What Jon Stewart’s Rant Ignored about Congress

Congress ended up in some hot water recently—and for once, lawmakers did little to cause the trouble. At a House Judiciary Subcommittee on the Constitution hearing on legislation to reauthorize the 9/11 Victim Compensation Fund, television personality and hearing witness Jon Stewart went on a rant.

Noting many empty spaces on the committee dais, Stewart said, “You should be ashamed of yourselves for those that aren’t here, but you won’t be, because accountability doesn’t appear to be something that occurs in this chamber.” Noting that lawmakers tweeted about never forgetting the heroes of 9/11 on that sad anniversary, he accused them of “callous indifference and rank hypocrisy.”

1. The Hearing Wasn’t Really Empty

As a reporter pointed out on Twitter, most subcommittee members did attend the hearing. But because the hearing took place in the full committee hearing room—that has a dais where all the members of the full committee can sit—the space looked empty.

Holding a hearing in a bigger room than was actually required doesn’t represent “callous indifference and rank hypocrisy” so much as Congress not prioritizing the “production values” Stewart might find on a typical television or film set.

2. The Bill Ended Up Passing Anyway

3. Members of Congress Juggle Lots of Priorities

Because I’ve worked in both the House and Senate, I would use many words to describe the average member of Congress, but “lazy” and “indifferent” don’t often come to mind. Members sit on multiple committees, and multiple subcommittees within those committees. They often have to hop back and forth between hearings, and between the various congressional office buildings, to monitor witness testimony and ask questions.

On top of as many as half a dozen committee hearings and markups in a typical legislative workweek, members of Congress also have to juggle votes and speeches on the House and Senate floor, meetings with constituents, time with their staff to manage the office and discuss priorities, and—yes—raise funds for their re-election.

It might seem callous for a member to take the “drive-by” approach to a hearing—show up, ask questions, then leave—but frankly, most members of Congress don’t have time in their schedules to spend hours listening to witnesses speak at a hearing.

4. Most Congressional Hearings Are Boring

Take, for instance, Wednesday’s hearing on single-payer health care. The Hill called the hearing “mostly partisan and light on substance, with Members using their allotted time to rail for or against the proposal instead of questioning the panel of health care experts and advocates at the witness table.”

I watched much of the four-hour affair, and the publication delivered a spot-on description. Most members used their five minutes for “questions” to give a four-minute speech, followed by a softball inquiry or two to a friendly witness: “Don’t you agree with my point?” I spent the last two hours wondering how many more lawmakers had yet to ask their “questions,” so the hearing could mercifully conclude.

As I noted recently, most members of Congress don’t ask particularly sharp or hard-hitting questions—and in many cases, don’t ask questions at all. I could do with far fewer hearings myself, or at least proceedings that replace the oral element with written testimony. But congressional committees hold hearings to signal their priorities, and establish a written record for future legislative action. I wouldn’t call congressional hearings entirely theatrical in nature, but they do have a strong theatrical element.

5. The Alternatives Are Far Worse

The first would disappoint many issues, causes, and organizations, who want congressional committees to take time to spotlight “their” issue. It would make Congress a less diverse institution, with a smaller bandwidth to examine the many national and international issues worthy of attention from policy-makers.

It would also subject Congress to the equivalent of a “heckler’s veto,” whereby the few hearings committees did hold would focus on issues with celebrity supporters—to prevent rants like Stewart’s from putting Congress in a bad light—rather than unheralded topics that might warrant greater attention.

As to the second, some numbers might put the issue in perspective. The Constitution originally suggested that every member of Congress would represent 30,000 constituents. At that rate, and given a population of around 330 million, the House of Representatives would currently have 11,000 members—more than 25 times its current size.

Such an enormous legislative body would not just become unwieldy, it would raise federal spending. According to the Republican Study Committee, the House of Representatives has proposed $3.97 billion in spending on its operations over the next fiscal year. If an increase in the size of the House led to a proportional increase in spending, expansion to the size originally contemplated by the Constitution would result in roughly $100 billion in spending on members of Congress and their staffs—a figure the public would likely find unacceptable.

Congress has many faults worth addressing and reforming. But Stewart’s comments notwithstanding, compelling greater lawmaker attendance at hearings does not rank high on that list.

This post was originally published at The Federalist.

Will Democrats Shut Down the Government to Force Taxpayer Funding of Abortions?

Last week, the Hyde Amendment, which prohibits taxpayer funding of most abortions, became the focus of presidential politics. First Joe Biden said he still supported the amendment, then changed his position one day later, after tremendous political pressure from farther-left Democrats.

But the press should focus less on whether Democrats support taxpayer-funded abortion-on-demand. Virtually all Democrats running for president now support that position, as did the party’s 2016 national platform.

Democrats Don’t Want to Vote on Hyde

For all the focus last week on the Hyde Amendment, named after its prime advocate, the late Rep. Henry Hyde (R-IL), reporters have not focused on the Labor-Health and Human Services spending bill that the House of Representatives will consider this week. The committee-approved bill includes the following language:

SEC. 506. (a) None of the funds appropriated in this Act, and none of the funds in any trust fund to which funds are appropriated in this Act, shall be expended for any abortion.

In other words, an appropriations bill approved by the Democratic-run House Appropriations Committee still includes the Hyde Amendment language. (Subsequent sections exempt cases of rape, incest, or to save the life of the mother—the Hyde Amendment exceptions—from the funding ban.)

Yet the chairwoman of that Committee, Rep. Nita Lowey (D-NY), co-sponsored stand-alone legislation (H.R. 1692) repealing the Hyde Amendment protections that she included in her spending bill.

How Far Will They Go?

Even if Republicans did not control the Senate, 41 pro-life senators could filibuster any measure lacking Hyde Amendment protections, thus preventing the legislation from passing. And of course, President Trump can, and likely would, veto any appropriations bills that omitted pro-life protections on taxpayer funding of abortion.

The likelihood during this Congress of legislation passing that excludes the Hyde Amendment seems infinitesimal. Moreover, such legislation passing during the next Congress could well require 1) a Democrat to win the presidency, 2) Democrats to retake the Senate, and 3) Democrats to agree to end the legislative filibuster, which dozens of them claim they oppose.

This Is All Just Failure Theater

Events in the House this week show that liberal members of Congress are essentially “going through the motions” about repealing the Hyde Amendment. Several of them, led by Rep. Ayanna Pressley (D-MA), offered an amendment to strike Hyde from the spending bill. However, on Monday the House Rules Committee reported a rule for consideration of the underlying bill that did not make the amendment in order.

Likewise, Pressley could have omitted that authorizing language, and submitted a shorter amendment just striking the Hyde provisions. She did not—and that she did not strongly suggests that she and her colleagues wanted to give the House Rules Committee, and therefore Democratic leadership, an “out” to block consideration of her amendment.

Pressley’s office claimed “the Congresswoman believes that she and her colleagues must use every tool and tactic available to fight for reproductive justice.” But if she wanted to use “every tool and tactic,” she would have drafted an amendment without an obvious procedural flaw giving the leadership political cover to reject it. She and her liberal colleagues would also demand a vote on her amendment, and vote against the rule to consider the bill unless and until Democrats give them one.

Pressley didn’t do the former, and when the vote on the rule came on Tuesday, she and her colleagues didn’t do the latter either. Instead, she cut a deal with the leadership whereby everyone could “save face”—as evidenced by the fact that House Rules Committee Chairman Jim McGovern, on the same day he denied her amendment a vote, co-sponsored the stand-alone bill requiring taxpayer funding of abortions.

Flip-Flops Ahead

In the coming months, however, Moulton will face a flip-flop decision of his own, as will the many other Democratic presidential candidates currently serving in Congress. Will they vote for spending bills that include the Hyde Amendment—as any final appropriations package almost certainly must include its provisions to get enacted into law—even though they claim to support repealing the amendment?

On Sunday, Democratic presidential candidate Bernie Sanders (I-VT) laid the groundwork for just such a reversal. In an interview with CNN, he admitted that “sometimes in a large bill you have to vote for things you don’t like.” (That makes a good argument for Congress to stop passing massive spending bills that they don’t bother to read.)

Of course, if Democrats don’t want to flip-flop on taxpayer funding of abortion, they have another alternative: Refuse to pass any spending bills that include the Hyde Amendment provisions. If House Speaker Nancy Pelosi (D-CA) wants to shut the federal government down until Republican lawmakers approve taxpayer-funded abortion-on-demand, well, good luck with that. But if she and her Democratic colleagues don’t want to follow that strategy, then they should get ready to explain to their constituents why they voted for legislation that retained the Hyde Amendment after promising to abolish it.

In crass political terms, Biden didn’t help his candidacy by wavering over the Hyde Amendment last week. But even though they may not yet realize it, most of his fellow presidential candidates may soon have their own flip-flop moments on taxpayer funding for abortion.

This post was originally published at The Federalist.

Meet the Radical Technocrat Helping Democrats Sell Single-Payer

If anyone had doubts about the radical nature of Democrats’ health care agenda, they needn’t look further than the second name on the witness list for this Wednesday’s House Ways and Means Committee hearing on single-payer health care: Donald Berwick of the Institute for Healthcare Improvement.

If that name sounds familiar, it should. In summer 2010, right after Obamacare’s passage, President Obama gave Berwick a controversial recess appointment to head the Centers for Medicare and Medicaid Services (CMS). Democrats refused to consider Berwick’s nomination despite controlling 59 votes in the Senate at the time, and he had to resign as CMS administrator at the end of his recess appointment in late 2011.

Berwick’s History of Radical Writings

Even a cursory review of Berwick’s writings explains why Obama’s only option was to push him through with a recess appointment, and why Democrats refused to give Berwick so much as a nomination hearing. As someone who read just about everything he wrote until his nomination—thousands of pages of journal articles, books, and speeches—I know the radical nature of Berwick’s thinking all too well. He believes passionately in a society ruled by a technocratic elite, thinking that a core group of government planners can run the country’s health care system better than individual doctors and patients.

Here is what this doctor believes in, in his own words:

  • Socialized Medicine: “Cynics beware: I am romantic about the National Health Service; I love it. All I need to do to rediscover the romance is to look at health care in my own country.”
  • Control by Elites: “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”
  • Wealth Redistribution: “Any health care funding plan that is just, equitable, civilized, and humane must—must—redistribute wealth from the richer among us to the poorer and less fortunate.”
  • Shutting Medical Facilities: “Reduce the total supply of high-technology medical and surgical care and consolidate high-technology services into regional and community-wide centers … Most metropolitan areas in the United States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology imaging.”
  • End of Life Care: “Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been available for centuries.”
  • Cost-Effectiveness Rationing of Care: “The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”
  • Doctors Putting “The System” over their Patients: “Doctors and other clinicians should be advocates for patients or the populations they service but should refrain from manipulating the system to obtain benefits for them to the substantial disadvantage of others.”
  • Standardized “Cookbook Medicine”: “I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care.”

For those who want a fuller picture of Berwick’s views, in 2010-11 I compiled a nearly 30-page dossier featuring excerpts of his beliefs, based on my comprehensive review of his prior writings and speeches. That document is now available online here, and below.

Where’s the Political Accountability?

Some of Berwick’s greatest admiration is saved for Britain’s National Health Service on the grounds that it was ultimately politically accountable to patients. For instance, Berwick said his “rationing with our eyes open” quote was “distorted,” claiming that

Someone, like your health insurance company, is going to limit what you can get. That’s the way it’s set up. The government, unlike many private health insurance plans, is working in the daylight. That’s a strength.

When running for governor of Massachusetts in 2013, Berwick claimed he “regrets listening to White House orders to avoid reaching out to congressional Republicans.” But that doesn’t absolve the fact that Berwick went to great lengths to avoid the political accountability he previously claimed to embrace.

It also doesn’t answer the significant questions about why Obama waited until after Obamacare’s enactment to nominate Berwick—deliberately keeping the public in the dark about the radical nature of the person he wanted to administer vast swathes of the law.

Thankfully, however, Wednesday’s hearing provides a case of “better late than never.” Republicans will finally get a chance to ask Berwick about the extreme views expressed in his writings. They will also be able to raise questions about why Democrats decided to give him an official platform to talk about single payer (and who knows what else).

This post was originally published at The Federalist.

Medicaid Expansion Has Louisianans Dropping Their Private Plans

If any state can serve as the poster child for the problems associated with ObamaCare’s Medicaid expansion, it’s Louisiana, which joined the expansion in 2016, after Democrat John Bel Edwards became governor. An audit released last year exposed ineligible Medicaid beneficiaries, including at least 1,672 people who made more than $100,000. But Louisiana’s Medicaid expansion has revealed another waste of taxpayer funds, both in the Pelican State and nationwide: the money spent providing coverage to people who already had health insurance.

Via a public-records request, the Pelican Institute obtained data demonstrating that thousands of Louisiana residents dropped their private coverage to enroll in Medicaid under the expansion. A spreadsheet compiled by the Louisiana Department of Health put the count between 3,000 and 5,000 people a month, and that doesn’t count those who enrolled in Medicaid first, then dropped private coverage.

When asked about the spreadsheet, Medicaid officials stated in an email that the Health Department “stopped producing” the data in late 2017 when it discovered its vendor’s information “was limited to [third-party liability] during the period of Medicaid enrollment.” Because the vendor couldn’t track beneficiaries before or after their Medicaid enrollment, the spreadsheet arguably underestimated the number of people dropping private coverage to enroll in Medicaid.

The Health Department’s internal spreadsheet information comports with other coverage estimates. A survey by Louisiana State University researchers found that, from 2015-17, enrollment in private insurance fell precipitously among low-income Louisiana residents eligible for Medicaid under the expansion. The number of people covered by private health insurance declined by tens of thousands, even as Medicaid enrollment skyrocketed by more than 141,000.

That masses of Louisiana residents canceled their private coverage to enroll in “free” Medicaid should surprise no one. In 2007 Massachusetts Institute of Technology economist Jonathan Gruber, who later became an architect of ObamaCare, concluded that some coverage expansions would see rates of “crowd-out”—government programs squeezing out private insurance—approaching 60%. Eight years later, Louisiana’s Legislative Fiscal Office estimated that crowd-out would cost taxpayers between $900 million and $1.3 billion over five years. Because enrollment in Medicaid expansion vastly exceeded initial projections, the true cost may rise far higher.

Federal budget analysts have yet to quantify the effect of crowd-out on Medicaid expansion—but they should, because estimates suggest that Washington is spending billions annually funding Medicaid for people with prior health coverage. Montana officials recently released a study boasting of 8,700 workers who would have employer-sponsored coverage but for Medicaid expansion, claiming that expansion provided “cost savings to businesses” of up to $114 million. Only in a bureaucrat’s mind would more government spending, taxes and government dependency represent “cost savings.”

In response to the Louisiana audit, the state recently purged more than 30,000 ineligible people from the rolls. Health Secretary Rebekah Gee claimed the action demonstrated how she and Gov. Edwards “want to make sure that only those that need Medicaid have Medicaid.” But good stewards of taxpayer dollars, upon receiving preliminary reports of people dropping coverage to enroll in Medicaid, would have demanded better data and fashioned policy solutions to address the problem. The Louisiana Department of Health did neither and stopped compiling the data.

Generations of Louisiana politicians, since Gov. Huey Long in the 1930s, have claimed that fostering an economy rooted in government dependence will lead to prosperity. But the more than 67,000 residents who have left the state in the past three years alone see a stagnant economy and a slowly sinking state. Louisiana can do better, and other states thinking about Medicaid expansion should think again.

This post was originally published at The Wall Street Journal.

Note to Britain: You Can Have Your NHS

As expected, the American press has heavily covered President Trump’s visit to Europe, including his time spent in Great Britain. But a row (that’s British for “argument”) that has gone under-reported on this side of the Atlantic also holds major implications for American patients.

Based on comments the President made earlier in the week, British politicians now believe they need to protect the country’s National Health Service (NHS) from “privatization” at the hands of American corporations. But even as they do so, another controversy—about the ways in which Britain denies life-saving treatments to patients, solely on cost grounds—illustrates the problems with socialized medicine, which the left wants to export to the United States.

Concern about Trade Agreements

During a press conference in London Tuesday, a British reporter questioned Trump about a post-Brexit trade deal between the U.S. and Britain. The reporter specifically asked whether “the entire economy needs to be on the table” in those discussions, “including the NHS.” Trump responded that “everything with a trade deal is on the table.”

Those comments—which Trump later attempted to walk back—prompted outrage that Britain’s “beloved” NHS was at risk. British politicians across parties raised concern that American companies could receive NHS contracts (even though subsidiaries of U.S. corporations have already done so), or that a free trade agreement could supersede legislative efforts by Parliament to prohibit additional private contracting within the health service.

The Health Secretary, Matt Hancock—an announced candidate in the race to succeed Theresa May as Conservative Party leader and Prime Minister—epitomized the sentiments, claiming that “the NHS

NHS Denying Patients Care

The controversy continued at Prime Minister’s Questions in the House of Commons Wednesday. In that hourlong session, no fewer than five questions asked whether the NHS was “for sale,” or some variation thereof. But the sixth NHS-related question, by Labour MP Karl Turner, proved the most revealing:

Twelve months ago, the Prime Minister told this House that she wanted a speedy resolution to the funding row between NHS England and Vertex regarding the drug Orkambi to treat cystic fibrosis. My seven-year-old constituent Oliver Ward wrote to the Prime Minister recently asking what progress she has made. Could the Minister please give Oliver some good news and tell him that he need not get up every day worrying about this terrible injustice?

Turner’s question referred to Orkambi, a drug that could help thousands of British patients currently suffering from cystic fibrosis. But the NHS refuses to pay for the drug—not because it does not work, but because it does not meet cost thresholds that government bureaucrats have set.

Britain’s National Institute for Health and Clinical Excellence decided in 2016 that the NHS would not pay for Orkambi at the price set by its manufacturer. For the three years since, British patients have not found that decision very NICE at all.

A Precursor of an American Single-Payer System?

Unfortunately, however, liberals want to export the British model of rationing health care on cost grounds to the United States. Recall President Obama’s comments about the issue a decade ago:

The chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here….There is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place.

Months after those comments, the New York Times ran an article, entitled “Why We Must Ration Health Care,” that argued for bringing a British-style rationing model to our shores.

This prevailing mentality among intellectual elites explains why neither the House nor Senate single-payer bills prohibit a government-run health plan from implementing cost-effectiveness research. In fact, the House bill explicitly provides for cost-effectiveness research as a method of determining drug prices, because most liberals believe that bureaucrats can and should have the power to restrict access to care on cost grounds. Most Americans, on the other hand, would strongly object to this rationing of care.

As for British politicians saying the NHS “isn’t for sale,” I could not care less—I wouldn’t want to buy it even if it were. The American health care system has its flaws, to be sure, but I have little interest in creating a system where government bureaucrats have near-total control over patients’ medical decisions, and use that power to deny access to life-saving care. I think most Americans would agree.

This post was originally published at The Federalist.

This Presidential Candidate Loves Obamacare–But Won’t Sign Up for It

If the 2020 presidential campaign illustrates anything so far, it’s the yawning chasm between Democrats’ rhetoric and their reality. Not only do the party’s presidential candidates not practice what they preach, they seemingly have little shame in failing to do so.

Last Thursday evening, one of the candidates running for the Democratic nomination, Sen. Michael Bennet (D-CO), appeared on CNN for a town hall discussion. During the discussion, Bennet criticized his fellow senator and presidential candidate, Bernie Sanders (I-VT), for his single-payer health-care plan.

Qualifies for Obamacare Subsidy, Yet Won’t Buy a Plan

In his town hall comments, Bennet claimed that “what we would be better off doing in order to get to universal health care quickly is to finish the job we started with” Obamacare. Yet consider this paragraph from Bennet’s op-ed the week previously, in which he outlined health care, and his recent prostate cancer diagnosis, as the reason for announcing his candidacy: “My cancer was treatable because it was detected through preventive care. The $94,000 bill didn’t bankrupt my family because I had insurance through my wife’s employer” (emphasis mine).

Remember: The federal Office of Personnel Management promulgated an arguably illegal rule in October 2013 that makes members of Congress eligible for subsidies for Obamacare coverage. Yet even with access to these illegal subsidies, Bennet has no interest in buying an Obamacare plan. That might be because he knows—as I do by being forced onto an exchange plan—that these Obamacare plans are junk insurance, with high premiums, high deductibles, and in many cases poor access to physician networks.

Do As I Say, Not As I Do

Some may argue that because Bennet does not support Sanders’s single-payer proposal, at least he will not force others to give up their health coverage (even as he refuses to go on to Obamacare). But in 2009, one analysis of a government-run “public option,” which Bennet supports as an alternative to single-payer, concluded that it would lead to a reduction in private insurance coverage of 119.1 million people. This would shrink the employer-provided insurance market by more than half.

Even Bennet’s “moderate” proposal could lead to many millions of Americans immediately losing the coverage they have if employers drop coverage en masse. Yet will Bennet give up his employer coverage and go on to Obamacare? Not a chance.

Some may question why I write about this topic so often. After all, if every member of Congress, or every Democratic presidential candidate, suddenly decided to sign up for Obamacare, it wouldn’t significantly affect the exchange’s overall premiums and coverage numbers. But lawmakers’ coverage decisions have outsized importance because they reveal their true motivations.

Obama’s action, however, represents the exception that proves the rule. Instead, liberals want to order other people to buy Obamacare health insurance while not doing so themselves. They epitomize Ronald Reagan’s 1964 speech “A Time for Choosing,” in which he referred to a “little intellectual elite in a far-distant capital,” who believe they “can plan our lives for us better than we can plan them ourselves.”

By promising to expand Obamacare even as he fails to enroll in it himself, Bennet demonstrated himself part and parcel of that “little intellectual elite.” So have his fellow Democratic presidential candidates. Americans should take note—and vote accordingly next November.

This post was originally published at The Federalist.

Democrats’ Anti-Choice Agenda

In response to various abortion legislation enacted in Alabama, Georgia, Missouri, and other states, the left has called for a national day of protest on this Tuesday. The groups calling for the protest object to “Donald Trump’s anti-choice movement.”

The groups know of which they speak. The left wants to prohibit choice in medicine, by forcing doctors and health-care providers with religious objections to perform abortions. Multiple Democrat health-care bills would not only force taxpayers to fund abortions, they would commandeer doctors to perform abortions—not to mention other medical procedures that might violate their deeply held religious beliefs.

Existing Conscience Protections

The second conscience provision, the Church Amendment, exists in permanent federal law. It prohibits organizations from discriminating against individuals who refuse to participate in abortions or sterilizations. However, the Church Amendment’s provisions only apply to entities receiving grants or loans under certain statutes and programs:

  • The Public Health Service Act;
  • The Community Mental Health Centers Act;
  • The Developmental Disabilities Services and Facilities Construction Act; and
  • Contracts for biomedical or behavioral research under any HHS program.

The last three programs in particular represent a relatively small percentage of federal funding. And while the Public Health Service Act encompasses a broad set of programs, it does not contain nearly the amount of federal funding as larger entitlements like Medicare and Medicaid.

Single Payer Undermines Conscience Protections

Single-payer legislation in both the House (H.R. 1384) and Senate (S. 1129) would undermine conscience protections. These bills would create a new, automatic funding mechanism for the single-payer program.

Because the single-payer program would not get funded through the Labor-HHS appropriations bill, the Weldon Amendment conscience protections included in that measure would not apply to the program. For the same reason, the Hyde Amendment’s prohibition on taxpayer funding of abortion, also included in the Labor-HHS spending bill, would also not apply.

In theory, the Church Amendment conscience protections would still apply. However, these protections only apply to the discrete federal programs listed above, and therefore may not apply in all cases. Moreover, if existing federal grant programs get subsumed into a new single-payer system—as the sponsors of the legislation would no doubt hope—then conscience protections might go away entirely.

Medicare for America: No Conscience Protections At All

Eliminating conscience protections would fit the rubric established by the Medicare for America bill (H.R. 2452). As I pointed out in the Wall Street Journal last week, the legislation belies its “moderate” label, as it would ban all private health care. On top of that, language on page 51 of the version of the bill introduced earlier this month makes clear that conscience protections do not apply to any medical professional, under any circumstance:

(3) HEALTH CARE PROVIDERS.—Health care providers may not be prohibited from participating in the Medicare for America [sic] for reasons other than their ability to provide covered services. Health care providers and institutions are prohibited from denying covered individuals access to covered benefits and services because of their religious objections. This subsection supercedes any provision of law that allows for conscience protection.

Even more than the Sanders bill, this language makes clear: Doctors have zero conscience protections under Medicare for America, whether about abortion or any other issue. To put it another way, medical professionals can practice their faith for one hour at church on Sunday, but if they wish to live their religious beliefs, they must join another profession.

Philosophical and Practical Concerns

Beyond the moral concerns outlined above, abolishing conscience protections could come with very severe unintended consequences. More than 600 Catholic hospitals (to say nothing of hospitals with other religious affiliations) serve more than one in seven U.S. patients.

Would passage of these bills force these religiously affiliated facilities to close, rather than have the facilities and the professionals within them violate their consciences? And if facilities close, or doctors leave the profession rather than performing procedures that violate their deeply held religious beliefs, who will pick up the slack? After all, our nation already faces looming physician shortages, and the promise of “free” care under a government-run system will only encourage more consumption of health services.

Liberals might want to keep the focus on the state initiatives in Alabama and elsewhere. But forcing people to violate their religious beliefs, and potentially chasing doctors and nurses out of the medical profession as a result, represents the truly radical policy.

This post was originally published at The Federalist.

What You Need to Know About Medicaid Crowd Out

A PDF version of this document is available on the Pelican Institute’s website

In recent weeks, lawmakers have focused on the tens of thousands of ineligible individuals who improperly received benefits under Louisiana’s Medicaid expansion. But fighting waste, fraud, and abuse in Medicaid should also include reforms to address another important issue—crowd out. The term refers to Louisiana residents who have dropped their existing coverage to enroll in Medicaid expansion—in other words, government programs “crowding out” private insurance. Here’s what you need to know about crowd out and Medicaid expansion:

Tens of Thousands of People Have Dropped Private Coverage to Enroll in Medicaid

Recently, the Pelican Institute filed a public records request to obtain internal Louisiana Department of Health (LDH) data showing that for much of 2016 and 2017, several thousand individuals dropped their existing health coverage to enroll in Medicaid expansion. With enrollment in Medicaid expansion averaging approximately 15,000 individuals per month in 2017, the data indicates a significant percentage of enrollees dropped their prior coverage to join Medicaid expansion.

Funding Benefits for People Who Previously Had Health Insurance Consumes Scarce Medicaid Resources

Crowd out populations pose big potential costs for Louisiana taxpayers. In 2015, the Legislative Fiscal Office assumed that if Louisiana expanded Medicaid, the state would spend between $900 million and $1.3 billion over five years providing Medicaid coverage to individuals with prior health coverage.

When testifying before the House Appropriations Committee on April 23, LDH staff indicated that, during the fiscal year ending this June 30, the average expansion enrollee cost Medicaid $523.85 per month, or $6,286.20 per year. Multiplying this average cost per enrollee by the number of individuals who dropped private coverage, according to last year’s LSU Health Insurance Survey, yields a potential cost to state and federal taxpayers of $461.6 million this fiscal year:

  • Dropped coverage from a current employer: 40,147; Potential cost to taxpayers: $252.4 million
  • Dropped coverage from a former employer: 23,086; Potential cost to taxpayers: $145.1 million
  • Dropped privately purchased coverage: 10,201; Potential cost to taxpayers: $64.1 million

Because the LSU researchers extrapolated the coverage numbers from survey responses, and because the survey responses varied only slightly from 2015 to 2017, the results for privately purchased coverage, and coverage from a former employer, might have occurred due to random chance, rather than any actual drop in coverage rates. Regardless, the decline in coverage from a former employer DID meet the tests of statistical significance; this crowd out is costing the Medicaid program on the order of $145.1 million per year. Moreover, the potential fiscal impact of the crowd out problem demonstrates the need for more accurate data on the issue.

Crowd Out Metrics

The March 2019 LSU report cites a seminal 1996 work from MIT Professor Jonathan Gruber to define crowd out—the decrease in private insurance divided by the change in public insurance. To put it simply, crowd out should quantify the percentage of Medicaid enrollees who dropped their private coverage to enroll in expansion. Unfortunately, LDH has used different—and inaccurate—metrics to define crowd out on several occasions in attempts to minimize its impact.

For instance, in August 2017, the Department counted 5,659 “Medicaid expansion members who have private insurance whose private insurance policies ended 0-60 days prior to Medicaid expansion enrollment”—4,957 whose coverage ended 0-30 days prior to enrollment in expansion, and another 702 whose coverage ended 31-60 days prior to enrollment. The Department’s internal spreadsheets calculated one crowd out rate of 1.3%, based on a total enrollment in expansion of 442,674.

But this calculation creates an inherently inaccurate result, because it divides the number of new enrollees who dropped coverage by the number of total enrollees in the program. An accurate crowd out rate would compare like with like—dividing the number of new enrollees who dropped private coverage in a given month by the overall number of new enrollees in that month. This metric would accurately determine what percentage of new enrollees are dropping coverage.

Using that rubric, Louisiana’s Medicaid expansion suffers from far higher crowd out rates. According to data provided by LDH in response to the Pelican Institute’s public records request, in August 2017 a total of 13,955 individuals enrolled in expansion—8,783 who had previously enrolled in Medicaid, and 5,172 who had never done so before. Dividing the number of new enrollees who dropped private coverage in the prior 30 days (4,957) by the number of new enrollees overall (13,955) yields a potential crowd out rate of 35.5%—far higher than the 1-2% figure cited in the internal LDH spreadsheets.

At the April 23 House Appropriations Committee hearing, Medicaid director Jen Steele cited data from the LSU Health Insurance Survey to estimate a crowd out rate of 2.4%. But that survey data expressed coverage changes as a percentage of the overall low-income population, not based as a percentage of Medicaid enrollees—making it another inaccurate metric.

Based on LDH’s own internal data, that rate more likely approaches 30-40%.

Need for Better Program Integrity

The debate regarding crowd out comes on the heels of the Medicaid eligibility situation, in which LDH acknowledged that 1,672 individuals with six-figure incomes—including at least one individual reporting a higher income than Gov. John Bel Edwards’ annual salary—enrolled in Medicaid expansion. LDH’s failure to address the crowd out problem, and at the same time, the expansion enrollment of individuals with six-figure incomes suggests the need for fundamental reform to Louisiana’s Medicaid program. Government officials at all levels must serve as smart stewards of scarce taxpayer dollars, and a growing number of signs raise questions about LDH’s fulfillment of this critical role.

Conclusion

Solutions to mitigate crowd out should focus on using scarce government resources wisely, while promoting independence and self-sufficiency amongst beneficiaries. For instance, Indiana recently proposed a waiver that would allow beneficiaries transitioning off of Medicaid to keep a portion of their Medicaid dollars. Those retained dollars could fund co-payments on their new private insurance, whether purchased through an employer or individually. These and similar innovative concepts would encourage beneficiaries to transition off of government assistance and into private coverage.

The Inconvenient Truths of Louisiana’s Medicaid Expansion

In the wake of a wave of stories about the tens of thousands of ineligible individuals who received Medicaid benefits, supporters keep trying to defend Louisiana’s expansion of Medicaid to the able-bodied. But their defenses ignore several inconvenient truths.

First, money doesn’t grow on trees. Health Secretary Rebekah Gee recently claimed that Louisiana’s “Medicaid expansion comes at no additional cost to taxpayers.” Because she believes the federal government will pay all the cost of Medicaid expansion, she thinks Louisiana taxpayers are “off the hook” for the program’s spending. But anyone who had to mail a check to the Internal Revenue Service on April 15 would disagree. By definition, any new government spending imposes a cost to taxpayers, because Louisiana residents pay taxes to Washington just like everyone else.

And Louisiana has seen a ton of new government spending due to Medicaid expansion. In 2015, the Legislative Fiscal Office projected spending on expansion to total $1.2 billion-$1.4 billion per year. In the last fiscal year, Louisiana spent nearly $3.1 billion on expansion—or more than double the Fiscal Office’s original estimates.

Second, the truly vulnerable continue to get overlooked due to Medicaid expansion. Secretary Gee claimed that her “top priority is to ensure every dollar spent [on Medicaid] goes towards providing health care to people who need it most.” But Louisiana still has tens of thousands of individuals with disabilities on waiting lists for home and community-based services—who are not getting the care they need, because Louisiana has focused on expanding Medicaid to the able-bodied.

Since Louisiana expanded Medicaid in July 2016, at least 5,534 Louisiana residents with disabilities have died—yes, died—while on waiting lists for Medicaid to care for their personal needs. Louisiana should have placed the needs of these vulnerable patients ahead of expanding coverage to able-bodied adults—tens of thousands of whom already had private health insurance and dropped that insurance to enroll in Medicaid expansion.

This skewed sense of priorities pervades supporters of Medicaid expansion. One recently claimed that most of the individuals improperly enrolled in expansion “are poor, but not poor enough to qualify for coverage” under Medicaid.

The Louisiana Legislative Auditor’s report suggests otherwise. The 100 Medicaid recipients studied by the auditor, 93 of whom did not qualify for benefits for at least one month they received them, had an average—repeat, average—household income of $67,742. Fourteen of the recipients reported income of over $100,000. One recipient reported income of $145,146—well above Governor John Bel Edwards’ annual salary of $130,000.

The Louisiana Department of Health recently acknowledged that at least 1,672 individuals receiving over $100,000 qualified for Medicaid benefits. Supporters of Medicaid expansion can claim that these six-figure Medicaid beneficiaries classify as “poor,” but hardworking taxpayers forced to foot the bill for these recipients would likely disagree.

Louisiana taxpayers deserve policies that prioritize the most vulnerable in society—individuals with disabilities currently dying on waiting lists—rather than funding benefits for enrollees with six-figure incomes, or able-bodied adults who dropped their private coverage to enroll in Medicaid. They deserve more than claims that money grows on trees, or that expanding dependency will lead to growth and prosperity. They deserve better than Medicaid expansion’s failed status quo.

This post was originally published in the Daily Advertiser.

Why Do Louisiana Republicans Want to Replace Obamacare with Obamacare?

For the latest evidence that bipartisanship occurs in politics when conservatives agree to rubber-stamp liberal policies, look no further than Louisiana. Last week, that state’s senate passed a health-care bill by a unanimous 38-0 margin.

The bill provides that, if a court of competent jurisdiction strikes down all of Obamacare, Louisiana would replace that law with something that…looks an awful lot like Obamacare. Granted, most remain skeptical that the Supreme Court will strike down all (or even most) of Obamacare, not least because the five justices who upheld its individual mandate in 2012 all remain on the bench. Notwithstanding that fact, however, the Louisiana move would codify bad policies on the state level.

If a federal court strikes down the health-care law, the bill would re-codify virtually all of Obamacare’s major insurance regulations on the state level in Louisiana, including:

  • A prohibition on pre-existing condition exclusions;
  • Limits on rates that insurers can charge;
  • Coverage of essential health benefits “that is substantially similar to that of the essential health benefits required for a health plan subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019,” including the ten categories spelled out both in the text of Obamacare and of the Louisiana bill;
  • “Annual limitations on cost sharing and deductibles that are substantially similar to the limitations for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019”;
  • “Levels of coverage that are substantially similar to the levels of coverage required for health plans subject to the federal Patient Protection and Affordable Care Act as of January 1, 2019”;
  • A prohibition on annual and lifetime limits; and
  • A requirement for coverage of “dependent” children younger than age 26.

The Louisiana bill does allow for slightly more flexibility in age rating than Obamacare does. Obamacare permits insurers to charge older individuals no more than three times younger enrollees’ premiums, whereas the Louisiana bill would expand this ratio to 5-to-1. But in every other respect, the bill represents bad or incoherent policy, on several levels.

First, the regulations above caused premiums to more than double from 2013 through 2017, as Obamacare’s main provisions took effect. Reinstating these federal regulations on the state level would continue the current scenario whereby more than 2.5 million people nationwide were priced out of the market for coverage in a single year alone.

Second, the latter half of the Louisiana bill would create a “Guaranteed Benefits Pool,” essentially a high-risk pool for individuals with pre-existing conditions. Given that the bill provides a clear option for individuals with pre-existing conditions, it makes little sense to apply pre-existing condition regulations—what the Heritage Foundation called the prime driver of premium increases under Obamacare—to Louisiana’s entire insurance market. This provision would effectively raise healthy individuals’ premiums for no good policy reason.

Third, the legislation states that the regulations “shall be effective or enforceable only” if a court upholds the Obamacare subsidy regime, “or unless adequate appropriations are timely made by the federal or state government” in a similar amount and manner. Curiously, the bill does not specify who would declare the “adequa[cy]” of such appropriations. But should a court ever strike down most or all of Obamacare, this language provides a clear invitation for Democratic Gov. John Bel Edwards to demand that Louisiana lawmakers raise taxes—again—to fund “adequate appropriations” reinstating the law on the state level.

As on the federal level, conservatives in Louisiana should not fall into the trap of reimposing Obamacare’s failed status quo for pre-existing conditions. Liberal organizations don’t want to admit it, but the American people care most about making coverage affordable. Obamacare’s one-size-fits-all approach undermined that affordability; better solutions should restore that affordability, by implementing a more tailored approach to insurance markets.

Recognizing that they will get attacked on pre-existing conditions regardless of what they do, conservatives should put forward solutions that reduce people’s insurance costs, such as those previously identified in this space. Conservatives do have better ideas than Obamacare’s failed status quo, if only they will have the courage of their convictions to embrace them.

This post was originally published at The Federalist.