Coyote Blog

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From Joe Biden, in the debates:

"No one making less than $250,000 under Barack Obama's plan will see one single penny of their tax raised, whether it's their capital gains tax, their income tax, investment tax, any tax."

Oops:

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

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

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

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

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

This is a tax on middle America, and Obama knew he was going to propose it way back in the campaign.  This is not something he just thought up or was a victim of changing circumstance.  This is an out and out lie on his part.

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

I write back in the comments:

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

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

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

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

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

Apparently I have entered into a contract, which keeps getting amended, but no one ever sends me a copy or asks for my signature.

I heard an angry town-hall participant in Texas claim health insurance was not a right. If you could not pay for it, you should not have it. That's neither realistic nor desirable. Everyone requires certain goods and services, such as food and shelter. There exists an implicit social contract that people who cannot afford these goods will get them from the state.

The last time I understood that we entered into a social contract was in the late 18th century, when we exited our old relationship with Great Britain and entered a new one defined by the Constitution.  But I am pretty sure that government provision of food, shelter, and health care were not in this contract.

Then, in the 1930s, we were told"food" is in the contract.  Then, in the 1960's, we were told "shelter" is on the list.  Now apparently health care is on the list.  Can someone send me a copy of this contract, so I can know what else is on it?

Isn't it ironic that the only "contract" the Left respects is the kind that I don't sign, don't consent to, and don't enter of my own free will?   Of course, a contract that one party doesn't consent to and only enters into by force is not a contract at all.  As Wikipedia puts it for the definition of a contract, "Agreement [to a contract] is said to be reached when an offer capable of immediate acceptance is met with a 'mirror image' acceptance (ie, an unqualified acceptance)."

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

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

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

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

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

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

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

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

Two large drivers of high health insurance costs in certain states is 1) bans on interstate competition for health insurance and 2) state-by-state mandates for minimum coverage.  These two government actions lead to some states having remarkably higher health insurance prices than others.  Via Carpe Diem:

The average health insurance ranges from a low of $1,254 in Wisconsin to a high of $8,537 in Massachusetts, and the national average is $2,613. That kind of variation couldn't exist in a competitive market for health insurance. Interstate competition for health insurance would go a long way towards bringing health insurance costs down.

That Massachusetts model sure is doing wonders, huh?  If reimportation of drugs from Canada makes sense, why not of policies across state lines? See where your state ranks here.

A Cafe Hayek Reader asks:

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

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

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

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

I answer in the comments:

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

So why would anyone insure me?

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

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

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

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

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

One of the reasons GM entered bankrupcy was that its slow and ponderous beauracracy couldn't handle the pace of the modern marketplace.  But one thing even than beauracracy could do was produce dealer rebate checks in a timely manner.  When many of your dealers are running on only a thin cash flow margin, even GM knew it was important to get rebate checks to dealers quickly.

So it is a bad sign that the government, who wants to run the auto industry, the banking industry and soon the health care industry, can't seem to process checks in a timely manner:

Some New Mexico auto dealers have backed out of the cash-for-clunkers program and more may do so as the federal government takes its time providing cash reimbursements.

Dealers across the state are owed more than $3.6 million, according to a dealers' group which says that so far Uncle Sam has only written three checks totaling about $14,000....

Dealerships put up the cash for the rebates after being told by the Obama administration they would be paid back within 10 days of the sale.

And here:

Hundreds of auto dealers in the New York area have withdrawn from the government's Cash for Clunkers program, citing delays in getting reimbursed by the government, a dealership group said Wednesday.The Greater New York Automobile Dealers Association, which represents dealerships in the New York metro area, said about half its 425 members have left the program because they cannot afford to offer more rebates. They're also worried about getting repaid....

Schienberg said the group's dealers have been repaid for only about 2 percent of the clunkers deals they've made so far.

Many dealers have said they are worried they won't get repaid at all, while others have waited so long to get reimburse

The problems cited in other analyses are two that I see all the time in dealing with the government:

1. Obsession with minute paperwork errors, and rejection of applications for the smallest errors.  For a variety of reasons, government clerks in this kind of program seldom have the knowledge, the incentives, or even the ability to parse between errors and omissions that matter and errors and omissions that are irrelevant.   In fact, if the same application comes back 5 times, that's just more job security.  I have discussed this a number of times, as state liquor license boards have rejected our applications repeatedly for ridiculously small, meaningless errors (here and here, for example)

   Here is my prediction:  You will soon see someone inside the government blaming the dealers, saying it is all because they are not following the 300-page process correctly or not filling out the forms correctly.

2. Absolute unwillingness to write a check.  Some of you know that I am in the odd position of being a libertarian who does a lot of business with the government, a result of my effort to privatize the operation of public recreation.  I am in the position of sometimes paying the government money (I typically don't get paid to operate a facility, I operate it for profit and pay the government a rent or concession fee) and sometime in the position of getting paid.  The government always demands all of its money owed to it well in advance (think of withholding, where you pay the government your taxes months before the true April 15 deadline).  The government only pays in arrears, and sometimes well in arrears.  Last winter, my funding troubles (when my bank holding my line of credit went bust) were aggravated by the fact that the government took 15 months to pay us $175,000 they owed us, at the same time it demanded an additional $500,000 in advance rent payments on the next year.

By the way, since every post related to the government this month must be related to health care in some way, what they government is doing on cash for clunkers is highly related to the difference in overhead costs between Medicare and private insurance companies.

The cash for clunkers processing is taking a long time in part because the government is worried about fraud and wants to make sure every car it pays out on was really qualifying and destroyed properly.  This takes time and manpower and overhead.  But this is exactly what private medical insurance companies spend their overhead on -- making sure that claims are real and justified and are not padded.  Medicare has lower overhead costs, in part because of government accounting hides some overhead, but in part because Medicare does not do any due diligence before it cuts a check.  It gets a form, it sends out a check.  It does little checking to see if the claim is real.

I don't tend to shop at Whole Foods because they offer a value proposition that does not appeal to me.  Their prices are too high for products that generally don't seem noticeably better than ones I can get in other stores.  To some extent the placebo effect of having "all natural" on the package does not really work for me, though I do buy most of my fish and meat there  (and not just because I like the irony of buying only meat products from a store populated by vegans).

That said, I like having the choice in stores.  I even drop by a farmers market once in a while, though generally the hassle is not worth it for me.  The same is true in beers -- I am seldom in the mood for something as dark and rich as a Belhaven, I love the explosion of choices in beer we have seen since the dark days of the late 70's/early 80's.  Other people will make different choices.  Cool.

Which makes it all the more ironic that those who benefit from the explosion in retail choice in the free marketplace are using that choice to protest the CEO of Whole Foods for advocating similar levels of choice in health care.  Anyway, I would write more but Radley Balko did a much better job here.

You see, he shared his ideas on health care reform, thinking that you, being so famously open-minded and all, might take to a few of them, or that it at least might start a conversation. I guess he felt he'd built up some cache with you, and wanted to introduce you to some new ideas. His mistake wasn't in intentionally offending his customers. He's a businessman who has built a huge company up from the ground. I'm sure he knows you don't deliberately offend your customers. His mistake was assuming you all were open-minded enough consider these ideas without taking offense"”that you wouldn't throw a tantrum merely because he suggested some reforms that didn't fall in direct line with those endorsed by your exalted Democratic leaders in Washington. In retrospect? Yeah, it was a bad move. Turns out that many of you weren't nearly mature enough to handle it.

Its hard even to understate the how absolutely nuts self-styled "progressives" have gone over this pretty tame and sober editorial in the IBD.  Here is just one example -- this is a mainstream green blogger and not some weird comment to a Kos post.  I honestly thought this was satire at first:

I agree with CEO John Mackey that it's okay to make money by making your green business big. But Mackey crossed the line with an op-ed in the Wall Street Journal this weekend, whose very publication put him in the company of the lunatic right-wing fringe who edit the paper's opinion section.

The op-ed reads like a page from the Republican playbook, touting individual responsibility for one's health. What a load of unorganic crap!

Holy brothers-keeper Batman - He's advocating individual responsibility!!  Here, since I have not reproduced it before, are the "lunatic" ideas of Mr. Mackey:

"¢"‰Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs).

"¢"‰Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits.

"¢"‰Repeal all state laws which prevent insurance companies from competing across state lines.

"¢"‰Repeal government mandates regarding what insurance companies must cover.

"¢"‰Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year.

"¢"‰Make costs transparent so that consumers understand what health-care treatments cost.

"¢"‰Enact Medicare reform.

"¢"‰Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

The tort reform area is one where Obama is particularly disingenuous. It is just amazing that anyone could write about the cost of medicine being driven by too many useless procedures without once mentioning the words malpractice or defensive medicine.  I wonder if this might explain Obama's silence on tort reform (via maggies farm)

I have written before about the  demagoguing going on about "health insurance profits" and just how BS those charges are.  Here is Obama yet again:

"There have been reports just over the last couple of days of insurance companies making record profits, right now," Obama said during a prime-time news conference. "At a time when everybody's getting hammered, they're making record profits, and premiums are going up. What's the constraint on that? ... Well, part of the way is to make sure that there's some competition out there."

This follows Pelosi saying:

I'm very pleased that our Chair of our Democratic Congressional Campaign Committee and member of the leadership will be talking too about the immoral profits being made by the insurance industry and how those profits have increased in the Bush years. We all believe in the profit motive; we all want to reward success.  But having that success come at the expense of America's working families "” have that success come by withholding care, when a person becomes ill, is just not right and we're going to take this issue in a new direction.

And pundits saying even crazier stuff, including Kevin Drum (who is actually one of the saner members of the left) writing:

It means the health insurance industry is scared that we might actually do something in 2009 and they want to be seen as something other than completely obstructionist. That means only one thing: they've shown fear, and now it's time to bore in for the kill and gut them like trouts. Let's get to it.

Rick Perry links to several posts debunking this claim, and shows a profit margin consistent with what I have found in my research -- about 3.3% of revenues, which my posts (linked above) showed has fallen over the last several years.  This profitability level ranks 86th(!) on the list of American industries, behind such rapacious industries as auto parts wholesalers and confectioners (see table in his post).  Look out everyone, if this industry is too profitable for this administration, then just about every industry in the country is too profitable.  Heck, this margin is even worse than mine, and I operate in an industry universally described as having "thin margins."

What do you call a man who thinks a 3.3% profit margin is too high?  How about "Marxist."

Update: My guess is that there is some health insurer who due to a merger grew larger and therefore made a higher profit in absolute dollar terms, so my guess is that Obama is not flat out lying.  But he is freaking close, given that he credits such profits to fee increases and denying services rather than business growth.  Profitability should be judged on margins, not total dollars (even better, it really should be judged on return on equity or return on assets employed, but that is rocket science to the economic monkeys wielding bone tools we have in the media).

To some extent, there are signs Obama may be willing to walk back health care "reform" to just insurance "reform," though the two are highly related.  As a minimum, insurance "reform" is likely to include rules that no one can be denied coverage, community rating, and minimum covered service requirements.

These are really, really expensive.  Megan McArdle on the NY experience:

John Cole takes me to task for not knowing that health insurance premia have tripled in New York State.  Indeed, he's right--I should have checked.

But this is not the "gotcha" the left believes.  I erred so low because I was trying to be charitable to the cause of national health care.  You see, the reason that insurance premia are so high in New York State is that New York State enjoys community rating, guaranteed issue, and a very generous bevy of mandatory services.  The result is that the cost of insurance is very, very high.  What I failed to realize was just how radically out of line New York's rules had pushed its health care costs.  The average premium across the United States has increased about 25% since 2004.  In New York, the rate of inflation has apparently been about 16 times that.  I wasn't "aware" that insurance premiums have doubled and tripled over the last seven years, because for the country as a whole, this isn't true.

McArdle is sometimes irritating in bending over backwards to be fair to folks whose views don't deserve such charity and who would not ever extend the same favor back at her.  So it is kind of fun to see her going a bit postal over the last few days.

Several people have emailed me this: Apparently the White House web site is asking that you report anyone writing things on health care that don't match the Administration position so the White House can "keep track".

There is a lot of disinformation about health insurance reform out there, spanning from control of personal finances to end of life care. These rumors often travel just below the surface via chain emails or through casual conversation. Since we can't keep track of all of them here at the White House, we're asking for your help. If you get an email or see something on the web about health insurance reform that seems fishy, send it to flag@whitehouse.gov.

Wow, "disinformation."  You wonder why people ever listen to those counter-revolutionaries and aren't satisfied with just reading Pravda.

Well, we at the global headquarters of CoyoteBlog Enterprises are certainly happy to help.  I sent them this email today:

Thanks for the opportunity to report disinformation where people write things that don't match what the President is saying on health care.  Please check out this document I found on the web -- a number of parts bear very little relationship, and in fact outright contradict, what the President is promising about health care reform.

The link is to a copy of the House health care reform bill.  If you are so inclined, you might wish to offer similar help.

Postscript: My son, who is a big fan of dystopic novels like George Orwell's "1984" might ask if he would get extra credit for turning in a family member.

Update #1: The White House site in question is really ridiculous.  It responds to critiques of what is actually in the bill with statements like "the President has consistently said that if you like your insurance plan, your doctor, or both, you will be able to keep them."  Well duh, of course he has.  But this President, even more than the average President, will say just about anything.

At this point, since the President is purposely uninvolved in the crafting of the legislation and has admitted at times that he doesn't even know the details of what is in it, talking about his promises or preferences is irrelevant.   In fact, nobody is talking about the President's promises and intentions any more, with actual legislation on the table.   They are talking about what is actually in the written bills in the House and Senate.

So the question is, what is in the actual legislation, and does it match Obama's promises, and the current answer is clearly "no."  And will the President veto a health care bill that doesn't follow through on his promises?  Don't make me laugh.  He is going to sign any bill with "health care" in the title no matter what it says -- his advisers have already made that clear by saying that the entire Presidency is riding on having some kind of bill pass that does something with health care.

By the way, in this we can see the White House strategy for passing such controversial bills.  Their hope is to jump directly from the President's "everyone is a winner and there is no cost" rhetoric directly to signed legislation.  They want people focused on his promises, which are enticing, and not the reality of the actual language of the bills, which is ugly and in many ways bear no relationship to the President's rhetoric.  This worked for the stimulus and almost worked for Waxman-Markey and was tried again for health care.

Nancy Pelosi said this the other day (emphasis added)

I'm very pleased that our Chair of our Democratic Congressional Campaign Committee and member of the leadership will be talking too about the immoral profits being made by the insurance industry and how those profits have increased in the Bush years. We all believe in the profit motive; we all want to reward success.  But having that success come at the expense of America's working families "” have that success come by withholding care, when a person becomes ill, is just not right and we're going to take this issue in a new direction.

In the past, other leftish pundits have been even more direct:

It means the health insurance industry is scared that we might actually do something in 2009 and they want to be seen as something other than completely obstructionist. That means only one thing: they've shown fear, and now it's time to bore in for the kill and gut them like trouts. Let's get to it.

I don't have time to redo the analysis, but for the third quarter 2008 (the last quarter of the dreaded Bush years that increased insurance profits so much) I looked up on Google Finance the profit margins of major health care insurers, providers, and HMO's.  I am not sure who the Democrats would consider the real Satan of health insurance (ala ExxonMobil or Wal-Mart) but if I left a key company off you are welcome to suggest it in the comments.  Anyway, 3Q08 profit margins were:

Cigna: 3.50%

United Health Group: 4.56%

Aetna: 3.64%

WellCare:  4.08%

Amerigroup: 3.51%

Humana 2.56%

WellPoint: 5.49%

So, if you are a business owner (and that includes those of you who own equities, which are ownership shares), be very afraid.  Look at your company or your favorite stockholding.  If they have margins of 2.5% or more of revenues (and that includes just about every profitable company in America -- I think the industrial average is in the eights) then Nancy Pelosi and the Democrats consider your profits immorally high and they intend to gut you like a trout.

Update: OK, I had a bit of time to update numbers, so I took Cigna, which is the first on the list, and looked at their net profit margin over 4 years:

2005:  7.6%

2006:  7.0%

2007:  6.4%

2008:   1.5%

Hmm, not sure I see the profits increasing in the Bush years -- looks like they are going down to me.  I would also observe that they never in the last four years even rise to average for a large American public company.

From a MoveOn email I received today (emphasis in original):

But Americans can't afford to wait: while the Senate is on vacation, over 400,000 people will lose their health coverage.

Really?

The source is here.  Reading the text and the sourcing, it is a great example of how a wild-assed guess can be turned into a "fact" if one buries it in a long enough chain of sourcing.  But the really funny part is that the Senate plan does not even begin to be implemented until 2013, and implementation is not complete until something like 2018.  These dates will not change whether the legislation is passed before or after the recess, but if a single month is so devastating, one wonders why MoveOn has quietly accepted the 2013 implentation date (not conincidently after the next Presidential election).

Postscript: Number of extra people who will not, no matter what their insurance status, be able to get critical care in the next month:  zero.

The NY Post has a very good editorial on the health care bills (HT:  Q&O).  Too much good stuff to excerpt, it includes even more crazy provisions in the House and Senate bills I had not seen yet (its like a scavenger hunt as people go through the 1000 pages, or maybe more like searching for landmines).

But since the bill doesn't even start taking effect until 2013 (except for the higher taxes, which come earlier, of course), we have to really really rush and make sure its approved before the August recess (and before critics are able to actually read the thing - no chance those in Congress will read it, ever).  Also, its such a burning problem, it just must be solved now, as evidenced by...

The most recent ABC News/Washington Post poll (June 21) finds that 83 percent of Americans are very satisfied or somewhat satisfied with the quality of their health care, and 81 percent are similarly satisfied with their health insurance.

They have good reason to be. If you're diagnosed with cancer, you have a better chance of surviving it in the United States than anywhere else, according to the Concord Five Continent Study. And the World Health Organization ranked the United States No. 1 out of 191 countries for being responsive to patients' needs, including providing timely treatments and a choice of doctors.

I have written a number of times, the fact that we spend more on health care is not a bug, its a feature.  We are the wealthiest nation on earth, and there is only so much we can spend on food, clothing, shelter, plasma TV's and other necessities.  We choose to spend a lot of that extra money on our health and longevity.  Why is that a bad decision?

Not much I even need to add to this, via Riehl World View:

On Tuesday, the Senate health committee voted 12-11 in favor of a two-page amendment courtesy of Republican Tom Coburn that would require all Members and their staffs to enroll in any new government-run health plan. Yet all Democrats -- with the exceptions of acting chairman Chris Dodd, Barbara Mikulski and Ted Kennedy via proxy -- voted nay.

In other words, Sherrod Brown and Sheldon Whitehouse won't themselves join a plan that "will offer benefits that are as good as those available through private insurance plans -- or better," as the Ohio and Rhode Island liberals put it in a recent op-ed. And even a self-described socialist like Vermont's Bernie Sanders, who supports a government-only system, wouldn't sign himself up.

Does anyone else find this reminiscent of Obama's decision to send accept a scholarship for his own education, send his kids to private school in DC, and then, nearly as his first action as President, kill the voucher program that let other African American kids in DC go to private school.

Previously, I used 1970s gas price lines as an example of a situation where the government, as Uwe Reinhardt puts it, "reduce[d] rationing on the basis of price and ability to pay."

Here is another example:  The Pruitt Igoe housing project in St. Louis, which was abused so badly by its occupants it had to be torn down less than 20 years after it was built.

I will remind you of my earlier comparison of universal health care to public housing:

Lyndon Johnson wants to embark on a futile attempt to try to provide public housing to the poor?  Our taxes go up, a lot of really bad housing is built, but at least my housing did not get any worse.  Ditto food programs "” the poor might get some moldy cheese from a warehouse, but my food did not get worse.  Ditto welfare.  Ditto social security, unemployment insurance,and work programs.

But health care is different.  The author above is probably correct that some crappy level of terribly run state health care will probably be an improvement for some of the poor.  But what is different about many of the health care proposals on the table is that everyone, not just the poor, will get this same crappy level of treatment.  It would be like a public housing program where everyone's house is torn down and every single person must move into public housing. That is universal state-run health care. Ten percent of America gets pulled up, 90% of America gets pulled down, possibly way down.

Apparently in the future I will have two health plan choices -- my current plan or the government plan.  And the only reason I will be able to keep my current plan is that is will be grandfathered in.  A few years ago I switched plans, to get one with a better price and mix of benefits for my family.  I will never be allowed to do this again under the new health care bill:

It didn't take long to run into an "uh-oh" moment when reading the House's "health care for all Americans" bill. Right there on Page 16 is a provision making individual private medical insurance illegal.

When we first saw the paragraph Tuesday, just after the 1,018-page document was released, we thought we surely must be misreading it. So we sought help from the House Ways and Means Committee.

It turns out we were right: The provision would indeed outlaw individual private coverage. Under the Orwellian header of "Protecting The Choice To Keep Current Coverage," the "Limitation On New Enrollment" section of the bill clearly states:

"Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day" of the year the legislation becomes law.

So we can all keep our coverage, just as promised "” with, of course, exceptions: Those who currently have private individual coverage won't be able to change it. Nor will those who leave a company to work for themselves be free to buy individual plans from private carriers....

Wow, even for this cynical libertarian, this is a new low of technically complying with a promise while in substance completely violating the spirit of that promise.

By the way, how long will my current insurer even be able to offer me my plan given that it cannot generate any new business  (I use Assurant, who specializes in individual policies for self-employed people like myself).

This is a great example of what I have been saying all along - regulation always helps large companies more than small.   Everything in this legislation is tailor-made to help large companies who already have health plans and pound small companies and the self-employed.  This is in part because the large companies have the lobbying muscle to get themselves a seat at the table as the bill is crafted.   But it is more than just neglect, it is an outright attack.  Large companies most fear competition from smaller, lower cost competitors.  Anything to make the life of small business more expensive and difficult helps cement the big guys market position.

Update: Here is a scary thought -- what will it do to entrepeneurship in this country when a decision to leave a large company and go into business for oneself bascially means giving up private health insurance and going on Medicare?

Update #2: For readers, as well as a place for me to find it in the future, here is a link to all 1000+ pages of the bill.  Enjoy.

I have suspected that this was coming, but I guess I have just buried my head in the sand, knowing that I would be taking a complete screwing and not wishing to contemplate it.

Sens. Edward Kennedy, D-Mass., and Chris Dodd, D-Conn., say their plan would preserve employer-sponsored insurance coverage and create an affordable public option for those who need it....

The bill includes a "pay or play" provision that would require employers to provide adequate coverage for their workers or subsidize a system that will.

"Pay or play" would require companies to pay the government $750 per full-time worker per year ($375 for part-timers) if they don't offer health coverage, or if they offer "qualified" coverage but pay less than 60% of workers' premiums. Small businesses that employ fewer than 25 workers would be exempt.   (Via Q&O)

I run a recreation business with about 500 part-time, seasonal employees.  Most of them work for the equivilent of about 1/4 of a year, or about 500 hours.  Almost all are over 70, and already on Medicare and Social Security, so we have no health plan  (no way to get a reasonable plan anyway for a bunch of 70 year olds).

Adding up the numbers, this turns into $187,500 bill I would have to pay to the government for not providing health care to people who already mostly have health care.  I will pay 1/2 the full time rate despite my employees working far less than 1/2 of the year.

One thing you can be sure of -- this may be the final death of my current human resources model.  We typically hire more people, working fewer than 40 hours, because retired folks don't generally want to (or can't) work a full week.   That's been OK, because 4 people working 10 hours a week has always cost me the same as 1 person working 40 hours.   But if I am getting charged $375 per worker whether she/he works 1 hour or 1000, you can bet I am going to hire fewer workers for longer hours.  There are probably a myriad of other implicaitons for my business model,  I just have not yet thought it through.

The largest government medical insurance program, Medicare, is threatening to nearly bankrupt the federal government with its rising costs that no one in 30 years has figured out how to manage, short of attempts at price controls (controls which are driving doctors out of the business).  Treat with extreme skepticism mystery double-secret methodologies that the Obama administration promises will cut costs 30% when no such savings have ever been achieved in Medicare.

The largest government run medical care organization, the VA, apparently provides awful service and is rife with fraud and errors due to poor accountability.

So, despite 89% of Americans reporting themselves satisfied with their medical care (one of the highest approval ratings for ... anything I have seen out of a poll) we are going to replace our current system with one run by the government.

Outstanding.

Postscript: You will often get quoted enormous numbers (often as high as 47 million) for the uninsured.  This seems to be the driving force behind the felt need for health care change.  But when someone quotes this number to you, ask for the number excluding a) college students; b) people who make over $50,000 a year who could presumably pay for their own coverage; c) illegal immigrants;  d) people transitioning between jobs and e) people already eligible for Medicare/Medicaid but don't bother to sign up until they are actually sick.  You will get a number a LOT lower, closer to 10-15 million.

If we need to do something more to help 10 million or so poor people, then lets help 10 million or so poor people.  Let's not screw up what exists for the other 290 million or so people in this country.  As I wrote before

But health care is different.  The author above is probably correct that some crappy level of terribly run state health care will probably be an improvement for some of the poor.  But what is different about many of the health care proposals on the table is that everyone, not just the poor will get this same crappy level of treatment.  It would be like a public housing program where everyone's house is torn down and every single person must move into public housing. That is universal state-run health care. Ten percent of America gets pulled up, 90% of America gets pulled down, possibly way down.

Health care reform by hatchet, axe, and saw*.

Update: From Doug Ross

The Kaiser Family Foundation, a liberal non-profit frequently quoted by the media, puts the number of uninsured Americans who do not qualify for current government programs and make less than $50,000 a year between 13.9 million and 8.2 million. That is a much smaller figure than the media report and is also subject to "the 45% rule", wherein that percentage will transition to new jobs within a four-month time-frame.

This is from Tori Barnett on John Stossel's blog (Stossel being yet another member of the powerful Princeton Tower Club libertarian blogging set):

As we approach ABC's Wednesday White House Health Care town meeting, I'm thinking more about how health insurance"”private or government run"”destroys the individual's incentive to shop around. People spending their own money and dealing directly with doctors is the only thing that honors individuals' different preferences and controls costs.  How can we hold costs down at all if the market isn't allowed to work?

But few people are talking about that.

The pundits write about the popularity of Medicare.  Of course it's popular.  People love getting free stuff.  But Medicare is on an unsustainable path. It is more than 30 trillion dollars in the red!

As I wrote previously:

Take purchasing a car.  When I need a new car, who determines what car I end up with?   Why, I do.  And who pays for the car and shops around for a price that makes sense in the context of the perceived value of the car?  Why, I do again.  The person who uses the car, the person who chooses the type and quality of the car, and the person who pays for the car are all the same person.

This clever procurement model of integrating the payer, the shopper, and the user all into a single individual is one we use for, well, just about every product and service we buy.  Milk, Internet service, DVD's, house painting, airline tickets "” all the same model.

OK, lets consider a model that does not work this way.  Let's say someone just rear-ended your car and, miracle of miracles, they actually have a good, solid insurance policy that owes you for your car repairs.  In this case, you will be consuming the repair services, and have the incentive to find the absolute best, cost-no-object body shop you can find to do the best, most fabulous job fixing your car, because someone else (ie the insurance company) is paying.  The insurance company has a different incentive.  They want to get off with as small a loss as possible, to protect their profitability as well as keeping prices low for future policy-holders.  They are going to want you car fixed cheap, particularly since you are probably not even their customer.  They are going to try to deliver the minimum.

No surprisingly, people tend to get ticked off in these situations, as they grind against the opposing incentives of the insurance company.  It's one reason that the insurance field is highly regulated (because nowadays people complain to their Congressman whenever they get irritated).  It's also a measure of how ineffective regulation is in really managing this friction, since despite zillions of government rules people still get pissed off.  The reason is that there is simply no good solution.   Both parties want a solution at the extreme end of a cost-value scale, neither have much of an incentive to compromise, and neither will be happy with a solution in the middle of these extreme incentives, and no amount of government fiddling with the tradeoff point is going to change this.

OK, but in this example, at the end of the day, it is just a car, and probably this is a once-in-a-lifetime event.  What if we replace "car" with "baby daughter" or "grandmother" or "your life?"  Now, as Bill Murray says, the kidding around is pretty much over.  It is a recipe for an incendiary disaster.  Which is exactly what we have in health care.

If we take these three roles - user, service quality specifyer, and payer/price shopper - there are very few places in medicine today where these three roles are united.  Further, despite the fact that the vast majority of the problems in US health care are demonstrably from this role separation, none of the plans currently being considered by Obama or Congress unify these three parties.

With my high deductible medical policy, I am actually one of the few middle/upper class folks who actually shops for health care.  And I can tell I am in the minority by the reaction I get from doctors and medical services companies, that look at me like I am from Mars when I ask for detailed pricing, or when I order less than the full and complete battery of potential tests and services based on my own judgment and price/value trade offs.  Folks in the medical profession are used to people saying "whatever, the insurance company is paying for it."

The post went on to show data for medical care expenses NOT generally covered by insurance, so that they are paid out of pocket.  Not surprisingly, these expenses are the only part of health care seeing actual real price drops:

With gays upset that Obama has aligned himself squarely behind DOMA and Don't-ask-don't-tell in the military, he has decided to pay them off rather than address their equal treatment questions:

President Barack Obama, whose gay and lesbian supporters have grown frustrated with his slow movement on their priorities, is extending benefits to same-sex partners of federal employees but stopping short of a guarantee of full health insurance, a White House official said.

The health insurance exception is particularly funny given Obama's current universal-coverage-driven health care proposals.

Apparently, the Obama administration is worried about the shortage of GP physicians.  Personally, I think anything we do within the present framework, or more onerous government interventionist approaches likely to be proposed by Obama, will fail at reversing this problem.  If plumbers were not allowed to contract directly for price and scope of service with individual homeowners they serve, and were forced instead to fill out 23 yards of paperwork just to get paid rates that were set by government bureaucrats, subject to thousands of pages of regulations any one of which could cause his payment request to get rejected, we would have a shortage of plumbers too.

However, since no one in Washington currently seems to be in the mood topromote commercial relationships in medicine that mirror how we contract for every other product and service, I guess we can nibble at the edges of the problem.  David Bernstein suggests:

I have yet to see in any of these articles one simple reform proposed: abolish the requirement of an undergraduate degree before attending medical school, and turn medical school into a five or six-year post-high school program instead. This would eliminate two or three years of debt, and, perhaps even more important, the opportunity costs of two or three years of college. Right now, an aspiring physician must go to college for four years (and take many classes that have nothing to do with his future career), then medical school for four years, and then typically do a poorly paid internship and then residency for another five years. By the time this aspiring physician goes into practice, he will be at least thirty-one years old, and have eight years of student loan debt.

I have a better solution.  Why do we have a one-size-fits-every-corner-of-the-medical-field education and licensing at all?  Why do I need to pay for someone with 8 years of college and five years of residency to put three stitches in my kids' cut?  Or to write a Viagra scrip?  In dentistry, why do oral hygienists all seem to be in dentists' offices?  Why do I need to pay the overhead of a dentist to get my teeth cleaned?

We shouldn't really be surprised, I guess, about this licensing approach -- when the government turns over the licensing board to the incumbents of the industry being licensed, they have every incentive to choke off supply and to kill any initiative that might create low-cost competition for themselves.

So the licensing system that is all or nothing -- you are either a full-fledged medical doctor that can handle anything, or someone who is allowed to handle nothing.  This is reinforced by the payment system we have, where people do not bear the marginal cost of the services they consume.  So, since every office visit costs them the same (zero or a fixed copay), they might as well ask for the most experienced and over-educated guy they can find -- it's not costing them any extra.

Well, this is true for most people.  I have a high-deductible health insurance policy, and we often consider the price of different alternatives. Here is an example.  I am a healthy person, but still go in for a physical each year.  Nothing complicated happens in these visits.  Surely there could be some kind of less-trained traige MD who could conduct such screenings, passing folks on to the full-fledged doctors if anything unusual pops up.  If you told me that I could be seen by such a person for $100 or a full MD for $300, I would certainly consider it, particularly since the triage guy's schedule probably runs smoother as he doesn't get bogged down with the unexpected -- he just passes those folks on.

From Mickey Kaus:

Democratic blogger Ezra Klein appears to be positioning Dem health care reforms as a way to cut costs, on the grounds that a reformed system will be able to make "hard choices" and "rational" coverage decisions, by which Klein seems to mean "not providing" treatments that are unproven or too expensive--when "a person's life, or health, is not worth the price." Matthew Yglesias' recent post seems to be saying the same thing, though clarity isn't its strong suit. (He must have left it on Journolist.)

...

The "rational," cost-cutting, "hard-choices" pitch isn't just awful marketing--I don't even think it's accurate. Put it this way: I'm for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling's example of a young patient with cancer, where "the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200." No "rational bureaucracy" would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life.  But I think the government--faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public's sentimental bias toward life--is less likely to be "rational" than the private sector.

That is to say, the government's more likely to pay for the treatment (assuming a doctor recommends it). So it's government for me.

He comes oh-so-close to getting it right, but then falls short.

Klein is right that the pressure will be to ration care -- we already see such rationing being seriously considered in Massachusetts (the model of choice for Democrats) under the weight of massive expenditures.

But Kaus is correct that if some high-powered and well-funded interest group gets behind a certain procedure, cost-effective or not, the government overlords of the program will likely approve it.   As a result, for example, no potential treatment for breast cancer will ever be denied given the proven strength of women's groups lobbying for breast cancer treatment (already, breast cancer research is hugely over-funded vs. other diseases given its mortality, due in large part to this powerful lobbying).

But it is not one dynamic or the other.  Both will exist.  There will be huge pressures to cut back somewhere, as costs skyrocket.  And there will be huge pressure from certain interest groups to fund treatment for certain diseases in unlimited amounts.  The result will not be, as Kaus posits,  that everything will be funded more than it is today -- the result will be that certain procedures and conditions with strong lobbying and political muscle will get funded more, with the difference being made up from cutting funding for conditions and procedures without a well-organized lobby.

Access to care will no longer be determined by money, but by political pull.  (Yeah, I know, it's Ayn Rand's world and we all just live in it).