A Citizen's Guide to Indiana

Fareed Zakaria has an opinion entitled Curbing the cost of health care.

“[T]he situation on the ground suggests that markets work imperfectly in this realm.”

Ya think?

He notes that France seems to get better results treating lung cancer at 1/8 of the cost. If my math is right, that means France spends 12.5 cents for every dollar we spend on treating lung cancer and gets much better results. He notes that Britain spends 1/5 what the U.S. does on diabetes treatment (20 cents per dollar) and gets better results.

This doesn’t seem to be the voice of a socialist hater of free markets. He seems almost apologetic. But one of the problems seems to be that the market incentives for health care providers aren’t in favor of efficiency or wellness.

France and Britain are better at tackling diabetes and lung disease because they take a systemic approach that gives all health-care providers incentive to focus on early detection and cost-effective treatment and that makes wellness the goal. “In America,” he said, “no one has incentives to make quality and cost-effective outcomes the goal. There are so many stakeholders and they each want to protect themselves.

We spend twice as much on health care as any other country and get outcomes that are the same or worse. That has to mean there are horrible inefficiencies in the system; and the market’s invisible hand isn’t doing a lot to sort things out. This isn’t a simple transaction where a consumer compares easily analyzed widgets and makes purchasing decisions based on clear information about quality and price or simply walks away from the transaction if there are no satisfactory offerings. Health care is complicated; quality can be subtle and delayed; price is only loosely based on cost and both are horribly opaque to the consumer. And, so often, the transaction is anything but voluntary. It’s often a matter of, literally, life and death.

I myself have an uneasiness about the Affordable Care Act. It’s a Rube Goldberg machine that might not work well if at all. But, for political reasons, it’s all we could get. The status quo is broken, cruel, and awful. Politicians demanding a return to the status quo (usually with a call for repeal and only vague mumblings about a replacement) are, at best, being petulant because “their side” lost.

Reposting from years past, but in light of the holiday, that might be appropriate.

Two hundred and thirty-one thirty-two thirty-six years ago, some Virginia planters with dissonant views of liberty (“How is it that we hear the loudest yelps for liberty among the drivers of negroes?” – Samuel Johnson) got together with some Boston smugglers and rabble rousers who had lost respect for their leader. And, thank goodness they did. They founded a nation based on a radical notion that all men are created equal. They were audacious enough to declare this truth “self-evident.” Think of what a departure this was. There was no automatic deference to anyone else based on their station in life. Governments, they declared, derived their just power from the consent of the governed. They felt so aggrieved by a hereditary leader who had abused his authority so egregiously they felt that he could no longer be tolerated. They felt that his tenure in power was “a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States.” Among the abuses were deprivation of trial by jury and an inclination to raise the military authority above the civil authority. Humble petitions for redress were met only with further injury. I’ll leave drawing parallels to more modern events as an exercise for the reader.

As always, I think it is valuable to read the whole text of the Declaration of Independence, so, here you go:

The Declaration of Independence of the Thirteen Colonies
In CONGRESS, July 4, 1776

The unanimous Declaration of the thirteen united States of America,

When in the Course of human events, it becomes necessary for one people to dissolve the political bands which have connected them with another, and to assume among the powers of the earth, the separate and equal station to which the Laws of Nature and of Nature’s God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. –That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, –That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness. Prudence, indeed, will dictate that Governments long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security. —Such has been the patient sufferance of these Colonies; and such is now the necessity which constrains them to alter their former Systems of Government. The history of the present King of Great Britain [George III] is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these States. To prove this, let Facts be submitted to a candid world.

He has refused his Assent to Laws, the most wholesome and necessary for the public good.

He has forbidden his Governors to pass Laws of immediate and pressing importance, unless suspended in their operation till his Assent should be obtained; and when so suspended, he has utterly neglected to attend to them.

He has refused to pass other Laws for the accommodation of large districts of people, unless those people would relinquish the right of Representation in the Legislature, a right inestimable to them and formidable to tyrants only.

He has called together legislative bodies at places unusual, uncomfortable, and distant from the depository of their public Records, for the sole purpose of fatiguing them into compliance with his measures.

He has dissolved Representative Houses repeatedly, for opposing with manly firmness his invasions on the rights of the people.

He has refused for a long time, after such dissolutions, to cause others to be elected; whereby the Legislative powers, incapable of Annihilation, have returned to the People at large for their exercise; the State remaining in the mean time exposed to all the dangers of invasion from without, and convulsions within.

He has endeavoured to prevent the population of these States; for that purpose obstructing the Laws for Naturalization of Foreigners; refusing to pass others to encourage their migrations hither, and raising the conditions of new Appropriations of Lands.

He has obstructed the Administration of Justice, by refusing his Assent to Laws for establishing Judiciary powers.

He has made Judges dependent on his Will alone, for the tenure of their offices, and the amount and payment of their salaries.

He has erected a multitude of New Offices, and sent hither swarms of Officers to harass our people, and eat out their substance.

He has kept among us, in times of peace, Standing Armies without the consent of our legislatures.

He has affected to render the Military independent of and superior to the Civil power.

He has combined with others to subject us to a jurisdiction foreign to our constitution and unacknowledged by our laws; giving his Assent to their Acts of pretended Legislation:

For Quartering large bodies of armed troops among us:

For protecting them, by a mock Trial, from punishment for any Murders which they should commit on the Inhabitants of these States:

For cutting off our Trade with all parts of the world:

For imposing Taxes on us without our Consent:

For depriving us, in many cases, of the benefits of Trial by Jury:

For transporting us beyond Seas to be tried for pretended offences:

For abolishing the free System of English Laws in a neighbouring Province, establishing therein an Arbitrary government, and enlarging its Boundaries so as to render it at once an example and fit instrument for introducing the same absolute rule into these Colonies:

For taking away our Charters, abolishing our most valuable Laws, and altering fundamentally the Forms of our Governments:

For suspending our own Legislatures, and declaring themselves invested with power to legislate for us in all cases whatsoever.

He has abdicated Government here, by declaring us out of his Protection and waging War against us.

He has plundered our seas, ravaged our Coasts, burnt our towns, and destroyed the lives of our people.

He is at this time transporting large Armies of foreign Mercenaries to compleat the works of death, desolation and tyranny, already begun with circumstances of Cruelty and perfidy scarcely paralleled in the most barbarous ages, and totally unworthy the Head of a civilized nation.

He has constrained our fellow Citizens taken Captive on the high Seas to bear Arms against their Country, to become the executioners of their friends and Brethren, or to fall themselves by their Hands.

He has excited domestic insurrections amongst us, and has endeavoured to bring on the inhabitants of our frontiers, the merciless Indian Savages, whose known rule of warfare, is an undistinguished destruction of all ages, sexes and conditions.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A Prince whose character is thus marked by every act which may define a Tyrant, is unfit to be the ruler of a free people.

Nor have We been wanting in attentions to our British brethren. We have warned them from time to time of attempts by their legislature to extend an unwarrantable jurisdiction over us. We have reminded them of the circumstances of our emigration and settlement here. We have appealed to their native justice and magnanimity, and we have conjured them by the ties of our common kindred to disavow these usurpations, which, would inevitably interrupt our connections and correspondence. They too have been deaf to the voice of justice and of consanguinity. We must, therefore, acquiesce in the necessity, which denounces our Separation, and hold them, as we hold the rest of mankind, Enemies in War, in Peace Friends.

We, therefore, the Representatives of the united States of America, in General Congress, Assembled, appealing to the Supreme Judge of the world for the rectitude of our intentions, do, in the Name, and by the Authority of the good People of these Colonies, solemnly publish and declare, That these United Colonies are, and of Right ought to be Free and Independent States; that they are Absolved from all Allegiance to the British Crown, and that all political connection between them and the State of Great Britain, is and ought to be totally dissolved; and that as Free and Independent States, they have full Power to levy War, conclude Peace, contract Alliances, establish Commerce, and to do all other Acts and Things which Independent States may of right do. And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

I know, suddenly it’s all health care all the time with me. But the Medicaid Expansion was completely off my radar, and I’m learning. It’s also suddenly more of a state issue than it was before the Supreme Court decision because the court made the expansion much less compulsory.

The Urban Institute has a helpful paper (pdf) on how failure to adopt the expansion would affect health care for people making 138% of the federal poverty level or less. The scheme of the health care reform bill pretty well assumed this expansion of the Medicaid system. So, in those states that opt out, there are some pretty dramatic holes. Apparently those at poverty level up to 138% might be eligible for some subsidies if the extension isn’t adopted. But people below the poverty level but not eligible for Medicaid under the current scheme are in bad shape.

They give some numbers for Indiana: 410,000 below the poverty line; 108,000 between the poverty line and 138% of the poverty line; 517,000 affected by the Medicaid expansion; 947,000 uninsured and 54.6% of the uninsured are potentially Medicaid eligible under the expansion.

Christine Vestal, writing for Governing’s Stateline blog, discusses the likelihood that Medicaid expansion would ease the cost of providing medical care to inmates.

Typically inmates do not qualify for Medicaid. And, until somewhat recently, simply being incarcerated was a reason for disqualification. (“The reasoning was that states and local governments had historically taken responsibility for inmate health care so the federal-state Medicaid plan was not needed.”) The fact of incarceration was eased as a reason for disqualification in 1997, but, in its current form, most inmates don’t qualify for Medicaid anyway. “That’s because all but a few states limit Medicaid to low-income juveniles, pregnant women, adults with disabilities and frail elders.”

That would change with the adoption of a Medicaid expansion. As I understand it, most people making under 133% of the federal poverty level would qualify. (About $15,000 for your average, unmarried inmate.) Why would you, as a law abiding citizen, want to pay for the health care of a good for nothing scofflaw? Doesn’t matter – you already are. Under IC 11-12-5-5.5 county jails are required to reimburse hospitals and medical providers for care given to inmates at 104% of the Medicare rate. State prisons are also required to provide medical care to inmates.

This is a big deal and a big expense for jails. You see a lot of people with big health problems coming into jail. Because they lack health insurance (and, to be honest, a lot of other life skills), a lot of times the only treatment they get is in jail. Or, if they have gotten treatment, it is sporadic and they frequently don’t do a good job managing their illnesses when they’re out of jail. See, e.g., this from the Indiana Law Blog about DuBois County:

June 26, 2012 – Monday afternoon, the Dubois County Council met and heard from Sheriff Donny Lampert on a request for a standard appropriation for medical expenses for inmates at the Security Center.

The $150,000 appropriation is a standard amount, but one inmate has racked up a bill of about $80,000 for medical treatment that could not be disclosed due to privacy laws. The inmate is doing better now, but the result is a high bill from an Evansville area hospital.

Neera Tanden, has noted that this sort of dynamic might put a lot of municipal leaders at odds with state leaders who take a dogmatic stand against the federal Medicaid expansion.

Mayors might recognize a “big windfall” for communities in the Medicaid expansion as currently uncompensated local costs born by municipalities begin to be eased with the new Medicaid funds from the federal government. And they might turn against their governors if they see them getting in the way of easing one strain on tight local budgets, Tanden suggested.

In any case, making jails the medical providers or medical insurers of last resort for marginal elements of our society is a horribly inefficient way to deliver health care. I expect a lot of local officials would like to get out of that part of the health care business to the extent possible. Ideological rejection of the Medicaid expansion by state officials might make that impossible.

J.K. Wall has a good article for the IBJ (h/t Indiana Law Blog entitled Ruling Could Leave 290k Hoosiers Uncovered. It’s a good article that you should read, but I disagree with the title. It’s not the ruling that would leave Hoosiers uncovered. The fault, dear Brutus, is not in our stars, but in ourselves; or rather, it would be in our lawmakers.

After last week’s U.S. Supreme Court ruling gave Indiana the option not to expand its Medicaid program and some state legislators promised to do exactly that, Indiana hospitals started to worry.

That’s because a decision by Indiana to leave its Medicaid program unchanged could leave as many as 290,000 Hoosier adults, who would have been newly eligible for Medicaid coverage, with no good options.

Out of mostly political pique, lawmakers could decide to take it out on those 300k Hoosiers who don’t qualify for Medicaid as currently structured but who would qualify for the Medicaid expansion because their income is 133% of the poverty level or less (about $32,000 for a family of four). I believe the rest of the health care reform law focuses on solutions for people with incomes above that level with the underlying assumption being that those earning below that level would have been covered by the Medicaid expansion. This gap includes pretty much all of the non-disabled, childless poor as well as adults with children if the family income is between about $6,000 and that $32,000 mark. In particular, it is:

[I]t is parents with incomes below 100 percent of the poverty limit and above 24 percent of the limit—as well as all childless adults below the poverty limit—that would be left out if Indiana did not expand its Medicaid program.

The reason federal lawmakers made the assumption that states would expand is because, as written, the law was pretty draconian in its response to states that did not expand — it defunded even current federal Medicaid contributions. The Supreme Court deemed that too coercive and struck the defunding provision, giving states much more freedom to decline expansion. There may be dispassionate policy arguments against expansion; but we are unlikely to get a dispassionate approach to this issue from lawmakers. Health care policy has been heavily politicized, and declining or agreeing to participate in the Medicaid expansion will be as much a tribal marker as anything else. If you’re not of Obama’s tribe, you’ll vote against expansion. If you are of Obama’s tribe, you’ll vote for it. Policy reasons will be given; but it’s difficult to believe at this juncture that those ostensible reasons will be much more than pretextual.

Apparently this would represent a serious blow to hospitals who would get Medicaid reimbursements of about $0.60 on the dollar for this group of people (leaving aside for a moment the huge issue about setting the proper baseline for medical costs) instead of the approximately $0.10 on the dollar they currently are able to realize on bad debt associated with this population. A study commissioned by Gov. Daniels (not necessarily a neutral actor) had Indiana’s share of expanded coverage at about $160 million per year between 2014 – 2020. (By my back of the napkin math, this represents about $533 per covered individual or about $23 per Hoosier per year; however you want to cut it.)

The Courier Press has an editorial on the health care decision. (An aside: I wonder if perception of the decision will be altered because it doesn’t have a snappy name like “Bush v. Gore” or “Brown v. Board of Education.” – National Federation of Independent Businesses v. Sebelius (pdf) doesn’t exactly roll off the tongue.)

The editorial noted a Rasmussen poll (a polling outfit that generally has its thumb on the right side of the scale) that said 54% of likely voters favored a ruling that the act was unconstitutional. But then it correctly noted that rulings on constitutionality shouldn’t be popularity contests. (Reminds me of the Onion piece: “Area Man Passionate Defender of What He Imagines the Constitution to Be” — “Mortensen told reporters that he’ll fight until the bitter end for what he roughly supposes the Constitution to be.”)

The Courier Press editorial says that upholding the mandate requirement will result in 30 million people being obligated to buy health insurance; of which maybe 4 million will opt to pay the penalty instead.

My understanding is that the impact on the uninsured is roughly as follows:

#No need to buy insurance if your income is below the tax reporting threshold. ($9,500 single; $19,000 married filing jointly).

#No need to buy insurance if the premium exceeds 8% of your household income.

#Option to pay the penalty instead of buying insurance. The penalty will start lower but will reach $695 or 2.5% of income. So, if you go with the penalty-as-tax rationale, it’s a 2.5% tax increase offset by a tax credit for those who buy health insurance.

The mandate is a necessary trade off for limiting or eliminating an insurer’s ability to deny coverage. Health insurance only works when there is uncertainty about who is going to get sick – we might be able to estimate the total incidence of sickness and the total cost of managing that sickness. That cost is manageable over the group as a whole but potentially unmanageable to any given individual. Each individual in the group is willing to kick-in to cover the costs in order guard against the possibility that particular individual might be the one who gets sick. It’s a way of managing risk. Once you have certainty as to who is sick, you are no longer managing risk.

If insurers can no longer deny coverage for pre-existing conditions, the incentive is gone to pay up front to manage risk. You just wait until you get sick before spending your money on insurance. That’s why they need to mandate purchase of insurance – or come up with some other way to make sure you’re kicking into the pool. Insurance only works when the healthy are subsidizing the sick.

In any case, I think we all need to do a better job of learning about and explaining to others the details of this health care bill. That 54% opposed number goes way down when the people are asked about the specifics of the plan. It’s only when it’s this vague abstraction called “Obamacare” that people really dig in their heels. And as a corollary to that, opponents of Obamacare should really be pressed on their alternate plans. The status quo is unsustainable and pretty much no one will go on record as being in favor of the status quo. But plans to repeal Obamacare immediately with only vague hand waving about an alternate system is nothing more than a plan to continue with the broken, expensive system we have now.

Now that the healthcare reform law has been upheld, I think there are at least two areas where the states (including Indiana) have to take action.

One area is Medicaid expansion. As written, I think the law basically forced states into expanding their Medicaid program. It penalized states for not expanding their Medicaid programs by gutting (eliminating?) federal funding for their existing programs. One majority of the court held that this penalty was unconstitutionally coercive. A separate majority of the court held that the remedy for this unconstitutional coercion was, basically, to read it out of the statute. So, states don’t put their existing Medicaid programs at risk by declining to adopt the expansion.

The expansion itself provides for Medicaid coverage to individuals with income 133% of the poverty line or below. This is up from something like 65% currently along with a requirement that you meet one of the eligibility categories. (Broadly speaking – there are nuances.) The federal government would pay all of the expansion expenses for the first few years and then requiring the states to contribute incrementally more, up to 10% of the costs in 2020 and thereafter. Now states have to decide whether they want to take the 90% federal government match or not. From a pure state cost/benefit perspective, it’s tough to walk away. But, from a political perspective, I imagine that a lot of red states will turn away the federal money at the expense of their poorer citizens.

The other major state action I know about has to do with healthcare exchanges. I’m going from an explanation from an acquaintance whose opinion I trust. What the law mandates, as I understand it, is that each state (or group of states) create an insurance exchange. If they don’t, the federal government will do it for them. Each exchange must have at least two insurance companies competing in it, of which one must be a not for profit. If not, the federal government will create a not-for-profit mutual insurance company. Inaction will, therefore, lead to federal interference.

The stories out of Colorado Springs about the Waldo Canyon fire are pretty horrific. Here is a recent one from the Guardian. Next to Indiana and Ohio, Colorado is probably the state I know best. My Dad moved there sometime around 1978, and I’ve been going there ever since. It’s where I first learned about drought. And probably something about government antipathy — I seem to recall picking up some dissatisfaction about water policy. (In particular, I remember flushing the toilet and saying, “there goes the water to Denver” to some general levity from adults in the vicinity.)

A couple of notes: 1) The idiots who pointed to snow storms as evidence that Al Gore was stupid and wrong about global warming should be offered up as human fire breaks. This doesn’t prove the case for global warming – just that they’re misguided for conflating weather with climate.

2) These fires go well beyond anything individuals can contend with on their own. Government is vitally necessary to combat the flame and will be vitally necessary to deal with the aftermath. It should be interesting to see how Colorado Springs – a hotbed of anti-government sentiment copes with that reality. My guess is by grabbing federal money and resources with both hands, ignoring the dissonance, and, if confronted, by explaining that their only against other, unspecified, types of evil government.

Also, as a final note, Indiana is dryer than I remember seeing it. The fireworks lobby is making noises about what a bad idea and potentially illegal for governments to restrict fireworks use. I’ve seen individuals grumping about their god-given right to use fireworks around the Fourth of July. Without getting too deep into the weeds on this issue just now, don’t be stupid people. I know the fireworks people need to make money, and people like to celebrate their country by blowing stuff up. But sending hot, flamey things into bone dry vegetation puts everyone at risk.