The Medicare Debate, Part II

It barely made a blip on the news, so you may not have heard that the U.S. credit rating was just downgraded again for the fourth time in the past fourteen months. Downgrades are dangerous because they signal to other countries that the U.S. is now a riskier place to invest in, and this raises our cost of borrowing money. But the bigger problem for Americans is the reason for the downgrades: our government is less likely to pay its debts, and is therefore less likely to honor its commitments to people who are counting on government assistance in their senior years.

One of our biggest obligations is Medicare. It's the third-most expensive federal program ($560 billion spent in 2011, or about $3000 per working-age adult¹), and due to the wave of retiring baby boomers its cost is expected to nearly double within a generation.² Our current path is unsustainable — and will result in millions of people shelling out more for their medical care than they've been planning on.

So what do we do about it? The status quo approach is to cut costs by reducing pay for doctors who treat Medicare patients...but this would also reduce the quality of care (see my last post). VP candidate Paul Ryan has an alternative plan, one that's been both attacked and championed by people who probably don't really understand it. (I know — I was one of them.) But now that I've read his plan, here's what you need to know:

Nothing changes for anyone currently 55 or older.

For everyone else, when you become eligible for Medicare you will choose your own health insurance plan. You can choose the traditional fee-for-service option (the way it is now, where government reimburses doctors directly), or you can select from among a variety of private insurance plans within the new Medicare Exchange.

Every year, each insurer in the Exchange will declare the price that they must be paid in premiums in order for them to cover enrollees' medical costs. Medicare then pays for all or some of your premiums depending on your income and the price of your plan.

The "benchmark" that determines how much Medicare pays for is the price of the baseline plan, which is either traditional fee-for-service or the second-cheapest private plan, whichever is cheaper. But what's not clear is what "benchmark" means — that is, if you choose the baseline plan, are your premiums fully covered or not? What is clear is that of the people who select the baseline plan, Medicaid-eligible seniors will have no out-of-pocket expenses, other low-income seniors will receive additional assistance, and high-income seniors will have to pay a share of their premiums.

If you choose a plan that's more expensive than the baseline, you'll have to cover the difference. Choose a plan cheaper than the baseline and you'll receive a rebate for the difference.

Each insurer in the Exchange must abide by two ground rules. First, they have to cover at least the actuarial equivalent of the fee-for-service benefits package. This means that while each plan will provide different coverage, every plan's coverage will be at least as valuable as traditional Medicare and you'll know upfront what's included in your plan. Second, they have to accept all applicants regardless of any high-risk/pre-existing conditions. Medicare will support this provision by paying for the increase in premiums that's necessary for high-risk individuals and by regularly transferring money from plans with more low-risk seniors to plans with more high-risk seniors.

The vision here is to have companies compete for customers by thinking of creative and efficient ways to cover medical expenses for less than it costs Medicare to do so today. If this plan fails and the anticipated cost reductions don't pan out, there's a provision to cap Medicare expenditure growth at nominal GDP growth plus 0.5 percent. This means that if insurance prices rise faster than that upper growth rate, some seniors (Medicaid-eligibles excluded) would have to cover the spillover costs. Whatever the merits, this is a more truthful way of dealing with ballooning costs than trying in vain to hide the problem from seniors by paying doctors less.

No plan will magically wipe away the underlying problem of having an increasingly strapped government provide for an aging population...but applying the tried-and-true principles of competition and personal choice/responsibility is a step in the right direction.

1. There were 183.9 million U.S. adults ages 20-64 in 2009.
2. Peter G. Peterson Foundation. "Budget Explainer: Medicare."

The Medicare Debate, Part I

Turn on your TV and I bet you'll hear one of the Presidential candidates claim that if we elect the other guy, Medicare patients are bound to suffer. You'll hear Romney allege that Obama took $700 billion out of Medicare to pay for Obamacare.

It's true: Obamacare comes with a $716 billion reduction in government's Medicare expenditures over the next 10 years. The majority of these cuts will reduce how much doctors and insurance companies will be reimbursed for the care that they provide/fund.

But there's a perception out there that since these cuts are made to providers, they won't affect patients. A recent Reuters article "Top Six Myths about Medicare" says that the cuts to providers are "mostly meaningless to patients." In National Journal's "10 Things You Need To Know About The Medicare Debate", Thing #1 reads: "President Obama's cuts to Medicare do not affect any benefits." And a Washington Post analysis says "there's one area these cuts don't touch: Medicare benefits."

One of the most important medical benefits people have is the ability to be seen by a doctor when in need. Arbitrarily cutting pay for doctors could certainly impact this benefit.

If a doctor's pay per patient is reduced, he'd need to cram in more patients per day in order to earn as much as before. This trend would leave fewer available doctors for people with urgent medical needs. Some doctors would look to avoid Medicare patients altogether. A 2010 American Medical Association survey of doctors attests to this.

The broader issue here is the unwillingness of some to consider or even acknowledge the existence of unintended consequences of government intervention. And if we can disagree about the effects of this one small aspect of Obamacare, imagine what other unforeseen consequences lie within its 2,700 pages.

In my next post I'll analyze Paul Ryan's proposal for Medicare. I skimmed it the other day and it's more complicated than either side would have you believe.

Making Money

The piercing tone from his clock radio is his signal to stumble out of bed, collect himself, and get ready to face another day at work. Shower, breakfast, coffee, commute. He plans the day ahead, then spends it working hard — making tradeoffs, meeting deadlines, and trying to find some value in those unavoidable meetings. He closes up shop and drives home, eager to finally spend some time with the people who mean the most to him. And at the end of it all he lands in bed, ready or not to hit repeat.

The more money he makes during his days — and the more he’s made throughout his life — the more likely he is to hear politicians clamor for him to pay his fair share back to society. Senate hopeful Elizabeth Warren recently sounded off about the need for the most successful businessmen to pay their fair share in taxes, declaring, “You built a factory and turned it into something terrific, or a great idea? God bless, keep a big hunk of it. But part of the underlying social contract is you take a hunk of that and pay forward for the next kid who comes along.”

Putting aside the fact that high earners already do pay a large share of their earnings in taxes, Warren’s point and those like it overlook the reality that a person making money is in itself a benefit to society.

The vast majority of people who make money do so only because they’ve delivered goods or services of comparable value. Both parties — employer and employee — benefit from the exchange, and each side’s gain ultimately extends to society at large. An employee’s ability to meet his employer’s needs leaves the employer free to focus on growing the business in order to tackle the needs of potential new customers. This dynamic helps those folks whose needs will now be met as well as those who will be hired to fill new positions in the growing business. In addition, the wealth amassed over the course of a person’s career won’t just be spent on yachts and palaces but also invested back into the economy, spurring the growth of existing businesses and the creation of new ones. As John F. Kennedy famously put it, “a rising tide lifts all boats.”

The wealthiest among us are in this way already contributing the most to society, and those contributions have little to do with taxes.

During a 2010 financial reform event in Illinois, President Obama said, “I do think at a certain point you’ve made enough money.”

I say you can’t get enough of a good thing.

Boehner's Flaw

In discussing his latest debt ceiling plans, House Speaker John Boehner said yesterday, "Remember one of the principles here: we are not going to increase the debt limit by anything more than what we're willing to cut spending." Specifically he's proposing to raise the debt ceiling by $1 trillion ($1T) and to reduce future spending by around $1T. The concept sounds reassuring at first, but in practice it wouldn't come close to solving the problem we face.

The debt ceiling exists to limit the amount of debt we can carry. Our debt grows when our federal government spends more than it receives in taxes and has to borrow money to cover the difference. For each of the past 3 years the government has spent about $1.5T that it didn't have, and our debt grew by that much each year.

Boehner's proposal is to raise the debt ceiling by $1T and to cut spending by $1T over the next 10 years. That would mean cutting spending by only $0.1T each year, which would reduce next year's deficit from $1.5T to $1.4T. Well if we only raised the ceiling by $1T, those cuts wouldn't even get us through 1 year without us hitting the ceiling again, at which point Congress could just apply Boehner's principle again...and then again, and again, essentially just paving the way for more astronomical deficits.

The real flaw here is in comparing the amount of spending cuts to the amount we raise the debt ceiling. The right thing to do is to compare the amount of spending cuts to our projected deficits. If we're about to annually spend $1.5T we don't have, we need to cut $1.5T in spending per year! Accomplish that, and there would be no need to raise the debt ceiling.

Creating Wealth

There is a widespread notion that there’s only a fixed amount of wealth in the world — that one can only gain wealth at the expense of others. This belief goes hand in hand with a variety of common viewpoints: the conviction that one man’s fortune is unfair to the rest of us; the guilt many Americans feel on account of our relative wealth in the world; and the fear that immigrants who send money back home have reduced our overall wealth. But what exactly is wealth? And if the fixed-wealth view is wrong, how is wealth created?

Wealth is anything that helps a person or group meet their needs and desires. People use wealth to meet needs on their own (e.g., a house is a form of wealth that provides shelter) and by interacting with others who are in a position to help (e.g., money is wealth that can be used to buy food from a vendor). To better understand the nature of wealth, let’s consider whether a simple transaction between two people adds wealth to their community, and whether wealth has been taken from others in the process.

Let’s say that Grace needs a jacket and pays James $50 to make one for her. For simplicity we’ll assume that James already has the materials and machinery necessary for the job.

After the exchange, the community has gained one jacket at the expense of the materials required to make it. Since the jacket is able to meet needs such as warmth and comfort that the raw materials alone could not, wealth has been added to the community.

In addition, James has likely learned something by making the jacket. Perhaps he’s discovered a way to speed up the process or to improve the quality of his product. James is now better able to meet the needs of others; his newfound knowledge is a form of wealth added to the community.

The 50 dollars themselves still exist, but are they worth as much as they were before? Do transactions like this reduce the value of currency or raise it? Well an increase in the supply of a product tends to reduce its price because the additional competition among suppliers forces them to slash prices to compete for customers. And lower prices mean more bang for the buck. So this transaction is representative of the type of production that increases the value of currency, which adds wealth to communities throughout the world.

On the other hand, the machinery used to make the jacket has undergone wear and tear that will eventually take it out of service, leaving it unable to meet needs any longer. Over time, different forms of wealth are inevitably lost: products age and lose their value, and people leave the work force taking their expertise with them. But if beneficial transactions happen efficiently and often enough, overall wealth creation will outpace these natural losses.

In the end, Grace and James have added wealth to their community without taking it from anyone! Wealth has been created.

Sadly, the fixed-wealth misconception is self-fulfilling: antipathy toward achievers leads to tax-raising schemes that stifle people’s ability and incentive to create wealth. In this time of need, we should allow and encourage talented and motivated people to do what they do best.

Economics vs. Politics

In Applied Economics: Thinking Beyond Stage One, Thomas Sowell illustrates the major difference between economic and political mindsets:

"Politics offers attractive solutions, but economics can offer only tradeoffs. For example, when laws are proposed to restrict the height of apartment buildings in a community, politics presents the issue in terms of whether we prefer tall buildings or buildings of more modest height in our town; economics asks what you are prepared to trade off in order to keep the height of buildings below some specified level. In places where land costs can equal or exceed the cost of the apartment buildings themselves, the difference between allowing ten-story buildings to be built and allowing a maximum of five stories may be that rents will be much higher in the shorter buildings, because land costs are now twice as high per apartment.

"Nor are money costs the only costs. With twice as many shorter buildings now required to house the same number of people, the community must spread outward since it cannot spread upward, and that means more commuting and more highway fatalities. The question then is not simply whether you prefer shorter buildings, but how much do you prefer shorter buildings, and what price are you prepared to pay to mandate height restrictions in your community. A doubling of rents and three additional highway fatalities per year? A tripling of rents and ten additional highway fatalities per year? Economics cannot answer such questions — it can only make you aware of a need to ask them.

"Economics was christened 'the dismal science' because it dealt with inescapable constraints and painful tradeoffs instead of more pleasant, unbounded visions and their accompanying inspiring rhetoric, which many find so attractive in politics and in the media. Moreover, economics follows the unfolding consequences of decisions over time, not just what happens in stage one, which may indeed seem to fulfill the hopes that inspired these decisions. Nowhere are the consequences more long-lasting than in housing, where a community can have an aging and shrinking supply of apartment buildings with accompanying housing shortages for decades, or even generations, after passing rent control laws which have a track record of leading to such consequences in countries around the world.

"The passage of time insulates many political decisions from public awareness of their real consequences. Only a small fraction of New Yorkers today are old enough to remember what the housing situation was there before rent control laws were introduced during World War II. Only a dwindling number of Californians are old enough to remember when that state's housing prices were very much like housing prices in the rest of the country, instead of being some multiple of what people pay elsewhere for a home or an apartment. These and other consequences of particular political decisions in the past are today just facts of life that new generations have grown up with as something as natural as the weather or other circumstances of their existence which are beyond their control.

"The vast numbers of frustrated California motorists who endure long commutes to and from work on congested highways are unlikely to see any connection between their daily frustrations and attractive-sounding policies about 'open space' or 'farmland preservation.' Nor are economists who point out that connection likely to be as popular with them as politicians, who are ready to offer solutions to rescue these motorists from their current problems using the same kind of one-stage thinking that created those problems in the first place."¹

1. Thomas Sowell. Applied Economics: Thinking Beyond Stage One.

Heeding Hazlitt

David Axelrod, Senior Advisor to President Obama, recently advocated the Stimulus Bill (the American Recovery and Reinvestment Act of 2009):

"This summer will be the most active Recovery Act season yet, with thousands of highly-visible road, bridge, water and other infrastructure projects breaking ground across the country, giving the American people a first-hand look at the Recovery Act in their own backyards and making it crystal clear what the cost would have been of doing nothing...The Recovery Act is putting millions of Americans to work and helping the economy grow again."

Axelrod is correct in saying that the bill's spending provides employment and improves infrastructure. However, further analysis calls into question whether such spending actually helps the economy grow.

Distinguished economist Henry Hazlitt provides such analysis in his compelling book, Economics in One Lesson:¹

"A certain amount of public spending is necessary to perform essential government functions. A certain amount of public works—of streets and roads and bridges and tunnels, of armories and navy yards, of buildings to house legislatures, police and fire departments—is necessary to supply essential public services. With such public works, necessary for their own sake, and defended on that ground alone, I am not here concerned. I am here concerned with public works considered as a means of 'providing employment' or of adding wealth to the community that it would not otherwise have had.

"A bridge is built. If it is built to meet an insistent public demand, if it solves a traffic problem or a transportation problem otherwise insoluble, if, in short, it is even more necessary than the things for which the taxpayers would have spent their money if it had not been taxed away from them, there can be no objection. But a bridge built primarily 'to provide employment' is a different kind of bridge. When providing employment becomes the end, need becomes a subordinate consideration. 'Projects' have to be invented. Instead of thinking only where bridges must be built, the government spenders begin to ask themselves where bridges can be built. Can they think of plausible reasons why an additional bridge should connect Easton and Weston? It soon becomes absolutely essential. Those who doubt the necessity are dismissed as obstructionists and reactionaries.

"Two arguments are put forward for the bridge, one of which is mainly heard before it is built, the other of which is mainly heard after it has been completed. The first argument is that it will provide employment. It will provide, say, 500 jobs for a year. The implication is that these are jobs that would not otherwise have come into existence.

"This is what is immediately seen. But if we have trained ourselves to look beyond immediate to secondary consequences, and beyond those who are directly benefited by a government project to others who are indirectly affected, a different picture presents itself. It is true that a particular group of bridgeworkers may receive more employment than otherwise. But the bridge has to be paid for out of taxes. For every dollar that is spent on the bridge a dollar will be taken away from taxpayers. If the bridge costs $1,000,000 the taxpayers will lose $1,000,000. They will have that much taken away from them which they would otherwise have spent on the things they needed most.

"Therefore for every public job created by the bridge project a private job has been destroyed somewhere else. We can see the men employed on the bridge. We can watch them at work. The employment argument of the government spenders becomes vivid, and probably for most people convincing. But there are other things that we do not see, because, alas, they have never been permitted to come into existence. They are the jobs destroyed by the $1,000,000 taken from the taxpayers. All that has happened, at best, is that there has been a diversion of jobs because of the project. More bridge builders; fewer automobile workers, radio technicians, clothing workers, farmers.

"But then we come to the second argument. The bridge exists. It is, let us suppose, a beautiful and not an ugly bridge. It has come into being through the magic of government spending. Where would it have been if the obstructionists and the reactionaries had had their way? There would have been no bridge. The country would have been just that much poorer.

"Here again the government spenders have the better of the argument with all those who cannot see beyond the immediate range of their physical eyes. They can see the bridge. But if they have taught themselves to look for indirect as well as direct consequences they can once more see in the eye of imagination the possibilities that have never been allowed to come into existence. They can see the unbuilt homes, the unmade cars and radios, the unmade dresses and coats, perhaps the unsold and ungrown foodstuffs. To see these uncreated things requires a kind of imagination that not many people have. We can think of these non-existent objects once, perhaps, but we cannot keep them before our minds as we can the bridge that we pass every working day. What has happened is merely that one thing has been created instead of others."²

1. It's amazing that a book written 60 years ago directly addresses what Axelrod said just last week.
2. Henry Hazlitt. Economics in One Lesson: The Shortest and Surest Way to Understand Basic Economics, pg. 19-21.