Cassidy on Health Care

(HT Wall Street Journal, "Confessions of an ObamaCare Backer")  John Cassidy of The New Yorker makes a valuable contribution to the health care debate in, "Some Vaguely Heretical Thoughts on Health-Care Reform."  He begins by stating his normative priors.  While they are not mine, they are logical and well ordered.

I regard an expansion of the government safety net as ethically essential, economically justified, and long overdue. It is indefensible for a country as rich as the United States to fail to provide adequate health care for many of its citizens. In extending our health-care system, all we are doing is catching up with Otto Von Bismarck’s Germany, which recognized a hundred and twenty-five years ago that universal health and disability coverage, along with old age pensions and a system of public education, were essential elements of a modern society.

He believes that the bill may be the best that the Obama administration can achieve but that it only deals with one of two problems, coherent universal coverage.

Moreover, given the reluctance of “Blue Dog” Democrats, such as Nebraska Senator Ben Nelson, to support anything that smacks of big government, and President Obama’s determination to coöperate with moderate Republicans, the proposed reform may be the most that can be accomplished today. But we will be dealing with its consequences for decades to come, and I think it’s important to be clear about what the reform amounts to.

Let’s remind ourselves of the basics. There are two big (and linked) problems with the current health-care system. It excludes 46.3 million Americans, according to the Census Bureau, and it is inordinately expensive. The proposed reform purports to tackle both of these problems; in fact, it only addresses the first one in any systematic manner. The future cost savings that the Administration and its congressional allies are promising to deliver are based on wishful thinking and sleight of hand. Over time, the reform, as proposed, would almost certainly add substantially to the budget deficit, thereby worsening the long-term fiscal crisis that the country faces. Financing this measure alone wouldn’t break the U.S. Treasury. Other elements of the fiscal picture, such as the looming increases in interest payments on the national debt and an explosive growth in Medicare spending as the baby boomers retire—are far larger. But the numbers involved in health-care reform are still significant—perhaps one per cent of annual G.D.P.

Cassidy believes group coverage and third party payment are largely responsible for the escalation of medical costs.  I stated much the same in "Rationing Health Care."

The Pelosi bill, in particular, wouldn’t do much, if anything, to address the overall escalation in health-care costs, much of which is rooted in the nature of insurance, where individuals consume costly health services, and different people—the other members of their risk pool—pay for them. This is the “moral hazard” problem that the economist Kenneth Arrow identified as long ago as 1963. (For an easy-to-understand account of Arrow’s argument, see this riveting new book on market failure.) In the past twenty years, many ideas have been tried in the effort to restrict the growth of spending within a private insurance system, the most notable of which was the creation of H.M.O.s. Some have enjoyed temporary success. None have worked for long.

He also explains the political reasons that the attempts to pass a health care bill that is budget neutral will likely fail.  Oh how I wish that I would have used a Cadillac in my example rather than a BMW.  

According to the C.B.O., in summary, many more people will, with government assistance, buy private insurance coverage (some twenty-one million) and many others (about fifteen million) will become newly eligible for Medicaid, which is wholly financed by the taxpayer. Surely, this will cost considerable sums of money and add to the deficit. Or will it? The Democrat-controlled C.B.O. says that the Pelosi plan will actually reduce the deficit by a hundred and four billion dollars between 2010 and 2019, thereby satisfying President Obama’s claim that the reform will be deficit neutral. Furthermore, the C.B.O. suggests that the legislation’s impact on the deficit will continue to be negative in the following decade, from 2019 to 2029. I wish I could believe these figures, but I don’t.

Two large items underpin the Administration’s math: five hundred and seventy-two billion dollars of tax increases over ten years, and roughly the same amount of cost savings on Medicare and other existing government health programs. Most of the revenue increase would come from levying a 5.4 per cent surcharge on Americans individuals who earn more than five hundred thousand dollars a year and joint filers that earn more than a million dollars. I am a big supporter of progressive taxation, but at some point it becomes politically unsustainable. If health-care reform goes through, and the Bush tax cuts expire in 2011, top earners will face a marginal tax rate of forty-five per cent at the federal level. Add in state and local taxes, plus Social Security and Medicare payments, and wealthy people in New York, say, would be facing tax rates of about sixty per cent. As sure as night follows day, this would generate more tax evasion and a political backlash. Without a doubt, the next Republican-controlled Congress would reverse the changes.

If it decides to forgo soaking the rich, the Administration could return to its earlier proposal, which was included in a Senate Finance Committee bill that Senator Max Baucus put forward, to tax firms that provide their employees with costly “Cadillac” health-care plans. “A policy such as this is probably the number one item that health economists across the ideological spectrum believe is likely to stem the explosion of health-care costs,” Christine Romer, the chair of the White House Council of Economic Advisers, said in a recent speech. But this idea wouldn’t work politically, either. To raise enough revenue, the tax on swanky insurance plans would have to be set as high as forty per cent. When labor unions, some of whose members enjoy coverage in these plans, learned about this punitive levy they objected loudly, prompting Pelosi to drop the idea, which, broadly speaking, amounts to taxing the upper middle class to provide benefits for the lower middle class.

I particularly agree with the quote by Christine Romer.  If the goal is to increase the number of people insured, like Melissa Thomasson, I would prefer granting tax subsidies for private purchasers of health insurance rather than taxing employer provided plans. 

Cassidy concludes,

So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.

Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be virtually impossible to rescind. At some point in the future, the fiscal consequences of the reform will have to be dealt with in a more meaningful way, but by then the principle of (near) universal coverage will be well established. Even a twenty-first-century Ronald Reagan will have great difficult overturning it.

That takes me back to where I began. Both in terms of the political calculus of the Democratic Party, and in terms of making the United States a more equitable society, expanding health-care coverage now and worrying later about its long-term consequences is an eminently defensible strategy. Putting on my amateur historian’s cap, I might even claim that some subterfuge is historically necessary to get great reforms enacted. But as an economics reporter and commentator, I feel obliged to put on my green eyeshade and count the dollars.