Coyote Blog

A while back I wrote about how hard it was to get in to see an ENT here in Phoenix.  I finally got my ear infection diagnosed by one of those local walk-in emergency clinics that are popping up in malls.  They prescribed antibiotic pills and drops, which I took diligently for 10 days.

My ear stopped hurting, but the hearing did not clear up.  Eventually, it started hurting again and my hearing was really blocked.  Fortunately I had held onto my appointment I made weeks ago with an ENT, and went in yesterday.  Apparently, I had an enormous fungal infestation.  The bacteria competes with the fungus normally and keeps it in check.  Once the bacteria were temporarily wiped out, the ecosystem in my ear canal was out of whack and the fungus went crazy.

The doctor vacuumed out an absolutely disgustingly large chunk of, uh, gross stuff from my ear and it was immediately better.  He put some topical cream on it, and it feels great this morning and my hearing is back.

Update:  I am not trying to make any point about the health care system.  I got perfectly good service from both doctors, though I was frustrated it took so long to see an ENT.  I find the whole microscopic ecosystem on and in our bodies fascinating, so I overshared on this experience.  I saw something the other day about twins, one of whom was fatter and one of whom was thinner, with the differences attributed to differences in the bacteria in their gut.

From our favorite politically-blinkered economist who used to be smart:

Chait stresses the youth aspect:

Fortunately for Obama, this field of battle favors his side. To pass the law, he needed to win over skeptical senators. To defend it in court, he needed conservative jurists. But identifying and persuading young people is a battle Obama does not expect to lose to Republicans, and in place of the federal outreach funds, the administration is deploying a campaignlike array of weapons: microtargeting, including door-to-door outreach, and all forms of media. (A few weeks ago, Katy Perry tweeted out a link informing her 42 million followers that health care was available beginning October 1.)

Yep, when it comes to reaching hipsters, or young people in general — I know, Katy Perry — Dems have big advantages; all that coastal cultural elite hatred suddenly turns into a big disadvantage for the right.

A couple of thoughts:

• Katy Perry is part of the cultural elite?  We have sure dumbed down that concept.
• As to Ms. Perry, whose music is actually a guilty pleasure of mine, health care has been available to your twitter followers all their lives, not just beginning October 1.  A better way to put this is that, as of October 1 you will be forced to buy some amount of health care whether you want it or not.  
• The whole campaign aimed at young people is simply obscene.  I understand that folks like Ms. Perry honestly believe that young people are getting a better deal, and that she is doing them a service.  Fine, millionaires can be low information voters too.  But people in the Administration have a much more cynical purpose, which explains the magnitude of the campaign described by Chait:  For Obamacare to work and not be a fiscal disaster, it depends on young people overpaying for health insurance.  The Administration knows that young people are overpaying -- the whole system depends on it -- and yet they are telling them it is in their interest to sign up.   A private company that did this would be in jail.
• I think this whole campaign is going to fail due to a basic fallacy of Progressive thinking.  Progressives are convinced that consumers are helpless dupes of advertising.  They in fact criticized health care advertising expenses in the private world for years for this reason, making this whole campaign incredibly ironic.  Obama and company are convinced that with enough advertising, average consumers will buy anything, even if it is a bad deal, because they are convinced that this is how consumer capitalism works (it got him elected, didn't it?)  I think they are going to be disappointed.

I find Republican strategy in the recent Obamacare and budget fight to have been insanely aggravating, and that is coming from someone who hates Obamacare.

Yes, I understand why things are happening as they are.  From a re-election strategy, their approach makes total sense.  A lot of these House guys come from majority Republic districts where their biggest re-election fear comes from a primary challenge to the right of them.  I live in one of these districts, so I see what perhaps coastal media does not.  In everyday conversation Republicans are always criticizing their Congressmen for not rolling back Obamacare.  Republicans need to be able to say in a primary, "I voted to defund Obamacare".  Otherwise I guarantee every one of them will be facing a primary opponent who will hammer them every day.

But from the perspective of someone who just wants the worst aspects of this thing to go away, this was a terrible approach.  Defunding Obamacare entirely was never, ever, ever going to succeed.  Obama and Democrats would be happy to have a shutdown last months before they would roll back his one and only signature piece of legislation.  They may have caved in the past on other issues but he is not going to cave on this one (and needs to be seen not caving given his recent foreign policy mis-steps that has him perceived as weak even in his own party).  And, because all the focus is on Obamacare, we are going to end up with a budget deal that makes no further progress on containing other spending.

The Republicans should have taken the opportunity to seek targeted changes that would more likely have been accepted.  The most obvious one is to trade a continuing resolution for an elimination of the IPAB, one of the most undemocratic bits of legislation since the National Industrial Recovery Act.  Another strategy would have been to trade a CR for a 1-year delay in the individual mandate, a riskier strategy but one the Administration might leap at given that implementation problems in exchanges are giving them a black eye.  Finally, an even riskier strategy would have been to tie a CR to a legislative acknowledgement that the PPACA does not allow subsidies in Federally-run exchanges.  This latter might not have been achievable (and they might get it in the courts some day anyway) but if one argues that any of these is unrealistic, then certainly defunding Obamacare as a whole was unrealistic.

I think as a minimum they could have killed the IPAB, but now they will get nothing.

Update:  This line from All the President's Men seems relevant:

You've done worse than let Haldeman slip away: you've got people feeling sorry for him. I didn't think that was possible. In a conspiracy like this, you build from the outer edges and go step by step. If you shoot too high and miss, everybody feels more secure. You've put the investigation back months.

A couple of weeks ago, I started losing hearing in one ear.  A bit later, it started to hurt.  Suspecting an infection, I called my ENT's office.  They said they couldn't see me for four weeks, and would not let me switch to see anyone else in their 10-person practice (against their practice rules, which raises the question of, from a customer point of view, why there is any benefit to a large practice at all -- the large pool of doctors provides the illusion of more customer service capability but in fact the sole logic of the practice is cost-sharing of overhead and support staff).  So eventually I just went to one of those walk-in urgent care clinics in a strip mall near me and had the GP there look at it.  I found that I did in fact have an infection and got an antibiotic scrip and some drops and was told if it did not get better in 7 days, go see a specialist.

So it has been a week and the pain is mostly gone but I still have lost most of my hearing in the ear.  So I tried to make an appointment at my ENT again -- 4 weeks.  I described my situation, and said something seemed wrong.  4 weeks.

So I talked to two friends who are both semi-retired ENT's.  They said to get my butt to a doctor ASAP because it could be nothing or it could be something really bad that needs immediate intervention.  But no ENT would see me for weeks.  So one of my friends said they would help me, but they needed audiology tests.  Turns out, those are being scheduled 3 weeks out.  I finally called in a favor with a friend of a friend and found someone to test me next Monday, just four days from now.  Four days seems a long wait for something that could be an emergency, but it beats the hell out of 4 weeks.

This is what we have done to the practice of medicine.  With a myriad of professional licensing requirements and regulatory burdens that raise the fixed cost of opening a practice, we have managed to simultaneously raise prices while limiting supply.

I am not going to add to the confusion on this.  For a lot of people who already have health insurance, the answer will be "maybe".  Older folks and folks with health problems may see less expensive policies, and younger people will likely pay more.

I do, however, want to add two observations that are often lost in this discussion:

• For the millions of people who have chosen not to buy health insurance and now will be forced to do so by law, they will certainly be paying more.  Anything is more than the "zero" which has been these peoples' preference to date.
• A more interesting question is:  what will happen to premiums in the second year.  Right now, insurance companies are pricing as if all these young people who have not been buying policies will be forced to do so by the law (a key, maybe the key, funding source for Obamacare is forcing young healthy people to buy overpriced policies to subsidize older people).  What if they refuse?  After all, the penalties in the first several years are not very severe, and Obamacare removes any risk from not being covered, because if one gets sick he can just run and sign up then, like getting home insurance once your house is on fire.  The prices on the exchanges in 2014 will be very interesting.

As I linked in an earlier article, Kevin Drum and his commenters are justifying the Obamacare tax on tanning salons based in part on the fact that tanning (via skin cancers) adds to future health care costs, which now (via Obamacare and Medicare) will likely have to be born by taxpayers.

Frequent readers will know that I have opposed government paying for health care for years in part due to the incentive it gives the government to micromanage individual behaviors to reduce its costs (I call this the health care Trojan Horse).

But here is the simple question for today.  If individual choices and behaviors should be taxed if they add to health care costs (a proposition Drum sees as so self-evident that Republicans are Neanderthals for opposing the idea), then why isn't anyone suggesting a tax on sex?   I can't think of any discretionary behavior that has more implications for health care costs than sex.  There's contraception, abortion, STD's, pre-natal care, birth, and at least 18 years of juvenile health care with no taxes being paid.  Not to mention a new future Medicare recipient who, by current law, will pay in far less to the system than he or she will take out.

Kevin Drum preahces against the evils of teen tanning, which he follows with a conclusion that obviously Republicans are evil for opposing a tanning tax

Indoor tanning, on the other hand, is just plain horrifically bad. Aaron Carroll provides the basics:indoor tanning before age 25 increases the risk of skin cancer by 50-100 percent, and melanoma risk (the worst kind of skin cancer) increases by 1.8 percent with each additional tanning session per year. Despite this, the chart on the right shows the prevalence of indoor tanning among teenagers. It's high! Aaron is appalled:

This is so, so, so, so, so, so, so bad for you. Why don’t I see rage against this in my inbox like I do for diet soda? Why can’t people differentiate risk appropriately?

And who would fight a tax on this?

I am not going to get into the argument here (much) about individual choice and Pigovian taxes (by the way, check out the comments for a great example of what I call the Health Care Trojan Horse, the justifying of micro-regulation of our behavior because it might increase government health care costs).

I want to write about risk.  Drum and Carroll are taking the high ground here, claiming they are truly the ones who understand risk and all use poor benighted folks do not.  But Drum and Carroll repeat the mistake in this post which is the main reason no one can parse risk.

A key reason people don't understand risk is that the media talks about large percent changes to a small risk, without ever telling us the underlying unadjusted base risk.   A 100% increase in a risk may be trivial, or it might be bad.  A 100% increase in risk of death in a car accident would be very bad.  A 100% increase in the risk of getting hit by lightning would be trivial.

Last year I predicted that the biggest economic story of 2013 would be the end of full-time work (due to Obamacare) in the retail service industry.  I seldom make predictions, but wrote that at the time because I was amazed that this shift to part time work was all we were talking about in the small business world, since for technical reasons in the law we had to have these changes in place in 2013, well before the 2014 start of the employer mandate.

The media world is finally catching up, particularly after recent jobs reports where the totality of net new job creation (and more) was in part time jobs.  Here is yet another story from the media finally noticing a business conversation that has been going on for almost a year:

Employers around the country, from fast-food franchises to colleges, have told NBC News that they will be cutting workers’ hours below 30 a week because they can’t afford to offer the health insurance mandated by the Affordable Care Act, also known as Obamacare.

“To tell somebody that you’ve got to decrease their hours because of a law passed in Washington is very frustrating to me,” said Loren Goodridge, who owns 21 Subway franchises, including a restaurant in Kennebunk. “I know the impact I’m having on some of my employees.”

Goodridge said he’s cutting the hours of 50 workers to no more than 29 a week so he won’t trigger the provision in the new health care law that requires employers to offer coverage to employees who work 30 hours or more per week. The provision takes effect in 16 months....

The White House dismisses such examples as "anecdotal." Jason Furman, chairman of the president’s Council of Economic Advisors, said, “We are seeing no systematic evidence that the Affordable Care Act is having an adverse impact on job growth or the number of hours employees are working. … [S]ince the ACA became law, nearly 90 percent of the gain in employment has been in full-time positions.”

But the president of an influential union that supports Obamacare said the White House is wrong.

"It IS happening," insisted Joseph Hansen, president of the United Food and Commercial Workers union, which has 1.2 million members.  "Wait a year. You'll see tremendous impact as workers have their hours reduced and their incomes reduced. The facts are already starting to show up. Their statistics, I think, are a little behind the time."

This has to be spin by the Obama Administration and not an honest belief.  There is no way they could have missed this:

In June, the household survey reported that part-time jobs soared by 360,000 to 28,059,000 – an all time record high. Full time jobs? Down 240,000.  And looking back at the entire year, so far in 2013, just 130K Full-Time Jobs have been added, offset by a whopping 557K Part-Time jobs.

I have written before that I think these changes are here to stay.  In some cases it is actually easier for businesses to stitch together full service coverage from part-time workers, as I discussed in this article at Forbes.

This story has pretty much shifted from "I predict" to "I told you so" to "duh."  But everyone from Karl Rove to the Teamsters now recognize that Obamacare is on a path to destroying full-time employment in the retail service sector.  Via the WSJ, in an editorial by Rove:

These union heads charged that unless Mr. Obama enacts "an equitable fix," the Affordable Care Act "will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week."...

Union leaders are correct that ObamaCare "creates an incentive to keep employees' work hours below 30 hours a week." After all, employers can avoid a $2,000-per-worker fine if they don't provide insurance as long as employees work fewer than 30 hours a week. Union leaders have realized—too late—that ObamaCare will affect the livelihood of millions of workers who wait tables, wash dishes, clean hotels, man registers, stock shelves and perform other tasks that can be limited to shifts of less than 30 hours a week. The White House take on this concern? Press Secretary Jay Carney said it "is belied by the facts."

But the data from the Bureau of Labor Statistics show that, in 2010, the year ObamaCare passed, full-time employment grew at an average monthly rate of 114,000 while part-time employment dropped an average of 6,000 a month. So far this year, as ObamaCare is being implemented, full-time employment has grown at an average monthly rate of 21,700 while part-time employment has increased an average of 93,000 a month.

Frequent readers will know that I have been predicting for over a year that the economic story of 2013 would be the end of full time work in the retail service sector due to the PPACA, or Obamacare (example).   QED, from the most recent economic report:

In June, the household survey reported that part-time jobs soared by 360,000 to 28,059,000 – an all time record high. Full time jobs? Down 240,000.  And looking back at the entire year, so far in 2013, just 130K Full-Time Jobs have been added, offset by a whopping 557K Part-Time jobs.

It is unclear how the 1-year delay in the employer mandate implementation will affect this.  Probably not a lot -- based on the way Obamacare was being implemented, companies needed to be switching workers to part-time now (really, early this year) so that they would qualify as part-time for next year  (a company needed 6-12 months of records from this year to prove the employee was part-time).  In other words, most companies have already switched, and having done so, will not likely switch back just for one year.

Besides, as I have written before, it is actually cheaper and easier for many retail establishments to stitch together full coverage of their business hours from part-time workers.   Making jobs full-time is a hassle, and was done by most of us mainly for competition reasons, ie to be able to attract the best employees.  Other laws like California's absurd lunch-break mandate (which has caused me to make working through lunch a firing offense at our company) just add to the cost of offering full-time work.   If everyone is only offering part-time, and the labor market is weak with plenty of workers available, there is no reason to go back to offering full time employment.

Well, it certainly comes as happy news to this correspondent that the Administration announced this week it will delay health insurance mandates on businesses.  Our company has spent a ton of time since last November trying to minimize the expected cost of the mandates -- the initial cost estimates of which for our business came in at three times our annual net income.  Our preparation has been hampered by the fact that the IRS still has not finalized rules for how these mandates will be applied to a seasonal work force.  Like many retail service businesses, we have studied a number of models for converting most of our work force to part time, thus making the mandates irrelevant for us.

I know this last statement has earned me a fair share of crap in the comments section as a heartless capitalist swine, but the vitriol is just absurd.   Many of the folks criticizing me can't or don't want to imagine themselves running a business, so let's say you have an annual salary of $40,000.  Now, on top of all your other expenses, the government just mandated that you have to pay an extra $120,000 a year for something.  That is the situation my business is in.  Are you just going to sit there and allow your savings to become a smoking hole in the ground, or are you going to do something to avoid it?  Unlike the government, I cannot run a permanent deficit and I cannot create new revenues by fiat.  Congress allowed business owners a legal way to avoid the health insurance mandate, and I am going to grab that option rather than be bankrupted.  So are every other service business I know of, which is why I have predicted that full-time jobs are on the verge of disappearing in the retail service sector.

Anyway, it appears that the IRS and the Administration could not get their act together fast enough to make this happen.  Not a surprise, I suppose.  You and I have both been in committee meetings, and have seen groups devolve into arguments aver useless minutia.  This is not a monopoly of the government, it happens in the private sector as well.  But in the private sector, in good companies, a leader steps in and says "I have heard enough, it is going to be done X way, now go do it."  In government, the incentives work against leaders cutting through the Gordian knot in this way, so the muddle can carry on forever.

There are at least two more shoes that are going to drop, one bad, one good:

1. On the bad side, while companies like mine complain about the cost of the PPACA, they are going to freak when they see the paperwork.  My sense is that we are going to be required to know in great detail what kind of health insurance policy every one of our employees have, even if it was not obtained through our company, and will have to report that regularly to the government.  In addition, there are gong to be new reporting requirements to new agencies for wages and hours.  It is going to be a big mess, and my uneducated guess is that someone in the last week or so looked at that mess and decided to hold off announcing it.

   But readers can expect a Coyote freak out whenever it is announced, because it is going to be bad.  Wal-mart will be fine, it has the money to build systems to do that stuff, but companies like mine with 500 employees but only 2 staff people are going to get slammed.  There is a reason government agencies, even government schools, have more staff than line personnel -- they live and breath and think in terms of complex reporting and paperwork.  They love it because for many it is their job security.  Swimming every day in that water, it is no surprise they impose it without thought on the private sector.  This makes it hard for companies like ours that try to have 99% of our employees actually serving customers rather than pushing paper.

2. The individual mandate is toast for next year.  No way it happens.  If the Administration cannot get the corporate piece done on time, there is no way in hell it is going to get the exchanges up and running.  And even if they do, some prominent states with political influence with this President, like Illinois and California, likely will not get their exchanges done in time and will beg for a delay.

A number of people pointed out that the posted Obamacare rates in California are about twice what individuals are paying today at low-cost sites.  This was in response to a deceptive California press release that claimed they were much lower, but got this result only by comparing apples to oranges.

Rick Ungar has two responses, that seem to be the emerging talking points on the left:

1. He found some bad Internet reviews of the low-cost source that Conservatives and libertarians used as a better point of comparison for Obamacare rates
2. Some of the people had to pay up to 50% more than the published rates due to pre-existing conditions.

Avik Roy has a number of responses to Ungar (and Ezra Klein, who raises the same points as Ungar).  I would raise three points:

1. Neither he nor Klein address the issue of the fundamental deceptiveness of the California press release.  I don't think anyone can defend comparing individual rates to business group rates as anything but apples to oranges.  If the Obamacare story is so great, why was the deceptiveness necessary?
2. Everyone gets bad reviews on the Internet.  If one transaction out of a thousand goes bad, that one will write a negative review online and few of the satisfied will bother.  If sex were a product on Amazon.com, it would likely have some 1-star reviews.  That being said, it is amazing to me that government control is seen as the solution to customer service issues.  I could be wrong, but I would stack up the reviews of the worst health insurance company in America against the DMV and Post Office any day of the week.
3. The published rates online are for the healthiest class of people.  I have never once had someone sell me health insurance and not make this clear.  Calling them teaser rates is a misnomer, particularly since, as Avik Roy notes, about 75% of the people who apply get these rates.  One in four have to pay 50% more today, so we are going to make 4 in 4 pay 100% more under Obamacare, and that is better?!?

To that last point, I will quote something I said years and years ago, long before Obamacare was passed:

The looming federal government takeover of health care as proposed by most of the major presidential candidates will be far worse than anything we have seen yet from government programs.  Take this example:  In the 1960's, the federal government embarked on massive housing projects for the poor.  In the end, most of these projects became squalid failures.

With the government housing fiasco, only the poor had to live in these awful facilities.  The rest of us had to pay for them, but could continue to live in our own private homes.

Government health care will be different.  Under most of the plans being proposed, we all are going to be forced to participate.  Using the previous analogy, we all are going to have to give up our current homes and go live in government housing, or least the health care equivalent of these projects.

Postscript:  Citizen Kane has over 100 1-star reviews.  Some are about the packaging or this particular version but many are about the movie.   The novel Gone with the Wind has dozens.

Postscript #2:  A sample Yelp review of a local USPS office

This place is the pits.

There are no supplies in any of the racks unless you want to send something Express Mail. All of the Priority Mail stuff is constantly gone and they don't have any more. Not that there's anyone to stock the racks even if they did.

People used to leave reviews complaining that there were "only two" workers. Those days are long gone--there is now ONE counter person at all times. That means if you get behind someone that has questions, or can't understand a customs form, or wants to argue about mail being held, you are just stuck.

Why not use the automated machine, you ask? Because its printer has been broken for two weeks and you can't actually print the postage that you might buy. Not that there's a sign telling you this--you have to spend a few minutes going through the process only to be told at the end that the transaction can't be completed because the printer isn't working.

I know they are making cuts because they are out of money, but it's a vicious cycle they'll never get out of because they've now effectively made it impossible to patronize the postal service.

Stay far, far away.

I would not be at all surprised if California banned online reviews of health care exchanges.  One department of the CA state government threatened to revoke all my contracts unless I took down a blog post simply linking to negative Yelp reviews of one of the department's facilities.

Good stuff from Peter Suderman at Reason

 In March, journalist Steven Brill published a lengthy piece in Time magazine on high medical bills, comparing hospital “chargemaster” rates—the listed prices—to the rates paid by Medicare. And over the weekend, Elisabeth Rosenthal compared U.S. prices for a variety of health services to the lower prices paid by other countries.

Both pieces offer essentially the same thesis: The U.S. spends too much on health care because the prices Americans pay for health care services are too high. And both implicitly nod toward more aggressive regulation of medical prices as a solution.

Part of the reason these pieces get so much attention is that most Americans don’t actually know much of anything at all about the prices they pay for health services. That’s because Americans don’t pay those prices themselves. Instead, they pay subsidized premiums for insurance provided through their employers, or they pay taxes and get Medicare or Medicaid. Even people who purchase unsubsidized insurance on the individual market don’t know much about the particular prices for specific health services. They may open their wallets for copays to health providers, or cover some expenses up to a certain annual amount, but in many if not most cases they are not paying a full, listed price out of pocket.

What that means is that, in an important sense, the “prices” for health care services in America are not really prices at all. A better way to label them might be reimbursements—planned by Medicare bureaucrats and powerful physician advisory groups, negotiated by insurers who keep a watchful eye on the prices that Medicare charges, and only very occasionally paid by individuals, few of whom are shopping based on price and service quality, and a handful of whom are ultra-wealthy foreigners charged fantastic rates because they can afford it.

This is the real problem with health care pricing in the U.S.: not the lack of sufficiently aggressive price controls, but the lack of meaningful price signals.

Much more at the link.  If they really want an interesting comparison, compare the prices of medical care not covered by insurance (actually pre-paid medical plans) in the US, and those that are -- e.g. for plastic surgery vs. other out-patient surgeries.

Apparently, those comparisons that claimed California insurance rates were coming down under Obama were bogus, essentially comparing apples to oranges.

Except they're not cheaper than what's currently available, as Peter Suderman noted here yesterday. That directly relevant point is totally obscured by phony claims that “it is difficult to make a direct comparison of these rates to existing premiums in the commercial individual market."

The chart [below] is from Avik Roy at Forbes. Here's more:

“The rates submitted to Covered California for the 2014 individual market,” the state said in a press release, “ranged from two percent above to 29 percent below the 2013 average premium for small employer plans in California’s most populous regions.”

That’s the sentence that led to all of the triumphant commentary from the left. “This is a home run for consumers in every region of California,” exulted Peter Lee.

But this is fantasy baseball. As Roy explains, the Obamacare folks are comparing significantly different products: "[Lee is] comparing apples—the plans that Californians buy today for themselves in a robust individual market—and oranges—the highly regulated plans that small employers purchase for their workers as a group."

When you compare, say, the new catastrophic plans being offered to similar ones that are out there right now, the supposed Obamacare price advantage strikes out faster than Dave Kingman in the clutch.

Essentially what is going on here is that Obama is touting a 5% drop in the price for a Ferrari, and hiding the fact that the Ford Taurus is going to double in price.  Or worse, the Ford Taurus will not even be for sale, so middle class Taurus buyers will be forced to buy a Mercedes or Ferrari.   Health care buyers don't care that a package of features is going to be a bit cheaper if they don't want those features.   And recognize that the price increase for healthy young people who feel no need to buy a policy will be facing an infinite price increase, from zero to whatever he now has to pay.

What she said

The banning of catastrophic-only plans infuriates me the most. Those are the only plans that are actually financially sensible for a healthy individual to purchase. Everything else on the market is a perverse by-product of the employer-based insurance system.

Worst case scenario with a catastrophic-only plan is you end up with $10,000 in debt. That’s a debt load many times smaller than what the Federal government thinks students should take out to get a college degree. We’ll let you borrow $100,000 to get a sociology degree but, we think that $10,000 is an unconscionable amount to pay for medical expenses? So unconscionable that we have to FORCE YOU to buy a plan with more extensive coverage?

Of course, we all know the real reason for this. it’s meant to force healthy young people to subsidize healthcare for older sicker people. Just force them to pay more for insurance than they ought to, and force them to buy more extensive coverage than is rational.

This is a depressing but all too familiar story of crony protections for incumbent operators

Only one company is competing for Tempe’s lucrative contract for ambulance services to support the Fire Department.

The Tempe City Council chose to allow only Professional Medical Transport to compete for the contract because city officials believe that the state’s approval last year of Rural/Metro Corp.’s purchase of that company effectively ended competitiveness in the market.

Indeed, the Ambulance market used to be competitive. State law makes it nearly impossible to start an ambulance company, or for an existing company to get access to the Arizona market. However, this used to be ok, because there once were a handful of companies competing in the market. That meant that having a statute that artificially blocked new entrants wasn't a huge problem.

Then a strange thing happened...Rural Metro bought all the other companies. Then they hired a team of the best lobbyists in the state in order to prevent the law from being changed. Frankly, it's a brilliant move.

This session, I worked with a client that wants to break into the inter-facility transfer market. Inter-facility transfers are scheduled transports of stable patients who aren't able to ride in cabs, private cars or stretcher vans. They are by definition, non-emergency transfers, but they still require an ambulance. And that ambulance has to be licensed as an "ambulance". The problem is that it is statutorily impossible to break into the market...which like I said, was fine until Rural Metro bought the other companies.

Our bill to open up the market to competition didn't even get a hearing.

The one disagreement I have is that it was somehow "OK" to prevent competition when there were three competitors but not when there is one.  This reminds me of why Republicans can't be trusted to make a case for free market capitalism.  New competitors can bring just as much to the table in already crowded markets as they can to monopolies.  Were we "OK" when there were just 3 major networks, or are we better off with competition from 600 cable channels?  Were we "OK" with just the big 3 auto makers or are we better off with Toyotas and Kias as choices?

One of the great under-reported stories of the health care field has been the certificate of need process for hospitals which, in most communities, has prevented construction of competing hospitals.  So then, like in this example, all the hospitals in a local community buy each other, and an instant monopoly is created.  Capitalism is blamed, but in fact the resulting high prices are a result of government action.

Kevin Drum is lauding the transparency an Oregon health insurance exchange which was initiated some apparently welcome price competition into a market for now standardized products.  My response was this:

I applaud any effort by this Administration and others to improve the transparency of pricing in the medical field.  I would have more confidence, though, if all of you folks were not pushing for 100% pre-paid medical plans that will essentially eliminate price-shopping by individuals, and in so doing effectively eliminate the enormous utility of prices.  Prices will soon be meaningful for one thing -- insurance -- in the health care field and absolutely meaningless for everything else in the field.

By the way, at the same time you are improving competition on price, you are eliminating by fiat all competition on features (e.g. what is covered, what deductible I want, etc).  This "success" is like the government mandating one single cell phone design, and then crowing how much easier shopping is for consumers because there is now only one choice.  A simple world for consumers is not necessarily a better world.  I am sure Medieval peasants had a very simple shopping experience as well.

Via ABC

The Internal Revenue Service official in charge of the tax-exempt organizations at the time when the unit targeted tea party groups now runs the IRS office responsible for the health care legislation.

Sarah Hall Ingram served as commissioner of the office responsible for tax-exempt organizations between 2009 and 2012. But Ingram has since left that part of the IRS and is now the director of the IRS’ Affordable Care Act office, the IRS confirmed to ABC News today.

What Obama most needed in the IRS ACA office was someone willing to ignore the clear language of the PPACA legislation and ram through IRS tax subsidies for insurance policies in the Federal (vs. state) exchanges -- subsidies that were purposefully and explicitly denied in the plain language of the law.

For years Progressives, led by President Obama during the legislative process for the PPACA, have attacked health insurance companies for their profits and overhead.  I never understood the former -- at generally 5% of revenues or less, even wiping health insurance profits out altogether would offset less than a year's worth of health care inflation.  The Progressive hatred for health insurance overhead was actually built into the PPACA, with limits on non-care expenses as a percent of premiums.

Progressive's justification for this was to compare health insurer's overhead against Medicare, which appears to have lower overhead as a percentage of revenues.  This is problematic, because lots of things that private insurers have to pay for actually still are paid for by the Federal government, but just don't hit Medicare's books due to funky government accounting.  Other private costs, particularly claims management, are areas that likely have a real return in fraud reduction.  In this case, Medicare's decision not to invest in claims management overhead shows up as costs elsewhere, specifically in fraudulent billings.

None of these areas of costs make for particularly fertile ground for demagoguing, so the Progressive argument against health insurance overhead usually boils down to marketing.  This argument makes a nice fit with progressive orthodoxy, which has always hated advertising as manipulative.  But health insurance marketing expenses mainly consist of

1. Funding commissions to brokers, who actually sell the product, and
2. Funding people to go to company open enrollments and explain health care options to participants

Suddenly, now that Progressives have taken over health care via the PPACA and federal exchanges, their tune has changed.  They seem to have a near infinite appetite for marketing money to support construction of the exchanges (which serve the role of the broker, though less well because there is no support)  and information about options to potential participants.  That these are exactly the kinds of expenses they have railed against for years in the private world seems to elicit no irony.  Via Cato

Now we learn, from the Washington Post’s Sara Kliff, “Sebelius has, over the past three months, made multiple phone calls to health industry executives, community organizations and church groups and directly asked that they contribute to non-profits that are working to enroll uninsured Americans and increase awareness of the law.”

This follows on from revelations in California (revelations that occurred before a new California law that makes PPACA costs double-secret).

[California] will also spend $250 million on a two-year marketing campaign [for its health insurance exchange]. By comparison California Senator Barbara Boxer spent $28 million on her 2010 statewide reelection campaign while her challenger spent another $22 million.

The most recent installment of the $910 million in federal money was a $674 million grant. The exchange's executive director noted that was less than the $706 million he had asked for. "The feds reduced the 2014 potential payment for outreach and enrollment by about $30 million," he said. "But we think we have enough resources on hand to do the biggest outreach that I have ever seen." ...

The California Exchange officials also say they need 20,000 part time enrollers to get everybody signed up––paying them $58 for each application. Having that many people out in the market creates quality control issues particularly when these people will be handling personal information like address, birth date, and social security number. California Blue Shield, by comparison has 5,000 employees serving 3.5 million members.

New York is off to a similar start. New York has received two grants totaling $340 million again just to set up an enrollment and eligibility process.

These are EXACTLY the same sorts of marketing costs progressives have railed on for years in the private world.

Yes, more evidence that the PPACA is ending full-time work in the American retail service sector

Circle K Southeast joined a growing list of national companies shifting workers to part-time status this week, in order to avoid paying Obamacare’s mandatory benefits, CBS-WTOC reports.

The alternative is to pay a $2,000 fine per fulltime worker who is not covered, leading Circle K to become the latest in a long line of companies to slice employee hours to avoid increased costs.

Here was my article several weeks ago in Forbes, though I have been predicting this since last year (when my own company started planning for the same change).

I don't have time to excerpt but, as I predicted, the media is finally catching up to the enormous shift (mainly in the retail and service sector) to part-time work.    I had a long article on this at Forbes last week.

... expect a big price increase.

From my broker, in response to my wife's query as to why our health insurance renewal was so much more expensive this year.  It is by far the largest single year increase we have ever had.  He said:

this is just he beginning of higher costs for insurance and many changes will be taking place due to the full implementation of Obamacare

My new Forbes article is up, and it is on my favorite under-reported story, the end of full-time work in the American retail sector

I don’t generally publish end-of-year predictions, mainly because I usually am wrong (a failing that does not seem to prevent any number of others from doing so, however).  But last year I made an exception when I predicted that the biggest economic story of 2013 would be the death of the full-time job in the American retail service sector.

But this was not really an exception to my rule about predictions, because this was not really a prediction at all, at least in the sense that a “prediction” is an educated guess of some future uncertain event occurring.  Late last year, within the service world, this change was already occurring – at restaurants, at hotels, and in retail stores, managers were already formulating plans.  In a large sense, by making this prediction, I was betting on the score of a game that had already been played — all we are doing now is waiting for the media to catch up and report the results to the public at large....

The tree fell in the forest months ago, but it is only just now being heard.

Sorry, link was broken, now fixed

I predicted last year that the biggest economic story of the year would be the end of full-time employment in the retail service industry.  An update:

The nation's largest movie theater chain has cut the hours of thousands of employees, saying in a company memo that ObamaCare requirements are to blame.

Regal Entertainment Group, which operates more than 500 theaters in 38 states, last month rolled back shifts for non-salaried workers to 30 hours per week, putting them under the threshold at which employers are required to provide health insurance. The Nashville-based company said in a letter to managers that the move was a direct result of ObamaCare.

Frequent readers will know that last year, I declared that the end of full-time employment in the American service industry (due to Obamacare) would be the biggest economic story of 2013.  The mainstream media either has not yet noticed or cannot be bothered with a story that does not put Obama in the best possible light, but the story is starting to get out none-the-less.

Expect a lot more of this.  The service industry generally does not operate 8 hours a day, 5 days a week anyway, so its labor needs do not match traditional full-time shifts.  Those of us who run service companies already have to piece together multiple employees and shifts to cover our operating hours.  In this environment, there is no reason one can't stitch together employees making 29 hours a week (that don't have to be given expensive health care policies) nearly as easily as one can stitch together 40 hours a week employees.   In fact, it can be easier -- a store that needs to cover 10AM to 9PM can cover with two 5.5 hour a day employees.   If they work 5 days a week, that is 27.5 hours a week, safely part-time.  Three people working such hours with staggered days off can cover the store's hours for 7 days.

Based on the numbers above, a store might prefer to only have <30 hour shifts, but may provide full-time 40 hours work because good employees expect it and other employers are offering it.  But if everyone in the service business stops offering full-time work, there will be no reason not to go to such a plan, and thousands of dollars per employee to do so.