The economics of ObamaCare

Bill's forum was the first! All subjects are welcome. Participation by all encouraged.

Moderator: Available

Post Reply
User avatar
Bill Glasheen
Posts: 17299
Joined: Thu Mar 11, 1999 6:01 am
Location: Richmond, VA --- Louisville, KY

The economics of ObamaCare

Post by Bill Glasheen »

This is an editorial. As such, it is opinion. So if you don't agree with it, understand that it's meant to be analysis and interpretation of the facts, and not simply the facts.

However this is one of the best real world examples of The Laffer Curve that I've seen. If you haven't had a basic course in economics, some of the terms (e.g. elasticity) may be foreign to you. Personally as an undegraduate major in applied math, I found the language of economics to be annoying. Elasticity? Why can't you just say slope? But then again, maybe it's just me. <sigh...>

Anyhoo... This is one of the more articulate and quantitative assessments I've seen in the editorial section of a newspaper. But then again, The Wall Street Journal isn't a McPaper, so...

Fasten your seatbelts! 8)

- Bill

Wall Street Journal Online - March 30, 2010
OPINION - March 30, 2010

The Rich Can't Pay for ObamaCare

By ALAN REYNOLDS


President Barack Obama's new health-care legislation aims to raise $210 billion over 10 years to pay for the extensive new entitlements. How? By slapping a 3.8% "Medicare tax" on interest and rental income, dividends and capital gains of couples earning more than $250,000, or singles with more than $200,000.

The president also hopes to raise $364 billion over 10 years from the same taxpayers by raising the top two tax rates to 36%-39.6% from 33%-35%, plus another $105 billion by raising the tax on dividends and capital gains to 20% from 15%, and another $500 billion by capping and phasing out exemptions and deductions.

Image
Chad Crowe

Add it up and the government is counting on squeezing an extra $1.2 trillion over 10 years from a tiny sliver of taxpayers who already pay more than half of all individual taxes.

It won't work. It never works.

The maximum tax rate fell to 28% in 1988-90 from 50% in 1986, yet individual income tax receipts rose to 8.3% of GDP in 1989 from 7.9% in 1986. The top tax rate rose to 31% in 1991 and revenue fell to 7.6% of GDP in 1992. The top tax rate was increased to 39.6% in 1993, along with numerous major revenue enhancers such as raising the taxable portion of Social Security to 85% of benefits from 50% for seniors who saved or kept working. Yet individual tax revenues were only 7.8% of GDP in 1993, 8.1% in 1994, and did not get back to the 1989 level until 1995.

Punitive tax rates on high-income individuals do not increase revenue. Successful people are not docile sheep just waiting to be shorn.

From past experience, these are just a few of the ways that taxpayers will react to the Obama administration's tax plans:
  • Professionals and companies who currently file under the individual income tax as partnerships, LLCs or Subchapter S corporations would form C-corporations to shelter income, because the corporate tax rate would then be lower with fewer arbitrary limits on deductions for costs of earning income.
  • Investors who jumped into dividend-paying stocks after 2003 when the tax rate fell to 15% would dump many of those shares in favor of tax-free municipal bonds if the dividend tax went up to 23.8% as planned.
  • Faced with a 23.8% capital gains tax, high-income investors would avoid realizing gains in taxable accounts unless they had offsetting losses.
  • Faced with a rapid phase-out of deductions and exemptions for reported income above $250,000, any two-earner family in a high-tax state could keep their income below that pain threshold by increasing 401(k) contributions, switching investments into tax-free bond funds, and avoiding the realization of capital gains.
  • Faced with numerous tax penalties on added income in general, many two-earner couples would become one-earner couples, early retirement would become far more popular, executives would substitute perks for taxable paychecks, physicians would play more golf, etc.
In short, the evidence is clear that when marginal tax rates go up, the amount of reported incomes goes down. Economists call that "the elasticity of taxable income" (ETI), and measure it by examining income tax returns before and after marginal tax rates claimed a bigger slice of income reported to the IRS.

The evidence is surveyed in a May 2009 paper for the National Bureau of Economic Research by Emmanuel Saez of the University of California at Berkeley, Joel Slemrod of the University of Michigan, and Seth Giertz of the University of Nebraska. They review a number of studies and find that "for an elasticity estimate of 0.5 . . . the fraction of tax revenue lost from behavioral responses would be 43.1%." That elasticity estimate of 0.5 would whittle the Obama team's hoped-for $1.2 trillion down to $671 billion. As the authors note, however, "there is much evidence to suggest that the ETI is higher for high-income individuals." The authors' illustrative use of a 0.5 figure is a perfectly reasonable approximation for most purposes, but not for tax hikes aimed at the very rich.

For incomes above $100,000, a 2008 study by MIT economist Jon Gruber and Mr. Saez found an ETI of 0.57. But for incomes above $350,000 (the top 1%), they estimated the ETI at 0.62. And for incomes above $500,000, Treasury Department economist Bradley Heim recently estimated the ETI at 1.2—which means higher tax rates on the super-rich yield less revenue than lower tax rates.

If an accurate ETI estimate for the highest incomes is closer to 1.0 than 0.5, as such studies suggest, the administration's intended tax hikes on high-income families will raise virtually no revenue at all. Yet the higher tax rates will harm economic growth through reduced labor effort, thwarted entrepreneurship, and diminished investments in physical and human capital. And that, in turn, means a smaller tax base and less revenue in the future.

The ETI studies exclude capital gains, but other research shows that when the capital gains tax goes up investors avoid that tax by selling assets less frequently, and therefore not realizing as many gains in taxable accounts. In these studies elasticity of about 1.0 suggests the higher tax is unlikely to raise revenue and elasticity above 1.0 means higher tax rates will lose revenue.

In a 1999 paper for the Australian Stock Exchange I examined estimates of the elasticity of capital gains realization in 11 studies from the Treasury, Congressional Budget Office and various academics. Whenever there was a range of estimates I used only the lowest figures. The resulting average was 0.9, very close to one. Four of those studies estimated the revenue-maximizing capital gains tax rate, suggesting (on average) that a tax rate higher than 17% would lose revenue.

Raising the top tax on dividends to 23.8% would prove as self-defeating as raising the capital gains tax. Figures from a well-know 2003 study by the Paris School of Economics' Thomas Piketty and Mr. Saez show that the amount of real, inflation-adjusted dividends reported by the top 1% of taxpayers dropped to about $3 billion a year (in 2007 dollars) after the 1993 tax hike. It hovered in that range until 2002, then soared by 169% to nearly $8 billion by 2007 after the dividend tax fell to 15%. Since very few dividends were subject to the highest tax rates before 2003 (many income stocks were held by tax-exempt entities), the 15% dividend tax probably raised revenue.

In short, the belief that higher tax rates on the rich could eventually raise significant sums over the next decade is a dangerous delusion, because it means the already horrific estimates of long-term deficits are seriously understated. The cost of new health-insurance subsidies and Medicaid enrollees are projected to grow by at least 7% a year, which means the cost doubles every decade—to $432 billion a year by 2029, $864 billion by 2039, and more than $1.72 trillion by 2049. If anyone thinks taxing the rich will cover any significant portion of such expenses, think again.

The federal government has embarked on an unprecedented spending spree, granting new entitlements in the guise of refundable tax credits while drawing false comfort from phantom revenue projections that will never materialize.

Mr. Reynolds is a senior fellow with the Cato Institute and the author of "Income and Wealth" (Greenwood Press, 2006).
User avatar
Bill Glasheen
Posts: 17299
Joined: Thu Mar 11, 1999 6:01 am
Location: Richmond, VA --- Louisville, KY

Post by Bill Glasheen »

More on ObamaCare economics.

This was never addressed. ObamaCare is about to throw gasoline onto this over-utilization fire.

Honey, go get the marshmallows!

- Bill

References: New York Times, March 29, 2010
Law May Do Little to Help Curb Unnecessary Care

Image

By GINA KOLATA
Published: March 29, 2010

Dr. Robert Colton, an internist in Boca Raton, Fla., has a problem, and he knows it. His patients come in wanting, sometimes demanding, tests and treatments that are unnecessary, just adding to the nation’s huge health care bill. He even has patients, he says, who come in and report that their chief complaint is, “I need an M.R.I.”

And what does Dr. Colton do?

“I do the damn test,” he said. “There is no incentive for me, Rob Colton, to reduce overutilization. If the person wants it, what are you going to do, say no?”

And the new health care legislation, he says, is not going to make a bit of difference.

To truly change the nation’s chronic overuse of medical care, there will have to be a substantial change in the way patients think about health care, how medicine is practiced and how it is paid for, economists and doctors say.

The legislation does little to help in those areas. It is important, medical experts say, because it opens the door to medical care for millions of people who were shut out because they could not afford insurance or because they had pre-existing conditions or had reached lifetime caps on insurance payments. But controlling overuse is not its focus.

Some, like Jonathan Gruber, a health economist at M.I.T., say change eventually has to come because the nation is on an unsustainable path.

“Unless we are prepared to spend 50 percent of our G.D.P. on health care, it has to happen,” Dr. Gruber said.

And at least the legislation takes a stab at the overuse problem, he said. For example, in a few years it will tax expensive health care plans. The idea is that if employers offer less expensive plans, with higher co-payments and deductibles, patients might demand less expensive care. Then there are the insurance exchanges that will compete for customers and might lower costs by refusing to pay for unnecessary tests and procedures.

“The relative comparison is not the perfect world,” Dr. Gruber said. “The relative comparison is the world without this bill.”

But it will not be easy to put the brakes on overuse. Estimates of the amount of medical care that is unnecessary range from 10 to 30 percent, although no one knows for sure. Many doctors concede that they see overuse and that it has just become a part of the medical landscape.

Doctors often blame patients for demanding useless care, but many also concede that patients often have too little knowledge or power to say no to tests or treatments. The new law includes money for comparative effectiveness studies, and those can give guidance on which tests and treatments are better than others. But the law in no way forces patients or doctors to choose one test or treatment over another or to aim for the cheapest alternative. And it does nothing to change the reimbursement system, in which doctors often make more money if they order more tests, for instance.

In radiology, for example, there are clear guidelines, based on medical evidence, for CT scans of the head and neck. Among other things, the guidelines say CT scans are not necessary after most car accidents. Many patients have no real risk of brain injury from an accident, and there are good methods of deciding who is at risk and who is not. The guidelines have not put a dent in overuse.

The joke among radiologists, said Dr. Howard P. Forman, a radiologist and health services researcher at Yale, is that “the indication for getting a head CT after a car accident is if you have a head.”

The law includes pilot programs that Medicare is testing that pay doctors more for delivering better care at a lower cost. For example, groups of doctors can share in the savings to Medicare if they spend less money and improve the quality of their patients’ care.

Such programs, linking medical outcomes and payments, might help if they were translated into Medicare policy, said Dr. Mark B. McClellan, the former leader of the Centers for Medicare and Medicaid Services, who is now at the Brookings Institution. But more should be done, Dr. McClellan said, considering the scope of the overuse problem.

“It would be good to have more arrows in the quiver,” he said.

It is no surprise that Congress shied away from a serious effort to hold down overuse. The public has made it clear that it does not want to be told what medical care it can and cannot have.

“The minute you attack overutilization you will be called a Nazi before the day is out,” said Uwe E. Reinhardt, a health economist at Princeton.

Some hold out hope for the comparative effectiveness studies.

But “there is no direct link between the development of that evidence and the use of that evidence,” said Bryan R. Luce, senior vice president for science policy at United Biosource Corp., a Washington consulting firm.

The idea of the comparative effectiveness guidelines is a sort of an “if you build it, they will come” notion, said Dr. J. Sanford Schwartz, a health economist and internist at the University of Pennsylvania. But that is not going to be sufficient, he said. There needs to be a way to effectively link what the guidelines say and how they are put into effect, how they are interpreted, what insurers pay for and what doctors do.

One way to make those links is to do what some other countries do — say that there will be no payments for care that is not deemed the most cost-effective. But politicians shy away from such measures, Dr. Luce said. “That is not likely to happen soon, particularly at a national level,” he said.

It would mean rationing, said Dr. Robert D. Truog a professor of medical ethics, anesthesia, and pediatrics at Harvard Medical School. “That’s the word nobody wants to use. It’s just a firecracker. Nobody wants to touch it.”

The result is a crazy system in which, he points out, a government-appointed task force on screening mammography was explicitly forbidden to consider the costs of offering mammograms to women for whom the benefit is very small.

“The point is that as long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not,” Dr. Truog said.

But that does not seem to be in the offing. And some, like Dr. Schwartz, despair.

“Einstein once said, ‘Insanity is doing the same thing over and over again and expecting a different result,’ ” Dr. Schwartz said.

Meanwhile in Florida, Dr. Colton says, he and his doctor friends would welcome a way to stop overuse. They would, he said, embrace guidelines and a payment system that denies reimbursement for unnecessary medicine and protects doctors from malpractice suits if they follow the guidelines.

“I really believe that in our heart of hearts most doctors want to curb this,” Dr. Colton said. “We know what we are doing. And we are frustrated, too. But we can’t help ourselves. There is nothing to stop us and nothing to be gained by stopping.”
IJ
Posts: 2757
Joined: Wed Nov 27, 2002 1:16 am
Location: Boston
Contact:

Post by IJ »

"Meanwhile in Florida, Dr. Colton says, he and his doctor friends would welcome a way to stop overuse. They would, he said, embrace guidelines and a payment system that denies reimbursement for unnecessary medicine and protects doctors from malpractice suits if they follow the guidelines.

“I really believe that in our heart of hearts most doctors want to curb this,” Dr. Colton said. “We know what we are doing. And we are frustrated, too. But we can’t help ourselves. There is nothing to stop us and nothing to be gained by stopping.” "

Nothing to stop you? How about integrity and professionalism? Nothing to be gained by stopping? How about knowing you did the right thing and are contributing to the success of the nation's healthcare system and financial future? It's a sad state of affairs.
--Ian
User avatar
Bill Glasheen
Posts: 17299
Joined: Thu Mar 11, 1999 6:01 am
Location: Richmond, VA --- Louisville, KY

Post by Bill Glasheen »

IJ wrote:
It's a sad state of affairs.
Thank you, Ian!

- Bill
IJ
Posts: 2757
Joined: Wed Nov 27, 2002 1:16 am
Location: Boston
Contact:

Post by IJ »

http://www.nytimes.com/2009/11/08/magaz ... are-t.html

This is an excellent article on quality improvement in medicine and features the work of Brent James, MD. He is a leader in the field who works at Intermountain Healthcare in Salt Lake City, Mormonia, Utah... I attended his ~62 hour advanced training program in quality improvement a few years back and found it inspiring. Occasionally, I think someone is going to listen to him and we might pull through this quality / price maelstrom. Other times I think we'll be destroyed by it but he'll be too nice to say I told you so.

Short version: right now, everyone makes decisions for the patients based on random intuition and incentives to do more for the sake of more. The alternative is giving the patient what's best for their condition--if only someone will man up / woman up, if only the doctors will swallow some of their pride, and make it happen.
--Ian
IJ
Posts: 2757
Joined: Wed Nov 27, 2002 1:16 am
Location: Boston
Contact:

Post by IJ »

And here's more evidence that your supposedly expert doctor crafting individualized care for you is actually going on impulses and paychecks. If we don't stop this garbage--and I think we have to go after their wallets--we're toast.

...

Older Adults Increasingly Face Complex, Risky, and Costly Spinal Stenosis Surgery

Patients may ask about a study showing that older adults with spinal stenosis are more frequently undergoing complex (and more hazardous and expensive) surgery.

Writing in JAMA, researchers detail an investigation using Medicare claims data between 2002 and 2007. During that period, the overall number of lumbar stenosis operations declined slightly, while use of the most complex approach increased some 15-fold.

In examining 2007 data, the researchers found that more complex fusion operations had double the rate of major medical complications and double the 30-day mortality of decompression alone. The average hospital charge for the more complex procedure was some $80,000 — versus $24,000 for decompression.

An editorialist concludes that "conflicting economic incentives are clearly at work," noting that a surgeon's reimbursement for the more complex approach can be ten times that of simple decompression. Current financial incentives and market forces in medicine, he says, amount to "a formidable economic and social problem."
--Ian
User avatar
Bill Glasheen
Posts: 17299
Joined: Thu Mar 11, 1999 6:01 am
Location: Richmond, VA --- Louisville, KY

Post by Bill Glasheen »

IJ wrote:
This is an excellent article on quality improvement in medicine and features the work of Brent James, MD.
I first met him about 17 years ago. The dude has been around.

Intermountain Healthcare is a well-known high quality health plan. That mountain region is the only area Wellpoint/Anthem operates where they don't dominate the marketplace. Good reason there...

- Bill
Post Reply

Return to “Bill Glasheen's Dojo Roundtable”