Battle Over Pricing COVID Treatments Shows Danger of Biden’s Rationing Approach

Given the dramatic impacts of coronavirus on our daily lives — killing tens of thousands and shutting down hundreds of thousands of businesses — most Americans would find it unthinkable to deny patients access to COVID-19 treatments on the grounds of cost. But that is just what presumptive Democratic nominee Joe Biden proposes to do. It is simply the latest in a long string of examples of how the left’s support for centralized health care will harm patients and the economy.

Gilead Sciences recently announced pricing plans for its new coronavirus treatment named remdesivir. It set the price for the drug at $3,120 for a five-day course of treatment; government payers will pay roughly one-third less than that ($2,340), in another case of individuals with private insurance subsidizing those on Medicare and Medicaid.

For a drug that reduces the length of virus-related hospital stays, Gilead’s price sounds like good value for patients and insurers. But the bureaucrats Biden wants to place in charge of health care won’t necessarily agree.

Bureaucratic Analysis

Biden’s campaign health-care plan calls for “establishing an independent review board to assess pharmaceuticals’ value,” based on either the therapy’s price overseas “or, if the drug is entering the U.S. market first … an evaluation by independent board members.” Medicare and Obamacare plans will pay the rate set by these “independent” bureaucrats.

Yet consider the way one such board determined prices for remdesivir. According to a National Institutes of Health study, the drug reduced the average hospital stay for COVID patients by four days compared to individuals who did not receive the drug. Additionally, although the changes were not statistically significant, it also reduced death rates slightly.

Remdesivir’s manufacturer, Gilead Sciences, donated nearly 1 million courses of the drug, which the federal government and hospitals will distribute to patients (the prices Gilead set will take effect when hospitals run out of the donated doses in the next few weeks).

Two days after National Institutes for Health reported its results, the Institute for Clinical and Economic Review, which conducts cost-effectiveness research on new pharmaceuticals, released a preliminary pricing analysis for remdesivir. It arrived at a maximum value of $4,460 for a full treatment course if remdesivir reduces mortality in coronavirus patients, and $390 if it does not. A revised analysis, released in late June, slightly increased remdesivir’s maximum value ($4,580-$5,080) if it reduces mortality, and slightly decreased its value ($310) if it does not.

‘Economic’ Institute Excludes Economic Impact Analysis

The glaring omissions in ICER’s analysis, however, reveal an organization that knows the price of everything and the value of nothing. The institute assumed “that policymakers would view it inappropriate” to include “potential broader economic benefits associated with future economic recovery” in its pricing.

Likewise, an updated document regarding assessments of coronavirus treatments states that “the scale of the COVID-19 pandemic makes it impossible to model the impact of patient treatment on economic factors such as unemployment, taxes, [and] education” and that it would only attempt to quantify economic benefits for “a universally effective vaccine or a near/total cure.”

Despite a name that states the institute engages in economic review, ICER shows a callous indifference towards the more than 46 million people who have filed for unemployment since the pandemic began. That a drug like remdesivir might help end coronavirus lockdowns and other social distancing measures, restoring normalcy to a nation severely affected by the virus, doesn’t apparently matter to the ICER bean-counters.

The problems with ICER’s analysis don’t end there. One of its models “set the costs of research and development to zero” because Gilead had previously developed remdesivir as a Hepatitis C drug — ignoring the costs needed to determine whether and how a Hepatitis drug might treat coronavirus. Moreover, by reducing hospital stays by an average of four days, remdesivir would save the health system money at a price well above $310—and perhaps even above $5,080.

Life and Death Access to Treatments

Both ICER’s analyses and the premise behind them seem fundamentally flawed, yet Biden wants to impose them on American patients. His “solutions” would limit access to breakthrough therapies — either because companies will refuse to sell to government programs at the prices bureaucratic boards dictate, or because these price controls mean companies will develop fewer such drugs to begin with.

For patients with critical illnesses, restricting access to drugs could become a matter of life and death. But Biden’s plan could restrict access to coronavirus therapies in a way that becomes a matter of life and death not just for millions of Americans, but the economy as well.

This post was originally published at The Federalist.

Pelosi Health Bill Would Expand Fraud, Undermine Federalism

Anyone who thought the defeat of Sen. Bernie Sanders in the Democrat presidential primaries ended the left’s quest for government control of health care should think again. Legislation introduced last week by House Democratic leaders, to be voted on by the House this week, would substantially expand Washington’s role in the welfare state, encouraging wasteful and fraudulent Medicaid spending and undermine the constitutional principles of federalism.

It seems bad enough that House Democrats decided to raid Medicare to the tune of nearly half a trillion dollars to fund their legislation. That these raided funds would go towards more than $200 billion in new Medicaid spending on individuals potentially ineligible for the program seems especially irresponsible.

Increased Fraud Risk

While expanding federal subsidies for exchange plans, the legislation would accelerate Obamacare’s movement to federalize Medicaid by placing additional requirements and mandates on states. For instance, the bill requires all Medicaid plans — even in states with approved Medicaid waivers — to cover individuals determined eligible for a minimum of 12 months.

Government audits have demonstrated that this policy of continuous eligibility leaves Medicaid programs ripe for waste, fraud, and abuse. In November 2018, Louisiana’s legislative auditor published a study showing individuals initially deemed eligible for Medicaid remained on the rolls despite having incomes as high as $145,146. Following the audit, Louisiana began more frequent eligibility checks and removed more than 30,000 ineligible individuals from the rolls — including at least 1,672 with incomes of over $100,000 — saving taxpayers approximately $400 million.

Broader economic studies confirm the experience of Louisiana. One report released last summer found that most of Obamacare’s coverage gains came from Medicaid and not insurance exchanges — even at income levels well above the threshold for Medicaid expansion. At a time a growing amount of evidence suggests millions of ineligible individuals are enrolling in Medicaid, the new House bill would sharply restrict states’ ability to remove ineligible individuals from the rolls.

On Friday, the Congressional Budget Office released its fiscal analysis of the Democrat legislation. The CBO concluded the continuous eligibility provision alone would result in $216.8 billion in new federal spending plus additional unfunded costs on states. A descriptive analysis of this provision was not provided by the CBO, but it is likely much of the $216.8 billion would fund Medicaid spending on individuals who beforehand would have lost eligibility for the program.

Unconstitutional Orders on States

Importantly, the bill undermines the flexibility of states in other ways, punishing any that have not accepted Obamacare’s Medicaid expansion to able-bodied adults. It would phase in a 10-percentage point reduction in non-expansion states’ federal match rate for administrative expenses — even as it imposes more administrative costs in the form of new reporting requirements. The move directly violates the Supreme Court’s 2012 opinion in NFIB v. Sebelius, which said Congress cannot “penalize states that choose not to participate in that new program [i.e., Medicaid expansion] by taking away their existing Medicaid funding.”

In permanently extending the State Children’s Health Insurance Program, the bill would eliminate the caps on federal funding that have defined the program since its creation nearly a quarter-century ago. It would also perpetually expand provisions first included in Obamacare that prohibit states from restricting eligibility. Together, these changes would essentially convert a program originally designed as a block grant into a permanent entitlement for states and individuals.

Wasteful Spending Is Obamacare on Steroids

Despite all these new restrictions on Medicaid and children’s health insurance programs, the bill does expand state flexibility in one important way: by eliminating all income eligibility thresholds for children. If states want to provide government-funded health care to the children of millionaires, the legislation would give them federal funds to do so, demonstrating that House Speaker Nancy Pelosi and her fellow Democrats only support Medicaid flexibility when states expand the number of people receiving government health care.

As Pelosi argues for a trillion-dollar bailout of state and local budgets, she has offered an excellent reason for Congress to reject both the bailout and the Obamacare “enhancement” act. Rather than giving states additional flexibility to remove ineligible individuals and narrow their budget gaps, the bill’s additional — and in at least one case, unconstitutional — mandates would cause Medicaid spending to balloon, leading to more state bailouts in subsequent years. Both taxpayers and the Constitution deserve better than this latest plan to put Obamacare on steroids.

This post was originally published at The Federalist.

Democrats Raid Medicare to Pay for Obamacare (Again!)

As Ronald Reagan would say, “There they go again.” A decade after Democrats raided Medicare by more than half a trillion dollars to fund Obamacare, House Speaker Nancy Pelosi (D-Calif.) and her Democratic colleagues recently introduced new Obamacare legislation that would raid Medicare by nearly another half-trillion dollars.

Sadly, the House plans to vote on this legislative package before the Independence Day holiday. Lowering spending in one unsustainable entitlement to fund another represents the height of fiscal irresponsibility. For Democrats, however, it looks like par for the course.

Obamacare on Steroids

Democrats have titled their bill the Obamacare “enhancement” act — and for good reason, because it would effectively put the law on quite the figurative steroids. The bill would stymie recent efforts by the Trump administration to offer more insurance options to consumers, such as short-term, limited-duration insurance and association health plans.

Instead, it would make skyrocketing premiums “affordable” by dedicating more taxpayer dollars towards Obamacare exchange subsidies, while also directing $10 billion per year to insurance companies via a new — and permanent — federal bailout fund.

The legislation would also balloon Obamacare’s Medicaid expansion to able-bodied Americans. It would require states to keep individuals on the rolls for 12 months, allowing affluent individuals to remain in this “low-income” program. The income cap on coverage for children would also be eliminated, permitting states to cover children of millionaires while receiving federal dollars for doing so if they choose.

At a time evidence already suggests significant waste and fraud takes place among individuals receiving Medicaid coverage, the Pelosi legislation would add to the ever-increasing budget woes of numerous states by forcing them to keep ineligible individuals on the rolls.

Socialist-Style Price Controls

How would Democrats fund all this new spending? From Medicare.

The Obamacare “enhancement” legislation includes drug pricing provisions that the House of Representatives passed last December. The provisions would require drug companies to “negotiate” prices with the Department of Health and Human Services (HHS),  which would effectively dictate prices to drug companies based on benchmarks laid out in the bill. Companies that do not “negotiate” would face excise taxes that could cause the manufacturer to lose money on every drug it sells in the United States.

The Congressional Budget Office confirmed back in December that these “negotiation” provisions would lead to the development of fewer drugs, as companies invest less in research and development. The CBO also said, however, that the blunt price controls would reduce Medicare and Medicaid spending. So Democrats used these price controls to fund their recent Obamacare expansion bill.

Raiding Medicare (Again)

According to CBO, the vast majority of the savings from drug pricing — a total of $448.2 billion over ten years, to be exact — used to fund the Obamacare bill comes from Medicare. That the Democrats are effectively raiding Medicare to expand entitlements for younger Americans makes the Obamacare “enhancement” legislation all the more odious and irresponsible, though, at this point, we really shouldn’t be surprised.

We’ve seen this act before. Indeed, the Obama administration spent years trying to justify the raid on Medicare. Kathleen Sebelius, then the HHS secretary, testified before Congress that provisions in the law would “both” extend Medicare’s solvency and pay for Obamacare. This is a position that defies both logic as well as common sense.

As it stands, Medicare has already become functionally insolvent. The year before Obamacare’s passage, the program’s trustees projected the Hospital Insurance Trust Fund would run out of money to pay all its bills in 2017 — three years ago. The Obamacare double-counting gimmicks that Sebelius testified about may appear to have extended the program’s solvency, but if only on paper. But the true cost of these things cannot remain hidden forever. According to current projections, even the funds from these phony solutions will run out by 2026.

Doing the Wrong Thing About Medicare’s Insolvency

Yet what would Pelosi and House Democrats do about Medicare’s looming insolvency? Not just nothing — worse than nothing. Rather than using the savings from their socialistic price controls to make Medicare solvent, they would take that money and throw it at health insurers to prop up Obamacare. As shocking as it may seem to some, this behavior echoes Pelosi’s 2011 interview with CNBC, when she bragged about how Democrats “took half a trillion dollars out of Medicare” to pay for Obamacare.

The Obamacare “enhancement” demonstrates how Pelosi and her fellow Democrats don’t care about fiscal responsibility or protecting America’s seniors. Instead, they view Medicare just as they did in 2010: A slush fund to raid on a whim as part of their effort to expand government-run health care at any cost.

This post was originally published at The Federalist.

Reduce Nursing Home Populations to Limit Coronavirus’ Spread

Why have so many nursing home patients died from coronavirus nationwide? The key to answering that question lies in many of the nation’s leading politicians’ policy responses to the pandemic. Most notably, Gov. Andrew Cuomo (D-N.Y.) issued an ill-conceived order requiring nursing homes to accept COVID-positive patients.

Forcing institutions to accept positive patients “seeded” coronavirus in nursing homes, where it spread like wildfire. Although Cuomo eventually rescinded that measure, the decision was too late to save the thousands of nursing home patients who died before it could undo the damage initially wrought. Last Thursday, in a display of callous indifference to the loved ones of deceased patients desperate for answers, Cuomo called the focus on his order a “shiny object” and “pure politics.”

But the high death toll in nursing homes also reflects underlying policy differences that preceded coronavirus: Some states house more individuals in nursing homes than others. These disparities, coupled with the inherent infection risk present in nursing homes, should provide states new motivation to accelerate the movement of seniors and individuals with disabilities out of institutional facilities wherever and wherever possible.

Differences Among States

As of 2017, more certified nursing facilities operated in Florida than in New York. But the larger average size of New York’s facilities means the state has nearly 35 percent more nursing home beds than Florida — even though Florida has 35 percent more seniors older than age 65 than New York does. New York’s nursing homes average 185.1 beds per facility, the highest in the country by far. With a larger nursing home population and larger facilities, the virus had more room to rampage than in other states with smaller facilities and smaller nursing home populations.

During the past several weeks, the growing death toll in nursing homes prompted state and federal officials to surge resources to facilities, from testing to personal protective equipment to infection control specialists. But policymakers should ask a more fundamental question: Why do we still have so many individuals in nursing homes at all? The spread of COVID is likely reduced by home-based care while providing an environment most patients prefer, and often at lower costs than nursing homes.

Over the past several decades, Congress and states have begun to redirect Medicaid spending from institutional care towards home and community-based services. From 1988 to 2016, the percentage of Medicaid long-term care spending directed toward home-based services grew from 10 percent to 57 percent.

But in some states, the powerful nursing home lobby still thwarts policy efforts that would empty facility beds. As of 2016, for one example, New York spent more on institutional care than Florida and California did combined.

A Better Solution

By contrast, Rhode Island’s global compact, approved in January 2009, consolidated myriad Medicaid waivers into a single effort increasing access to home-based care. The state’s experiment succeeded: The number of individuals receiving institutional care declined 6.2 percent, while those receiving community-based care rose by 25.8 percent. Rhode Island’s rebalancing towards community-based care helped keep overall Medicaid spending flat during a time of enrollment growth, and did so by increasing access to care, not limiting it.

States like Rhode Island that have moved individuals needing long-term care out of nursing homes wherever possible have the potential to see fewer incidents of mass deaths. Indeed, vulnerable populations will still need to take precautions to avoid COVID regardless. But moving seniors out of congregate settings like nursing homes would minimize the risk of a “super-spreader” incident in which a single individual infects dozens or even hundreds of patients.

Congress Inhibits Reform

With its ability to reduce health-care spending and the risk of infection, the coronavirus pandemic should have given states added incentive to transition Medicaid beneficiaries into home-based care — had Congress not gotten in the way. Legislation passed in March giving states an increase in the federal Medicaid match conditioned the additional dollars on states not limiting benefits. As a result, more aggressive attempts by states to direct spending to community-based care — for instance, by capping nursing home slots, or requiring beneficiaries to try home-based care first — could jeopardize states’ additional federal matching funds.

When I served on the congressional Commission on Long-Term Care in 2013, one of my colleagues often said the next person who told him she wanted to enter a nursing home would be the first person to express such a desire. That adage holds as true today as it did seven years ago, and this truth should compel states to promote home and community-based care wherever possible at all times. During the coronavirus pandemic, however, such a transition won’t just give seniors better care in a way that saves health-care costs — it could save seniors’ lives.

This post was originally published at The Federalist.

New Study Confirms How the Welfare State Perpetuates Poverty

Ronald Reagan had an old adage about the nine most terrifying words in the English language: “I’m from the government and I’m here to help.” Recently, a new paper reinforced that truth and adds to the existing literature showing how America’s welfare state often traps generations in a cycle of poverty.

At its core, a complicated set of welfare programs and tax breaks generate sizable incentives for many low-income Americans not to increase their incomes and improve their station in life. This “poverty trap” results in well-intentioned government programs hurting those they were designed to help.

Marginal Tax Rates

The study, published by the National Bureau of Economic Research (NBER), examined marginal net tax rates on American households. Their analysis included the phase-out effects of various government programs and the extent to which those phase-outs discourage work.

For instance, consider the $1,200 payments in March’s coronavirus “stimulus” legislation. Individuals with incomes under $75,000 qualified for the full $1,200 payment, while the payment was reduced by 5 percent for each dollar of income over $75,000. As a result of this phase-out rate, individuals with incomes over $99,000 receive no payment.

For every additional dollar of income a person making $75,000 received, he will lose five cents of his “stimulus” payment, plus have to pay regular federal income taxes (likely at a 22 percent rate), payroll taxes (7.65 percent), and state and local income taxes where applicable.

Put another way, the coronavirus checks gave people making between $75,000-$99,000 added incentive to reduce their income. By working fewer hours, sheltering income from taxes, or both, people could “maximize” their “free” payment from the federal government.

The researchers studied data from 2016, well before this year’s “stimulus” (or the coronavirus). But as the paper’s introduction notes, many other federal programs and laws have similar distortionary effects:

Earn $1 too much two years back and your Medicare Part B premiums will rise by close to $800. Earn $1 too much and, depending on the state, lose thousands of dollars in your own or your family’s Medicaid benefits. Hold $1 too much in assets and forfeit thousands in Supplemental Security Income. Earn an extra dollar and receive thousands of dollars in Obamacare subsidies. Earn $1 beyond Social Security’s earnings ceiling and watch your Social Security payroll tax drop to zero. Earn $1 too much and flip onto the Alternative Minimum Tax (AMT), reducing your marginal income-tax bracket from a rate as high as 37 percent to 28 percent. Earn $1 too much and lose 22 cents, in the Earned Income Tax Credit and the list goes on.

If this appears to look almost like a game, you’re not far off. It’s hard not to view it as the government picking winners and losers through its various program parameters. Made an extra $1 of income? Too bad — now we’re taking your subsidy away. Do not pass go, do not collect $200.

Worst Effects on the Poor

Unfortunately, these distortionary effects hit poor and near-poor households the hardest. As Gene Steuerle of the Urban Institute has documented, phase-outs of programs like cash welfare, food stamps, the Earned Income Tax Credit, and Obamacare subsidies mean households making roughly $10,000-$40,000 can lose almost as much in government benefits as they gain in added income by working additional hours.

The new NBER study further quantifies this phenomenon. It finds that, both over the current year and over their lifetimes, individuals in the lowest income quintile (the bottom 20 percent) face higher marginal tax rates than those in the next three income quintiles (from the 20th percentile of income through the 80th percentile). Essentially, when taking the phase-out of government benefits into account, the poor face more disincentives to work than the middle class.

It gets worse. One in four low-income households (those with income in the bottom 20 percent) face lifetime marginal net tax rates of more than 70 percent. As the authors put it: “One in four of our poorest households, regardless of age, make between two and three times as much for the government than they make for themselves in earning an extra $1,000.” Given the construct of the modern welfare state, it seems less logical to ask why poor people wouldn’t work and instead to ask why they would.

There is, however, one silver lining in the paper: States can help undo the damage caused by poorly crafted federal policy. The NBER researchers found that a “typical household can raise its total remaining lifetime spending by 8.1 percent by moving from a high-tax to a low-tax state.”

Break the Cycle of Poverty

Obamacare didn’t create the phenomenon of the welfare state discouraging work, but it did make this worse. The Congressional Budget Office noted repeatedly that the phase-outs in the law’s insurance subsidies penalize individuals who earn more income. Its most recent in-depth analysis, conducted in February 2014, concluded the law would reduce the labor supply by the equivalent of about 2.5 million full-time jobs.

More recently, of course, lawmakers in the CARES Act provided a $600 per week federal supplement to unemployment insurance, further discouraging work. Because more than two-thirds of unemployed individuals can now make more money on unemployment than they did while working, businesses face difficulty recruiting furloughed employees back to their jobs.

At a time our country faces a massive recession brought on by the coronavirus lockdowns, America’s welfare state exacerbates that stagnation. Reforming the system to eliminate work disincentives could save taxpayer funds. More importantly, it would encourage all Americans to embrace the dignity of work.

This post was originally published at The Federalist.

End the Absentee Congress

When House Speaker Nancy Pelosi (D-CA) met with protestors on the East Front of the Capitol last Wednesday, she echoed the nation’s outrage over the horrific killing of George Floyd while in police custody. She also provided ample justification for ending the constitutionally questionable experiment in proxy voting that the House recently authorized.

It raises an obvious question of double standards: If Pelosi can gather with masses of protestors in Washington, why can’t she convene Congress in person? Officials in Congress have come up with numerous protocols to protect members of Congress as well as their staff from contracting the coronavirus—measures not always used by the protestors. Yet in the past week, several members who refused to travel to Washington for votes in late May personally attended protests in their districts.

These elected officials have their priorities backward. If members can protest in mass gatherings with their constituents, they can engage in another mass gathering to represent their constituents—by flying to Washington and doing the job that taxpayers paid them to do.

Resolution Passed in May

On May 15, Democrats in the House of Representatives voted along party lines on a resolution permitting the speaker to authorize remote voting by proxy for 45-day periods. The following week, Pelosi issued such an authorization, citing health issues surrounding the coronavirus. The House utilized proxy voting during three sessions from May 26-28, after which House Democratic leaders said they would keep the chamber in recess for most of June.

Pelosi did not count herself alone among House Democrats in deciding the Floyd protests superseded prior health concerns over large public events. A review of their Twitter accounts reveals that at least one-fifth of the 70 House Democrats who utilized proxy voting to avoid assembling in Washington attended some form of mass gathering—whether a roundtable, press conference or protest—in the days following Floyd’s killing.

Pelosi wore a mask when meeting with the protestors, and many of the House Democrats who attended protests did likewise. But particularly given the new social distancing precautions at the Capitol, it becomes difficult to square the notion of voting by proxy, or keeping the House in recess, to avoid gathering 435 House members in Washington during the pandemic when some of those very same folks attend even larger gatherings in their home districts.

The ironies of these circumstances abound. House Democrats who voted to impeach President Trump for abuse of power have increased the authority of Pelosi and House leaders, passing a resolution that permits as few as 20 members physically present in Washington to convene the House of Representatives. Those protesting systemic injustices have temporarily curtailed their ability to change that system, by absenting themselves from Washington for weeks at a time.

A Better Alternative

Of course, some members of Congress have understandable health-related reasons for avoiding travel to Washington. Others may feel a need to quarantine to protect vulnerable family members, or after possible exposure to the virus themselves.

In those circumstances, the longstanding legislative custom of pairing can allow members on both sides of an issue to express their views in a way that will not affect legislative votes. For instance, in October 2018 Sen. Steve Daines (R-MT) wanted to support the Supreme Court nomination of Brett Kavanaugh—but his daughter’s wedding prevented him from making the Saturday vote. In this case, Sen. Lisa Murkowski (R-AK), who opposed the nomination, voted “present” rather than “no,” so that her vote would essentially “cancel out” Daines’ non-vote.

End the Proxy Charade

Proxy voting in Congress presents numerous issues. For one, it raises questions about whether members not physically present in Washington count towards the quorum required by the Constitution for each chamber of Congress to conduct business. House Republicans have already filed a lawsuit against the proxy voting system on that basis.

Proxy voting also empowers party leaders over the rank-and-file, by keeping the latter more distant from the Capitol for long periods. The bosses in Congress make too many decisions unilaterally as it is—House members should halt the Pelosi power grab by stopping the charade of proxy voting.

For those whose health issues preclude travel, both parties should facilitate a pairing process through the usual channels. In all other cases, Congress should return to in-person voting, with appropriate social distancing and health protocols in place. It’s time to end proxy voting, and nix Pelosi’s Potemkin Congress.

This post was originally published at The Federalist.

The Better Solution for Our Health Insurance System: A Plan You Can Actually Keep

Sometimes, liberals and conservatives agree on a policy problem, but disagree strongly on the best solutions to that problem. Our health insurance system presents one case of such a disconnect between problems and solutions.

In the last Democratic presidential debate, hosted by CNN in March, Vermont Sen. Bernie Sanders said that the coronavirus pandemic made the “dysfunctionality of the current health care system … obviously apparent.” He elaborated in an April op-ed in Politico, in which he noted that “already, an estimated 9.2 million workers have lost their employer-sponsored insurance, and as many as 35 million people might lose coverage by the end of the crisis.”

Sanders makes a valid point: The pandemic does illustrate the shortcomings of our system of health coverage. But his single-payer health care plan — or even Joe Biden’s proposal for a (purportedly) voluntary government-run “option” in which individuals could enroll — would take the system in the exact opposite direction.

The dysfunctionality of the system exists largely because employers control most Americans’ health insurance. Most conservatives would therefore support letting individuals control their health coverage, rather than liberals’ plan to replace employer control with government control. Thankfully, the Trump administration has moved health policy in that exact direction, laying the groundwork for a movement toward more personalized insurance options.

The Problem: Employer-Provided Health Insurance

Sanders cited a study from Health Management Associates stating that as many as 35 million individuals could lose access to employer-sponsored insurance due to coronavirus-related layoffs. A revised paper, released in late May, did not specifically update estimates for the number of people losing employer insurance, but still showed significant coverage losses. Other estimates have indicated similarly large numbers of Americans losing their employer coverage.

The sudden job losses sparked by coronavirus lockdowns have illustrated one of the three major problems with employer-provided health insurance. Individually and collectively, these flaws have represented a problem hidden in plain sight for decades.

Lack of choice: The largest survey of employer-provided health insurance found that in 2019, exactly three-quarters of firms (75%) offered only one type of health insurance plan. In general, large firms offer more choices than small businesses, but even among the largest firms — those with more than 5,000 workers.

Because the employer and not the employee owns the insurance policy, workers often end up stuck with whatever plan their employer chooses. An individual who doesn’t want to enroll in an HMO, or whose doctors lie outside his or her employer’s provider network, might have few choices but to switch jobs or accept a plan that does not meet his or her needs.

In its first season, the U.S. version of “The Office” satirized this dynamic, when resident megalomaniac Dwight Schrute got charged with picking the office health plan — and let the power go to his head. While Americans don’t have to worry about contracting “Count Choculitis,” one of the fictitious diseases Schrute’s co-workers invented to needle him in the episode, they do face the very real worry that their employer’s choices and wishes regarding health care might not align with their own.

Flawed incentives: A conversation with one of my friends several years ago illustrated this problem. My friend said he loved the insurance plan his employer provided: “I can go to the doctor and it only costs me a $5 co-pay.”

I posed a thought experiment: What if your health insurance suddenly became taxable, and you had to pay $1,500 or so in taxes on that coverage? (At the time, a top-of-the-line plan cost about $6,000 for an individual, and I assumed a 25% state and local tax rate.) He responded immediately: “I wouldn’t want the plan — I would tell them to raise my co-pays and deductibles.”

That response illustrates the policy problem of employer-sponsored insurance: Everyone thinks they’re spending everyone else’s money. Employees don’t pay taxes on employer coverage; an IRS ruling during World War II, later codified by Congress, exempts employer-provided benefits from both income and payroll taxes.

All the incentives regarding employer-provided health care point in the wrong direction. Exempting employer coverage from taxation encourages individuals to take more compensation in untaxed health insurance benefits rather than taxable wages. Many employees don’t even realize that the employer’s share of the contribution for their coverage — which averaged nearly $15,000 for a family policy in 2019 — comes out of their own wallets in the form of lost wages.

All the flawed and misaligned incentives mean that the co-pay of “only” $5 my friend talked about years ago costs far more than that — to workers, employers and the economy as a whole. It’s one major reason why our health care system represents such a large, and rising, share of our economy.

Lack of portability: This issue arises because employers and not individuals own their health plans. As a result, when individuals lose their jobs, they also lose their health coverage. That dynamic results in the double whammy Americans have experienced during the pandemic, when workers lose their coverage at the same time they have unexpectedly lost their job — compounding families’ financial distress.

Lack of portability also exacerbates the problem of pre-existing conditions. Upon entering the workforce in their teens or 20s, most individuals have yet to develop a pre-existing condition like cancer or diabetes. But every time individuals switch jobs, they lose their employer-provided health coverage — making them vulnerable if they have developed a condition in the intervening time.

The worst kinds of situations occur when individuals must leave their jobs because they have become too sick to work. These patients face not one but two potential sources of financial ruin: They have lost their source of income, and face the prospect of astronomical medical bills without a means to fund them.

Cure the Disease, Not the Symptoms

In the past several years, Democrats have spent lots of time talking about the need to protect individuals with pre-existing conditions. But in focusing on pre-existing conditions, the left focuses on the symptom, rather than the underlying problem.

Remember: When Obamacare went into effect in January 2014, at least 4.7 million individuals received cancellation notices, according to The Associated Press. These individuals had plans that they liked, and wanted to keep — but the Obama administration wouldn’t let them. Politifact called the promise that Americans could keep their plan the 2013 “Lie of the Year,” and that lie affected many individuals who had developed, or feared that they would develop, a pre-existing condition. Let’s spare the notion that Democrats want to “protect” people with pre-existing conditions, when they “protected” millions of people right out of their coverage.

Liberals don’t talk about the underlying policy issue that creates the pre-existing condition problem — that people don’t own their own health coverage — because they don’t want people to own their own insurance. They want Washington to control health care decisions, not individual patients. It’s the classic example of former President Ronald Reagan’s nine most terrifying words in the English language: “I’m from the government and I’m here to help.”

But if individuals could buy an insurance policy upon joining the workforce — one that they owned, not their employer — and retain that policy from job to job for decades, most individuals could buy coverage well before they develop a pre-existing condition, and keep that coverage after they do so, the pre-existing condition problem would rapidly diminish. (Yes, a small percentage of Americans, most notably those born with congenital illnesses, develop pre-existing conditions very early in life, but other policy solutions can address this population.)

Trump Administration’s Solution

You wouldn’t know it, given all the carping and hostility from the left, but the Trump administration has put forward a very positive solution that answers the policy problems associated with employer-provided health coverage. It should increase portability in ways that help solve the pre-existing condition problem, while also providing additional choice and competition.

The administration’s policy, implemented through regulations finalized in 2019, allows employers to contribute funds to workers on a pre-tax basis through Health Reimbursement Arrangements. These HRAs allow individuals to purchase coverage that they own, not their employers — making the coverage portable from job to job.

The HRA concept provides wins for employers, employees and the economy as a whole:

• Employers get predictability when it comes to their health insurance offerings. By providing employees a fixed sum (say, $300 or $500 a month) into the HRA, they will not have to worry about changing plans from year to year, a sudden spike in costs because of a sick employee, or many of the other paperwork hassles associated with offering coverage.
• Employees get both choice and portability. They can select the insurance plan that best meets their needs — the doctors, deductibles and plan features that they want. Not only can they keep the plan when they switch jobs, the fact that they and not their employer chose the coverage in the first place will make them more likely to do so.
• The economy will benefit from individuals selecting the plans they want, rather than the plans employers select for them. Insurers will have to provide better, more customized plans that fit individuals’ needs, and employees will have incentives to make better choices to stretch the HRA dollars their employers provide them.

Ideally, Congress would amend the law regarding Health Savings Accounts, to allow individuals to use HSA dollars to fund health insurance premiums. Because HSA funds cannot pay insurance premiums in most cases under current law, the Trump administration had to use Health Reimbursement Arrangements (which are owned by employers) rather than Health Savings Accounts (which are always owned by individuals) to fund individual coverage.

Providing contributions via an HSA, as opposed to an HRA, would allow employees to control any unused employer contributions upon leaving a job. That way, individuals would not only have a source of coverage in the event of a layoff, they could develop a source of savings to pay for that coverage while unemployed. But until Congress acts, the Trump administration’s Health Reimbursement Arrangement regulations represent a tremendous step forward toward a more logical, patient-centered insurance system.

Empower Patients, Not Government

Coronavirus has made the problems with government control of health care apparent. As Joe Biden (of all people) noted in the March CNN debate, Italy has a single-payer system — and that nation had to ration access to ventilators, whereas the United States did not.

The pandemic has exposed the flaws in our health insurance system. But it comes just as the Trump administration has shown a better path forward. By empowering patients rather than government bureaucrats, Health Reimbursement Arrangements can help transform the coverage system into something that lowers costs and provides the care American patients prefer.

This post was originally published at the Daily Caller’s American Renewal blog.

Why Republicans Get No Points for Opposing Democrats’ $3 Trillion Coronavirus Bill

On May 15, Speaker Nancy Pelosi (D-Calif.) will bring to the floor of the House a sprawling, 1,815-page bill. Released mere days ago, the bill would spend roughly $3 trillion—down from the $4 trillion or more that lawmakers on her socialist left wanted to allocate to the next “stimulus” package.

Most House Republicans will oppose this bill, which contains a massive bailout for states and numerous other provisions on every leftist wish list for years. But should anyone give them credit for opposing the legislation? In a word, no.

Conservatives shouldn’t give Republican lawmakers any credit for opposing bills that have no chance of passage to begin with—bills they never should vote for anyway. I didn’t go out and rob a bank yesterday. Should I get a medal for that? Of course not. You don’t get credit for doing the things you’re supposed to do.

Conservatives should demand more than the soft bigotry of low expectations that Republican lawmakers’ miserable track record on spending has led them to expect. For starters, instead of “just” voting no on the Pelosi bill’s additional $3 trillion in spending, why not come up with a plan to pay for the $3 trillion Congress has already spent in the past several months?

Yes, government needs to spend money responding to coronavirus, not least because government shut down large swathes of the economy as a public health measure. But that doesn’t mean Congress can or should avoid paying down this debt—not to mention our unsustainable entitlements—starting soon.

Decades of ‘Conservative’ Grifters

Two examples show how far Republican lawmakers stray from their rhetoric. In July 2017, former House Majority Leader Eric Cantor (R-Va.) said of his prior rhetoric regarding Obamacare, from defunding the law to “repeal-and-replace”: “I never believed it.” Of course, he waited to make this admission until he had left office and taken a lucrative job at an investment bank.

Cantor’s comments confirmed conservatives’ justifiable fears: That Republican lawmakers constantly play them for a bunch of suckers, making promises they don’t believe to win power, so they can leverage that power to cash in for themselves.

Perhaps the classic example of the “all hat and no cattle” mentality comes via former House Speaker Paul Ryan (R-Wis.). Notwithstanding Ryan’s reputation as a supposed fiscal hawk, consider his actions while in House leadership:

  • Instead of reforming entitlements, Ryan led the charge to repeal the first-ever cap on entitlement spending. He could have nixed Obamacare’s Independent Payment Advisory Board, a group of unelected officials charged with slowing the growth of Medicare spending, while keeping the spending cap. Instead, he got Congress to repeal the board and the spending cap that went with it—worsening our entitlement shortfalls.
  • For years, Ryan proposed various reforms to the tax treatment of health insurance, because economists on both the left and the right agree it encourages the growth of health-care costs. But as speaker, Ryan supported delays of a policy included in Obamacare that, while imperfect, at least moved in the right direction towards lowering health care costs. The delays allowed Congress to repeal the policy outright late last year, in a massive spending bill that shifted both spending and health-care costs the wrong way.
  • As chairman of the House Ways and Means Committee, Ryan gave then-House Speaker John Boehner (R-Ohio) the political cover he needed to pass a Medicare physician payment bill that increased the deficit and Medicare premiums for seniors. The legislation did include some entitlement reforms, but at a high cost—and didn’t even permanently solve the physician payment problem.

Ryan’s “accomplishments” on spending as a member of leadership echo his prior votes as a backbench member of Congress. Ryan voted for the No Child Left Behind Act; for the Medicare Modernization Act, which created a new, unpaid entitlement costing $7.8 trillion over the long term; and for the infamous Troubled Asset Relief Program Wall Street bailout.

Over his 20-year history in Congress, I can’t think of a single instance where Ryan took a “tough vote” in which he defied the majority of his party. Instead, he always supported Republicans’ big-spending agenda. In that sense, tagging Ryan as a RINO—a Republican in Name Only—lacks accuracy, because it implies that most Republican lawmakers have a sense of fiscal discipline that only Ryan lacks.

It doesn’t take a rocket scientist to draw the line from Ryan’s brand of “leadership” to Donald Trump. The latter spent most of his 2016 campaign illustrating how Republican elected officials failed to deliver on any of their promises, despite talking up their plans for years.

Stand for Principle, or Stand for Nothing

When Republicans enter the House chamber on Friday to cast their votes against Pelosi’s bill, they should take a moment to contemplate her history. In the 2010 elections, Pelosi lost the speakership in no small part because of Obamacare. One scientific study concluded that the Obamacare vote alone cost Democrats 13 seats in the House that year.

Pelosi did not relinquish the speakership gladly; few would ever do that. But she proved willing to lose the speakership to pass the law—and would do so again, if forced to make such a binary choice.

I know not on what policy grounds, if any, Republicans would willingly sacrifice their majorities in the way Pelosi and the Democrats did to pass Obamacare. (Reforming entitlements? Tax cuts? Immigration?) That in and of itself speaks to the Republican Party’s existential questions, and the ineffective nature of the party’s “leadership.”

It also provides all the reason in the world that House Republicans should not trumpet their votes against the Pelosi legislation on Friday.

This post was originally published at The Federalist.

How Government-Run Health Care Worsened the Coronavirus Crisis

Leftist politicians have spent a great amount of time over the past two months attacking President Trump for his handling of the coronavirus crisis. But instead of reflexively criticizing the administration, those liberals might want to examine how the left’s dream of government-run health care has exacerbated the crisis within the United States.

One of the major causes of the dearth of testing over the past several months: Low payments from Medicare, which led to low payment rates from private insurance plans. It may come as a shock to people like Rep. Alexandria Ocasio-Cortez (D-NY), but guess what labs did when low payments meant they suffered a financial loss for every coronavirus patient tested? They performed fewer tests.

Low Reimbursements Equals Fewer Tests

A recent expose in USA Today highlighted how Medicare “lowballed payments” to labs for coronavirus tests, leading those labs to restrict the number of tests they performed. An executive at one lab, Aaron Domenico, told the paper that “I’m an American first, and if I could do it for cost, I’d be happy to do it for the people at cost.” But Medicare initially reimbursed laboratories only $51 for a coronavirus test, much less than Domenico’s costs of $67 per test.

Paying $51 for a diagnostic test sounds like a lot, but Medicare gives laboratories nearly twice that amount, or approximately $96, to test for the flu. And government bureaucrats setting unrealistically low prices meant that private insurers followed Medicare’s lead. Little wonder that the head of the National Independent Laboratory Association said “a number of labs are holding back” on performing additional tests “because they didn’t want to lose money.”

Thankfully, on April 14 Medicare raised its reimbursement for a coronavirus test from $51 to $100. Unsurprisingly, the number of tests performed daily has roughly doubled since that point. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma said she “recognized that there may have been some issues with reimbursement” discouraging labs from performing coronavirus tests.

Bureaucrats Can’t Micromanage Health Care

Therein lies one of the major problems with government-run health care: The notion that federal bureaucrats can determine the correct price for every prescription drug, laboratory test, physician service, or hospital procedure across the country. Donald Berwick, a former CMS administrator who helped develop Sen. Elizabeth Warren’s single-payer proposal, once said, “I want to see that in the city of San Diego or Seattle there are exactly as many MRI units as needed when operating at full capacity. Not less and not more.”

Berwick’s comments suggest that the federal government can determine the “right” amount of MRI units in each city, and use policy levers to achieve that “correct” outcome. But the coronavirus testing fiasco demonstrates how federal bureaucrats often do a poor job of trying to micromanage health care from Washington. Paying doctors and laboratories too much will encourage over-consumption of care, while paying too little discourages providers from even offering the service.

Low Payments Lead to Job Losses, Too

The problems with coronavirus testing also preview the left’s efforts to expand government-run health care. For instance, Joe Biden’s campaign platform calls for a government-run health plan that “will reduce costs for patients by negotiating lower prices from hospitals and other health care providers.”

But all these proposals—whether they would abolish private insurance outright, as Warren and Sen. Bernie Sanders support, or offer a government-run “option,” as in Biden’s platform—would have the government “negotiate” prices by forcing doctors, nurses, and hospitals to accept less money. By lowering payment levels, those plans would lead to massive job losses—as many as 1.5 million jobs in hospitals alone under a transition to single-payer, according to one estimate in the prestigious Journal of the American Medical Association.

The pay cuts and furloughs affecting many front-line health workers—the health-care sector lost 1.4 million jobs during the month of April—provide a preview of the future. Instead of suffering temporary revenue declines due to the coronavirus pandemic, hospitals and medical practices would face permanent reductions in revenue from lower-paying government programs.

Worse yet, care will suffer when people cannot access the care they need at the paltry prices government programs will pay. While the left lays the coronavirus testing flaws at the feet of President Trump, they should look instead at the government-run programs they support as a major source of the problem. Voters being asked to endorse the movement towards socialism in November should take note as well.

This post was originally published at The Federalist.

Medicaid’s Blue State Bailout

In discussing future coronavirus legislation, Senate Majority Leader Mitch McConnell (R-Ky.) has taken a skeptical view towards additional subsidies to states, including a potential “blue state bailout.” But current law already includes just such a mechanism, giving wealthy states an overly generous federal Medicaid match that results in bloated program spending by New York and other blue states.

Section 1905(b) of the Social Security Act establishes Federal Medical Assistance Percentages, the matching rate each state receives from the federal government under Medicaid. The statutory formula compares each state’s per capita income to the national average, calculated over a rolling three-year period. Poorer states receive a higher federal match, while richer states receive a lower match.

However, federal law sets a minimum Medicaid match of 50 percent, and a maximum match of 83 percent. No poor states come close to hitting the 83 percent maximum rate, but a total of 14 wealthy states would have a federal match below 50 percent absent the statutory minimum. (In March, Congress temporarily raised the federal match rate for all states by 6.2 percentage points for the duration of the coronavirus emergency.)

Absent the statutory floor, Connecticut would receive a match rate of 11.69 percent in the current fiscal year, according to Federal Funds Information Service, a state-centered think-tank. At that lower federal match, Connecticut would receive approximately one federal dollar for every eight the state spends on Medicaid, rather than the one-for-one ratio under current law.

Federal taxpayers pay greatly because the overly generous match rate for wealthy states leads to additional Medicaid spending. In fiscal year 2018, Connecticut spent far more on its traditional Medicaid program ($6.5 billion in combined state and federal funds) than similarly sized states like Oklahoma ($4.9 billion) and Utah ($2.5 billion). Those totals exclude the dollars Connecticut received from Obamacare, which guarantees all states a 90 percent Medicaid match for covering able-bodied adults.

The budget crisis in New York that preceded the pandemic stems in large part from Washington’s overly generous match for wealthy states. Absent the statutory floor, the state would receive a Medicaid match of 34.49 percent this fiscal year, meaning it would have to spend approximately two dollars to receive an additional federal dollar.

But the one-to-one Medicaid match guaranteed under federal law led New York to expand its program well beyond most states’. At more than $77 billion in 2018, New York Medicaid cost taxpayers more than three times the $23.4 billion spent by the larger state of Florida. And a federal audit last summer concluded that New York Medicaid spent $1.8 billion on more than 600,000 ineligible enrollees in just a six-month period. Little wonder that Gov. Andrew Cuomo in January called the state’s fiscal situation “unsustainable” after the state announced a $6 billion budget deficit, most of which came from Medicaid.

To his credit, Cuomo proposed changes to crack down on Medicaid fraud and enact other program reforms. He also criticized Congress when it passed legislation to block New York and other states from changing their Medicaid programs during the pandemic. But he has not acknowledged the underlying flaws in federal law that, by encouraging profligate blue state spending, created the problem in the first place.

Of the 14 wealthy states that benefit from the guaranteed 50 percent minimum Medicaid match, Hillary Clinton won 11. If the dramatic drop in oil and commodity prices in recent weeks persists, the three traditionally red states—Alaska, North Dakota, and Wyoming—that benefit from the statutory floor may no longer do so, should those states’ income decline. In the number of states affected and overall spending levels, the 50 percent minimum Medicaid match encourages overspending by blue states at the expense of federal taxpayers in red states.

In December 2018, the Congressional Budget Office estimated that removing the guaranteed 50 percent Medicaid match would save $394 billion over ten years. If McConnell and his colleagues want to tackle rising federal debt while stopping blue state bailouts, they should amend the Medicaid statute accordingly.

This post was originally published at The Federalist.