Entries Tagged as 'health care reform'

Health Mandates: OK For Perry, Not For Romney

June 23rd, 2011 at 12:07 am 15 Comments

I was watching the debate between Conn Carroll and Noah Kristula-Green yesterday morning and I was struck by a question that Noah posed to Carroll about Rick Perry’s prior support of a vaccine mandate for girls in Texas.

Noah asked Carroll why conservatives would overlook such a mandate while at the same time blasting Mitt Romney’s health care mandate.

Carroll appeared to be at a loss for words. He first attempted to say that Perry’s mandate affects fewer people and therefore would not be as much of an issue.

Actually, in 2006, the uninsured of Massachusetts represented 6.4 percent of the entire population. The other 93.6 percent were already insured. Romney’s reforms affected a much smaller group than Perry’s proposed requirement that all sixth grade girls receive a vaccine shot.

Furthermore, at the time, conservatives in Texas were greatly upset over Perry’s mandate. Social conservatives blasted Perry, arguing that his proposals promoted “sexual promiscuity.” Others questioned how much such a mandate would cost the state of Texas. Some legislatures were angry that Perry had circumvented the legislative process.

None of those criticisms can (or should) be levied at Romneycare. No, not even the cost factor — Romneycare was about 1.2 percent of the state budget in 2010. And far from “circumventing the legislative process,” Romneycare was a wonderful display of bipartisan cooperation.

So why does Carroll think Romney has a problem, but Perry doesn’t? Why has the Republican establishment been feverishly shopping for an anti-Romney?

Because Romney’s past health care reform reminds everybody of the Republican Party’s past support/acceptance of the individual mandate. The order of events goes a little something like this.

1. Republican leader/policy makers either supported the individual mandate or didn’t think much about it.

2. At the same time, talk radio/Fox News developed a culture of warrior opposition to anything that resembles a Democrat.

3. A Kenyan Socialist decided to adopt a Republican idea in his health care plan.

4. Talk radio/Fox News blasted the health care plan, while Republican leaders/policy makers scrambled to come out against the individual mandate.

5. All would be sound and well for these Republican leaders/policy makers, if this guy Mitt Romney, who is a walking embodiment of past Republican beliefs on health care, would just go away.


Weinergate Takes the Heat Off the GOP

David Frum June 4th, 2011 at 6:30 am 108 Comments

Did or did not a New York congressman send a photo of a man’s crotch to a Seattle college student?

That’s the question the American political elite has spent the past half-week debating. Silly? Degrading? Check and check. Yet this silly and degrading spectacle is having very serious real world consequences.

Consequence 1: Up until the underwear story, the Democrats were clobbering Republicans in the Washington messaging war. Republicans in the House of Representatives are demanding huge and immediate cuts in federal spending. They are threatening to force a default on federal obligations if they don’t get those cuts. Both the demand and the threat are hugely unpopular: the demand with ordinary voters, the threat with economic elites.

On May 24, the voters got a chance to speak in a special congressional election in western New York state. The district — NY 26 — had once been held by Jack Kemp. It was regarded as one of the safest Republican seats outside the South. This time, the Republican vote collapsed in an election whose main theme was the Republican budget and the cuts it implies for the popular Medicare and Medicaid programs.

The Democrats were looking forward to pounding the Medicare theme all summer. They need to do the pounding fast, before the Republican tactic of refusing to allow new borrowing pushes the federal government into insolvency sometime in August. They cannot afford to lose a day of airtime. Thanks to New York congressman Anthony Weiner, they have just lost a week.

Consequence 2: The big Democratic healthcare law is heading to a constitutionality challenge in the Supreme Court. With a 5-4 conservative majority on the court, many Democrats worry about the outcome of the case. Anthony Weiner had been leading a long-shot campaign to affect the result: demand that one of the five conservatives, Clarence Thomas, recuse himself from the case.

Weiner argued: Clarence Thomas’ wife works for a conservative advocacy group, collecting over $150,000 in salary. The conservative advocacy group opposes the healthcare law. Therefore Thomas has a conflict of interest in the matter and should not rule in the case.

It’s not really a very good argument. Mrs. Thomas will be paid exactly the same whether the healthcare law survives or is struck down. The Thomas household has no financial interest in the outcome of the case. Mrs. Thomas has expressed strong opinions — but who would argue that judge’s spouses are not allowed to express opinions? And does this apply to all spouses equally? For example: Alice Batchelder is chief judge of the U.S. federal court of appeals for the 6th circuit — a very important job. Her husband Wiliam Batchelder has been a member of the Ohio state legislature for 30 years, rising to Republican house leader. Nobody has ever suggested that Mr. Batchelder quit his job. Why is Mrs. Thomas any different?

So the Weiner argument is “out there.” Few Democrats will want to join the combative and abrasive Weiner in his anti-Thomas campaign. Nevertheless, many of them are quietly glad to see Weiner volunteering for the attack dog role. But as long as he is consumed by his own personal troubles, his anti-Thomas campaign goes silent.

Make no mistake: Weiner’s problems are all of his own making. When the underwear story broke over Memorial Day weekend, he had the option: tell the truth at once, no matter how embarrassing, and put the story behind him. Even in the worst case -yes, he sent the picture -it’s not as if any laws were broken. The woman who received the photo was not offended and has issued no complaint. Anthony Weiner would not be the first boorish and juvenile member of Congress in history, and he won’t be the last. Story closed.

Instead, Weiner issued a fog of evasive and absurd statements in a series of self-damning issues. He himself did the most to enlarge and extend the story.

He had his motives: He hopes to run for mayor of New York City in 2013, and so he wants to avoid putting on the record any admissions that could be used against him.

But what Weiner’s fellow Democrats see is that this silly underwear story -and Weiner’s fog-of-evasion strategy for dealing with the story -has cost their party airtime, momentum, and advantage. Why? One senior Democrat I know summed it all up, “Anthony has always been all about Anthony.”

Result: Weiner has done more to aid Republicans this week than anybody on the Republican side. And in a week where the two parties are locked in a struggle as serious and important as any issue since the U.S. went to war in Iraq, Republicans need all the aid they can get.

Originally published in the National Post.

Palin’s Mandate Hypocrisy

June 2nd, 2011 at 4:06 pm 65 Comments

On the day Mitt Romney formally announced his bid for the GOP presidential nomination, former Alaska Governor took a shot at his Massachusetts health care plan by criticizing government mandates.

RealClearPolitics reports:

‘[E]ven on a state level and a local level, mandates coming from a governing body, it’s tough for a lot of us to accept because we have great faith in the private sector and in our own families and in our businessmen and women in making decisions for ourselves,’ Palin said. ‘Not any level of government telling us what to do.’

And yet… even her home state of Alaska has a few mandates of its own:

  • Alaska requires that you must have a copy of your policy, certificate of self-insurance, or identification card in your immediate possession when you are driving a motor vehicle.
  • If you are involved in an accident that results in bodily injury, death, or property damage exceeding $501, you will be required to show proof of insurance.
  • You must carry limits of at least $50,000 per person, $100,000 per accident, and $25,000 for property damage.
  • Alaska law requires that all companies make a written offer of Uninsured/Underinsured Motorists Coverage.

Hospitals: The New Teachers’ Unions?

David Frum May 31st, 2011 at 8:26 am 18 Comments

Are hospitals the new public-school teachers’ unions?

From the New York Times today:

More generally, [hospitals] are apprehensive about Medicare’s plans to reward and penalize hospitals based on untested measures of efficiency that include spending per beneficiary.

A major goal of the new health care law, often overlooked, is to improve “the quality and efficiency of health care” by linking payments to the performance of health care providers. The new Medicare initiative, known as value-based purchasing, will redistribute money among more than 3,100 hospitals.

Medicare will begin computing performance scores in July, for monetary rewards and penalties that start in October 2012.

The desire to reward hospitals for high-quality care is not new or controversial. … However, adding in “efficiency” is entirely new and controversial, as no consensus exists on how to define or measure the efficiency of health care providers.

One of the truest and most powerful conservative ideas of the 1980s and 1990s was to stop measuring our commitment to “education” by measuring “inputs” (spending per student, class-size)  and instead to measure “outputs” (student learning). Schools and teachers resisted, but were rightly over-ruled. Now the country is heading to a re-enactment of this debate with health. Here’s hoping that Republicans can overcome both political opportunism and also the temptation of donations from the hospital industry and again adhere to the right side of the issue.


More Businesses Opting Out of Obamacare

May 18th, 2011 at 11:06 am 33 Comments

Last week, pills the Obama administration approved over 200 new waivers for the Democrats’ health reform bill, more proof that businesses realize the plan is fundamentally flawed.

To say that Obamacare is fundamentally flawed is like saying Donald Trump would probably not be welcome at the Harvard Faculty Club (then again if he gave them an endowed chair, they might make him a lifetime member).

That companies and unions need to  request waivers of the requirements for a $750,000 level of coverage and comprehensive services including vision, dental, and other services when they currently provide much lower levels of health insurance for their employees illuminates the central problem with the law. To paraphrase Jimmy McMillan: the cost is too damn high.

Most small companies can’t afford to provide comprehensive fee for service, unmanaged health insurance to their employees. If business can’t provide it now, the unaffordability of comprehensive insurance will be transferred to the taxpayers. Subsidies will be provided to the new insurance exchanges and we’ll have to borrow trillions of dollars more in the coming years to pay for it.

If Obamacare succeeds in its essential goal of providing comprehensive health insurance to another 30 million people, companies will be foolish not to put their employees into the newly created plans. Certainly all the companies and organizations that have requested waivers will be doing exactly that. They can’t afford comprehensive insurance now and won’t be able to afford it in 2014.

The political debate over Medicare’s future is focused on the cost of care yet the Obama administration has been silent about controlling costs for the currently uninsured under-65 cohort. The whole focus of Obamacare is on finding money to insure that group and not on controlling the costs of the care they will receive.  These costs are another burden soon to be shouldered by a nation deep in debt.


Will Pawlenty Defend His Health Care Record?

David Frum May 12th, 2011 at 5:21 pm 19 Comments

A question for Tim Pawlenty at the next Republican debate.

“When you became governor in 2003, doctor Minnesota had under 395,000 citizens without health insurance. In 2008, the last year before the recession struck, Minnesota had 446,000 citizens without health insurance. Do you regard that as an important failure of your administration? If not, why not?”


Journal’s Romneycare Attack Misses the Mark

David Frum May 12th, 2011 at 1:19 pm 23 Comments

Today’s Wall Street Journal savagely criticizes Mitt Romney’s health care record.

Let’s try to reverse-engineer the editorial to see what the editors believe Romney should have done instead.

When Mr. Romney took office in 2003, the state was already enforcing public utility-style regulation of insurers for premiums and multiple benefit mandates. The resulting distortions were increasing rates fast, along with the natural increases from good but expensive Massachusetts medicine.

In other words: rate regulation of insurers is bad. Using regulation to hold rates down causes rates to go up instead.

The conceit was that a universal reform would cover everyone and all but pay for itself by reorganizing the state’s health-care finances

Universal coverage: bad. Universal coverage will force costs up.

In the name of personal responsibility, Mr. Romney also introduced the individual mandate, first in the nation, requiring everyone to buy coverage or else pay a penalty. Free riders, he said, transferred their own costs to others, either through higher premiums or taxes. This is the same argument the Obama Administration is now using to justify the coercion of the individual mandate in the federal courts.

Individual mandates: bad. The “free rider” argument only conceals state coercion.

The people who don’t buy coverage though they can afford it aren’t really a major fiscal problem …. People who are priced out of coverage require subsidies—so in practice the logic of the individual mandate is that it is a government mandate too.

Subsidies to cover private health insurance for those who cannot afford it: bad. They cause government to grow.

Entitlements automatically grow and grow, and then the political class begins to make decisions that used to be left to markets and individuals.

Political decisions about health coverage: bad. Instead the decision about who should not be covered should be left to markets: if the market does not assign you enough money for coverage, you should not have coverage.

The only good news we can find is that the uninsured rate has dropped to 2% today from 6% in 2006. Yet four out of five of the newly insured receive low- or no-cost coverage from the government.

A decline in the number of the uninsured is good if and only if they receive no public aid. Then it becomes bad.

The assumptions encoded in the Journal editorial make nonsense of the Journal‘s conclusions.

Once government takes on the direct or implicit liability of paying for health care for everyone, the only way to afford it is through raw political control of all medical decisions.

Mr. Romney’s refusal to appreciate this, then and now, reveals a troubling failure of political understanding and principle. The raucous national debate over health care isn’t about this or that technocratic detail, but about basic differences over the role of government. In the current debate over Medicare, Paul Ryan wants to reduce costs by encouraging private competition while Mr. Obama wants the cost-cutting done by a body of unelected experts like the one emerging in Massachusetts.

But of course the Paul Ryan plan for Medicare does feature a mandate – which is supposedly bad, according to the WSJ. And the Romney plan for Massachusetts did encourage private competition – and yet somehow failed to control costs, which shouldn’t happen according to the WSJ.

The WSJ wants to argue that “it’s not so much the money as the principle of the thing.” But of course the real evil as diagnosed by the Journal is precisely the money. So long as less money is spent, as Ryan proposes, then mandates cease to be a problem for the WSJ. If more money as spent, as occurred under Romney, then private market competition ceases to be an important benefit for the WSJ.

Put bluntly, it’s not a very attractive argument.

And it’s an argument that Mitt Romney could decisively refute today if he wished. He would begin: “Unlike the Wall Street Journal, I do not think that leaving millions of people uninsured is a good way to hold healthcare costs down.” You could even describe such an argument as “no apologies”.


Can Mitt Move Beyond Romneycare?

May 11th, 2011 at 8:13 am 37 Comments

It’s perhaps hard not to feel some sympathy for the situation Mitt Romney has found himself in. By the close of the 2008 Republican primary, he was seen as the standard-bearer of conservatism, picking up the support of the likes of Ann Coulter and Jim DeMint. Yet now, he finds himself attacked as a lefty RINO and utter traitor to the conservative cause—for Romneycare, a measure he backed in 2006. Romney’s record as governor did not change from 2008 to 2011 (he stopped being governor in 2007), but the perception of the conservative commentariat has. Notoriously derided as a flip-flopper, Romney has now found that some in the right-leaning punditocracy have flip-flopped on him. And these attacks on Romney emphasize not merely how the partisan optics have changed since 2008, which they have, but often criticize his politics on a much deeper, ideological level.

The Massachusetts health-care law has become an albatross around the neck of the man who could maybe almost be the Republican front-runner. The passage of Obamacare made health-care reform a central litmus-test issue for grassroots conservatives. The fact that the Obama White House boasts of similarities between Romney’s reforms and Obamacare is not going to endear Republicans to Romney.

From the perspective of free-market conservatism, the reforms Romney sponsored have not been a resounding success. The rate of health-care uninsurance in the Bay State has dropped significantly, which is good (over 98% of the Commonwealth has health insurance). Wait times have potentially increased a little, though trends for longer delays for receiving care were in place before Romneycare passed. But costs are exploding. Romney’s Democratic successor, Deval Patrick, is now looking to create a regulatory infrastructure to control insurance rates (and thereby doctor pay) as a way of coping with these skyrocketing bills. With unchecked Democratic power in Massachusetts, further state control of health-care delivery may be only just around the corner. Unless further reforms are made, Romney’s health-care reform may prove to be quite the shot in the arm for private health-care in Massachusetts: a lethal injection.

So Romney’s big speech on Thursday may prove to be a necessary but also somewhat desperate gamble. Faced with the (perhaps unfair) public perception that he is an opportunist who will shift in whatever direction may benefit him the most, Romney seems to have decided that he cannot utterly repudiate the Massachusetts health-care law. The fact that he has spent so many years defending these reforms would give a repudiation now an especially high political price.

Either a total defense of Romneycare or a total repudiation of it could damage his image in the eyes of grassroots conservatives and potential swing voters. Successfully resolving the health-care issue could help scrape away some of the veneer of artificiality so many voters have doubts about while also burnishing his conservative bona fides. Here are some thoughts about what Romney might want to achieve politically in this address:

Make clear the distance from Obamacare: Romney may attack Obamacare as inefficient, destructive, problematic, and so forth, but he should particularly emphasize those features of it (such as the 50-state mandate) that differ from the Massachusetts reforms. Attacking Obamacare is bound to win applause from righties. But Romney’s attacks will ring hollow if he has not posed enough plausible distance between his policies in Massachusetts and those of Obama.

Build on the strengths of Romneycare: There are some positive, free-market features of the Massachusetts health-care law, which the Heritage Foundation praised. Romney could tout those.

Show technical expertise: The ability to maneuver through complex bureaucracies will be key for any potential Republican administration. Romney has a wealth of experience in running large organizations and a considerable proficiency with the details of policy. His speech on Thursday can showcase those skills. This speech doesn’t have to be—and probably shouldn’t be—a total wonkfest, but a suggestion of Romney’s wonky tendencies would play to his strengths as a credible, center-right technocrat.

Move the debate forward: This is perhaps the most important political objective for the speech. If Romneycare dominates his Republican primary narrative (including both his campaign and what is said about his campaign), Romney loses. Game over. In this speech, Romney needs to change the topic to present a forward-looking approach to federal health-care reform (which he looks likely to do). Romney knows that even the all-out repeal of Obamacare will not be enough for our nation’s health-care system, which does need reform. Moreover, every serious Republican candidate is probably going to talk about repealing Obamacare. By focusing on a specific set of policies for a way forward, Romney can distinguish his candidacy from the rest of the pack. For his political survival, Romney must make this campaign about the future.

Moreover, the right does need creative ways of trying to reform the health-care system to make it more affordable and efficient. Such a tangled web of government/non-profit/for profit institutions has been set up that any reform will have to be as careful as possible to avoid any drastic and unpleasant unintended consequences. By focusing on the future of health-care reform (both for the private market and for Medicare, Medicaid, and other government programs), Romney can keep the past from sucking all the air out of present debates.

This could be a pivotal speech for Romney. If Romney can prove his viability on the health-care issue, he could start to solidify a core of support. If he cannot resolve the public perception of his health-care policies, he may find himself limping along and find the path to the nomination that much harder. Moments of testing can make or break a candidacy, and this may be one such moment.

Originally published at A Certain Enthusiasm.


Is the GOP Serious About Means-Testing?

David Frum April 19th, 2011 at 10:15 pm 26 Comments

Can we get beyond the welfare state?

Yuval Levin argued yes in an article in National Affairs.

I argued no, here.

Now Reihan Salam at NRO joins the discussion.

Reihan’s contribution is to defend the concept of means-testing social benefits. He points out that Australia seems to have achieved positive results by means-testing. What’s wrong then with Yuval Levin championing (and Paul Ryan legislating) the means-testing of Medicare?

Some answers to Reihan.

1) This is not a debate about means-testing. The Paul Ryan plan does not means-test Medicare, with some getting Medicare in full, but others paying more. After the Ryan plan goes into full effect ten years hence, nobody will get Medicare as it currently exists. Everybody will get a voucher that falls more or less short of what is needed to buy a Medicare-like policy. The vouchers for the affluent will fall even further short than the vouchers for the poor. But the vouchers for the poor will fall short too.

2) Most welfare state programs are in fact means-tested, entirely uncontroversially. Not even Jesse Jackson thinks that everybody should get food stamps. Medicaid is means-tested. Section 8 is means-tested. Unemployment insurance is not precisely means-tested, but you only collect if you are out of work. Ditto for the federal subsidies for COBRA benefits contained in the 2009 stimulus. (Plus those subsidies can be taxed back later from people who return to highly paid work.) If there is a debate about means-testing these classic welfare programs, I don’t know who is on the other side.

3) Yet there are important social programs in the U.S. that are not means-tested. I’d be interested to hear which of the following Reihan and Yuval think should be means-tested: veterans benefits? home mortgage deductibility? farm programs? in-state college tuition? I agree that the American welfare state all too often redistributes upwards. One important reason for this upward-redistribution is that much of the “spending” in the federal welfare state takes the form of tax deductions and tax credits – and the Ryan plan is noticeably hazy about those.

4) It’s true that Australia does a good job of means-testing benefits. But there is one benefit that Australia confers on virtually everybody, with only some slight clawbacks from the more affluent. It happens to be the benefit that Americans are debating most intensely right now: health care. All Australians are guaranteed health insurance. Through a program called Medicare, as it happens. Old and young. Rich and poor. Everybody.

5) Meanwhile, on this side of the Pacific, Medicare spends an average of $12,000 per recipient. In the past, that cost has approximately doubled every 10 years. If that trend continues, today’s 54-year-olds – the first cohort to be affected by the Ryan plan – will face premiums averaging $48,000 per couple. Today’s 44-year-olds will face premiums averaging $96,000 per couple. Per year. And rising.

Perhaps those trends will slow. Let’s hope they do. But there is no way on earth that the typical American family – hell, that the bottom 80% of American families – can accumulate the savings over their working lives sufficient to buy Medicare insurance as it has been known to this date.

I’m all for ferocious cost-cutting within Medicare. I’m all for intensified competition. I liked the concepts in Ryancare back when they were still called Romneycare. But let’s face it: until those concepts start working so brilliantly effectively that Medicare costs actually drop, means-testing in Medicare is code for denying Medicare to many, many older Americans.

Is that what Yuval Levin and Reihan Salam want? I don’t believe it. But if it’s not what they want, this would be an excellent time to speak out – before this policy is publicly identified as the agreed policy of the conservative movement and the Republican party.


Obama Doubles Down on Price Controls

April 14th, 2011 at 7:31 am 16 Comments

President Obama has outlined a set of proposals for reducing the cost of Medicare. The White House assumes that empowering an independent panel to simply pay less for services will reduce the overall cost of care. On the surface this may seem a reasonable approach, help but in reality this won’t address the problem.

In fact, thumb it’s the same rationale that’s behind the sustainable growth rate: the program that’s the reason the “Doc Fix” has to be enacted every year or so. That program failed because while the payment per service was supposed to be reduced, the number of services continued to rise and hence overall cost continued to rise.

Let’s not forget that the political maneuvering around this issue is brutal and has left Congress completely unable to work a solution.  After all, physicians were scheduled to have a 29% reduction in overall Medicare payments but the recission was cancelled by Congress.  It’s always been rejected. The idea that this time around an independent payment commission will be immune from all political pressures and can hold the line on payments is wishful thinking at its most wildly optimistic.

The Ryan plan actually calls upon the basic idea of the Clinton health care plan of the 1990s. It employs the managed care model in which an insurance company is the intermediary between payers (in this case the federal government) and physicians and hospitals or other providers of care. This is the only model that has been shown to reduce health care expenditures (see health care spending in the mid-90s).

Admittedly, it’s not very popular but it is effective and it leads to improved care. Also, when well executed, it can be very popular with patients: Kaiser Health Plan has a superb patient satisfaction rating.

The Ryan approach has a chance of success since it makes patients extremely price sensitive, puts in local regulation of health care, and gives the insurance intermediary the incentive to keep costs low and thereby maximize their profits.

Give seniors the opportunity to define their health care plans, to have a financial stake in their care, and provide insurance companies the opportunity for both oversight of care and also the possibility of real competition for subscribers. This plan has a chance to work.

Why would the President’s plan for price controls work this time when they’ve never worked before?

Moreover, the Medicare shortfall will be about $37 trillion by 2050. How will a $430 billion reduction by 2023 and a $1 trillion reduction in the next decade cover a $37 trillion deficit?

Paul Ryan’s approach calls for a defined contribution for Medicare rather than a defined benefit. Of course this will cost individuals more than the defined benefit approach. But what’s the point of a defined benefit promised by a bankrupt nation that can’t afford the benefit?

The nation has now heard from both Republicans and Democrats that Medicare is a successful program.  This couldn’t be more wrong.   A successful program is a sustainable program. Employing price controls to control spending will be as successful as Prohibition.