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Posts Tagged ‘Third party payer’

I’ve often complained that government-created third-party payer is the main problem with America’s healthcare system, and I was making that point well before Obamacare was imposed upon the country.

The issue is very straightforward. In a genuine free market, people pay “out of pocket” for routine expenses. And they rely on insurance only in cases where they may face large, unexpected costs.

But in our current healthcare system, thanks to Medicare, Medicaid, and the tax code’s healthcare exclusion, most of us buy services with other people’s money and that dramatically distorts incentives.

Here’s some of what I wrote about this messed-up approach back in 2009.

…our pre-paid health care system is somewhat akin to going to an all-you-can-eat restaurant. We have an incentive to over-consume since we’ve already paid. Except this analogy is insufficient. When we go to all-you-can-eat restaurants, at least we know we’re paying a certain amount of money for an unlimited amount of food. Many Americans, by contrast, have no idea how much of their compensation is being diverted to purchase health plans. Last but not least, we need to consider how this messed-up approach causes inefficiency and higher costs. We consumers don’t feel any need to be careful shoppers since we perceive that our health care is being paid by someone else. Should we be surprised, then, that normal market forces don’t seem to be working? …Imagine if auto insurance worked this way? Or homeowner’s insurance? Would it make sense to file insurance forms to get an oil change? Or to buy a new couch? That sounds crazy. The system would be needlessly bureaucratic, and costs would rise because we would act like we were spending other people’s money.  But that’s what would probably happen if government intervened in the same way it does in the health-care sector.

As you can see, I’m frustrated.

I think the system is inefficient from an economic perspective. But I’m also a consumer, and I’m very dissatisfied whenever I have to deal with the healthcare system.

Fortunately, more and more people are adding their two cents on this topic.

Here’s some great analysis on the issue by Mark Perry of the American Enterprise Institute. He starts by pointing out how prices for health care generally climb much faster than the overall CPI price level.

Between 1998 and 2014 the price of medical care services in the US (as measured by the BLS’s CPI for Medical Care Services) has increased by 88.5%, or more than twice the 45.8% increase in consumer prices in general over that period… On an annual basis, medical care costs in the US have increased more than 4% per year compared to an average inflation rate of only 2.4% over the last 16 years.

He then explains that a big problem is third-party payer, which eviscerates normal market forces.

As a result, consumers are relatively insensitive to price, which means producers and providers can charge more and be relatively inefficient.

One of the reasons that medical care costs in the US have increased almost twice as much as general consumer prices since 1998 is that a large and increasing share of medical costs are paid by third parties (private health insurance, Medicare, Medicaid, Department of Veterans Affairs, etc.) and only a small and shrinking percentage is paid out-of-pocket by consumers. According to data from the Census Bureau, almost half (47%) of health care expenditures in 1960 were paid by consumers out-of-pocket, and by 1990 that share had fallen to 20% and by 2009 to only 12%. …Consumers of health care have no incentive to monitor prices and be cost-conscious buyers of medical services when they only pay 10% themselves, and the incentives of medical care providers to hold costs down are greatly reduced knowing that their customers aren’t price sensitive.

Mark then asks what the world would look like if the free market was allowed to function. And he identifies a niche in the healthcare system where that happens.

How would the market for medical services operate differently if consumers were paying out-of-pocket for medical procedures in a competitive market? Well, we can look to the $7.5 billion US market for elective cosmetic surgery for some answers.

And the information he shares is remarkable.

The table…shows the top five most popular surgical procedures and top five most popular non-surgical procedures for 2014, the number of each of those procedures performed last year, the total expenditures for each procedure, the average price per procedure both in 1998 and 2014, and the percent increase in price since 1998 for each procedure. …For the top ten most popular cosmetic procedures last year, none of them has increased in price since 1998 more than the 45.8% increase in consumer price inflation…, meaning the real price of all of those procedures have fallen over the last 16 years. …For three of the top five favorite non-surgical procedures in 2014 (botox, laser hair removal and chemical peel), the nominal prices have actually fallen since 1998 by large double-digit percentage declines of -23.6%, -31.2% and -30.1%.  …none of the ten cosmetic procedures in the table above have increased in price by anywhere close to the 88.5% increase in medical care services since 1998.

Here’s Mark’s chart, and I’ve circled the relevant bits of data.

Just in case it’s not obvious, Mark then draws the should-be-obvious conclusions from this data.

Simply stated, when people spend their own money, they are careful shoppers. And when consumers are careful shoppers, that leads to competitive pressure on producers and providers to be much more efficient.

The competitive market for cosmetic procedures operates differently than the traditional market for health care in important and significant ways. Cosmetic procedures, unlike most medical services, are not usually covered by insurance. Patients paying out-of-pocket for cosmetic procedures are cost-conscious, and have strong incentives to shop around and compare prices at the dozens of competing providers in any large city. Because of that market competition, the prices of almost all cosmetic procedures have fallen in real terms since 1998, and some non-surgical procedures have even fallen in nominal dollars before adjusting for price changes. In all cases, cosmetic procedures have increased in price by less than the 88.5% increase in the price of medical care services between 1998 and 2014.

That last sentence is the key. Because of third-party payer, overall health care expenses have climbed about twice the rate of inflation.

For cosmetic surgery, where normal market forces operate thanks to an absence of government-imposed and government-subsidized third-party payer, prices climb slower than overall inflation.

Here’s a video, produced by the Center for Freedom and Prosperity, on the problem of third-party payer.

As you can see, Obamacare made the problem worse, but it’s just one small part of a really big problem caused by decades of government intervention.

P.S. The video expands upon the analysis provided in a previous CF&P video.

P.P.S. Setting aside the debate about whether it’s right or wrong, the abortion market also is an interesting case study of how prices don’t rise when consumers pay out of pocket.

P.P.P.S. Government-created third-party payer also is screwing up the market for higher education.

P.P.P.P.S. Mark Perry not only is a good economist, as you can see above, but he’s also a brave guy for being willing to antagonize feminists.

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Way back in 2010, immediately after Obamacare was rammed down our throats, I put together four guiding principles for a counter-offensive.

One of my goals was to help people understand that the problem was far greater than Obamacare. Indeed, the so-called Affordable Care Act was merely another step on a long (and very bad) journey to healthcare statism.

The way to think of Obamacare is that we are shifting from a healthcare system 68 percent controlled/directed by government to one that (when all the bad policies are phased in) is 79 percent controlled/directed by government. Those numbers are just vague estimates, to be sure, but they underscore why Obamacare is just a continuation of a terrible trend, not a profound paradigm shift.

Two years ago, I elaborated on this thesis and even put together a couple of charts to emphasize the point.

Obamacare was enacted in 2010, and it was perceived to be a paradigm-shifting change in the healthcare system, even though it was just another layer of bad policy on top of lots of other bad policy. Immediately after the legislation was approved, I offered a rough estimate that we went from a system that was 68 percent dictated by government to one that was 79 percent dictated by government. …all of the same problems still exist, but now they’re exacerbated by the mistakes in Obamacare.

My numbers were just vague approximations, of course, but I think the basic premise was spot on.

And my theory is still accurate. But you don’t have to believe me.

Writing for the Washington Examiner, Philip Klein makes the critical point that repealing Obamacare wouldn’t result in a free-market system.

Instead, we’d be stuck with the pre-Obamacare system that was decrepit because of already-existing programs, mandates, regulations, and other forms of intervention.

…repeal is not enough. Even if simple repeal were politically obtainable, Americans would still be left with a broken healthcare system. Government regulations would still be stifling competition and individual choice and government healthcare programs would still be driving the nation’s unsustainable long-term debt problem. If Republicans achieved repeal without agreeing on a way to reform healthcare along free market lines, it’s inevitable that Democrats would eventually lead another overhaul of the system that would grant even more power to the federal government.

Philip is totally correct.

Before Obamacare, we had a system that didn’t work very well because of government. But in a horrifying example of Mitchell’s Law, many people decided that more government was the solution to the problems already caused by government.

Hence, we got so mis-named Affordable Care Act.

But if Obamacare is repealed, we’ll simply be back in the same unstable situation. And Philip is right that the statists will then simply argued for a different type of government expansion. Probably single payer, notwithstanding all the horror stories from places such as the United Kingdom.

Some may argue at this point that it doesn’t really matter because Obama is in the White House with a veto pen, so critics have a couple of years to figure out their next step.

Maybe, but it’s also possible that the Supreme Court will (for a change of pace) make the right ruling on a key Obamacare case later this year. And this would probably force policy makers to re-open the law.

…a Supreme Court decision expected by late June could invalidate Obamacare subsidies for millions of Americans. If Republicans don’t have an alternative ready, congressional leaders will be under tremendous pressure to pass a simple “fix” that would allow the subsidies to continue to flow, thus further entrenching Obamacare before a Republican president theoretically is able to act in 2017. For these reasons and many others it’s important for Republicans to unite around an alternative to Obamacare.

Philip (who has an entire book on this issue) then proceeds to categorize Obamacare critics as being in three different camps on the issue of how to proceed.

The first approach comes from those who believe that fully repealing Obamacare is probably unrealistic, but who still see an opening to reform the overall healthcare system in a more market-oriented direction. I call this the Reform School. The second approach comes from a crowd that believes full repeal is a necessity, but can only occur if opponents of the law create a market-friendly alternative with enough financial assistance to make health insurance widely available to those Americans who want to purchase it. I call this the Replace School. And finally, there is a third approach, which advocates repealing the law, returning to pre-Obamacare levels of taxes and spending, and then using that clean slate as the basis to overhaul the system in a free market manner to bring down costs. I call this the Restart School.

Since I focus on fiscal policy issues rather than healthcare, I don’t know if there are substantive – or merely strategic – differences among these three groups.

But I will say (assuming you actually want to solve the problem) that at some point you have to deal with the government programs and interventions that have given us a third-party payer crisis.

So I will reiterate what I wrote back in 2010 as part of my proposed counter-offensive.

The only way to fix healthcare is to restore the free market. That means going back to a system where people pay out-of-pocket for most healthcare and use insurance to protect against genuine risk and catastrophic expenses. The time has come to reduce the size and scope of government. …Change Medicare into a system based on personal health accounts and shift all means-tested spending to the states. …the flat tax is ideal from a healthcare perspective since it gets rid of the healthcare exclusion in the tax code as part of a shift to a tax system with low rates and no double taxation.

This video, narrated by Julie Borowski for the Center for Freedom and Prosperity, looks at the Obamacare/third-party payer issue.

And if you want to examine some of the component issues of healthcare reform, we have videos on Medicaid, Medicare, and tax reform.

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I’ve been fretting for a long time that poorly designed entitlement programs are going to turn America into a decrepit welfare state.

Medicare obviously is a big part of the problem, but the fraud-riddled Medicaid program may be even worse.

The program is a nightmare for both federal taxpayers and state taxpayers.

In an article for the Daily Caller, John Graham of the Independent Institute has some very grim analysis of the fiscal black hole otherwise known as Medicaid.

In 2014, total Medicaid spending is projected to grow 12.8 percent because Obamacare has added about 8 million dependents. A large minority of states have chosen to increase residents’ eligibility for Medicaid by expanding coverage to adults making up to 138 percent of the federal poverty level. Unfortunately, more states are likely to expand this welfare program. This is expected to result in a massive increase in the number of Medicaid dependents: From 73 million in 2013 to 93 million in 2024. Medicaid spending is expected to grow by 6.7 percent in 2015, and 8.6 percent in 2016. For 2016 to 2023, spending growth is projected to be 6.8 percent per year on average. This comprises a massive increase in welfare dependency and burden on taxpayers.

But the actual numbers may be worse than these projections.

…official estimates often low-ball actual experience. This is because it is hard to grapple with how clever states are at leveraging federal dollars. …The incentive lies in Medicaid’s perverse financing merry-go-round. In a rich state like California, for example, the federal government (pre-Obamacare) spent 50 cents on the dollar for adult dependents. So, if California spent 50 cents, it automatically drew 50 cents from the U.S. Treasury. And most states had a bigger multiplier. Which state politician can resist a deal like that? …The situation will deteriorate because Obamacare’s Medicaid expansion significantly increases states’ perverse incentives to game Medicaid financing. …Newly eligible Medicaid beneficiaries will be fully financed by the federal government for 2014 through 2016. Then, it slides down until the federal government funds 90 percent of their costs starting in 2020, with the states footing 10 percent. Recall the cunning with which states developed ways to abuse federal taxpayers when they could only double their money from Uncle Sam. The new normal is that they will be able to get nine times their money!

By the way, these numbers would be even worse if it wasn’t for the fact that many states refused the lure of “free” federal money to expand Medicaid.

So what’s the solution? Graham suggests federalism is the answer.

A reform in the right direction would be to get rid of the federal match in favor of a block grant, based on a simple measurement of the population in each state, and precisely define a limited federal commitment.

He’s exactly right, at least in the short run.

Let’s copy the success of welfare reform and turn over a fixed amount of money – along with concomitant authority and responsibility – to state governments and let them figure out the best way of delivering health care to lower-income populations.

In the long run, of course, I’d like to phase out the block grant so that states are responsible for both collecting the money and providing the services.

But before we get to the point of adopting health care policies for an ideal libertarian society, we first have to stop the bleeding (or, to be more accurate, hemorrhaging) and stabilize the program.

And that’s why I fully agree that the federalism approach, in the form of block grants, is the right policy.

Here’s my video on the topic.

And since I’m sharing videos, I can’t resist commenting on the latest “Gruber-gate” scandal. The MIT professor and Obamacare insider (he got $400,000 of taxpayer money to help design the plan) has become an embarrassment for the left because he has been caught on tape saying that the legislation relied on deception. He even said that proponents of Obamacare took advantage of the “stupidity” of American voters.

You can watch the most well-know example by clicking here. But he also denigrated supposedly “stupid” Americans in this video.

I want to defend one small component of Gruber’s statement.

But I want to be completely clear that I’m not defending his elitist disdain for ordinary Americans. Indeed, I don’t think voters are stupid. Instead, to the extent they’re uninformed, it’s the result of serial dishonesty from Washington or because they’ve decided it’s not worth their time to pay attention to the crowd in DC (the “rational ignorance” hypothesis).

The part of Gruber’s statement that has merit is that he’s talking about the fact that there’s a big loophole in the tax code for fringe benefits. To be more specific, tens of millions of Americans get part of their compensation in the form of fringe benefits such as health insurance. Yet while workers are taxed on their “cash” income, they are not taxed on their “fringe benefit” income (a policy sometimes called the “healthcare exclusion”).

And this has created, over time, a very inefficient system of over-insurance.

To understand why this system doesn’t make sense, just think about your homeowner’s insurance or auto insurance. Those policies, unlike health insurance, work reasonably well and costs remain relatively stable. Why is there a big difference?

The difference is that employee income that is diverted to health insurance avoids both income tax and payroll tax, so there is a significant monetary incentive for gold-plated plans. And these plans often include insurance coverage for ordinary medical expenses, which contributes to the problem of third-party payer.

No wonder health insurance is so costly. After all, imagine what would happen to the price of your homeowner’s insurance if it had to cover the cost of a new couch? Or repainting the hallway? Or what about the cost of your auto policy if it covered the cost to fill up with gas or get an oil change?

We instinctively recognize that this would be insanely inefficient and expensive, yet that’s how our health insurance system operates thanks to a giant tax preference.

So Gruber was right to say it’s a problem. And I’ve even said that addressing the exclusion is a very tiny silver lining in the awful dark cloud of Obamacare.

But now that I’ve bent over backwards to say something nice, now let me point out that Gruber (and Obama and other statists) didn’t have the right solution. Yes, they wanted to cut back on the tax exclusion, but only because they wanted to use the money for other purposes (such as subsidies that also exacerbate the third-party payer problem).

The right approach, by contrast, is to phase out the healthcare exclusion and use every penny of revenue to “pay for” lower tax rates. That way you get a win-win situation for the economy. A more rational, market-based healthcare system and a less punitive tax code for productive behavior.

Now that we’ve addressed a serious point, let’s laugh about the fact that Gruber’s comments have created a big headache for the White House. We’ll start with this Steve Kelley cartoon.

And here’s Gary Varvel’s take on the honesty of the Obama White House on the topic of health care.

Last but not least, Lisa Benson optimistically suggests that the serial dishonesty of Obamacare supporters may be undone by the Supreme Court.

Which would be poetic justice, since Professor Gruber also was caught on tape – over and over again – stating that Obamacare only allowed subsidies for people getting insurance policies through state-based exchanges.

And now the Supreme Court will decide whether those subsidies, notwithstanding statutory language, can be provided via the federal exchange.

Though I’m not holding my breath since certain Justices on the Court already have demonstrated that they’re willing to put politics above the law.

P.S. Just in case I wasn’t sufficiently clear, good tax reform also is good health reform. That was one of the points I made in my tax reform speech at the Heritage Foundation and I suspect I’ll continue making that argument until we win or I’m dead (and I don’t want to take odds on which happens first).

P.P.S. On a more upbeat note, the House of Representatives approved budgets in 2011, 2012, 2013, and 2014 that assume Medicaid gets block-granted to the states. So that reform may actually happen while I’m still breathing.

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People sometimes think I’m strange for being so focused on the economic harm that results from third-party payer. But bear with me and we’ll see why it’s a very important issue.

If you’re not already familiar with the term, third-party payer exists when someone other than the consumer is paying for something. And it’s a problem because people aren’t careful shoppers when they have (proverbially) someone else’s credit card.

Moreover, sellers have ample incentive to jack up prices, waste resources on featherbedding, and engage in inefficient practices when they know consumers are insensitive to price.

I’ve specifically addressed the problem of third-party payer in both the health-care sector and the higher education market.

But I’ve wondered whether my analysis was compelling. Is the damage of third-party payer sufficiently obvious when you see a chart showing that prices for cosmetic surgery, which generally is paid for directly by consumers, rise slower than the CPI, while other health care expenses, which generally are financed by government or insurance companies, rise faster than inflation?

Or is it clear that third-party payer leads to bad results when you watch a video exposing how subsidies for higher education simply make it possible for colleges and universities to increase tuition and fees at a very rapid clip?

That should be plenty of evidence, but I ran across a chart that may be even more convincing. It shows how prices have increased in various sectors over the past decade.

So what make this chart compelling and important?

Time for some background. The reason I saw the chart is because David Freddoso of the Washington Examiner shared it on his Twitter feed.

I don’t know if he added the commentary below, or simply passed it along, but I’m very grateful because it’s an excellent opportunity to show that sectors of our economy that are subsidized (mostly by third-party payer) are the ones plagued by rising prices.

It’s amazing to see that TVs, phones, and PCs have dropped dramatically in price at the same time that they’ve become far more advanced.

Yet higher education and health care, both of which are plagued by third-party payer, have become more expensive.

So think about your family budget and think about the quality of PCs, TVs, and phones you had 10 years ago, and the prices you paid, compared with today. You presumably are happy with the results.

Now think about what you’re getting from health care and higher education, particularly compared to the costs.

That’s the high price of third-party payer.

P.S. This video from Reason TV is a great illustration of how market-based prices make the health care sector far more rational.

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America’s health care system is a mess, and we can assign almost all the blame on government. Simply stated, we don’t have functioning and efficient markets because Medicaid, Medicare, tax-code distortions, and other forms of regulation and intervention have created a system that is crippled by a third-party payer crisis.

There’s no logical reason to expect consumers to be smart shoppers, after all, when they’re only responsible for directly paying just 11 cents for every $1 of health care they consume. And providers have little reason to be efficient when they know that consumers are largely insensitive to price.

Let’s now apply these insights to the political controversy over birth control. Except, as I explained in July, there is no fight over birth control. As far as I’m aware, nobody is trying to ban birth control.

The real fight is whether the government should mandate that health insurance plans include coverage for birth control (and certain abortifacients).

Writing for Bloomberg, Megan McArdle explains that Obamacare’s birth control mandate is silly because a modest and routine expense shouldn’t be covered by insurance at all.

I am not very patient with the political fights over the Affordable Care Act’s contraception mandate. …Generic birth-control pills are a cheap, regular expense used by many millions of people, exactly the sort of thing that insurance is not designed for. All this does is spread the cost around a bit while adding administrative overhead for your policy.

Moreover, the better policy is to allow birth control to be purchased without a prescription.

In other words, address the issue by reducing government regulation rather than imposing a mandate!

…make birth-control pills available over-the-counter rather than a prescription item. This is an excellent idea. It was an excellent idea before Obamacare passed, and it will remain a fine policy even if Obamacare somehow vanishes into dust. Physicians assess the danger of giving you birth control by asking simple questions you can ask yourself: Are you over 35, a smoker or troubled by a family history of early stroke?

Seems like a good idea, right? Particularly since it should appeal to Republicans that want less regulation and also appeal to Democrats that want easier access to birth control.

The Republicans are on board, as Byron York reports.

…the GOP has a new policy response… The idea is to make the birth control pill available over the counter, to all, 24/7, without a prescription. It’s becoming a trend among Republican candidates in Senate races around the country. In North Carolina, GOP candidate Thom Tillis recently embraced it. So has Ed Gillespie in Virginia. Mike McFadden in Minnesota. Gardner in Colorado. And one of the leading proponents of the move is a potential 2016 GOP presidential candidate, Louisiana Gov. Bobby Jindal. …Gardner first rolled out the proposal in a Denver Post op-ed in June. The birth control pill has safely been in use since it was first approved 44 years ago, Gardner argued. “When other drugs have that kind of track record, we approve them for purchase without a prescription,” he wrote. “Name-brand drugs like Advil, Pepcid, Claritin, Prilosec and many others were once sold by prescription only, but moved to over-the-counter sale once they’d been proven safe and unlikely to be abused.”

But some Democrats are hostile.

Indeed, a columnist for the Denver Post is very upset that some GOPers are supporting over-the-counter access to birth-control pills.

Following the lead of Colorado U.S. Senate candidate Cory Gardner, a handful of Republicans in midterm races across the country are now embracing over-the-counter sales of birth control pills without a prescription. Don’t be fooled. It’s a disingenuous move that could actually make the pill more expensive for women… But women already pay for those pills as part of the health care coverage they purchase through employers. Why would we want to pay for them twice? …What happens, however, if birth control pills are sold over the counter? Insurance companies will likely stop covering them. That means women will keep paying health insurance premiums, plus an additional out-of-pocket fee for pills. …And free doctor visits to discuss birth-control risks could also be replaced with fee-based pharmacy consults to determine whether women have risk factors like smoking, hypertension or migraines that prevent safe use of the pill, reports the American College of Obstetricians and Gynecologists. That’s hardly a “cheaper and easier” alternative — which is why Politifact rates Gardner’s claim as “mostly false.”

I strongly suspect that the author simply wanted to make a partisan attack on the Republican Senate candidate in Colorado. After all, more substantive and serious people on the left, including those at both Vox and Think Progress, favor over-the-counter access to birth control.

But let’s assume she really believes what she wrote. In which case she would get an F from any economics professors because health insurance companies obviously include predicted costs when pricing their policies. So if the mandate disappears and birth control is available without a prescription, then insurance companies will be able to lower the cost of the policies they sell.

In other words, women wouldn’t be paying twice. Indeed, they’ll pay less, though that will only be obvious to those who understand that employer-provided health plans are part of overall employee compensation.

There is another reason, other than partisanship, for some on the left to oppose Republican proposals to allow birth control to be sold over the counter. And you won’t be surprised to learn that self interest is playing a role.

Writing for The Federalist, Ben Domenech notes that Planned Parenthood wants to retain the current prescription-only approach.

You may think Ben made a big mistake, or that I misinterpreted. After all, isn’t that contrary to the organization’s ostensible mission of reducing unwanted pregnancies?

Well, Ben points out that Planned Parenthood may be more interested in maximizing handouts than it is in reducing pregnancies.

…interestingly enough, Planned Parenthood is pushing back on over-the-counter contraception. Why is this? Why would Planned Parenthood want to decrease the availability of contraception, and require women to see a doctor in order to get it? That seems awfully paternalistic of them. …birth control is a major lead generator for Planned Parenthood, to the degree that they can’t afford to lose their existing purpose as a source of prescribed contraception without it hurting their status as an institution. …Now you can understand why they wouldn’t want potential customers to be free to go to CVS or Walgreens or Rite Aid instead of heading to Planned Parenthood – providing those and other services is worth a lot of taxpayer money, $540 million in FY 2012 alone. And if you don’t provide those services, you can’t bill the taxpayers for them. …That’s why they want to keep the government’s ban on over-the-counter birth control intact.

Here’s a chart from Ben’s article that shows “what percentage of Planned Parenthood’s “services” are related to contraception.” As he notes, “it’s over a third of their activity.”

So I guess it makes sense – at least from an amoral perspective – that the organization wants to limit access to over-the-counter birth control.

By the way, the GOP plan for easier access to birth control is not a move to uncharted territory.

Here’s a map from a pro-reform left wing group that shows that over-the-counter birth control pills are easily available to most of the world’s women.

Let’s close by sharing one final – and very persuasive – piece of information from the experts at Reason.

Women already have over-the-counter access to Plan B, which involves larger doses of the hormones that are present in birth control pills.

…the Food and Drug Administration (FDA) has been considering making oral contraceptives available over-the-counter (OTC) for more than twenty years. “Plan B,” an emergency contraceptive, became available OTC last year. That one-step pill is simply a more potent dose of the same hormones that make up regular birth control pills. There’s no good medical justification for the differentiation. Yet in America, regular birth control pills remain stubbornly behind the pharmacy counter and behind the times.

In other words, the usual pro-regulation argument is that prescriptions are necessary because consumers can’t be trusted to make their own decisions with strong doses of medicine.

But the government already has made Plan B available over the counter while blocking similar access to birth control pills. Go figure.

P.S. Planned Parenthood is not the only interest group that has behaved in a disreputable and dishonorable fashion.

P.P.S. If you want to know what happens to healthcare in the absence of pervasive third-party payer, check out this remarkable chart.

P.P.P.S. Since today’s topic was birth control, let’s use this opportunity to revisit our collection of Sandra Fluke humor. Just in case you don’t remember, she was the 30-year old college student who got her 15 minuted of fame by demanding that other people pay for her expenses. Anyhow, if you want to laugh, check out this great Reason video, this funny cartoon, and four more jokes here.

P.P.P.P.S. On a separate topic, I added my two cents late last year to a debate inside libertarian circles over whether America’s plethora of welfare programs should be replaced by a single “basic income” grant that would be given to all Americans. Sort of a guaranteed minimum income.

I acknowledged that the current system is a mess, but I suggested that decentralization was a better approach.

…it seems that nothing could be worse than the current system. …But what about the idea of trashing what we have today and instead offering everyone some sort of basic income? …I agree, but only sort of. I like the idea of radical reform, but I think there’s a better road to Rome. It’s called federalism.

But what if someone held a gun to my head and said federalism wasn’t an option and demanded that I choose between the “basic income” and the status quo?

There’s not an obvious right answer, but I suspect I would prefer the devil I know because of fears that we might get more redistribution and even bigger government.

And I’m not the only one to have that opinion. Here’s what a proponent of more redistribution wrote about the concept.

Basic Income, unlike the programs we have now, will be politically easy to raise once it’s in place. …if you have one big, high-profile redistribution program, you can get enough popular support to overcome the concentrated opposition of the rich people footing the bill. …by endorsing Basic Income, libertarians are walking right into a trap. Anti-redistributionists’ great fear has always been that the masses will use the power of majority rule to simply vote themselves more money. As things stand, the fragmentation of our redistribution programs makes it easier for the anti-redistributionists to punch holes in the safety net. If the fragmented system were replaced with one universal, high-profile program, the result would be a huge political gift to redistributionists.

But maybe I’m just a pessimist. Tyler Cowen has a different perspective.

…let’s say a historical accident swept Basic Income proponents into power for a term and they passed that legislation.  Over time those income transfers would prove larger, more visible, and they would at least appear superficially more anti-work than the public stomach for them.  I predict they would be restricted along a number of possible dimensions, starting with (partial) work requirements for the able-bodied. Under most plausible assumptions about the Basic Income level, most people would not be recipients, nor would they expect to be potential net gainers from the program. …So I think the “why send money to people who aren’t working?” intuition will crowd out the “I want to think of myself as someone who helps other people” feeling.

I guess it depends on how the “basic income” is designed. If the government sends checks to everybody (as some are proposing), then Tyler’s “plausible assumption” about recipients would be wrong.

Which reinforces in my mind that my original idea was right. Let’s go with federalism and get Washington out of the business of redistribution.

The decentralized approach has been very successful in Switzerland and its also the system that’s consistent with the Constitution.

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I’ve often explained that “third-party payer” is a major problem in our healthcare sector.

This occurs when consumers can buy healthcare with other people’s money. For instance, nearly half of all healthcare spending in America is directly financed by government. And a big chunk of supposedly private healthcare spending is actually the result of government policies that encourage and subsidize over-insurance (in which case, people may be buying healthcare with their own money, at least indirectly, but in a system akin to a pre-paid all-you-can-eat buffet).

Anyhow, one of the big downsides of this system is that third-party payer undermines market discipline and leads to higher prices and massive inefficiency in the health sector.

This then leads to a perverse outcome as politicians point to the higher prices and inefficiency and say this is evidence of market failure!! In a stereotypical example of “Mitchell’s Law,” they then propose more government to ostensibly deal with problems created by government (and people wonder why I have lots of gray hair).

We have the same problem in higher education, except it may be even worse if you look at these charts. Simply stated, government loans and grants have enabled colleges, schools, and universities to dramatically boost tuition and engage in massive bureaucratic featherbedding.

Interestingly, the Obama Administration has a proposal that sort of addresses this issue. The Department of Education is proposing “gainful employment” regulations that would, among other provisions, limit loans and financial aid on the basis of whether a school produces students with high student-loan debt relative to post-graduate earnings.

This sounds like it might be a good idea. After all, it would presumably lead to less government spending.

But there’s a catch. A giant catch, as explained by Brian Garst of the Center for Freedom and Prosperity.

…if it is truly needed to protect students, why are public and private non-profit universities excluded? For-profit schools only serve about 20% of all higher education students, and yet are the exclusive target of the regulation.

Yes, you read correctly. The Obama Administration is not trying to save money or impose accountability. Instead, it is seeking to undermine competition.

You may think I’m making this up, but a former senior bureaucrat at the Department of Education bragged, in a speech to a left-wing group, that the goal is to stamp out for-profit schools.

Here’s another excerpt from the folks at the Center for Freedom and Prosperity.

Former deputy undersecretary of education Robert Shireman, who initiated the Gainful Employment regulations, is currently under investigation for ethics violations and conflicts of interest relating to these effort. He has made clear through public comments that he sees eradicating private-sector colleges as his ultimate goal. In a recent speech delivered at the Center for American Progress, he said he does not believe that a business should own a college.

This fight illustrates why government intervention is so corrupting.

I don’t like any federal subsidies to education, whether for K-12 or for higher education. I don’t care whether the subsidies are for government schools, non-profit private schools, or for-profit private schools.

So I would like to cut off loans, grants, and other funds to for-profit schools, but that should happen at the same time that handouts also are being eliminated for other types of schools (Tim Carney has a very good explanation of why there are no good guys in this fight).

Let me close with an analogy.

I don’t want federal money in the healthcare system. So that means I don’t want payments of taxpayer money to private hospitals and private physicians.

But I would be even more agitated if the Obama White House said that it would “save money” by cutting off health funds, but only monies going to the private providers. The net result is that we all would be forced into VA-type treatment from government.

The moral of the story is to shrink government across the board.

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The new leftist website, Vox, has an article by Sarah Kliff on Vermont’s experiment with a single-payer healthcare system.

But I don’t really have much to say about what’s happening in the Green Mountain State, other than to declare that I much prefer healthcare experiments to occur at the state level. Indeed, we should reform Medicaid and Medicare and also fix the tax code so that Washington has no role in healthcare. Then the states can experiment and compete to see what works best.

But that’s a topic for another day. The real reason I cite Kliff’s article is that Ezra Klein tweeted this image from the article and stated that is was “The case for single payer, in one graphic.”

Vox Third-Party Payer

I don’t know if the numbers in the graphic are correct, but I have no reason to think they’re wrong.

Regardless, I certainly don’t disagree with the notion that our healthcare system is absurdly expensive and ridiculously inefficient.

In other words, the folks at Vox have accurately diagnosed a problem.

However, do these flaws prove “the case for single payer”?

It’s probably true that “single payer” has a lower monetary cost than the system we have today (assuming you don’t include the cost of substandard care and denied treatment), but that doesn’t mean it’s the ideal system.

Indeed, there is a better way to deal with the waste, inefficiency, and bureaucracy of the current system. third-party-2The answer is free markets and genuine insurance, both of which would help address the real problem of third-party payer.

Third-party payer, for those who are new to the healthcare field, is what you get when somebody other than the consumer picks up the tab. And because of government intervention, that’s what happens with about 90 percent of healthcare spending in the United States. Here’s what John Goodman had to say about this problem.

Almost everyone believes there is an enormous amount of waste and inefficiency in health care. But why is that? In a normal market, wherever there is waste, entrepreneurs are likely to be in hot pursuit — figuring out ways to profit from its elimination by cost-reducing, quality-enhancing innovations. Why isn’t this happening in health care? As it turns out, there is a lot of innovation here. But all too often, it’s the wrong kind. There has been an enormous amount of innovation in the medical marketplace regarding the organization and financing of care. And wherever health insurers are paying the bills (almost 90 percent of the market) it has been of two forms: (1) helping the supply side of the market maximize against third-party reimbursement formulas, or (2) helping the third-party payers minimize what they pay out. Of course, these developments have only a tangential relationship to the quality of care patients receive or its efficient delivery.

And here’s some analysis from a study published by the National Bureau of Economic Research.

In most industries, higher quality is associated with higher prices. That is not true in medical care, however, largely because of the public sector. …Every analysis of medical care that has been done highlights the significant waste of resources in providing care. Consider a few examples: one study found that physicians spent on average of 142 hours annually interacting with health plans, at an estimated cost to practices of $68,274 per physician (Casalino et al., 2009). Another study found that 35 percent of nurses’ time in medical/surgical units of hospitals was spent on documentation (Hendrich et al., 2008); patient care was far smaller. …In retail trade, the customer is the individual shopper. If Wal-Mart finds a way to save money, it can pass that along to consumers directly. In health care, in contrast, the situation is more complex, since patients do not pay much of the bill out-of-pocket. Rather, costs are passed from providers to insurers to employers… About one-third of medical spending is not associated with improved outcomes, significantly cutting the efficiency of the medical system and leading to enormous adverse effects.

Here’s my humble contribution to the discussion, starting with an explanation of how special tax breaks deserves some of the blame.

…how many people realize that this bureaucratic process is the result of government interference? For all intents and purposes, social engineering in the tax code created this mess. Specifically, most of us get some of our compensation in the form of health insurance policies from our employers. And because that type of income is exempt from taxation, this encourages so-called Cadillac health plans. …We have replaced (or at least agumented) insurance with pre-paid health care.

I then explain why this isn’t a good idea.

Insurance is supposed to be for unforseen major expenses, such as a heart attack. But our gold-plated health plans now mean we use insurance for routine medical costs. This means, of course, we have the paperwork issues…, but that’s just a small part of the problem. Even more problematic, our pre-paid health care system is somewhat akin to going to an all-you-can-eat restaurant. We have an incentive to over-consume since we’ve already paid. Except this analogy is insufficient. When we go to all-you-can-eat restaurants, at least we know we’re paying a certain amount of money for an unlimited amount of food. Many Americans, by contrast, have no idea how much of their compensation is being diverted to purchase health plans. Last but not least, we need to consider how this messed-up approach causes inefficiency and higher costs. We consumers don’t feel any need to be careful shoppers since we perceive that our health care is being paid by someone else. Should we be surprised, then, that normal market forces don’t seem to be working?

And I ask readers to think about the damage this approach would cause if applied in other sectors of the economy.

Imagine if auto insurance worked this way? Or homeowner’s insurance? Would it make sense to file insurance forms to get an oil change? Or to buy a new couch? That sounds crazy. The system would be needlessly bureaucratic, and costs would rise because we would act like we were spending other people’s money.  But that’s what would probably happen if government intervened in the same way it does in the health-care sector.

This is probably more than most people care to read, but it underscores the point that we don’t have a free market in health care. Not now, and not before Obamacare.

So the folks at Vox are right about the current system being a mess. But I disagree with the notion that more government is a way to solve problems created by government.

The real answer, as I’ve already noted, is to get Washington out of health care. This means entitlement reform AND tax reform.

And if you want to get a flavor of why this would generate better results, watch this Reason TV video and read these stories from Maine and North Carolina.

So how do we get there? Repealing Obamacare is a necessary but far from sufficient condition. Cato’s Adjunct Scholar, John Cochrane, has a nice roadmap of what’s really needed.

Though Vermont certainly is welcome to travel in the other direction. It’s always good to have bad examples and I wouldn’t be surprised if the “Moocher State” played that role.

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