Health Care

2010 09 17
Mark Pauly on (Intra)class warfare

The other day I noted a seemingly bizarre inconsistency in Mark Pauly’s 1995 analysis of why the Clinton health reforms failed politically. I didn’t say, and don’t believe, that Pauly’s endorsement of the inconsistent political explanations was designed to promote a given ideological viewpoint. True, he seemed eager to discount the extent to which monied interests influenced the debate over health care. But at least he was willing to draw attention to those interests in the first place. That said, the following passage from the same text seems much less benign:

I hasten to add that this is not my own personal preference; I would prefer more redistribution. But I realize that I am being out-voted by other middle-class people who do not want to play more taxes. Indeed, I strongly suspect that a major blow to bipartisan health reform was the success of the president’s budget plan, which sopped up (and then some) any surplus willingness of the upper middle class to pay more taxes. We could have had universal insurance coverage or a lower budget deficit, but not both.” (Mark Pauly, “The Fall and Rise of Health Care Reform: A Dialogue,” 1995, p. 12.)

Here Pauly is claiming that it was the “upper middle class” who felt the brunt of the 1993 Clinton tax increases. This made them less willing to pay for health reform. Is this explanation plausible?

No, it is not.

According to economist Robert Pollin, the 1993 Clinton tax increases “increased the levy on [family] incomes over $140,000 from 30 to 36 percent, with an addition 10 percent surcharge for incomes over $250,000″ (p. 26). And according to the Center on Budget and Policy Priorities, these families had incomes in the top 5% of the national income distribution.

Here is a graphic from a report by the Federal Reserve Bank of Cleveland that shows the increase in taxes for families at different income levels:

Given that the the median family income was 54,369 in 1990, and given that only families in the top 3-4% (those above $200,000) really saw an appreciable increase in taxes, it seems to me quite inaccurate to say that the “upper middle class” paid for these increases. One might therefore think that the (upper) middle class should have been willing to pay higher taxes in order to finance universal health insurance for their fellow class-mates. That’s one way to look at it. Another way is to note that ostensibly non-ideological analyses misrepresented the nature of the tax increases, and thereby led the middle class to think their taxes had gone up. The point of such analyses, of course, would be to kill the increases politically. And the main reason one would want to do that is so that the rich would not have to pay higher taxes.

So I am beginning to question the sincerely of such Pauly pronouncements as, “I hasten to add that…I would prefer more redistribution.” That said, I’m still learning a ton from reading and re-reading Pauly’s latest book.

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2010 09 15
Intro, Meet Conclusion (Another in the “right-of-center health care analysis” series)

I recently mentioned Mark Pauly’s recent book on reforming the individual insurance market, which I plan to write more on shortly. But tonight I’m reading an exchange between Pauly and Princeton health economist Uwe Reinhardt from 1995 or 1996, and I’m simply flabbergasted by two claims Pauly makes. One the one hand, we get this statement from the introduction:

It is..probably true in large part, that the health care reform proposed by the president [Clinton] failed because Harry and Louise were more effective at scaring the middle class than were Ira [Magaziner] and Hillary [Clinton].

Then there’s this from the conclusion:

It might be helpful to point out a logical contradiction: if the middle class are so concerned about the welfare of the nonpoor uninsured that they will not force them to pay for the insurance coverage, why are the middle class unwilling to pay for that insurance for them? It appears that a little altruism is a dangerous thing…If we cannot convince the decisive voters of the value of what we value, then I think we need to accept the verdict of democracy.

So let me get this straight. Health reform failed because of a year-long insurance industry-funded campaign to scare the middle class. And it failed because the middle class decided in its infinite and dispositive wisdom that there is no social obligation to aid those without insurance. Huh?

To be fair, there is also this from the introduction:

[It is] a little surprising that two economists are talking about what is essentially a political issue, but I suppose that is the way it has to be.

God I hope that’s not true.

More on Pauly’s more recent book and John Goodman’s way of thinking about health care anon.

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2010 08 17
Right Wing Health Reform Alternatives (I)

Posted by in: Economics, Health Care

I have moved on today to taking a look at John Goodman’s “Characteristics of an Ideal Health Care System.” Goodman has an informative and always pointed Health Policy Blog. He is President of the National Center for Policy Analysis, and the last page of his paper notes that the Wall Street Journal once called him “the father of Medical Savings Accounts.”

I expect I’ll be writing more about Goodman’s Ideal Plan, but one thing leaped out at me straightaway as somewhat curious. Like most proponents of Medical Savings Accounts, Goodman appears to want insurance to come in the form of low-premium/high-deductible plans.

Not being utterly callous, Goodman is willing to subsidize the purchase of insurance, to some extent (although he’s willing to offer subsidies of identical amounts to rich and poor alike). In order to determine the level these subsidies should be set at, Goodman argues that we already a socially set number: it is “the amount we expect to spend (from public and private sources) on free care for that person when he or she is uninsured.” Goodman then cites Texas, which he says spends an average of about $1,000 per year per uninsured person on free care. He then notes, “Interestingly, $4,000 is a sum adequate to purchase private health insurance for a family in most Texas cities.”

Although writing in 2001, Goodman’s $4,000 Texas insurance policy must have been a high-deductible policy. According to this Health Affairs article, average job-based family coverage was $588 per month in 2001, or $7,056 per year.  Surely a $4,000 policy, in the non-group market no less, would involve a significant deductible. If so, then the following is what I find curious:

A common misconception is that health insurance reform costs money. For example, if health insurance for 40 million people costs $1,000 a person, some conclude that the government would need to spend an additional $40 billion a year to get the job done. What this conclusion overlooks is that we are already spending $40 billion or more on free care for the uninsured, and if all 40 million uninsured suddenly became insured they would – in that act – free up the $40 billion from the social safety net.

If those $4,000 policies (in 2001) were high-deductible policies, then at least some, and perhaps many, trips to the ER by those with such policies will incur expenses that would not be reimbursed by their insurance. But if so, then the $40 billion that would go toward subsidies to insure the currently uninsured would not necessarily offset the entire $40 billion in free care that we provided to them now.

I really feel scummy pointing out that this health reform proposal with which I wholly disagree is not the free lunch Goodman presents it as. Ick.

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2010 08 17
Health Reform and Marginal Tax Rates

Posted by in: Economics, Health Care

I’ll hopefully have more thoughts on this soon. This post is just to get the two money quotes down.

In designing my upcoming course on ethical issues in health reform, I’ve been reading a lot of health economics, despite not knowing very much at all about the subject. And not knowing much at all leaves me helpless to evaluate disputes between health economists. A rule of thumb in these cases is to find out which experts are considered level-headed and always worth listening to by most of their peers. Again, how else could I proceed.

Two such experts in health economics are Victor Fuchs and Joseph Newhouse. Fuchs is well-known in many circles for his book, Who Shall Live? Newhouse is well-known for leading the RAND Health Insurance Experiment in the 1970s-80s. This week I have been reading article from Fuchs’ book entitled “Economics, Values, and Health Care Reform,” and a recent article by Newhouse on the recent health care reform law and the residual issues we are left with. Each is worth reading, but the latter is really, really informative, especially because Newhouse both praises the law for (what I see as) its virtues and expresses deep skepticism and concern over other elements. (If you want the paper, let me know in the comments.)

Here are two quotations from the aforementioned papers that I hope to return to in the coming weeks. First, Fuchs:

There are only two ways to achieve systematic universal coverage: a broad-based general tax with implicit subsidies for the poor and the sick, or a system of mandates with explicit subsides based on income. I prefer the former because the latter are extremely expensive to administer and seriously distort incentives; they result in the near-poor facing marginal tax rates that would be regarded as confiscatory if levied on the affluent.

And here’s Newhouse:

Although necessary to achieve compliance, the subsidies will have the negative effect of increasing marginal tax rates. Consider a family of four whose income is $55,250, or 250 percent of the federal poverty level. Their current marginal tax rate is 22.65 percent plus any state or local income taxes. Assuming that, as of 2014, the family buys the most generous health insurance plan covered by the subsidy, the premium will be limited to 8.05 percent of the family’s income. This feature of the law will effectively add 8.05 percentage points to the family’s marginal tax rate, since any additional dollar of income will reduce the subsidy by eight cents. Thus, the family’s marginal tax rate will rise by roughly a third. Economic research suggests that this would be likely to reduce the labor supply of those who are not the principal income support of the household.

Being a liberal and being largely ignorant in the way of health economics, I’m often too tempted to dismiss the sorts of concerns expressed here by Newhouse. Sometimes I have good evidence for this, as when I dismiss claims that raising the minimum wage will eliminate jobs. Sometimes I have to admit that I’m just not sure what to think about claims that it would be easier to ignore.

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2009 10 11
Can we Distinguish Insurance from Stereos?

In response to what he dubs “the stupidest argument against health reform”–namely the argument that universal health insurance requires people to pay for someone else’s health care–upyernoz writes:

“paying for someone else” is the whole concept behind insurance. the idea of insurance is that there are certain things (floods, catastrophic medical costs, car crashes) which can be so economically devastating that individuals would be ruined if they had to pay the entire thing out of their own pocket. insurance is a way of pooling risk, everyone pays in, only the unlucky ones draw out. but then everyone can feel more secure knowing they have insurance to fall back on if disaster hits.

in other words, all insurance involves you paying other people’s bills (or other people paying your bills). that’s what insurance is all about. you can call it “socialism” if you want, that’s not an argument, that’s just slapping a label on something. but if you happen to believe it’s evil to pay for other people, then cancel all your insurance policies.

While I’m certain ‘noz and I stand united on the moral imperative of health reform that gives all Americans access to high-quality affordable healthcare, I don’t think his account of the argument he targets is fair, and thus I don’t think he offers a very satisfying response to the person who endorses that argument. Here, as I understand it, is ‘noz’s line of argument:

1. Proponents of the Stupidest Argument Against Health Reform maintain that they should not be forced to pay for another’s medical care.

2. But proponents of the Stupidest Argument willingly buy various forms of insurance without complaining.

3. But buying insurance just is the paying for another’s medicare care.

4. So to be consistent, the proponents should either withdraw their objection to health care reform, or else “cancel all [their] insurance policies.”

I think we can see clearly where ‘noz’s line of argument fails by changing the story a bit:

1. Opponents of income maintenance policies maintain that they should not be forced to pay for another’s wages/income.

2. But opponents of income maintenance policies willingly buy stereos without complaining.

3. But buying stereos just is the paying for another’s wages (namely those who make stereos).

4. So to be consistent, the opponents should either withdraw their objection to income maintenance policies, or else stop buying stereos.

It seems clear that while purchasing a stereo does in fact pay another’s wages, it is false to say that paying another’s wages is the “whole concept” of purchasing a stereo. But then what distinguishes purchasing insurance from buying a stereo? Each seems to amount to the same thing: parting with a sum of money to procure a good or service which is available to one only because certain others are willing to help produce that good or provide that service only because they too get something out of the economic arrangement.

The fact seems to be that those who wish to buy stereos and those who wish to buy insurance may not really care about the economic arrangements and contracts that lie in the background of these purchases. They do not really care that buying a stereo and buying insurance involves paying an amount of money a portion of which ends up paying another’s bills. The one person wants a stereo, and parts with a certain amount of money to get it. The other wants protection from the economic risks associated with (the treatment of) ill health, and pays an insurance premium to get it. It just so happens that, in our world, the reason why these purchases are available to one at all is that other people, who play different roles in the relevant economic domain, also get something out of their involvement. So, again, what could make the purported difference between buying stereos and buying insurance?

If this analogy is as revealing as I think it is, it shows why the proponent of the Stupidest Argument may not be making the silly mistake that ‘noz ascribes to him. To extend the analogy: Assume a tax is levied on all stereo purchases in order fund income maintenance policies for the unemployed. And assume that a would-be stereo-purchaser objects to this. Then that objection cannot be met simply by pointing out that he didn’t have a problem paying another’s wage through his purchase before the tax was levied.

In the case of health insurance, what would be the analog to the stereo tax that the proponent of the Stupidest Argument objects to? Since insurance is typically paid for through premiums, the proponent will likely claim that he should not have to subsidize another’s premium. But this raises the question of whether the initial distribution of income is itself fair, as that is the distribution that determines who has what to put toward premiums. To the extent that it is unjust that some work long hours in dreary jobs for what is now a largely depreciated compensation package, that can provide a reason to ask those who are favored by the structure of the economy to give some back to subsidize the premiums of those who get the short end of the stick.

Another barrier to insurance access has to do with differentials in health status (of which “pre-existing conditions” are one kind). To use a stylized example, assume that you and I form a two-person health insurance market, and that I am fairly healthy and you have a disease that can be treated with only very expensive health interventions. In this situation, each of us is presented with the option to buy insurance. But which insurance we buy, if any, will be influenced by which insurance products are available. If the only insurance product is one that pays for the sort of interventions you need, that product will be very expensive. In that case, I may choose not to buy it, since I feel there are other things I’d rather spend that amount of money on. But that may leave you without the prospect of insurance, since the resulting premium for you will be the same price as the expensive medical care you were hoping to avoid having to pay for directly by purchasing insurance in the first place. You will face a similar problem if there are in fact several insurance products available, and if I choose one that is cheaper. For that one will be cheaper precisely because it doesn’t not cover the expensive treatment you need. So while you may be able to afford that cheaper product, it doesn’t do you much good.

These thought experiments seem to show that the proponent of the Stupidest Argument is also probably objecting to having to subsidize the insurance choices that the market makes expensive for others because they are either more risk averse than he his, or because they in fact require more expensive insurance than the proponent himself wishes to purchase with the funds he has chosen to dedicate to health risk reduction. This is in fact not an objection we should dismiss as stupid, as I think the two-person example shows.

I’m sure ‘noz and I agree that when the simple two-person example is replaced with the much more complex picture presented by the macro situation in the U.S. today–a situation in which income is not distributed fairly and where individuals’ health status is profoundly influenced by myriad social circumstances beyond their control–there is a solid argument in favor of providing all Americans with at least basic health care paid for by general, progressive taxation. But even if we are right, we cannot dismiss the objections of those who disagree with us simply by pointing out that all insurance involves using what was once one person’s money to pay for the health care of another.

The moral of the story is this: it is false to say that the “whole concept” of insurance as such is to pay for another’s care. Yes, it involves that, but the sense in which it does is just the sense in which buying stereos involves paying another’s wage. Not much of moral relevance follows. But, it is absolutely true that the whole concept of certain social insurance schemes is to spread risk and cross-subsidize care for appropriate moral reasons. But those reasons cannot themselves be teased out of the idea of insurance as such.

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