Repealing “Son of Obamacare”

The election of Donald Trump brings conservatives an opportunity to repeal a misguided piece of health care legislation that cost hundreds of billions of dollars, will blow a major whole in our deficit, has led to thousands of pages of regulations, and will further undermine the integrity of the doctor-patient relationship.

Think I’m talking about Obamacare?

I am — but I’m not just talking about Obamacare.

I’m also talking about the Medicare and CHIP Reauthorization Act (MACRA), which passed last year (with a surprising level of Republican support) and contains many of the same flaws as Obamacare itself.

Just as Republicans are preparing legislation to repeal and replace Obamacare, they also need to figure out how to undo MACRA.

Last month, the Obama administration released a 2,398-page final regulation — let me say that again: a 2,398-page regulation — implementing MACRA’s physician reimbursement regime.

In the new Congress, Republicans can and should use the Congressional Review Act to pass a resolution of disapproval revoking this massive new regulation. They can then set about making the changes to Medicare that both Paul Ryan and Donald Trump have discussed: getting government out of the business of 1) fixing prices and 2) micro-managing the practice of medicine.

MACRA’S FUNDAMENTALLY FLAWED, STATIST APPROACH

Since the administration released its physician-payment regulations — nearly as long as Obamacare itself – some commentary has emphasized (rightly) the burdensome nature of the new federal regulations and mandates.

But the more fundamental point, rarely made, is that we need more than mere tweaks to free doctors from an ever-tightening grip exercised by federal overseers. After more than a half century of failed attempts at government price-setting and micro-management of medical practice, it’s time to get Washington out of the business of playing “Dr. Sam” once and for all.

In fact, even liberals tend to acknowledge this occasionally. In a May 2011 C-SPAN interview, Noam Levey of the Los Angeles Times asked then-administrator of the Centers for Medicare and Medicaid Services Donald Berwick why he thought the federal government could use Medicare as it exists to reform the health-care system:

In nearly half a century of federal-government oversight, the federal government hasn’t succeeded in two really important things: Number one, Medicare costs are still growing substantially more quickly than the economy; and number two, that fragmented [health care] system . . . has persisted in Medicare for 46 years now. . . . Why should the public, when it hears you, when it hears the President say, “Don’t worry, this time we’re going to make it better, we’re going to give you a more efficient, higher-quality health care system,” why should they believe that the federal government can do now what it essentially hasn’t really been able to do for close to half a century? [Emphasis added] 

Dr. Berwick didn’t really answer the question: He claimed that fragmented care issues “are not Medicare problems — they’re health system problems.” But in reality, liberal organizations like the Commonwealth Fund often argue Medicare can be leveraged as a model to reform the entire health care system — and that is exactly what MACRA, in defiance of historical precedent, tries to do.

When a 2012 Congressional Budget Office report examined the history of various Medicare payment demonstrations, it concluded that most had not saved money. A seminal study undertaken by MIT’s Amy Finkelstein concluded that the introduction of Medicare, and specifically its method of third-party payment, was one of the primary drivers of the growth in health-care spending during the second half of the 20th century.

After five decades of failed government control and rising costs driven by the existing Medicare program, the solution lies not in more tweaks and changes to the same program.

The answer lies in replacing that program with a system of premium support that gets the federal government out of the price-fixing business entirely.

The notion that the federal government can know the right price for inhalation therapy in Birmingham or the appropriate reimbursement for a wart removal in Boise is a fundamentally flawed and arrogant premise — one that conservatives should whole-heartedly reject.

Unfortunately, most critics of MACRA have not fully grasped this. A law that prompts the federal bureaucracy to issue a sprawling regulation of nearly 2,400 pages cannot on any level be considered conceptually sound.

Believing otherwise echoes Margaret Thatcher’s famous maxim about consensus politicians and conviction politicians: Some analysts, seeking a consensus among their fellow technocrats, push for changes to make the 2,400-page rule more palatable. But our convictions should have us automatically reject any regulation with this level of micro-management and government-enforced minutiae.

THE NEED FOR COMPREHENSIVE REFORM

It bears worth repeating that, in addition to perpetuating the statist nature of Medicare, MACRA raised the deficit by over $100 billion in its first ten years — and more thereafter — while not fundamentally solving the long-term problem of Medicare physician-payment levels.

More than a decade ago, after President Bush and a Republican Congress passed the costly Medicare Modernization Act (MMA), creating the Part D prescription-drug entitlement, conservatives argued even after the law’s passage that the new entitlement should not take effect. If the MMA was “no Medicare reform” for including only a premium-support demonstration project, conservatives should likewise reject MACRA, which includes nothing – not even a demonstration project — to advance the premium-support reform Medicare truly needs.

Any efforts focused on building a slightly better government health-care mousetrap distract from the ultimate goal: removing the mousetrap entirely. In his 1964 speech A Time for Choosing, Reagan rejected the idea “that a little intellectual elite in a far distant capital can plan our lives for us better than we can plan them ourselves” — and Republicans should do the same today.

In the context of health care, this means not debating the details of MACRA but replacing it, sending power back to where it belongs — with the people themselves.

Last week’s election results give the new Congress an opportunity to do just that, by disapproving the MACRA rule and moving to enact comprehensive Medicare reform in its place. After more than five decades of the same statist health care policies, it’s finally time for a new approach. Here’s hoping Congress agrees.

This post was originally published at National Review.

The Republican Party Split That Donald Trump’s Nomination Won’t Resolve

The general election campaign has not begun, but preliminary polling suggests that Donald Trump is a decided underdog against Hillary Clinton. For the Republican Party, there is an issue beyond the Election Day outcome–and one that, at least right now, looks unlikely to be resolved no matter who wins in November.

More so than reports of John Kasich suspending his campaign, it was Sen. Ted Cruz’s withdrawal from the Republican primary race Tuesday night that sparked reactions from Republicans ranging from begrudging acceptance to continued hostility. Mr. Trump’s ascendance illustrates a split within the Republican Party, between the “establishment” and the “tea party” lanes, that has been widening for years. It is likely to persist, as both factions disagree on the elements that led to Mr. Trump’s meteoric rise.

A core point in the internal GOP dispute is whether political confrontation or ideological conservatism most motivates voters, including the party’s base. Steve Schmidt, a consultant to John McCain’s presidential campaign in 2008, said on MSNBC Tuesday night that Mr. Trump’s rise was fueled by voter frustration stoked by the tea-party wing. He and other establishment figures view anger as a poor substitute for substantive policy solutions and a dead-end political strategy in general.

On the other hand, those aligned with tea-partyers view the Trump phenomenon as rising from discontent with an insufficiently conservative leadership. They see voters’ frustration and anger rooted in an establishment that overpromised and underdelivered, for example by promising to fight President Barack Obama’s executive orders on immigration “tooth and nail” in November 2014 but, just a few months later, ruling out a partial government shutdown over the issue as “not an option.”

A Cruz nomination would have left little doubt about the party’s ideological direction. Mr. Cruz often echoed Ronald Reagan’s desire to speak “in bold colors, not pale pastels,” and relying on motivated conservatives to help drive general election turnout. A Cruz-Clinton match-up would have made clear the potential, and potential limits, of a “base strategy.”

Conversely, Trump’s ideological heterodoxies—on health care, abortion and even about Hillary Clinton herself—reshuffle the political landscape. Mr. Trump falls outside the “establishment” and “tea party” labels, as neither side fully embraced his ascent. Mr. Trump said Wednesday that “As far as the Republican Party coming together, it will, maybe not 100%, but it’ll come together 99% and the 1% I don’t want and it won’t have any impact.” What shape the GOP takes as some elements rally behind him and others consider different directions will definitely have an impact on the Republican Party as we have known it.

This post was originally published at the Wall Street Journal Think Tank blog.

Jonathan Gruber, Transparency, and Obamacare’s IPAB

The administration faced a political firestorm last week, when videos emerged featuring MIT professor—and paid Obamacare consultant—Jonathan Gruber making comments on “the stupidity of the American voter,” and claiming that only a deliberately opaque and deceptive process was essential to the law’s enactment. But the administration may soon face a policy controversy as well—for the law features a board that can operate in nontransparent ways, and which will empower technocrats like Mr. Gruber himself.

While the Independent Payment Advisory Board, or IPAB, may bring to mind the latest Apple product offering, the reality is far different. Designed to control health spending, the board of 15 experts—nominated by the president, based in part on suggestions from congressional leaders, and confirmed by the Senate—will have the power to make binding rulings to slow the growth in Medicare outlays. Furthermore, the administration’s budget proposed giving IPAB even more authority, by reducing the caps on Medicare spending the board will be charged to enforce.

IPAB has yet to be constituted. The budget sequester and other savings proposals have thus far kept Medicare spending below the targets that would trigger IPAB recommendations, and Republican leaders have indicated to President Barack Obama their disinclination to provide the White House suggestions for nominees. As a result, the president has yet to make formal nominations—not least because, if the Medicare spending target is reached, requiring IPAB to make formal recommendations to Congress, but IPAB does not do so, that power would then lie within the Department of Health and Human Services itself.

IPAB faces several characteristics that could imbue it with the lack of transparency Mr. Gruber infamously discussed in his speeches:

  • Former Obama administration official Peter Orszag wrote a piece for the New Republic in which he cited IPAB as one way to “counter the gridlock of our political institutions by making them a little less democratic.” In 2012, Politico stated that, while in the White House, Mr. Orszag had “pushed” to include the board in the law.
  • Section 3403 of Obamacare, which creates IPAB, does not require the board to conduct any open meetings. The law merely says that “the board may hold such hearings…as the board considers advisable;” it does not require IPAB to do so.
  • Likewise, while the law prohibits IPAB from “ration[ing] health care,” the term “rationing” is nowhere defined in statute. Former Health and Human Services Secretary Kathleen Sebelius conceded this point, and acknowledged that HHS would likely have to define “rationing” before the board could begin its work—but it has yet to do so.

Prior to the recent controversies, Mr. Gruber seemed like exactly the type of expert—an “individual with national recognition for [his] expertise in health finance and economics”—that might have received an appointment to IPAB. Interviewed for a 2011 article about who might serve on the board, Mr. Gruber didn’t rule it out entirely, while admitting that statutory restrictions on IPAB members’ outside activities might dissuade individuals from applying.

As it happens, Mr. Gruber currently serves on the board of the Massachusetts Connector, an entity charged with implementing the Commonwealth’s health care overhaul. However, to judge from comments made to reporters last week, an aide to Gov. Deval Patrick seemed keen to downplay his influence: “When his term expires at some point, that will be a decision for someone else at that time.”

But beneath the political controversy lies a philosophical question. Fifty years ago last month, Ronald Reagan summarized the concern in his “A Time for Choosing” speech:

This is the issue of this election—whether we believe in our capacity for self-government, or whether we abandon the American revolution and confess that a little intellectual elite in a far-distant capital can plan our lives for us better than we can plan them ourselves.

Therein lies the Obama administration’s bigger problem—how to reconcile a law that increases the influence of independent experts with a high-profile example of such an expert who repeatedly treated American voters with open hostility and contempt. At a time when both the health care law and the federal government itself remain historically unpopular with voters, the Gruber controversy only heightens the perceived distance between the governing and the governed.

This post was originally published at the Wall Street Journal Think Tank blog.

Gov. Jindal Op-Ed: The “Stupid Party,” Revisited

Nearly two years ago, after Mitt Romney’s presidential campaign went down to defeat, I gave some ideas in these pages on CNN about how Republicans can win future elections. On that list was an instruction that Republicans need to stop being the “stupid party.”

While it is true that we as Republicans need to do a better job articulating our principles and being the party of bold new ideas, the Democrats have a far worse problem. Democrats need to stop being the party that thinks Americans themselves are stupid.

To take one example: At a House Ways and Means Committee hearing in April, members asked Treasury official Mark Iwry if the Obama administration believed it could delay Obamacare’s individual mandate, much as the Treasury delayed the employer mandate.

Iwry’s response was stunning: “If we believe it is fair to individuals to keep that (individual mandate) in place because it protects them…then we don’t reach the question (of) whether we have legal authority.”

The level of sheer arrogance in that response boggles the mind. A Treasury spokesman later publicly disclosed the Obama administration’s official position: The federal government, namely the IRS, is requiring all individuals to purchase insurance to “protect” the American people from themselves.

Lest anyone think this attitude comes from anywhere other than the very top of the Obama administration, take the President’s own comments last October. In a speech in Boston at the peak of the controversy surrounding insurance cancellations, the President repeatedly derided canceled plans as “substandard…cut-rate plans that don’t offer real financial protection.” And he didn’t just insult the plans themselves, he insulted the people who purchased them: “A lot of people thought they were buying coverage, and it turned out to be not so good.”

In other words, if you like your current plan, you’re delusional—or a dimwit.

The President soon backtracked, and unilaterally waived portions of the bill he signed into law, allowing some individuals to keep their plans, temporarily. But while the President expressed regret for having engaged in what Politifact dubbed the “Lie of the Year,” he has not once apologized for the arrogant and patronizing attitude underpinning the entire controversy—one in which the President believes that he and his bureaucrats know better than everyday Americans.

Sadly, this attitude does not just pervade Washington liberals; it’s also right at home in my state of Louisiana.

In 2012, the executive director of a state teachers’ union claimed that school scholarship programs wouldn’t work, because low-income parents could not make decisions about their children’s education, saying they “have no clue.”

These comments perfectly illustrate the left’s double standards. Both President Barack Obama and Eric Holder—the attorney general who filed suit to impede our scholarship program but lied to Congress about it last month—choose to educate their children at elite Washington schools costing more than $35,000 per year.

But if Americans of more modest financial means—whose annual income may be dwarfed by the tuition fees President Obama easily pays for his daughters—want their children to escape failing schools, or buy the health plan they want, the left exclaims: “Oh no, we can’t let you do that.”

That’s exactly how The Nation magazine reacted to the health care alternative I recently endorsed. Responding to the plan’s new incentives giving individuals more choices and insurance options, its analysts claimed that “most people are not informed well enough (sic) to make the right choices about which plan to buy, what it covers, what it will cost them, and especially how to decide what care to seek.” That’s what The Nation considers an “epic fail:” allowing the “ignorant” American people to pick their own health care options.

I will readily admit that we do need to improve the transparency of health care cost and quality information. And of course in an emergency no patient in cardiac arrest will be able to “comparison shop” for treatment options.

But if The Nation, President Obama, or anyone else on the left thinks the American people are too dumb to pick a school or health plan, they should say so publicly—and in so many words.

Ronald Reagan famously quipped that the nine most terrifying words in the English language are “I’m from the government, and I’m here to help.”

I believe the best way to help is to empower citizens, trusting them to make good choices, not creating nanny states to “protect” individuals from themselves. As a matter of policy, giving Americans choice in schools and health care is simply the right thing to do.

And as a matter of politics, insulting voters’ intelligence is just plain stupid.

This post was originally published at CNN. 

Gov. Jindal Op-Ed: A Taxing Insurance System

If President Obama is interested in lowering inequality, he has a funny way of showing it. In a speech last December, the President claimed that income inequality is “the defining challenge of our time,” and pledged new government action to reduce the gap between rich and poor.

Ironically enough, one of the policies the President claimed will “solve” inequality—the massive health care legislation he signed into law—will result in the health insurers who provide care to the lowest-income Americans getting taxed.

You read that right: Obamacare taxes health insurers who provide care through Medicaid, the state-federal partnership providing care to low-income families and individuals with disabilities. The law raises $8 billion in taxes on insurers this year, rising to over $14 billion annually by 2018.

Under the law, most managed care plans that provide treatment to vulnerable populations in Medicaid will be subject to the tax. Likewise, most Medicare Advantage plans chosen by seniors will be forced to pay this new Obamacare surcharge.

Because of the way the law was written and applied, the health insurer tax will have some truly perverse effects. In Louisiana, we will have to pay our Medicaid plans more to offset the cost of the health insurer tax. But in doing so, we will claim federal matching funds on those higher Medicaid payments. Imagine that: The federal government is paying states to fund the taxes Washington itself imposed!

Democrats like to claim that these taxes will be borne by “greedy” insurance companies, and that ordinary Americans won’t suffer. But non-partisan experts have said insurers’ cost of the tax will be passed on to insurers’ customers, which is consistent with economic theory—and basic common sense.

Both the Congressional Budget Office and the Joint Committee on Taxation agree that these taxes will ultimately be paid by consumers, in the form of higher premiums. The Joint Committee on Taxation said that repealing the insurer tax would reduce premiums by 2-2.5 percent. That means the insurer tax raises premiums by $350-400 per year for the average family health insurance plan.

Remember that Obamacare’s individual mandate was ruled a tax by the Supreme Court two years ago. So Obamacare taxes you if you don’t buy health insurance, and taxes most people who do buy insurance. Businesses face the same dilemma: Large firms are taxed if they don’t provide their workers with insurance, but if they offer their employees coverage, the law’s health insurance tax could raise their premiums even higher.

And all these taxes—enforced by your helpful friends at the IRS—are harming American families, and our economy. The Congressional Budget Office recently concluded that Obamacare raises effective marginal tax rates, discouraging millions of Americans from working. CBO also concluded that the law will reduce aggregate labor compensation, and result in lower demand for lower-wage workers.

To end where we began: A law that taxes those providing care to the most vulnerable, raises insurance premiums on struggling families, and reduces the American workforce and compensation is exactly the wrong way to address income inequality. In fact, it epitomizes Ronald Reagan’s famous quip that the nine most terrifying words are “I’m from the government and I’m here to help.” President Obama should go back to the drawing board on his agenda, and Congress should repeal Obamacare and focus on enacting true health reform—changes that will lower costs, not raise them.

This post was originally published at Townhall.

Obamacare Meets Monty Python

The Case for Medicare Reform

The panel meets in secret, is controlled by special interests, and helps determine the allocation of nearly $100 billion in federal health care spending.

Is it some clandestine panel created by Obamacare? Hardly. It’s a panel controlled by the American Medical Association (AMA)—and, as The Washington Post reported in a front-page article yesterday, it has been micro-managing the way Medicare pays physicians for nearly a quarter-century.

The panel is just one part of the complex bureaucratic machinery that sets Medicare physician payment enacted by Congress in 1989. Instead of payment set by the free market forces of supply and demand, the panel assigns “value” to different medical procedures. So, in theory, a doctor performing an hour-long surgery should be paid four times as much as a physician undertaking a 15-minute procedure.

In practice, however, the process is far from straightforward. As the Post article demonstrates, the panel operates with virtually no public transparency, little government oversight, and a structural bias toward specialty physicians over primary care procedures. Curiously, in 1989 one of the arguments advanced for this payment system is that it would rectify the bias against primary care doctors.

Worse than the inaccuracies in the current payment system is the premise underlying it: That the Medicare bureaucracy and its group of “experts” can determine the “right” price of nearly every service performed by physicians nationwide.

Later this afternoon, the House Energy and Commerce Committee will begin its markup of Medicare physician payment legislation. While the legislation would revamp the process for setting Medicare reimbursements, as a Heritage Backgrounder released last week demonstrates, it does not represent fundamental reform of the Medicare program. Instead, many of the same medical specialty societies that have abused the current rate-setting process would receive new powers to control patient care—by setting guidelines that physicians must follow and cutting doctors’ pay if they do not.

True reform of the Medicare program would use a premium support system and market forces to unleash competition that will drive down health costs. Getting the federal government out of the price-control business would allow innovative reimbursement solutions to take root.

As usual, Ronald Reagan said it best:

This is the issue:… whether we believe in our capacity for self-government or whether we abandon the American Revolution and confess that a little intellectual elite in a far-distant capital can plan our lives for us better than we can plan them ourselves.

When revamping Medicare physician payment, Congress has the opportunity to take power away from that “little intellectual elite” and should not hesitate to do so. And, rather than attempting to empower other bureaucratic entities to micromanage the health system, it should return that power back to the place where it belongs—with the people themselves.

This post was originally published at The Daily Signal.

Morning Bell: Obamacare, Simplified

With open enrollment in Obamacare’s exchanges set to start in fewer than three months, the law’s supporters are attempting to change the subject from Obamacare’s many delays and glitches. Instead, they’re mounting a campaign to sell the unpopular measure to the public.

President Obama yesterday gave a speech on Obamacare, trying to justify the fact that premiums continue to rise, violating his 2008 campaign promise to lower them by $2,500 per family per year. The Kaiser Family Foundation even released a video that attempts to simplify and explain the 2,700-page measure.

But there’s another helpful chart that shows how Obamacare will work, and it’s taken from an official report released by government auditors. Click on the image below to see how the Treasury’s inspector general for tax administration explained the Obamacare enrollment process, in testimony before the House Oversight Committee on Wednesday:

President Obama's Plan to "Simplify" Your Health Care

The process for determining subsidy eligibility could require 21 different steps, involving at least five separate entities—the Social Security Administration, the Department of Homeland Security, the Department of Health and Human Services, the Internal Revenue Service, and state exchanges—and utilizing a process called the Income and Family Size Verification Project.

Given this bureaucratic nightmare, it’s little wonder that another report from government auditors released last month said that “critical” deadlines to create the Obamacare exchanges had been missed. Nor should any be surprised that yesterday, Treasury’s inspector general for tax administration testified it “is concerned that the potential for refund fraud and related schemes could increase” due to Obamacare.

Yet the Obama Administration believes spending more money will solve the problem. Just for the IRS implementation of Obamacare, the Administration requested $439.6 million for nearly 2,000 bureaucrats.

Obama yesterday attempted to portray Obamacare as defending Americans from insurance companies. But who will defend the American people from Obamacare? The law’s confusing maze of programs, regulations, and processes brings to mind Ronald Reagan’s famous maxim that “the nine most terrifying words in the English language are ‘I’m from the government, and I’m here to help.’”

If a picture is normally worth a thousand words, the Obamacare chart above should be worth trillions. Because Congress—seeing that Obamacare is not just too big to fail, but too big to succeed—should refuse to spend a single dime implementing this behemoth of a health care law.

This post was originally published at The Daily Signal.

The “Imperial” Experts of IPAB — or Why Ronald Reagan Was Right

This weekend a liberal blogger with the American Prospect wrote a post responding to Paul Krugman’s Friday New York Times column on the Independent Payment Advisory Board (IPAB).  The post argues that Congress cannot address policy issues (like how to control health care costs), meaning unelected bureaucrats like those on the IPAB should be granted unfettered power to do so themselves: “Despite many reasons for caution—the words George W Bush foremost among them—I’m becoming more of a believer in an imperial presidency in domestic policy.”  In other words, “imperial” bureaucrats like those on the IPAB should be permitted to enact whatever policies they want unilaterally.

Perhaps not surprisingly given the current debate surrounding the IPAB, liberal intellectual elitism along these lines has surged in recent weeks:

  • The White House’s defense of the IPAB talked about the “experts” who would make decisions on controlling costs in Medicare – and then claimed that “experts” agreed the IPAB was a positive tool for doing so.  (It’s entirely possible that the same “experts” praising the IPAB would be the same “experts” serving on it – meaning the arguments in the post could be viewed as the sound of one hand clapping.)
  • Krugman’s column also talked about a board of “experts” who would be charged with “saying no” to patient treatments – because patients are too feeble-minded to serve as consumers themselves.
  • The Post’s Ezra Klein asserted that “Patients don’t know enough…to say ‘no’ to what a doctor says they need” and argued one of the only ways to reduce costs was to create “systems where doctors and providers have to negotiate with the government” – because a bureaucracy can do a better job of controlling costs (through arbitrary price controls).
  • Former Speaker Pelosi claimed in a speech that “elections shouldn’t matter as much as they do.”

With entitlement reform at the center of a national debate, one of the central questions of the next two years is whether the American people want an “imperial” board of unelected but “expert” bureaucrats making their health care choices – or whether they want to preserve the power to make those decisions themselves.  The Great Communicator said it best:

This is the issue of this election: whether we believe in our capacity for self-government or whether we abandon the American revolution and confess that a little intellectual elite in a far-distant capitol can plan our lives for us better than we can plan them ourselves.