Michael Bloomberg: Against Obamacare Before He Was For It

Last week, old footage emerged of former New York City mayor, and current Democratic presidential candidate, Michael Bloomberg talking about health care rationing. In his comments from 2011, he advocated denying costly care to older patients:

If you’re bleeding, they’ll stop the bleeding—if you need an X-ray, you’re going to have to wait. That’s just…All of these costs keep going up, nobody wants to pay any more money, and at the rate we’re going, health care is going to bankrupt us….You know, if you show up with prostate cancer, you’re 95 years old, we should say, ‘Go and enjoy. Have a nice life. Live a long life. There’s no cure, and we can’t do anything.’ If you’re a young person, we should do something about it.

Perhaps more important is why Bloomberg made those particular comments. At the time, in February 2011, he was paying condolences to a Jewish family that had lost a loved one. One of the deceased man’s family noted that the man “was in the emergency room for 73 hours before he died and…that overcrowding in emergency rooms in New York had become out of control.”

This entire episode undermines the message of Bloomberg’s current ad blitz claiming that as mayor, he expanded access to health care in New York City. Plus, what did the mayor say about ER overcrowding back in 2011? “It’s going to get worse with the health care bill [i.e., Obamacare].” He also predicted that hospitals would close as a result.

Obamacare a ‘Disgrace’

During last week’s Democrat primary debate in Las Vegas, former Vice President Joe Biden brought up some of Bloomberg’s other comments about Obamacare. Biden correctly noted that Bloomberg had called Obamacare a “disgrace.” In a June 2010 speech at Dartmouth University just after the law’s enactment, Bloomberg said “We passed a health care bill that does absolutely nothing to fix the big health care problems in this country. It is just a disgrace.”

Reporters in the past several days have highlighted some of Bloomberg’s prior comments about the law:

  • In his Dartmouth speech, Bloomberg also pointed out that Democrats “say they’ve insured or provided coverage for another 45 million people…except there’s no more doctors for 45 million people.”
  • In a 2011 radio appearance, Bloomberg said that Obamacare “did not solve the basic problems, two basic problems with health care, which…got lost in all of the negotiations as every special interest in Congress got a piece or lost a piece or negotiated about a piece.”
  • In a December 2009 appearance on “Meet the Press,” Bloomberg criticized Democrats for not reading or understanding the legislation: “I have asked congressperson after congressperson, not one can explain to me what’s in the bill, even in the House version, certainly not in the other version. And so for them to vote on a bill that they don’t understand whatsoever, really, you’ve got to question the kind of government we have.”

It’s notable that Biden didn’t mention Bloomberg’s last quote—about members of Congress not reading or understanding the legislation—in Wednesday’s debate. Of course, that might have something to do with Biden’s own recent admission that “no one did understand Obamacare”—presumably including himself, at the time the vice president of the United States.

Changing His Tune

Now that Bloomberg is running for the Democratic nomination, he’s come around to supporting Obamacare. When asked about his prior comments, a Bloomberg campaign spokesman told CNN Obamacare’s only flaw lay in the fact that it didn’t go far enough. As a result, Bloomberg’s health plan proposes more government spending, funded by higher taxes, and—in a first—price controls on the entire health-care sector, including what you can and cannot pay your doctors.

On the merits of his policy platform, I’ll give the last word to Bloomberg himself, in his June 2010 speech at Dartmouth University. While Bloomberg said President Obama started out with good intentions, he said Congress “didn’t pay attention to any of those big problems and just created another program that’s going to cost a lot of money.”

It’s an apt description of Bloomberg’s own health care plan—to say nothing of his competitors for the Democratic presidential nomination.

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.

What John Oliver Didn’t Mention about Single Payer Health Care

During the first episode of this season of “Last Week Tonight,” HBO host John Oliver used his monologue to make the case for the United States to adopt a single-payer health-care system. While Oliver articulated many of the shortcomings of the current system, much of his arguments in favor of a single-payer system missed the mark.

As Oliver noted in his program, whether to adopt single payer represents a debate between the devil one knows and the devil one doesn’t. Skeptics of single payer have the advantage of inertial bias—that is, people may not want to give up what they currently have.

On the other hand, supporters of single payer can characterize the future however they like—even if it doesn’t always line up with the facts. That dynamic has allowed supporters to frame single-payer health-care as “Medicare for All,” even though the legislation introduced by Sen. Bernie Sanders (I-Vt.) would abolish the current Medicare program.

In his program, Oliver acknowledged some of the trade-offs associated with a move to a government-financed health-care system. But he also minimized others, and failed to explain some of the fundamental flaws in Sanders’ approach.

Cost Explosion

Oliver’s segment attempted to tackle the three primary critiques of a single-payer system: It will cost too much; lead to lines and waiting lists for care; and undermine individual choice. On the cost front, Oliver noted that estimates will vary as to whether the Sanders bill will lead to an increase in overall health-care spending. After admitting that the bill could either reduce health spending or cost “a f-ck of a lot more,” Oliver basically threw up his hands, calling the exact amount of spending under the new system unknowable.

On this front, Oliver didn’t analyze why health costs would likely rise under single payer. He mentioned (correctly) that Sanders’s bill would essentially abolish all premiums, deductibles, and co-payments for health care in the United States, making the new system much more generous than the current Medicare program, and much more generous than single-payer systems in places like Canada and Great Britain.

But Oliver did not mention four critical words that majorly affect costs: “Induced demand for care.” In other words, because Sanders’ legislation would make all health care “free” to patients, they would demand much more of it. According to the Urban Institute, a liberal think-tank, a single-payer system that eliminated cost-sharing would result in nearly $1 trillion more in health spending per year than a single-payer system that retained a system of co-pays and deductibles roughly equivalent to Obamacare’s Gold health insurance plans.

Along with many liberals, Oliver views eliminating cost-sharing as a feature of Sanders’ single-payer proposal. But at containing the costs of such a system, it represents a major bug—one Oliver never acknowledged.

Waiting Lists

Oliver did concede that waiting lists for care exist in other countries’ single-payer systems. However, he contended that patients wait primarily for non-emergency care, using knee replacements as an example. (Many patients wouldn’t call the concept of waiting nearly 10 months for a knee replacement—the average wait in Canada for an orthopedic procedure—a non-urgent matter.) He also didn’t point out that 4.56 million individuals in Britain—roughly 7 percent of that country’s population—were on waiting lists for care as of last fall, an increase of roughly 40 percent in the past five years.

Oliver’s discussion of waiting lists also missed a critical point: Sanders’s legislation would go further than other countries with single-payer systems, because it would prohibit individuals from purchasing private health insurance. Canadian and British patients who object to government waiting lists can purchase private coverage, and obtain care via that route.

Under Sanders’s proposal, American patients would not have that choice: They could only opt-out of the single payer system by paying for their treatment entirely in cash. Because not even a family making several hundred thousand dollars per year could afford the full costs of a heart transplant or chemotherapy, the vast majority of Americans would have no choice but to wait for care until the government system got around to treating them.

Choice

That brings up Oliver’s discussion of choice, and whether taking choice away matters. He points out—rightly—that many Americans do not have a substantive choice of either insurers or doctors, because their employers control the former, and by definition the latter.

But it doesn’t require the federal government taking over the entire health-care system to solve this problem, and give Americans a true choice among insurance plans and doctors. I have pointed out on many occasions the ways the Trump administration has acted to make coverage more portable, so that individuals, not employers, and not the federal government, choose the coverage options they prefer.

Oliver talks about the choices some patients currently face: whether to seek treatment they cannot pay for, or rationing medicines based on cost grounds. But patients would face similar choices under a government-run system—just for different reasons.

Oliver acknowledged the likelihood of waiting lists under a single-payer system, as have other supporters. For instance, the head of the People’s Policy Project has argued that costs won’t rise under single payer 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.” In other words, people will seek care, but not be able to obtain it.

In such circumstances, people won’t have a “choice” at all. Because they cannot purchase private insurance to cover treatments the government plan does not, they can either wait for care or they can…wait for care. That’s not just not giving patients choices, it’s harming patients by prohibiting them from buying the insurance they want to buy with their own money.

Towards the end of the segment, Oliver revealed his own bias against giving American patients any choices. After a clip of former South Bend Mayor Pete Buttigieg’s claim that “I trust Americans to make that right choice” on health care, Oliver responded to laughs: “Okay, well, hold on there. You trust Americans to make the right choice? You know Americans choose to drink Bud Light, right?”

Even as he tries to rebut conservative claims that single-payer would undermine Americans’ choices, Oliver admits that he doesn’t really want to give Americans a choice at all. He would rather use government to impose his beliefs on others, and force them to comply.

At minimum, Oliver’s program acknowledged the very real trade-offs associated with a single-payer health-care system. But had he explained those trade-offs fully, the American people would understand why single payer would result in adverse consequences to both our health-care system and our economy as a whole.

This post was originally published at The Federalist.

How Single Payer Would Make Outbreaks Like Coronavirus Worse

The past several weeks have seen two trends with important implications for health policy: Vermont Sen. Bernie Sanders’s burst of momentum following strong political showings in both Iowa and New Hampshire has drawn greater attention to his proposal for single-payer health care, as China struggles to control a coronavirus outbreak that first emerged at the end of last year.

The two events are linked by more than just time. The coronavirus outbreak provides a compelling argument against Sanders’s so-called “Medicare for All” program, which would upend the health-care system’s ability to respond to infectious disease outbreaks.

In an Outbreak, Could You Obtain Care?

For starters, supporters of Sanders’s plan have admitted that under single payer, not all patients seeking care will obtain it. In 2018, People’s Policy Project President Matt Bruenig claimed that while demand for care might rise under single payer, “aggregate health service utilization is ultimately dependent on the capacity to provide services, meaning utilization could hit a hard limit.”

By eliminating virtually all patient payments for their own care, single payer would increase demand for care—demand Bruenig concedes the system likely could not meet, even under normal circumstances. Consider that an outbreak centered more than 6,000 miles from the Pacific coast has already led to a run on respiratory face masks in the United States. During a widespread outbreak on our shores, an influx of both sick and worried-but-well patients could swamp hospitals already facing higher demand for “free” care.

Bureaucrats’ Questionable Spending Priorities

While Sanders’s legislation attempts to provide emergency surge capacity for the health-care system, experience suggests federal officials may not spend this money wisely. Section 601 of the House and Senate single-payer bills include provisions for a “reserve fund” designed to “respond to the costs of treating an epidemic, pandemic, natural disaster, or other such health emergency.” However, neither of the bills include a specific amount for that fund, leaving all decisions for the national health care budget in the hands of the Department of Health and Human Services.

And federal officials demonstrated a questionable sense of policy priorities in the years leading up to the 2014 Ebola outbreak. Of the nearly $3 billion from Obamacare’s Prevention and Public Health Fund given to the Centers for Disease Control in the years 2010-2014, only about 6 percent went towards building epidemiology and laboratory capacity. Instead, CDC spent $517.3 million funding grants focused on objectives like “improving neighborhood grocery stores” and “promoting better sidewalks and street lighting.”

Socialized Medicine Brought to Its Knees By…the Flu?

Including a system of global budgets as part of a transition to single payer would leave hospitals with little financial flexibility to cope with a sudden surge of patients. Sanders’s Senate version of single-payer legislation does not include such a payment mechanism, but the House single-payer bill does. Sen. Elizabeth Warren and other liberal think-tanks believe the concept, which provides hospitals lump-sum payments to cover the facilities’ entire operating budget, can help reduce health-care costs.

But in its May 2019 report on single payer, the Congressional Budget Office noted that consistently slow growth of global budget payments in Britain’s National Health Service has “created severe financial strains on the health care system.” And how: Rising hospital bed occupancy rates have created longer wait times in emergency rooms, with patients stuck on gurneys for hours. In one example of its annual “winter crisis,” two years ago the NHS postponed 55,000 surgeries due to capacity constraints, with one ER physician apologizing for “Third World conditions of the department due to overcrowding.”

A British health system barely able to cope with a predictable occurrence like a winter flu outbreak seems guaranteed to crumble in the face of a major pandemic. Voters lured by the siren song of socialism should bear that in mind as they ponder news of the coronavirus and Sanders’ “Medicare for All.”

This post was originally published at The Federalist.

No, $400 in Routine Health Care Costs is Not a Reason to Socialize Medicine

Sometimes, even heated discussions on Twitter can bring both light and heat by illuminating policy discussions. On Wednesday evening, Elizabeth Bruenig wrote a since-deleted tweet, using her transition from a writing position at the Washington Post to one at The New York Times to argue for single-payer health-care system:

Vance made a compelling point on policy, but one that conflated two issues. I wholeheartedly agree with his position on wanting to make coverage portable. But I don’t believe that a movement to de-link health coverage from employment means the government should pay for the health costs of comparatively affluent individuals.

Need for Portability

In her tweet, Bruenig admitted her period of uninsurance came from switching jobs. As a mother of two, including a newborn, Bruenig quite likely—and understandably—arranged some time between her two positions to spend with her young children.

On that front, I agree with both Bruenig and Vance about the good policy reasons to move away from individuals obtaining health coverage from their employers. As I outlined in prior writings, much of the problem of pre-existing conditions comes from our employer-based health insurance system: When you lose your job, you lose your coverage, which causes understandable worry for employees who have pre-existing conditions.

Making health coverage portable would allow individuals to take their insurance from job to job. This change would eliminate the friction people like Bruenig face when they’re between jobs, and greatly reduce (but not eliminate) the problem of pre-existing conditions, because people who develop such conditions during their working careers would own their own coverage, purchased before they became ill. The Trump administration has taken big strides on that front, publishing a regulation that will allow individuals—not their employers—to select and own their own health coverage, while still receiving an employer subsidy to cover some or all of the cost of their premiums.

However, people on the left talk about making health coverage portable not by giving power to individuals but by giving power to government. To borrow a medical metaphor, most liberals and socialists focus on the symptom (pre-existing conditions) rather than the underlying disease (lack of portable insurance). They favor either government regulation regarding pre-existing conditions, which encourages people to wait until they become sick to buy insurance, or in Bruenig’s case, an entirely government-run system.

Affordability for Individuals—And Taxpayers

While I agree with both Bruenig and Vance on the need to improve coverage portability (even if I disagree with the former on the way to go about it), I disagree in this instance about the separate question of who should pay for those costs.

But context matters, and in this case, the context looks quite different. Bruenig’s husband Matt also works; a former attorney for the National Labor Relations Board, he heads the People’s Policy Project, a socialist think-tank. As a result, their family has a second source of income, and another source of employer-based health insurance. (While Bruenig referenced health bills for her children, she didn’t say that her children faced an insurance gap. Given that context, I assume, but do not know for certain, that her husband’s insurance covers her children.)

Consider also the most recent breakdown of IRS tax filing data by income. As of 2017, households with adjusted gross income exceeding $97,870 represented the top quintile (i.e., top 20 percent) of filers, and households with adjusted gross income exceeding $145,135 represented the top 10 percent of filers. Bruenig and her husband almost certainly exceed the threshold to put themselves in the top 20 percent, and quite possibly the top 10 percent as well. Do I believe someone with that kind of income should receive government assistance for health insurance costs? In a word, no.

I haven’t yet completed my tax returns for 2019, but based on my paperwork compiled to date, I expect to declare just over $100,000 in income from my business last year. Of course, because I run my own business, I have to pay my own health insurance premiums. And my age (I’m roughly ten years older than Bruenig) means I pay more in premiums for Obamacare exchange coverage than she would if she bought temporary insurance there—and I do it month after month, not just when I have a gap between jobs.

In short, the Twitter mob calling me an “elite” for my tone and comments about savings ignore the fact that, based upon their station in life, Bruenig and her husband qualify on that front too. Unlike them, however, I don’t believe the federal government has a place subsidizing my insurance costs.

A Question of Priorities

I’ll give the last word to a Democrat: Maryland Rep. Steny Hoyer. As I mentioned in my book, in 2009, Hoyer, then as now the House majority leader, took to the House floor to make this compelling statement about entitlement spending and federal priorities:

At some point in time, my friends, we have to buck up our courage and our judgement and say, if we take care of everybody, we won’t be able to take care of those who need us most. That’s my concern. If we take care of everybody, irrespective of their ability to pay for themselves, the Ross Perots of America, frankly, the Steny Hoyers of America, then we will not be able to take care of those most in need in America. [Emphasis added.]

I agree with both Vance and Bruenig on the need to make health coverage more portable. But on the separate question of who pays, and saving scarce taxpayer resources for those who need them most, I stand with Hoyer.

This post was originally published at The Federalist.

Is Elizabeth Warren Trying to Use a “Goldilocks” Strategy to Win the Democratic Nomination?

In blessing the presidential candidacy of Sen. Elizabeth Warren (D-MA), former Housing and Urban Development Secretary and recent presidential dropout Julian Castro used an interesting rationale to explain his endorsement: “More than any other candidate in this race…Elizabeth Warren is the candidate who can unite the entire Democratic Party.”

That premise may well explain the strategy behind her campaign, to win the Democratic nomination as the “Goldilocks” candidate—not too hot, and not too cold.

The strategy wouldn’t make Warren a political moderate, by any stretch. No nominee who has endorsed a conversion to a single-payer system of socialized medicine would fall into that category. But making Warren the candidate most acceptable (or least unacceptable) to moderates and leftists alike does mean that, the longer the nomination fight plays out, the stronger her chances might get.

Contested Convention Ahead?

In the past several weeks, multiple stories have analyzed the possibility of a prolonged contest for the Democratic nomination. In the fourth quarter of 2019, four candidates—Vermont Sen. Bernie Sanders, former South Bend Mayor Pete Buttigieg, former Vice President Joe Biden, and Warren—raised more than $20 million, suggesting they will have ample resources to compete in primaries throughout the spring. The nomination fight also features two billionaires who have the ability to self-fund their campaigns, Tom Steyer and former New York City Mayor Mike Bloomberg.

Couple the field of well-financed candidates with the Democratic Party’s proportional allocation method, in which any candidate exceeding 15 percent of the vote in a state receives a share of that state’s delegates, and you have the recipe for a prolonged campaign of attrition. In this year’s “bizarro world” scenario, each of the half dozen candidates has the means to continue competing in primaries, and because many (if not most) will amass delegates along the way, they will have every incentive to do so.

It seems premature to make definitive judgments on the complexion of the campaign weeks before the first ballots get cast. But Democrats may convene in Milwaukee this July without a single candidate controlling the majority of delegates necessary to win the presidential nomination.

Least Common Denominator Candidate

If Democrats do end up with a contested convention, it seems unlikely to result in an outcome in which a previously undeclared candidate emerges from the shadows to win the nomination. Given the acrimony throughout the 2016 campaign, when Sanders’ supporters (rightly) protested at a process rigged against their candidate, the idea that a “white horse” candidate such as Michelle Obama, Oprah Winfrey, or someone similar could win the nomination without having entered a single primary seems far-fetched, not least because of the outrage that would ensue.

So a contested convention would feature the candidates currently declared, and only the candidates currently declared, battling for the nomination. At that point, it likely would become less a contest of persuasion—which candidate can I most enthusiastically support?—than an attempt to cobble together a coalition of delegates that focuses on a different test: Which candidate offends the least?

Of the four candidates leading the polls, Warren appears to win this test, by a fairly wide margin. Consider the negatives against the other candidates:

  • Biden’s age (77) has raised questions throughout the campaign about his physical stamina and mental acuity. Even after he reversed himself (under pressure) on taxpayer funding of abortion, Biden’s history of positions on issues—from his support for the 2005 bankruptcy bill, to his vote for the Iraq War, to his support for the 1994 crime bill, to his treatment of Anita Hill—remain to the right of the party, drawing scorn from leftists as a moderate supported by corporate interests.
  • Like Biden, Sanders’ age (78) remains an issue, particularly given his heart attack in October. While many on the left believe he has strong appeal to working-class voters, particularly in the Rust Belt, who have deserted the party, establishment types worry that a self-proclaimed socialist will prove unelectable in November.
  • Buttigieg has age concerns as well because of his relative youth (he turns 38 this month). He has little political experience outside South Bend, won his last mayoral election with a total of 8,515 votes, and lost his only statewide campaign by a nearly 25-percentage point margin. And his experience working at McKinsey has become fodder for attacks by the far-left, who love to hate the candidate they call “Wall Street Pete.”

By contrast, Warren has comparatively few obvious drawbacks. While a septuagenarian, her age (70) makes her several years younger than Biden and Sanders, and younger than President Trump. She has endorsed a host of far-left policies, but insists she remains a capitalist to her bones. And in a field that has shrunk to become dominated by white men, a Warren nomination would provide Democrats an identity politics card.

For all these reasons, Warren remains the top second choice of voters in most polls, even as her standing as voters’ first choice has shrunk. It makes her well-placed to serve as the compromise candidate should Democrats face a contested convention, which by definition would involve at least some delegates choosing their second-favorite candidate as the nominee.

The two biggest strikes against her appear largely self-inflicted: The controversy over her ancestry (exacerbated by her DNA test), and her evasions on health care. While Trump would bring the latter up often—indeed, has already done so—it seems unlikely any opponent would make it an issue during a fight for the Democratic nomination. (At least he or she would not do so publicly.)

As for health care, she evaded questions about how to pay for single payer for months, and finally released a funding plan in early November, only to say two weeks later she wouldn’t push for single payer until the third year of her term. This bobbing and weaving coincided with a pullback in her polling numbers. But to take the longer view, it syncs up well with a larger “Goldilocks” political strategy.

Her eventual position, in which she pledged to enact a robust “public option” immediately, followed by a push for single payer later, drew little love from either moderates (who don’t like talk of single payer at all) or leftists (who want to enact single payer immediately, as Sanders has promised). But it represents the kind of clunky political compromise could easily envision a party’s platform committee drafting. That makes it entirely consistent with an attempt to position Warren in ways that offend the fewest number of Democrats—a helpful strategy in the event of a contested convention.

Obama Wild Card?

One other figure could loom large over a prolonged nomination fight: Barack Obama. Two reports in recent weeks suggest first that Obama doubts Biden’s connection with voters, and second that Obama has talked up Warren’s candidacy behind closed doors. While one must caveat the articles with two of the biggest weasel words in politics—“If accurate”—these reports suggest that, should the nomination fight become prolonged, the last Democratic president may weigh in on behalf of the Massachusetts senator. While such a development might not decide the nomination, it could go a long way in doing so.

After Warren’s fumbling on health care this fall, some had begun to write off her candidacy. Indeed, this author said she had “Swift-boated” herself, by turning her supposed strength as a policy wonk into her biggest weakness. Paradoxically, however, while Warren’s machinations cost her in the polls over the short term (and would harm her in a general election campaign), they could help her to win the Democratic nomination.

This post was originally published in The Federalist.

Three Ways Pete Buttigieg Is No Moderate

In recent weeks, former South Bend Mayor Pete Buttigieg has enjoyed a boomlet in polls for the Democratic presidential nomination, helped in no small part by fawning press coverage. Politico and others have examined the candidate and his supposedly “moderate” message.

Rhetoric aside, however, the substance of Buttigieg’s policy plans seem anything but moderate. On multiple issues, Pete has embraced positions far to the left of anything Hillary Clinton dared endorse in her campaign four years ago, and which seem “moderate” only in comparison to the socialist delusions of candidates like Sen. Bernie Sanders (I-Vt.).

1. Big Tax Increases on the Middle Class

As I first noted last month, Buttigieg has supported at least one, and quite possibly several, tax increases on the middle class. His retirement security plan included one explicit tax increase on working families, endorsing legislation that would raise payroll taxes as part of a new regime of paid family leave.

The retirement white paper, released just before Thanksgiving, implicitly endorsed a second tax increase on the middle class as well. The plan proposed a new entitlement program, Long-Term Care for America, designed to replace the CLASS Act included in Obamacare, but which Congress repealed prior to its implementation due to solvency concerns. Buttigieg’s paper didn’t say how it would pay for the new spending created by the program, but other studies cited by the campaign did: They proposed another increase in the payroll tax, which would also fall on middle-class families.

I wrote about Buttigieg’s tax plans in the Wall Street Journal last month. Yet following that article, no one from the Buttigieg campaign bothered to refute, smack down, or otherwise correct my assertion that their candidate wants to tax middle-class families.

The deafening silence from the Buttigieg campaign regarding my op-ed suggests the candidate does indeed want to raise taxes on the middle class—he just hopes that no one will notice that fact. It seems like an ironic bit of silence, given that Buttigieg attacked Sen. Elizabeth Warren (D-MA) for being “extremely evasive” on the issue of middle-class tax increases last fall.

2. ‘Insurance, Whether You Want It or Not’

Buttigieg likes to advertise his health care plan as “Medicare for All Who Want It,” but as several stories over the holiday revealed, it comes with an intrusive twist. While his plan says that “individuals could opt out of public coverage,” they could do so only “if they choose to enroll in another insurance plan.”

In other words, Buttigieg would compel people to buy insurance—whether they want to or not, enforcing this revived individual mandate through the tax code. On April 15, individuals who didn’t enroll in health insurance the previous year would get a bill for coverage, which could total $5,000 or more, whether they wanted that coverage or not, and whether they knew they had that coverage or not.

It’s far from clear that this new “mandate on steroids” would pass constitutional muster. In 2012, the Supreme Court under Chief Justice Roberts blessed Obamacare’s mandate as a tax in part because “for most Americans the amount due will be far less than the price of insurance…It may often be a reasonable financial decision to make the payment rather than purchase insurance.”

Roberts justified Obamacare’s mandate as a tax because it gave the public a genuine choice: Buy insurance, or pay the IRS a tax. Buttigieg’s plan would give the public a Hobson’s choice: Buy insurance, or have insurance bought for you. It represents a significant increase in federal powers—one courts could (and should) strike down.

3. ‘Glide Path’ to Socialized Medicine

Notwithstanding his use of a strengthened individual mandate, Buttigieg ultimately wants to end up with a single-payer system of socialized medicine. He has made no bones about his objective, claiming that his health-care plan would provide a “glide path” to socialism.

As with most of the 2020 Democratic candidates who haven’t endorsed single payer explicitly, Buttigieg’s plan contains several characteristics designed to promote the growth of government-run health care. For instance, he would automatically enroll millions of individuals into the government-run health plan. (He claims Americans could opt out of the government plan, but if he wants the system to end in single payer, how easy would he make it for them to do so?) And he has proposed capping the amount that both private and public insurers can pay physicians and hospitals for health treatments, another way to funnel Americans into the government-run system.

Buttigieg’s plan would create the architecture to create a government-run system of socialized medicine. He just would build that edifice slightly more slowly than Sanders would. It represents but one of the big-government dreams of a candidate who, despite soothing rhetoric, has little in the way of policies to justify the term “moderate.”

This post was originally published at The Federalist.

Joe Biden’s Obamacare Gaffe Points to a Larger Truth

In Iowa just before the New Year, former Vice President Joe Biden had an interesting response to a voter’s concerns about Obamacare. The voter said his father had lost his coverage when the law’s major provisions took effect in 2014, and the “replacement” plans proved far more expensive. Asked to apologize for what PolitiFact dubbed its “Lie of the Year” for 2013—that “If you like your plan, you can keep it”—Biden demurred by claiming the following:

There’s two ways people know when something is important. One, when it’s so clear when it’s passed that everybody understands it. And no one did understand Obamacare, including the way it was rolled out. And the gentleman’s right—he said you could keep your doctor if you wanted to, and you couldn’t keep your doctor if you wanted to, necessarily. He’s dead right about that.

On its face, Biden’s comments initially resemble House Speaker Nancy Pelosi’s “We have to pass the bill so that you can find out what is in it” gaffe. But in reality, they hint at a larger truth: the federal government has gotten so big and sprawling, nobody really understands it.

Pelosi’s ‘Kinsley Gaffe’

Just before Obamacare’s passage in March 2010, Pelosi made comments that conservatives have parodied for most of the ten years since:

Upon closer inspection, though, her comments centered on the political messaging about the law, rather than the underlying policy. She prefaced her infamous quote by noting that “You’ve heard about the controversies within the bill, the process about the bill.”

But in Pelosi’s view, the American people had not heard about the substance of the bill itself: “I don’t know if you have heard that it is legislation for the future.” She went on to talk a bit about preventive care measures contained in Obamacare, which in her view would lower health-care costs. She then gave her infamous quote about passing the bill “so that you can find out what is in it, away from the fog of the controversy.”

Pelosi’s statement still seems extraordinary. She admitted that, even with Barack Obama—who won the presidency in fair measure through his rhetoric—in the White House, more than 250 Democrats in the House, and 60 Democrats in the Senate, Obamacare had proven a political failure. Democrats had lost the messaging battle in 2009 and 2010, and could only hope that enacting the legislation and allowing Americans to see its purported benefits could turn the dynamic around.

But Pelosi’s comments said “we have to pass the bill so that you can find out what is in it”—emphasis on the second person. She still claimed to know the contents of the legislation, contra the recent claims of the vice president at the time.

So Much for ‘Experts’

On one level, Biden’s comments echoed Pelosi’s. He talked about “the way it was rolled out”—a likely reference to the messaging battles of 2009-10, the “debacle” of the exchange launch in late 2013, or a combination of the two.

But unlike Pelosi—who said the public didn’t understand Obamacare—Biden said that “no one did understand Obamacare.” One wonders whether the statement meant to inoculate Obama from accepting blame for his “like your plan” rhetoric, even though Obama himself apologized for misleading the public on the issue in late 2013.

Regardless, Biden’s rhetoric echoes the example of Max Baucus, at the time the chairman of the Senate Finance Committee. Asked shortly after the legislation passed whether he had read Obamacare prior to its enactment, he responded that “I don’t think you want me to waste my time to read every single word of that health care bill,” because “we hire experts” who are the only people who “know what the heck it is:”

Except that four years later, one of those “experts” who worked on Baucus’ staff at the time, Yvette Fontenot, admitted that when drafting Obamacare’s employer mandate, “We didn’t have a very good handle on how difficult operationalizing the provision would be at that time.” So, to borrow Baucus’ own phrase, even one of his self-appointed “experts” didn’t “know what the heck it is” either.

Why Expand a Government You Can’t Even Understand?

Biden’s comments once again reveal that the federal government has become too big and sprawling for anyone to understand. Yet he and his Democratic colleagues continue to push massive, multi-trillion-dollar expansions of government as part of their presidential campaigns. Sen. Elizabeth Warren goes so far as to claim that “experts” can fix just about everything that’s wrong with the world, even though Biden’s admission shows that they need to start by fixing the problems they caused.

As the old saying goes, when you’re in a hole, stop digging. That axiom applies equally to Biden’s propensity to put his foot in his mouth and Democrats’ desire to expand a government they do not understand.

This post was originally published at The Federalist.

Elizabeth Warren’s Health Care “Choice:” Dishonesty

In Thursday night’s Democratic presidential debate, Sen. Elizabeth Warren (D-MA) may debut before a nationwide audience a surprising mantra for someone openly committed to enacting a single-payer system of socialized medicine: Choice.

NBC reports that Warren said on Saturday: “We’re going to push through…full health care coverage at no cost for everyone else who wants it—you can buy it for a modest amount. You don’t have to, but it’s your choice.”

To clarify her “you can buy it” comments, Warren’s most recent health care plan said she would immediately make “free” coverage available to anyone making less than two times the federal poverty level ($51,500 for a family of four in 2019), with sliding-scale premiums capped at no more than 5% of income for those making more than 200% of poverty. Her recent speeches have focused on selling this “transition” plan—“free” coverage if you want it, but only if you want it—rather than her earlier single-payer program.

Some conservatives have claimed that Warren’s change in rhetoric marks the “last gasp” for the left’s move towards socialized medicine. Don’t you believe it. Warren hasn’t given up on anything. Nor have Pete Buttigieg and the other candidates who have campaigned against “Medicare for All.” They, and she, have just chosen to become less candid with the American people about how they hope to achieve their ultimate objectives.

Why Warren Pivoted

Two reasons in particular explain why Warren suddenly embraced the mantra of choice. First, most Americans who have health insurance right now like their plan. A Gallup survey found that nearly seven in ten Americans find their health coverage either excellent (27%) or good (42%). In the 18 years since Gallup first started asking this question, the approval number for Americans’ health coverage has never dropped below 63%.

When millions of people received cancellation notices as Obamacare took effect, Barack Obama found out in 2013 how much people like their current coverage. He felt compelled to issue a public apology for his “Lie of the Year,” telling people they could keep their existing plans when many could not. In part due to these events six years ago, the fear of taking people’s coverage away has dominated the health care discussions at this year’s Democratic presidential debates.

By emphasizing choice, Warren seeks to minimize this potential source of controversy for key constituencies. In the Democratic primaries, union households who have negotiated generous health benefits may blanch at losing those benefits; one confronted Sen. Bernie Sanders (I-VT) about the issue in Iowa this past summer.

Then in next year’s general election, educated and affluent voters who have good health coverage will similarly fear a new plan taking that coverage away. As Philip Klein recently noted in the Washington Examiner, proposing the eradication of existing insurance options could well cost Warren in places like the suburbs of Philadelphia, Detroit, and Milwaukee—critically important battleground areas in battleground states.

De-Emphasizing (Middle Class) Tax Increases

Second, Warren’s earlier rhetoric about taking coverage away from all Americans implies another, similarly awkward question: How will you pay for this massive expansion of government? Warren tried to answer this query by releasing a funding proposal in early November, but in truth, it raised more questions than it answered.

To give but one example: Since Warren released her plan, one study found that her proposed wealth tax would raise $1 trillion less in revenue than she claimed. That $1 trillion gap represents money that she would have to get from somewhere else.

Her revenue plan has myriad other gimmicks buried inside (analyzed in detail here). For instance, her estimates didn’t take into account the fact that the tax increases will shrink the economy, and therefore by definition won’t produce all the revenue she claims.

Warren released her revenue plan claiming that she could fund the full cost of her single-payer plan without raising taxes on the middle class. But the more she pushed that plan, the more people would pick apart all the gimmicks—and Warren’s opponents would rightly claim the gap between what she said her plan would raise and what it actually does would end up coming from the middle class. As a result, Warren “chose” to pivot to her “choice” mantra, navigating away from the Scylla and Charybdis of taking away people’s coverage, and raising taxes on the middle class to do so.

Forcing People to ‘Choose’ Socialism

The change in Warren’s tone doesn’t mean she’s changed her ultimate objective, however. Consider her comments at a town hall on Monday: “When tens of millions of people have had a chance to try [the buy-in proposal], I believe, at that point, we’re going to be ready to vote for” single payer (emphasis added).

Like Buttigieg, Warren sees a buy-in program—call it a “government-run plan,” call it a “public option,” call it “Medicare for All Who Want It”—as creating a natural “glide path” to single payer. They remain quite outspoken in their goal: They want to achieve a socialized medicine system. If given the opportunity, they will use policy to accomplish that objective—just slightly more slowly than under an immediate transition to single payer.

A throwaway line in a recent Vox article got at this same point. The article focused on open enrollment for exchange plans, and the fact that insurers must limit enrollment to a certain period of time, because Obamacare’s costly pre-existing condition provisions encourage individuals to wait until they become sick to sign up for coverage. The penultimate paragraph included this claim:

Under the various public options that have been proposed, uninsured people would be automatically enrolled in the new optional government plan. One advantage the government has over private insurers is it doesn’t need its books to balance perfectly; adverse selection [a disproportionate number of sick people signing up] isn’t as big a concern. [Emphasis mine.]

The highlighted line demonstrates how liberals would use taxpayer funds for the government-run plan: subsidizing coverage in advance, or bailing out the government plan after the fact if premiums are set too low, or too many sick people enroll, or both. Vox’s line hints at the left’s true goal through a “public option:” To sabotage private plans, and force people into socialized medicine, one person at a time.

Warren’s “choice” mantra sounds innocuous, but its underlying premise—by her own admission—seeks to create a single-payer system, just over a slightly longer period. Conservatives who think her approach represents anything other than a change in tactics should think again. The wolf attacking private insurance hasn’t disappeared so much as put on a disguise of sheep’s clothing.

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.