study examines data on federal tax payments and constructs longitudinal earnings histories for individuals who were born between 1981 and 1984. It also analyzes administrative records on Medicaid eligibility of children in this cohort.

Friday, April 24, 2015

Paul Krugman: Zombies of 2016

Some bad ideas just won't die:

Zombies of 2016, by Paul Krugman, Commentary, NY Times: Last week,...Chris Christie ... gave a speech in which he tried to position himself as a tough-minded fiscal realist. In fact, however, his supposedly tough-minded policy idea was a classic zombie — an idea that should have died long ago in the face of evidence that undermines its basic premise, but somehow just keeps shambling along.
...Mr. Christie ... thought he was being smart and brave by proposing that we raise the age of eligibility for both Social Security and Medicare to 69. Doesn’t this make sense now that Americans are living longer?
No, it doesn’t..., almost all the rise in life expectancy has taken place among the affluent. The bottom half of workers,... who rely on Social Security most, have seen their life expectancy at age 65 rise only a bit more than a year since the 1970s. Furthermore,... many ... still have to perform manual labor.
And while raising the retirement age would impose a great deal of hardship, it would save remarkably little money. ...
And there are plenty of other zombies out there. Consider, for example, the zombification of the debate over health reform. ...
Finally, one of the interesting political developments ... has been the triumphant return of voodoo economics, the “supply-side” claim that tax cuts for the rich stimulate the economy so much that they pay for themselves.
In the real world, this doctrine has an unblemished record of failure..
In the world of Republican politics, however, voodoo’s grip has never been stronger. Would-be presidential candidates must audition in front of prominent supply-siders to prove their fealty to failed doctrine. ... Supply-side economics, it’s now clear, is the ultimate zombie: no amount of evidence or logic can kill it.
So why has the Republican Party experienced a zombie apocalypse? One reason, surely, is the fact that most Republican politicians represent states or districts that will never, ever vote for a Democrat, so the only thing they fear is a challenge from the far right. Another is the need to tell Big Money what it wants to hear: a candidate saying anything realistic about Obamacare or tax cuts won’t survive the Sheldon Adelson/Koch brothers primary.
Whatever the reasons, the result is clear. Pundits will try to pretend that we’re having a serious policy debate, but, as far as issues go, 2016 is already set up to be the election of the living dead.

Monday, March 30, 2015

Paul Krugman: Imaginary Health Care Horrors

Why doesn't the public know how successful Obamacare has been?:

Imaginary Health Care Horrors, by Paul Krugman, Commentary, NY Times: ...Representative Pete Sessions of Texas, the chairman of the House Rules Committee, recently ... declared the cost of Obamacare “unconscionable.” If you do “simple multiplication,” he insisted, you find that the coverage expansion is costing $5 million per recipient. But ... the actual cost per newly insured American is about $4,000.
Now, everyone makes mistakes. But this wasn’t a forgivable error..., one indisputable fact is that it’s costing taxpayers much less than expected — about 20 percent less...
But that is, of course, how it’s been all along with Obamacare. Before the law went into effect, opponents predicted disaster on all levels. What has happened instead is that the law is working pretty well. So how have the prophets of disaster responded? By pretending that the bad things they said would happen have, in fact, happened. ...
Remember, Obamacare was also supposed to be a huge job-killer. ... Well, Obamacare went into effect fully at the beginning of 2014 — and private-sector job growth actually accelerated, to a pace we haven’t seen since the Clinton years. ...
Finally, there’s the never-ending hunt for ... for ordinary, hard-working Americans who have suffered hardship thanks to health reform. ... Remarkably, however, they haven’t been able to find those stories. ...
In reality, the only people hurt by health reform are Americans with very high incomes, who have seen their taxes go up, and a relatively small number of people who have seen their premiums rise because they’re young and healthy...
In short, when it comes to the facts, the attack ... has come up empty-handed. But the public doesn’t know that. ...
And the favorable experiences of the roughly 16 million Americans who have gained insurance ... have had little effect on public perceptions. Partly that’s because the Affordable Care Act, by design, has had almost no effect on those who already had good health insurance..., they have seen no change in their status.
At a deeper level, however, what we’re looking at here is the impact of post-truth politics. We live in an era in which politicians and the supposed experts who serve them never feel obliged to acknowledge uncomfortable facts, in which no argument is ever dropped, no matter how overwhelming the evidence that it’s wrong.
And the result is that imaginary disasters can overshadow real successes. Obamacare isn’t perfect, but it has dramatically improved the lives of millions. Someone should tell the voters.

Monday, February 16, 2015

Drug Prices are Bankrupting America

Jeff Sachs:

The Drug that is Bankrupting America: America is the land of breakthrough science ... in the case of the new hepatitis C virus (HCV) cure named sofosbuvir, sold under the brand name Solvadi by the drug company Gilead Sciences. There is no question that Solvadi is a godsend - a lifesaver for millions ... around the world ... Yet Solvadi is also the poster child of a US healthcare system that is being bankrupted by greed, lobbying and indefensible policies on drug pricing.
The basic facts are these. ... Gilead set the price for a twelve-week treatment course of Solvadi at $84,000... According to researchers at Liverpool University, the actual production costs of Solvadi for the twelve-week course is in the range $68-$136. ...
The standard defense by the drug companies ... is that drug discovery is costly and their high profits reimburse the R&D costs. Here is where the story of Solvadi gets even more interesting. The total private-sector outlays on R&D were ... almost surely under $500 million, meaning that the decade-long R&D outlays were likely recouped in a few weeks of drug sales.
Here is the background. Sofosbuvir was developed under the leadership of Prof. Raymond Schinazi, a brilliant professor of biochemistry at Emory University. The US Government heavily funded Prof. Schinazi's research...
Solvadi ... shows how publicly financed science easily turns into arbitrarily large private profits paid for by taxpayers. The challenge facing the US is to adopt a rational drug pricing system that continues to spur excellent scientific breakthroughs while keeping greed in check. Big Pharma and the US public are on a collision course when they should be partners for the advancement of health.

Friday, January 30, 2015

'Don't Trade Away Our Health'

Joe Stiglitz:

Don't Trade Away Our Health: A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.
Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.
Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs. ...

Friday, December 05, 2014

Paul Krugman: Democrats Against Reform

Despite the political difficulties it has caused, Obamacare was not a mistake:

Democrats Against Reform, by Paul Krugman, Commentary, NY Times: It’s easy to understand why Republicans wish health reform had never happened.... But it’s more puzzling — and disturbing — when Democrats like Charles Schumer, senator from New York, declare that the Obama administration’s signature achievement was a mistake.
In a minute I’ll take on Mr. Schumer’s recent remarks. But first, an update on Obamacare..., which continues to rack up remarkable (and largely unreported) successes ... with more than 10 million people gaining coverage since last year. ... And ... a huge majority of the newly insured are pleased with their coverage...
What about costs? There were many predictions of soaring premiums. But... Premiums for 2014 came in well below expectations...
In short,... as a policy intended to improve American lives, it’s going really well. Yet it has not ... been a political winner for Democrats. Which brings us to Mr. Schumer.
The Schumer critique — he certainly isn’t the first to say these things... — calls health reform a mistake because it only benefits a minority of Americans, and that’s not enough to win elections. What President Obama should have done ... was focus on improving the economy as a whole.
This is deeply wrongheaded in at least three ways.
First, while it’s true that most Americans have insurance through Medicare, Medicaid, and employment-based coverage..., but what happens if you’re fired, or your employer goes bust, or it cancels its insurance program? What if you want to change jobs for whatever reason, but can’t find a new job that comes with insurance? ...
Second, whenever someone says that Mr. Obama should have focused on the economy, my question is, what do you mean by that? Should he have tried for a bigger stimulus? I’d say yes, but ... especially after 2010 scorched-earth Republican opposition killed just about every economic policy he proposed. Do you think this would have been different without health reform? Seriously? ...
Finally, we need to ask, what is the purpose of winning elections? The answer, I hope, is to do good — not simply to set yourself up to win the next election. ....
And one related observation: If more Democrats had been willing to defend the best thing they’ve done in decades, rather than run away from their own achievement and implicitly concede that the smears against health reform were right, the politics of the issue might look very different today.

Tuesday, November 18, 2014

'The Structure of Obamacare'

Paul Krugman says pundits need to do their homework:

The Structure of Obamacare: The big revelation of this week has been how many political pundits have spent six years of the Obama administration opining furiously about the administration’s signature policy without making the slightest effort to understand how it works. They’re amazed and in denial at the suggestion that it has the same structure as Romneycare, which has been obvious and explicit all along...
So, why was Obamacare set up this way? It’s mainly about politics, but nothing that should shock you. Partly it was about getting buy-in from the insurance industry; a switch to single payer would have destroyed a powerful industry, and realistically that wasn’t going to happen. Partly it was about leaving most people unaffected: employment-based coverage, which was the great bulk of private insurance, remained pretty much as it was. ... And yes, avoiding a huge increase in on-budget spending was a consideration, but not central.
The main point was to make the plan incremental, supplementing the existing structure rather than creating massive changes. And all of this was completely upfront; I know I wrote about it many times.
Look, I understand why the hired guns of the right have to act ignorant and profess outrage. But I really am shocked at centrists who apparently thought they could opine on the politics of health reform, year after year, without taking a hour or two to learn how the darn thing was supposed to work.

It seems to me this takes some degree of willful ignorance.

Monday, November 10, 2014

Paul Krugman: Death by Typo

Do these people not understand, or care, how history will view them?

Death by Typo, by Paul Krugman, Commentary, NY Times: My parents used to own a small house with a large backyard, in which my mother cultivated a beautiful garden. At some point, however — I don’t remember why — my father looked at the official deed defining their property, and received a shock. According to the text, the Krugman lot wasn’t a rough rectangle; it was a triangle more than a hundred feet long but only around a yard wide at the base.
On examination, it was clear what had happened: Whoever wrote down the lot’s description had somehow skipped a clause. And of course the town clerk fixed the language. After all, it would have been ludicrous and cruel to take away most of my parents’ property on the basis of sloppy drafting, when the drafters’ intention was perfectly clear.
But it now appears possible that the Supreme Court may be willing to deprive millions of Americans of health care on the basis of an equally obvious typo. And if you think this possibility has anything to do with serious legal reasoning, as opposed to rabid partisanship, I have a long, skinny, unbuildable piece of land you might want to buy.
Last week the court shocked many observers by saying that it was willing to hear a case claiming that the wording of one clause in the Affordable Care Act sets drastic limits on subsidies to Americans who buy health insurance. It’s a ridiculous claim... But the fact that the suit is ridiculous is no guarantee that it won’t succeed — not in an environment in which all too many Republican judges have made it clear that partisan loyalty trumps respect for the rule of law. ...
Now, states could avoid this death spiral by establishing exchanges — which might involve nothing more than setting up links to the federal exchange. But how did we get to this point?
Once upon a time, this lawsuit would have been literally laughed out of court. Instead, however, it has actually been upheld in some lower courts, on straight party-line votes — and the willingness of the Supremes to hear it is a bad omen.
So let’s be clear about what’s happening here. Judges who support this cruel absurdity aren’t stupid; they know what they’re doing. What they are, instead, is corrupt, willing to pervert the law to serve political masters. And what we’ll find out in the months ahead is how deep the corruption goes.

Thursday, October 02, 2014

Why is our Infant Mortality so Bad?

Aaron Carroll:

So why is our infant mortality so bad?: ...Everyone knows that in international comparisons, the infant mortality rate in the US is terrible. Some people think it’s because we code things differently and try harder to save premature babies. Others think that’s not true, and that this points to other problems in the health care system.
As always, though, it’s probably a mixture of many things. A new NBER working paper gets at just that. “Why is Infant Mortality Higher in the US than in Europe?” ... What did they find?
Reporting differences ... explained up to 40% of the disadvantage in US infant mortality. But that would only get us closer. It would still leave us way worse. ... What accounted for the real disadvantage was postneonatal mortality, or mortality from one month to one year of age. That difference was almost entirely due to excess inequality in the US. ...
So there are two main takeaways from this paper. The first is that although reporting differences can account for some of our worse infant mortality statistics, most of the differences we see are not due to that explanation. The second is that most of the rest of the disadvantage is due to differences in postneonatal mortality, that likely require fixes to the healthcare system. Whether the ACA does so remains to be seen.

Tuesday, September 02, 2014

Fed Watch: Solid Start to September

Tim Duy:

Solid Start to September, by Tim Duy: The ISM manufacturing report came in ahead of expectations with the strongest number since 2011:

ISMa090114

Moreover, strength was evident throughout the internal components:

ISM090114

Note too that the report is consistent with other manufacturing numbers:

ISMb090114

If this is a taste of the data to expect this fall, it is tough to see how the Fed will be able to maintain their "considerable period" language much longer.

Monday, September 01, 2014

Paul Krugman: The Medicare Miracle

Good news on health care costs:

The Medicare Miracle, By Paul Krugman, Commentary, NY Times: So, what do you think about those Medicare numbers? What, you haven’t heard about them? Well, they haven’t been front-page news. But something remarkable has been happening on the health-spending front, and it should (but probably won’t) transform a lot of our political debate.
The story so far: We’ve all seen projections of giant federal deficits... Policy wonks have long known ... that ... health care, rather than retirement, was driving those scary projections. Why? Because, historically, health spending has grown much faster than G.D.P., and it was assumed that this trend would continue.
But a funny thing has happened: Health spending has slowed sharply ... This is a really big deal...
But what accounts for this good news? ... Medicare is spending much less than expected, and those Obamacare cost-saving measures are at least part of the story. The conventional wisdom on what is and isn’t serious is completely wrong.
While we’re on the subject of health costs, there are two other stories you should know about.
One involves the supposed savings from running Medicare through for-profit insurance companies. That’s the way the drug benefit works, and conservatives love to point out that this benefit has ended up costing much less than projected, which they claim proves that privatization is the way to go. But the budget office has a new report on this issue, and it finds that privatization had nothing to do with it. Instead, Medicare Part D is costing less than expected partly because enrollment has been low and partly because an absence of new blockbuster drugs has led to an overall slowdown in pharmaceutical spending.
The other involves the “sticker shock” that opponents of health reform have been predicting for years. Bulletin: It’s still not happening. ...
What’s the moral here? For years, pundits and politicians have insisted that guaranteed health care is an impossible dream, even though every other advanced country has it. Covering the uninsured was supposed to be unaffordable; Medicare as we know it was supposed to be unsustainable. But it turns out that incremental steps to improve incentives and reduce costs can achieve a lot, and covering the uninsured isn’t hard at all.
When it comes to ensuring that Americans have access to health care, the message of the data is simple: Yes, we can.

Tuesday, August 05, 2014

'Republican Craziness Is Undermining the South’s Massive Keynesian Stimulus'

Ha:

Someone needs to tell Republicans that you’re not actually supposed to govern according to the rhetoric used to gull the rubes.

More here.

Saturday, July 26, 2014

'The Illogic of Employer-Sponsored Health Insurance'

Uwe E. Reinhardt:

The Illogic of Employer-Sponsored Health Insurance, by Uwe E. Reinhardt, NY Times: ... Persuaded by both theory and empirical research, most economists believe that employer-based health insurance... ostensibly paid by employers ... is recovered from employees through commensurate reductions in take-home pay.
Evidently the majority of Supreme Court justices who just ruled in Burwell v. Hobby Lobby case do not buy the economists’ theory. These justices seem to believe that the owners of “closely held” business firms buy health insurance for their employees out of the kindness of their hearts and with the owners’ money. On that belief, they accord these owners the right to impose some of their ... religious beliefs ... on their employee’s health insurance. ...
The Supreme Court’s ruling may prompt Americans to re-examine whether the traditional, employment-based health insurance ... is really the ideal platform for health insurance coverage in the 21st century. The public health insurance exchanges established under the Affordable Care Act are likely to nibble away at this system....
In the meantime, the case should help puncture the illusion that employer-provided health insurance is an unearned gift bestowed on them by the owners and paid with the owners’ money, giving those owners the moral right to dictate the nature of that gift.

Monday, July 14, 2014

Paul Krugman: Obamacare Fails to Fail

Why don't we hear more about the success of Obamacare?:

Obamacare Fails to Fail, by Paul Krugman, Commentary, NY Times: How many Americans know how health reform is going? For that matter, how many people in the news media are following the positive developments?
I suspect that the answer to the first question is “Not many,” while the answer to the second is “Possibly even fewer”... And if I’m right, it’s a remarkable thing — an immense policy success is improving the lives of millions of Americans, but it’s largely slipping under the radar.
How is that possible? Think relentless negativity without accountability. The Affordable Care Act has faced nonstop attacks from partisans and right-wing media, with mainstream news also tending to harp on the act’s troubles. Many of the attacks have involved predictions of disaster, none of which have come true. But absence of disaster doesn’t make a compelling headline, and the people who falsely predicted doom just keep coming back with dire new warnings. ...
Yes, there are losers from Obamacare. If you’re young, healthy, and affluent enough that you don’t qualify for a subsidy (and don’t get insurance from your employer), your premium probably did rise. And if you’re rich enough to pay the extra taxes that finance those subsidies, you have taken a financial hit. But it’s telling that even reform’s opponents aren’t trying to highlight these stories. Instead, they keep looking for older, sicker, middle-class victims, and keep failing to find them.
Oh,... the overwhelming majority of the newly insured, including 74 percent of Republicans, are satisfied with their coverage.
You might ask why, if health reform is going so well, it continues to poll badly. It’s crucial ... to realize that Obamacare, by design, by and large doesn’t affect Americans who already have good insurance. As a result, many peoples’ views are shaped by the mainly negative coverage in the news... Still, the latest tracking survey from the Kaiser Family Foundation shows that a rising number of Americans are hearing about reform from family and friends, which means that they’re starting to hear from the program’s beneficiaries.
And as I suggested earlier, people in the media — especially elite pundits — may be the last to hear the good news, simply because they’re in a socioeconomic bracket in which people generally have good coverage.
For the less fortunate, however, the Affordable Care Act has already made a big positive difference. The usual suspects will keep crying failure, but the truth is that health reform is — gasp! — working.

Friday, June 27, 2014

Paul Krugman: The Incompetence Dogma

Why heve predictions from "the enemies of health reform" been so wrong?:

The Incompetence Dogma, by Paul Krugman, Commentary, NY Times: Have you been following the news about Obamacare? The Affordable Care Act has receded from the front page, but information about how it’s going keeps coming in — and almost all the news is good. Indeed, health reform has been on a roll ever since March, when it became clear that enrollment would surpass expectations despite the teething problems of the federal website.
What’s interesting about this success story is that it has been accompanied at every step by cries of impending disaster. At this point, by my reckoning, the enemies of health reform are 0 for 6. That is, they made at least six distinct predictions about how Obamacare would fail — every one of which turned out to be wrong.
“To err is human,” wrote Seneca. “To persist is diabolical.” Everyone makes incorrect predictions. But to be that consistently, grossly wrong takes special effort. So what’s this all about?
Many readers won’t be surprised by the answer:... a dogmatic belief in public-sector incompetence — is now a central part of American conservatism, and the incompetence dogma has evidently made rational analysis of policy issues impossible.
It wasn’t always thus. If you go back two decades, to the last great fight over health reform, conservatives seem to have been relatively clearheaded about the policy prospects, albeit deeply cynical. ...
But that was before conservatives had fully retreated into their own intellectual universe. Fox News didn’t exist yet; policy analysts at right-wing think tanks had often begun their careers in relatively nonpolitical jobs. It was still possible to entertain the notion that reality wasn’t what you wanted it to be.
It’s different now. It’s hard to think of anyone on the American right who even considered the possibility that Obamacare might work, or at any rate who was willing to admit that possibility in public. Instead, even the supposed experts kept peddling improbable tales of looming disaster...
And let’s be clear: While it has been funny watching the right-wing cling to its delusions about health reform, it’s also scary. After all, these people retain considerable ability to engage in policy mischief, and one of these days they may regain the White House. And you really, really don’t want people who reject facts they don’t like in that position. I mean, they might do unthinkable things, like starting a war for no good reason. Oh, wait.

Friday, June 20, 2014

Paul Krugman: Veterans and Zombies

Don't let "zombie arguments" derail health care reform:

Veterans and Zombies, by Paul Krugman, Commentary, NY Times: You’ve surely heard about the scandal at the Department of Veterans Affairs. A number of veterans found themselves waiting a long time for care, some of them died before they were seen, and some of the agency’s employees falsified records to cover up the extent of the problem. It’s a real scandal...
But the goings-on at Veterans Affairs shouldn’t cause us to lose sight of a much bigger scandal:... the Veterans Affairs scandal, while real, is being hyped out of proportion by people whose real goal is to block reform of the larger system.
The essential, undeniable fact about American health care is how incredibly expensive it is — twice as costly per capita as the French system, two-and-a-half times as expensive as the British system. You might expect all that money to buy results, but the United States actually ranks low on basic measures of performance...
As you might guess, conservatives don’t like the observation that American health care performs worse than other countries’ systems because it relies too much on the private sector and the profit motive. So whenever someone points out the obvious, there is a chorus of denial... It turns out, however, that such claims invariably end up relying on zombie arguments — that is, arguments that have been proved wrong, should be dead, but keep shambling along because they serve a political purpose.
Which brings us to veterans’ care. ... It’s still true that Veterans Affairs provides excellent care, at low cost. Those waiting lists arise partly because so many veterans want care, but Congress has provided neither clear guidelines on who is entitled to coverage, nor sufficient resources to cover all applicants. ...
Yet, on average, veterans don’t appear to wait longer for care than other Americans. And does anyone doubt that many Americans have died while waiting for approval from private insurers?
A scandal is a scandal... But beware of people trying to use the veterans’ care scandal to derail health reform.
And here’s the thing: Health reform is working. Too many Americans still lack good insurance, and hence lack access to health care and protection from high medical costs — but not as many as last year, and next year should be better still. Health costs are still far too high, but their growth has slowed dramatically. We’re moving in the right direction, and we shouldn’t let the zombies get in our way.

Thursday, June 12, 2014

Medicare Growth is Really Low

Aaron Carroll:

Medicare growth is really low: ... It turns out that actual Medicare growth for the first eight months of the fiscal year has been 0.3%. That’s amazing. But, of course, there are some temporary policies in place that have been restraining spending. These include things like the seqester, some ACA stuff, and frozen means-tested Medicare premium income thresholds.* Without these policies in place, growth would have been 2.5%. ...
Economic growth is 3.9%. That means that Medicare growth is nowhere near the GDP + 1% or so that would be needed to see the IPAB kick in. This has important, and positive, effects on the long-term federal budget outlook.
*Of course, there are temporary ACA-related things like the filling-in donut hole, which are increasing spending as well, so actual growth is likely less. Amazing!

Thursday, May 22, 2014

Unique Economics of Healthcare: Credence Goods

Cameron Murray:

Unique economics of healthcare: I was prompted to write this follow-up on health economics following a recent post by blogger Noah Smith, who weighs in with some reasonable views after some intense criticism of the ‘freakonomic’ Chicago-boy Steven Levitt. In a meeting with UK PM David Cameron, Levitt and his co-author apparently made some rather absurd remarks to him about health care.

They told him that the U.K.’s National Health Service -- free, unlimited, lifetime heath care -- was laudable but didn’t make practical sense.  
"We tried to make our point with a thought experiment," they write. "We suggested to Mr. Cameron that he consider a similar policy in a different arena. What if, for instance...everyone were allowed to go down to the car dealership whenever they wanted and pick out any new model, free of charge, and drive it home?"
Rather than seeing the humor and realizing that health care is just like any other part of the economy, Cameron abruptly ended the meeting... 

This nonsense reminds me that what constitutes economic debate in the US is often laughable at best.

Health care is obviously not like most other parts of the economy. As I said last week medical services are credence goods - goods which we don’t know whether we need, and even once we’ve consumed them, still don’t know if they were good value. In economic terms, these goods suffer from the worse of possible information failures, particularly with respect to the asymmetry of information between the seller (in this case the doctor) and the consumer.

For these goods the demand curve may slope any which way, and people are often left to use price as the only signal of quality (or quantity for that matter). This means that a socially optimal level of medical service provision cannot be determined using basic marginal economic analysis. ...

Monday, May 05, 2014

Paul Krugman: Inventing a Failure

Surprise! Republicans are opposed to Obamacare. But the lengths they'll go to to validate their beliefs in the face of evidence to the contrary is startling:

Inventing a Failure, by Paul Krugman, Commentary, NY Times: On Thursday, House Republicans released a deliberately misleading report on the status of health reform, crudely rigging the numbers to sustain the illusion of failure in the face of unexpected success. Are you shocked?
You aren’t, but ... the fact that this has become standard operating procedure for a major party bodes ill for America’s future.
About that report: The really big policy news of 2014, at least so far, is the spectacular recovery of the Affordable Care Act from its stumbling start... This is a problem for Republicans, who have bet the ranch on the proposition that health reform is an unfixable failure. ... How can they respond to good news?
Well,... they have ... continued to do what they’ve been doing ever since the news on Obamacare started turning positive: sling as much mud as possible at health reform, in the hope that some of it sticks. Premiums were soaring, they declared, when they have actually come in below projections. Millions of people were losing coverage, they insisted, when the great bulk of those whose policies were canceled simply replaced them with new policies. The Obama administration was cooking the books, they cried (projection, anyone?). And, of course, they keep peddling horror stories about people suffering terribly from Obamacare, not one of which has actually withstood scrutiny.
Now comes the latest claim — that many of the people who signed up for insurance aren’t actually paying their premiums. ... Previous attacks on Obamacare were pretty much fact-free; this time the claim was backed by an actual survey purporting to show that a third of enrollees hadn’t paid their first premium.
But the survey was rigged. (Are you surprised?) ...
So why are Republicans doing this? Sad to say, there’s method in their fraudulence.
First of all, it fires up the base. ... Beyond that, the constant harping on alleged failure works as innuendo even if each individual claim collapses in the face of evidence. ...
So Republicans are spreading disinformation about health reform because it works, and because they can — there is no sign that they pay any political price when their accusations are proved false.
And that observation should scare you. What happens to the Congressional Budget Office if a party that has learned that lying about numbers works takes full control of Congress? What happens if it regains the White House, too? Nothing good, that’s for sure.

Friday, April 11, 2014

Paul Krugman: Health Care Nightmares

Dreaming of politicians on the right who actually care about the unemployed, the uninsured, and the unfortunate. But it's just a dream:

Health Care Nightmares, by Paul Krugman, Commentary, NY Times: When it comes to health reform, Republicans suffer from delusions of disaster. They know, just know, that the Affordable Care Act is doomed to utter failure, so failure is what they see, never mind the facts on the ground.
Thus, on Tuesday, Mitch McConnell, the Senate minority leader, dismissed the push for pay equity as an attempt to “change the subject from the nightmare of Obamacare”; on the same day, the nonpartisan RAND Corporation released a study estimating “a net gain of 9.3 million in the number of American adults with health insurance coverage...” Some nightmare. And the overall gain ... must be considerably larger.
But ... Obamacare is looking like anything but a nightmare... It will be months before we have a full picture, but it’s clear that the number of uninsured Americans has already dropped significantly...
Republicans clearly have no idea how to respond... At the state level, however, Republican governors and legislators are still in a position to block the act’s expansion of Medicaid, denying health care to millions of vulnerable Americans. And they have seized that opportunity with gusto: Most Republican-controlled states, totaling half the nation, have rejected Medicaid expansion. ...
What’s amazing about this wave of rejection is that it appears to be motivated by pure spite. The federal government is prepared to pay for Medicaid expansion, so it would cost the states nothing, and would, in fact, provide an inflow of dollars. ...Jonathan Gruber ... recently summed it up: The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.” Indeed.
And while supposed Obamacare horror stories keep on turning out to be false, it’s already quite easy to find examples of people who died because their states refused to expand Medicaid. According to one recent study, the death toll from Medicaid rejection is likely to run between 7,000 and 17,000 Americans each year.
But nobody expects to see a lot of prominent Republicans declaring that rejecting Medicaid expansion is wrong, that caring for Americans in need is more important than scoring political points against the Obama administration. As I said, there’s an extraordinary ugliness of spirit abroad in today’s America, which health reform has brought out into the open.
And that revelation, not reform itself — which is going pretty well — is the real Obamacare nightmare.

Friday, April 04, 2014

Paul Krugman: Rube Goldberg Survives

Supporters of health reform should "go ahead and celebrate":

Rube Goldberg Survives, by Paul Krugman, Commentary, NY Times: Holy seven million, Batman! ...Obamacare has made a stunning comeback from its shambolic start..., the original target of seven million signups, widely dismissed as unattainable, has been surpassed.
But what does it mean? That depends on whether you ask the law’s opponents or its supporters. You see, the opponents think that it means a lot, while the law’s supporters are being very cautious. And, in this one case, the enemies of health reform are right. This is a very big deal indeed.
Of course, you don’t find many Obamacare opponents admitting outright that 7.1 million and counting signups is a huge victory... But their reaction to the results — It’s a fraud! They’re cooking the books! — tells the tale. ...
So why are many reform supporters ... telling us not to read too much into the figures? ... I’d argue that they’re missing the forest for the trees.
The crucial thing to understand about the Affordable Care Act is that it’s a Rube Goldberg device, a complicated way to do something inherently simple. ... Remember, giving everyone health insurance doesn’t have to be hard; you can just do it with a government-run program..., extending Medicare to everyone would have been technically easy.
But it wasn’t politically possible,... health reform had to be run largely through private insurers, and be an add-on to the existing system... And, as a result, it had to be somewhat complex. ... It’s a system in which many things can go wrong; the nightmare scenario has always been that conservatives would seize on technical problems to discredit health reform... And last fall that nightmare seemed to be coming true.
But the nightmare is over. ... Now we know that the technical details can be managed... This thing is going to work.
And, yes, it’s also a big political victory for Democrats. They can point to a system that is already providing vital aid to millions of Americans, and Republicans — who were planning to run against a debacle — have nothing to offer in response. And I mean nothing. ...

So my advice to reform supporters is, go ahead and celebrate. Oh, and feel free to ridicule right-wingers who confidently predicted doom.

Clearly, there’s a lot of work ahead, and we can count on the news media to play up every hitch and glitch as if it were an existential disaster. But Rube Goldberg has survived; health reform has won.

Monday, February 24, 2014

Paul Krugman: Health Care Horror Hooey

 Paul krugman:

Health Care Horror Hooey, by Paul Krugman, Commentary, NY Times: Remember the “death tax”? The estate tax is quite literally a millionaire’s tax — a tax that affects only a tiny minority of the population, and is mostly paid by a handful of very wealthy heirs. Nonetheless, right-wingers have successfully convinced many voters that the tax is a cruel burden on ordinary Americans...
You might think that such heart-wrenching cases are actually quite rare, but you’d be wrong: they aren’t rare; they’re nonexistent. In particular, nobody has ever come up with a real modern example of a family farm so ld to meet estate taxes. The whole “death tax” campaign has rested on eliciting human sympathy for purely imaginary victims.
And now they’re trying a similar campaign against health reform. ...
Even supporters of health reform are somewhat surprised by the right’s apparent inability to come up with real cases of hardship. Surely there must be some people somewhere actually being hurt by a reform that affects millions of Americans. Why can’t the right find these people and exploit them?
Sophistry, a concept taught by the ancient Greek philosophers in order for a rhetorician to recognise spurious logic and arguments, is alive...See All Comments Write a comment
The most likely answer is that the true losers from Obamacare generally aren’t very sympathetic. For the most part, they’re either very affluent people affected by the special taxes that help finance reform, or at least moderately well-off young men in very good health who can no longer buy cheap, minimalist plans. Neither group would play well in tear-jerker ads.
No, what the right wants are struggling average Americans, preferably women, facing financial devastation from health reform. So those are the tales they’re telling, even though they haven’t been able to come up with any real examples.
Hey, I have a suggestion: Why not have ads in which actors play Americans who have both lost their insurance thanks to Obamacare and lost the family farm to the death tax? I mean, once you’re just making stuff up, anything goes.

Saturday, February 08, 2014

'The Media's Disastrous Coverage of the CBO Report'

Friday, February 07, 2014

Paul Krugman: Health, Work, Lies

The CBO's report on Obamacare is --surprise -- being misrepresented:

Health, Work, Lies, by Paul Krugman, Commentary, NY Times: ... On Tuesday, the budget office released a report on the fiscal and economic ... effects of the Affordable Care Act. ...
The budget office has now increased its estimate of the size of these effects. It believes that health reform will reduce the number of hours worked in the economy by between 1.5 percent and 2 percent, which it unhelpfully noted “represents a decline in the number of full-time-equivalent workers of about 2.0 million.”
Why was this unhelpful? Because politicians and, I’m sorry to say, all too many news organizations immediately seized on the 2 million number and utterly misrepresented its meaning. For example, Representative Eric Cantor, the House majority leader, quickly posted this on his Twitter account: “Under Obamacare, millions of hardworking Americans will lose their jobs and those who keep them will see their hours and wages reduced.”
Not a word of this claim was true. The budget office report didn’t say that people will lose their jobs. It declared explicitly that the predicted fall in hours worked will come “almost entirely because workers will choose to supply less labor”  ... Oh, and because labor supply will be reduced, wages will go up, not down.
We should add that the budget office believes that health reform will actually reduce unemployment over the next few years. ...
So was Mr. Cantor being dishonest? Or was he just ignorant of the policy basics...? It doesn’t matter — because even if it was ignorance, it was willful ignorance. Remember, the campaign against health reform has, at every stage, grabbed hold of any and every argument it could find against insuring the uninsured, with truth and logic never entering into the matter.
Think about it. We had the nonexistent death panels. We had false claims that the Affordable Care Act will cause the deficit to balloon. We had supposed horror stories about ordinary Americans facing huge rate increases, stories that collapsed under scrutiny. And now we have a fairly innocuous technical estimate misrepresented as a tale of massive economic damage.
Meanwhile, the reality is that American health reform — flawed and incomplete though it is — is making steady progress. No, millions of Americans won’t lose their jobs, but tens of millions will gain the security of knowing that they can get and afford the health care they need.

Tuesday, January 07, 2014

'What Happened to US Life Expectancy?'

life expectancy at birth

More here.

Saturday, December 14, 2013

'US Ranks Near Bottom in Efficiency of Health Care Spending'

It's even worse for women:

US ranks near bottom among industrialized nations in efficiency of health care spending. EurekAlert: A new study by researchers at the UCLA Fielding School of Public Health and McGill University in Montreal reveals that the United States health care system ranks 22nd out of 27 high-income nations when analyzed for its efficiency of turning dollars spent into extending lives.
The ... U.S.'s inferior ranking reflects a high price paid and a low return on investment. For example, every additional hundred dollars spent on health care by the United States translated into a gain of less than half a month of life expectancy. In Germany, every additional hundred dollars spent translated into more than four months of increased life expectancy.
The researchers also discovered significant gender disparities within countries.
"Out of the 27 high-income nations we studied, the United States ranks 25th when it comes to reducing women's deaths," said Dr. Jody Heymann, senior author of the study and dean of the UCLA Fielding School of Public Health. "The country's efficiency of investments in reducing men's deaths is only slightly better, ranking 18th." ...
"While there are large differences in the efficiency of health spending across countries, men have experienced greater life expectancy gains than women per health dollar spent within nearly every country," said Douglas Barthold, the study's first author...

'A Health Care Mystery Explained'

Paul Krugman:

A Health Care Mystery Explained: Ezra Klein is puzzled ... by Republican hypocrisy on health care. For many years the GOP has advocated things that are supposed to bring the magic of the marketplace and individual incentives to health care: higher deductibles to give people “skin in the game”, competition among private insurers via exchanges — competition that would include reducing costs by limiting networks — and, of course, for cuts in Medicare. Now the GOP complains bitterly that some Obamacare policies have high deductibles, that it relies on the horror of exchanges, that some networks are limited, and that there are cuts in Medicare.
Klein suggests that Republicans are really upset by other aspects of Obamacare, but are going after the easy targets even though they’re attacking their own ideas. ... I suspect that he knows that the issue is both bigger and simpler than he says. ...
The purpose of most health care reform is to help the unfortunate — people with pre-existing conditions, people who don’t get insurance through their jobs, people who just don’t earn enough to afford insurance. Cost control is also part of the picture, but not the dominant part. ...
And here’s the thing: Republicans don’t want to help the unfortunate. They’ll propound health-care ideas that will, they claim, help those with preexisting conditions and so on — but those aren’t really proposals, they’re diversionary tactics designed to stall real health reform. ...
Hence the rage of the right. Here they were, with a whole raft of ideas they could throw out, like chaff thrown out to confuse enemy radar, to divert and confuse any attempt to actually provide insurance to the uninsured. And those dastardly Democrats have gone ahead and actually incorporated those ideas into real reform.
Once you realize this, you also realize that people who warn that by opposing Obamacare Republicans are undermining their own proposals are missing the point. Yes, the Ryan plan to privatize Medicare looks a lot like Obamacare — but Ryan comes to Medicare not to save it, but to bury it, so the question of whether his plan could work is irrelevant.
There’s no mystery here; it’s just top-down class warfare as usual.

Friday, November 29, 2013

Paul Krugman: Obamacare’s Secret Success

Bending the cost curve:

Obamacare’s Secret Success, by Paul Krugman, Commentary, NY Times: The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs. ...
So, how’s it going? ... Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic .... Since 2010, when the act was passed, real health spending per capita ... has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is the still-depressed economy, which might be causing people to forgo expensive medical care. But this explanation turns out to be problematic in multiple ways. ...
A better story focuses on what appears to be a decline in ... expensive new blockbuster drugs, even as existing drugs go off-patent and can be replaced with cheaper generic brands. ... But since drugs are only about 10 percent of health spending, it can only explain so much.
So what aspects of Obamacare might be causing health costs to slow? One clear answer is the act’s reduction in Medicare “overpayments”... A less certain but likely source of savings involves changes in the way Medicare pays for services. The program now penalizes hospitals if many of their patients end up being readmitted soon after being released — an indicator of poor care — and readmission rates have, in fact, fallen substantially. Medicare is also encouraging ... “accountable care,” in which health organizations get rewarded for overall success in improving care while controlling costs.
Furthermore, there’s evidence that Medicare savings “spill over” to the rest of the health care system...
And the biggest savings may be yet to come. The Independent Payment Advisory Board, a panel with the power to impose cost-saving measures (subject to Congressional overrides) if Medicare spending grows above target, hasn’t yet been established, in part because of the near-certainty that any appointments to the board would be filibustered by Republicans yelling about “death panels.” Now that the filibuster has been reformed, the board can come into being.
The news on health costs is, in short, remarkably good..., health reform is starting to look like a bigger success than even its most ardent advocates expected.

Monday, November 25, 2013

Paul Krugman: California, Here We Come?

Obamacare can work:

California, Here We Come?, by Paul Krugman, Commentary, NY Times: It goes without saying that the rollout of Obamacare was an epic disaster. But what kind of disaster was it? Was it a failure of management, messing up the initial implementation of a fundamentally sound policy? Or was it a demonstration that the Affordable Care Act is inherently unworkable? ...
Well, your wish is granted. Ladies and gentlemen, I give you California.
Now, California isn’t the only place where Obamacare is looking pretty good. A number of states that are running their own online health exchanges instead of relying on HealthCare.gov are doing well. ...
California is, however, an especially useful test case. First of all, it’s huge: if a system can work for 38 million people, it can work for America as a whole. Also, it’s hard to argue that California has had any special advantages other than that of having a government that actually wants to help the uninsured. ...
For one thing, enrollment is surging. ... To work as planned, health reform has to produce a balanced risk pool — that is, it must sign up young, healthy Americans as well as their older, less healthy compatriots. And so far, so good: in October, 22.5 percent of California enrollees were between the ages of 18 and 34, slightly above that group’s share of the population.
What we have in California, then, is a proof of concept. Yes, Obamacare is workable — in fact, done right, it works just fine.
The bad news, of course, is that most Americans aren’t lucky enough to live in states in which Obamacare has, in fact, been done right. They’re stuck either with HealthCare.gov or with one of the state exchanges, like Oregon’s, that have similar or worse problems. Will they ever get to experience successful health reform?
The answer is, probably yes. ...
There will also probably be growing use of workarounds — for example, encouraging people to go directly to insurers. This will temporarily defeat one of the purposes of the exchanges, which was to make price comparisons easy, but it will be good enough as a short-term patch. And one shouldn’t forget that the insurance industry has a big financial stake in the success of Obamacare, and will soon be pitching in with big efforts to sign people up.
Again, Obamacare’s rollout was a disaster. But in California we can see what health reform will look like, beyond the glitches. And it’s going to work.

Monday, November 18, 2013

'The Party of Practical Reform'

David Warsh on Republican opposition to the Affordable Care Act:

One Simple Step: ... What accounts for the ferocity of the opposition to the individual mandate as a means of assuring that all citizens are medically insured? What’s at stake here, I think, is the Republican Party’s wish to be seen as the party of reform. Traditionally, conservatives in US politics have been those who seek to defend the status quo, good and bad, whatever it is, while reformers are those who promise to improve matters, one way or another. Ronald Reagan was the master of these traditional conservatives, content as he was to affirm the achievements of the New Deal and the Second World War, but ready to insist that they had gone far enough, at least for a time.
It was only after Reagan left office that young Republicans eager to occupy the White House sought to present themselves as the party of reform, House speaker Newt Gingrich with his “opportunity society,” George W. Bush with his “ownership society.” These reforms had to do mainly with curtailing or eliminating altogether measures that had been adopted in the past, the Social Security retirement system chief among them, in the name of aggregate economic efficiency and growth.
The individual health insurance mandate is an invention of those times. It was proposed twenty-five years ago by Republican strategists at the Heritage Foundation, a conservative Washington think-tank, partly as a means of dealing with the problem of those who cannot obtain or cannot afford medical insurance. Essentially, it was a public health measure, tantamount to creating a new personal responsibility to have a doctor and, presumably, listen to him or her to some degree (don’t drink those half-gallon sodas).
Massachusetts Republican governor Mitt Romney put the individual mandate into practice in 2005 as a step toward a presidential campaign. But in 2008 the Democrats wrested the reform impulse away from the Republicans and, In 2010, passed the measure themselves. The bitter mood of the present day has everything to do with whether the Democrats or the Republicans are to be viewed going forward as the party of practical reform. ...

Thursday, November 14, 2013

'The Backbones of Banana Slugs'

Robert Reich:

Having the Backbone to Set Minimum Standards for Health Insurance: Democrats are showing once again they have the backbones of banana slugs.
The Affordable Care Act was meant to hold insurers to a higher standards. So it stands to reason that some insurers will have to cancel their lousy sub-standard policies.
But spineless Democrats (including my old boss Bill Clinton) are caving in to the Republican-fueled outrage that the President “misled” Americans into thinking they could keep their old lousy policies — and are now urging the White House to forget the new standards and let people keep what they had before.
And some congressional Republicans are all too eager to join them, and allow insurers to offer whatever crap they were offering before...