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Political Health Care Priorities

Doctor Leo Spaceman

from The Jewish World Review, The Process is the Punishment by Mark Steyn:


It is one of the many distinctive features of Obama-style “health” “care” “reform” that, while it has not led to the hiring of a single additional doctor, nurse or hospital janitor, it did require the biggest expansion of the IRS since the Second World War. So, when he wasn’t rolling Easter eggs and advising the moppets on whether they needed to declare the luxury Belgian white chocolate balls with praline filling, he was participating in vital meetings on how many extra SWAT teams he was going to need to enforce the new colonoscopy non-compliance penalty.

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Health Insurer of Last Resource

Doctor Leo Spaceman

from Insurance May Not Save Lives, But It Saves Money by Megan McArdle in Bloomberg View:

We shouldn’t minimize the financial benefit, however. Medical bankruptcy is nowhere near half of all bankruptcies, but it is not trivial, either. And the addition of financial stress to a serious illness is certainly not trivial. Medical expenses really are different from other kinds of public policy programs, because they can be so wildly variable; 99 families out of 100 would be better off if you gave them cash instead of insurance, but the 100th will be hit by an expense that they could never realistically pay.

And that is what insurance is really for. As a health-care economist pointed out to me when the Oregon results came out, they were not actually all that surprising. Insurance is a financial product. It handles financial problems very well. We don’t expect car insurance to make us better drivers, or homeowner’s insurance to keep our house from burning down. Sure, insurance may change some behavior on the margins. But the direction of that change is not necessarily clear: Do you drive more safely to keep your rates down, or take more chances, because someone else will pay the bill if you damage another car? And whatever changes insurance produces are probably pretty marginal. Mostly what insurance does is protect us from financial ruin … and thereby, let us sleep a little easier at night.

You will call me immodest, but I’d suggest that the best model is exactly the one I suggested when health-care reform was being debated: Get rid of all of our government’s existing health insurance programs and make the government the insurer of last resort for all medical expenses above 15-20 percent of adjusted gross income. Allow very generous tax-free savings in health savings accounts that can be passed on to heirs, but spent only on medical expenses. Make the deductible percentage lower, or provide some sort of subsidized gap insurance, for people with very low incomes.

It’s absolutely progressive: Warren Buffet pays his full medical bills, while low-income families pay very little, and folks in between can choose to self-insure out of savings. It creates something like a normal market to exert pressure on health costs, because people are spending their own money on treatment, not someone else’s. It obviates the need for a massive government price-setting apparatus, which means we can put our regulatory muscle into researching comparative effectiveness of treatments and transparency efforts to inform consumers about which providers and treatments offer better outcomes. And I think it might even be politically attractive because it’s largely voluntary. No one’s forced to get rid of their employer health benefit; it’s just that there’s now a more attractive option that will encourage employees to demand cash or health savings account contributions instead of insurance coverage. Insurers can continue to sell insurance, if anyone wants to buy, or insure the gaps, safe in the knowledge that their losses are limited. It will be expensive, of course. But the government already spends a fantastic amount providing health insurance and subsidizing employer policies; we’ve got a big pot of cash to move into a more rational, market-oriented system.


An excellent plan- that relieves the burden of a financial catastrophe yet uses real market forces to bend the costs curve down, rather than government edict with perverse incentives and hidden- and often not so hidden- costs.

There may still need to be some rules on pre-existing conditions, but nothing close to the micromanagement and mandates of the ACA mess.

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Legislative Intent


from Petterico’s Pontifications, King v. Burwell: Intentionalism Trumps Textualism, and the Rule of Law Dies:


There is much disagreement about this on both sides. The conservatives point to Jonathan Gruber, a central ObamaCare drafter. The lefties note that Gruber was elected by nobody, and they point to a complete absence of any reliable evidence by an actual legislator saying that they wanted to use subsidies to coerce the states. (The famous Baucus statement is pretty ambiguous, even according to Michael Cannon, not to mention the fact that Baucusadmitted he didn’t even read the bill.) Frankly, I don’t think the winning position in this murky debate is very clear. Whatever the origin of the “established by the state” language, I think the best explanation of its retention in the final bill is that the legislators foolishly assumed every state would set up an exchange. They guessed . . . poorly.

My own personal opinion is that allowing one’s self to be dragged into the muck of a messy debate about intent misses the point. My view is that arguing about legislative intent is a fool’s errand, because as I said way back in 2010,there really is no such thing as legislative intent:

[L]egislation cannot be interpreted according to legislative intent because, even in theory, it is often impossible to ascribe a single intent to a set of words that is the product of numerous different intentions. If 60 people vote for a provision, and 30 intend it to mean one thing, and the other 30 intend for it to mean the precise opposite, there is no coherent way to determine a single “intent” behind the text.


Tips to Instapundit.

Legislative intent would appear to be a significant development in our court.

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Insurance is Not Access

Doctor Leo Spaceman

from Scott Atlas at the Wall Street Journal, Repairing the ObamaCare Wreckage

Why is private health insurance so important? Insurance without access to medical care is a sham. And that is where the country is heading. According to a 2014 Merritt Hawkinssurvey, 55% of doctors in major metropolitan areas refuse new Medicaid patients. The harsh reality awaiting low-income Americans is dwindling access to quality doctors, hospitals and health care.

Simultaneously, while the population ages into Medicare eligibility, a significant and growing proportion of doctors don’t accept Medicare patients. According to the nonpartisan Medicare Payment Advisory Commission, 29% of Medicare beneficiaries who were looking for a primary-care doctor in 2008 already had a problem finding one.

Because government reimbursement for health care is often below cost, costs are shifted back to private carriers, pushing up premiums. Nationally, the gap between private insurance payment and government underpayment has doubled since ObamaCare, according to a 2014 study by Avalere Health for the American Hospital Association. Premiums for private policies will certainly continue to rise, ultimately beyond the reach of the middle class.

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Confirming Failure

Doctor Leo Spaceman

from The Volokh Conspiracy, Let’s recall why the Affordable Care Act is so messed up by David Bernstein:

Few people, including Senators and their staffs, had time to read the whole 2,700 page bill, much less note any possible weaknesses, flaws, or ambiguities. Reid and other Senate Democrats weren’t terribly worried about this. The bill was set to go to the House, then back to the Senate, then to “reconciliation” between the House and the Senate versions, and then to the president for his signature. Everyone thought there would be plenty of opportunities to make changes.

But a major impediment arose soon after the Senate bill passed. Democratic Senator Ted Kennedy had died that past summer, and the January special election to replace him was won by Republican Scott Brown, who ran as a strong opponent of Obamacare. This deprived the Democrats of their filibuster-proof majority in the Senate, and meant that the Senate would not be able to pass a revised bill. The only way to pass Obamacare at this point was to have the House vote on identical legislation to the Senate bill, while engaging in legally dubious procedural maneuvering. And that’s what the Democrats did.

The House passed the Senate bill as is, and then also passed a separate reconciliation bill with minor changes, eliminating some of the law’s most egregious flaws but leaving the rest intact….

Congress ultimately passed a Senate bill that nobody wanted, and, indeed, that likely no one had read in its entirety when the Senate passed it, and that certainly no one fully understood. Senator Max Baucus, one of Obamacare’s chief architects, not only acknowledged not reading the bill, but opined that it would have been a “waste of time” to do so, because only experts could understand it….

Obama and the Democrats, however, believed that two things would happen that would justify their actions. First, Obamacare would become increasingly popular, and, second, that the Democrats would continue to control both houses of Congress. Obama and Congressional Democrats therefore assumed that any snafus that arose because Obamacare consisted of a hastily-drafted Senate bill never meant to become law could be easily fixed by Congress.

Of course, it didn’t work out that way. The ACA has never polled well, and the Republicans took over the House and then the Senate, in part due to dissatisfaction with Obamacare. Since the Republicans have no stake in fixing a law they unanimously opposed, and the Obama Administration has no intention of reopening the legislation to major changes, the Administration has been left with using and abusing executive discretion to delay, ignore, and modify statutory provisions to get the law to work, or just to avoid the negative political consequences of it working as planned.