What happened to the promises of Obamacare?

Megan McArdle points out in the Washington Post:

Obamacare’s supporters talked a lot about illnesses contributing to more than half of all bankruptcies, which implied there should have been a sharp decrease in 2014, when Obamacare’s major coverage provisions took effect. There wasn’t.

Obamacare’s supporters frequently cited America’s abysmal infant mortality rate, which implied that once Obamacare was in full swing, infant mortality should decrease sharply. It didn’t.

Obamacare’s supporters claimed that tens of thousands of people were dying every year because they didn’t have health insurance, which implied that by 2019, our overall mortality rate should be substantially lower than it had been in 2009, with a noticeable kink around 2014. Instead, mortality rates, which had been trending downward, leveled off around that time.

Obamacare’s supporters talked a lot about reducing health-care costs, or at least the rate at which they were growing. Sadly, no.

In 2011, Doug Elmendorf, head of the Congressional Budget Office, testified that by 2021, 24 million people would be buying their insurance on the Obamacare exchanges. … In reality, the most recent data suggest it’s half that. …

That’s not to say Obamacare did nothing; the percentage of Americans who are uninsured has fallen from 16.7 percent in 2009 to 9.2 percent in 2019. … But even its most zealous boosters should be willing to admit that the program the Supreme Court saved this week is far from the revolutionary transformation its architects envisioned.

My post-debate thoughts on the presidential race

I want to vote for a Democrat in the primary and general. I’ve never voted for a Republican for president, and I’ve voted in every presidential election since I voted for Gore in 2000, without regretting any of my general-election votes. (I went into more details in this Facebook post.)

The candidates who made the best impression on me in the two nights of the first Democratic debate were Senator Amy Klobuchar of Minnesota, and former Colorado Governor John Hickenlooper.

Those aren’t necessarily my favorite candidates; there are others I’ll seriously consider. I don’t know who I’ll support, and many candidates are sure to drop out before the New York primary, which could force me to adjust my preferences. But I have ruled out several candidates, including Bernie Sanders and Elizabeth Warren.

I want the Democrats to be ready to make a strong case in the general election that while they might be pretty liberal, they’re not socialists, and they understand the importance of pragmatism and compromise. Klobuchar and Hickenlooper have given the impression they’d be able to convey this to America.

Too many other candidates have not. An example is the candidates who’ve suggested they would abolish all private health insurance in America. That would move us further left than most developed countries. (Contrary to what’s sometimes said, few countries have single-payer health care; most countries with universal health care have a multiple-payer system involving government and private insurers. See this 2014 Washington Post article by Ezra Klein.) America is badly in need of sweeping reform to health insurance, but destroying every private health insurer in the country would seem radical and extreme to most Americans. Donald Trump couldn’t ask for a more generous gift.

Nominating one of the relatively moderate candidates is the way to win over swing voters in swing states, and make the Trump presidency rightly go down in history as a mistake that America corrected at the first available opportunity.

What does "Medicare for All" really mean?

"Medicare for All" really means "Repeal and Replace Medicare and Obamacare."

This Wall Street Journal piece from last month explains:

More than 100 House Democrats have endorsed Rep. Pramila Jayapal’s Medicare for All Act of 2019. Fourteen Democratic senators have co-sponsored a similar bill from Sen. Bernie Sanders.

The title is deeply misleading. It implies that the current Medicare system would be extended to all Americans. In fact, Medicare for All differs from Medicare in fundamental ways—with much broader coverage, no cost sharing, and fewer choices of health-care plans. . . .

Medicare for All would cover a panoply of dental, vision and mental-health services not covered by Medicare. Under the latest version of the House bill, the federal government would also pay for all long-term nursing and home care—estimated by the Urban Institute to cost roughly $3 trillion over the next decade.

The program would replace Medicare, Medicaid and the Children’s Health Insurance Program, as well as all employer-sponsored insurance and direct individual insurance (including the ObamaCare exchanges). It would cover not only uninsured American citizens but every U.S. resident. . . .

Despite this substantial expansion of coverage, Medicare for All would not require beneficiaries to contribute premiums, deductibles or copayments. By contrast, most parts of Medicare require some form of cost sharing by patients. . . .

Because of the broad coverage of services and patients without cost sharing, Medicare for All would entail dramatically higher federal spending on health care than Medicare and other programs. . . .

Finally, Medicare for All would eliminate the plan choices Medicare now allows. . . . Medicare for All would prohibit any insurer or employer from privately offering any services covered by this legislation—which means essentially all medical services.

Medicare for All allows even less in the way of plan choice than other single-payer systems. In the United Kingdom, patients may purchase private insurance for medical services even if they are available through the National Health Service. Canada does not cover dental, vision or long-term care, so two-thirds of Canadians purchase these services through private health insurance.

Health care in America: "bizarre loopholes kick in at the darkest moments"

The Atlantic has an important piece about the outrageous state of health care in America:

Medical debt is a uniquely American phenomenon, a burden that would be unfathomable in many other developed countries.

According to a survey published this month in the American Journal of Public Health, nearly 60 percent of people who have filed for bankruptcy said a medical expense “very much” or “somewhat” contributed to their bankruptcy. That was more than the percentage who cited home foreclosure or student loans. (The survey respondents could choose multiple factors that contributed to their bankruptcy.) . . .

A 2016 study found that a third of cancer survivors had gone into debt as a result of their medical expenses, and 3 percent had filed for bankruptcy. . . .

“It’s just life,” says Deborah Thorne, a sociologist at the University of Idaho who co-authored the latest bankruptcy study. “It’s not like they’ve done anything wrong.” . . .

In interviews, half a dozen consumer advocates told me they are concerned that the problem will get worse, since the uninsured rate is going up. . . .

Emergency-room visits and planned surgical procedures are the most common causes of large medical bills that patients simply can’t afford to pay, advocates told me. Often, a hospital might be covered by a person’s insurance network, but the individual doctors who work there and the ambulance company that services it aren’t, a situation that can lead to something called balance billing.

Sometimes, bizarre loopholes kick in at the darkest moments, like the fact that a baby would be covered upon birth under Medicaid or the Children’s Health Insurance Program, the government insurance program for children, but a stillbirth might not be covered. . . . (Indeed, one study found that average hospital costs for stillbirths are more than $750 higher than for live births.)

In some states, hospitals are required to provide charity care to certain low-income and uninsured patients, but several advocacy groups told me that these patients sometimes get regular bills instead. “We were seeing hospitals sending debtors to debt collections without saying anything to the debt collectors” about charity care, says Emilia Morris, the legal director of Central California Legal Services. “The debt collectors are trying to collect these debts without making charity care available. The patient sometimes gets sued, gets a judgment entered against them, without ever having heard of charity care.” . . .

[T]he current system requires people to independently negotiate on their own behalf with giant corporations over tens of thousands of dollars, often while recovering from a major illness. . . .

Read the whole thing here.

4 takes on Jonathan Gruber's remarks on Obamacare

Gruber, an MIT economics professor who's considered a key architect of Obamacare (and Romneycare), infamously said:

Lack of transparency is a huge political advantage. And basically call it the stupidity of the American voter, or whatever, but basically that was really, really critical in getting the thing to pass . . . . And I wish Mark was right, we could make it all transparent, but I'd rather have this law than not.

Howard Dean:

The problem is not that he said it. The problem is that he thinks it. The core problem with the damn law is it was put together by a bunch of elitists who don’t really, fundamentally understand the American people. That’s what the problem is.

(That's my own transcription of Dean; the quote at that link is incorrect.)

Ann Althouse (my mom):

MIT prof Jonathan Gruber is sorry he was transparent about the lack of transparency in getting Obamacare passed. . . . He wants his old lack of transparency back. He revealed what he liked so much about it. Now, why can't he have it back? Well, Professor Gruber, it just doesn't work that way. Once you've let us see that you mean to deceive us, we won't get fooled again . . . unless you're right, and we really are stupid.

Tyler Cowen:

It’s a healthy world where academics can speak their minds at conferences and the like without their words becoming political weapons in a bigger fight. . . . I’m simply not very interested in his proclamations on tape, which as far as I can tell are mostly correct albeit overly cynical. (If anything he is overrating the American voter — most people weren’t even paying close enough attention to be tricked.) Criticisms of Gruber are not criticisms of a policy, and it is policy we should focus upon and indeed there is still a great deal of health care policy we need to figure out. It’s hardly news that intellectuals who hold political power, even as advisors, very often do not speak the truth. If anything, I feel sorry for Gruber that he has subsequently felt the need to so overcompensate by actively voicing such ex post cynicism, it is perhaps the sign of a soul not at rest.

In the meantime, I’d like to see more open discourse, not less. Perhaps we should subsidize people who end up looking foolish, rather than taxing them.

Bryan Caplan responds to Tyler Cowen:

Tyler and I start at the same place yet end continents apart. We see the same facts: Lying politicians and the elite intellectuals who craftily decorate their masters' lies. But Tyler starts with a strong moral presumption that Whatever People in Our Society Routine[ly] Do is morally acceptable. Indeed, he bends over backwards to see the world from their point of view.

I, in contrast, start with a strong moral presumption in favor of scrupulous honesty. Unless you have strong reason to believe that lying will have awesome consequences, you shouldn't lie. Instead of bending over backwards to make excuses for liars, we should bend over backwards to tell the truth. The fact that most people fall short of this puritanical standard shows that most people ought to shape up and fly right.

And when people fleetingly realize that every society is ruled by liars, they are right to shudder.

The first debate of the 2012 general election

I'll be live-blogging it here tonight.

As always, any quotes I write down will be done without a transcript or pause/rewind button. So they might not be verbatim, but I'll try to be accurate.

For more live-blogging, check out Althouse (my mom), TalkingPointsMemo, and Democracy in America.

[Added later: Here's the transcript, and here's video of the whole debate:]



9:06 - President Obama criticizes the "top-down policies that got us into this mess." Is Obama trying to pitch himself as the candidate of bottom-up policies? That's hard to believe.

9:07 - Mitt Romney brushes off Obama's charges that he's going to take a top-down approach or "cut taxes for the rich."

9:08 - Romney says that Obama believes in something that doesn't work: "trickle-down government."

9:09 - Moderator Jim Lehrer asks Obama to expand on the idea of trickle-down government, and Obama responds by explaining his education policy of "race to the top." The debate has been very vertical so far.

9:10 - Obama makes the unpopular admission that the government needs to both reduce spending and increase revenues in order to control the deficit.

9:11 - Romney to Obama: "I'm not going to reduce the share of taxes paid by high-income people. High-income people are doing just fine."

9:12 - Romney describes the economic slump as an "economy tax" on the middle class.

9:14 - Romney makes the implausible promise to make "no tax cut that adds to the deficit."

9:16 - Obama says that even if you cut all deductions that benefit the wealthy, it wouldn't make up for the shortfall in revenue that would result from Romney's tax cuts for them. Is Obama assuming that all these enormous changes in the tax code would have no effect on behavior?

9:22 - Romney's explanation for how his math adds up is that he would cut taxes for small businesses, which would create jobs.

9:23 - Obama says that Romney is making "the same sales pitch [on taxes] that was made in 2001 and 2003." Obama equates his own approach with Bill Clinton's. So, "we've got some data on which approach is likely to create jobs for middle-class Americans."

9:24 - Romney goes on at unnecessary length about the debating rules: "He got the first answer, so I have the last word on this topic," etc.

9:26 - Romney: "The amount of debt we're adding, at a trillion dollars a year, is simply not moral."

9:27 - Romney promises that he'd go through all government programs, figure out which ones don't work, and stop funding them. This sounds uncannily similar to a promise Obama made in one of the 2008 general-election debates. (See my live-blog from October 7, 2008 — coincidentally, it's in the update from the exact same time, 9:27.)

9:31 - Obama attacks Romney for raising his hand in a primary debate when the Republican candidates were asked if they'd turn down an offer of a 10-to-1 ratio of spending cuts and tax increases.

(I stopped live-blogging here for about 20 minutes because the ABC News and YouTube feeds were too choppy. The C-SPAN feed works much better.)

9:52 - Romney says that Dodd-Frank is "the biggest kiss given to New York banks I've ever seen." He criticizes the "unintended consequences" of financial regulation, but says that some financial regulation is essential.

9:53 - Obama seems at a loss for words for an uncomfortably long time before he goes into his explanation of the causes of the financial crash.

9:54 - Obama: If you think the problem is that we had too much regulation of Wall Street, then Romney is your candidate. Romney rejects this: "It's not that Dodd-Frank was always wrong with too much regulation. Sometimes it doesn't give clear regulation."

9:56 - Romney is asked why he wants to repeal Obama's health-care law. He cites the Congressional Budget Office saying that Obamacare will make health insurance cost $2,500 more per person. Also, "it puts in place an unelected board that will tell people, ultimately, what kinds of treatments they can have." He wants you to think "death panels" without him having to say it.

9:59 - Obama says that Obamacare will definitely let you keep your health insurance. (This calls for a fact-check!) It will just mean that health-insurance companies "can't jerk you around." He admits that "Governor Romney did a good thing" by enacting Romneycare.

10:02 - Romney says that Romneycare is different from Obamacare because the latter will cause people to lose their health insurance. He also reels off a dizzying array of other distinctions, which I doubt many viewers will be following.

10:03 - Obama mocks Romney's references to the "unelected board." Obama characterizes this as making "smart choices" and using "best practices"; the alternative is "to let businesses decide how long they can afford to keep paying premiums until they just give up."

10:05 - Obama says Romney is right that health-care premiums have been going up for the past 2 years — but they've been going up more slowly than in the past 50 years.

10:06 - What would Romney enact in place of Obamacare? He won't describe the whole thing, because the description would be too long. But his plan would include a rule against barring people with pre-existing conditions. And he'd let young people stay on their parents' plans, though he adds that this could happen purely through the free market.

10:10 - Obama says that Romney "says he's going to replace Obamacare" (yes, he did call it "Obamacare"), but he won't say what he's going to replace it with. "Is the reason he's keeping his policies secret, because they're too good?"

10:11 - Romney responds that he's holding back from giving more specifics because he's doing what Ronald Reagan did: laying out "principles" such as creating incentives for economic growth, broadening the tax base, and cutting taxes. Oddly, he adds a compliment to Obama for sharing some of Reagan's economic principles.

10:14 - Obama: "The genius of America is free enterprise." However, there are "things we do better together." He then segues back to his education policy: "Government can help. It can't do it all."

10:16 - Romney responds to Obama: "I reject the idea that I don't believe in great teachers or more teachers. Every state can make that decision on its own."

10:16 - Romney quotes various phrases from the Declaration of Independence, including "the pursuit of happiness." He seems to say that this means that the government has a responsibility to provide for those who are unable to provide for themselves.

10:18 - Romney says that federal funding should "follow the child" — that is, let the child and their parents decide where to go to school.

10:20 - Obama says that Romney hasn't been clear about his education proposals, but he would cut the education budget by 20%.

10:22 - Romney to Obama: "As president, you're entitled to your own house and your own airplane, but not your own facts. I'm not going to cut education funding."

10:24 - Lehrer says they're short on time for the remaining issues, but he's not going to claim he's done a good job of moderating. Obama: "Jim, you've done a great job!" Lehrer: "Oh, well, no . . ."

10:26 - Romney lists various things he's going to do on "day 1" as president. Obama points out that Romney is going to have "a busy first day," since he's also promised to repeal Obamacare on day 1.

10:30 - Obama: "Four years ago, I said I wasn't a perfect man and I wouldn't be a perfect president, and that's a promise Governor Romney probably thinks I've kept."

That's all. Check in here again for the vice-presidential debate next week.

UPDATE: About an hour into the debate, Josh Marshall of TalkingPointsMemo, who of course is favorable to Obama, said:

My read so far is that if you go by energy and tossing out lots of data points, then Romney is running circles around the president. Obama has only on a few occasions really pressed a point hard. Whether that means he’s ‘winning’ I don’t know. But energy level, Romney all the way. But I think there are a lot of traps that Obama’s put out there for Romney. Romney really pressed his insistence that he just isn’t going to do what he says his plan is going to do. I think those statements – and the statement about vouchers – might be unpacked badly for him over the next few days.

The 7 bloggers at the Economist's blog Democracy in America seem to be unanimous in saying that Romney won. "W.W." (Will Wilkinson) says:

Romney won decisively. Obama clearly approached the debate with a mainly defensive strategy, hoping to come away without having done anything to rock his very comfortable boat. But the boat did rock. Obama was flummoxed by Romney's superior preparation, intensity, and execution, and tonight's truly dismal performance from the president has put the sustainability of his lead in question, if not actually in peril.

Another blogger at the Economist, "T.N.," says:

Obama seemed to sleepwalk through much of the debate - and the fact that so many potential attack lines were not exploited suggests that . . . this might be a deliberate tactic - to bore his way to victory over the next month.

Andrew Sullivan says:

Look: you know how much I love the guy, and you know how much of a high information viewer I am, and I can see the logic of some of Obama's meandering, weak, professorial arguments. But this was a disaster for the president for the key people he needs to reach, and his effete, wonkish lectures may have jolted a lot of independents into giving Romney a second look.

Obama looked tired, even bored; he kept looking down; he had no crisp statements of passion or argument; he wasn't there. He was entirely defensive, which may have been the strategy. But it was the wrong strategy. At the wrong moment.

The person with authority on that stage was Romney - offered it by one of the lamest moderators ever, and seized with relish. This was Romney the salesman. And my gut tells me he sold a few voters on a change tonight. It's beyond depressing. But it's true.

There are two more debates left. I have experienced many times the feeling that Obama just isn't in it, that he's on the ropes and not fighting back, and then he pulls it out. He got a little better over time tonight. But he pulled every punch. Maybe the next two will undo some of the damage. But I have to say I think it was extensive.

Does Obamacare let everyone keep their health insurance plan?

A friend of mine posted this on Facebook:

Got a long letter from my health insurance saying the Affordable Care Act is causing my health benefits to be significantly reduced and my premiums to increase. I'm sure I'm not the only one.

Dear Obama, that's fine, but don't call it the Affordable Care Act.

Here's Politifact on President Obama's claim that "[i]f you're one of the more than 250 million Americans who already have health insurance, you will keep your health insurance. This law will only make it more secure and more affordable." Politifact says:

[A] March 2012 study by the Congressional Budget Office, the nonpartisan number-crunching arm of Congress, projected that 3 million to 5 million fewer non-elderly people would obtain coverage through their employer each year from 2019 through 2022 than would have been the case before the law was passed. Including those with individually purchased policies enlarges that decline by an additional 1 million to 3 million Americans.

CBO’s estimate is broadly in line with a number of other independent estimates. . . .

In reality, Americans are not simply able to keep their insurance through thick and thin. Even before the law has taken effect, the rate of forced plan-switching among policyholders every year is substantial, and the CBO figures suggest that the law could increase that rate, at least modestly, even if Americans on balance benefit from the law’s provisions.

Politifact concludes: "We rate Obama’s claim Half True." That seems pretty generous.

Thomas Sowell on the need to end Medicare as we know it

Sowell writes:

There are people who take seriously such statements as those by President Barack Obama that Republicans want to "end Medicare as we know it."

Let's stop and think, if only for the novelty of it. If you make any change in anything, you are ending it "as we know it." Does that mean that everything in the status quo should be considered to be set in concrete forever?

If there were not a single Republican, or none who got elected to any office, arithmetic would still end "Medicare as we know it," for the simple reason that the money in the till is not enough to keep paying for it. The same is true of Social Security. . . .

We are not yet Greece, but we are not exempt from the same rules of arithmetic that eventually caught up with Greece. We just have a little more time. The only question is whether we will use that time to make politically difficult changes or whether we will just kick the can down the road, and keep pretending that "Medicare as we know it" would continue on indefinitely, if it were not for people who just want to be mean to the elderly.

In both Europe and America, there are many people who get angry at those who tell them the truth that the money is just not there to sustain huge welfare state programs indefinitely. But that anger might be better directed at those who lied to them by promising them benefits that were inherently unsustainable.

President Obama and Paul Ryan are almost the same on Medicare.

Explains Matthew Yglesias:

Medicare is . . . an open-ended promise to pay the bills for most of the health care services consumed by the elderly. It’s almost as if the government had a program that just gave senior citizens free shoes in unlimited quantities. The main difference is that undergoing medical treatment is generally unpleasant and it has no real resale value, so in practice people only want to consume so much of it. . . .

Both Ryan and Obama want to put an end to this and give Medicare a finite growth target. And, indeed, they’ve both converged on the same target. Ryan put out two budget plans based on very stingy Medicare proposals: The most recent version of his idea caps Medicare growth at the underlying GDP growth rate plus 0.5 percentage points. Obama, in his remarkably little noticed Fiscal Year 2013 budget proposal, offers the very same target on Page 33. Both campaigns, in other words, propose putting Medicare on a fixed diet and they agree on the precise diet.

Where they disagree is on how to implement the cuts. Ryan’s proposal is to turn Medicare into a voucher program where seniors would get a subsidy with which to buy an insurance package, with the value of the subsidy limited by the overall growth target. Obama’s proposal is to hit the growth target the way foreign single-payer systems limit their costs, with more aggressive bureaucratic management of what Medicare is willing to pay for and how much it’s willing to pay.

The difference between outsourcing (Ryan) and centralized rationing (Obama) is an important one, but from a patient’s point of view they might end up looking pretty similar. Under Ryan’s approach, the poor will be left with bare-bones plans and more affluent seniors will either pay higher premiums to get more deluxe plans or else pay out-of-pocket for noncovered services. Under Obama’s approach, the poor will be left with bare-bones Medicare and more affluent seniors will either buy separate supplemental insurance plans or else pay out-of-pocket for noncovered services. The workability of Obama’s idea, in my view, is well-validated by international experience while the Romney/Ryan alternative amounts to taking a leap of faith in the magic of the private sector. But ironically it’s essentially the same leap of faith Obama is taking in his signature health care program for nonseniors—the view that an adequately regulated, subsidized system of private insurance plans can provide reasonable coverage at reasonable cost.

Medicare and reality

An article in Reason magazine defends Paul Ryan's Medicare plan:

At the rate we're going, Medicare, Medicaid, Social Security, and interest payments will consume the entire federal budget by 2025—leaving nothing for defense, law enforcement, national parks, highways, food stamps and all the other responsibilities the government is supposed to handle. Either drastic spending cuts or staggering tax increases would be needed.

To insist that Medicare can and should remain just as it is today is either delusional or dishonest . . . .

It's easy to improve health care if cost is no object. It's easy to reduce costs if you can tolerate worse health outcomes. The trick is to balance the two needs. The Ryan plan is a credible attempt. . . .

Democrats have a point in saying what Ryan offers is not as good as the current version of Medicare. It's also not as good as the Big Rock Candy Mountain, the pot of gold at the end of the rainbow or the valley of Shangri-La.

His option does, however, have the virtue of a connection to the real world. It's a place his critics can't avoid forever.

Yes, President Obama did cut Medicare ...

. . . not just for health-care providers, but for senior citizens too.

UPDATE: Matthew Yglesias agrees:

Reducing Medicare's generosity to health care providers is an idea I'm happy to get behind, but there's a reason Medicaid is not considered a particularly high-quality health insurance program and its low reimbursement rates are a key part of it—lots of doctors refuse to accept Medicaid patients. Already Medicare is stingier than private plans, and in large high-income metro areas the most-in-demand doctors often decline to see Medicare payments. Any change at the margin to make it less lucrative for doctors will increase the number of providers who try to shun Medicare payments.

All things considered, I'm fine with that. . . . But if your top priority in life is to make senior citizens' health care as excellent as possible at any price, then Obama's savings are in fact contrary to that goal.

A question about Obamacare

Won't the health-care law encourage people not to have health insurance? You pay a tax that's less than what health insurance would have cost. Wait till you're seriously ill to buy it, and you'll be entitled to get it. In the past, people were more incentivized to get health insurance even if they were healthy, so they wouldn't run into the pre-existing condition problem.

Who's the loser after today's health-care ruling?

I don't know if today's decision upholding President Obama's health-care law was better for Obama or Mitt Romney. But there is a clear loser: almost every pundit in America.

Everyone who said the law should, or would, be held constitutional under the Commerce Clause was wrong. Everyone who said the law should, or would, be held unconstitutional under the Commerce Clause was also wrong. Almost no one got it right.

Ann Althouse (my mom) lists 3 ways that Obama is the real loser:

Romney has at least 3 big arguments:

1. Obama imposed a huge new tax on working people.

2. Obama deceived the American people by saying it was not a tax, when it was.

3. The law made it look like money would go to insurance companies — in the form of new premiums — that would keep premiums low as the companies were required to take on people with pre-existing conditions, but now we find out that the money is really going to go to the federal government.

Justice Scalia gets the law of supply and demand wrong at oral argument

And Matthew Yglesias thinks Scalia's error could actually make the case that the Affordable Care Act is constitutional.

Newt Gingrich supported an individual mandate to buy health insurance as late as 2005.

TalkingPointsMemo reports:

Newt Gingrich has attacked Mitt Romney on the issue of the individual health insurance mandate, while chalking up his own past support for the idea as an indiscretion in the 1990’s. But as it turns out, those 1990’s stretch all the way to 2005 — and beyond, to 2008 — when Gingrich gave as passionate an explanation of the mandate idea as any current supporter could ever muster. . . .

At a forum in 2005, alongside then-Sen. Hillary Clinton (D-NY) and former Sen. John Breaux (D-LA), Gingrich explained the tradeoffs that both the right and the left would have to make in health care: For the right, some transfer of wealth is involved in providing health care for the working poor, the disabled, and other groups. And for the left, individuals should still have control over their health care, rather than total government management.

“I mean, I am very opposed to a single-payer system — but I’m actually in favor of a 300 million-payer system. Because one of my conclusions in the last six years, and founding the Center for Health Transformation, and looking at the whole system is, unless you have a hundred percent coverage, you can’t have the right preventive care, and you can’t have a rational system, because the cost-shifts are so irrational, and create second-order problems.”

This led Gingrich to a few conclusions of how to implement such a system: Convert Medicaid into a health insurance voucher system as it applies to the working poor (on the rationale that the creation of food-stamps do not involve the government running its own grocery stores); Create very large risk pools for individuals to purchase insurance (i.e., exchanges); and minimize insurance companies from cherry-picking customers.

I'm interested not just in the fact that Gingrich took these positions, but in the way he argued for them. Even while supporting a supposedly liberal policy, he used self-consciously tough language:

But my point to conservatives is, it’s a model of responsibility. If I see somebody who’s earning over $50,000 a year, who has made the calculated decision not to buy health insurance, I’m looking at somebody who is absolutely as irresponsible as anybody who was ever on welfare. Because what they’ve said is, a) I’m gambling that I won’t get sick, and b) I’m gambling that if I do get sick, I can cheat all my neighbors.

Now when you talk to hospitals, a very significant part of their non-collectables are people who have money, but have calculated that it’s not worth the cost to collect it.

And so I’m actually in favor of finding a way to say, if you’re above whatever — whatever the appropriate income level is, you oughtta have either health insurance, or you oughtta post a bond. But we have no right, we have no right in this society, to have a free-rider approach if you’re well off economically, to say we’ll cheat our neighbors.

You can see him make those remarks starting around 3:45 in this video. He starts out by admitting it might sound "un-conservative," but arguing that it's analogous to welfare reform:



Gingrich's argument is a good example of what I see as the fundamental divide in how liberals and conservatives think of themselves, or at least how they hold themselves out to the public. Liberals present themselves as caring. Conservatives present themselves as tough. I don't know of any other unifying theory that explains why conservatives/Republicans disagree with liberals/Democrats on so many disparate issues — economic, social, foreign policy.

Since Gingrich is committed to his image as a conservative, even if he takes a seemingly liberal or moderate position on health care, he isn't going to frame it as being concerned for those who lack health insurance. It's about cracking down on people who abuse the system. That's how conservatives like to talk, so I'm sure at the time he thought he was making a brilliant point that was consistent with conservatism. But for conservative Republican primary voters who are driven by opposition to Obama's health-care reform, I'm not seeing any reason to choose Gingrich over Romney.

UPDATE: Politico has a similar article:

If Republicans are flocking to Newt Gingrich to get away from Mitt Romney’s health care problems, they could end up with a nominee with … awfully similar health care problems.

Or maybe worse: While Romney signed a state mandate into law, Gingrich once went a step further and advocated a federal one.

Policy uncertainty and jobs

"Policy uncertainty" has dramatically increased since the September 2008 crash. (via)

That article (written by 3 economists at Stanford and University of Chicago) notes that it's hard to disentangle uncertainty about policy (tax rates, health-care law, regulations) from uncertainty about the economy as a whole. But the authors tried to isolate policy uncertainty as a distinct factor inhibiting businesses from hiring people.

They "estimate that restoring 2006 levels of policy uncertainty would yield an additional 2.5 million jobs over 18 months."

UPDATE: My mom, Ann Althouse, remarks: "And yet the government is always scrambling to help us out with new policies." She quotes President Obama from today:

“If Congress does nothing, then it’s not a matter of me running against them. I think the American people will run them out of town. I would love nothing more than to see Congress act so aggressively that I can’t campaign against them as a do-nothing Congress.”

She urges us to "[r]econsider the amazing value of nothing."

America's tax rates would be similar to Europe's if health-care costs counted as taxes.

Bruce Bartlett explains:

When Americans see these data they are usually incredulous that Europeans submit to such seemingly oppressive tax levels. Conservatives, in particular, tend to view freedom as a fixed sum: the bigger government is as a share of G.D.P., the less freedom there is for the people (if government consumes, say, 40 percent of G.D.P., then people are only 60 percent free).

The late Milton Friedman popularized this idea, but even he thought that freedom would not be seriously threatened in Western democracies until government spending reached 60 percent of G.D.P. We are far away from that “tipping point,” as he called it; in 2010, total federal, state and local government spending amounted to 36 percent of G.D.P.

American conservatives tend to ignore the composition of spending; to them, just about all spending is equally bad. . . .

Average American workers must pay for health care out of their pockets, or through their employers in the form of lower wages. Europeans prefer to pay higher taxes and get government health care for every resident in return.

Conservatives universally believe that whenever the government provides a service it will be vastly more costly than if the private sector does so. This is why they support the plan offered by Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee, to essentially privatize Medicare. Conservatives believe competition will drive down health costs for the elderly.

But O.E.C.D. data show that Americans pay vastly more for health care than the residents of any other major country. . . .

[I]f we had a health care system like those in most developed countries, we could, in effect, give every American an increase in their disposable income of 8 percent of G.D.P. – about what they pay in federal income taxes – and have health care no worse than they have in Britain or Japan. It would be like abolishing the federal income tax in terms of allowing people to spend more of their income on something other than health care.

Because most people have little more choice about medical spending than they do about the taxes they pay, one can think of the two as being similar in nature. . . .

Looking at taxes alone, the burden in the United States is 25 percent below the O.E.C.D. average, but including the additional health costs Americans pay, the United States is just 4.7 percent below average.

Does Mitt Romney have a good chance at being the Republican presidential nominee?

An ongoing discussion between two New Republic writers. One of them, Jonathan Cohn, thinks Romney has a good chance, while the other, Jonathan Chait, thinks he's doomed by the health-care issue.

One factor I don't see either of them bring up: the conventional wisdom is that Republicans prefer a candidate who's run for president in the past. (I suppose Republicans would say they like to see someone diligent and battle-tested, who's paid their dues — and Democrats would say Republicans are uncomfortable with newness and youth.)

Of course, this isn't an ironclad rule. George W. Bush's nomination in 2000 might seem to be a counterexample since he hadn't run before. But the main other strong candidate, John McCain, hadn't run before either, so this wasn't a factor as between those two. OK, Pat Buchanan had run in the past, but he never had a chance. The general rule isn't a silver bullet that renders all other factors irrelevant.

John McCain's nomination in 2008, on the other hand, is a clear example of the general rule. None of the other plausible candidates (Romney, Mike Huckabee, Rudy Giuliani, Fred Thompson) had run for president before.

You might think 2012 doesn't even offer an opportunity to test the theory, if you think Romney's record on health care makes him an implausible candidate off the bat (along with his flipflop on abortion, his general reputation as a flipflopper, and the fact that he was governor of a state that Republicans view as ultra-liberal). If health care is truly a deal-killer for most Republicans, then it doesn't matter if Romney's record as a candidate in 2008 is an advantage; he has no chance anyway.

Well, I'm not convinced. Everyone knows health care is a major obstacle for Romney. But every presidential candidate faces obstacles. You generally can't completely rule out someone who would otherwise be a formidable candidate based on a single issue. McCain got the nomination despite a very long list of issues on which he had flipflopped and/or taken liberal positions. He was on record attacking the Bush tax cuts on first principles, saying they were unfairly tilted toward the rich. Sure, he later tried to characterize his past position as narrowly as possible (by saying he objected to the tax cuts only if there continued to be excessive spending), but this was as disingenuous as Romney's attempt to distinguish health care as a national issue from the decision he made at the state level: it's hard to imagine any voters actually basing their vote on such transparently post hoc line-drawing. McCain simply took the hit on taxes and other issues, but he ended up getting enough votes to be the nominee. And aren't tax cuts at least as defining an issue for Republicans as health care?

What Medicare services should be cut?

The New York Times' Room for Debate gives some suggestions.

The devastating sentence Mitt Romney deleted from the paperback edition of his book

Romney, referring to the results of his health care reform in Massachusetts, wrote:

“We can accomplish the same thing for everyone in the country.”

Again, that sentence appeared in the hardcover edition (early 2010) but was absent from the paperback edition of his campaign book. The book's title: No Apology.