Pursuit of Truthiness

my gut tells me I know economics

Archive for the ‘Politics’ Category

The Lancet on Medicare for All: Optimistic Yet Depressing

leave a comment »

This Lancet article gives an optimistic but plausible take on what would happen to health spending if we expanded the current version of Medicare to cover all Americans: a 13% drop in health spending.

Why Optimistic

The big problem I see in the article is that it claims to be evaluating what would happen if we passed the Sanders Medicare for All proposal, which involves changing current Medicare in a way that would make it much more expensive- removing coinsurance and deductibles. Removing cost-sharing would increase utilization for most everyone, not just people who are currently uninsured or “underinsured” (which they count at a combined 79 million); studies on Medigap insurance suggest this could raise spending 33% relative to standard Medicare. The Lancet study ignores this, but it would turn their predicted 13% spending reduction into a nearly 20% spending increase.

Why Depressing

Still, I like having a study like this around, as it gives a clear presentation of what one version of Medicare for All might look like and where various savings and costs might come from. The depressing part is that even if all of their optimistic projections are true, and if a giant reform like Medicare for All actually happened, America would still have by far the highest health care spending in the world, with at-best average results. The latest OECD data shows the US spending 16.9% of GDP on healthcare, with Switzerland in a distant second place spending 12.2%. If Medicare for All, the biggest reform of the US health care system since at least 1965 and possibly ever, actually worked as predicted here, we would be spending 14.7% of GDP on health care- still far more than Switzerland or anywhere else (which makes sense as Medicare is costly by international standards). The article doesn’t put their mortality estimates into life expectancy terms, but the 68000 fewer annual deaths they predict represents a 2.4% drop; a 2.4% increase in life expectancy would bring us from 78.6 years to 80.5 years, still on the low end for rich countries.

This shows how our problems are bigger than just insurance and health financing, but even ‘just’ fixing the financing part (either with M4A or any other major reform) is unlikely.

Why It Won’t Happen

The authors argue that Medicare for all is politically feasible because, under their somewhat optimistic assumptions, the average American saves some money, while the average doctor and hospital roughly breaks even (Medicare generally pays less than private insurance but more than Medicaid and charity care), with the savings coming from lower administrative costs, lower fraud, and lower pharmaceutical prices. But I think this misreads the politics; while the Median Voter Theorem can be a good first approximation, the US political system tends to favor the well-off, special interests, and those who trying to maintain the status quo rather than change it. The paper itself makes clear who some of the losers from Medicare for All would be: private insurers, pharmaceutical companies, doctors and hospitals with a higher-than-average share of privately insured patients, and most people who spend a less-than-average share of their income on health care (which higher-income people tend to do; they also vote at higher rates). Further, “936,000 administrative positions and 746,600 positions in the health-care insurance industry are estimated to become redundant”. Many influential groups would suffer concentrated costs that would motivate dedicated lobbying effort against, while the largest benefits would be concentrated among the ~10% of Americans who are uninsured, who tend to be relatively poor. The ACA was a much smaller reform that did much more to buy off or otherwise placate most of these interest groups, and it still barely passed and lead to a huge political backlash, a lesson that at least some major relevant political figures took to heart.

Written by James Bailey

February 18, 2020 at 2:03 pm

The Long Tail of Criticism

with one comment

One of the many bizarre features of our current political and cultural moment is that every side feels like they’re losing.

One of the generally wonderful features of the internet is the Long Tail– lower costs of search distribution have made it easier to find things that were previously obscure, or didn’t exist at all in mediums like TV, radio, and print publishing that had relatively high fixed costs and strict gatekeepers.

But I’m realizing there is a dark side to this Long Tail feature of the internet- the Long Tail of Criticism. No matter how small or obscure a group is, they have been criticized somewhere on the internet. A group like economists, psychologists, or English professors, who number at most in the low hundreds of thousands, have now been the subject of literally hundreds of critical articles. In politics, people can branch out beyond criticizing Democrats and Republicans to complain about ever-smaller groups like libertarians, Bernie Sanders supporters, “the alt-right”, or fans of whatever public intellectual you don’t like.

Unlike with the classic Long Tail phenomenon where the growth in niche products comes at the expense of mainstream ones, the growth in niche criticism seems to coincide with a near-constant barrage of criticism at large/mainstream groups (genders, races, religions, nationalities, major political parties). Social media seems to ensure that critical pieces reach those they target, if nothing else because members of targeted groups fell the need to denounce them; Twitter is a spectacular engine for making sure people let you know the dumbest or most offensive thing anyone said today so that they can tell you how dumb or offensive it was.

Because people tend to identify more strongly with the smaller groups they are a part of, this Long Tail criticism may be felt more strongly. Sometimes it starts to seem like the internet is bent on attacking the specific groups I identify with, but probably people in every group feel the same way.

I’d love to hear from anyone who thinks “actually, my group is winning and people on the internet love us”. You must be a cat.

Cats heart

Written by James Bailey

May 21, 2018 at 10:05 am

ACA Repeal- Is There Any Safe Way Out?

leave a comment »

It’s not the first time I’ve thought so, but it now looks like efforts to repeal most or all of the ACA are now well and truly dead, and Republicans are wondering what to do instead.

The option currently on the table is the so-called “skinny repeal” of the ACA that repeals only the individual and employer mandates, leaving the rest in place. I haven’t said much about the repeal efforts so far, partly because I don’t think the economics of the issue are likely to change minds on either side. But the “skinny repeal” is one case where the effects are a bit different than you might think at first.

It might seem like a “skinny repeal” is a compromise position between full repeal and no repeal, and so it would have effects on premiums, the number of uninsured, and other outcomes of interest that are in between the two. But in fact, it is likely that repealing  the individual mandate alone would be worse than either full repeal or no repeal, because it more likely to cause an adverse selection death spiral.

Basically, pre-ACA in most states, individual insurance was cheap if you were healthy but hard to get if you were sick. With the ACA insurers had to sell to everyone (sick and healthy) at the same price, so healthy people were forced to pay more but sick people benefited. Take away only the individual mandate but leave the other parts that make insurance more expensive and healthy people leave the market; when only sick people buy insurance then average costs go up, so premiums go up, so more healthy people leave… and soon insurers will just leave the market because they are losing so much money, so both healthy and sick people are worse off.

I can see the political appeal of doing guaranteed issue but dropping the individual mandate; it sounds like a compromise, and dropping guaranteed issue sounds mean (you must hate sick people) while dropping the mandate sounds nice (freedom!). But it is likely to be the worst of both worlds. Several states have found this out the hard way, including Massachusetts (in a fascinating political twist, this was actually why Romneycare really was different from and better than Obamacare).

If Republicans really want to kill off part of Obamacare in order to take a scalp and say with a somewhat straight face they kept their repeal promise, the employer mandate is much safer to repeal on its own; it might actually strengthen the exchanges by pushing more healthy people on to them, and it was a bit bizarre and counterproductive in the first place from the economist’s perspective. Just repeal the employer mandate, claim victory, and go home. Or, while I’m dreaming, turn to reforming the supply side of health care instead of messing around with insurance.

 

 

Written by James Bailey

July 27, 2017 at 4:14 pm

Stop Feeding the Trolls

with one comment

So many of the problems of this decade could be fixed by people learning not to feed the trolls.
Most obviously, internet comment sections would only be half as terrible as they are now.
Donald Trump wouldn’t have got the nomination without the huge amount of free airtime from news channels covering his latest outrageous statement.

Growing political polarization is partly due to how the straw man / weak man fallacy is amplified by trolls. Many actual news stories are about the outrageous thing some random Twitter egg on the other side said.
Terrorism would be cut in half if shooting a bunch of innocent people weren’t the quickest way to get famous.
….
I just wish there were an easy way to fix this without censorship. The necessary culture change sounds incredibly difficult, but I hope that with time we will learn how to adapt to social media and 24 hour news.

For a start, I plan to never do terrorists’ jobs for them by sharing stories of their terror. I encourage my friends to do likewise.

Written by James Bailey

July 22, 2016 at 3:12 pm

Open Borders and the Welfare State: Must We Choose?

with 2 comments

“You can’t have both open borders and a welfare state” –Milton Friedman

Friedman’s concern is that immigrants are disproportionately poor, and would overwhelm the resources of the welfare state.

Friedman’s dictum has been widely accepted across the political spectrum. Modern liberals might like to have both open borders and a welfare state, but have settled for just a welfare state, partly out of this concern. Conservatives have used the trade-off to argue against both immigration and the welfare state, though neither is a goal many hold dear these days. A few people, mostly libertarians, actually want open borders and see the trade-off as an argument against the welfare state- noting that the welfare state isn’t really pro-poor if it supports the relatively rich first-world poor while keeping others trapped in third-world poverty.

But I haven’t seen many people question Friedman’s welfare/immigration trade-off in principle, except for open borders advocates noting that immigrants can be legally excluded from welfare (in fact to some extent they already are in the US).

But consider the United States- we have open borders within the country, from Maine to Hawaii. US welfare programs are largely administered at the state and local level, and the generosity of these programs varies widely (see Medicaid expansion, for instance). I’ve been all over the US, and I’ve heard many people complain about welfare being too generous, and worry about immigrants coming here just to get on welfare. But I can’t say I’ve ever heard someone complaining about people migrating from other US states to get on welfare in their state, even in a relatively generous state like New York or California.

Am I just living in a bubble, or do people really never worry about this? And if so, what does this imply for the Friedman immigration/welfare trade-off?

Written by James Bailey

November 7, 2015 at 6:45 pm

Win-Win Medicaid Reform

leave a comment »

In my recent post on a way forward after a ruling for the plaintiffs in King vs Burwell, I suggested Republicans use the opportunity to do a sort of Medicaid privatization along the lines that Arkansas has done. While my post was just obsoleted by the fact that the Supreme Court ruled the other way, I now think that the case for states to do their own reforms is even stronger.

In order to make the ACA Medicaid expansion politically palatable for Republicans, Arkansas did a sort of privatization of Medicaid- using Medicaid funds as “premium assistance” to allow recipients to choose a private plan from the ACA exchanges.

While the Obama administration wasn’t crazy about this idea, they (and some progressives) decided it was better than no Medicaid expansion, and so granted a waiver from the usual Medicaid rules to allow this to proceed.

There are some real potential problems with the Arkansas full privatization approach.

First, Arkansas hopes to save money- or at least not lose it- by privatizing.  This is actually a condition of the federal waivers allowing their experiment. This may or may not work out- private plans might operate more efficiently and reduce costs through cost-sharing, but they also make higher payments to providers.

Second, while Medicaid is in some ways bad insurance (because many providers do not accept it), in one way it is better for recipients than just about any private plan- it requires little to no cost-sharing. In many states, Medicaid plans have a $0 deductible and $0 co-pays for all covered services. Federal Medicaid rules prevent deductibles and co-pays from getting anywhere near as high as normal plans, the thought being that Medicaid recipients are too poor to afford them.

These costs, of course, are offset by benefits- especially the greater access to providers through private plans. Do the benefits outweigh the costs? After years of studying what happens in Arkansas, we will get some idea of whether privatization is more or less expensive than traditional Medicaid, and of whether the provider-acceptibility benefits outweigh the poor-people-paying-deductibles costs. But we don’t have to wait to see what the average person thinks- we can just let each individual choose.

Tell each Medicaid recipient that they can either get traditional Medicaid, or choose a plan from the ACA exchange. If you are worried about how much this will cost the state budget, estimate how much traditional Medicaid spends per enrollee and limit the choice of exchange plans to those that cost less than that.

This is a win-win-win: taxpayers save money, Medicaid recipients that value traditional Medicaid’s low cost-sharing can keep their plans, and Medicaid recipients that are willing to put up with some cost-sharing in order to get providers to actually see them can do so.

This should have been bloody obvious. It took me months after hearing about Arkansas to think of it. But apparently people in Iowa are ahead of the curve, and seem to be doing exactly this.

After the King vs Burwell ruling, it is clear that the ACA exchanges are here to stay. It is time to stop trying to fight them and start seeing the incredible pro-poor, pro-market possibilities for reform they create.

Written by James Bailey

June 28, 2015 at 5:35 pm

How should Republicans respond to King v Burwell? The Judo solution for the ACA.

with 2 comments

Any time now the Supreme Court will rule on the legality of Affordable Care Act subsidies through federal health insurance marketplaces.

A ruling for the administration means we keep the status quo (barring some weird saving construction), so there is nothing for Republicans to respond to.

But what should they do if the court rules for the plaintiffs, and 37 states lose their ACA subsidies?

Cave

The caving option is to do a straight renewal of the subsidies; some Congressmen are discussing doing this at least temporarily. But this means giving up a great bargaining position.

Kick Over The Stool

The die-hard conservative option is to do nothing, and hope the ensuing chaos reflects worse on the Democrats. As Jon Gruber has said, the key components of the ACA stand together like a three-legged stool. Without the subsidies, the individual mandate becomes a cruel tax on the poor, and without the mandate (or if people choose to ignore it and pay the fine, as many will without the subsidies) guaranteed issue and community rating mean people can game the system (wait to sign up for insurance until you get sick), creating the mother of all adverse selection problems. If Democrats get more of the blame for the wreck that the health insurance system will become with ACA-minus-subsidies, then Republicans might get the votes to repeal the ACA entirely. But I doubt this would be the case.

One-for-One Trade

The more responsible solution is a compromise- reinstate the subsidies legislatively in return for getting rid of a different part of the ACA they find more offensive. But what would this be? Gruber is right that the major parts of the ACA hang together, and removing one major part by itself is worse than either repealing or keeping the whole thing. Removing only the individual mandate, or only guaranteed issue, or only community rating would be very bad ideas.

I think the employer mandate is the best candidate for one big piece that could be safely removed- and it is the one Democrats are unlikely to go to bat to fight (indeed, we’ve seen the absurd spectacle of the Obama administration trying to delay this part of their own health bill while Republicans sue them to implement it). But would this be such a big victory? It would help business and labor markets, but the employer-based system is still by far the largest alternative to government insurance, and politically it may be unwise for Republicans to weaken it- especially if they continue to attack the parts of the ACA that support the market for individual insurance.

One-for-Many Trade

Rather than killing one other big piece of the ACA in return for reinstating subsidies, Republicans could find more success by making many marginal changes to the ACA. Make the subsidies a bit less generous (it is kind of absurd that they currently go up to 400% of the poverty level), cut back a bit on the Medicaid expansion (as most Republicans at the state level have been doing anyway)- reduce Federal contributions a bit, and cut eligibility a bit. Allow a bit more rating in health insurance, especially for health behaviors that are partly in peoples control (like weight).

Add Instead of Subtract

Even better, in the unlikely event that Republicans are willing to spend this chance to do something constructive rather than go after a partial repeal, would be to move forward a new health policy proposal. This could be one of the oldie-but-goodie conservative health reform proposals, like making it easier to sell insurance across state lines, or equalizing the tax treatment of individual and employer insurance. It could be a random new proposal, like getting rid of innovation-hampering Certificate of Need laws. But, if I can be allowed to dream for a moment, they could take this chance to move forward the free-market elements of the ACA.

Judo Flip

The fact that many of the ACA ideas were first advanced by the conservative Heritage Foundation and enacted by Mitt Romney has become a political talking point for the left, but it wasn’t simply a coincidence or a big mistake. Before the ACA, the market for individual insurance was largely broken. It is a tough economic question how to apportion the blame for this across markets vs misguided government regulations- but the judgement of voters was clear, and the flaws of the market for individual insurance were a consistent impetus for left-wing solutions up to and including single-payer.

Despite the ACA’s many flaws, it has succeeded in making the market for individual insurance functional enough. Individual insurance could be more convenient, it could certainly be cheaper, but now it basically works. And this changes everything.

Why should the government operate a Medicaid program directly, providing insurance that many doctors refuse to take and that recipients hardly value, when for a similar cost they could give away vouchers for gold-level private insurance plans that doctors will actually accept? Arkansas realized this early on, and got permission from the feds to let Medicaid recipients choose real private plans, freeing them from a low-quality government monopoly.

Republicans should support this privatizing potential of the ACA, and change federal Medicaid rules to allow all states to do this. Or if they really want to push the envelope- and I’d want to study the Arkansas experience much more before supporting this- they could make vouchers for individual plans the new default for Medicaid, and require states to get waivers to do anything else. This would judo flip the ACA into a tool for a huge reduction in the role of government in health insurance.

Written by James Bailey

June 23, 2015 at 10:49 am