The Insane Vaccine Debate

Conservatives often complain that welfare – Medicaid included – tends to trap the poor in a cycle of dependence on government largesse for the simple reason that all means-tested welfare programs come with strong disincentives for beneficiaries to increase their income. If your pay increases beyond a certain point, you lose taxpayer-funded benefits, which are almost always worth more than a slight bump in pay. Policy wonks call this an “income cliff,” and Pence’s plan has the highest one yet for the Medicaid expansion population.

Consider that under Pence’s plan, a Hoosier earning $16,104 (or 138 percent of the federal poverty level, the income limit for Medicaid expansion under Obamacare) will pay a maximum of $322 a year for very generous HIP 2.0 coverage with no other out-of-pocket costs. If this person’s income increases at all, he loses his HIP account and will be forced to buy coverage on the Obamacare exchange, where his healthcare costs will skyrocket to nearly $2,800 a year in deductibles and copays for the benchmark silver plan.

Faced with such a choice, who would ever choose to earn more? In his statement, Pence said his goal is “to ensure that low-income Hoosiers have access to a health care plan that empowers them to take charge of their health and prepares them to move to private insurance as they improve their lives.” Yet the incentives built into his Medicaid scheme almost guarantee that poor Hoosiers will never opt to move to private insurance. They will instead become permanent dependents of Indiana’s expanding welfare system.

On March 4, the Supreme Court will hear arguments in a case that could upend Obamacare completely. In King v. Burwell, the court – if it follows the plain text of the law, which says that only individuals purchasing coverage on an “exchange established by the state” are eligible for federal insurance subsidies – could cause disruption to individuals in the 36 states that did not establish a state exchange and instead rely on the federally run healthcare.gov exchange. For this reason, many observers have argued conservatives need to present an alternative vision of health reform before the court rules.

I wholeheartedly agree with that position. However, I fear many of the proposals being discussed by Republicans in Washington, DC do not truly represent conservative reform.

Take one major issue related to Obamacare: taxes. The law is chock full of them – no fewer than 18 revenue raisers totaling over $1 trillion through 2022.Yet several alternative proposals being discussed by Republicans don’t actually repeal the law’s tax increases. Instead, they repeal the law’s tax increases, only to replace them with new revenue hikes. So, rather than raise taxes by more than $1 trillion, as Obamacare did, these plans raise taxes by perhaps “only” $500 billion.

This puts Republicans in the positions of being “cheap” Democrats, or Democrat-lite. We’ll raise taxes – but just … less than Obamacare. We’ll spend hundreds of billions on new entitlement programs – but just … less than Obamacare.

But the problem with programs that look like Obamacare is that they bring with them many of Obamacare’s problems. Remember when the Congressional Budget Office concluded that Obamacare will result in more than 2 million Americans working fewer hours, or leaving the labor force altogether? That’s because the law’s insurance subsidies are structured in ways that will cause individuals to work fewer hours, keeping their income low to maintain eligibility for subsidized insurance. Some so-called conservative health plans also have characteristics that will discourage work – even if perhaps less than Obamacare does.

The Affordable Care Act lets subsidies flow to insurance plans purchased on exchanges established by state governments. Since most states haven’t set up exchanges, following the law would have required limiting the subsidies geographically. The administration decided to offer them more widely, to include plans purchased on federal exchanges in states that declined to establish their own. If the Supreme Court decides to reinstate the law’s limits, millions of people whose plans are subsidized will suddenly face much higher premiums. And if they drop their coverage, it could cause premiums to rise for those who are left on the exchange, even people whose own plans aren’t subsidized.

Republicans could respond to this situation by saying it’s Obama’s fault and not their problem. But that would be a pretty callous reaction, and it probably wouldn’t be politically sustainable. A new poll from the Kaiser Family Foundation shows that if the court restricts the subsidies, 64 percent of people think Congress should “pass a law so that people in all states can be eligible for financial help from the government to buy health insurance.” Democrats would present a united front calling for quick fixes: The recalcitrant states could set up exchanges or deem the federal exchange for their residents to be “state-established”; Congress could pass a short bill blessing the subsidies everywhere.

Acceding to such demands, however, would present its own disadvantages. Republicans would have to expand the reach of Obamacare right after the court had shrunk it, entrenching a model of health-care policy they consider bad for the country and enraging many of their supporters. Because of the way Obamacare is written, the ruling would end the employer mandate and limit the reach of the individual mandate in the affected states. Going along with the Democrats would mean voting for these especially unpopular features of Obamacare. If the only alternatives are doing nothing or effectively reversing the court’s decision, Republicans will split over which to choose and fight each other about it.

I’ve recently discovered a new “pretorian band of government,” if you will: the health care insurers working hard to protect their Obamacare subsidies.

Now, to be fair, insurers were already hand-in-glove with the government, thanks in no small part to Medicare Advantage and Medicare Part D. Still, Obamacare has further cemented this relationship. Compare and contrast two headlines.

The first, from United Press International, dated October 9, 2009: “Health insurers report slams Baucus bill.” The opening sentence reads: “The day before a U.S. Senate panel votes on healthcare reform, an insurance industry report said a family premium in 2019 could cost $4,000 more than thought.”

The insurers did not like the weak individual mandate in the “Baucus bill,” which was the version of reform worked out by the Senate Finance Committee – and more or less adopted by the entire Congress. And so it seemed as if the insurers were actually opposed to reform.

Now let us jump ahead to the present day, for our second headline, from National Journal, dated January 29, 2015: “Can The Health Care Industry Save Obamacare? / Hospitals and insurance companies are coming to the law’s defense before the Supreme Court.” The opening sentence: “Health insurance companies and hospitals mounted an aggressive defense of Obamacare’s insurance subsidies Wednesday, warning the Supreme Court that eliminating the payments would be ‘grossly inequitable’ to millions of Americans.”

Quelle surprise! Former enemies are now friends. How can this be?

As with so much else about American politics, it just goes to show that if James Madison predicted something, the smart money is on it coming true.

Obamacare forces people to buy health insurance; it subsidizes their private insurance; it increases Medicaid, which is often run through private insurers; and more. The law created new fees and taxes, but insurers have announced they will simply pass those new costs onto customers, who, by law, are required to buy this product.

Most importantly – for both consumers and shareholders – Obamacare is also driving consolidation in the industry. In 2011 and 2012, the big insurance companies bought up some smaller ones. Modern Healthcare, in another article this month, says a second wave of mergers is coming. Hospital mergers have been another fruit of Obamacare.

More starkly, the law keeps out new competitors, building a moat around the existing insurers. As was laid out at an AEI event in 2013, “By capping the medical loss ratio, you guarantee that only the incumbent players are in the marketplace. New insurers can’t launch without losing a lot of money in the initial years.” This suggests less competition, thus larger profit margins.

As many as 6 million people will have to pay a penalty under ObamaCare for going without health insurance in 2014, federal officials suggested in projections released Wednesday.

That means between 2 percent and 4 percent of all taxpayers lacked medical coverage for all or part of the year and do not qualify for an exemption under the individual mandate, according to the Treasury Department.

Another 10 to 20 percent of taxpayers – or 15 million to 30 million people – were uninsured but will qualify for an exemption from the mandate, shielding them from paying $95 or 1 percent of household income when they file their taxes.

Wednesday’s estimates are the clearest picture so far from the administration ahead of ObamaCare’s first tax season. The percentages were provided by Mark Mazur, assistant secretary for tax policy at the Treasury Department.