Health

Where to Cut

This morning the GOP will release its budget proposal for 2012.  When I heard last week that it would propose $1 trillion in cuts to Medicaid, I was troubled.  If you ask me were to start to cut $1 trillion, it wouldn’t be at healthcare for the poor and disabled.  It would be at the Defense Department.  We spend more on defense than the rest of the world combined and nearly 7 times more than the next-highest spender.  Obviously, we have security concerns and challenges that can’t be met without a strong military, but we could could spend hundreds of billions less per year and and still far outspend anyone else.  It doesn’t seem wise to me to continue such extravagant levels of military spending.

Then yesterday I learned that the Medicaid cuts would be accompanied by drastic changes to Medicare (elimination of Medicare as we know it).  Joshua Michael Marshall writes:

The Medicare system has been in place in the United States for a bit more than 40 years. The premise is simple: once you hit retirement age you move into a single payer health care insurance system in which Medicare takes responsibility for your care, regardless of the state of your health or income level. There are copays. No one's crazy about exactly how much is covered. Some doctors opt out. You've probably heard all of this at one point or another. But the key is that you're in the program. And for the rest of your life you're out of the private health insurance system. You're covered. Permanently and on the same terms as everyone else.

What Ryan is proposing is something different.  Ezra Klein summarizes:

Paul Ryan’s plan for Medicare and Paul Ryan’s plan for Medicaid rely on the same bait-and-switch: They use a reform to disguise a cut.

In Medicare’s case, the reform is privatization. The current Medicare program would be dissolved and the next generation of seniors would choose from Medicare-certified private plans on an exchange. But that wouldn’t save money. In fact, it would cost money. As the Congressional Budget Office has said (pdf), since Medicare is cheaper than private insurance, beneficiaries will see “higher premiums in the private market for a package of benefits similar to that currently provided by Medicare.”

In Medicaid’s case, the reform is block-granting. Right now, the federal government shares Medicaid costs with the states. That means their payments increase or decrease with Medicaid’s actual rate of spending. Under a block grant system, that’d stop. They’d simply give states a lump sum at the beginning of the year and that’d have to suffice. And if a recession hits and more people need Medicaid or a nasty flu descends and lots of disabled beneficiaries end up in the hospital with pneumonia? Too bad.

In both cases, what saves money is not the reform. It’s the cut. For Medicare, the cut is that the government wouldn’t cover the full cost of the private Medicare plans, and the portion they would cover is set to shrink as time goes on. In Medicaid, the block grants are set to increase more slowly than health-care costs, which is to say, the federal government will shoulder a smaller share of the costs than it currently does.

Needless to say, I’ve got serious concerns about what Ryan’s plan would do to our social safety net.  However, it is quite unusual in that it actually proposes cuts at a level that would have a significant impact on the deficit.

Up until this point, the “cut or shut” discussion has been focused on non-defense discretionary spending…that is, the more minor parts of the budget.  Military and entitlements (Medicare, Medicaid, and Social Security) are the big ticket items.  All of the usual targets for cuts are small in comparison (and, therefore, of little impact): things like subsidies to oil companies ($4 billion/yr), corporation for public broadcasting (NPR, PBS, etc. $0.5 billion/yr), agricultural ($20 billion/yr), ethanol ($2.5 billion/yr), Planned Parenthood and the rest of Title X ($0.3 billion/yr), renewable energy ($5 billion/yr), National Endowment for the Arts ($0.2 billion/yr). TARP and the auto bailout draw much criticism too.  However, TARP is on target to cost less than $50 billion in total, a bargain for avoiding a total collapse of the global economy.  The auto bailout will cost less than $25 billion.  These are all large numbers, but even added together they are small relative to defense and entitlements.  To have a significant impact you have to address defense and/or entitlements and/or significantly increase revenue (e.g. allowing Bush tax cuts to expire would cut the deficit in half).  Focusing on "non-defense discretionary spending" cannot solve the problem.

Unfortunately, it sound’s like the GOP’s “Path to Prosperity” will go aggressively after entitlements but treat the Defense Department with kids gloves by merely “…accepting Defense Secretary Robert Gates's plan to target inefficiencies at the Pentagon.”  It also goes after some of those items I listed above such as agricultural subsidies and renewable energy.  Tax reform is in there too:

This budget would focus on growth by reforming the nation's outdated tax code, consolidating brackets, lowering tax rates, and assuming top individual and corporate rates of 25%. It maintains a revenue-neutral approach by clearing out a burdensome tangle of deductions and loopholes that distort economic activity and leave some corporations paying no income taxes at all.

Simplifying the tax code and getting rid of some of the deductions and loopholes sounds good to me.  However, federal taxes as a percentage of GDP are currently at their lowest level in the last 60 years.  If the debt is really such a crisis level, it would seem prudent to reform the tax code in a way that isn’t revenue-neutral and helps pay off the debt (at least until we are back on a more sustainable course).  Unfortunately, a significant portion of the GOP cares more about reducing the size and scope of government and making sure taxes are never increased than they do about actually reducing the debt.


Updated 2011-04-05:
Changed the CPB funding link and clarified that taxes as a percentage of GDP (i.e. taking into account the effect of the recession on the economy) are at historically low levels.

More Thoughts on Health Care Reform

One of the more interesting things to me about all this is that so many people are so sure that they absolutely hate this bill.  I don't expect everyone to be excited about it.  About half of us think government is more the problem than the solution.  I don't expect that half to be glad that the government is getting more involved in health care, but please be reasonable.

Let me say it again, this bill you're denouncing as Socialism is a moderate Republican's health insurance reform bill.  It's remarkably similar to one Chafee (R) proposed in 1993 and what Bob Dole (R), Howard Baker (R), and Tom Daschle (D) proposed last year.  It is the result of months of negotiations among the Gang of Six (R: Enzi, Grassley, Snowe; D: Baucus, Bingaman, Conrad). It contains a multitude of Republican amendments.  Yes, the government will be more involved than it is now, but that doesn't mean you get to redefine Socialism.  No, the vote wasn't bipartisan, but that was by design of the GOP's strategy for regaining power and not Obama's desire or the bill's actual merits.

If you, like the vast majority of us, get your health insurance via an employer-subsidized plan, then the government is already helping you out in big ways...ways that it isn't helping those who must get coverage on the individual market.  It is subsidizing employer-sponsored coverage to the tune of $250 billion per year by excluding that form of income from income tax.  Furthermore, pre-existing conditions are not an issue in the employer-based market because of government regulation (Health Insurance Portability and Accountability Act of 1996).  Why is it that you deserve these benefits but someone who is out of work or only able to get part-time work or is a freelancer does not?

It's not true that a majority opposes this bill because it is too liberal.  It is true that about half of us favor it or think it is not liberal enough.  Congress isn't ignoring the will of the people.  Obama and the Democrats ran on health reform and won the White House and large majorities in Congress.  Now they are delivering on a major campaign promise.  This is not an act tyranny.  This is democracy.

Also, there are no actual pro-abortion dimensions to the bill.  Claiming otherwise despite the facts diminishes our credibility as pro-lifers...and credibility is something we greatly need to be able to change hearts and minds about abortion.

I seem to have noticed a trend away from "Leave health care alone!  Our system is the best in the world!" to "Everyone agrees we need reform, but not this reform!"  OK, what do you want?  Tort reform?  Fine, but that's a drop in the bucket.  End discrimination against pre-existing conditions?  If you do that, then you need the individual mandate...otherwise only the sick will buy insurance.  If you have the individual mandate, then it's more important than ever to have adequate subsidies so that everyone can afford it.  Sounds like a decent plan you've got there, but it sounds suspiciously familiar.

In the end, I'm glad more of the minority will now have the access to affordable health care that the majority of us already have.  I hope you can understand that even if you think I'm misguided.

Health Insurance Reform, Abortion, Conspiracy Theories, Etc.

Tomorrow the House will vote on the Senate health reform bill and a set of amendments to it.  They will do it with explicit votes rather than the "deem and pass" strategy that had been floated.  Although the Senate will still have to pass the amendments itself via reconciliation, it is assumed that those votes are there.  That means tomorrow's votes will likely be decisive.

Much of today's drama surrounded whether or not Bart Stupak could be brought back on board by addressing his concerns about the Senate bill's abortion language.  Apparently that's not going to happen.  On the other hand, an executive order incorporating Stupak's language is apparently being considered.

The debate over whether or not the Senate bill subsidizes abortion is quite odd.  Folks like Stupak and the United States Conference of Catholic Bishops say it does.  Folks like Brad Ellsworth, The Catholic Health Association, and Catholics in Alliance for the Common Good say it doesn't.  The status quo (via the Hyde Amendment) is that the federal government doesn't pay for abortions, and President Obama has made it clear that he doesn't want the health insurance reform bill to change that status quo.

A look at the bill's abortion language makes if difficult to understand why so many people are apparently so sure that it funds abortions.  While not requiring or preventing insurance plans to include abortion coverage, it prevents public money from funding them. It requires that the state-based exchanges have at least one plan available that doesn't cover abortions and allows a state to rule out abortion coverage if it chooses.  Nevertheless, there seem to be two remaining threads to the pro-life opposition to the Senate bill.

First, the bill stipulates that anyone who wants to purchase a plan that includes abortion coverage in the state-based exchanges must make a separate payment for that coverage, and the insurer must keep that pool of money separate from any governmental subsidies so that they don't directly fund abortions.  This is not adequate to Stupak because there will be people who would not have insurance at all without the federal subsidies who then purchase abortion coverage for their subsidy-enabled health insurance.  Stupak seems to take the view that once you give someone aid you are effectively subsidizing any other way that they choose to spend money. By that logic I'm sure I have "paid for" all kinds of bad things (by giving money to a church that gives aid to people who also spend their money on bad things), but of course I haven't actually "paid for" those things.  Also, many employer-sponsored insurance plans cover elective abortions.  A Guttmacher Institute Study indicated 87 %, while a Kaiser Family Foundation said 46 % (LifeNews believes the KFF numbers).  I checked on mine (Aetna), and it does.  Famously, the Republican National Committee's plan covered elective abortion until it became a news story, and the argument could be made that even Focus on the Family indirectly pays for abortions.  By Stupak's logic, isn't everyone who pays premiums to those plans indirectly funding abortions?  Furthermore, the tax exclusion for employer sponsored health care is (by Stupak's logic) an enormous abortion subsidy that dwarfs the small, theoretical one that is his current focus.

Secondly, the bill includes funding for "community health centers" which some have claimed could provide abortions.  This may in fact be (theoretically) true since that funding would come via a route that might not be subject to the Hyde Amendment.  However, it's been argued that there are other long-standing regulations that would prevent programs administered by the Health Resources and Services Administration (programs such as the community health centers) providing abortion services and that the funds will end up in the same pot as other funds subject to the Hyde Amendment, effectively making it subject to the same restrictions.

Here is what National Association of Community Health Centers has to say about it:

Community health centers "have never performed abortions," said Dan Hawkins, senior vice president of policy and programs for the group. "They do not plan to or seek to become a provider of abortions. They don't do that."

Community health centers are focused on their mission of providing primary and preventive health care -- things like immunization and prenatal care -- to those typically underserved by the health care community, he said.

Community health centers were around for 11 years before the Hyde Amendment went into effect in 1976 and they never provided abortions, he said. And last year, they got $2 billion in federal stimulus funds. Of that, $500,000 was for operational funding. It has already been used to provide health care to more than 2 million additional people, he said. Like the Senate bill's proposal, the stimulus money came separate from the HHS appropriation funds (with its Hyde Amendment limits) and contained no specific abortion language. And again, none of it was used for abortions.

Hawkins makes one last point: the $7 billion over five years through the Senate health care bill would be combined by the secretary of HHS (currently Obama appointee Kathleen Sebelius) with the roughly $2.2 billion the centers receive through the annual appropriations bill.

"In our opinion, once this money is combined with the appropriated funds, the Hyde restrictions will apply to the whole thing," Hawkins said.

Together with repeated assurances from Sebelius that no federal funds will be used to pay for abortions, Hawkins said, "We feel confident the restriction (against abortions) will apply."

"And again," Hawkins said, "they haven't done abortions and they aren't looking to do them in the future."

To summarize, it's debatable (but very unlikely) that there is a theoretical risk that the bill could enable direct funding of abortions...but even if it is theoretically possible, it is still highly unlikely.  Even so, claims like "monstrously anti-life" and "the most anti-life piece of legislation in the history of our country" are common.  Such hyperbole is especially puzzling because there is good reason to think that the health insurance reforms will actually reduce the abortion rate.  As T.R. Reid recently argued:

There's a direct connection between greater health coverage and lower abortion rates. To oppose expanded coverage in the name of restricting abortion gets things exactly backward. It's like saying you won't fix the broken furnace in a schoolhouse because you're against pneumonia. Nonsense! Fixing the furnace will reduce the rate of pneumonia. In the same way, expanding health-care coverage will reduce the rate of abortion.

At least, that's the lesson from every other rich democracy.

The latest United Nations comparative statistics, available at http://data.un.org, demonstrate the point clearly. The U.N. data measure the number of abortions for women ages 15 to 44. They show that Canada, for example, has 15.2 abortions per 1,000 women; Denmark, 14.3; Germany, 7.8; Japan, 12.3; Britain, 17.0; and the United States, 20.8. When it comes to abortion rates in the developed world, we're No. 1.

No one could argue that Germans, Japanese, Brits or Canadians have more respect for life or deeper religious convictions than Americans do. So why do they have fewer abortions?

One key reason seems to be that all those countries provide health care for everybody at a reasonable cost. That has a profound effect on women contemplating what to do about an unwanted pregnancy.

Reid summarizes:

When I studied health-care systems overseas in research for a book, I asked health ministers, doctors, economists and others in all the rich countries why their nations decided to provide health care for everybody. The answers were medical (universal care saves lives), economic (universal care is cheaper), political (the voters like it), religious (it's what Christ commanded) and moral (it's the right thing to do). And in every country, people told me that universal health-care coverage is desirable because it reduces the rate of abortion.

It's only in the United States that opponents of abortion are fighting against expanded health-care coverage -- a policy step that has been proved around the world to limit abortions.

Michael New disputes Reid's thesis, claiming the figures Reid uses exaggerate the abortion rate in the U.S., ignores the impact of our racially-diverse population, and ignores the "experience of states that have offered more generous provision of public health benefits."  However, as David Gibson points out:

A study published in the latest New England Journal of Medicine shows that abortion rates declined during the first two years that Massachusetts implemented a near-universal health coverage program much like the nationwide plan currently before Congress.

As Ezra Klein put it:

...abortions were on a longer-term downward trend in Massachusetts, so it's possible (I might even say likely) that the reform didn't matter and abortion was dropping for other reasons. But it's hard to look at this data and say that the reforms led to a large increase in abortions.

Ron Sider, President of Evangelicals for Social Action, said the following about the bill:

It is a moral outrage for the richest nation in history to leave 47 million of its people without health insurance. This legislation substantially extends coverage and also retains the long-standing stance of the Hyde Amendment against federal funding of abortion. It will save thousands of lives, cover millions of people, and prevent federal funding of abortion."

It's disappointing to me that so many pro-life groups have opposed health reform so so vehemently and with so much hyperbole.  This is not the only way I've recently been disturbed by the tactics of the pro-life movement. 

Conspiracy theories seem to be flourishing these days: for example, 911 Truthers, birthers, and whatever nonsense Glenn Beck is pushing this week.  Here is one more: as reported in the New York Times:

Across the country, the anti-abortion movement, long viewed as almost exclusively white and Republican, is turning its attention to African-Americans and encouraging black abortion opponents across the country to become more active.

A new documentary, written and directed by Mark Crutcher, a white abortion opponent in Denton, Tex., meticulously traces what it says are connections among slavery, Nazi-style eugenics, birth control and abortion, and is being regularly screened by black organizations.

Black abortion opponents, who sometimes refer to abortions as “womb lynchings,” have mounted a sustained attack on the Planned Parenthood Federation of America, spurred by a sting operation by young white conservatives who taped Planned Parenthood employees welcoming donations specifically for aborting black children.

William Saletan has questioned the consistency of the messages of some of the conspiracy theorists.  Admittedly, the figures regarding abortion in the black community are certainly tragic:

Data from the federal Centers for Disease Control and Prevention show that black women get almost 40 percent of the country’s abortions, even though blacks make up only 13 percent of the population. Nearly 40 percent of black pregnancies end in induced abortion, a rate far higher than for white or Hispanic women.

...but I'm not glad to see pro-life groups encouraging conspiracy theories about racists specifically targeting blacks for elimination or to hear claims that blacks are worse off now than they were under slavery...

What All the Fuss is About

In response to my claim that the government isn't taking over health care, I was recently asked what's all the fuss about, then?

My answer: politics

(most of what follows is h/t Ezra Klein)

As Maggie Mertens recently pointed out (link) and summarized with the table at the end of this post, the current senate health care bill is remarkably similar to the bill proposed in 1993 by a moderate Republican senator (John Chafee), 19 other Republican senators, and 2 Democrats - considered the major GOP proposal at the time.  Naturally, therefore, the Republicans are celebrating that the Dems some 17 years later are pushing a GOP health care bill.  Not so much.

Instead, here's a sampling of what we get...

We get this from the Republican National Committee (link):

PH2010030303718

and we get commentary like this by conservative pundit Mark Steyn from the National Review (link):

I’ve been bandying comparisons with Britain and France but that hardly begins to convey the scale of it. Obamacare represents the government annexation of “one-sixth of the U.S. economy” — i.e., the equivalent of the entire British or French economy, or the entire Indian economy twice over. Nobody has ever attempted this level of centralized planning for an advanced society of 300 million people. Even the control freaks of the European Union have never tried to impose a unitary “comprehensive” health-care system from Galway to Greece. The Soviet Union did, of course, and we know how that worked out.

Annexation of 1/6 of the economy?  Ezra Klein rebuts (link):

Putting aside the question of whether government regulations are the same as "annexation" (in which case, the apple I'm eating is federally annexed, and I never knew socialism could be this crisp and delicious), the regulations in question are limited to insurance being offered on the exchanges.

Why does that matter? Because the exchanges, as you can see on Page 20 of this CBO analysis, are expected to serve 25 million people by 2019. That is to say, these regulations will be limited to less than 10 percent of the market. And that 10 percent of the market will be primarily composed of the uninsured.

Why would conservatives be freaking out so extravagantly about a health bill nearly identical to their own from 17 years ago?  Did the GOP propose a socialist health care bill in 1993?  Were they plotting an unprecedented expansion of government, an annexation of 1/6 of the economy?  No.  Then what is all the fuss about?

The fuss is all about politics (Waterloo).

From Kaiser Health News (link):

Major Provisions Senate Bill 2009 Sen. Chafee (R) Bill 1993 Rep. Boehner (R) Bill 2009

Require Individuals To Purchase Health Insurance
(Includes Religious and/or Hardship Exemption)

Yes

Yes

No (individuals without
coverage would be taxed)

Requires Employers To Offer Health Insurance To Employees

Yes (above 50 employees, must help pay for insurance costs to workers receiving tax credits
for insurance)

Yes (but no requirement to contribute to premium cost)

No

Standard Benefits Package

Yes

Yes

No

Bans Denying Medical Coverage For Pre-existing Conditions

Yes

Yes

No (establishes high risk pools)

Establish State-based Exchanges/Purchasing Groups

Yes

Yes

No

Offers Subsidies For Low-Income People To Buy Insurance

Yes

Yes

No

Long Term Care Insurance

Yes (sets up a voluntary insurance plan)

Yes (sets standards for insurance)

No

Makes Efforts To Create More Efficient Health Care System

Yes

Yes

Yes

Medicaid Expansion

Yes

No

No

Reduces Growth In Medicare Spending

Yes

Yes

No

Medical Malpractice Reform

No

Yes

Yes

Controls High Cost Health Plans

Yes (taxes on plans over $8,500 for single coverage to $23,000 for family plan)

Yes (caps tax exemption for employer-sponsored plans)

No

Prohibits Insurance Company From Cancelling Coverage

Yes

Yes

Yes

Prohibits Insurers From Setting Lifetime Spending Caps

Yes

No

Yes

Equalize Tax Treatment For Insurance Of Self-Employed

No

Yes

No

Extends Coverage To Dependents

Yes (up to age 26)

No

Yes (up to age 25)

Cost

$871 billion over 10 years

No CBO estimate

$8 billion over 10 years

Impact On Deficit

Reduces by $132 billion over 10 years

No CBO estimate

Reduces by $68 billion over 10 years

Percentage Of Americans Covered

94% by 2019

92-94% by 2005

82% by 2019

Reconciliation

Apparently the Democrats are steeling themselves to go it alone and pass health care reform via reconciliation (link):

...Obama is saying that unless Republicans support comprehensive reform as Obama and Dems have defined it — dealing with the problem of 30 million uninsured and, by extension, seriously tackling the preexisting condition problem — they will almost certainly move forward with reconciliation.

As they do, I'm sure the claims that they're ramming an unpopular bill down our throats or ramming it through Congress will only get louder.  Here is what I think is important to keep in mind (hats off to Ezra Klein and Greg Sargent)...

The health plan is unpopular.

That plot illustrates the enormous success that the opponents of reform have had in shifting public opinion.  Much of that unpopularity comes from people who think it goes too far, but a significant fraction from people who don't think it goes far enough...who think single-payer or a public option is a necessary element of real reform, for example.  On the other hand, the individual components of the bill are quite popular (link):

percent_supporting_-thumb-450x277As Klein puts it (link):

Health-care reform is unpopular. But if you actually tell people what's in the health-care reform bill, then it becomes quite popular.

This says to me that the polling that says that health care reform is "unpopular" is not a strong argument for killing Obamacare.  Furthermore, (link):

If polls are so important to the Republicans, why aren't they for the public option?

Although it's not in the Senate bill, most Americans support the public option (a health insurance plan offered by the U.S. government) (link, link).

Obamacare gets portrayed as a radical, partisan plan...but "Republican" ideas are prominent in it (link), and the current Senate bill is much closer to 1993's proposal by moderate Republican Chafee than Boehner's plan is (link).  Again from Klein (link):

We've got a situation in which Democrats are essentially pushing moderate Republican ideas while Republicans push extremely conservative ideas, but because neither the press nor the voters know very much about health-care policy, the fact that Republicans refuse to admit that Democrats have massively compromised their vision is enough to convince people that Democrats aren't compromising.

Republicans are generally wary of allowing the federal government to define the characteristics of minimally-acceptable health insurance.  Klein points out that this philosophical opposition doesn't prevent them from defining minimum standards of their own  (link):

Philosophically, Republicans do have a disagreement with this. It's regulation, after all. But in practice, they accept it. When Republican passed health savings accounts into law, they included definitions of the minimum standards a plan had to meet to qualify. When they passed the Medicare Prescription Drug Benefit into law, they defined what a plan would have to do to qualify for the program.

Klein makes another good point today (link):

There's a difference between the statements "America has the best health-care system in the world" and "With enough money, you can purchase the best health care in the world in America." But that difference gets run over in political conversations. Sen. John Barrasso, for instance, just mentioned that a Canadian premier recently got heart surgery in Miami. Best health care in the world, baby!

America has about 50 million uninsured people within its borders. Canada has exactly 13 premiers. People should ask themselves a very simple question: Do they think they are likelier to lose their job and fall into the health-care situation of the uninsured or become an influential politician and enjoy the health-care options available to the most powerful people in the world?

The complaint that I expect hear most in the coming days is that it will be a travesty to pass Obamacare via reconciliation (i.e. with a 51-vote simple majority rather than a 60-vote supermajority in the Senate).  For example, Bill Frist in today's Wall Street Journal (link):

Senate Majority Leader Harry Reid has announced that while Democrats have a number of options to complete health-care legislation, he may use the budget reconciliation process to do so. This would be an unprecedented, dangerous and historic mistake.

Budget reconciliation is an arcane Senate procedure whereby legislation can be passed using a lowered threshold of requisite votes (a simple majority) under fast-track rules that limit debate. This process was intended for incremental changes to the budget—not sweeping social legislation.

Using the budget reconciliation procedure to pass health-care reform would be unprecedented because Congress has never used it to adopt major, substantive policy change. The Senate's health bill is without question such a change: It would fundamentally alter one-fifth of our economy.

However, as Julie Rovner pointed out (link), during the past 30 years reconciliation has been used many times and is actually the norm for major changes in health care.  A quick summary:

1982 — TEFRA: The Tax Equity and Fiscal Responsibility Act first opened Medicare to HMOs
1986 — COBRA: The Consolidated Omnibus Budget Reconciliation Act allowed people who were laid off to keep their health coverage, and stopped hospitals from dumping ER patients unable to pay for their care
1987 — OBRA '87: Added nursing home protection rules to Medicare and Medicaid, created no-fault vaccine injury compensation program
1989 — OBRA '89: Overhauled doctor payment system for Medicare, created new federal agency on research and quality of care
1990 — OBRA '90: Added cancer screenings to Medicare, required providers to notify patients about advance directives and living wills, expanded Medicaid to all kids living below poverty level, required drug companies to provide discounts to Medicaid
1993 — OBRA '93: created federal vaccine funding for all children
1996 — Welfare Reform: Separated Medicaid from welfare
1997 — BBA: The Balanced Budget Act created the state-federal childrens' health program called CHIP
2005 — DRA: The Deficit Reduction Act reduced Medicaid spending, allowed parents of disabled children to buy into Medicaid

As another example, Timothy Noah chronicles how welfare reform was accomplished (link). 

Finally, Ezra Klein makes another good point on this topic (link):

It's a bit annoying, though, that Democrats keep justifying the reconciliation process based on the fact that Republicans have done it, too. The reconciliation process makes sense because majority votes make sense.

Health Care Reform and the National Debt

Current tax rates are relatively low by historical standards.  Here is a table and plot of the rates going back to 1913: link

They're also relatively low by international standards.  See Table 1 in this article from Forbes: link

The combination of our aging demographics and skyrocketing health care costs means higher taxes are inevitable.  See Figure 1 here regarding the coming debt explosion which will be driven primarily by health care costs: link

If you care about the debt and taxes, then the status quo regarding health care is not an option.  Things like tort reform won't make a significant difference.  The non-partisan CBO has estimated that it would only lower health care spending by 0.5 % (link), and the story is much the same for selling insurance across state lines (link).

More fundamental reform is required, yet even the relatively modest currently-proposed reforms are nearly dead.  This doesn’t look good.

Update 2009-02-19:
Admittedly, federal income tax rates don't tell the full story about the tax burden. However, the international comparison in the Forbes article is total taxes (federal, state, and local). In terms of historical U.S. figures, the data from The Tax Foundation show that local and state taxes as a percentage of income have remained stable for the last 30 years (link). In terms of % of GDP (another metric of the tax burden), this figure shows that state and local taxes rose steadily from 1945 to 1970, but not astronomically (link). None of these data support the view that taxes are currently abnormally high. Given the impending debt explosion driven by demographics and health care costs, I'm betting taxes will rise eventually no matter which party is in power.

Bypassing Conference

The Democratic leadership in Congress is making plans to bypass the conference process for working out a compromise between the health care reform bills that passed the House and Senate.  From Jonathan Cohn (link):

According to a pair of senior Capitol Hill staffers, one from each chamber, House and Senate Democrats are “almost certain” to negotiate informally rather than convene a formal conference committee. Doing so would allow Democrats to avoid a series of procedural steps--not least among them, a series of special motions in the Senate, each requiring a vote with full debate--that Republicans could use to stall deliberations, just as they did in November and December.

In terms of the optics, this is bad.  It confirms the GOP talking-point that reforms the people don’t want are being crafted in secret and rammed through Congress.  For example, in the words of a spokesman for John Boehner (link):

“Something as critical as the Democrats’ health care bill, with its Medicare cuts and tax hikes, shouldn’t be slapped together in a shady backroom deal. Skipping a real, open Conference shuts out the American people and breaks one of President Obama’s signature campaign promises. It would be a disgrace — to the Democratic Leaders if they do it, and to every Democratic Member who lets them.”

On the other hand, when it comes to health care reform the Republicans have only a strategy of saying “No” (Republicans voted against the House version 176 to 1;  Republicans voted against the Senate version 39 to 0).  Contrary to the talking point that the Democrats have ignored Republicans in shaping the bills and are rushing reform, the original timelines were much delayed while the Gang of 6 (link) worked deliberately on a bipartisan bill.  Even the Republican participation in those negotiations was questionable (e.g., Grassley: link and link).  Even after significantly influencing the Senate bill, none of Republican members of the Gang of 6 voted for it.  Even after reform bills had passed both houses of Congress, the GOP Senate leadership was still vowing to keep fighting (link).  Given these realities, it seems like the Republicans have already said “No” to reform.  Why indulge the Republicans’ plans to further obstruct?

Apparently, bypassing conference isn’t especially unusual (link):

Hill aides say it often happens with major or contentious pieces of legislation (though not apparently in this current Congress). "This is what we normally do," said one Hill aide, "it is pretty standard."

But it’s certainly nothing like what Obama promised during the campaign (link):

I'm going to have all the negotiations around a big table. We'll have doctors and nurses and hospital administrators. Insurance companies, drug companies -- they'll get a seat at the table, they just won't be able to buy every chair. But what we will do is, we'll have the negotiations televised on C-SPAN, so that people can see who is making arguments on behalf of their constituents, and who are making arguments on behalf of the drug companies or the insurance companies. And so, that approach, I think is what is going to allow people to stay involved in this process.

As a bonus, here’s a plot (link) of life expectancy vs. health care spending for various countries (with the size of the circle proportional to the number of doctor visits per person):

healthscatter2

The Pope, AIDS, and Condoms

From The Wall Street Journal:

Pope Benedict XVI said on his way to Africa Tuesday that condoms weren't the answer in the continent's fight against HIV, his first explicit statement on an issue that has divided even clergy working with AIDS patients.

Pope Benedict had never directly addressed condom use. He has said that the Roman Catholic Church is in the forefront of the battle against AIDS. The Vatican encourages sexual abstinence to fight the spread of the disease.

"You can't resolve it with the distribution of condoms," the pope told reporters aboard the Alitalia plane headed to Yaounde, Cameroon, where he will begin a seven-day pilgrimage on the continent. "On the contrary, it increases the problem."

Not surprisingly, Benedict's statements elicited much criticism.  It was easy to imagine that the Catholic church's teachings about contraception were dictating his viewpoint rather than a rational assessment of the situation on the ground.  Criticism of his statements acknowledged that condoms aren't foolproof and sometimes fail either due to operator error or loss of integrity (link).

Then the official transcript tweaked his words to make it a little less extreme, indicating that condoms risked increasing the problem (link).

Then Edward Green came to the pope's defense.  I assume Green's views on this subject are controversial, but he does have some credibility (link):

Edward C. Green is one of the world's leading field researchers on the spread of HIV and public health interventions. He's the director of the Harvard AIDS Prevention Research Project, and is a leading advocate for evidence-based interventions.

I understand Green's point, and I think it's a good one.  If condoms are the answer for AIDS in Africa, we should be able to see it in the data.  As he said (link):

We have found no consistent associations between condom use and lower HIV-infection rates, which, 25 years into the pandemic, we should be seeing if this intervention was working.

How could condoms contribute to the problem?

...the best evidence we have supports the pope’s comments. He stresses that “condoms have been proven to not be effective at the ‘level of population.’”

“There is,” Green adds, “a consistent association shown by our best studies, including the U.S.-funded ‘Demographic Health Surveys,’ between greater availability and use of condoms and higher (not lower) HIV-infection rates. This may be due in part to a phenomenon known as risk compensation, meaning that when one uses a risk-reduction ‘technology’ such as condoms, one often loses the benefit (reduction in risk) by ‘compensating’ or taking greater chances than one would take without the risk-reduction technology.”

In an interview with Christianity Today (link), Green commented further on what he thinks is and isn't working:

We are seeing HIV decline in eight or nine African countries. In every case, there's been a decrease in the proportion of men and women reporting multiple sexual partners. Ironically, in the first country where we saw this, Uganda, HIV prevalence decline stopped in about 2004, and infection rates appear to be rising again. This appears to be in part because emphasis on interventions that promote monogamy and fidelity has weakened significantly, and earlier behavior changes have eroded. There has been a steady increase in the very behavior that once accounted for rates declining — namely, having multiple and concurrent sex partners. There is a widespread belief that somehow Uganda had fewer condoms. In fact, foreign donors have persuaded Uganda to put even more emphasis on condoms.

I can buy that it's possible that on the level of populations the focus on condom distribution might counter-intuitively fail to reduce the prevalence of AIDS and that this complexity may be underappreciated.  Complicated issues are often over-simplified into inaccurate or incomplete sound bites. 

On the other hand, I think that the pope's and Green's comments are also an over-simplification because they seem not to acknowledge this fact (as others have pointed out): an African woman for whom monogamous sex with an uninfected spouse is not an option is much safer if her spouse uses a condom.  That's the difference between considering the efficacy of condom availability on the individual versus population level.  We should be concerned about both.

Part of the issue is also probably that passing out condoms makes someone some cash and is much easier than the hard work of significantly changing a culture's views regarding sexual fidelity.  It probably makes sense to start with the easier job...but not just stop there either.

Restrictive laws do not reduce abortion

Technorati Tags:

So says the byline of an article in The Economist from last week.  It makes the case that for those of us who desire to see abortion numbers drop (I think we're pretty much all in that category), legislation is not a tool that anyone should expect to be effective for achieving that outcome:

[According to] the largest global study of abortion ever...Restricting abortions...has little effect on the number of pregnancies terminated. Rather, it drives women to seek illegal, often unsafe backstreet abortions leading to an estimated 67,000 deaths a year. A further 5m women require hospital treatment as a result of botched procedures.

In Africa and Asia, where abortion is generally either illegal or restricted, the abortion rate in 2003 (the latest year for which figures are available) was 29 per 1,000 women aged 15-44. This is almost identical to the rate in Europe—28—where legal abortions are widely available. Latin America, which has some of the world's most restrictive abortion laws, is the region with the highest abortion rate (31), while western Europe, which has some of the most liberal laws, has the lowest (12).

Between 1995 and 2005, 17 nations liberalised abortion legislation, while three tightened restrictions. The number of induced abortions nevertheless declined from nearly 46m in 1995 to 42m in 2003, resulting in a fall in the worldwide abortion rate from 35 to 29. The most dramatic drop—from 90 to 44—was in former communist Eastern Europe, where abortion is generally legal, safe and cheap. This coincided with a big increase in contraceptive use in the region which still has the world's highest abortion rate, with more terminations than live births.

Smoking Ban for Apartment Dwellers

Technorati Tags: , , ,

This kind of thing doesn't usually bother me too much, but even I'm wondering if the smoking ban coming to Belmont, California, goes too far...off-balance in the tension between your right to make decisions for yourself and my right not to be harmed by your decisions.

From "Smoking ban looms for Belmont apartment dwellers" by Steve Rubenstein in the SF Chronicle:

Belmont apartment dwellers who like to light up in their homes have 14 months to kick the habit, work out a compromise with their nonsmoking neighbors or get out of town.

Under the city's new smoking ban, among the toughest in the nation, apartment residents whose secondhand smoke invades their neighbors' units will be subject to fines of as much as $1,000.

The measure, which the City Council enacted Tuesday on a 3-2 vote, bans smoking in multiunit dwellings as well as in parks, outdoor restaurants and other public places. The apartment provision takes effect around New Year's 2009, while lighting up elsewhere is banned as soon as the law officially takes effect in about a month.

Hardly a loophole exists for Belmont denizens hooked on the weed. For example, the new law allows an actor to smoke onstage during the performance of a play - but only if smoking is an "integral part of the story."

The city says the tenant smoking ban will be enforced only if neighbors complain. It's believed to be the first such law in the country.

Syndicate content

Recent comments