Health-insurance deductibles and the average American’s assets — July 20, 2017

Health-insurance deductibles and the average American’s assets

Here‘s a little thing about health-insurance deductibles:

In short, the BCRA makes changes to regulations that will cause annual deductibles for individual market health plans to skyrocket — to $13,000. But other regulations set the legal limit on annual out-of-pocket spending to $10,900. This means the BCRA’s health plans could actually violate the law.

If you want to get a sense of how large a $13,000 deductible is, consider this, from the Federal Reserve:

respondents are asked how they would pay for a hypothetical emergency expense that would cost $400. Just over half (54 percent) report that they could fairly easily handle such an expense, paying for it entirely using cash, money currently in their checking/savings account, or on a credit card that they would pay in full at their next statement (collectively referred to here as “cash or its functional equivalent”). The remaining 46 percent indicate that such an expense would be more challenging to handle and that they either could not pay the expense or would borrow or sell something to do so.
[…]
among respondents who would not pay the expense in-full using cash or its functional equivalent, 38 percent would use a credit card that they pay off over time and 31 percent simply could not cover the expense.

So around 1 in 7 Americans couldn’t pay a $400 expense in any way.

(There’s a BankRate survey that seems to ask a similar question, but I couldn’t identify the exact question. The Fed’s question is precisely laid out. And of course it’s a more trustworthy source.)

When people talk about how insurance ought to be only for catastrophic expenses, I hope they realize what ‘catastrophe’ entails for a lot of Americans.

A couple conservative pieces on health insurance — July 8, 2017

A couple conservative pieces on health insurance

One from Philip Klein. And another from Peter Suderman.

Both pieces openly acknowledge what the liberal side has been saying for a long time — that Obamacare is a three-legged stool, and that you can’t keep the pre-existing-condition regulations (“guaranteed issue”) without keeping the rest. Klein and Suderman then, fascinatingly, land on conclusions exactly opposite to the ones that liberals would land on. Both Klein and Suderman would do away with guaranteed issue, community rating, and all the rest. They would then replace Obamacare with catastrophic insurance, health savings accounts, high-risk pools, and so forth. Fundamentally, they don’t view health care as a human right, and they don’t believe that government has any business getting involved in the insurance market. If you start from those premises, you’ll likely end up where they do.

You get this sort of clarity from op-ed writers, but not from elected officials. I would posit that that’s because the moral basis of Obamacare is in line with most Americans’ values: most Americans would, I think, agree that you shouldn’t be denied care just because you had a pre-existing condition. (A close friend’s son had open-heart surgery very early in life — I want to say before he turned 2 years old. Do we want him to be uninsurable for the rest of his days?) Having granted this premise, elected officials can either give Americans something in line with their moral values — that is, Obamacare or stronger — or can do what writers at Reason would find congenial, tear off the Band-Aid, and give them health care that’s stingy and (by most Americans’ lights) immoral. It’s no wonder that conservative politicians hesitate to take the orthodox-economist position; or, having taken it, refuse to admit that that’s the position they’ve taken. The BCRA can only pass most Americans’ moral muster under cover of darkness.

Parts of the orthodox-economist position are in line with wonky liberalism. Suderman, for instance, writes that the tax deduction for employer-sponsored health insurance “is the original sin of the United States health care system,” and is “[w]orth more than $250 billion annually.” Many liberals would love to get rid of it; I certainly would. There’s a liberal case against it: it’s regressive, and it makes a dollar of health insurance worth more than a dollar of salary, with the predictable effect that employers pay less in salary and more in health insurance. (I’ll look around for research on how much of Americans’ well-documented wage stagnation can be explained by this tax preference.)

The much-maligned “Cadillac tax” in Obamacare sought to do away with this regressive tax expenditure, albeit stealthily. High-value employer-based health-insurance plans would be taxed, and the definition of “high value” would not be adjusted for inflation. So over time, more and more health plans would be subject to the tax. The dream was that high-value health plans would slowly fade away and salaries would rise; we’d take away with one hand (the Cadillac tax) what we gave with another (the tax deduction).

I have no problem granting that this is ugly: to correct one tax sin, we create another. It’s the embodiment of a libertarian parody of how government works. While granting this, I’m sympathetic: politics is the art of the possible. My liberal dream also collides with the art of the possible: I’d prefer something akin to the Canadian system or expanding Medicare to everyone, or expanding the VA hospital system to everyone, but those are also not yet possible. We take what we can get for now.

In any case, it doesn’t matter: the Cadillac tax was unpopular with everyone, including labor unions. Orthodox economics runs up against the art of the possible.

I’m happier with a discussion centered around the Philip Kleins and Peter Sudermans of the world than I am with one centered around Paul Ryan and Mitch McConnell; at least the former are more honest about what they want. Though this, from Suderman, is misleading:

Medicare, meanwhile, offers a huge system of federal benefits to older Americans that typically run far beyond what most have paid in. Its introduction was associated with explosive growth in hospital-costs inflation during the 1970s.

That was absolutely true about Medicare … in the 70s. It’s not true anymore. The keyword you want to Google for here is the “prospective payments system”. See this review from the Centers for Medicare and Medicaid Services, for instance. Suderman has better arguments than this; I wonder why he chose to use a poor argument there.

Obamacare featured lots of experiments to control costs, including the Independent Payment Advisory Board, which Sarah Palin famously derided as “death panels”. It’s somewhat isolated from the political process, presumably because politicians realize that doing what’s right will often be at odds with what voters want.

I don’t believe, though, that any number of experiments in cost control will sway those of a libertarian cast of mind, because I believe we’re fundamentally having a debate over values rather than one over implementation details. I’m happy that those values — the desire for universal coverage against the belief that health care should be treated like any other market good — are out in the open. Let’s argue it on those moral grounds.

Health-care-debate frustration of the day, Philip Klein-of-the-Washington Examiner edition — July 7, 2017

Health-care-debate frustration of the day, Philip Klein-of-the-Washington Examiner edition

And now, this podcast, namely The Gist with Mike Pesca. Three things Klein says frustrate me:

  1. Shelley Moore Capito was pro-Obamacare repeal when Obama was president and her opposition was all talk. Now that she’s got some power over the BCRA, she’s chafing at the reductions in Medicaid. Pesca raises the obvious point that Capito doesn’t want the residents of West Virginia to suffer, which is what you’d expect from their senator. Klein responds that maybe the citizens of West Virginia should pay higher taxes, then.

    I didn’t think this needed to be said, but that’s not how the United States works. Wealthy people subsidize poor people. Wealthy states subsidize poor states. Senators represent individual states, with actions that sometimes affect other states. The way deals work is that my state gets a little something, your state gets a little something, we each pay for the other, and that’s how we govern. Oppose that way of doing things if you like, but we’re a unified nation of 50 states. The Civil War resolved that question. I’m surprised to see Klein reaching for such a juvenile model of how our government works.

    You can also feel free to call her a hypocrite if you like. Me, I’m well and truly exhausted of the hypocrisy label being bandied about. Don’t get me wrong: when Republican politicians thunder on about homosexuality and the decline of the traditional family, then turn out to be philanderers or closeted, I smirk as much as the next smug liberal. But the real problem isn’t hypocrisy. The real problems are that these politicians are wrong in their evaluation of the country’s moral decline (I for one think that starting a war for no good reason in Iraq is a far graver sin than is falling in love with someone of your own gender), and are pushing policies that condemn a subset of their fellow-citizens to second-class status. Let’s stop talking about hypocrisy, and instead talk about whether the politicians are right or wrong.

  2. Klein returns to the old canard about how government involvement in health care leads to rationing. He neglects to mention that it’s already rationed; it’s just rationed by income. “If there’s only a finite amount of care to go around, the wealthy should get it rather than the poor” is a coherent worldview, which I think the bulk of Americans would reject as morally abhorrent (because it is). I would like Klein to come out and say that this is his principle. Everything else that he says hints that he doesn’t believe health care is a human right, and that he does believe it should be rationed by income. I’d like to see him be explicit about this principle.

  3. Klein also mentions that he’d like a world where consumers shop for the best options. Everyone knows why this doesn’t work, so again I didn’t think it was necessary to go over it. First, someone like me — who visits the doctor a few times a year for routine checkups — is not responsible for the bulk of medical expenses. People in the final year of life, people with multiple chronic ailments, people whose illnesses require expensive treatments, etc. are responsible for the bulk of medical expenses. Klein is implicitly asking cancer patients to shop around for the cheapest chemotherapy. Which is absurd for reasons that I really do not intend to go into.

    Second, shouldn’t insurance companies already have an incentive to negotiate for the best prices? Why don’t they? Why would consumers — who certainly have less leverage than insurers — be expected to do a better job at negotiating or shopping around than the insurers do? And here’s a completely non-rhetorical question to which I don’t have an answer: I’ve wondered for a while why insurers don’t already tell their patients, “We’ll pay for your chemotherapy, but it’s half the price if you travel across the state to a cheaper hospital. We’ll even pay to drive you there and back, and for the hotel when you get there. Even after paying for all that travel, it’s still cheaper for us.”

    Third, I return always — practically every day — to Socialism: Converting Hysterical Misery into Ordinary Unhappiness for a Hundred Years. Who actually wants to spend his time on hold with insurance companies, trying to cajole them into paying for a coronary bypass? This is not the world I want to live in, and I doubt it’s the world you want to live in either. I have a hard time imagining that Philip Klein wants to live in that world, but maybe he expects that in Marketopia, concierge services will appear whose job it is to sit between you and the insurance company, negotiating on your behalf? Is adding another layer of rentiers really the dream end-state for conservatives? I honestly wonder what the goal here is.

Ezra Klein’s latest interview with Avik Roy is maddening — July 6, 2017

Ezra Klein’s latest interview with Avik Roy is maddening

The tl;dl to this episode is that Avik Roy believes some future hypothetical Republican health-insurance bill will be a significant improvement over the existing health-insurance market. It happens that the actually existing Better Care Reconciliation Act is not that bill, which Roy seems to have no problem conceding. It’s not clear at all from the interview which problems Roy actually thinks the BCRA solves, yet this is the bill about which Roy tweeted

There’s some hypothetical Republican Congress, says Roy, which will care about providing universal coverage for the poor, but it’s not this Republican Congress; there’s some hypothetical humanitarian Republican health-care bill which could hypothetically arise out of the ashes of the BCRA, but the BCRA is not that bill. Roy says we’re supposed to be happy with the BCRA because it’s the result of a debate between the hardcore “throw the poor out in the street” wing of the Republican Party and the “let’s give the poor some health insurance that they can’t afford” wing of the Republican Party. It’s a compromise, and at least they managed to get legislation out the door. The Democratic Party wants, as a core tenet of its platform, to provide health-insurance coverage to everyone, so the result of a Democratic compromise is something that’s at least ideologically coherent: we knew we couldn’t get single payer, and even the public option was too liberal for the likes of Joe Lieberman. It’s not at all clear what the result of this notional Republican compromise is supposed to accomplish.

I believe Roy is a person of conscience, and I take him at his word that he wants good coverage for everyone. Central to his belief system, though, seems to be a cramped view of government that is likely to make it work more poorly and get less public support. Health insurance, he says, is meant to prevent bankruptcy. If you believe that, you’re going to downplay the humdrum day-to-day use of health insurance — e.g., going in for a checkup, or getting a routine dental cleaning; those aren’t the sort of things that threaten people with medical bankruptcy. You’re also going to land, as Roy does, on a spare view of the government’s role in health insurance. The government, he says, should be subsidizing the poor more and the wealthy less. I agree with this, which is why I think it’d just be simpler to provide a service, pay for it with taxes, and make those taxes steeply progressive. Roy takes it in a different direction: if I understand him, he would have the government provide stingy care for catastrophic illnesses only, and only to the poor.

I have major concerns when we think about government like this. Universal programs get universal buy-in: if your wealthy grandfather gets Medicare, he’s going to fight like hell to keep it — even if, by Roy’s lights, he’s too wealthy to need it. In the world Roy envisions, only the poor, who don’t donate to political campaigns and often can’t afford to take time off from work to vote, have an incentive to fight for (Roy’s version of) Medicaid.

The government Roy envisions provides systematically poor service. It’s not just in health insurance; you see Roy-style government also in, say, mass transit. Hence the excellent Matt Yglesias Twitter thread ending here:

Here in the U.S. our mass transit is dirty, overcrowded, and unreliable, at least in part because of an Avik Roy-style ideology that thinks the government should be providing a “safety net”: if every other means of getting to work fails for you, at least you’ve got this one crappy option; if you’re poor, at least you won’t end up too far in debt trying to pay for your health care. So people come to think of government as the provider of crappy services. So they bail on those services and use the expensive private options. So the services become crappier and the cycle continues.

And in many cases what Roy envisions is just too complicated. Roy and Klein go back and forth about premiums, deductibles, cost-sharing, etc., as though we didn’t already have a government which is extremely good at collecting taxes. The Laniel Plan for government is: provide people an excellent service (subways, health care via the VA, health insurance via Medicare), then tax them for it, and make the tax code steeply progressive. (Roy and I would agree that removing the tax deduction for employer-sponsored health care is vital here. Doing so would be both good for the overall health system and very progressive.) No deductibles. No copays.

Scale out just the tiniest bit. The goal should be that the insurance you get via the government — whether it’s Medicare or Medicaid or the VA or the ACA exchanges — is as good as the best employer-provided health insurance. Why are we always settling for a “safety net”? We’re a wealthy country. We can afford to provide stellar coverage to everyone. Not only can we afford to provide excellent services; our habit of not providing them has led us to the state we’re in, where government services are near-universally perceived as … well, as the government cheese of whatever service they’re supposed to provide. We’re in a self-fulfilling vicious cycle now, where government services are perceived as poor, which makes cutting their funding politically easier, which leads to poor government services. I’d like to see us reverse that into a virtuous cycle.

It seems clear that Roy would disagree with all of this, and that Democrats would agree with most of it. To the extent that our laws look muddled — as, arguably, Obamacare did — it’s because we know that the thing we actually want (single-payer, basically) is not feasible, so we unfortunately compromise into something muddled. Whereas it’s not clear what Roy wants; and to the extent that it is clear what he wants, what he wants is something that would make the government work even less well. What’s truly terrifying is that Roy is the moderate in his party.

Blog-post series idea, quantitative-literacy department: Top Tens — January 23, 2017

Blog-post series idea, quantitative-literacy department: Top Tens

Here’s a quick idea for a series of blog posts: “If you want to do [x], you will need to address the following 10 items; everything else is negligible.” For instance: if you want to cut the Federal budget appreciably, you’ll need to cut defense, Medicare, Medicaid, Social Security, or the interest on the federal debt; everything else amounts to very little. (In particular, the National Endowment for the Arts amounts to very little. There may be a list of sound ideological reasons to kill it, but budget-balancing is not at the top of that list.)

Or: if you want to raise American life expectancy, you’ll need to reduce a few major causes of death; giving everyone a flu shot, while useful, won’t cut it.

Or: if you want to reduce health-care costs, you’ll need to focus on the last few years of life; making me pay more for the occasional X-ray won’t cut it.

These are just hypothetical examples, and I’ve not worked out the detailed numbers on any of them; doing so would be part of the fun of the exercise. The goal of the exercise, overall, is to give people — including myself! — a clarifying idea of where the big wins come from. For instance, how much life expectancy could we gain from imposing a $1 tax on cigarettes? (A book I read recently but haven’t yet reviewed probably contains exactly this number.)

Useful idea? What else would people like to see in such a series?

Prisoner’s dilemma — January 12, 2017

Prisoner’s dilemma

Suppose someone gave all of America’s media outlets a choice: a sociopath will be at a given place at a given time; if any of you film him, he will destroy the United States, though you’ll get phenomenal ratings; whereas if everyone turns off the cameras, you’ll get slightly less revenue and the U.S. will live another day. I have a fairly good idea how this would turn out.

Anyway, what’s everyone doing on Inauguration Day?

I am actively looking forward to voting for Hillary Clinton — October 12, 2016
The white working class is large — October 11, 2016

The white working class is large

I had been incorrectly thinking of the white working class as some small interest group, but — depending upon how you define it — it’s actually quite large. Check out the Census Bureau’s data on population sizes by educational attainment, which I’ve turned into a shared read-only spreadsheet.

(Note, by the way, that when I tried to import that Census XLSX file into Google Docs, Google mangled it and dropped the age breakdown in the leftmost column. Apple’s spreadsheet ingested it properly.)

If we define the white working class as white adults with less than a bachelor’s degree, there are 132.8 million such people. In a nation of 321 million people, that’s around 40% of the population. Given that 77.1% of the population is 18 years old or older, that means there are around 247 million adults. So of those 247 million adults, the majority are non-college-educated whites.

(Few of my friends lack a college degree. Another example of the bubble I’m in.)

It’s worth noting that around 3/4 of all voters in 2012 were non-Hispanic whites. And around 63% of all voters in 2012 did not have a bachelor’s or advanced degree (source: Census Bureau). I’ve not found cross-tabs that count voters by race and educational attainment, but then I haven’t looked very hard.

I have a hunch that elite discourse — being framed by journalists who’ve mostly been educated at elite universities — has convinced many of us that the white working class are a minority whose magnitude approximates that of many other minorities. My rough sense of the magnitudes here convinces me that, in fact, they’re a majority in whatever way you care to slice it.

I’m making no political point here. For one thing, whites are doing really well, relative to other races. And to be crystal-clear about it: nothing Donald Trump has said suggests that he would help the demographic that is purportedly his base. But it’s striking how large that base is.

You don’t have to deserve it — June 29, 2016

You don’t have to deserve it

A World to Make: Eleven Theses for the Bernie Sanders Generation has really stuck with me over the past few months; it reappears in my head with some regularity, especially this thesis:

  1. Not Everything Has to Be Earned
    Bill Clinton often said that he wanted a fair return for people who “work hard and play by the rules.” And of course working hard and honoring the rules (at least where the rules are fair and legitimate) deserves respect. But the national fixation on people getting what they “deserve,” from meritocratic rewards in higher education to incarceration (“Do the crime, do the time,” the prosecutors say) has gotten out of hand. It locks us into a mutual suspicion of people getting away with something—pocketing some perk or job or government benefit that they didn’t “really earn”—while ignoring the way the whole economy tilts its rewards toward those who already have wealth. A left program should shift the attention from zero-sum questions about who gets what, and at whose expense, to bigger questions about what everyone should get just for being part of the social order: education (including good higher education), health care, safety in their neighborhood, an infrastructure that works.

I get that there’s a mismatch between what’s ethically correct — which I think the above thesis is — and what’s politically possible. Matt Yglesias makes the reasonable point in a recent episode of The Weeds that it really is much easier to sell welfare of the “pay people only if they work [i.e., ‘deserve it’]” variety, rather than the “give poor people cash” variety. There’s a broader question there of how we developed a public morality such that these are the terms of the debate, but I get the practicalities.

In a lot of ways the Democratic primary of 2016 has felt like an argument between those two poles: what small incremental improvements can we make to the welfare state (Clinton), versus how do we change the way we even discuss the topic such that fundamental improvement is possible (Sanders). We need both.

Laniel on Krugman on Bernie — April 15, 2016

Laniel on Krugman on Bernie

What annoys me about Krugman’s Bernie take is that he’s not even said, “Yeah, I’m a real supporter of single-payer health care, but Bernie is just going about it the wrong way. If he’d change x, y, and z, it would be a realistic plan.”

The positive approach to addressing Bernie would be to offer him constructive policy ideas. If Krugman felt like Democrats needed to be realist in their policy proposals, he’d try to work out realistic numbers for Bernie’s single-payer and college-education plans. But Krugman isn’t doing that. Instead he’s just pointing to every bit of anti-Bernie writing that comes his way, taking it as conclusive, and shutting down the debate there. Worse, Petulant Krugman is coming out, as when — in this latest column — he writes:

But never mind. As you know, I’m only saying these things because I’m a corporate whore and want a job with Hillary.

My problem with his anti-Bernie columns isn’t that I think he’s a corporate shill. My problems are twofold. First, his mind seems made up. And second, look through Krugman’s older blog posts for times when he’s mentioned single payer. Clearly he supports single payer. I assume he supports universal college education. Well then, why not push for those things? If he believes that Bernie is an unelectable, impractical candidate, and hence that he’s going to support Hillary, why not do what he can to bring Hillary more toward the left? Bernie has clearly pulled Hillary leftward; maybe now Bernie needs to be pulled in the direction of realism. Why isn’t Krugman acting as the agent of realism here? Instead he’s acted, since the beginning, as someone whose mind is made up against Bernie. I don’t get it.

(For the record: I voted for Hillary in the primary, but I’m still conflicted about that decision. I believe that any liberal who’s thought about this Democratic primary should also be conflicted. These are both strong candidates, both with obvious weaknesses, and I’d be happy with either of them in the White House.)

Krugman’s beef seems to be that Bernie’s campaign is irremediably flawed by the same sort of unreality that plagues the Republican candidates’ tax plans. (Krugman has also accused the Sanders campaign of having gone off the rails. I blame this on the ludicrous length of the election season, which eventually causes everyone to lose his mind. And again, I think Krugman is grasping at whatever straw he can find. Matt Taibbi responds appropriately.) But here’s a question: is reality in campaign proposals really all that important? The Obama campaign in 2008 advanced a health-insurance plan that lacked an individual mandate, which we know now — and which Hillary knew then — is unworkable because of adverse selection. What virtue does reality have here? The man got into office and fought for what he promised us he’d fight for. Does it matter that he couldn’t make the numbers work out during the campaign? I’m really not convinced by realism as a virtue during a campaign. When it comes time to produce an actual budget that gets scored by the CBO: yes, I want realism then. At that time, Bernie will have a staff whose full-time job is to put together a budget that makes sense. I hope he chooses appropriate staff. But during a campaign? What I want to know is that my guy is fighting for what I care about.

(To the extent that it’s unrealistic, people have criticized Bernie’s plans for costing more than he says. I am willing to pay a lot to get a Northern European social-insurance state here. That is, even if he were more realistic about what it costs, I’d still support him.)

And again: if realism in fact does matter, it seems to me that it’s Krugman’s job to point out what could make Bernie’s numbers more realistic. Does Krugman want single-payer in his lifetime? Does he want us to return to a world where we provide free world-class tax-financed college education? If not now, when? I’m not asking that question rhetorically; I assume that Krugman really believes that now is not the time for single-payer health care, that getting single-payer would require Congressional action, that Congressional action is not plausible, and that only a Clinton presidency which will achieve incremental reform through executive action will succeed in attaining anything. But clearly Krugman’s heart is with Bernie; so why doesn’t Krugman act that way?

And let’s address head-on that point about the need for Congressional action: yes, it’s true. But I think people have a static picture of U.S. government. They envision that Sanders will inherit a Republican majority in both houses of Congress and a conservative majority on the Supreme Court. But things change. Maybe the Trump candidacy will bring liberals to the polls. Maybe we’ll replace Scalia with a more-liberal justice; maybe Kennedy will leave the Court and be replaced by someone liberal. There’s a not-implausible political theory by which Sanders stands some chance of passing real progressive legislation. And in either case, I think Krugman is obliged to lay out his political theory. Because it seems pretty clear that Krugman made up his mind about Bernie well before former CEA chiefs declared Bernie’s budget unrealistic. So it seems to me that Krugman needs to declare what his actual problem is.