Tom Miller

Serious political debate in Republican circles over the substance, scope, and scale of what should “replace” the Affordable Care Act (ACA) has been more or less frozen in suspended animation since its enactment in March 2010 for three reasons. (1) Grassroots activists focused on outright repeal as a common unifying goal. (2) Elected GOP officials and other Republican candidates for office scrambling to stay in front of the energetic parade opposing ObamaCare found it much easier to hope that the Supreme Court would do most of their work by ruling the Affordable Care Act unconstitutional and invalid in its entirely. (3) Developing a coherent and popular replacement plan is a much heavier lift, particularly once one tries to move beyond the facile rhetoric and sound bites of past proposals that dodge the difficult policy complexities and political tradeoffs of sustainable health reform.

This short-term equilibrium will end, one way or another, after the Supre

Last Thursday, the Institute of Medicine finally released its long-awaited set of recommendations for how the Secretary of Health and Human Services should accomplish the impossible -- determining the "essential health benefits" for tens of millions of Americans under the to-be-implemented Affordable Care Act. Early reviews indicate that, not surprisingly, there is no way to please everyone, or perhaps even anyone, in this highly political exercise. The countervailing pressures "essentially" are that one side wants to ensure that benefits are more comprehensive and generous to ensure that everyone either gets what they want, or what other interests and experts think they must get anyway. The other side (paying for those essential benefits) worries that setting benefits levels too high will only drive health care costs even higher and make insurance coverage even less affordable and available. This traditional dilemma arises whenever health benefits policy must be determined through the pressure cooker of health care politics and the HHS bureaucracy.

Insurance Company Consolidation, Market Competition, and Premium Costs

The American Medical Association recently issued another one of its increasingly predictable, but incomplete, “studies” of insurance market consolidation. Although it does not yet have a monopoly in producing such reports, the AMA appears to have cornered the political market for such one-sided analysis. (This is in contrast to its declining share of the market for physician memberships, which reflects its performance in other political arenas).

Making somewhat more sense of the Herfindahl-Hirschman Index or "HHI" (representing the sum of squared market shares of each opposing firm’s side in a market, if not the square of a rent-seeker’s hypotenuse) and other totems of antitrust lore requires better sorting out of the relevant markets in question. In the case of health insurance, their competitive dynamics differ greatly – depending on whether one is examining the national market for large, self-insured employers (and government bodies); state markets sha

But Are Milked for All They Are Worth

Perhaps the only thing that is more inflated than recent insurance premiums is the distorted depiction of administrative costs and profits for private insurers. A pox on both sides of a pseudo statistical debate that borrows factoids both liberally and selectively.

First, the AHIP presentation does overreach misleadingly (and not particularly cleverly), by essentially doubling the denominator size of health spending dollars – including those for publicly financed programs like Medicare and Medicaid -- to make the health insurance industry’s already unremarkable profit levels appear even smaller. Of course, industry profits can be reported in various ways and remain subject to a range of accounting devices. But at least one more straightforward approach would use several years of recent data and measure profits as a percentage of revenue. Scott Harrington of the Wharton School did this in his presentation a

Says John Goodman:

“As for portability, I don’t know anyone inside the Beltway who advocates repealing the prohibition that keeps employers from buying individually-owned insurance for their employees.”

John should get out more, or review some of his older files. These are not “new” issues and remarkably enough, other people have thought about them, too.

For example, on July 26, 2001, then-representative Jim DeMint introduced the Health Care Account Act of 2001 (H.R. 2658, with 22 co-sponsors including Paul Ryan, Richard Burr, Mike Pence, and Dick Armey), which addressed the conflict in regulatory treatment between HIPAA and ERISA for potential defined contribution employer plans by selectively excluding “health care expenditure accounts” from the definitions of group health plans to which HIPAA group health plan requirements would otherwise apply. It also treated eligible defined contributions to those accounts as excluded from gross income for federal tax purposes.

I didn’t discover the HIPAA vs. ERISA

Newt Gingrich and John Goodman offer their ten best ideas for health reform. The ideas are neither particularly new nor detailed, but, to be fair, their original exposition undoubtedly was limited by the constraints of the op ed genre and the temptation to offer the most popular and least complex policy nostrums. Moreover, the competition in the health reform arena is not that keen, even beyond the confines of partisan posturing.

The greater problem lies in converting the equivalent of policy sound bites into effective and robust policy changes. Consider the challenges facing the Gingrich-Goodman proposals in the real world:

· Make insurance affordable. Changing the current tax treatment of health care spending could make tax subsidies more equitable and/or better targeted. But this approach doesn’t make health care any less expensive; it just shifts the bill to someone else. We might rearrange tax subsidies so that some categories of people get more of them and others get less, or we could try to borrow eve

How Low Can We Go?

Even when a televised “summit” gathers the highest level of government officials, the search for common ground may descend to the lowest common denominator, at best, or just provide a more artificial replay of their respective twin peaks of political posturing, at worst (e.g. trying to turn Rep. Ryan’s Roadmap into Roadkill). In the case of this year’s mirage of health reform, we probably should count on rewarding the soft bigotry of low expectations. In any case, a more realistic objective would not be to finally achieve grudging capitulation by either hyper partisan side this year, but rather a somewhat clearer presentation to this fall’s cranky voters of how and why they differ.

The electoral majority of November 2008 reflected in Congress has grown badly out of synch with a de facto popular majority that balks at swallowing an indigestible prescription for comprehensive overhaul of health care policies and practices. But since it’s still February, let’s rerun health policy Groundhog Day with a dri

Ceasefire Is Another ‘Once in a Lifetime’ Chance for Reform

By Thomas P. Miller

(as posted on The Enterprise Blog

blog.american.com/

January 20, 2010, 9:05 am)

The most honest analysis of last night’s shocker in Massachusetts is “Wow, I didn’t see that one coming (until everyone else did just a few days ago).” But there will be no shortage of profoundly updated analyses (and excuses) by the many pundits who got most of this past year’s health policy debate and its larger political context wrong. On the other side, one can find exaggerated claims of a mandate to move in an opposite direction, rather than simply calling a timeout and reflecting before reloading.

Hence, before the next round of clichés and conventional wisdom, a much humbler reflection would start with recognizing the profound disconnection between, on the one hand, the relentless push of the White H