Will Disclosing Prescription Drug Prices in TV Ads Make Any Difference?

Why did the Trump administration last Monday propose requiring pharmaceutical companies to disclose their prices in television advertisements? A cynic might believe the rule comes at least in part because the drug industry opposes it.

Now, I carry no water for Big Pharma. For instance, I opposed their effort earlier this year to repeal an important restraint on Medicare spending. But this particular element of the administration’s drug pricing plan appears to work in a similar manner as some of the president’s tweets—to dominate headlines through rhetoric, rather than through substantive policy changes.

Applies Only to Television

The rule “seek[s] comment as to whether we should apply this regulation to other media formats,” but admits that the administration initially “concluded that the purpose of this regulation is best served by limiting the requirements” to television. However, five companies alone accounted for more than half of all drug advertisements in the past year. Among those five companies, the advertisements promoted 19 pharmaceuticals—meaning that new disclosure regime would apply to very few drugs.

If the “purpose of this regulation” is to affect pharmaceutical pricing, then confining disclosures only to television advertisements would by definition have a limited impact. If, however, the “purpose of this regulation” is primarily political—to force drug companies into a prolonged and public legal fight on First Amendment grounds, or to allow the administration to point to disclosures in the most prominent form of media to say, “We’re doing something on drug costs!”—then the rule will accomplish its purpose.

Rule Lacks Data to Support Its Theory

On three separate occasions, in the rule’s Regulatory Impact Analysis—the portion of the rule intended to demonstrate that the regulation’s benefits outweigh its costs—the administration admits it has very few hard facts: “We lack data to quantify these effects, and seek public comment on these impacts.”

It could encourage people to consume more expensive medicines (particularly if their insurance pays for it), because individuals may think costlier drugs are “better.” Or it could discourage companies from advertising on television at all, which could reduce drug consumption and affect people’s health (or reduce health spending while having no effect on individuals’ health).

Conservative think-tanks skewered several Obamacare rules released in 2010 for the poor quality and unreasonable assumptions in their Regulatory Impact Analyses. Although released by a different administration of a different party, this proposed regulation looks little different.

Contradictions on Forced Speech?

Finally, the rule refers on several occasions to the Supreme Court’s ruling earlier this year in a case involving California crisis pregnancy centers. That case, National Institute of Family and Life Advocates v. Becerra, overturned a California state law requiring reproductive health clinics, including pro-life crisis pregnancy centers, to provide information on abortion to patients.

The need for that distinction arises because the pharmaceutical industry will likely challenge the rule on First Amendment grounds as an infringement on their free speech rights. However, a pro-life administration attempting to force drug companies to disclose pricing information, while protecting crisis pregnancy centers from other forced disclosures, presents some interesting political optics.

A Political ‘Shiny Object’

Ironically enough, most of the administration’s actions regarding its prescription drug pricing platform have proven effective. Food and Drug Administration Commissioner Scott Gottlieb has helped speed the approval of generic drugs to market, particularly in cases where no other competitors exist, to help stabilize the marketplace.

Other proposals to change incentives within Medicare and Medicaid also could bring down prices. These proposals won’t have an immediate effect—as would Democratic blunt-force proposals to expand price controls—but collectively, they will have an impact over time.

This administration can do better than that. Indeed, they already have. They should leave the political stunts to the president’s Twitter account, and get back to work on more important, and more substantive, proposals.

This post was originally published at The Federalist.

Politico Reporter’s “Fact Check” of Trump Riddled with Omissions

Who will fact check the fact checkers? That question reared its head again late last week, as a reporter from Politico attempted to add “context” to health-care-related comments the president made at a political rally in Las Vegas. As with Trump himself, what Politico reporter Dan Diamond omitted said just as much as what he included.

During his speech, the president talked about pre-existing conditions, saying Republicans want to “protect patients with pre-existing conditions:”

I’ve previously written about the Obamacare lawsuit in question—why I oppose both the lawsuit, and the Justice Department’s intervention in the case, as unwise judicial activism—and Republicans’ poor response on the issue. But note what neither Diamond nor Trump mentioned: That the pre-existing condition “protections” are incredibly costly—the biggest driver of premium increases—and that, when voters are asked whether they would like these provisions “if it caused the cost of your health insurance to go up,” support plummets by roughly 40 percentage points.

If you need any more persuading that the media are carrying liberals’ water on pre-existing conditions, consider that the Kaiser Family Foundation released their health care tracking survey earlier this month. In it, Kaiser asked whether people are worried that “if the Supreme Court overturns the health care law’s protections for people with pre-existing health conditions you will have to pay more for health insurance coverage.”

The survey didn’t mention that all individuals are already paying higher premiums for those “protections” since Obamacare took effect—whether they want to or not, and whether they have a pre-existing condition or not. In fact, the survey implied the opposite. By only citing a scenario that associates premium rises with a Supreme Court ruling striking down the provisions, Kaiser misled respondents into its “preferred” response.

Then last week, Politico ran another story on the Republican strategy to “duck and cover” regarding the states’ lawsuit, which might of course have something to do with the tenor of Politico’s “reporting” on pre-existing conditions in the first place.

Next, to Single-Payer Proposals

Following the comments about pre-existing conditions, the president then went on the attack, and Diamond felt the need to respond.

Diamond accurately notes that “there is no consensus ‘Democrat plan.’” As the saying goes, the left hand doesn’t always know what the far-left hand is doing. But Trump also made crystal clear what specific Democratic plan he was describing—the single-payer plan written by Sen. Bernie Sanders (I-VT). He even quoted the $32 trillion estimated cost of the plan, as per a Mercatus Center study that became the topic of great dispute earlier this summer.

Here’s what Section 102(a) of Sanders’ bill (S. 1804) says about coverage under the single-payer plan: “SEC. 102. UNIVERSAL ENTITLEMENT. (a) IN GENERAL.—Every individual who is a resident of the United States is entitled to benefits for health care services under this Act. The Secretary shall promulgate a rule that provides criteria for determining residency for eligibility purposes under this Act.”

And here’s what Section 107(a) of the bill says about individuals trying to keep their own health coverage, or purchasing other coverage, to “get out” of the single-payer system:


(a) IN GENERAL.—Beginning on the effective date described in section 106(a), it shall be unlawful for—

(1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or

(2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act.

In other words, the Sanders bill “would force every American on to government-run health care, and virtually eliminate all private and employer-based health care plans”—exactly as the president claimed.

His “most” wording cleverly attempted to elide the fact that the most prominent Democratic plan—the one endorsed by everyone from Sanders to Sens. Elizabeth Warren (D-MA), Cory Booker (D-NJ), Kamala Harris (D-CA), and Kirsten Gillibrand (D-NY), and vigorously pursued by the activist left—does exactly what Trump claimed.

I have little doubt that, had the president inflated the Mercatus study’s estimated cost of Sanders’ single-payer plan—for instance, had Trump said it would cost $42 trillion, or $52 trillion, instead of using the $32 trillion number—Diamond (and others) would have instantly “fact checked” the incorrect number. Given that Diamond, and just about everyone else, knew Trump was talking about the single-payer bill, this so-called “fact check”—which discussed everything but the bill Trump referenced—looks both smarmy and pedantic, specifically designed to divert attention from the most prominent Democratic plan put forward, and Trump’s (accurate) claims about it.

Medicare Benefits Not Guaranteed

Ironically, if Diamond really wanted to fact check the president, as opposed to playing political games, he had a wide open opportunity to do so, on at least two levels. In both cases, he whiffed completely.

In the middle of his riff on single-payer health care, President Trump said this: “Robbing from our senior citizens—you know that? It’s going to be one of the great catastrophes ever. The benefits—they paid, for their entire lives—are going to be taken away.” Wrong, wrong, wrong.

Politicians can claim all they want that people “paid into” Medicare to get back their benefits, but it isn’t true. The average senior receives far more in benefits than what he or she paid into the system, and the gap is growing. Medicare’s existing cash crunch makes a compelling case against expanding government-run health care, but it still doesn’t mean that seniors “paid for” all (as opposed merely to some) of the benefits they receive.

Second, as I have previously noted, Sanders’ bill is not “Medicare-for-all.” It’s “Medicare-for-none.” Section 901(a)(1)(A) of the bill would end benefits under the current Medicare program, and Section 701(d) of the bill would liquidate the existing Medicare trust fund. If seniors like the Medicare coverage, including the privately run Medicare Advantage plans, they have now, they would lose it. Period.

To sum up, in this case Politico ignored:

  1. The cost of the pre-existing condition “protections”—how they raise premiums, and how Obamacare advocates don’t want to mention that fact when talking about them;
  2. The way that the most prominent Democratic health care bill—the one that President Trump very clearly referred to in his remarks—would abolish private coverage and force hundreds of millions of individuals on to government-run health care;
  3. Inaccurate claims President Trump made about seniors having “earned” all their Medicare benefits; and
  4. The fact that Sanders’ bill would actually abolish Medicare for seniors.

And people say the media have an ideological bias in favor of greater government control of health care. Why on earth would they think that?

This post was originally published at The Federalist.

Florida Democrats’ Campaign to Abolish Seniors’ Medicare

Full disclosure: I have done paid consulting work for Florida’s current governor, Rick Scott, in his campaign against Democratic Sen. Bill Nelson. And I have provided informal advice to Rep. Ron DeSantis, the Republican nominee for governor. However, neither the Scott nor DeSantis campaigns had any involvement with this article, and my views are—as always—my own.

On Tuesday, Democrats in Florida nominated an unusual candidate for governor, and it has nothing to do with his skin color or background. Tallahassee Mayor Andrew Gillum, who would serve as Florida’s first African-American governor if elected, says on his campaign’s website that the health plan U.S. Sen. Bernie Sanders (I-VT) has offered at the national level “will help lower costs and expand coverage to more Floridians.”



(1) IN GENERAL.—Notwithstanding any other provision of law, subject to paragraphs (2) and (3)—

(A) no benefits shall be available under title XVIII of the Social Security Act for any item or service furnished beginning on or after the effective date of benefits under section 106(a)… [emphasis added].

In case you didn’t know, Title XVIII of the Social Security Act refers to Medicare. Section 901(a)(1)(A) of Sanders’ bill, which he brands as “Medicare-for-all,” would prohibit the Medicare program from paying out any benefits once the single-payer system takes effect. Section 701(d) of his bill would liquidate the Medicare trust funds, transferring “any funds remaining in” them to the single-payer plan.

In other words, Democrats just nominated as a statewide candidate in Florida—a state with the highest population of seniors, and where seniors and near-seniors (i.e., all those over age 50) comprise nearly half of the voting electorate—someone who, notwithstanding Sanders’ claims about his single-payer bill, supports legislation that would abolish Medicare for seniors entirely. Good luck with that.

That’s What ‘Radical Experiment’ Means, Folks

The recent hullabaloo over an estimated budget score of the Sanders plan, which would require tens of trillions—yes, I said trillions—of dollars in tax increases, highlighted only one element of its radical nature. However, as I pointed out in a Wall Street Journal op-ed earlier this year, the Sanders experiment would go far beyond raising taxes, by abolishing traditional Medicare, along with just about every other form of insurance.

Everyone else, which is roughly 300 million people, would lose their current coverage. Traditional Medicare, Medicaid, and the State Children’s Health Insurance Program would all evaporate. Even the Federal Employee Health Benefit Program would disappear.

With those changes in coverage, people could well lose access to their current doctors. As a study earlier this summer noted, medical providers like doctors and hospitals would get paid at much lower reimbursement rates, of 40 percent lower than private insurance. (A liberal blogger claimed earlier this week that, because other payers reimburse at lower levels than private insurers, the average pay cut to a doctor or hospital may total “only” 11-13 percent.)

Doctors and hospitals would also have to provide more health care services to more people, since “free” health care without co-payments will induce more demand for care. If you think doctors will voluntarily work longer hours for even less pay, I’ve got some land I want to sell you.

Déjà vu All Over Again?

In 1983, the British Labour Party wrote an election manifesto that one of its own members of Parliament famously dubbed “the longest suicide note in history.” That plan pledged unilateral nuclear disarmament, higher taxes on the rich, to abolish the House of Lords, and renationalization of multiple industries.

Although Sanders’ bill weighs in at 96 pages in total, opponents of the legislation can sum up its contents much more quickly: “It abolishes Medicare for seniors.” That epithet could prove quite a short suicide note for Gillum—and the Left’s socialist dreams around the country.

This post was originally published at The Federalist.

How Single-Payer Supporters Defy Common Sense

The move to enact single-payer health care in the United States always suffered from major math problems. This week, it revived another: Common sense.

On Monday, the Mercatus Center published an analysis of single-payer legislation like that promoted by socialist Sen. Bernie Sanders (I-VT). While conservatives highlighted the estimated $32.6 trillion price tag for the legislation, liberals rejoiced.

Riiiiiigggggggghhhhhhhhhttttt. As the old saying goes, if something sounds too good to be true, it usually is. Given that even single-payer supporters have now admitted that the plan will lead to rationing of health care, the public shouldn’t just walk away from Sanders’ plan—they should run.

National Versus Federal Health Spending

Sanders’ claim arises because of two different terms the Mercatus paper uses. While Mercatus emphasized the way the bill would increase federal health spending, Sanders chose to focus on the study’s estimates about national health spending.

Although it sounds large in absolute terms, the Mercatus paper assumes only a slight drop for health spending in relative terms. It estimates a total of $2.05 trillion in lower national health expenditures over a decade from single-payer. But national health expenditures would total $59.7 trillion over the same time span—meaning that, if Mercatus’ assumptions prove correct, single-payer would reduce national health expenditures by roughly 3.4 percent.

Four Favorable Assumptions Skew the Results

However, to arrive at their estimate that single-payer would reduce overall health spending, the Mercatus paper relies on four highly favorable assumptions. Removing any one of these assumptions could mean that instead of lowering health care spending, single-payer legislation would instead raise it.

First, Mercatus adjusted projected health spending upward, to reflect that single-payer health care would cover all Americans. Because the Sanders plan would also abolish deductibles and co-payments for most procedures, study author Chuck Blahous added an additional factor reflecting induced demand by the currently insured, because patients will see the doctor more when they face no co-payments for doing so.

Second, the Mercatus study assumes that a single-payer plan can successfully use Medicare reimbursement rates. However, the non-partisan Medicare actuary has concluded that those rates already will cause half of hospitals to have overall negative total facility margins by 2040, jeopardizing access to care for seniors.

Expanding these lower payment rates to all patients would jeopardize even more hospitals’ financial solvency. But paying doctors and hospitals market-level reimbursement rates for patients would raise the cost of a single-payer system by $5.4 trillion over ten years—more than wiping away any supposed “savings” from the bill.

Finally, the Mercatus paper “assumes substantial administrative cost savings,” relying on “an aggressive estimate” that replacing private insurance with one single-payer system will lower health spending. Mercatus made such an assumption even though spending on administrative costs increased by nearly $26 billion, or more than 12.3 percent, in 2014, Obamacare’s first year of full implementation.

Likewise, government programs, unlike private insurance, have less incentive to fight fraud, as only the latter face financial ruin from it. The $60 billion problem of fraud in Medicare provides more than enough reason to doubt much administrative savings from a single-payer system.

Apply the Common Sense Test

But put all the technical arguments aside for a moment. As I noted above, whether a single-payer health-care system will reduce overall health expenses rests on a relatively simple question: Will doctors and hospitals agree to provide more care to more patients for the same amount of money?

Whether single-payer will lead to less paperwork for doctors remains an open question. Given the amount of time people spend filing their taxes every year, I have my doubts that a fully government-run system would generate major improvements.

But regardless of whether providers get any paperwork relief from single-payer, the additional patients will come to their doors seeking care, and existing patients will demand more services once government provides them for “free.” Yet doctors and hospitals won’t get paid any more for providing those additional services. The Mercatus study estimates that spending reductions due to the application of Medicare’s price controls to the entire population will all but wipe out the increase in spending from new patient demand.

If Sanders wants to take a “victory lap” for a study arguing that millions of health care workers will receive the same amount of money for doing more work, I have four words for him: Good luck with that.

Health Care Rationing Ahead

I’ll give the last word to, of all things, a “socialist perspective.” One blog post yesterday actually claimed the Mercatus study underestimated the potential savings under single-payer: “[The study] assumes utilization of health services will increase by 11 percent, but aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit below the level [it] projects” (emphasis mine).

In other words, spending will fall because so many will demand “free” health care that government will have to ration it. To socialists who yearningly long to exercise such power over their fellow citizens, such rationing sounds like their utopian dream. But therein lies their logic problem, for any American with common sense would disagree.

This post was originally published at The Federalist.

How Will Senate Health Bill Lower Premiums? Corporate Welfare

When the Congressional Budget Office (CBO) releases its estimate of Senate Republicans’ Obamacare discussion draft this week, it will undoubtedly state that the bill will lower health insurance premiums. A whopping $65 billion in payments to insurers over the next three years virtually guarantees this over the short-term.

Indeed, Senate Republican staff have reportedly been telling members of Congress that the bill is designed to lower premiums between now and the 2020 election—hence the massive amounts of money for plan years through 2021, whose premiums will be announced in the heat of the next presidential campaign.

Second, conservatives should consider what will happen four years from now, once the $65 billion has been spent. Ultimately, throwing taxpayer money at skyrocketing premiums—as opposed to fixing it outright—won’t solve the problem, and will instead just create another entitlement that health insurers will want to make permanent.

Where That Figure Comes From

Section 106 of the bill creates two separate “stability funds,” one giving payments directly to insurers to “stabilize” state insurance markets, and the second giving money to states to improve their insurance markets or health care systems. The insurer stability fund contains $50 billion—$15 billion for each of calendar years 2018 and 2019, and $10 billion for each of calendar years 2020 and 2021. The fund for state innovation contains $62 billion, covering calendar years 2019 through 2026.

Some have stated that the bill provides $50 billion to stabilize health insurance markets. That actually underestimates the funds given to health insurers in the bill. A provision in the state innovation fund section—starting at line 21 of page 22 of the discussion draft and continuing through to line 7 of page 23—requires states to spend $15 billion of the $62 billion allotted to them—$5 billion in each of calendar years 2019, 2020, and 2021—on stabilizing health insurers. (So much for state “flexibility” from Republicans.)

The Potential Impact on Premiums

What kind of per-person subsidy would these billions generate? That depends on enrollment—the number of people buying individual insurance policies, both on the exchanges and off. Earlier this month, the administration revealed that just over 10 million individuals selected a plan and paid their first month’s premium this year, and that an average 10 million Americans held exchange plans last year. Off-exchange enrollment data are harder to come by, but both the Congressional Budget Office and blogger Charles Gaba (an Obamacare supporter) estimate roughly 8 million individuals purchasing individual market plans off of the exchange.

On an average enrollment of 10 million—10 million in exchanges, and 8 million off the exchanges—the bill would provide an $833 per enrollee subsidy in 2018, 2020, and 2021, and $1,111 per enrollee in 2019. In all cases, those numbers would meet or exceed the average $833 per enrollee subsidy insurers received under Obamacare’s reinsurance program in 2014, as analyzed by the Mercatus Center last year.

How much would these subsidies lower premiums? That depends on the average premium being subsidized. For 2018 and 2019, premium subsidies would remain linked to a “benchmark” silver plan, which this year averages $5,586 for an individual. However, in 2020 and 2021, the subsidy regime would change. Subsidies would be linked to the median plan with a lower actuarial value—roughly equivalent to a bronze plan, the cheapest of which this year averages $4,392.

The bill therefore should—all else equal—reduce premiums by at least 15 percent or so, solely because of the “stability” payments to insurers. However, other changes in the bill may increase premiums. Effectively repealing the individual mandate by setting the penalty for non-compliance to $0, while not repealing most of the major Obamacare regulations will encourage healthy individuals to drop coverage, causing premiums to rise.

If CBO finds that the bill won’t reduce premiums by at least 15 percent, it’s because it doesn’t actually repeal the insurance mandates and regulations driving up premiums. The “stability” funding is simply using government funding to mask the inflationary effects of the regulations, at no small cost to taxpayers.

What About After the Presidential Election?

But what happens in years after 2021, when “stability” funding drops off by 75 percent? How “stable” is a bill creating such a dramatic falloff in insurer payments? How will such a falloff not create pressure to create a permanent new entitlement for insurers, just like insurers have pressured Republicans to create the “stability” funds after Obamacare’s “temporary” reinsurance program expired last year?

More than four decades ago, Margaret Thatcher properly pointed out that the problem with socialism is that it eventually runs out of other people’s money. Throwing money at insurers may in the short term bail them out financially and bail Republicans out politically. But it’s not sustainable—nor is it a substitute for good policy.

This post was originally published at The Federalist.

The Report Every State Legislator Should Read

Regardless of the outcome of November’s elections, health care will likely return to the forefront of policy debates in 2017 — both in Washington and in state capitals across the country. Should Hillary Clinton capture the White House, liberal groups, proclaiming that Obamacare is here to stay, will likely push to expand Medicaid in the states that have rejected the program’s massive expansion under Obamacare. Hospital groups will no doubt work hand-in-glove with the Left on these efforts, claiming that only Medicaid expansion will allow hospitals to remain viable, particularly in rural areas.

That’s why a report released by the Congressional Budget Office (CBO) earlier this month should be read by every state legislator in every state likely to debate expansion next year. In analyzing profit margins over the coming decade, the nonpartisan CBO concluded that Medicaid expansion will not make a material difference in hospitals’ overall viability.

The CBO paper modeled the impact of various provisions of Obamacare in 2025, and compared those outcomes with hospitals’ profitability in 2011, before the law’s major provisions took effect. Each scenario allowed CBO analysts to isolate the effects of separate provisions — for instance, the law’s reduction in Medicare payments to reflect improved productivity, expanded health-insurance coverage through Medicaid and the exchanges, and other payment changes.

By analyzing the effects of expanded insurance coverage, and examining whether expanding Medicaid in more states would impact hospitals’ financial condition, CBO shows that such an expansion will not materially improve their solvency:

Differing assumptions about the number of states that expand Medicaid coverage have a small effect on our projections of aggregate hospitals’ margins. That is in part because the hospitals that would receive the greatest benefit from the expansion of Medicaid coverage in additional states are more likely to have negative margins, and because in most cases the additional revenue from the Medicaid expansion is not sufficient to change those hospitals’ margins from negative to positive. Moreover, the total additional revenue that hospitals as a group would receive from the newly covered Medicaid beneficiaries…is not large enough relative to their revenues from other sources to substantially alter the projected aggregate margins.

A “small effect” and “not large enough…to substantially alter” projections — far from the panacea hospitals claim Medicaid expansion will be for their bottom lines.

The report provides several reasons why Medicaid expansion will not cure hospitals’ financial woes. Whereas CBO assumed that exchange plans would reimburse hospitals above their average costs, “Medicaid’s payment rates are below hospitals’ average costs.” Medicaid revenues will likely grow more slowly over time, as Medicaid payment rates cannot exceed Medicare levels — and Obamacare dramatically slowed those Medicare reimbursement levels. Moreover, CBO estimated “that the use of hospitals’ services among the newly insured will increase by about 40 percent as a result of having insurance.” If Medicaid pays hospitals less than their average costs, then inducing additional patient demand by expanding coverage could actually exacerbate hospitals’ shortfalls, not improve them.

To put it bluntly, hospitals made a horrible deal by endorsing Obamacare in 2009. The industry agreed to annual reductions in their Medicare payments forever in exchange for a one-time increase in the number of insured patients. The CBO report quantifies how badly the hospital industry missed its target. Even if hospitals revolutionize their productivity — a standard nonpartisan experts doubt they will achieve — the added revenue from Obamacare’s coverage expansions will barely offset the effects of the Medicare-reimbursement reductions. Under the worst-case scenario, as many as half of all hospitals could become unprofitable within a decade — and the entire industry could face negative profit margins.

Medicaid expansion cannot save hospitals from the financial woes they inflicted upon themselves by endorsing Obamacare — but it can make both federal and state governments less solvent in the process. Prior research has shown how the Medicaid rolls in states that did expand drastically exceeded projections — and a new Mercatus Center report released earlier this month noted that costs per beneficiary have grown as well.

With the costs of Medicaid growing in states that did expand, and CBO showing meager financial benefits to hospitals as a result of expansion, state legislators have every reason to resist the temptation to dramatically expand the welfare state under Obamacare.

This post was originally published at National Review.

JEC Member Viewpoint: Sen. Jim DeMint on Mandates to Cover Dependent Children

This Member Viewpoint by Sen. Jim DeMint was originally published by the Joint Economic Committee.

Numerous press reports in recent weeks have focused on what actions Congress may take in the event that Obamacare is repealed, or struck down in its entirety by the Supreme Court.  Many of these stories have focused on the law’s new mandate requiring insurers to cover policy holders’ children under age 26.  Several Members of Congress have expressed support for this provision, and one has even proposed extending the mandate for coverage of dependent children to all those under age 31.[1]  If the latter proposal passes, 28-year-old Mark Zuckerberg, with an estimated net worth of $17.5 billion, would be one of those eligible for dependent coverage under his parents’ health insurance.[2]

While the Obama Administration has attempted to use the under-26 mandate to sell their unpopular health law, the mandate itself is not without costs and perverse incentives, both to the health system and the economy as a whole.  A closer examination of the costs of this new government mandate reveals it may not be the panacea supporters have claimed.

Impact on Costs:  In its interim final rule implementing the under-26 mandate, the Administration claimed the provision would impose transfer costs of $3.5-$6.9 billion annually, and would raise premiums by 1 percent per year.[3]  However, a George Mason University study released in January found that the Administration omitted several key components in its regulatory impact analysis for this rule, understating its cost, potentially by billions.[4]  Given an average premium for employer-sponsored insurance of $15,073 in 2011,[5] an under-26 mandate raising costs by 1 to 3 percent would increase premiums by $151 to $452 per year.[6]  Conservatives have frequently criticized Obamacare for raising health insurance premiums, in direct violation of candidate Obama’s promise to lower them.[7]  Even the Administration admits that the under-26 mandate has led to higher premiums for businesses and families.

Impact on Coverage:  While many press reports have focused on the “children” obtaining coverage thanks to the under-26 mandate, fewer have examined how many individuals have lost coverage due to the federal requirements.  However, studies suggest these numbers are not insignificant.  For instance, multiple[8] studies[9] have suggested that every 1% increase in premiums increases the number of uninsured by approximately 200,000-300,000 individuals nationwide.  With the under-26 mandate raising premiums by at least 1%, and potentially much more for some plans, it is reasonable to conclude that hundreds of thousands of individuals have lost coverage – because they were priced out of the individual market, or because their employers decided to stop offering coverage – as a result of the new requirements.  These newly uninsured individuals represent what authors William Graham Sumner and  Amity Shlaes famously referred to as the “Forgotten Men” – the individuals suffering harm as a result of government intervention.

Meanwhile, the mandate would turn one of the health market’s few remaining natural incentives on its heads, discouraging young adults from purchasing insurance for themselves.  Instead of mandating that health insurance plans include family coverage for adult children, policy should encourage all young adults to purchase an individual health plan that they can afford and keep throughout their lives.

Impact on Jobs:  The under-26 mandate could have a negative impact on jobs and the economy, in two respects.  First, to the extent that businesses are forced to absorb the billions of dollars in costs associated with the mandate, they would prove less eager to take on additional workers, or increase hours for existing workers.  Second, numerous[10] studies[11] have illustrated that extended unemployment benefits tend to lengthen the average duration of unemployment, and increase the unemployment rate, by discouraging individuals from looking for work.

For similar reasons, some would argue that the under-26 mandate likewise provides financial incentives that discourage work, thereby increasing unemployment.  Both the Congressional Budget Office and then-Speaker Pelosi have admitted that Obamacare’s health insurance provisions will hinder the labor market.  The CBO stated that the law as a whole will “discourage work,”[12] reducing the labor supply by about 800,000 jobs.[13]  Pelosi encouraged young people to “leave your work” and “go be creative and be a musician or whatever,” because Obamacare would provide them with health insurance, thanks to the under-26 mandate and similar provisions.[14]

The heightened focus on under-26 coverage in many respects focuses on the symptom of a larger problem.  Put simply, fewer Americans would need to remain on their parents’ health insurance if they had stable, full-time work.  As of last year, a majority of firms, and more than five of six firms with more than 25 employees, offer insurance coverage to their workers.[15]  However, most firms do not offer health benefits to part-time or temporary workers.[16]  Recent surveys indicating that half of all recent college graduates are unemployed or under-employed – a devastating indictment of the Obama Administration’s failed economic policies – illustrate the real reason why the under-26 provision has attracted so much attention:  Because millions of young Americans can’t find full-time work.[17]

Given prolonged economic stagnation and its toll on young Americans, economic growth and job creation – not new government mandates – should take precedence.  Just as conservatives insisted on reducing the length of extended unemployment benefits as part of the payroll tax extension earlier this year, removing disincentives for young people to seek full-time employment may be one ingredient necessary to restoring the job market to full strength.

As policymakers ponder the fate of the law in the wake of the Supreme Court’s ruling, Congress would be wise to consider the economic impacts listed above.  Re-instituting a government mandate on the private sector would have significant economic costs, and would also undermine the cause of individual liberty in the process.  A welfare state administered by the private sector, yet mandated by government, remains a welfare state at its core.


[1] Louise Radnovsky, Naftali Bendavid, and Sara Murray, “Tension in GOP Over Health Care Response,” Wall Street Journal May 23, 2012, http://online.wsj.com/article/SB10001424052702304019404577420210854278188.html.

[2] “Mark Zuckerberg,” Forbes 400 Profile, http://www.forbes.com/profile/mark-zuckerberg/.

[3] “Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act,” Federal Register May 13, 2010, http://www.gpo.gov/fdsys/pkg/FR-2010-05-13/pdf/2010-11391.pdf, Tables 1 and 5, pp. 27127-29.

[4] Christopher J. Conover and Jerry Ellig, “Beware the Rush to Presumption, Part A: Material Omissions in Regulatory Analyses for the Affordable Care Act’s Interim Final Rules,” Mercatus Center Working Paper 12-01, January 2012, http://mercatus.org/sites/default/files/publication/Beware_the_Rush_to_Presumption_PartA_ConoverEllig.pdf, pp. 14-15, 40-49.

[5] 2011 Kaiser Family Foundation/HRET Employer Health Benefits Survey, http://ehbs.kff.org/pdf/2011/8225.pdf, Exhibit 1.1, p. 1.

[6] Bruce Japsen, “Young Adults’ Coverage May Cost Parents Even More,” New York Times Prescriptions blog, November 23, 2011, http://prescriptions.blogs.nytimes.com/2011/11/23/young-adults-coverage-may-cost-parents-even-more/

[7] Freedom Eden, “Obama: 20 Promises for $2,500,” http://freedomeden.blogspot.com/2010/03/obama-20-promises-for-2500.html.

[8] Todd Gilmer and Richard Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured through 2013,” Health Affairs Web Exclusive, April 5, 2005, http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.143/DC1.

[9] Government Accountability Office, Impact of Premium Increases on Number of Covered Individuals is Uncertain GAO Report HEHS-98-203R, July 7, 1998, http://archive.gao.gov/paprpdf2/160930.pdf, pp. 3-4.

[10] Bhashkar Mazumder, “How Did Unemployment Insurance Extensions Affect the Unemployment Rate in 2008-10?” Chicago Fed Letter No. 285, April 2011, http://www.chicagofed.org/digital_assets/publications/chicago_fed_letter/2011/cflapril2011_285.pdf.

[11] Lawrence F. Katz and Bruce D. Meyer, “The Impact of the Potential Duration of Unemployment Benefits on the Duration of Unemployment,” NBER Working Paper No. 2741, October 1988, http://www.nber.org/papers/w2741.pdf.

[12] Congressional Budget Office, “The Budget and Economic Outlook: An Update,” August 2010, http://cbo.gov/sites/default/files/cbofiles/ftpdocs/117xx/doc11705/08-18-update.pdf, Box 2-1, Effects of Recent Health Care Legislation on Labor Markets, pp. 48-49.

[13] Lester Feder and Kate Nocera, “CBO: Health Law to Shrink Workforce by 800,000,” Politico February 10, 2011, http://www.politico.com/news/stories/0211/49273.html.

[14] Nicholas Ballasy, “Pelosi to Aspiring Musicians: Quit Your Job, Taxpayers Will Cover Your Health Care,” CNS News May 14, 2010, http://cnsnews.com/node/65950.

[15] 2011 Kaiser Family Foundation/HRET Employer Health Benefits Survey, Exhibit 2.3, p. 37.

[16] Ibid., Exhibits 2.5 and 2.6, p. 39.

[17] Associated Press, “Half of New Graduates are Jobless or Underemployed,” USA Today April 23, 2012, http://www.usatoday.com/news/nation/story/2012-04-22/college-grads-jobless/54473426/1.