Meanwhile, at True/Slant…

Erik Kain

Erik writes about video games at Forbes and politics at Mother Jones. He's the contributor of The League though he hasn't written much here lately. He can be found occasionally composing 140 character cultural analysis on Twitter.

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9 Responses

  1. Art Deco says:

    Your esteem for Dr. Cowan’s ideas is puzzling.

    1. Construct a path for federalizing Medicaid and put it on a sounder financial footing; call that the “second stimulus” while you’re at it. It’s better and more incentive-compatible than bailing out state governments directly and the program never should have been done at the state level in the first place.

    You offer as well that having state governments as insurers is ‘silly’. Why is this? Collectively, the state governments collect taxes and disburse benefits to the same body of people that the federal government does. A national program would have a larger actuarial pool, but even the least populous states have north of 175,000 households. That’ll do. The utility of state programs is that the scope of services covered, the assessments on the public, and the deductibles can be set in accordance with the particular preference of each. Please note, occupational licensing and tort law are generally the artifacts of state legislatures and state courts. If you are concerned about the effect of geographic variation in per capita income on a state’s ability to provide services, a straightforward no-strings-attached subsidy to state, county, and municipal government can be enacted, with a distributional formula which takes into account population and per capita income; Mississippi can then keep pace with Connecticut, more or less. If you are concerned about the effect of people migrating, keep in mind that only about 7% of the population change their state of residence in a given year; one might set up a parallel federal program to cover itinerant populations (e.g. military families) and ‘binder’s coverage’ for people who have moved in the last 18 months or are out of area when they are injured.

    2. Take some of the money spent on subsidizing the mandate and put it in Medicaid, to produce a greater net increase in Medicaid than the current bill will do, while still saving money on net. Do you people like the idea of a public plan? We already have one!

    He takes the rococo schemes of the administration and Congress as a point of departure. Must we enter that labyrinth?

    2b. Make any “Medicare to Medicaid” $$ trade-offs you can, while recognizing this may end up being zero for political reasons.</i.


    3. Boost subsidies to medical R&D by more than the Obama plan will do. Establish lucrative prizes for major breakthroughs and if need be consider patent auctions to liberate beneficial ideas from P > MC.

    Am I surprise that a professor is arguing for more academic pork barrel?

    4. Make an all-out attempt to limit deaths by hospital infection and the simple failure of doctors to wash their hands and perform other medically obvious procedures.

    Can’t we leave that to hospital administrators advised by their in house counsel? Neither Dr. Cowan or the President are likely to speak with much force on this issue.

    5. Make an all-out attempt, working with state and local governments (recall, since the Feds are picking up the Medicaid tab they have temporary leverage here), to ease the spread of low-cost, walk-in health care clinics, run on a WalMart sort of basis. Stepping into the realm of the less feasible, weaken medical licensing and greatly expand the roles of nurses, paramedics, and pharmacists.

    To the extent that this could be done, it would be through modification of esoteric state regulations. He is proposing to have federal authorities squeeze the nuts of state officials to make it happen. That in turn means adding conditions to funding, distorting local preferences, and more barnacles on the ship.

    6. Make an all-out attempt, comparable to the moon landing effort if need be, to introduce price transparency for medical services. This can be done.

    His analogy is strange. The absence of transparency has nothing to do with deficits of capital or technology.

    8. Invest more in pandemic preparation. By now it should be obvious how critical this is. It’s fine to say “Obama is already working on this issue” but the fiscal constraint apparently binds and at the margin this should get more attention than jerry rigging all the subsidies and mandates and the like.

    Does Dr. Cowan have a ready conception of how much you should devote to preparing for black swan events like the 1918 influenza epidemics?

    9. Establish the principle that future extensions of coverage, as done through government, will be for catastrophic care only.

    Why not limit all public provision to that in excess of a high deductible? Some hypotheses: 11.) there is a cultural expectation that you receive medical care at the price of a nominal co-pay, and politicians pander to that; 2.) politicians within the Democratic Party are governed by a potted conception of what is ‘fair’, which is to say that no benefit conferred by politicians within the Democratic Party on their favored clientele may ever be rescinded. The Democratic Party will have to be ignored if any work is to be done.

    11. Realize that you cannot tack “universal coverage” (which by the way it isn’t) onto the current sprawling mess of a system, so look for all other means of saving lives in other, more cost-effective ways. If you wish, as a kind of default position, opt for universal coverage if the elderly agree to give up Medicare, moving us to a version of the Swiss system and a truly unified method of coverage. But don’t bet on that ever happening.

    There is a certain amount of discussion in elementary microeconomics about compensating populations injured by trade liberalization. Why not make use of the funds expended on Medicaid for a program of comprehensive coverage of the whole population (over a high deductible) and then use the funds now allocated to Medicare for an addendum to Social Security: erect a medical savings account for each beneficiary and dump about $10,000 in it each year. The use of the account would be restricted to paying service providers and providers (under penalty of law) could accept drafts only for the provision of services specified in a state manual. If the funds in the account exceeded a certain standard balance (say, $25,000), the excess could by the beneficiary be transferred to another account to be used at his discretion.

    12. If you can tax health insurance benefits and cut a Pareto-improving deal overall, fine, but I am considering this to be too politically utopian and it’s not clear what the rest of that deal looks like. The original tax break makes no economic sense but you don’t want to end up with a big tax increase and a lot more people on the public books with little in return.

    Dr. Cowan is an economist, not a politician. Working out the ‘politics’ is not his job. All we have is the hope that some day good ideas can trump vested interests and stupidity.

    14. Commission a study of how much the Obama plan is spending per QALY saved. I agree that more health insurance saves lives, but a) the study should adjust appropriately for the superior demographics of those who hold or buy insurance, and b) the study should adjust for the income that would be lost through mandates and the safety that income would purchase. I worry greatly that we have never, ever seen this number presented and that if we did it would not be pretty. In any case, do the study, scream the number from the rooftops, and reread points 1-11. Enact.

    You are thinking that a Congress in the hands of the likes of Barney Frank and Henry Waxman would react to the data by crafting responsible public policy?Report

  2. Koz says:

    “Republican hypocrisy on fiscal responsibility.”

    Yeah, yeah.

    I don’t know where Mr. Bartlett has been over the last few years or so, maybe he’s been abducted by space aliens or something. It seems to have passed his notice that right now we’re in the middle of substantial debate about the expansion of the entitlement state and have been for the better part of a year or so. Given that Mr. Bartlett has shown no interest in participating in that debate except for anklebiting at the one side who’s trying to reduce the size of the entitlement state, it seems a lot more plausible to me to argue that Mr. Bartlett has no credibility on fiscal responsibility than to say the Republicans lack credibility there.Report

    • Cascadian in reply to Koz says:

      Republicans should regain their fiscal bonafides by advocating and working toward a repeal of Medicare D.Report

      • Koz in reply to Cascadian says:

        Maybe so, but obviously that has to wait until the current health care reform bills are defeated, which hasn’t happened yet and may never be.Report

        • Cascadian in reply to Koz says:

          Why not clean up one’s own mess before worrying about the someone elses mote? That would seem like taking personal responsibility that would be consistent with a conservative perspective.Report

          • Koz in reply to Cascadian says:

            Because the Democrats are the majority and they are, for the moment at least, setting the agenda. As we all (hopefully) know, the top item on their agenda is some expansion of the health care entitlement. The GOP (and the punditocracy at large) are reacting to that for now.

            When that no longer dominates the domestic agenda, other things might have a chance to get some oxygen. If the Democrats, or a significant number of them, want to repeal Medicare Part D, the GOP might be in a real pickle. Frankly, I think we can safely discount that scenario.Report

            • Cascadian in reply to Koz says:

              Oh, Republicans could continue to counter the Dems on health care. But, they could also vow to repeal part D as part of their election strategy for ’10. With such a good faith effort they might regain credibility.

              Why would Dems against part D place the Republicans in a pickle?Report

          • Koz in reply to Cascadian says:

            And on that subject, as much as the Demo’s hated Medicare Part D when it was passed on the theory that it was a giveaway to Big Pharma, I’m a little surprised they haven’t put together a “health care reform” bill that simply adjusts the reimbursements for prescriptions to Canadian levels or some other cheap monopsony price.

            Relative to the current bill, the politics of that are in their favor six ways to Sunday. It would negatively affect Big Pharma’s ability to produce new medications, but the political constituency for that is much weaker than the Tea Parties, conservatives, old people, etc. who are completely opposed to this bill and who have collectively been handing the Democrats their political head over the last six months or so.Report

  3. Jaybird says:

    I don’t see where Democrats have the right to complain about (something) because they never complained about it when (something else tangentially related).

    There. I’m glad we’ve established that neither side can ever complain about anything else ever again.Report