The Objective Standard Blog

Friday, August 28, 2009

The Dire Message of Mr. David Walker

Posted by John David Lewis at 3:13 pm

A person who is in the pay of the government is not always free to speak publicly about the most pressing issues he confronts. Administrators who are appointed to perform specific tasks are generally not free to contradict or even to challenge policies. They often cannot advocate for specific proposals, even if they think that such proposals will be needed to prevent catastrophe.

When Dr. Alan Carlin, a federal Environmental Protection Agency official, wrote a report in March, 2009 that criticized the EPA’s process of formulating regulations, the report was squashed both internally and publicly. Emails from EPA officials state that “a very negative impact on our office” made use of the report impossible. To protect the bureaucracy, Dr. Carlin was told to cease his criticisms.

Such officials must often make a choice: to remain silent and keep their jobs, or to resign and speak the truth. Faced with this dilemma, on March 12, 2008, David Walker chose to resign.

David Walker is the former Comptroller General of the United States, and former head of the Government Accountability Office. As the nation’s chief accountant he was appointed by President Clinton. He resigned near the end of George W. Bush’s second term. He had no authority to decide how a single penny of government funds should be collected or distributed. His job was to count those funds.

Mr. Walker’s enormous range of mind extends far beyond a single budget year. His long-range perspective allows him to project fiscal trends decades into the future, and to assess, through simulations, the impacts of policy decisions beyond their immediate effects. He truly understands the economic maxim, promoted by Henry Hazlitt, to look beyond the visible effects of any given policy and to consider its unseen consequences.

When Walker plotted these trends, and considered demographics among many other factors, what he found was “chilling.” If fundamental reforms are not begun now, he concluded, the United States will experience a financial and political collapse comparable to the fall of Rome.

In a presentation to the National Press Foundation, January 17, 2008, Mr. Walker brought forth the following facts and projections:

1. From 1966 to 2006, the percentage of federal funds spent on Medicare rose from 1% to 19%. This trend will grow exponentially as millions of “baby boomers” enter the entitlement pool.
2. For the same period, spending for mandated government commitments rose from 26% to 53% of the total budget. The budget is increasingly out of the control of government officials.
3. As of 2007, Medicare is running in arrears. In 2017 Social Security will be in deficit. By the year 2040, Medicare and Social Security alone will be running annual deficits of nearly 900 billion dollars.
4. Medicare spending from now until 2032 will be 235% of economic growth. By 2040, Medicare will be spending about 10% of the nation’s Gross Domestic Product annually, and the annual deficits of the United States will total some 20% of the total Gross Domestic Product.

The bottom line is this: mandated fiscal entitlements, projected into the future, are over 52,000 billion dollars. That will equal 90% of all household wealth in the U.S., and will place a burden of over 450 thousand dollars on every household in the land. This is almost ten times the present median household income level.

Mr. Walker concludes that “We face large and growing structural deficits largely due to known demographic trends and rising health care costs.” Further, “GAO’s simulations show that balancing the budget in 2040 could require actions as large as cutting total federal spending by 60 percent, or raising federal taxes to two times today’s level.”

To close the revenue gap through growth, the United States economy would need to expand in the double-digit range for the next seventy-five years. During the boom years of the 1990s, the economy grew at an average rate of 3.2%. Walker concludes, succinctly: “we cannot simply grow our way out of this problem.”

Health care entitlements constitute by far the largest single piece of this economic disaster. Those who think that creating thousands of billions of dollars in new government entitlements—in a health care bill that adds tens of millions of Americans to government programs—will do anything except hasten the coming bankruptcy are out of touch with reality.

Mr. Walker has taken his show on the road, in an attempt to educate Americans about the financial disaster they are creating. He was accompanied by both the Brookings Institute on the left, and the Heritage Foundation on the right. He stresses that this coming financial meltdown is known by everyone in Washington–but no one wants to acknowledge it. 

The Rasmussen poll shows that almost twice as many Americans think that cutting the deficit, rather than health care reform, should be the president’s top priority. Another poll shows that twice as many people think that the reform legislation will drive up costs than think it will lower costs. Perhaps these Americans grasp Mr. Walker’s point better than their elected representatives do.

A nation that violates the rights of its citizens cannot, in the long run, escape the consequences of its moral failure. When a nation with the unique strength of the United States does so systematically and over decades, the results must necessarily be catastrophic. The dire economic forecast of David Walker illustrates the connection between the moral and the practical. To regain our economic viability we must regain our moral viability.

Posted in: Business and Economics, Health Care, Individual Rights and Law

Thursday, August 20, 2009

Suppose Car Insurance Was Considered to Be a ‘Right’

Posted by John David Lewis at 11:42 pm

The major impetus behind the Democratic health care plans is not economic—it is moral. The claim that health care is a moral right has motivated enormous government coercions against the medical industry for nearly fifty years. But this moral claim has blinded people to the fact that huge price increases have necessarily followed the growth of the coercions.

To understand why, it is instructive to consider what would happen if car insurance were considered to be a “right” and the right was enforced by the government.

After the purchase of a home and the ordeal of major surgery, a car is most people’s biggest financial risk. One mistake—or one bad driver—can harm dozens of people. We need insurance, so why should it not be considered a right?

Car insurance is provided by companies that manage their investments in order to absorb financial losses. If insurance is considered to be a “right,” then someone must be force to provide it: either the companies directly, or the citizens through coercive taxation. Either way, the new “right” will be taken by physical force, that is wielded by the state against those who are bound, by law, to provide it.

To enforce this new “right,” the government must take money from some people and give it to others, without regard for the actual risk they pose. As huge amounts of money are pumped into insurance markets, demand increases, and prices rise. Government officials blame the companies, so they pass more controls, thus squeezing the supply. Prices rise further—the law of supply and demand cannot be thwarted.

People want to be protected from greedy repair shops and auto manufacturers. So the companies undergo a ten-year approval process costing millions of dollars for new products.  As lawsuits mount, courts enforce claims of strict liability against the companies—who pass the costs on. Price rises accelerate.

As people get used to a “right” to car insurance, they demand more coverage. Oil changes, brake jobs, torn seats and new tires become insurance matters. If insurance is a “right,” then no one should be deprived of these goods because he cannot pay for them. Every visit to the repair shop—big or small, routine or emergency—now involves an insurance claim. Prices escalate.

Male drivers under 25 pay more because they are statistically higher risks—but they resent this inequality. So they assert their “right” to insurance at the same price as older, wiser drivers. Companies spread the costs out across the board—and as good drivers face higher premiums, they demand more coverage. Prices shoot up further.

By this point, no one asks what a repair job will actually cost—they ask only about their “co-pay.” Customers have little incentive to keep costs down. Why bother to change the oil, if the insurance will give you a new engine?

As regulations increase, critics castigate companies who are unwilling to cover pre-existing conditions, such as a fender dented before the car was insured. As paperwork increases, repair shops that once had four mechanics and one secretary now have five secretaries, who spend their days filing claims. Prices rise further—until car insurance becomes a crushing burden.

By this point, the very idea that insurance should be used for catastrophic losses—not routine maintenance—has been lost. A chorus of calls for “reform” demands more government coercion to enforce the “right.” Anyone who suggests reducing the controls is shouted down by those who blame the “free market” for rising costs. By this point, most people have forgotten what a free market is—or that they had no “right” to insurance before someone else produced it—or that there was a time when insurance was not so costly.

This is fiction, of course—but it directly mirrors what has happened in health care. After World War II, companies began to offer employee health insurance because government controls forbid them from paying higher wages. Twenty years later, the “Great Society” lavished billions on programs—and as prices rose, regulation against the producers multiplied. HMOs and a host of other schemes were tried.

Now, bucking under the weight of economic distortions and regulations, the law of supply and demand is wreaking vengeance on those least able to pay. Medicare and Social Security are approaching insolvency, insurance companies are forbidden from selling across state lines or from offering innovative health savings accounts, and the solution offered is—even more programs, with a price tag so large that it that cannot be grasped by the human mind.

To expand government programs is not “reform.” It is an extension of sixty years of government interventions. The government now controls nearly fifty percent of all health care dollars—paid for by skyrocketing prices, taxes and borrowing. The correlation with history, and with the law of supply and demand, is precise and inescapable.

The primary cause of medical price increases is the government coercions. But the cause of the coercions is the idea that health care is a right. Until we understand that nothing is a “right” if others must be forced to provide it, we will continue to swallow the same poison, and we will reap even worse consequences in the future.

John David Lewis
Associate Professor
Philosophy, Politics and Economics Program
Duke University
Durham, NC 27708

Posted in: Business and Economics, Health Care, Individual Rights and Law

Monday, August 10, 2009

The Health Care Bill: What HR 3200, ‘America’s Affordable Health Choices Act of 2009,’ Says

Posted by John David Lewis at 3:26 pm

What does the bill, HR 3200, short-titled ‘‘America’s Affordable Health Choices Act of 2009,” actually say about major health care issues? I here pose a few questions in no particular order, citing relevant passages and offering a brief evaluation after each set of passages.

This bill is 1017 pages long. It is knee-deep in legalese and references to other federal regulations and laws. I have only touched pieces of the bill here. For instance, I have not considered the establishment of (1) “Health Choices Commissioner” (Section 141); (2) a “Health Insurance Exchange,” (Section 201), basically a government run insurance scheme to coordinate all insurance activity; (3) a Public Health Insurance Option (Section 221); and similar provisions.  

This is the evaluation of someone who is neither a physician nor a legal professional. I am citizen, concerned about this bill’s effects on my freedom as an American. I would rather have used my time in other ways—but this is too important to ignore.

We may answer one question up front: How will the government pay for all this? Higher taxes, more borrowing, printing money, cutting payments, or rationing services—there are no other options.  We will all pay for this, enrolled in the government “option” or not.

(All bold type within the text of the bill is added for emphasis.)

1. WILL THE PLAN RATION MEDICAL CARE?

This is what the bill says, pages 284-288, SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS:

 (ii) EXCLUSION OF CERTAIN READMISSIONS.—For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital.

and, under “Definitions”:

(A) APPLICABLE CONDITION.—The term ‘applicable condition’ means, subject to subparagraph (B), a condition or procedure selected by the Secretary . . .

and:

(E) READMISSION.—The term ‘readmission’ means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge.

and:

(6) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of— . . .

(C) the measures of readmissions . . .

EVALUATION OF THE PASSAGES:

1. This section amends the Social Security Act
2. The government has the power to determine what constitutes an “applicable [medical] condition.”
3. The government has the power to determine who is allowed readmission into a hospital.
4. This determination will be made by statistics: when enough people have been discharged for the same condition, an individual may be readmitted.
5. This is government rationing, pure, simple, and straight up.
6. There can be no judicial review of decisions made here. The Secretary is above the courts.
7. The plan also allows the government to prohibit hospitals from expanding without federal permission: page 317-318.

2. Will the plan punish Americans who try to opt out?

What the bill says, pages 167-168, section 401, TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE:

(a) TAX IMPOSED.—In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of—

(1) the taxpayer’s modified adjusted gross income for the taxable year, over

(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer. . . .

EVALUATION OF THE PASSAGE:

1. This section amends the Internal Revenue Code.
2. Anyone caught without acceptable coverage and not in the government plan will pay a special tax.
3. The IRS will be a major enforcement mechanism for the plan.

3. what constitutes “acceptable” coverage?

Here is what the bill says, pages 26-30, SEC. 122, ESSENTIAL BENEFITS PACKAGE DEFINED:

 (a) IN GENERAL.—In this division, the term ‘‘essential benefits package’’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security . . .

(b) MINIMUM SERVICES TO BE COVERED.—The items and services described in this subsection are the following:

(1) Hospitalization.

(2) Outpatient hospital and outpatient clinic services . . .

(3) Professional services of physicians and other health professionals.

(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care . . .

(5) Prescription drugs.

(6) Rehabilitative and habilitative services.

(7) Mental health and substance use disorder services.

(8) Preventive services . . .

(9) Maternity care.

(10) Well baby and well child care . . .

(c) REQUIREMENTS RELATING TO COST-SHARING AND MINIMUM ACTUARIAL VALUE . . .

(3) MINIMUM ACTUARIAL VALUE.—

(A) IN GENERAL.—The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B).

EVALUATION OF THE PASSAGES:

1.  The bill defines “acceptable coverage” and leaves no room for choice in this regard.
2. By setting a minimum 70%  actuarial value of benefits, the bill makes health plans in which individuals pay for routine services, but carry insurance only for catastrophic events, (such as Health Savings Accounts) illegal.

4. Will the PLAN destroy private health insurance?

Here is what it requires, for businesses with payrolls greater than $400,000 per year. (The bill uses “contribution” to refer to mandatory payments to the government plan.)  Pages 149-150, SEC. 313, EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE

(a) IN GENERAL.—A contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to 8 percent of  the average wages paid by the employer during the period of enrollment (determined by taking into account all employees of the employer and in such manner as the Commissioner provides, including rules providing for the appropriate aggregation of related employers). Any such contribution—

(1) shall be paid to the Health Choices Commissioner for deposit into the Health Insurance Exchange Trust Fund, and

(2) shall not be applied against the premium of the employee under the Exchange-participating health benefits plan in which the employee is enrolled.

(The bill then includes a sliding scale of payments for business with less than $400,000 in annual payroll.)

The Bill also reserves, for the government, the power to determine an acceptable benefits plan: page 24, SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

5 (a) IN GENERAL.—A qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage.

EVALUATION OF THE PASSAGES:

1. The bill does not prohibit a person from buying private insurance.
2. Small businesses—with say 8-10 employees—will either have to provide insurance to federal standards, or pay an 8% payroll tax. Business costs for health care are higher than this, especially considering administrative costs. Any competitive business that tries to stay with a private plan will face a payroll disadvantage against competitors who go with the government “option.”
3. The pressure for business owners to terminate the private plans will be enormous.
4. With employers ending plans, millions of Americans will lose their private coverage, and fewer companies will offer it.
5. The Commissioner (meaning, always, the bureaucrats) will determine whether a particular network of physicians, hospitals and insurance is acceptable.
6. With private insurance starved, many people enrolled in the government “option” will have no place else to go.

5. Does the plan TAX successful Americans more THAN OTHERS?

Here is what the bill says, pages 197-198, SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS

SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

(a) GENERAL RULE.—In the case of a taxpayer other than a corporation, there is hereby imposed (in addition to any other tax imposed by this subtitle) a tax equal to—

(1) 1 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $350,000 but does not exceed $500,000,

(2) 1.5 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $500,000 but does not exceed $1,000,000, and

(3) 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000.

EVALUATION OF THE PASSAGE:

1. This bill amends the Internal Revenue Code.
2. Tax surcharges  are levied on those with the highest incomes.
3. The plan manipulates the tax code to redistribute their wealth.
4. Successful business owners will bear the highest cost of this plan.

6. Does THE PLAN ALLOW THE GOVERNMENT TO set FEES FOR SERVICES?

What it says, page 124, Sec. 223, PAYMENT RATES FOR ITEMS AND SERVICES:

(d) CONSTRUCTION.—Nothing in this subtitle shall be construed as limiting the Secretary’s authority to correct for payments that are excessive or deficient, taking into account the provisions of section 221(a) and the amounts paid for similar health care providers and services under other Exchange-participating health benefits plans.

(e) CONSTRUCTION.—Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.

EVALUATION OF THE PASSAGES:

1. The government’s authority to set payments is basically unlimited.
2. The official will decide what constitutes “excessive,” “deficient,” and “efficient” payments and services.

7. Will THE PLAN increase the power of government officials to SCRUTINIZE our private affairs?

What it says, pages 195-196, SEC. 431. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES.

(A) IN GENERAL.—The Secretary, upon written request from the Health Choices Commissioner or the head of a State-based health insurance exchange approved for operation under section 208 of the America’s Affordable Health Choices Act of 2009, shall disclose to officers and employees of the Health Choices Administration or such State-based health insurance exchange, as the case may be, return information of any taxpayer whose income is relevant in determining any affordability credit described in subtitle C of title II of the America’s Affordable Health Choices Act of 2009. Such return information shall be limited to—

(i) taxpayer identity information with respect to such taxpayer,

(ii) the filing status of such taxpayer,

(iii) the modified adjusted gross income of such taxpayer (as defined in section 59B(e)(5)),

(iv) the number of dependents of the taxpayer,

(v) such other information as is prescribed by the Secretary by regulation as might indicate whether the taxpayer is eligible for such affordability credits (and the amount thereof), and

(vi) the taxable year with respect to which the preceding information relates or, if applicable, the fact that such information is not available.

And, page 145, section 312, EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND DEPENDENT COVERAGE:

(3) PROVISION OF INFORMATION.—The employer provides the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements of this section.

EVALUATION OF THE PASSAGE:

1. This section amends the Internal Revenue Code
2. The bill opens up income tax return information to federal officials.
3. Any stated “limits” to such information are circumvented by item (v), which allows federal officials to decide what information is needed.
4. Employers are required to report whatever information the government says it needs to enforce the plan.

8. Does the plan automatically enroll Americans in the GOVERNMENT plan?

What it says, page 102, Section 205, Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan:

(3) AUTOMATIC ENROLLMENT OF MEDICAID ELIGIBLE INDIVIDUALS INTO MEDICAID.—The Commissioner shall provide for a process under which an individual who is described in section 202(d)(3) and has not elected to enroll in an Exchange-participating health benefits plan is automatically enrolled under Medicaid.

And, page 145, section 312:

(4) AUTOENROLLMENT OF EMPLOYEES.—The employer provides for autoenrollment of the employee in accordance with subsection (c).

EVALUATION OF THE PASSAGES:

1. Do nothing and you are in.
2. Employers are responsible for automatically enrolling people who still work.

9. Does THE PLAN exempt federal OFFICIALS from COURT REVIEW?

What it says, page 124, Section 223, PAYMENT RATES FOR ITEMS AND SERVICES:

(f) LIMITATIONS ON REVIEW.—There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.

And, page 256, SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

(C) LIMITATION ON REVIEW.—There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting—

(i) the identification of a county or other area under subparagraph (A); or

(ii) the assignment of a postal ZIP Code to a county or other area under subparagraph (B).

EVALUATION OF THE PASSAGES:

1. Sec. 1123 amends the Social Security Act, to allow the Secretary to identify areas of the country that underutilize the government’s plan “based on per capita spending.”
2. Parts of the plan are set above the review of the courts.

Posted in: Business and Economics, Health Care, Individual Rights and Law