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.

Hospitals’ Corona Cash Crunch Shows Problems of Government-Run Care

The coronavirus pandemic has inflicted such vast damage on the American economy that one damaged sector has gone relatively unnoticed. Despite incurring a massive influx of new patients, the hospital industry faces what one executive called a “seismic financial shock” from the virus.

The types of shocks hospitals currently face also illustrate the problems inherent in Democrats’ proposed expansions of government-run health care. Likewise, the pay and benefit cuts and furloughs that some hospitals have enacted in response to these financial shocks provide a potential preview of Democrats’ next government takeover of health care.

Massive Disruptions

The health-care sector faces two unique, virus-related problems. The lockdowns in many states have forced physician offices to close, or scale back services to emergencies only. The cancellation of routine procedures (e.g., dental cleanings, check-ups, etc.) has caused physician income to plummet, just like restaurants and other shuttered businesses.

While many physician practices have seen a dramatic drop-off in patients, hospitals face an influx of cases—but the wrong kind of cases. According data from the Health Care Cost Institute, in 2018 a hospital surgical stay generated an average $43,810 in revenue, while the average non-surgical stay generated only $19,672.

The pandemic has raised hospitals’ costs, as they work to increase bed capacity and obtain additional personal protective equipment for their employees. But as one Dallas-based hospital system noted, coronavirus’ true “seismic financial shock” has come from the cancellations of elective surgeries that “are the cornerstone of our hospital system’s operating model.”

This rapid change in hospitals’ case mix—the type of patient facilities treat—has inflicted great damage. Replacing millions of higher-paying patients with lower-paying ones will rapidly unbalance a hospital’s books. Changing patient demographics, in the form of additional uninsured patients and patients from lower-paying government programs, only compounds hospitals’ financial difficulties.

A Preview of Democrats’ Health Care Future

The shock hospitals face from the rapid change in their case mix previews an expansion of government-run health care. The Medicare Payment Advisory Commission noted in a report released last month that in 2018, hospitals incurred a 9.3 percent loss on their Medicare inpatient admissions. To attempt to offset these losses as hospitals treat coronavirus patients, Section 3710 of the $2 trillion stimulus bill increased Medicare payments for COVID-related treatment by 20 percent.

With respect to the single-payer bill promoted by Sen. Bernie Sanders (I-VT), neither the conservative Mercatus Center nor the liberal Urban Institute assumed the higher reimbursement rates included in the stimulus bill. Mercatus’ $32.6 trillion cost estimate assumed no increase in current Medicare hospital or physician payments, while Urban’s $32 trillion cost estimate assumed a 15 percent increase in hospital payments and no increase in physician payments. Raising Medicare reimbursements to match the 20 percent increase included in the stimulus bill would substantially hike the cost of Sanders’ plan.

Conversely, presumptive Democratic nominee Joe Biden believes his “public option” proposal, by making enrollment in a government plan voluntary, represents much less radical change. But his plan increases the generosity of Obamacare subsidies and repeals current restrictions prohibiting workers with an offer of employer coverage from receiving those subsidies—both of which would siphon patients toward the government plan.

In 2009, the Lewin Group concluded that a government plan open to all workers would result in 119 million Americans dropping their private coverage. Such a massive influx of patients into a lower-paying government system would destabilize hospitals’ finances much the same way as coronavirus.

Economic Cutbacks and Job Losses

Sadly, the coronavirus pandemic has allowed us to see what a rapid influx of lower-paying patients will do to the hospital sector. A few weeks into the crisis, many systems have already resorted to major cost-cutting measures. Tenet Healthcare, which runs 65 hospitals, has postponed 401(k) matches for employees. In Boston, Beth Israel Deaconess has withheld some of emergency room physicians’ accrued pay, a measure sure to harm morale as first responders face long hours and difficult working conditions.

This economic damage from a rapid change in hospitals’ payer mix echoes a study in the Journal of the American Medical Association last spring. That study concluded that a single-payer health care system paying at Medicare rates would reduce hospital revenues by $151 billion annually, resulting in up to 1.5 million job losses for hospitals alone. Robust enrollment in the government-run health plan Biden supports would have only marginally lower effects.

Hospitals, like the rest of our economy, will in time recover from the financial impacts of the coronavirus pandemic. But they may not bounce back quickly, or at all, from another expansion of government-run health care—a fact that hospital workers facing cutbacks, and patients needing care, should take to heart in November.

This post was originally published at The Federalist.

The Coronavirus and Advance Directives

Sometimes, the right policy can come at the wrong time. Consider an article on how the coronavirus has upended nursing homes, hundreds of which have at least one—and in many cases far more than one—case among residents.

A Politico newsletter discussing the article last Monday included an ominous blurb: “The National Hospice and Palliative Care Association has been pushing Congress to give more support to advance care planning, perhaps in the next stimulus bill.” While the advocates may have the best of intentions, discussing advance care directives in the context of a global pandemic raises serious ethical questions.

Planning for Worst-Case Scenarios

End-of-life care remains a touchy political subject. In 2009, following comments by Gov. Sarah Palin (R-Alaska) about “death panels,” she defended her characterization of Democrats’ health care effort by pointing to a provision in a House draft allowing Medicare to cover end-of-life counseling. While the controversy prompted congressional Democrats to drop the provision from the bill that became Obamacare, the Centers for Medicare and Medicaid Services (CMS) in 2015 approved regulatory changes allowing Medicare to pay physicians for end-of-life consultations with their patients.

In most cases, talking through options and allowing patients to determine their intended course of treatment gives patients a voice in their own care. Advance care planning—whether through a formal directive, or even informal conversations amongst family members—also takes a weighty burden off of loved ones at a time of immense stress and emotional anguish.

My mother has told me throughout my adult life that, in extreme circumstances, she does not want medical personnel using extraordinary means to extend her life. Heart-breaking as it would be for me to relay that decision to her doctors, I could at least know I did not make that decision, but instead merely relayed a wish that my mother has expressed, consistently and repeatedly, over many years.

The Power of Persuasion

Under most circumstances, encouraging individuals to have these types of end-of-life conversations with their family members and physicians represents sound medical practice and wise public policy. But the middle of a global pandemic by definition does not constitute ordinary circumstances.

Here’s one telling example from Britain’s National Health Service. The BBC obtained a document from a regional medical group based in Sussex. The document, which sets out guidance for treating coronavirus patients in nursing homes, prompted one care manager to become “deeply concerned that residents and families are being pushed to sign” do-not-resuscitate forms:

The…guidance even provides a suggested script for GPs [general practitioners] to use in conversations with residents and families, part of which says ‘frail elderly people do not respond to the sort of intensive treatment required for the lung complications of coronavirus and indeed the risk of hospital admission may be to exacerbate pain and suffering.’

It goes on: ‘We may therefore recommend that in the event of coronavirus infection, hospital admission is undesirable.’

One care manager…[said] their GP had even told them ‘none of your residents aged over 75 will be admitted to hospital.’ They said they felt ‘shocked and numb’ to hear that. Another said: ‘We have been told flatly that it would be highly unlikely that they would be accepted into hospital.’

Put aside for a moment the fact that Britain’s system of socialized medicine has prompted at least some physicians to believe they should flatly refuse medical care to senior citizens (even though Health Secretary Matt Hancock denied such a policy exists). That such a system has also pressured family members to sign do-not-resuscitate orders for their loved ones speaks to the potential dangers of combining end-of-life counseling with the pressures faced by health care providers during a pandemic.

Preserve a Culture of Life

A content-neutral conversation among a doctor and a patient about constructing an advance directive, and what instructions to put in that advance directive, is one thing, but pressuring vulnerable patients to sign do-not-resuscitate orders during a global pandemic is quite another. Common sense, confirmed by the example from Britain, suggests that given the current medical crisis, the conversations could easily veer off-track from the former to the latter.

Advance care planning has its place in health care, but now seems an inauspicious time to push for its more widespread adoption. At present, our efforts should focus not just on preserving life, but on preserving a culture of life—and hurried conversations about end-of-life care in the current pandemic could undermine that culture significantly.

This post was originally published at The Federalist.

Colorado Plan Shows the Coercion Behind the Public “Option”

Former Vice President Joe Biden’s political comeback prompted health care stocks to surge last month following the Super Tuesday primaries. The rally, which occurred before the coronavirus pandemic took hold in the United States, stemmed in large part from Wall Street’s belief that Biden represents less of a threat to the sector as a potential president than Vermont Sen. Bernie Sanders’ single-payer health-care system.

But anyone who considers Biden’s alternative to single payer, the so-called “public option,” innocuous should look to Colorado. Lawmakers in the Centennial State recently revealed their version of the concept, and it represents an “option” in name only. Indeed, the state’s plan contemplates a level of coercion that in some respects exceeds that of Sanders’ system of socialized medicine.

Big Government Forces Hospitals’ Participation

For starters, the legislative proposal dictates prices for hospitals, based on a percentage of Medicare rates. As one might expect, the bill’s supporters believe the rates proposed in the legislation represent fair reimbursement levels, while some hospital executives disagree.

But the bill would also take away hospitals’ negotiating leverage, by requiring all Colorado facilities to participate in the new insurance offering. Hospitals refusing to participate would face fines of up to $40,000 per day. And if the prospect of nearly $1.5 million in government-imposed sanctions does not force a recalcitrant facility into submission, the bill also permits Colorado’s insurance commissioner to “suspend, revoke, or impose conditions on the hospital’s license.”

Think about that for a moment: The government forces hospitals to offer patients a service—even if the government’s price for that service could lead them to incur financial losses—and threatens to take away their license to do business if they refuse. That level of heavy-handed government involvement far exceeds the individual mandate in Obamacare.

Insurers Required to Participate, Too

The bill similarly requires all Colorado insurers to offer the new government-dictated “option” in each county in which they offer Obamacare exchange products. In counties where only one insurer currently offers coverage, the bill directs the insurance commissioner to “require carriers to offer the Colorado option in specific counties,” such that at least two carriers offer the plan in every county.

According to one report, the bill’s sponsors called their new offering the “Colorado option” rather than the “public option” because lawmakers did “not want to put the state budget at risk by creating a government-run insurance company.” Instead, lawmakers want to dragoon insurers into assuming that risk, even as the bill prohibits efforts by insurers to absorb potential losses from the “Colorado option” by raising rates elsewhere.

Worse Than Berniecare?

Sanders’ legislation would effectively put private insurers out of business, by making coverage for services covered by the single-payer system “unlawful.” The issue of whether to ban private insurance, and take away individuals’ ability to keep their current coverage, became a defining characteristic of Democrats’ nominating contest.

But the Colorado legislation could put private insurers and hospitals out of business, if they refuse the state’s commands. At least Sanders’ proposal allows hospitals to opt out of the government system if they decide—few would, but they do have that choice.

The Colorado legislation shows how Obamacare set a dangerous precedent, which Democrats want to extend throughout the health-care system. Just as Obamacare forced all Americans to buy a product for the first time ever, now lawmakers want to force hospitals and insurers to treat patients, even at their financial peril. Each could face a Hobson’s choice: Putting themselves out of business by incurring losses on “Colorado option” patients, or taking the “option” to decline to participate, at which point the state will regulate them out of business.

Colorado’s proposal of dubious merit and equally dubious constitutionality demonstrates the way in which even purported moderates like Biden have embraced a health-care agenda defined by ever-increasing levels of government intrusion and coercion. At present, Sanders’ single-payer legislation represents the far end of that continuum, but liberals will use proposals like Colorado’s “public option” to get there.

This post was originally published at The Federalist.

Why Pete Buttigieg’s Health Plan Might Be More Radical than Bernie Sanders’

During the most recent Democratic primary debate in New Hampshire, former South Bend Mayor Pete Buttigieg claimed that his health-care plan, unlike the single-payer proposal advocated by Vermont Sen. Bernie Sanders, would “not polarize the American people.” But contra the candidate’s claims, Buttigieg’s health plan advocates a policy—government price controls on the entire health-care sector—even more far-reaching than Sanders’s socialist approach.

Others have exposed how Buttigieg’s plan would force people to buy insurance costing thousands of dollars, whether they want it or not. But his proposal for government price controls across a $4 trillion health-care sector represents the most radical idea yet—because, unlike Sanders’s plan, individuals appear to have no way to opt out.

National Price Controls

Buttigieg’s plan, released in September, would “prohibit health care providers from pricing irresponsibly by capping their out-of-network rates at twice what Medicare pays.” (Upon entering the race for the Democratic presidential nomination last November, New York Mayor Michael Bloomberg also adopted this rate-capping provision in his health plan.) Buttigieg admits that, by capping out-of-network rates, his proposal would give insurers leverage to demand lower prices for in-network care, creating a de facto system of national price controls for the entire health-care sector.

Imposing price controls on nearly 20 percent of the American economy, and linking those price controls to Medicare rates, would have substantial distortionary impacts. For starters, Medicare often does not reimburse medical providers at a rate to recover their costs. The Medicare Payment Advisory Commission estimated last March that hospitals would incur a -11 percent margin on their Medicare patients in 2019.

Moreover, because Medicare payment rates reflect the cost of treating the over-65 population—not many Medicare beneficiaries need maternity care, for instance—even supporters of capping rates have questioned the wisdom of linking such caps to Medicare levels.

More broadly, a national system of price controls could create health-care shortages. Facing reductions in pay, doctors could decide to retire early, and aspiring physicians could avoid the profession entirely. With the United States already facing a shortage of up to 121,900 physicians between now and 2032, Buttigieg’s price controls would reduce the physician supply still further.

Pathway to Single Payer—With No Exit

Despite the contrast he attempts to draw with Sanders’s plan, Buttigieg’s price controls would likely lead to a fully government-run system. Buttigieg admits a desire for his plan to provide a “glide path” to single-payer; its price controls provide an easy mechanism for such a transition.

By reducing the payments that private health insurers can offer doctors and hospitals, Buttigieg would slowly sabotage individuals’ existing coverage, throwing all Americans into a government-run health system. Indeed, his price caps provide an easy mechanism to force more and more individuals off their private coverage. While Buttigieg says he wants to cap payments at double Medicare rates, he could lower that cap over time. Of course, capping private health-care reimbursements at less than Medicare rates would all-but-guarantee private health insurance would cease to exist, because few doctors would agree to accept it.

Patients facing long waits for care would have no way to get around queues created by Buttigieg’s socialistic price controls. Sanders’s single-payer legislation allows physicians and patients to contract privately by paying cash for health-care services. But Buttigieg’s plan does not envision a mechanism for Americans to opt out of his price control regime. If Medicare pays $50 for a service, a patient could not pay a physician more than $100 for that service—no matter how experienced or qualified the physician, and no matter how desperate the patient.

The questionable constitutionality of Buttigieg’s plan belies its purportedly moderate nature. On the one hand, he would compel all individuals to pay for health insurance—whether they want it or not, and whether they use it or not. On the other, he would prohibit individuals from engaging in private transactions with their own doctors and hospitals if the amounts of those transactions exceed federally defined limits.

Differences in tone notwithstanding, Sanders and Buttigieg represent two halves of the same general approach to health care, expanding a technocratic leviathan that will attempt to micromanage nearly one-fifth of the economy from Washington. Doctors and patients, take note.

This post was originally published at The Federalist.

How Socialized Medicine Will Lead to Waits for Care

Recently, a liberal think-tank, the Center for American Progress (CAP), issued a policy paper that promised “the truth” on waiting times in government-run health systems. If you want the truth about the issue, however, you’ll have to wait a long time for it if you choose to rely on CAP’s disingenuous analysis.

The CAP report cherry-picks facts to try to make an argument that a single-payer health-care system won’t result in rationing of health care. Unfortunately, however, even supporters of single payer have admitted that government-run care will increase waiting times for care.

Misleading Analysis

CAP’s paper starts out by criticizing President Trump and other conservative groups, who have asserted that a single-payer system would lead to “massive wait times for treatments and destroy access to quality care,” as Trump stated in his recent executive order on Medicare. CAP calls these assertions “false,” and then claims:

Patients in peer nations generally have similar or shorter wait times than patients in the United States for a variety of services, refuting the argument that universal coverage would necessarily result in longer wait times in the future. [Emphasis added.]

The above sentence, like the rest of the paper, uses clever semantic wordplay to obscure the issue. CAP claims that universal coverage wouldn’t necessarily result in longer wait times, but Trump and the right-leaning groups have criticized one specific form of universal coverage—single payer, in which the government serves as the sole funder of health care. (CAP repeats those misleading tactics by referencing the impact of prior coverage expansions in the United States, many of which used private insurers and none of which directly equate to a universal, government-funded health system.)

Of the paper’s four “peer nations” with universal coverage systems—Australia, France, Germany, and Sweden—only Australia and Sweden have government-run insurance plans. By contrast, France and Germany rely on private insurers to implement their universal coverage systems.

While it includes other systems without single-payer coverage in its analysis, CAP specifically excludes Britain’s National Health Service, known for its waiting times and rationed access to care. CAP claimed to omit the NHS in its analysis because “no candidate currently running for president is proposing nationalizing health care providers” a la the British model—a true enough statement, but a self-serving one.

If CAP included non-government-funded systems in its analysis, it certainly should have included the government-funded NHS. That it did not suggests the analysts wanted to “rig” the paper’s outcomes by relying solely on favorable examples.

Biggest Waiting Times to the North

The CAP paper’s most deliberate omission comes in the form of our neighbor to the north: Canada. The paper examined four metrics of access to care, based on data from an analysis by the (liberal) Commonwealth Fund of 11 countries’ health systems. Given the shabby results Canada’s health system showed on health care access, it seems little wonder that the leftists at CAP failed to disclose these poor outcomes in their paper:

  • Patients who reported they saw a doctor or nurse on the same or next day the last time they needed care: Canada ranked in a tie for last, with 43% agreeing. (The United States had 51% who agreed.)
  • Doctors who reported that patients often experience difficulty getting specialized tests like CT or MRI scans: Canada ranked third from last, with 40% agreeing. (The United States had 29% who agreed.)
  • Patients who reported they waited two months or longer for a specialist appointment: Canada ranked last, with 30% agreeing. (The United States had only 6% who agreed.)
  • Patients who reported they waited four months or longer for elective surgery: Canada ranked last, with 18% agreeing. (The United States had only 4% who agreed.)

As I discuss in my book, Canada’s health system suffers from myriad access problems, based on other metrics from Commonwealth Fund studies that CAP chose not to mention in their paper:

  • The second-lowest percentage of patients (34%) who said it was easy to receive after-hours care without going to the emergency room;
  • The lowest percentage of patients (59%) who said they often or always receive an answer the same day when calling the doctor’s office about a medical issue;
  • The highest percentage of patients (41%) using the emergency room; and
  • The highest percentage of patients (29%) waiting four or more hours in the emergency room.

With results like that, little wonder that the liberals at CAP didn’t want to highlight what single-payer health care would do to our health system.

Socialists Admit Care Rationing Ahead

That said, some socialist supporters of single payer have conceded that the new system will limit access to care. As I noted last year, the socialist magazine Jacobin said the following about one analysis of 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 [the study] projects.

Translation: People will demand additional care under single payer, but there won’t be enough doctors and hospitals to meet the demand, therefore resulting in waiting times and rationed access to care.

Lest one consider this admission an anomaly, the People’s Policy Project called a recent Urban Institute study estimating the costs of single payer “ridiculous” and “unserious,” in large part because of its “comical assumption” about increased demand for care: “There is still a hard limit to just how much health care can be performed because there are only so many doctors and only so many facilities.” Again, socialists claim that single payer won’t bust the budget, in large part because people who seek care will not be able to obtain it.

With analysts from the right and the socialist left both admitting that single payer will lead to rationed health care, CAP can continue to claim that waiting times won’t increase. But the best response to their cherry-picked and misleading analysis comes in the form of an old phrase: Who are you going to believe—me, or your lying eyes?

This post was originally published at The Federalist.

The Four Most Dangerous Words in Washington

More than three decades ago, Ronald Reagan rightly characterized the nine most terrifying words in the English language: “I’m from the government, and I’m here to help.” In Washington, a quartet of four words rank close behind Reagan’s nine in their ability to terrify: What are you for?

Countless people in official Washington, from leadership staff to reporters to liberals to lobbyists, use these four words, or some variation thereof, to try to get conservatives to endorse bad policy. Their words carry with them an implicit argument: You have to be for something, rather than just opposing bad policy.

Reagan would find that reasoning nonsensical. Why do you have to be for something when all the available options undermine conservative principles—because you’re from the government and you’re here to help? It’s a lazy straw-man argument, which might explain why so many people in Washington use it, but it’s a premise that conservatives should reject.

Example 1: Drug Price Legislation

On Monday, House Republican leaders released their alternative to House Speaker Nancy Pelosi’s prescription drug legislation. Their very first bullet in the summary of the legislation said that the bill includes “350 pages” of provisions. (Technically, the bill has 352 pages of content, while by contrast, the Rules Committee print of Democrats’ prescription drug legislation weighs in at 275 pages.)

Republicans quite rightly criticized Pelosi almost a decade ago for the awful process she used to enact Obamacare. Remember the speaker’s infamous quote about the legislation in March 2010, which House Republicans still have on their YouTube page:

Yet including the bill’s size as the first bullet point in their summary suggests Republican leadership considers it a feature, not a bug: “Look at how substantive we are—our bill is 350 pages long!” Granted, the House Republican package consists of a grab-bag of provisions related to drug pricing, most of which existed well before this week. Some of them doubtless contain good ideas, and ideas I have previously endorsed.

But think about what went into creating this “new,” 350-page bill. A bunch of leadership staffers sat around a big desk in the Capitol, decided what bills and provisions to include in the package—and, by extension, which bills to exclude from it. I know, because I’ve sat in those types of meetings. They released the legislation on Monday, and Congress likely will vote on it late Wednesday night (early Thursday at the latest).

Republican Members of Congress won’t have time to read all 352 pages of the House Republican bill. Some of them may not have time to read even the four-page summary of the bill. And their staff, who are currently overwhelmed by the litany of issues on Congress’ December agenda, from impeachment to a massive defense policy bill to another massive spending bill to the prescription drug debate, have neither the time nor the bandwidth to provide thoughtful advice and counsel.

But most if not all Republican members of Congress will vote for this drug price alternative they have not read and many do not fully understand. Why? Because most think they need to “be for something.” Because they believe that (false) premise, they will have effectively handed their voting card to unelected leadership staffers—who may or may not actually know what they are doing—to define what Republicans are “for.” It’s no way to run a railroad, let alone the country.

Example 2: Entitlements

My article last week about Democratic presidential candidate Pete Buttigieg’s proposed long-term care entitlement prompted an e-mail from a colleague. The e-mail asked a polite variation of the question noted above: If you don’t like Buttigieg’s approach to long-term care, what would you do instead?

My response in a nutshell: Nope. As I pointed out in the original post, our country faces $23 trillion—that’s $23,000,000,000,000—in debt—and rising. We can’t afford the entitlements and government programs we have now. To even talk about creating new programs (which would face their own solvency and sustainability concerns) only gives lawmakers and the American public a permission structure to avoid the hard decisions Congress should have made years ago to right-size our entitlements.

Example 3: ‘Surprise Billing’ Legislation

On Sunday, several members of key committees announced an agreement in principle on federal legislation regarding “surprise billing,” which arises when physicians and medical providers seek to recover charges when patients obtain care out-of-network during emergencies, or when patients inadvertently see an out-of-network physician (e.g., an anesthesiologist) at an in-network hospital.

(Disclosure: I have consulted with various firms about the potential outcomes and implications of this legislation. However, these firms have not asked me for my personal policy positions on the legislation, nor have they asked me to advocate for a position on it—as my positions, as always, are mine alone.)

I wrote back in July that this issue largely represented a solution in search of a problem, for multiple reasons. First, a relatively small number of hospitals and providers impose most of the “surprise” bills. Second, states have the power to fix this issue on their own by regulating providers, even if federal law makes it difficult for states to regulate all the insurers in their state.

So why do Republicans feel the need to sign off on federal legislation addressing a problem that states can decide to fix (or not to fix) themselves? Again, because lawmakers feel the need to “be for something.” That again brings to mind Reagan’s axiom about the nine most terrifying words, and the proposition that “I’m from the government and I’m here to help” often leads to unintended consequences.

No, Don’t Just ‘Do Something’

Perhaps by this point, some observers might have come up with an obvious question: How can you win elections if you don’t try to “do something?” The question has two simple answers.

First, citizens quite obviously do not vote solely based on a candidate’s ability to “do something,” such as expand the regulatory state, the welfare state, and government in general. If conservatives want to run campaigns based on giving voters “free stuff,” but just slightly less “free stuff” than Democrats, guess how many elections the conservative would win?

Second, as noted above, the “What are you for?” question has an obvious four-word response: “We can’t afford it.” That retort sadly has the feature of truth about it, as our country cannot sustain its current levels of government spending.

Any responsible parent knows that, no matter how often his child asks, letting that child eat ice cream three times a day does not represent good parenting. Congress long since should have imposed some of that sense of discipline on itself, and the American people.

Given our current fiscal situation, many policy proposals, no matter how popular, are not fiscally sustainable. The “What are you for?” question cleverly tries to elide that debate, in ways that will only undermine conservative principles, and our country’s solvency.

I’ll end by noting my strong support for the First Amendment: “Congress shall make no law.” (What, you thought it contains some other words too?) If Congress spent the majority of its time stopping bad laws and policies—particularly policies considered only slightly less bad than the original proposals—maybe our country wouldn’t face the prospect of paying off a growing mountain of debt.

This post was originally published at The Federalist.

Indian Health Service Scandal Shows Problems of Government-Run Care

As if voters didn’t have enough reasons to question government-run health care, the Wall Street Journal provided yet another last week. The paper ran a lengthy expose highlighting numerous cases of doctors previously accused of negligence receiving “second chances” in the government-run Indian Health Service (IHS), resulting in incidents wherein at least 66 patients died in IHS care.

Earlier this year, the Journal ran a separate investigative article explaining how the Indian Health Service repeatedly ignored warnings about a physician accused of sexually abusing patients, moving him from hospital to hospital. Together, these articles describe a broken culture within the Indian Health Service, demonstrating how government-run health systems provide poor-quality care, often harming rather than helping vulnerable patients.

Examples of Negligent Physicians Harming Patients

The Journal examined records from the Treasury’s Judgment Fund, which pays awards in malpractice cases wherein the federal government — in this case, the Indian Health Service — functions as the defendant. The reporters then cross-referenced the physicians involved in those cases with prior malpractice cases and disciplinary actions taken prior to the doctors joining the IHS. The results should shock patients:

  • A doctor “thrust into medical exile” after five medical malpractice settlements in five years, including a rejection by a Nevada licensing board, ended up finding work in the Indian Health Service, where the federal government had to pay an additional five malpractice claims on his behalf. The physician, who had previously left a sponge inside a patient’s breast (among other incidents) before going to work with the Indian Health Service, gashed an IHS patient’s bile duct, causing four liters of digestive fluid to leak into her abdomen and sending her into septic shock.
  • An obstetrician with a history of five malpractice settlements totaling $2.7 million, and sanctions from the California medical board stemming from a patient who bled to death following a caesarean section, found employment in the Indian Health Service. A year after his hire, a baby died in the womb because this doctor failed to treat his mother’s high blood pressure. IHS officials later concluded that the doctor’s history “forshadow[ed] the tragic events that transpired in October 2017.” The physician admitted to the Journal, “I just did not address patients’ primary medical needs in a satisfactory way.” But he still applied for and received a position with the IHS.
  • A surgeon sued for malpractice 11 times over an eight-year period while living in Pennsylvania later got a job with the Indian Health Service in New Mexico. There he “allegedly cut a tube connecting a patient’s liver to his stomach and punctured the man’s intestines during a 2008 gallbladder surgery.” The patient later died.
  • A physician disciplined in both Florida and New York for prescribing pain pills for her boyfriend — up to 1,350 oxycodone pills in a single day — was hired by the Indian Health Service because she had a “clean” medical license in Pennsylvania. While working for the IHS, she sent a patient complaining of dizziness home with a diagnosis of pink-eye. Days later, the patient suffered a stroke that has left him confined to a wheelchair and unable to speak. The federal government settled the subsequent malpractice case for $1 million because “hospital officials said in interviews that the doctor’s background made the case hard to defend.”
  • Another surgeon with nearly a dozen malpractice suits and a suspension for sexually abusing a patient during an exam received a job with the Indian Health Service. During his time as an IHS employee, the federal government paid a judgment exceeding $600,000 “over a colostomy the doctor performed that spilled fecal matter under a patient’s skin” and a $500,000 settlement for a botched hernia repair.
  • An obstetrician with at least seven reports in the National Practitioner Data Bank, including North Carolina sanctions over a potential sexual relationship with a patient, got a job with the Indian Health Service. In 2013, the doctor “struggled to deliver a baby” at an IHS facility. The baby developed an irregular heartbeat and died. The federal government paid a $900,000 malpractice claim because “a medical board reprimand later said [the doctor] should have resorted to a [caesarean] section ‘hours earlier.’”
  • A surgeon who lost his medical license in Illinois for “gross negligence” got another chance at a New Mexico IHS facility. “Two months after he arrived as the [IHS] hospital’s chief of surgery, he allegedly punctured a patient’s intestines during a surgery.” The patient ended up needing a dozen surgeries — which she wisely obtained outside the Indian Health Service — and a four-month hospital stay to recover.

Bureaucratic Nightmares

The Journal article also explained the circumstances by which all these physicians with histories of multiple malpractice claims or disciplinary actions came to work in the Indian Health Service. First, while the agency’s policies require hiring managers to consult the National Practitioner Data Bank for a physician’s history of malpractice claims or sanctions, the IHS does not monitor compliance with that requirement.

In one case, the CEO of a hospital who fired a surgeon for negligence said she “encourag[ed] him to consider another field of medicine than surgery.” However, the CEO didn’t know the surgeon had ended up practicing at an IHS facility until the Journal contacted her — because IHS apparently failed to investigate the surgeon’s history before hiring him.

Second, the federal government covers physicians’ malpractice claims through the Treasury’s Judgment Fund (the way the Journal reporters researched the hysicians’ history). Because IHS doctors don’t need to pay for malpractice insurance themselves — what one survey of IHS physicians considered the top benefit of working at the agency — it has become an effective “dumping ground” for physicians whose history of prior malpractice claims means they cannot obtain insurance on their own. IHS patients and federal taxpayers often end up paying the price, both literally and figuratively.

Poor Reimbursements Equal Poor Care

One former IHS official admitted that hiring managers have to make compromises when hiring physicians: “You get three candidates who come through and they all seem not great. But what you do is choose the lesser of three evils.” Hiring those “lesser evils” led to disastrous and often fatal consequences for dozens upon dozens of Indian Health Service patients.

Sen. Elizabeth Warren, D-Mass., says she wants to extend government-run health care to the rest of the United States. But rather than apologizing to Native Americans for DNA tests, she should instead apologize for the horrid conditions within the Indian Health Service, promise to replace that broken system with something that works, and vow not to wreak on the rest of the American health-care system the kind of havoc Native populations have faced for years.

This post was originally published at The Federalist.

The Costs of “Free” Health Care

Libertarian columnist P.J. O’Rourke once famously claimed that “If you think health care is expensive now, wait until you see what it costs when it’s free.” A left-of-center think-tank recently confirmed O’Rourke’s assertion. In analyzing several health care proposals, the Urban Institute demonstrated how eliminating patient cost-sharing from a single-payer system would raise total health care spending by nearly $1 trillion per year.

Those estimates have particular resonance given the recent release of a health care “plan” (such as it is) by Sen. Elizabeth Warren (D-Mass.). Warren’s policy proposals contain myriad gimmicks and rosy scenarios, all designed to hide the obvious fact that one cannot impose a $30 trillion-plus program on the federal government without asking middle-class families to paya lot—for its cost.

The Urban Institute estimates show that a single-payer plan maintaining some forms of patient cost-sharing (i.e., deductibles, co-payments, etc.) seems far more feasible—or less unfeasible—than the approach of Warren and Sen. Bernie Sanders (I-VT), who promise unlimited “free” health care for everyone. Mind you, I would still oppose such a plan—for its limits on patient choice, economically damaging tax increases, and likelihood of government rationing—but at least it would have the advantage of being mathematically possible. Not so with Sanders’ and Warren’s current approach.

Option 1: An Obamacare-Like Single-Payer Plan

In the October policy paper, several Urban researchers examined the financial effects of various health coverage proposals, including two hypothetical single-payer systems. The first single-payer system would cover all individuals legally present in the United States. Urban modeled this system to cover all benefits required under Obamacare, and fund 80 percent of Americans’ expected health costs per year, equivalent to a Gold plan on the Obamacare exchanges. Americans would still pay the other 20 percent of health spending out-of-pocket.

This proposed “lite” single-payer system would still require massive tax increases—from $1.4-$1.5 trillion per year. But it would actually reduce total health spending by an estimated $209.5 billion compared to the status quo.

This single-payer system generates calculated savings because Urban assumed the plan would pay doctors current rates under the Medicare program, and pay hospitals 115 percent of current Medicare rates. Because Medicare pays medical providers less than private insurers, moving all patients to these lower rates would reduce doctors’ and hospitals’ pay—which could lead to pay and job cuts for health professionals. But in the Urban researchers’ estimates, it would lower health spending overall.

Option 2: ‘Free’ Health Care Costs a Lot of Money

Compare these outcomes to a proposal closely modeled on the single-payer legislation supported by Sanders and Warren. Unlike the first proposal, this “enhanced” single-payer system would cover “all medically necessary care,” with “no premiums or cost-sharing requirements.” It would also enroll all U.S. residents, including an estimated 10.8 million illegally present foreign citizens.

The Urban researchers found that the single-payer plan with no cost-sharing would raise total health spending by $719.7 billion compared to the status quo. Compared to the “single-payer lite” plan, which provides benefits roughly equivalent to Obamacare, eliminating cost-sharing and covering foreign citizens would raise total health spending by $929.2 billion. Moreover, the plan with no cost-sharing requires a tax increase nearly double that of the “single-payer lite” plan—a whopping $2.7-$2.8 trillion per year.

The Urban Institute estimates confirm that making all health care “free,” as Sanders and Warren propose, would cause an enormous increase in the demand for care. This would overwhelm any potential savings from lower payments to doctors and hospitals, meaning the health sector would face a double-whammy, of getting paid less to do more work. These estimates also could underestimate the growth in health spending, because Urban’s researchers did not assume a rise in medical tourism or immigration when calculating the increase in demand for “free” health care.

Socialists’ ‘Solution’: Hold Costs Down by Rationing

Socialist supporters of Sanders’ plan attacked these estimates, claiming that the Urban Institute failed to consider that a single-payer system would ration access to “free” health care. The People’s Policy Project called Urban’s estimates of increased demand “ridiculous,” in part because “there is still a hard limit to just how much health care can be performed because there are only so many doctors and only so many facilities.”

Its position echoes that of the socialist magazine Jacobin, which in response to a single-payer study by the Mercatus Center last year admitted that “aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit.”

An increase in health spending of nearly $1 trillion per year, and increased waiting times and rationed access to care: either or both of those scenarios represent the costs of “free” health care, based on the words of leftists themselves. The prospect of either scenario should make Americans reject this socialist approach.

This post was originally published at The Federalist.