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Archive for the ‘Politics’ Category

ACA Repeal- Is There Any Safe Way Out?

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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.

 

 

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Written by James Bailey

July 27, 2017 at 4:14 pm

Stop Feeding the Trolls

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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?

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“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

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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.

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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

The Real Media Bias

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The most common accusation I hear about media bias is of “the liberal media”. It is true that every poll shows an overwhelming majority of the US media to be liberal Democrats, and I think they would have to be superhuman to completely prevent this from biasing their reporting.

But there is an even stronger institutional imperative for the media- keeping their jobs. This means selling papers, or keeping ratings high, which in turn means telling readers what they want to hear. One of the most powerful biases coming out of this is “if it bleeds, it leads”. This bias is widely recognized, but people have not recognized the extent to which it counteracts liberal bias.
The classic “it bleeds” stories are about crime, terrorism, and dangerous foreign leaders. With a few exceptions, the more worried or scared people are about crime and terrorism, the more conservative they get.
A truly liberal media would conspire not to cover these things- but it is hard for me to think of local outlets that don’t focus on crime (the weekly paper that is all about music?), or national ones that never mention ISIS. I conclude that “if it bleeds it leads” is the stronger bias.

Written by James Bailey

June 20, 2015 at 12:10 pm

Dennis Hastert and the Wisdom of James Madison

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If I understand the history correctly, in the late 1990s, the President was impeached for lying about a sexual affair by a House of Representatives led by a man who was also then hiding a sexual affair, who was supposed to be replaced by another Congressman who stepped down when forced to reveal that he too was having a sexual affair, which led to the election of a new Speaker of the House who now has been indicted for lying about payments covering up his sexual contact with a boy.  –Orin Kerr

It turns out that during the late ‘90s both parties were lead by lying philanderers. My first reaction is to mock the idea of “public service”, and say we have seen one more example of how the worst get on top. But upon further consideration, I’d say this is evidence of just how well our political system works- as Madison said, we want a system of government that can deal with the fact that men aren’t angels. The late ‘90s featured leaders very far from angels, yet it is remembered as a golden era for the country- peace, balanced budgets and a booming economy.

Written by James Bailey

May 31, 2015 at 2:57 pm