So far, the Supreme Court decision hasn’t seemed to have had much effect, though it wouldn’t be a surprise if it ended up swaying some people — softening some opponents, energizing others.
Gallup has the latest:
Americans are more likely to say the 2010 healthcare law upheld by the Supreme Court last week will hurt the national economy (46 percent) rather than help it (37 percent), while 18 percent say they don’t know or that it will have no effect. …
Average Americans are certainly in no better position than economists to know exactly how the legislation will affect the economy, but their assumptions and perceptions have political repercussions nevertheless. And at this point, Americans’ views on the economic impact of the ACA are more negative than positive.
Views of the economic impact of the ACA are, as is true with everything else about the legislation, bound up with politics. Republicans, who generally oppose the ACA, overwhelmingly think it will hurt the economy, while Democrats, who generally favor it, think it will help. Independents tilt toward the “hurt” rather than the “help” position.
The fact that the mandate is now a “tax” isn’t going to help in this area, which makes you wonder again how the Romney campaign managed to step on that message so badly. Independents are clearly receptive to the economic impact argument, which makes Obama’s comments about “moving on” from the health care debate seem even more tone deaf.
This isn’t partisan criticism. These are legitimate concerns from independent voters, and the president comes off as out of touch by dismissing them outright.
The devil is in the details and the statute is too big to understand all the details.
It is classic top-down central planning structure.
I prefer a decentralized market solution.
It creates more uncertainty - we will not know how this works for 5 to 10 years.
The uncertainty of healthcare, taxes, law and regulation combine to slow economic growth.
Since the Supreme Court upheld the Democrats’ 2010 health care law, Republicans, led by Mitt Romney, have reversed tactics and attacked the president and Democrats in Congress by saying that Medicare will be cut too much as part of that law. Republicans plan to hold another vote to repeal the law in the House next week, though any such measure would die in the Democratic-controlled Senate.
“Obamacare cuts Medicare — cuts Medicare — by approximately $500 billion,” Mr. Romney has told audiences.
I have been predicting this. There is more here: http://www.nytimes.com/2012/07/07/us/politics/mixed-message-as-republicans-claim-health-law-cuts-medicare.html?_r=1&hp
Paul Ryan offered this account:
Mr. Ryan, of Wisconsin, was unavailable for comment, but, pressed on the issue on ABC’s “This Week” on Sunday, he said: “Well, our budget keeps that money for Medicare to extend its solvency. What Obamacare does is it takes that money from Medicare to spend on Obamacare.”
ObamaCare Driving Away Doctors?
A recent Doctor Patient Medical Association poll, which found 90 percent of doctors say the medical system is on the wrong track and 83 percent are thinking about quitting.
90% say the medical system is on the WRONG TRACK
83% say they are thinking about QUITTING
61% say the system challenges their ETHICS
85% say the patient-physician relationship is in a TAILSPIN
65% say GOVERNMENT INVOLVEMENT is most to blame for current problems
72% say individual insurance mandate will NOT result in improved access care
49% say they will STOP accepting Medicaid patients
74% say they will STOP ACCEPTING Medicare patients, or leave Medicare completely
52% say they would rather treat some Medicaid/Medicare patient for FREE
57% give the AMA a FAILING GRADE representing them
1 out of 3 doctors is HESITANT to voice an opinion
2 out of 3 say they are JUST SQUEAKING BY OR IN THE RED financially
95% say private practice is losing out to CORPORATE MEDICINE
80% say DOCTORS/MEDICAL PROFESSIONALS are most likely to help solve things
70% say REDUCING GOVERNMENT would be single best fix.
I think technology is the future of healthcare.
Tech innovation will outweigh the new law and change the health industry for the better.
I agree technology will crush the dysfunctional healthcare system.
It has the potential to put the power back to the individual.
Costs will decrease and quality will increase.
Tech is the wildcard. It will change healthcare as we know it. But expect war from the current beneficiaries - doctors, hospitals, insurance firms - because tech will take power away from them and empower the individual.
Are people ready to take responsibility for their own healthcare?
Exploring and driving the future of medicine through exponential, game changing technologies.
Data & Web Enabled Healthcare
Genomics & Personalized Medicine
Medical Intervention & Surgical Robotics
Biotech Innovation & Entrepreneurship
20 years ago U.S. healthcare cost USD $2800, on average, per person. Ten years ago, that figure had risen to $4700 per person. And four years ago, in 2008, it was $7500 per person. It is much more today but the costs are not out yet.
Are we getting more value for our healthcare buck?
If not, why?
Value is the issue - healthcare is pretty good in US. We need more productivity.
In multiple studies, over 80 percent of Americans are satisﬁed with the quality of their own health care, a number rising steadily over the past several years.
Government ofﬁcials, policymakers, insurers and many academics use pseudo-data to justify their personal agenda centralizing power over health care to government by imposing the radical changes to America’s health care contained in the Patient Protection and Affordable Care Act (also known as "ObamaCare") on a largely unwilling public.
While a large majority of Americans think their health care system needs "fundamental change" and "cost transparency" and "value" - they also know, from personal experience, that American medical care is the best in the world.
Americans understand what they could lose in a government-centralized health system in which government is empowered to exercise unprecedented control over the most personal decisions in the lives of individuals. That is why a majority is against Obamacare.
By any variety of measures, Americans are responsible for the vast majority of all health care innovations, innovations from which the entire world beneﬁts. The top ﬁve U.S. hospitals conduct more clinical trials than all the hospitals in any other single developed country.
Since the mid-1970s, the Nobel Prize in medicine or physiology has gone to American residents more often than recipients from all other countries combined. From 1969 to 2008, Americans (2009 population, 307 million) won or shared the Nobel Prize in Medicine and Physiology ﬁfty-seven times compared with forty times by medical scientists from the European Union, Switzerland, Japan, Canada, and Australia combined (2009 combined population, 681 million).
Americans enjoy unrivalled access to the most advanced medical care in the world, and important facts—data published in leading peer-reviewed journals—point to the superiority of America’s health care.
What we need is a strategy to reduce costs. We need transparency for health costs.
I suggest investments in technology and instituting decentralized market mechanisms to bend the cost curve down.
Are consumers of health care—and taxpayers in public ﬁnancing—are obtaining the highest "value" for the resources devoted to health care?
That is, are we getting what we should in return for the investments that we make, as individuals and a society, in our health care?
Markets will not eliminate growth in health care costs—an inevitable product of technological change—or uninsurance. Markets will never solve the problem of how to ﬁnance care for the low-income chronically ill. But the power of markets to allocate resources efﬁciently—power evident in every other sector of the economy—is a critical part of the solution.
Yet markets cannot ﬂourish without the appropriate institutional support for consumer incentives and choice, provider accountability, and competition. These needed features are held back in the United States in substantial measure by the unintended consequences of public policies. Any serious reform of the U.S. health care system must begin by changing these policies.
First, reform should increase individual involvement in health care decisions. The most important impediment to achieving this goal is the tax preference for employer-provided health insurance. Current tax policy generally allows people to deduct employer-provided health-insurance expenditures, but requires direct out-of-pocket medical spending to be made from after-tax income. This tax preference has given consumers the incentive to purchase health care through low-deductible, low-copayment insurance instead of out-of-pocket.
This type of insurance has led to today’s U.S. health care market in which cost unconsciousness and wasteful medical practices are the norm. The reason is, as the late Nobel laureate Milton Friedman once put it, "Nobody spends somebody else’s money as wisely as he spends his own." The best way to reverse this trend would be to revoke the tax preference.
Another area in need of policy reform is the regulation of markets for health insurance. Like the tax preference, the unintended consequences of inefﬁcient insurance regulation are to drive up costs and increase uninsurance.
I suggest that insurance companies that meet certain federal standards be permitted to offer plans on a nationwide basis free from costly state mandates, rules, and regulations.
With this change, insurance would become available to individuals and small groups on the same terms and conditions as those currently available to employees of many large corporations.
I suggest three simple reforms:
1) better provision of information to providers and consumers;
2) an explicit public goal to control anticompetitive behavior by doctors, hospitals, and insurers;
3) reforms to the malpractice system to reduce wasteful treatment and medical errors.
I think the main problem with Obamacare is it put the crucial ﬁrst step of cost containment and innovation in the back seat of a car driven by costly expansion of access within a system of ﬂawed incentives.
49% Favor Strict Legal Interpretation of the Constitution
Thursday, July 12, 2012
Did the Founding Fathers mean what they said or did they view the U.S. Constitution as just a set of principles to guide the nation? That legal debate continues to this day.
But nearly half (49%) of Likely U.S. Voters believe the Constitution should be strictly interpreted as written, according to a new Rasmussen Reports national telephone survey. Forty-three percent (43%) disagree and say they are more inclined to view it as a “living document” subject to constant reinterpretation depending on the changing times.
Various leaks suggest that Chief Justice John Roberts switched his vote in the individual mandate case in order to protect his own and the Supreme Court’s reputation and enhance their legitimacy.
Whether or not that was his objective, it is interesting to ask whether the goal was achieved. Did the decision enhance the Court’s legitimacy more than it detracted from it?
So far, the answer seems to be “no.” Post-decision polls show that the majority of the public disagrees with the mandate decision, and overall public approval of the Court has fallen substantially.
Roberts probably did succeed in enhancing the Court’s reputation among law professors and left-wing legal elites, many of whom would have been very angry if the Court had invalidated the mandate.
But even among this group, the results are somewhat equivocal. Many of them probably believe or at least suspect that Roberts switched his vote out of fear for his reputation rather than because he genuinely believed in the federal government’s dubious tax argument (which had been rejected by every lower court to have considered it, including several liberal judges).
Those who do believe this may be happy about the result; but it is unlikely to enhance their opinion of Roberts himself, who on this account comes off as a man who cares more about his and the Court’s reputation among legal elites than about enforcing the Constitution.
In a recent post, political scientist Steven Teles argues that Chief Justice John Roberts’ decision to uphold the individual mandate was motivated by “statesmanship”:
[M]y guess is that Roberts would have joined a decision more or less striking down the mandate but severing it from the rest of the law, but he couldn’t get the rest of the four justices to go along with him. So he ended up having to cut a deal with the liberals….
Roberts, no doubt influenced by his position as Chief Justice, made the call that he could pull at the seam of the law pretty hard but couldn’t unravel it completely. Doing so really would put the Supreme Court in a state of outright war with the Democratic Party. There is an element in Supreme Court decision-making that can be explained by statesmanship rather than jurisprudence. Law professors are unlikely to be very impressed with that element, but it’s a real, permanent and unavoidable aspect of our system of government. On no really important aspect of jurisprudence did Roberts actually break from his conservative brethren, but he did make a different political judgment than they did—not on what the Court could get away with, but what was really appropriate for it to do on a matter of such great policy significance.
Roberts Was Against Treating the Mandate as a Tax Before He Was For It
On March 27, during the part of the Obamacare oral argument devoted to the individual mandate, Solicitor General Verrilli said that the Court has an “obligation to construe it as an exercise of the tax power, if it can be upheld on that basis.” To that, Chief Justice Roberts responded quite critically, interrupting the solicitor general and asking why then didn’t Congress call it a tax. The Chief does not seem particularly convinced on this issue, with the SG having a nonsensical answer of “there is nothing I know of that illuminates that.”
Yet, that is the exact issue he later accepted.
Here is the full exchange (from pages 49–50 of the transcript), including the preceding relevant exchange between Justice Kagan and the SG:
JUSTICE KAGAN: I suppose, though, General, one question is whether the determined efforts of Congress not to refer to this as a tax make a difference. I mean, you’re suggesting we should just look to the practical operation. We shouldn’t look at labels. And that seems right, except that here we have a case in which Congress determinedly said this is not a tax, and the question is why should that be irrelevant?
GENERAL VERRILLI: I don’t think that that’s a fair characterization of the actions of Congress here, Justice Kagan. On the—December 23rd, a point of constitutional order was called to, in fact, with respect to this law. The floor sponsor, Senator Baucus, defended it as an exercise of the taxing power. In his response to the point of order, the Senate voted 60 to 39 on that proposition. The legislative history is replete with members of Congress explaining that this law is constitutional as an exercise of the taxing power. It was attacked as a tax by its opponents. So I don’t think this is a situation where you can say that Congress was avoiding any mention of the tax power. It would be one thing if Congress explicitly disavowed an exercise of the tax power. But given that it hasn’t done so, it seems to me that it’s—not only is it fair to read this as an exercise of the tax power, but this Court has got an obligation to construe it as an exercise of the tax power, if it can be upheld on that basis.
CHIEF JUSTICE ROBERTS: Why didn’t Congress call it a tax, then?
GENERAL VERRILLI: Well--
CHIEF JUSTICE ROBERTS: You’re telling me they thought of it as a tax, they defended it on the tax power. Why didn’t they say it was a tax?
GENERAL VERRILLI: They might have thought, Your Honor, that calling it a penalty as they did would make it more effective in accomplishing its objective. But it is—in the Internal Revenue Code it is collected by the IRS on April 15th. I don’t think this is a situation in which you can say--
CHIEF JUSTICE ROBERTS: Well, that’s the reason. They thought it might be more effective if they called it a penalty.
GENERAL VERRILLI: Well, I—you know, I don’t—there is nothing that I know of that illuminates that, but certainly…
What a difference a few weeks make.
I think the spending clause portion of the decision could be the monster that derails Obamacare.
For the Court to invalidate a condition imposed on state receipt of federal funds for the first time since the New Deal is significant.
I would argue more important than the tax power holding.
I wonder why the liberal wing of the court would go along with this? They are smart enough to know 1) it could wreck the statutory scheme and 2) this precedent hurts federal power long term.
I speculate that Roberts forced the liberals to go along with this in return for upholding statute as tax.
"I think the main problem with Obamacare is it put the crucial ﬁrst step of cost containment and innovation in the back seat of a car driven by costly expansion of access within a system of ﬂawed incentives."
Yes indeed. A costly expansion of access with ﬂawed incentives is why Obamacare will never work.
"I think the spending clause portion of the decision could be the monster that derails Obamacare. For the Court to invalidate a condition imposed on state receipt of federal funds for the first time since the New Deal is significant."
Absolutely! In addition to all the Republican governors, at least seven Democratic governors have been noncommittal about their willingness to go along with expanding their Medicaid programs.
Why? Expanding their Medicaid programs would significantly hurt state finances. Obamacare's scheme does not work without the federal government's ability to coerce state governments to set up health exchanges and expand state Medicaid programs.
Read more: http://www.washingtonpost.com/national/health-science/medicaid-expansion-a-tough-sell-to-governors-of-both-parties/2012/07/12/gJQAF4RAfW_story.html?hpid=z4
While central planning may not be the right term for it, consider the 2010 health-care law, which gave the federal government the power to mandate the terms of everyone’s health-insurance package and which created an Independent Payment Advisory Board to determine the price, quantity, and quality of the medical services—from number of MRIs to the necessary accuracy of CT scans—that a medical professional provides.
Is that so different from the way centrally planned economies determine the price, quantity, and quality of livestock, wheat, or steel that can be produced?
Call a duck a duck: Obamacare is central planning.
The court held that participation in Obamacare’s insurance scheme is optional.
Rather than a requirement to buy coverage backed with a penalty for violators, the law now offers Americans two equally lawful and legitimate options: buy expensive insurance (which Obamacare will make all the more expensive), or pay a modest (and still largely unenforceable) tax and just buy insurance for the same price later if you need it.
Presented as a choice, not a command, this provision will invite a straightforward comparison, and for many Americans the choice will be to pay the tax. If a significant number elect to pay the tax, the entire scheme is doomed.
Yes, in theory Roberts decision states that participation in the insurance scheme is optional.
Of course, in practice, this doesn’t really make Obamacare optional, because although the law can no longer order consumers to buy what insurers are selling, it still strictly defines what insurers may sell.
Folks only have a choice between Obamacare and nothing. Many will prefer nothing, but that’s hardly a great set of options to choose from.
" If a significant number elect to pay the tax, the entire scheme is doomed."
I think not - it will simply increase the cost of our healthcare without value and productivity.
Yes, it will increase the cost of healthcare without value and productivity - the opposite of what the law purports to achieve.
And sooner or later that dooms the entire scheme of Obamacare and Americans will vote to repeal.
Under the SC decision, all states have to do is refuse to set up the health exchanges and refuse to play ball with the feds with medicaid. If that happens with enough states then Obamacare is destroyed.
What is preventing the national government from creating a national health exchange and nationalizing medicaid?
Under this scenario Obamacare works.
"What is preventing the national government from creating a national health exchange and nationalizing medicaid?"
How is this different from single payer, nationalized, government run healthcare?
Ah, it is not different from government run healthcare.
Some argue that was the stealth end goal. The Supreme Court decision simply redirects the rout to the goal.
Nationalizing health exchanges and medicaid is very likely under a Democratic House and Senate.
It was always assumed that very weak penalties in Obamacare were there as loss leaders. When they later proved too weak to work, they would be jacked up.
Now the SC decision makes this very difficult, the insurance companies who were bought off by the promise of compulsory customers for their government-dictated “insurance” policies may well be led to support repeal and replace.
I see no downsides to this. Due to the current system of tax credits and decades of insurance company rent-seeking, we have by far the most expensive system in the world, with the least amount of coverage.
Worst case scenario, the insurance companies are driven out of business and we develop a different system.
Best case scenario, the insruance companies are driven out of business and we develop a different system.
If Obamacare, the court decision and partial repeal is what's ultimately necessary to break our current, expensive system, I don't see what's wrong with that.
Insurance companies played the game that Congress created; tax credits for employer provided health insurance.
Subsides cause over supply; that's what happened.
Insurance companies aren't evil; they played by the laws that Congress created. Get mad at Congress.
Lets assume Roberts thought, right or wrong, that Obamacare was designed to fail and turn into a single-payer system.
His ruling makes sense as a way to prevent a single-payer system.
Roberts played the long game. He smoked out the game within the game.
"Lets assume Roberts thought, right or wrong, that Obamacare was designed to fail and turn into a single-payer system."
Yes indeed: Obamacare was designed to fail and turn into a single-payer system.
"Obamacare was designed to fail and turn into a single-payer system."
That is the only thing that makes any sense.
"Obamacare was designed to fail and turn into a single-payer system."
Here's a proposal:
1. Repeal Obamacare.
2. Override state laws prohibiting purchase of insurance across state lines, thereby repealing mandated coverage (this would be a regulation of real interstate commerce).
3. Specifically legalize catastrophic care insurance.
4. Allow deductability of individually-purchased health insurance, thereby untying it from employment.
5. Ensure availability to all of health-care savings accounts, and allow the amounts in the accounts to build up from year to year.
6. Incentivize through tax breaks or otherwise the creation of tax-purchase cooperatives or other groups, letting insurance companies spread their risks.
This would hardly be perfect, but it is preferable to Obamacare, which was designed to fail and turn into a single-payer system.
Single-payer systems inevitably let the government decide who lives and who dies and are antithetical to liberty.
I like Green's proposal. But what about the pre-existing conditions problem?
"...what about the pre-existing conditions problem?"
Create high risk insurance pools funded by the government.
"Create high risk insurance pools funded by the government."
That works. Yet fear that is what future medical insurance (from or controlled by the feds) will look like: low payments to providers (resulting in less provider choice) and rationing.
For underemployed healthy, young people, who are not covered under parent's plan, and living paycheck-to-paycheck, the advice is easy:
(1) Adjust withholding so no possibility of refund, thus, no possibility of tax penalty;
(2) Buy iPad instead of insurance you may never use;
(3) Bring iPad with you while freeloading at ER for your primary care;
(4) Ignore collection letters from hospital because you are judgment-proof and don't care if already disheveled credit report gets dinged; and
(5) Tweet or FB your "health coverage game plan" to other 99%ers.
Great Article by Tyler Cowen: http://www.nytimes.com/2012/07/15/business/medicaids-new-tug-of-war-economic-view.html?ref=business
Medicaid has never been especially popular, and when its expanded role becomes more widely understood, it is likely to become less popular still.
I am not expecting that governors will turn away nearly-free federal dollars outright. (Though probably some will, here is an update on how the governors are reacting, which as I see it involves lots of bargaining.) I am predicting that the extreme subsidies for states to hop on to the expansion will at some point weaken or go away.
Change might come soon. If Mitt Romney wins the presidential election, and if Republicans control both houses of Congress, they could turn Medicaid into a block grant program, where states can spend the money as they wish.
Even if President Obama is re-elected, some state governments will work hard to reduce the number of people covered by Medicaid. State officials know that limiting Medicaid will place more individuals in the new, subsidized health care exchanges, and that those bills will be paid by the federal government. The basic dynamic is that state and federal governments have opposite incentives as to how many people should be kept in Medicaid.
The proposal? Here is my best take on how Obamacare might evolve into something more practical:
1. Many of the states slip out of expanded Medicaid obligations and many employers slip out of expanded mandate obligations to cover their employees (waivers, willingness to pay fines, lobby to have the law altered). The system evolves toward a form of means-tested vouchers, sold on the exchanges.
2. The subsidies for the private exchanges become so expensive that the individual mandate is limited in scope. Eventually the mandate applies to catastrophic coverage only.
3. For catastrophic coverage, we move toward a mandate and subsidized exchanges, and for non-catastrophic coverage there is no mandate and health savings accounts, the latter supplemented by public contributions if needed or if you wish.
I am not predicting that, nor is it my first or even preferred second-best solution. It is however the best solution I can see evolving out of ACA in its current form.
Opponents of the Affordable Care Act predict the law will play out in four steps:
1 Put government in charge of healthcare.
2 Be shocked by rising costs.
3 Begin micromanagement and cost controls.
4 Endless pain.
Massachusetts, the model for the federal law, seems to have moved to step three, with a vote set this week on measures to contain runaway healthcare spending. We’ll see if step four is next.
As the Wall Street Journal report suggests, the legislation involves significant government oversight of the healthcare system and a major expansion of government bureaucracy:
If the measure is approved . . . [a]ll health-care providers would be required to report financial performance, market share, cost trends, and quality measures to the state.
A new oversight agency would monitor how providers are doing at controlling costs and provide reports on cost trends—information that will be used to develop further policy.
In addition, the bill charges the state’s attorney general, Martha Coakley, with monitoring trends in the health-care market, including price variation, though it doesn’t require her to take action. Ms. Coakley, a Democrat, has been a critic of hospitals that use their brand and clout to charger higher prices that aren’t justified by quality.
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