Coyote Blog

My health insurance broker wrote me this in response to our telling him we got a letter from Blue Cross (BC) terminating our policy

Did  your BC letter say your policy ended 12/31/13 or 12/31/14.  If it ends in 2014 I strongly suggest you stay where you are until you are forced into Obamacare which will probably raise your rates substantially.

Given that I run a small business with fluctuating earnings, my last two years tax returns show zero net income.  If I had not honor, I probably could go into the exchange (if and when I could actually get into the exchange) and qualify for a large subsidy.  I could also probably go uncovered, and just sign up when I get sick, and pay the penalty, which is trivial if you are showing no income on your taxes.

Does anyone know if the exchanges do a net worth or asset check?  I don't see how.  If they only look at taxes, I will appear dirt poor.

Blue Cross just wrote me that our current health insurance policy will not be renewable for next year.  Unfortunately, I have actual health insurance rather than pre-paid medical care (meaning that it has a high deductible and pays for catastrophic things rather than aromatherapy visits).  Kathleen Sebelius does not think what I have is "real insurance" so she and Obama have banned it, despite promising that if I like my health insurance I would be able to keep it.

Much of the climate debate turns on a single logical fallacy.  This fallacy is clearly on display in some comments by UK Prime Minister David Cameron:

It’s worth looking at what this report this week says – that [there is a] 95 per cent certainty that human activity is altering the climate. I think I said this almost 10 years ago: if someone came to you and said there is a 95 per cent chance that your house might burn down, even if you are in the 5 per cent that doesn’t agree with it, you still take out the insurance, just in case.”

"Human activity altering climate" is not the same thing as an environmental catastrophe (or one's house burning down).  The statement that he is 95% certain that human activity is altering climate is one that most skeptics (including myself) are 100% sure is true.  There is evidence that human activity has been altering the climate since the dawn of agriculture.  Man's changing land uses have been demonstrated to alter climate, and certainly man's incremental CO2 is raising temperatures somewhat.

The key question is -- by how much?  This is a totally different question, and, as I have written before, is largely dependent on climate theories unrelated to greenhouse gas theory, specifically that the Earth's climate system is dominated by large positive feedbacks.  (Roy Spenser has a good summary of the issue here.)

The catastrophe is so uncertain that for the first time, the IPCC left estimates of climate sensitivity to CO2 out of its recently released summary for policy makers, mainly because it was not ready to (or did not want to) deal with a number of recent studies yielding sensitivity numbers well below catastrophic levels.  Further, the IPCC nearly entirely punted on the key question of how it can reconcile its past high sensitivity/ high feedback based temperature forecasts with past relative modest measured warming rates, including a 15+ year pause in warming which none of its models predicted.

The overall tone of the new IPCC report is one of declining certainty -- they are less confident of their sensitivity numbers and less confident of their models which have all been a total failure over the last 15 years. They have also backed off of other statements, for example saying they are far less confident that warming is leading to severe weather.

Most skeptics are sure mankind is affecting climate somewhat, but believe that this effect will not be catastrophic.  On both fronts, the IPCC is slowly catching up to us.

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 don't really have a horse in this race, but I found it interesting to look at the deal Blackberry has made to sell itself to a Canadian insurance company.  The part of the business we all know and used to love -- the famous Blackberry handset business -- apparently is worth zero.

In a WSJ article, they cite the following valuations:

• Cash on hand:  $2.6 billion
• Patent portfolio:  $1 billion +
• Blackberry secure phone network:  $1 billion

Given that the price for the transaction is $4.7 billion, that implies the handset / smartphone business is worth zero.  Which comes as no surprise, given Blackberry's eroding position over the last 5 years or so.

The last item on the list above seems to cause a lot of debate.  I don't know enough to participate in that debate, but it appears to me that Blackberry's one last market bastion is the enterprise market where their enterprise servers and more proprietary network gave enterprises more control over their employees devices and how they used them.  Which made their decision in 2012 to apparently obsolete their installed base of enterprise servers with Blackberry 10 all the more bewildering.

I have wondered why Microsoft didn't try to use the enterprise market as a way to get into the tablet and handset market.  It would seem to play to its strengths and neither Android nor iOS are particularly enterprise-friendly.

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.

Assume the following conditions:

1. I am increasingly liable for any dumbass thing my employees say or do.  It does not matter if it is absolutely against my values and company rules, if someone, say, uses a racial epithet with a customer or another employee, I will likely at least get sued.  Given my deductibles on insurance, I am out $20,000 a case even if I win.
2. Minimum wages have increased faster than the production value of unskilled, inexperienced laborers.
3. Obamacare is raising the minimum cost of a full-time employee by at least $2,000-$3,000 a year, not including the as-yet-to-be-define but likely expensive record-keeping and administrative requirements 
4. In states like California, the law increasingly gives employees the ability to make new claims on my income (e.g. fake workers comp and disability claims) or to even make themselves un-firable (by asking for a family medical leave, or claiming a disability, or claiming to be a whistle-blower).

Against this backdrop, what am I going to do?  I am going to hire more skilled and experienced workers who justify my minimum employment costs.   I am going to hire mature people less likely to get me in trouble via their immature actions.  I am going to hire people with a long work history so I can see there is not a history of scams and fraud.

In other words, I am going to hire older people.  And thus:

Of all the issues I raised above, the first one gets the least attention but in our customer contact business is perhaps the most important.  The cost of hiring a knucklehead is immense.  And the folks that do stupid stuff in 1 are often the very same people who try to take us in 4.

I am a bit late on this, but like most libertarians I was horrified by this article in the Mail Online about Obama Administration efforts to nudge us all into "good" behavior.  This is the person, Maya Shankar, who wants to substitute her decision-making priorities for your own

If the notion -- that a 20-something person who has apparently never held a job in the productive economy is  telling you she knows better what is good for you -- is not absurd on its face, here are a few other reasons to distrust this plan.

• Proponents first, second, and third argument for doing this kind of thing is that it is all based on "science".  But a lot of the so-called science is total crap.  Medical literature is filled with false panics that are eventually retracted.  And most social science findings are frankly garbage.  If you have some behavior you want to nudge, and you give a university a nice grant, I can guarantee you that you can get a study supporting whatever behavior you want to foster or curtail.  Just look at the number of public universities in corn-growing states that manage to find justifications for ethanol subsidies.  Recycling is a great example, mentioned several times in the article.  Research supports the sensibility of recycling aluminum and steel, but says that recycling glass and plastic and paper are either worthless or cost more in resources than they save.  But nudgers never-the-less push for recycling of all this stuff.  Nudging quickly starts looking more like religion than science.
• The 300 million people in this country have 300 million different sets of priorities and personal circumstances.  It is the worst hubris to think that one can make one decision that is correct for everyone.  Name any supposedly short-sighted behavior -- say, not getting health insurance when one is young -- and I can name numerous circumstances where this is a perfectly valid choice and risk to take.
• The justification for this effort is social science research about how people manage decisions that involve short-term and long-term consequences

Some behavioral scientists believe they can improve people's self-control by understanding the relationship between short term memory, intelligence and delay discounting.

This has mostly been used to counter compulsive gambling and substance abuse, but Shankar's entry into government science circles may indicate that health insurance objectors and lapsed recyclers could soon fall into a similar category

I am sure there is a grain of truth in this -- all of us likely have examples of where we made a decision to avoid short term pain that we regretted.  But it is hilarious to think that government officials will somehow do better.  As I have written before, the discount rate on pain applied by most legislators is infinite.  They will do any crazy ridiculous thing that has horrible implications five or ten years from now if they can just get through today.  Why else do government bodies run massive sustained deficits and give away unsustainable pension and retirement packages except that they take no consideration of future consequences.  And it is these people Maya wants to put in charge of teaching me about delay discounting?

• It probably goes without saying, but nudging quickly becomes politicized.  Is nudging 20-something health men to buy health insurance really in their best interests, or does it help keep an important Obama program from failing?

Postscript:  Here is a great example of just how poorly the government manages delay discounting.  In these cases, municipalities are saddling taxpayers with almost certainly bankrupting future debt to avoid paying any short-term costs.

Texas school districts have made use of another controversial financing technique: capital appreciation bonds. Used to finance construction, these bonds defer interest payments, often for decades. The extension saves the borrower from spending on repayment right now, but it burdens a future generation with significantly higher costs. Some capital appreciation bonds wind up costing a municipality ten times what it originally borrowed. From 2007 through 2011 alone, research by the Texas legislature shows, the state’s municipalities and school districts issued 700 of these bonds, raising $2.3 billion—but with a price tag of $23 billion in future interest payments. To build new schools, one fast-growing school district, Leander, has accumulated $773 million in outstanding debt through capital appreciation bonds.

Capital appreciation bonds have also ignited controversy in California, where school districts facing stagnant tax revenues and higher costs have used them to borrow money without any immediate budget impact. One school district in San Diego County, Poway Unified, won voter approval to borrow $100 million by promising that the move wouldn’t raise local taxes. To live up to that promise, Poway used bonds that postponed interest payments for 20 years. But future Poway residents will be paying off the debt—nearly $1 billion, all told—until 2051. After revelations that a handful of other districts were also using capital appreciation bonds, the California legislature outlawed them earlier this year. Other states, including Texas, are considering similar bans.

Or here is another example, of New York (the state that is home to the mayor who tries to nudge his residents on everything from soft drinks to salt)  using trickery to consume 25 years of revenue in one year.

Other New York deals engineered without voter say-so include a $2.7 billion bond offering in 2003, backed by 25 years’ worth of revenues from the state’s gigantic settlement with tobacco companies. To circumvent borrowing limits, the state created an independent corporation to issue the bonds and then used the money from the bond sale to close a budget deficit—instantly consuming most of the tobacco settlement, which now had to be used to pay off the debt.

By the way, I recommend the whole linked article.  It is a pretty broad survey of how state and local governments are building up so much debt, both on and off the books, and how politicians bend every law just to be able to spend a few more dollars today.

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.

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.

So, what is the next danger to the Republic that requires coercive government control to protect us all from disaster?  Pedicabs:

Operating a pedicab used to be cheap and easy. A person could make a buck with little or no overhead and without restrictive, burdensome regulations.

That’s no longer true in some Valley cities that have approved ordinances limiting who can operate pedicabs on their streets. Scottsdale is the latest to tighten its rules, joining Phoenix and Glendale. No other Valley municipality regulates pedicabs.

To continue doing business in Scottsdale, pedicab operators must have a valid Arizona driver’s license, maintain insurance and adhere to regulations pertaining to the safety and visibility of the pedicab. The ordinance, which became law on May 9, includes penalties for non-compliance but does not specify any inspections.

Phoenix’s ordinance, which went into effect in August 2008, was in response to concerns and complaints from downtown stakeholders and patrons regarding pedicab activity, city spokeswoman Sina Matthes said. The ordinance is stricter than Scottsdale’s, requiring Police Department inspections and inspection tags.

Glendale’s ordinance, which became law in late 2007, requires a city-issued license and limits the hours of operation and what roads can be used by operators, said Sgt. Jay O’Neill of the Glendale Police Department.

Why the regulation.  What safety disaster led to this?  Well, apparently some poor pedicab operator allowed himself to be hit by a drunk driver.

Scottsdale’s ordinance was prompted by a Jan. 4 crash involving a suspected drunken driver and a pedicab trailer on Scottsdale Road near Rose Lane. The two pedicab passengers suffered serious head and spine injuries.

Scottsdale police determined that there were no mechanical or safety violations.

Here is some government cluelessness:  it is OK if we rape you as long as we ask for your feedback first

In Scottsdale, operators must maintain at all times a commercial general-liability insurance policy of at least $1 million per occurrence and $2 million annual aggregate.

Jay Ewing Jr., owner and operator of Big Papa Human Powered Transportation, said four people have asked him if he wanted to purchase their equipment because they are going out of business in connection with the Scottsdale regulations. He says a pedicab operator can expect to pay at least $250 a month for insurance....

Scottsdale police Cmdr. Jeff Walther said the transition has gone smoothly because all operators were made aware of the proposed changes and were given the opportunity to provide input before the regulations were approved by the council.

“I was surprised, my folks were surprised, that almost immediately there seemed to be a pretty dramatic decline in operators,” Walther said.

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.

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.

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.

There was no particularly good way to resolve the banking mess in Cyprus.  But what worries me about how things played out is that there appears to be no rule of law that applies to bank failure in Europe.  There should be some clear principle that guides a bank resolution - e.g. equity holders and bondholders get wiped out first, then uninsured depositors, then insured depositors.  Or perhaps there is some ratio of pain between insured and uninsured depositors.

It is clear that no such rule exists across Europe (or if it does, it does not enjoy any particular force such that folks feel free to ignore it in real time).  That is the real danger here.  Results, however bad, should be transparent and predictable in advance, which is far from what happened in Cyprus.  Without a rule of law, one gets a rule of men -- in other words, rules are set by individual whim, often based on which government or corporate interests wield the most influence.

Think I am being too cynical?  Here is a detail that was new to me about the depositor haircuts in Cyprus:

A few weeks ago, the Central Bank of Cyprus published a curious set of "clarifications for the better understanding of the resolution measures." The principle of a bail-in—that uninsured creditors should suffer losses before taxpayers are on the hook—turns out to contain a few lacunae. "Financial institutions, the government, municipalities, municipal councils and other public entities, insurance companies, charities, schools, and educational institutions" will be excused from contributing to the depositor haircuts, though insurers later were removed from the exempt list.

Apparently, individual parties are lining up for special exemptions as well (much like connected corporations did with the Obama Administration to get exemptions from early provisions of the PPACA).  Essentially, all bank losses will be assigned to depositors who don't have access to powerful friends in the government.

Kevin Drum and Matt Yglesias think that 401-K's are a total ripoff.

After the new fee disclosure statements went out, roughly the same percentage—half!—of participants said that they still do not know how much they pay in plan annual fees and expenses, according to a recent survey by LIMRA, an association of insurance and financial services organizations.

....For those 401(k) participants who said they thought they knew how much they paid in fees, most of them were way off base. One out of four participants thought they paid 25% or more in fees, 16% thought they paid between 10% to 24% in fees, and 30% thought they paid between 2% and 9% in fees. Only 28% of participants thought their fees were less than 2%.

That group is the closest to reality. On average fees and expenses range between 1 to 2 percent, depending on the size of the plan (how many employees are covered) and the employees’ allocation choices (index funds versus actively managed funds), says LIMRA.

First, this is bizarre, as the indictment here of private fund management seems to be that people are *gasp* paying fees that are much lower than they think they are.   Also, it may well be that these people are not mistaken, but just using a different mental definition for fee percentage.  After all, why is total assets necessarily the best denominator for this calculation?  Obviously the fund industry likes it that way because it gives the lowest number, but it could be that people are thinking about annual fees as a percentage of the annual income.  Thus a fee of 1-2% of assets could well be 25% of annual income.  Hell, since I invest for income growth, I could argue that this is a MORE rational way to think about fees.  Obviously Drum and Yglesias are just captive mouthpieces of big Mutual Fund.

Second, and perhaps more importantly -- do you know what retirement fund has higher implicit fees and a lower lifetime total return than nearly any private fund in existence?   Social Security.  Read your statement you get and do the math.  You will find that the total you will likely get out will be less than you put in, even BEFORE present value effects, even if you have put money in for 30 years.  In other words, the internal rate of return on your and your employer's taxes is less than zero.

Ahh, but you say, that is because your Social Security taxes are going to subsidize people who don't work.  Fine, but then don't be surprised if there is strong support for a retirement system that does not pass the money through government hands.  Even getting a crappy rate of return from some hack investment manager is likely still better than putting your money in a government system where cash is skimmed off to feed whatever political constituency has the clout to grab it.

Postscript -- by the way, I leave aside the issue of whether it is a productive thing to tax-subsidize.  I am generally against tax preference for selected behaviors, even relatively popular  ones like savings.  But Yglesias wants to replace 401-K's with some kind of coerced government system (the note about fees above is to make the case that the average person cannot be trusted and that our masters need to do the savings for us).  Image one giant Calpers.  Ugh.

Apparently it is somewhat unethical in the feminist world for women to go to the Ivy League and then become a full-time mom.   I know several women who have Ivy League undergrad or graduate degrees and have, for at least part of their lives, been full time moms.  I am married to one, for example.  I have a few thoughts on this:

1. People change plans.  Life is path-dependent.  Many women who ended up being full time moms out of the Ivy League will tell you that it still surprises them they made that choice.
2. Why is education suddenly only about work?  I thought liberal arts education was all about making you a better person, for pursuits that go far beyond just one's work life.  I, for example, get far more use of my Princeton education in my hobbies (e.g. blogging) than in my job.   The author uses law school as an example, and I suppose since law school is just a highbrow trade school one might argue it is an exception.  But what is wrong with salting the "civilian" population with non-lawyers who are expert on the law?
3. Type A Ivy League-trained full-time moms do a lot more that just be a mom, making numerous contributions in their community.  I am always amazed what a stereotyped view of moms that feminists have.
4. If spots in the Ivy League, as implied by this article, should only be held by people seriously wanting to use the degree for a meaningful lifetime career, then maybe the Ivy League needs to rethink what degrees it offers.  Ask both of my sisters about the value of their Princeton comparative literature degrees in the marketplace.  By this logic, should Princeton be giving valuable spots to poetry majors?
5. I can say from experience that the one thing a liberal arts education, particularly at Princeton which emphasized being well rounded, prepared me for was being a parent.  I can help my kids develop and pursue interests in all different directions.  One's love of learning and comfort (rather than distrust) of all these intellectual rubs off on kids almost by osmosis.  In other words, what is wrong with applying an Ivy League education to raising fabulous and creative kids?
6. The author steps back from the brink, but this comes perilously close to the feminist tendency to replace one set of confining expectations for women with a different set.

Oh and by the way, to the author's conclusion:

Perhaps instead of bickering over whether or not colleges and universities should ask us to check boxes declaring our racial identity, the next frontier of the admissions should revolve around asking people to declare what they actually plan to do with their degrees. There's nothing wrong with someone saying that her dream is to become a full-time mother by 30. That is an admirable goal. What is not admirable is for her to take a slot at Yale Law School that could have gone to a young woman whose dream is to be in the Senate by age 40 and in the White House by age 50.

I would argue the opposite -- the fewer people of both sexes who go to law school to be in the Senate by 40 and the White House by 50, the better.

Update:  My wife added two other thoughts

• Decades ago, when her mom was considering whether she wanted to go to graduate school, her dad told her mom that even if she wanted to be a stay at home mom, a good graduate degree was the best life insurance she could have in case he died young.
• Women with good degrees with good earning potential have far more power in any divorce.  How many women do you know who are trapped in a bad marriage because they don't feel like they have the skills to thrive in the workplace alone?

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.

I am a bit late to the game in addressing Krugman's comments several days ago when he said:

But the truth, hard as it may be for ideologues to accept, is that unrestricted movement of capital is looking more and more like a failed experiment.

This was in response to the implosion of Cyprus banks, which was exacerbated (but not necessarily caused) by the banks being a home for a lot of international hot money - deposits so large they actually dwarfed the country's GDP.

I generally rely on Bastiat's definition of the role of the economist, which I will quote from Wikipedia (being too lazy on this Friday morning to find a better source):

One of Bastiat's most important contributions to the field of economics was his admonition to the effect that good economic decisions can be made only by taking into account the "full picture." That is, economic truths should be arrived at by observing not only the immediate consequences â€“ that is, benefits or liabilities â€“ of an economic decision, but also by examining the long-term second and third consequences. Additionally, one must examine the decision's effect not only on a single group of people (say candlemakers) or a single industry (say candlemaking), but on all people and all industries in the society as a whole. As Bastiat famously put it, an economist must take into account both "What is Seen and What is Not Seen."

By this definition, Krugman has become the world's leading anti-economist.  Rather than reject the immediate and obvious (in favor of the larger picture and the unseen), he panders to it.  He increasingly spends his time giving intellectual justification to the political predilection for addressing symptoms rather than root causes.  He has become the patron saint of the candle-makers petition.

I am not naive to the fact that there are pools of international hot money that seem to be some of the dumbest money out there.  Over the last few years it has piled into one market or another, creating local asset bubbles as it goes.

But to suggest that international capital flows need to be greatly curtailed merely to slow down this dumb money, without even considering the costs, is tantamount to economic malpractice.

You want to know what much of the world outside of Western Europe and the US would look like without free capital flows?  It would look like Africa.  In fact, for the younger folks out there, when I grew up, countries like China and India and Taiwan and Vietnam and Thailand looked just like Africa.  They were poor and economically backwards.  Capital flows from developed nations seeking new markets and lower cost labor has changed all of that.  Over the last decade, more people have escaped grinding subsistence poverty in these nations than at any other time in history.

So we have the seen:  A million people in Cyprus face years of economic turmoil

And the unseen:  A billion people exiting poverty

By pandering to those who want to expand politicians' power based on a trivial understanding of the seen and a blindness to the unseen, Krugman has failed the most important role of an economist.

Other thoughts:  I would offer a few other random, related thoughts on Cyprus

• Capital controls are like gun and narcotics controls:  They stop honest people and do little to deter the dishonest.  In the case of Cyprus, Krugman obviously would have wanted capital controls to avoid the enormous influx of Russian money the overwhelmed the government's effort to stabilize the banks.  But over the last several weeks, the Cyprus banks have had absolute capital controls in place - supposedly no withdrawals were allowed.  And yet when the banks reopened, it become increasingly clear that many of the Russians had gotten their money out.  Capital controls don't work as a deterrence to money that is already corrupt and being hidden.
• No matter what anyone says, the huge capital inflows into Cyprus had nothing to do with the banking collapse.  The banks had the ability to invest the money in a range of international securities, and the money was tiny compared to the size of those security pools.  So this is not like, say, a housing market where in influx of money might cause a bubble.   The only harm caused by the size of the Russian investments is that once the bank went bad, the huge size of the problem meant that the Cyprus government did not have the resources to bail out the bank and protect depositors from losses.
• Capital controls are as likely to make bubbles worse as they are to make them better.  Certainly a lot of international money piling into a small market can cause a bubble.  But do capital controls really create fewer bubbles?  One could easily argue that the Japanese asset bubble of the late 80's would have been worse if all the money were bottled up in the country. When the Japanese went around the world buying up American movie studios and landmark real estate, that was in some sense a safety valve reducing the inflationary pressure in Japan.
• Capital controls are the worst sort of government expropriation.  You hear on the news that the "haircut" taken by depositors in Cyprus might be 20% or 80% or whatever.  But in my mind it does not matter.   Because once the government put strict capital controls in place, the haircut effectively became 100%, at least for honest people that don't have the criminal ability or crony connections to beat the system.  Cyprus basically produces nothing.  Since money is only useful to the extent that it can buy or invest in something, then bottling up one's money in Cyprus basically makes it worthless.
• Capital controls are a prelude to protectionism.   First, international trade is impossible without free flow of capital.   No way Apple is going to sell ipods in Cyprus if they cannot at some point repatriate their profits.  Capital controls can also lead to export controls.  If I can't export money, I might instead buy jets, fly them out of the country, and then sell the jets.
• Let's not forget that the core of this entire problem is a government, not a private, failure.  Banks and investors treated sovereign euro-denominated debt as a risk-free investment, and banking law (e.g. Basil II) and pension law in most countries built this assumption into law.  Cyprus banks went belly-up because the Greeks, in whom they had (unwisely) invested most of their funds, can't exercise any fiscal responsibility in their government.  If European countries could exercise fiscal responsibility in their government borrowing, 80% of the banking crisis would not exist (housing bubbles and bad mortgage securities have contributed in some countries like Spain).  There is a circle here:  Politicians like to deficit spend.  They write regulations to encourage banks to preferentially invest in this government paper.  When the government debt gets iffy, and the banks face collapse, the governments have to bail them out because otherwise there is no home for their future debt.  The bailouts get paid for with more debt, which gets crammed back into increasingly over-leveraged banks.    What a mess.
• All of this creates an interesting business school problem for the future:  What happens when there are no longer risk-free investments?  Throughout finance one talks about risk free rates and all other risks and risk premiums and discussed in reference to this risk-free benchmark.  In regulation, much of banking capital regulation and pension regulation is based on there being a core of risk free, liquid investments.  But what if these do not exist any more?
• I have thought a lot about a banking model where the bank accepts deposits and provides basic services but does no lending - a pure deposit bank with absolute transparency on its balance sheet and investments.  I think about a web site depositors can check every day to see exactly where depositors money is invested and its real time values.  Only listed, liquid securities with daily mark to market.   Open source investing, as it were.  In the past, deposit insurance has basically killed this business model, but I think public confidence in deposit insurance just took a big-ass hit this week.

Postscript:  I don't want to fall into a Godwin's law trap here, but I am currently reading Eichmann in Jerusalem and it is impossible for me to ignore the role strict capital controls played in Nazi Germany's trapping and liquidation of the Jews.

PS#2:  Oops,

The extent of the control over all life that economic control confers is nowhere better illustrated than in the field of foreign exchanges. Nothing would at first seem to affect private life less than a state control of the dealings in foreign exchange, and most people will regard its introduction with complete indifference. Yet the experience of most Continental countries has taught thoughtful people to regard this step as the decisive advance on the path to totalitarianism and the suppression of individual liberty. It is, in fact, the complete delivery of the individual to the tyranny of the state, the final suppression of all means of escape—not merely for the rich but for everybody.

Proponents of Obamacare and other aggressive government health care interventions often argue that government health insurance will be less expensive than private health insurance.  Ignoring the whole history of government provided services (which you have to do to accept this argument), it is entertaining to press them on what costs will go away.

First, they will argue "profits."  Health insurers "obviously" make a lot of profit, so doing away with that will amount to a lot of savings.  Several years ago, when Obama was actively demagoguing** the health insurance business, the profit margins of health insurers were all around 3-4% or less.  Which means in exchange for eliminating all private profit incentives towards efficiency and productivity, we get a 3% one time cost reduction.  Not very promising.

After profits, Obamacare supporters will point to administrative costs.  Their philosophy that private insurance administrative costs drive health inflation is built into Obamacare, which places a cap on non-care related costs as a percentage of premiums.  I would argue a lot of this cost is claims management and fraud detection that government programs like Medicare don't have, to their detriment, but let's leave that aside.  I think most Obamacare opponents are convinced that there are billions in marketing costs that could be eliminated.  This has always been their bete noir in pharmaceuticals, that drug companies spend too much marketing.

I have said for years that to a large extent, what outsiders call "marketing" in health insurance is actually customer service and information, in particular agents who go out to companies and help people understand and make their insurance choices.

Well, it turns out that when the shoe is on the other foot, Obamacare supporters suddenly are A-OK with massive health insurance marketing costs, even when what is being marketed is essentially a monopoly:

[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.

** Don't be fooled by the demagoguery.  This is standard Obama practice.  In exchange for eating sh*t from Obama in public, private companies get all kinds of crony favors in private.  Remember, health insurers got the US government to mandate that everyone in the country buy their products, and got the Feds to establish trillions in subsidies to help people do so.  This may be the greatest crony giveaway of all time, and to cover for it, like a magician distracting your eye from the sleight of hand, Obama made it appear in public as if he were health insurers' greatest enemy, rather than their sugar daddy.

Megan McArdle has a column I am going to excerpt at great length (sorry Ms. McArdle).  This is great article on a topic I have tried to explain many times here

After all, the insurance company has to make money.  That has to mean that the expected value of the claims they pay out is lower than the expected value of the premiums their customers pay in.  In some sense, then, the expected value of your insurance premium is negative.

But insurance does make everyone better off, because it covers very large costs that most people would have trouble paying.  Even most really good savers would have a hard time replacing the value of their house, or paying off a $250,000 judgement for an auto accident.  The expected value of those incidencts is very, very negative--more than just the value of the cash, you have to factor in the horror of being homeless or bankrupt.  When you factor in the homelessness, the bankruptcy, and so forth, the slighly negative expected financial value is more than outweighed by the positive value of being protected against personal catastrophe.  Not to mention the peace of mind one gets from not having to worry about homelessness, etc.

This is the magic of risk pooling.  But notice that it's the catastrophe which makes insurance a good deal.  You wouldn't get much value from buying "grocery insurance".  At best, you'd be paying an extra administrative fee to route your routine expenses through an insurer, rather than paying them directly.  At worst, you'll end up with bills skyrocketing as all sorts of perverse incentives appear.  After all, if the insurer is paying all your grocery claims, why not load up on filet mignon instead of ground turkey?

But insurers try very hard never to sell insurance for less than the cost of your expected claims.  If you expect to buy $10,000 worth of groceries next year, it will not charge you less than that for a "grocery policy".  And if we all drive up the costs of grocery insurance by consuming more, the insurer can do one of two things: raise everyone's "insurance premiums" to cover a filet mignon budget, or create a list of "approved groceries" that it will cover, and start hassling anyone who tries to file an excessively expensive claim.

Sound familiar?

This is why you should always have liability insurance, but should think twice about collision damage coverage.  It's why high deductibles are a good idea--for small expenses, it's better to self insure.  And it's why "catastrophic" health plans, which only cover the sort of extremely expensive events that most people would have difficulty financing, are a much better deal than the soup-to-nuts plans that most people get through their employers.  Those plans are expensive, both because they're paying for a higher percentage of your expenses, and because they drive up utilization--which means that they drive up next year's premiums even more.  Imagine what your car insurance would cost if it covered gasoline, routine maintenance, and those little air freshener trees you hang from the rearview mirror.  Then stop asking why health insurance costs so much.

But Kathleen Sebelius, the Secretary of HHS, thinks that catastrophic insurance isn't really insurance at all.

At a White House briefing Tuesday, Health and Human Services Secretary Kathleen Sebelius said some of what passes for health insurance today is so skimpy it can't be compared to the comprehensive coverage available under the law. "Some of these folks have very high catastrophic plans that don't pay for anything unless you get hit by a bus," she said. "They're really mortgage protection, not health insurance."

She said this in response to a report from the American Society of Actuaries arguing that premiums are going to rise by 32% when Obamacare kicks in, as coverage gets more generous and more sick people join the insurance market.  Sebelius' response is apparently that catastrophic insurance isn't really insurance at all--which is exactly backwards. Catastrophic coverage is "true insurance".  Coverage of routine, predictable services is not insurance at all; it's a spectacularly inefficient prepayment plan.

The last two lines are why I knew from the very beginning that the promise I would get to keep my health insurance was a lie.  Because I have true insurance, rather than a pre-payment plan for incidental health-related expenses, and the folks who wrote Obamacare think of insurance as pre-paid medical care (in fact, I believe they think of private insurance as a Trojan Horse for all-inclusive single payer government health care).

Kevin Drum thinks he has found the smoking health care gun - US doctors are paid more than everyone else.  That is why we have too-expensive medical care!  A few quick thoughts

• I am the last one to argue that doctors salaries are set anywhere like at a market clearing price.  Our certification system, crazy third-party payer systems, lack of price transparency, and absurd arguments over the "doc fix" and Medicare reimbursement rates all convince me that doctor salaries must be "wrong"
• The charts he shows have absolutely no correction for productivity, at least as I read the methodology.  Per the text, they don't even have correction for hours worked.  A McKinsey report several years ago found that US doctors made more, but also saw a lot more patients in a day.  GP care cost more than expected vs. other country's experience, but is due mostly to number of visits, not cost per visit.
• There is no correction for doctor expenses.  Malpractice insurance, anyone?  We have the most costly malpractice insurance in the world because we have the most broken system.  Doctors pay that out of their salary
• US GP salaries in Drum's linked report are actually falling, unlike all the other countries studied.  Seem to have fallen 6% in 10 years (page 18), whereas France, for example, has increased more than 10%.

To the last point, I have a hypothesis.  When you first overlay a government health care / price control regime, you get an initial savings.  Doctors are forced to work for less and they still, out of habit and momentum, abide by past productivity standards.  But over time, productivity, like any government-captured function falls.  And over time, doctors, like other civil service groups, become better at organizing and lobbying and begin to get increasing pay packages.  After all, if teachers and fire-fighters can scare Californians into absurd pay and benefit packages, what do you think doctors will be able to do once they learn the game?