Thursday, September 10, 2009

Obama's Speech

I didn't listen to the whole thing. There were aspects of it that were good, some that were innocous, some obnoxious. I love that health care reform is being billed as a free lunch. I actually agree to some extent, there is waste, fraud, and abuse in medicare and there are substantial savings to be gained. I just don't think it will happen and even if they did the savings are likely to be substantially lower than predicted. Some of those savings, such as cutting Medicare Advantage, aren't really "waste, fraud, and abuse" but cutting seniors benefits. Which is fine with me, but it is a misleading argument. I think the president deserves some credit for putting the individual mandate in there. That is an important part of health care reform and it is an unpopular part. The pay fors are stupid. This tax on insurers is absolutely absurd. The tax will be passed on to the consumer, so you might as well place it on the consumer. What I am afraid of is that the since the tax is opaque that consumers, such as public sector unions, will still insist on cadillac coverage as they aren't exposed to the full cost of coverage (you don't see the employers contribution on your pay stub) and thus will not achieve much if any cost containment (while deriving little revenue). This is just a stupid idea.

Increasingly I don't think that universal health care reform will happen. That said it's interesting to think about what a smaller scale reform package would look like. You can't really do community rating without a mandate. You can't do a mandate without subsidies. One area where you probably could get wide agreement would be on the national exchange. This would benefit those who live in states where real insurance (catastrophic) has been regulated out of existence. This wouldn't increase coverage much but it would be a significant step in the right direction. I could also see a cap on the employer exclusion making its way back into the conversation. I think what you would see is that the cap would be fairly high but not obscenely high and the tax exemption would be extended to everyone. This would be far from optimal policy but it would be an improvement nonetheless. The other thing I suspect would be part of a scaled down bill would be some form of medicaid expansion (more limited) and maybe a very limited tax credit for folks up to 300% of the poverty line.

Things that would be left out from current bills are: mandates (employer/individual); insurance reform (maybe with the exception of recission; that is probably happening regardless); anything involving medicare; any substantial pay fors (income surtax, taxing benefits; the goofy insurer tax); malpractice reform.

ONE LAST NOTE: I hated when he said it costs three times as much to buy health care on the individual market than as when your employer provides it. One might pay three times as much as their employer is not providing an premium contributions, but the cost is the same. If I have a plan through my employer that is $100 a month and my employer pays 2/3rds of the premium, the cost of the premium is still $100 a month, I just happen to pay directly $33 out of wages and another $67 (potentially) out of foregone wages. If I pay for a policy on the individual market the cost could be the same- $100 a month- but I would paying the full cost from wages. The difference is not cost but rather whether the policy is being paid for in the form of after-tax wages in the individual market or pre-tax wages/employer contributions(foregone wages). What you could say is that it costs more in relation to the tax advantage. If my marginal tax rate is 25% and I buy a policy in the individual market with $100 I would need to make $133 in before tax wages to pay for the policy. If I get my insurance through my employer the policy is paid for in pre-tax wages so that is a a real bonus (thus I would only need to earn $100 to pay for the $100 policy).

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