Coyote Blog

Massachusetts has a government health "reform" system very similar to the Baucus bill.  How's that working out for them?

I have a high deductible health plan, which makes a ton of sense to me.  For reasons I don't understand, by increasing my deductible from $100 to $2500 I save over $3,000 a year in premiums.  So even if I max my deductible every year, which I don't, I still don't pay as much in a year as my old BC/BS gold-plated policy.  And as an extra, added benefit, we have actually started price-shopping health care services, and that has been a real eye-opener as well.  Bottom line - one can get things like tests and X-rays a lot cheaper if one has the incentive to shop around.

So I worry about exactly this with the new federal health care bill:

Wendy Williams and her husband liked their health insurance plan.  The premium and annual deductibles made sense for them, and a more "gold-plated" plan was not worth the money.  Yet Massachusetts' health care regulators disagreed, and forced the Williams to pay a $1,000 fine if they wished to keep their insurance plan "” a plan they prefer to a comparable state-approved alternative....

If the federal government adopts an individual mandate, Ms. Williams fears her experience could soon replay itself nationwide.  She's right to fear.  Once there is an individual mandate, interest groups will flock to Washington seeking to have their preferred treatment or service incorporated into the requirements for acceptable health care plans.  Over time, the requirements will grow, and the cost of health care plans for many Americans will increase as a result.  Consequently, many individuals who have health care plans that fully meet their needs will suddenly find themselves "underinsured" "” and taxed fined as a result.

When reading the original House health care bill, it struck me that the new taxes on employers and such began immediately, but benefits were phased in between 2012 and 2017.  Apparently, this same thing is being done in the Baucus Bill, and I have learned that this is specifically aimed at gaming the CBO numbers.  Since journalism majors were such in large part because they didn't want to do any math, this ploy will likely work with the media, who will print the CBO findings but will be uninterested or incapable of deconstructing the numbers games.  From the Gormogons via TJIC:

What the CBO does not highlight, however, is that Sen. Baucus cooked the books. Under the Baucus plan, revenue enhancement (taxes) goes into effect immediately. Coverage does not kick in for two and one-half years. So, to make the numbers work, Sen. Baucus has to collect ten years of revenue to cover seven and one-half years of cost.

'Puter thought the whole thing smelled a little fishy, so he gave Sleestak and abacus, a quill and some parchment and set him on the CBO math. Using the above numbers, Sleestak calculates that projected revenues will generate $910 billion over 10 years. Outflows will be $829 billion over 7.5 years. Based on Sleestak's math, that's an average yearly inflow of $91 billion and an average yearly outflow of $110.5 billion, or a average annual deficit of $19.5 billion each year the benefits are actually paid.

TJIC rightly asks how this kind of game is any different from the one played by Madoff.  The only difference is that folks had the right to say "no" to Madoff whereas we will not have this ability with Congress.

A lot of my education was just a cover story that looked good a number of years of partying with no job look good on my resume without any real improvement in my long-term skills.  But my time in business school thinking about incentives and later at McKinsey & Co. doing the same for various employee compensation approaches has served me well through my whole life.  It's not that Congress and the media are bad at thinking through inventives -- its that they don't even try.  They accept the motivations and desires of the person proposing a plan as suffiecient gaurantee that the plan will actually reach those results.

I got a lot of mail last week on my post on incentives.  One loyal reader left me this link at Develish Details, a blog analyzing health care reform proposals.  Incentives are a frequent topic on the blog:

While it's true that paying by procedure creates the incentive to perform more procedures, some of which may be unnecessary, an outcomes based payment system has its own drawbacks. It creates the incentive for doctors to choose to treat patients who are less sick over those who are more sick. Very sick patients require a lot of attention and time, but are less likely to have a bonus-worthy outcome.

On the other hand, less sick patients are easier to treat, are likely to have a better outcome, and will offer a better bonus opportunity for the doctor. Doctors' time is scarce, so they must put it to the best use possible to provide for their families "“ and in a pay-for-outcomes system that means choosing easier to treat patients who will generate the highest bonuses. No matter how much we narrow the arbitrary measure of "outcome", the incentive for the doctor in an outcome based system, where "outcome" is defined by a third party, will always be to select the least sick patients at the expense of the sickest patients most in need of care.

Because human beings are complex organisms, defining what constitutes a "good", bonus-worthy outcome is itself a daunting, if not an altogether impossible undertaking for the third party tasked with producing and evaluating those metrics. Medical outcomes depend on many variables, including, but not restricted to the overall health of the patient (not just the condition being treated) and the patient's compliance with the treatment - a factor over which the doctor has no control.

I often tell people that in failing organizations like the government or GM, most of the folks who are "part of the problem" aren't bad people, they just have bad incentives.  I have to remind myself this all the time when dealing with government bureaucrats who are making it impossible for our company to make progress in some area.  These folks did not grow up imagining a life in which they block all growth and innovation, they simply found themselves in organizations  which provide strong incentives to act in this way.  Such consequences may be unintended, but they certainly aren't unexpected when one studies incentives.

To this end, the incentives in the new Baucus health care bill do not look good.  Here is one example:

Because Baucus and the Dems apparently can't be bothered to post the bill online, the Washington Examiner had to get a copy the old fashioned way.  When they did, here is what they found on pages 80-81, "hidden amid a lot of similar legislative mumbo-jumbo":

"Beginning in 2015, payment would be reduced by five percent if an aggregation of the physician's resource use is at or above the 90th percentile of national utilization."  Translated into plain English, it means that in any year in which a particular doctor's average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor's payments by 5 percent.
[...]

This provision makes no account for the results of care, its quality or even its efficiency.  It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked. And because no doctor will know who falls in the top 10 percent until year's end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more.  Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.

The result can't be anything but an incentive for doctors to provide less care to those who need it most, and, when they get tired of getting their pay cut for doing their job, leaving the medical profession altogether.  The article goes on to point out that nothing is done in the bill about the worst incentive to increase medical costs doctors face, the threat of unreasonable tort actions that causes doctors to order ever test and procedure imaginable to combat future second-guessing in front of a jury.

Forcing people to pay money or pay a fine on their tax return to buy a product they currently don't buy is a tax.  Particularly when that product will likely be over-priced to the young and healthy not buying it today to subsidize the older folks.

Ezra Klein writes:

For a long time, I took questions about stifling innovation very seriously. So did a lot of liberals. But then I realized that the people making those arguments wanted to do things like means-test Medicare, or increase cost-sharing across the system, and generally reduce costs in this or that way, which would cut innovation in exactly the same way that single-payer would hypothetically cut innovation: by reducing profits.

I also found that I couldn't get an answer to a very simple question: What level of spending on health care was optimal for innovation? Should we double spending? Triple it? Cut it by 10 percent? Simply give a larger portion of it to drug and device manufacturers? I'd be interested in a proposal meant to maximize medical innovation. I've not yet seen one.

The reason he could not get an answer to this very simple question is that it is stupid.  It is a non-sequitur.  It is, as Ayn Rand used to warn, a statist trying to force the argument to conform to his statist assumptions.

Let's take a different example, because medicine is so screwed up by government intervention that it can be confusing.  Let's imagine ourselves in the computer market in 1974.  The market is dominated by IBM mainframes, and innovation at the time was considered to be the penetration of mini computers (not to be confused with PCs, these were really just smaller mainframes) by DEC and HP.

Let's say that for some reason the US government decides it is fed up with the IBM "monopoly" and the high cost of mainframe computing and it wants to take over.  It feels like there is a lot of waste in mainframes as some people are using them for frivolous reasons while other companies who really need them can't afford them.  They might have created review boards to make sure that they thought each dollar spent on computing hardware and software was "worth it."

So, how much spending is needed to maintain innovation?  We know in hindsight that the PC revolution is looming in the next few years.  And in that context, Klein's question is absurd.  The answer is that spending per se, and even profits, in the mainframe computing market were irrelevant to the coming series of innovations.    The necessary preconditions were that entrepreneurs saw that new technology provided potential new value to consumers, and were allowed the freedom to launch these new products in hopes that the value these new products provided would be sufficiently high that consumers would pay enough for them to return their cost of manufacture and development and return them a profit.  Some succeeded, and some failed, but entrepreneurs were allowed to try, despite most "experts" predicting the PC was a silly toy.

Note that computer innovators were not required to trundle into some government computing board to justify the PC and its price, to justify how much, as Klein would say, needed to be spent on PC's.   If in fact they were forced to do so, if Jobs and Wozniak had to fly to Washington to justify the Apple I to the Computing Spending Decisions Board, they would have almost certainly been shot down.  Or told they could sell it but only for $200 and not their initial price of $2000.  We would have never had a PC revolution in a government single payer computing world, no matter how much, as Klein asks, was "spent" by the government.   It is possible that the government might eventually have greenlighted a PC (years later) just as the increasingly bureaucratic IBM did, but can you imagine how frail the PC revolution would would be if only IBM had ever sold PCs, without the slew of competitors that emerged, and if every innovation had to pass the scrutiny of a government review board before it could be launched?   Only a tiny percentage of PC innovation and of what we think of as a PC today, mostly in the basic architecture, ever came from IBM.

The very problem is that when government runs computers or health care, innovation is seen as a cost.  Klein, by asking the question in this way, is betraying exactly what is fundamentally wrong with a single-payer system.  The single-payer tends to think in terms of trying to deliver the current value proposition (ie the 2009 level of health care technology) as cheaply as possible.  The problem is that in 2039, it will still be focused on delivering the 2009 level of health care technology.  For the government -- a new drug, a new procedure, a new test -- these are all incremental costs, to be avoided.  Klein just wants a number he can plug into budget projections to say, "see, innovation is covered."  Its like Wesley Mouch asking John Galt near the end of Atlas Shrugged to tell him what orders to give.

I wrote about it just the other day.  You can see it in everything the Left writes -- increased spending is equated with increased costs which are therefore bad.  They all say that America's health care spending is rising and our per capita spending is higher than other nations and that this rising spending is somehow a problem to be fixed.  But there is a value side of the equation.  What are we getting from the spending?  When you leave out things the health care system can't do anything about (homicides and fatal accidents) Americans have the longest life expectancy in the world.  We are getting something for that extra money.  It is not just "cost" to be contained.  Is a year of life worth an extra $100,000 spending?  Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the tradeoff for them.

But, the left will say, we will put really smart people on this board, who are angels of public service, who will make perfect decisions on the price-value tradeoffs of innovation (have you noticed that all their programs seem dependent on this assumption?)  Back to our computer example, these guys, they would argue, would have been smart enough to have given Jobs and Wozniak the green light.  This is a fantasy.  It never happens.  No matter how good the people, every such government entity is driven by its incentives, and this group's incentives will be to cut spending.  Innovations that result in a net total increase in spending are not going to be well-received.

Further, these boards get politicized, always.  Companies will quickly learn they have a better chance, say, of getting a new breast cancer treatment rather than a new prostrate cancer treatment past the board because the current administration is closely tied to women's groups.  Just look at current government R&D spending, this already happens.  AIDS was under-funded given its mortality because Conservative administrations thought it a disease mainly of groups it found distasteful; today, women's cancers get far more funding than men's due to the strong political activism of women's groups and the success of the pink ribbon campaign.  Drug companies will learn that the quickest way to board approval may not be winning over the board, but getting certain interest groups to lobby the board, or maybe lobby Congress to override the board.  Just look at the promise not to politicize ownership of GM -- that lasted about 2 days before Congress was passing legislation reversing internal GM decisions and GM was making plant closures based on political rather than economic concerns.

But even beyond these problems, there are Hayekian ones as well.  In the mid-seventies, there might have been only a few thousand people who were excited enough to buy an early microcomputer and see its potential.  What are the odds that one of those folks would be on the government review board, particularly since few of them were in the mainstream establishment of the computing field (heck, few of them were over 19 years old).  And even if one were on the board, would they have approved a technology with only a few initial adherents?  The fact is innovation often requires adoption of bleeding edge risk-takers who are willing to try a new technology and iron out its kinks before the mainstream catches on.   The iPod was not the first music player -- a few of us struggled for years before the iPod with large and sometimes hard to use early mp3 players  -- but if these early MP3 players had not existed, the iPod would not exist.

Perhaps most importantly, everyone makes different tradeoffs.  It may make perfect sense for some person in Washington that a biopsy is not required for certain kind of positive cancer test results.  This may make perfect price-value sense to the beauracrat, but I know a number of people who would lose months or years of their life to worry -- worry that could be short-circuited with an inexpensive biopsy.   Or consider a new cancer treatment -- is a year of life worth an extra $100,000 spending?  Would I prefer to extend my life through chemo or increase the quality of life of the time I have left by avoiding chemo?   Everyone has a different answer, which is why we typically let each individual make these tradeoffs, and why people are uncomfortable having someone in the Post Office make the decision for them.

One could say that all of this does not answer Klein's question.  That is because his question, built on the wrong premise, is unanswerable.  I suspect he knows this and is, as Brad Warbiany posited in the link above, just setting up a straw man.  All I can do is try to give a feel what what innovation does require, and help folks to understand that it has little if anything to do with Klein's question.

So, if I had to come up with a pithy one sentence answer, here it would be:

Klein:  What level of spending on health care is optimal for innovation?

Me:  The very fact that you intend to control spending centrally, at any level high or low, is what kills innovation.

Postscript: For a totally different reason, I was reading this article on the Russian T-34 tank, probably the best all-around tank for its time ever made when considering its production volume (the Panther was theoretically a better tank but volume production of the scale of the T-34, not to mention mechanical reliability, eluded the Germans).  Apropos of government boards and innovation was this:

The L-11 gun did not live up to expectations, so the Grabin design bureau at Gorky Factory No. 92 designed a superior F-34 76.2 mm gun. No bureaucrat would approve production, but Gorky and KhPZ started producing the gun anyway; official permission only came from Stalin's State Defense Committee after troops in the field sent back praise for the gun's performance.

The Baucus Health Care bill follows in the tradition of many other pieces of recent legislation in raising taxes in ways such that Congress can claim that it didn't actually raise taxes.  Here are four such taxes in the Baucus Bill  (note that no one that I know of has read any actual legislative language, so this is based on the press releases by the bill's authors.  Actual bill language can only be worse).

Employer Penalty is a Tax: In a step right out of Goldilocks, the Baucus bill will impose "penalties" on employers with no employee health care plan as well as on employers who have plans that are "too rich."  Never mind the insanity of the government micromanaging how an employer chooses to structure his compensation package to employees.  These "penalties" are structured as percentages of wages -- the one for having no health care plan was 8% of wages in the last bill.  This is a direct tax on employment, making hiring people more expensive (effectively the same magnitude as doubling the Social Security tax).  So how does this effect the average person?  Think of it this way, for the same wage, you job will be more expensive to a company that it was before the bill, making it less likely you will get hired at that wage.

Insurance Mandate as a Tax: The mandate that everyone must have insurance is a tax on the young and the healthy, as I explained previously:

People focus too much on the penalty itself being a new tax.  But the new tax is actually the requirement that individuals buy a product (in this case a health insurance policy) that they feel has no value (or else they would purchase it of their own free will today).  The government stopped pretending long ago that these younger middle class families will get much value from such a policy.  In fact, if they did get value commensurate with the premiums they will be paying, the mandate would not be achieving its purpose.  The whole point is that healthy people pay more into the insurnace system than they get back to support sick people.  If that payment is mandatory, then it is a tax, even if it is called an "insurance mandate" instead.

In fact, this is made all the more clear when politicians also suggest that cheaper high deductible health insurance plans be banned, as they were in Massachusetts.  Again, the whole point is to get young healthy people to overpay for insurance, and allowing them to buy sensible, cheaper, high deductible insurance defeats the whole purpose.

In fact, the bill's supporters have explicitly discussed requirements that insurance companies raise the price of insurance to the young and healthy to help reduce premiums for the old and, er, politically more active.  This is a redistributive tax, hidden within an insurance rate structure that will be heavily regulated by Congress.  Though don't expect Congress to admit this when young folks start to complain, they will say "blame the insurance companies."  Which is the whole beauty of such a hidden tax.

Corporate Taxes as Consumer Taxes: The plan would place new excise taxes on insurance companies, drug companies, and medical device providers.  But these taxes, particularly in the low margin insurance businesses (Yeah, I know if you only listened to Obama, you would never realize they were low margin but they are) just get passed onto consumers in the form of higher prices.  Congress knows this, but pretends it doesn't happen, so it can tell the economically ignorant that it hasn't raised taxes on consumers, and that rising prices are all the fault of the evil insurance companies blah blah, you know the drill.

Price Controls as a Tax: A large part of the Baucus Medicare savings is instituting price controls on doctors and other medical suppliers --  basically cutting their reimbursement rates.  This, by the way, just confirms what we all have known, that Obama and the Democrats don't have some mysterious win-win way to cut medical costs.  The only levers they have are 1. Price Controls and 2. Denying care.

There is absolutely no difference to a doctor between price controls and a tax.  A cut in the reimbursement rate from $50 to $40 is the same as having a 20% tax put on his $50 reimbursement.  Again, price controls in this context are just a way of hiding a tax.

And this might be the most dangerous tax of all, as such price controls always, by the immutable laws of economics accepted by monetarists and Keynsians alike, reduce available supply.  Doctors, for example, are going to be less willing to stay in the medical profession.  The result is inevitably shortages and long waits, something that should surprise absolutely no one as shortages and queuing are endemic in every government health care system in the world, starting with liberal darling Canada, whose citizens get medical treatment quickly only by crossing the border into the US.

Kevin Drum presents this chart:

Look at the top and the bottom of the chart.  The top says "growth of health care costs" while the bottom says "average annual percentage change in total health expenditures."  Drum goes on in his post to use rising expenditures and rising costs interchangeably.  I responded in the comments:

You Want to Know Why Medical Care Is So Expensive?  Because the government has passed numerous laws to help medical practitioners enforce their monopoly on numerous medical services.

Today I encountered an egregious example.  1-800-Contacts will not ship my contact lens order.  Seeing that my 1-year prescription was about to run out (but still valid for another week, it expires on the 18th), I ordered a bunch of boxes of my daily lenses to see me through some more months.  The retailer called my eye doctor, who confirmed that the prescription was still valid but that the doctor would only allow me to buy one box because he wanted me to return for an exam soon.  They confirmed this by email:

Thank you for choosing 1-800 CONTACTS. While we were verifying your prescription, your eye care provider informed us that your prescription will be expiring soon. Unfortunately, this means that we are unable to ship your order....

But then we get to the real point

Also, if you would like assistance scheduling a new exam, we can help! We have a network of doctors with convenient locations and hours....

Sincerely,

The Doctor Network Team at 1-800 CONTACTS

So the email is not even from the customer service department.  It is from their doctor network.  Its clear the requirement is all about pumping up the eye doctor business.

I remember a Dilbert cartoon (or maybe it was the Far Side) where one copier repairman was pointing into a copier and telling the other that he should "set this dial for when he wanted to return."  We all have suspected something like this exists in copiers, but for all the dark humor, it really exists in the medical profession.

Why should the government force me to pay the doctor for as many visits as the doctor wants just to be able to purchase contact lenses?  One could argue this is for eye health or some happy BS like that, but we don't require everyone to visit the eye doctor at the doctor's pleasure, just people with bad vision who have daily wear contacts.  There is not, to my knowledge, any correlation between glaucoma and contact lens wearing, so why do I face such a government mandate while someone with 20/20 vision does not?

Further, why can't I self medicate on contact lens selection?  I know people who have been raised to be submissive sheep deferring to the almighty medical degree gasp at such a suggestion, but why not?  Because I have problems with both near and far sightedness, my choice of contact lens strength is a tradeoff anyway.  If I can see well long distance, I can't read anything without reading glasses.  Back off a bit on the far vision, allowing a little blurriness in one eye, and I can read in an emergency without my glasses.  I chose my own lens strength, and my doctor then wrote a prescription for it.  Why can't I just do this on my own, say with a trial kit of lenses from the manufacturer.  (for those who think it might be a size issue, there are only about 3 sizes in this type of lens, and they are far enough apart that once a size is selected, they are likely that size forever).  It's fine if people want to do this under a doctor's supervision, and I would certainly get into the doctor every two or three years, but why must the government mandate I go in more frequently, at the doctor's pleasure, not mine?

This kind of thing exists ad infinitum in the medical profession, with government mandates helping to protect over-educated professionals from lower-cost competition.  Why do I have to go to a dentist's office to get my teeth cleaned?  Why do I need someone with 12 years of medical training to put three stitches in my knee?  Why do I need a fully trained doctor to take me through the basics of a routine physical?  Why does Viagra require a prescription -- I mean, doesn't the doctor just take my word there is a problem, or is there actually a doctor out there who sends in hot nurses to prove whether I have an erectile problem?  OK, I might not begrudge that particular doctor visit.

Bruce McQuain points out something I think has not gotten enough attention in the health care bill.  The new taxes being proposed start in 2010, but the benefits don't begin until 2013 and are phased in through something like 2018.  That means for any 10-year budget look, there are 10 years of taxes but only 6-7 years of benefits.  And even with this trick, the plan STILL adds a trillion dollars to the deficit, even before the certainly more pessimistic CBO numbers come in.

Mark Mix has an article in the WSJ on various paybacks to unions buried in the current health care bill.  The steps range from forced-unionization of certain health care professions to direct subsidies of union health care funds to exemption of union health care plans from the rules everyone else will have to follow.

Update: The Greg Conko study also looks good, but I am only part way through it.

The leftish political strategy for over 100 years has been

1. Regulate something
2. Blame the free market for inevitable disruptions caused by the regulation
3. Use the above to justify more regulation
4. Repeat

Obama's speech has a classic example of this:

So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition. Unfortunately, in 34 states, 75% of the insurance market is controlled by five or fewer companies. In Alabama, almost 90% is controlled by just one company. Without competition, the price of insurance goes up and the quality goes down. And it makes it easier for insurance companies to treat their customers badly "“ by cherry-picking the healthiest individuals and trying to drop the sickest; by overcharging small businesses who have no leverage; and by jacking up rates.

This is ENTIRELY a situation manufactured by government and specifically state regulations.  States prevent out of state insurance companies from competing in the health insurance market.  Think you have the same Blue Cross/ Blue Shield I have (or used to have)?  Wrong.  I have Blue Cross/Blue Shield of Arizona.  You have Blue Cross/Blue Shield of whatever state you are in.  If Amazon.com had to create 50 separate state entities all with wildly different regulatory structures, you can bet they would focus on just a few states and there would therefore be a lot less competition.  Obama HAS to know this is true, so this is just a cynical argument aimed at the ignorant and uninformed.

By the way, what evidence is there that having 75% of the market in 5 companies is too concentrated?  I have been in a lot of industrial markets that were far more concentrated than that which were brutally competitive.

Two excerpts from Obama's speech:

That's why under my plan, individuals will be required to carry basic health insurance "“ just as most states require you to carry auto insurance.

Oh, jeez, I sure wish that were true.  Auto insurance covers only catastrophic damages, such as totaling your car or incurring serious liability by hurting someone.   It does not cover regular repairs, preventative maintenance, etc.  Also, state-mandated auto insurance has a range of coverage caps -- if you want a higher cap, you can pay for it.  No one expects their company to pay their auto insurance, and if a company were to provide it it would be considered a taxable benefit.  Compared to our current health insurance system, auto insurance-like health insurance would be a brilliant improvement.  Despite his making this analogy, this is absolutely NOT what he is suggesting.  Also from his speech:

Under this plan, it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies

Update: OK, here is another good pairing, from the same source -- first, he says that a public option will not be subsidized:

They argue that these private companies can't fairly compete with the government. And they'd be right if taxpayers were subsidizing this public insurance option. But they won't be. I have insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects.

But then he makes this comparison:

It would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities.

See?  The public option will not be subsidized and will work just like public universities which are highly subsidized.

By the way, it is almost impossible for government NOT to subsidize such an entity, in part because of the way government accounting differs from private accounting.  Government accounting is on a cash basis, so large up front investments show as a first year loss with no future expense implications.  In operation, it means capital spending is pretty much free.  And numerous charges that private firms take on, such as liability insurance, are not charged for on government books.   I compete with the government a lot, and have investigated this dynamic in depth.  Even why my costs are lower, the government, because of the way it accounts for things, often thinks its costs are much lower than mine and they under-price us.

Tonight, Obama reduced the number of "uninsured" Americans he is trying to help from 47 to 30 million.   Megan McArdle hypothesizes that he has dropped immigrants and illegal aliens from the number to avoid the political fallout from paying for these groups.

But we can also further drop the number from 30 million to 18 million, because 12 million people are in a category "reform" supporters say could afford insurance today but choose not to buy it.  Rather than being helped by the plan, these 12 million will be expected to either buy insurance they don't want or need or else face severe penalties from the feds:

Under the plan, people who earn between 100% and 300% of the poverty level (or between about $22,000 a year and $66,000 a year for a family of four) would face fees ranging from $750 to $1,500 a year.

For taxpayers with incomes above 300% of poverty, the penalty starts at $950 a year and reaches as high as $3,800 for families. Nearly 12 million people fit in this category, according to the National Institute for Health Care Management.

The idea behind the penalty is that those who can afford insurance but don't buy it are imposing costs on the entire health system. Under the proposal, nearly 12 million people who currently have no insurance could be subject to such fines, according to figures compiled by the National Institute for Health Care Management.

It is hard to argue these 12 million are being helped.  In fact, they are the milch cows helping to pay for the program, giving the lie to Obama's promise not to raise taxes on the middle class.

But of these remaining 18 million, as many as 10-14 million are eligible for Medicare, Medicaid, or SCHIP and are simply waiting until they need medical care before signing up.

Every time anyone counts it, there are about 8-10 million truly hard core poor and uninsured.  So we are going to screw up the medical care for the other 290 million of us to help these guys?   As I said before, this country is generous and if one were to point out a segment in true need, the money would likely be made available.  What concerns most people is not the libertarian fears I have of more spending and government, but the fear that helping a few folks will mean worse care for everyone else.  The analogy I have used many times is that people don't have a problem contributing to public housing for the poor (even if it turns out to suck), but they do have a problem if they are forced to leave their own home and enter the crappy public housing as well, in the name of some misplaced notion of egalitarian "fairness."

From Andrew Coulson.  Math and reading scores probably underestimate changes in learning (e.g. doesn't account for increased need to teach computer skills in this timeframe).  But discourse on education often seems to assume the blue line is flat to down.    It is interesting that among the left, this chart is proof that we need to spend more money while the exact same chart in health care (say with scores replaced by life expectancy) is proof we need to spend less money.  In fact, the health care chart would look better, because at least there the key metric of quality has increased over time.

Update: Here are the life expectancy stats, showing much more progress than education (despite being suppressed by an increasing murder rate in the period -- to really make it a metric of health care you need to pull out accidents and homicides).  So both health care and education spending go up a lot.  Education results show no improvement.  Health care results show strong improvement.  But education needs more money and health care less?  You'd almost think people's opinions on this were based more on feeding government run institutions and starving private ones, irregardless of results.

I posted the other day that one explanation of rising health care expenditures in the US is rising wealth.  As we are wealthier than other Western nations, doesn't it make sense we would spend more on our health than other nations.

James DeLong adds:

Robert Fogel, in his NBER paper, which has more detail than his American article (and will cost you $5), looks at changes in U.S. consumption patterns from 1875 to the present. A striking number is the reduction in the costs of the basics -- food, shelter, clothing took 74% of income in 1875; 13% in 1995. This has freed up a lot of income, and one of the great gainers has been health. In 1875, it took only 1% of consumption, largely because there was little to be bought, except for patent medicines loaded with alcohol and opiates, or a saw to lop off an injured limb. By 1995, it was 9%.Leisure was another big gainer -- 17% in 1875; 68% in 1995.

So if improvements in medical technology lead people to reallocate money toward health, fine.

The WSJ is reporting that Obama's speech will propose:

Starting next year, the plan also calls for annual fees of $6 billion on health-insurance providers, $4 billion for medical-device makers, $2.3 billion on drug makers and $750 million on clinical laboratories. The fees would be levied on individual companies based on market share.

Don't you love that, by the way.  The benefits are not programmed to begin until 2013 but the taxes start in 2010.  But let's rewrite this paragraph to be less economically ignorant:

Starting next year, the plan also calls for annual fees of $6 billion on customers of health-insurance providers, $4 billion for customers of medical-device makers, $2.3 billion on customers of drug makers and $750 million on customers of clinical laboratories. The fees would be levied on individual companies based on market share, then passed on to their customers in the form of price increases, as are all such fees, particularly on low-margin industries such as health insurance.

Congratulations.  Obama has embarked on his quest to reduce the cost of health care by increasing the costs of health care suppliers by over $13 billion per year.  That should work.

For years I have been saying that the government has only one lever to reduce costs (as any thought that they might reduce costs through increased productivity is just a joke rebutted by all of history):  Force people to use less, either by raising the price, reducing the supply, or outright banning certain expenditures in certain situations.

For the betting man, here is the lock of the week:  Obama, in his Wednesday speech, will outline a plan that does one thing but describe it as something nearly opposite.  This is a common political game, so it always is a good bet with any politician, but Obama has sharpened this approach into an art form.

The more interesting bet, which is probably more like 50/50, is whether Obama will

1. Offer only incremental changes, to make sure he gets something passed he can call health care reform, but will describe it to the radical end of his base as sweeping change, -OR-
2. Offer nearly the exact same core plan that is in the House bill that has so many folks concerned, but via changes in wording and euphemisms describe it to a worried public as something much more moderate.

I am honestly torn as to which it will be.  How are y'all betting?

Kevin Drum shows this chart as evidence we need government health care like the rest of the "civilized" world:

I write back in the comments:

I wonder if the graph you show is a bug or a feature.  My guess is that you could draw the same chart in the same shape with the US on the far left for consumption of items as diverse as "big screen TVs" and "pro sports tickets."  We would chalk up spending in any other area as simply a result of wealth.  Why not on health care?  Why is it so bad that we spend more money on something like health care which is arguably less frivolous and more critical than TV's or baseball games?

I would understand it if the argument was that we are not getting our money's worth, but that meme is just about dead.  The evidence is pretty clear that though life expectancy in the US is lower than some of these other countries, this is due to issues unrelated to health care (specifically murders and auto accidents).  When the cause of death is limited to things amenable to the health care system, the US ranks #1 in the world in life expectancy.  This is not even to mention the customer experience in accessing the health care system, which for all its irritations, is still ranked the best in the world.  We pay the most, and get the best results, because we can afford the best.

It makes me nervous that you think this is a problem.

PS- I certainly think there are efficiencies that could be wrung out from the health care system if people actually shopped with their own money for their own health care, as they do for every other product and service they buy.  This is proved out in the falling prices for non-insurance covered health procedures, such as laser eye surgery.  But it is a laugh to think the government will wring these savings out.  The government has never, ever, ever made a process more efficient.  All it can do to cut costs is a) institute price controls on suppliers, which eventually lead to shortages and reduced R&D and/or b)  Eliminate services.

Update: OMG, we need government take over of the automotive sector, because we spend more money on cars than any other country, and by the left's logic that is a sign of failure of the status quo.

Via Steve Chapman at Reason:

[President Obama] says though the United States spends more per person on medical care than any other nation, "the quality of our care is often lower, and we aren't any healthier. In fact, citizens in some countries that spend substantially less than we do are actually living longer than we do."

That's one of the favorite rationales for a government-led overhaul. But it gives about as realistic a picture of American medicine as an episode of Scrubs.

It's true that the United States spends more on health care than anyone else, and it's true that we rank below a lot of other advanced countries in life expectancy. The juxtaposition of the two facts, however, doesn't prove we are wasting our money or doing the wrong things.

It only proves that lots of things affect mortality besides medical treatment. Heath Ledger didn't die at age 28 because the American health care system failed him.

One big reason our life expectancy lags is that Americans have an unusual tendency to perish in homicides or accidents. We are 12 times more likely than the Japanese to be murdered and nearly twice as likely to be killed in auto wrecks.

In their 2006 book, The Business of Health, economists Robert L. Ohsfeldt and John E. Schneider set out to determine where the U.S. would rank in life span among developed nations if homicides and accidents are factored out. Their answer? First place.

That discovery indicates our health care system is doing a poor job of preventing shootouts and drunk driving but a good job of healing the sick. All those universal-care systems in Canada and Europe may sound like Health Heaven, but they fall short of our model when it comes to combating life-threatening diseases.

I have seen several folks of late testing out a meme that opposition to health care reform is mostly about churlish unwillingness to help people.  My sense is that this is dead wrong.

As a strong libertarian, that may well be my motivation.  But the vast majority of Americans accept and support the government safety net and generally will support reasonable expansions of it to address true need.   I think most Americans would be willing to help people who honestly need financial aid to pay the health care bills.  This is particularly true for children -- you don't remember people going ballistic over SCHIP, do you?

I am not representative.  The vast center of this country is willing to accept, even embrace, increased government interventions in the right cause.  I forgot to blog on it, but remember that poll a few weeks ago that a majority of Americans think the government should required that women take their husbands last name after marriage?  I think the notion that there is any kind of sizable block of small government libertarian type folks out there is simply a myth.

So health care intervention and spending can be sold - again remember SCHIP but also the prescription drug bill.  I think the Administration is having trouble selling it in this case for two reasons:

• They are having difficulty showing people who truly are not getting care.  Sure there are a lot of people who are uninsured, but I think that meme has been around enough for people to deconstruct.  Who isn't getting care?   Sure, for some folks getting care is a real hassle, but there are arguments to be made that accepting charity should not be that easy (remember the old Welfare?)  And sure, some folks have financial straights and can even face bankruptcy over health care bills, but our bankruptcy laws are incredibly generous and when tens of thousands are facing bankruptcy because they bought too many TV's on their credit cards, it almost seems honorable to face bankruptcy over your wife's cancer treatment.
• The second problem is what I call the public housing problem.  In the late 1960s, Americans were concerned about the poor and homeless and spent billions to build housing projects for them.  It turns out that this doesn't work out so well, but that is not my point.  My point is that Americans could be convinced to spend money to build poor people government homes.  BUT their position would have been very different if investments in public housing required the rich and middle class who were paying for the program to move out of their homes and into public housing as well.That is the fear that I think much of America has today.  If asked, they would likely pay to provide government health care in an instance where it was demonstrated that health care was entirely lacking.  They would likely suspect that such care, like much of public housing, would suck, but as it was being offered to someone who supposedly had nothing, it would represent a net improvement.  But they don't want to move into the projects themselves, and frankly don't understand why agreeing to help poor people afford more health care also means they have to move into the government system themselves.

The whole "health care rationing" debate is reaching new levels of absurdity.  In part, this is because the very term "rationing" is a confusing misnomer.

So here is what it boils down to:  For every product or service purchase, someone makes a price-value trade-off to determine if that product or service should be purchased for a given price in that particular instance.

One option for making this decision is to have the person who actually will consume the product or service -- and whose money will also be used to complete the transaction -- make this price-value tradeoff.  This is how we make these decisions for just about, um, absolutely everything that gets purchased.  Since it is your money and you are the one who will enjoy whatever is being purchased, it makes sense that you make the decision - is the price worth it?  Do you buy a cheaper substitute?  Do you do without?

A second way to do this would be to have someone who has you specifically in mind make the price value tradeoffs for you.  This might be like your wife volunteering to go out to buy you some new underwear.  While results may be superior for this approach in a few cases (e.g. my wife buying me clothes), in most cases this approach is fraught with information asymmetries that will likely lead to a suboptimal purchase.  Consider, for example, my wife buying me the cheap 28" TV when I had wanted to drop the big bucks on a 60" beauty.

If one were sloppy, he might say that this second approach is the role that exists with insurance companies or is being proposed for the government.  But this isn't the case.  Because these third parties are NOT making the decision with me and/or my personal preferences in mind.  They can't.  While my wife may have an imperfect understanding of my preferences, a government health board has none.

So a third model, and almost certainly the worst in terms of individual satisfaction, is to have a third party make price-value tradeoffs for me only with some notion of average preferences for average people, or worse, with an incentive system that has absolutely nothing to do with my satisfaction at all.  This is clearly the case for the government, and is probably the case for many private insurers today -- though at least in the latter case one could imagine a regulatory regime that allowed for much more competition and a range of offerings with different service levels and pricing, such that I was more likely to find a pairing close to my preferences than I would in a one-size-fits-no-one government regime.

Skeptics worry that such a range of choices would not exist under private competition, but in fact it does in every single market where the government allows it.  Take grocery stores, since the President of Whole Foods has come into so much criticism from government health care promoters.  The choices in grocery shopping are simply staggering -- just think what different price/value points Wal-Mart, Whole Foods, Safeway, AJ's, and the farmers market offer.

I am constantly amazed when people say that government health care is no different than private competitive models because there will always be rationing.  If you cannot see the difference between "rationing" for yourself based on your own budget and preferences and "rationing" by government committee, well I suppose you deserve what you get.  Except for the problem that unfortunately, I will be forced to take it too.

A Cafe Hayek Reader asks:

Imagine we had entirely private health insurance market "“ no Medicare or Medicaid.  If I live to be sixty-five, I will probably have a personal and/or family history that indicates a strong probability of developing an expensive chronic condition. I would wager that is true of almost all sixty-five year olds.

So here is my question: which insurer in their right mind would take on my risk?

I suspect none. Once philanthropy and savings were exhausted, I would surely risk a painful life and preventable death.

Do I want this? Does anyone? Isn't "socialized" medicine for older people an unpleasant moral necessity for our wealthy society? Please note I am deeply suspicious of most arguments cast in moral terms in discussions of politics and economics. I ask these questions guardedly.

I answer in the comments:

Imagine we had entirely private life insurance market "“ no government options at all. If I live to be sixty-five, I will probably have a pretty high probability of dieing in the next 15 years or so. I would wager that is true of almost all sixty-five year olds.

So why would anyone insure me?

Because the life insurance market has developed a very reasonable solution to this -- you negotiate a term life rate for X number of years. Your rate might be Y a year for 10 years, or 1.5Y a year for 20 years, or 2Y a year for 30 years. The longer the rate guarantee, the higher the rate. You are explicitly paying higher rates than you might have in younger, less risky years to make sure you get a coverage guarantee at an affordable rate in later, risky years.

Of course, if you play the grasshopper and never buy insurance until you are 65, your price is going to be awful. But I don't think it is a reasonable role for government to do all kinds of individual-liberty-defying and costly things just because you did not take responsibility for your old age earlier in life. However, saying that, I of course know that this is EXACTLY what the government does with Social Security.

I have a high deductible individual insurance plan from Assurant who specializes in insuring individuals, and they have been evolving to a pricing model sort of similar to the term life model I listed above, though they are not quite there yet.

To the folks that say this is no solace for folks already 65, that is an implementation transition issue, not an argument against the market's ability to deal with this. Certainly a lot of folks have paid Medicare taxes for years and are counting on it. Some kind of phase out, possibly where the government redirects Medicare funds to make up the difference in policy prices for having not started locking in earlier, is possible. But the question was not an implementation question - it was a question of whether the market inherently fails for 65-year olds, and I think the answer is that it does not. We have a perfectly serviceable analog in life insurance to prove it

I call this the "failure of imagination" argument against free markets.  Some sector of the economy (such as education) has been dominated by government for so long that folks can't imagine a private model.  For example, when I argue for private grade school education, I can't tell you how often people say "private schools are all really expensive, no one could afford them."  Private schools are expensive because in the current government model, the only market niche for private schools is for families that can afford to pay the government for education they don't use and then pay a second time for a private school.

Congress now understands that the majority of the public has deep concerns about their government health care bill.  So, they are responding by ... finding new and creative legislative approaches to a) avoid public scrutiny of what they are actually putting into the bill and b) reduce the number of votes they need for passage.  Kevin Drum explains the game:

The latest trial balloon from the Democratic leadership is that they might split healthcare reform into two bills.  The first would have all the controversial provisions and would go through the reconciliation process, where it needs only 50 votes.  The second would go through the normal process and therefore need 60 votes, but since it includes the stuff that's widely popular it would pass anyway.

I told you weeks ago they were going to pass this pig no matter what it took.  So now the only real floor vote will be on percieved benefits (more coverage, more spending, consumer mandates) while the costs, taxes, and individual restrictions will get done in the back room, where blue dogs can disavow any responsibility.

If this becomes unstoppable, I think the Republicans should make a high profile effort to move the implementation date up from 2013 to well before the next presidential election.   You can always tell whether legislators know in their hearts if something they are passing is really going to suck for a lot of people.  They push the implementation date back  (despite the fierce moral urgency to hurry up on this, as we are told) to after the next election.