The Independent Institute


Health Insurance Contributes to Past-Due Medical Debt

A new study of past-due medical debt, by Michael Karpman and Kyle J. Kaswell of the Urban Institute, shows that the expansion of health insurance coverage subsequent to the Affordable Care Act is associated with a reduction in the proportion of adults with past-due medical debt.

In 2012, 29.6 percent of U.S. adults had past-due medical debt, versus just 23.8 percent in 2015. The study does not define “past-due” nor the average amount of medical debt that is past-due. However, an earlier Urban Institute study defines credit card debt as past-due if it is over 30 days late. That study also reported 35.1 percent of adults in 2014 had debt in collection (that is, more than 180 days past-due)! The average amount was $5,178, or 7 percent of average household income of $72,254. The first study cites research that almost half of debt in collections is owed to hospitals and other providers.

What to make of this? Although health insurance is supposed to protect us from such a situation, it often does not. And it is not clear what effect Obamacare has had. Among insured people, 26.6 percent had past-due medical debt in 2012, versus 22.8 percent in 2015. Among uninsured people, 39.8 percent had past-due medical debt in 2012, versus 30.5 percent in 2015.

Review: Did Can We Take a Joke? Forewarn Middlebury College?

Liberal intellectuals may be finally getting around to confronting the illiberal behavior of fellow liberals, particularly the recent episodes on American college campuses. Writing at The Atlantic, Peter Beinart examines the physical attacks at Middlebury College against Charles Murray and his faculty host and (liberal) interlocutor Allison Stanger. Hopefully, this introspection will prompt them and others to take a fresh look at Can We Take a Joke?, a documentary released in 2016 that highlighted the rising tide of anti-free speech sentiment among college students that now appears to be coalescing into a mass movement.

The film, produced by Korchula Productions and directed by veteran documentarian Ted Balaker, uses comedy, particularly stand-up comedy, to show how campuses have become less and less tolerant of free speech. The film frames its discussion using clips of pioneer stand-up comic and social critic Lenny Bruce, whose sexually explicit jokes led to his arrest on obscenity charges and a landmark free speech case. Bruce’s comedy would be considered benign by current standards, however, and so the film spends most of its time on contemporary artists such as Gilbert Gottfried, Lisa Lampanelli, Penn Jillette, Karith Foster and Adam Carollla.

Can We Take a Joke? uses the real-world experiences of these mostly liberal comedians to show the rise of intolerance against non–politically correct social commentary. Comedians are the proverbial canary in the coal mine, typically among the first wave of victims of intolerance or government oppression. This is because they are often on the front lines of social commentary and social change, as Brookings Institution scholar Jonathan Rauch points out in the film.

Indeed, Lenny Bruce may be one of the best examples of the place comedy holds on the cusp of social change. He was dishonorably discharged (later reversed) from the U.S. Navy during active service in World War II, after his commanders took offense at his comedy routine featuring a performance in drag. Today stand-up comics use offensive material to draw attention to a wide range of social issues, from LGBT prejudice to body image to drug abuse to boorish behavior among the rich. Indeed, as several comedians in Can We Take a Joke? emphasize, their intent is often to either spark or contribute to a public discussion on these and other social and political issues.

When the film was released in 2016, its free speech message was not universally well received. Critics might give Roger and Me a pass on its distortions of facts to suit Michael Moore’s point, but Can We Take a Joke? was derided for its unapologetic defense of free speech. According to one reviewer, the film represented the “brief for the defense” but, in the interests of balance and justice, should have explored the other side of the argument. As the New York Times critic wrote in his review:

The documentary “Can We Take a Joke?,” a one-sided look at a multisided issue, does a fine job of defending a comic’s right to perform incendiary material. It would be better if it also at least acknowledged the possibility that some jokes ought not be told.

In other words, free speech is a matter of taste, no longer a fundamental principle of public discourse. Notably the Times review (and others) failed to mention that almost all stand-up comedy is performed in closed venues requiring tickets or admission, whether in private clubs or on public university campuses.

How does the attack on Charles Murray factor into this? Unlike Milo Yiannapolis, who is a professional provocateur, Murray is a serious researcher and scholar, with a sincere interest in provoking a civil public discussion on critical social issues of our times (see his CV here). He earned his Ph.D. in political science from the Massachusetts Institute of Technology, spent six years in Thailand engaged in development assistance and program evaluation, and served seven years at the American Institutes of Research, eventually becoming its chief political scientist. Murray’s pathbreaking book Losing Ground: American Social Policy from 1950 to 1980 became one of the principle critiques leading to bipartisan welfare reform in 1996. In person, he is remarkably humble, soft spoken, and respectful to his critics.

Some of his later works were more controversial, particularly The Bell Curve, co-authored with Harvard psychologist Richard J. Herrstein, a serious attempt to present a wide range of scholarly research and data that showed intelligence was connected to American class structure in society, politics, and the workplace. It’s The Bell Curve that critics have rallied behind to oppose his public speeches, including the talk at Middlebury College (which was on a different subject). The outrage directed against Murray’s heresies is so great, however, that other respected academics can claim publicly and without accountability that this particular scholar, who has shaped national policy, has been thoroughly discredited (he hasn’t), can’t do math (he can), and lacks any conceivable merits worthy of offering him a speaking invitation. 

Can We Take a Joke? is a far-reaching documentary that is more relevant now than when it was released in 2016. For those who champion free speech, individual rights, and civil liberties, it should be a centerpiece for brokering public discussions on college campuses. The core sentiment underneath the attack on comedy is a harbinger of intolerance toward ideas more generally. If the film can open more eyes to the dangers of this anti-intellectualism masking as social justice, it is certainly worth the price of admission. Of that I have no doubt.

Four Years after Chavez’s Death, Venezuela Sinks Deeper into the Abyss

Venezuela’s dictatorship has tried to turn the fourth anniversary of Hugo Chávez’s death into a mystical experience of sorts—and a dose of much-needed political oxygen. Not a simple task in a country with inflation predicted to run at 1,600 percent, an economic growth rate of negative ten percent, a painful shortage of the most basic stuff, the highest crime rate in the world (120 murders for every 100,000 residents), and three-quarters of the people telling pollsters they repudiate the government.

That said, it is certainly an accomplishment for Mr. Nicolás Maduro, Chávez’s chosen heir, to have remained in power this long after his predecessor’s passing.

What has happened? Two things. One, the military, which was reorganized with Cuban help, has remained loyal to the Maduro regime, due to a combination of mafia-style complicity in crime and common fear of the punishment the Chavista hierarchy would face after relinquishing power. Two, the unity of the opposition, that is, of the MUD (the Spanish acronym for the Democratic Unity Roundtable), has been severely hurt by the naiveté of certain leaders who believed that the regime’s periodic invitations to hold a dialogue (always coincident with its worst crises) could lead to a democratic transition.

The last such maneuver took place late last year, when the most effective leaders of the opposition were pushing for a recall referendum to which they were constitutionally entitled. The Maduro government, with the help of three former heads of state (José Luis Rodríguez Zapatero of Spain, Leonel Fernández of the Dominican Republic, and Martín Torrijos of Panama) plus the Vatican, invited the MUD to partake in what turned out to be a predictable charade rather than a meaningful negotiation. Maduro’s sole purpose was to gain time since he knew that, according to the Chavista constitution, the government’s removal in a recall referendum was possible only in 2016. If he managed to survive into 2017, Maduro had nothing to fear. And survive he did, with the help of part of the MUD’s leadership.

New Study Misdiagnoses Elevated U.S. Drug Prices

An interesting research article at the Health Affairs blog last week asserts there is no relationship between high U.S. prescription drug prices and drug companies’ research and development budgets. The point of the article is to debunk the argument that research-based drug companies must earn high profits if they are going to reinvest in R&D. While the data are correct, the article misunderstands the nature of capital markets.

As the authors point out, U.S. prices for patented prescription drugs are significantly higher, in real dollars, than prices in other developed countries. (Most observers claim this is because foreign governments impose price controls. I think it is more attributable to price differentiation due to variation in national income per capita.)

The analysis examines the 15 companies that sell the top 20 drugs (by worldwide sales) and estimates the amount of revenues attributable to U.S. “premium” pricing. It finds that those revenues exceed the firms’ R&D budgets—$166 billion versus $66 billion, in 2015. It also lists the amounts by company. For example, Merck earns about $11 billion from U.S. “premium” pricing, which is 159 percent of its R&D budget.

The Mullibuster Option

One of the zanier features of American politics is the Senate’s filibuster rule. Long ago, the Senate, by a simple majority vote, ruled that a supermajority is required to get any business done, with the result that often nothing gets done at all.

On the positive side, however, the threat of a filibuster has given the Senate a reputation for being more deliberate in its actions than the House of Representatives. It has often saved the country from legislation being ramrodded through the way it frequently is in the House.

In 2013, the Democrat-controlled Senate voted, 52 to 48, to waive the supermajority rule for the confirmation of federal judges, though not for the Supreme Court. At that time, Senate Minority Leader Mitch McConnell threatened, “I say to my friends on the other side of the aisle, you’ll regret this. And you may regret it a lot sooner than you think.” (New York Times, 11/22/13)

Now that the Republicans are back in power, it is therefore just a matter of time until they reciprocate and eliminate the filibuster altogether, beginning perhaps with the confirmation of Judge Neil Gorsuch. This so-called “Nuclear Option” will push the Republican agenda through, but regrettably it will also abase the Senate to the same low level as the House.

However, there is a third option between the filibuster and immediately passing unread bills with a simple majority, that allows the Senate to mull over contentious bills and appointments without blocking its business entirely. Under this “Mullibuster” option, any bill or confirmation that failed to pass by a 3/5 margin would be subject to tabling for a period of say 2 weeks, at which time it would come back for a new vote. If at that time the bill was exactly the same, it would require only a simple majority to pass. But if it has been amended in the meantime, the revision would be subject to the same Mullibuster rule.

The two week delay would give Senators, their staffs, and the blogospheric public time to actually read the bill, to scrutinize it for flaws, and to rally support or opposition back home. Perhaps the Senate would make the Mullibuster automatic for all measures that failed to gain 3/5 support, or perhaps it would require the formal request of one or more of the dissenting Senators.

If the Senate does adopt the Mullibuster, the House might even be shamed into adopting a similar rule...

See also my Feb. 1 post, “Term Limits for Supreme Court Justices?”

Update 3/28/17:
In a March 20 post entitled The Filibuster: A Primer on the Cato Institute’s blog Cato at Liberty, Robert A. Levy argues that the filibuster rule should be retained, and even written into the Constitution, “especially for votes on significant expenditures and tax increases—and also for confirmation of federal judges, who have lifetime tenure on the bench. Unless and until we establish judicial term limits, it’s little enough to insist that lifetime appointees be approved by 60 senators.”

Levy, an attorney who is Chairman of the Board of Directors of the Cato Institute, clarifies that while it would be straightforward to change Senate rules by a simple majority at the beginning of a session, current Senate rules allow mid-session rule changes themselves to be filibustered, with a 2/3 threshold for cloture. The true “nuclear option,” invoked by Democrats in 2013, “is a point-of-order, upheld by the presiding officer, declaring that the 67-vote requirement is unconstitutional.”

In an earlier post on this blog, I’ve concurred with Levy that there should be term limits on judicial appointments, but I think this is a separate issue from the filibuster.

In another earlier post on this blog, I’ve argued for an “Improved Balanced Budget Amendment” that would restrain deficits by requiring a supermajority vote in both houses to raise a constitutional limit on the national debt, with an “Anti-Chicken Mechanism” that would require the President to impound whatever expenditures are necessary to stay within that limit. However, I would not require a supermajority vote on individual appropriation bills.

Levy suggests no middle ground between retaining the filibuster as is and abolishing it altogether. He concedes that the latter now appears to be inevitable.

Replacing Obamacare with a Means-Tested Tax Credit

In his first joint address to Congress, President Trump promoted the idea of a tax credit to support people’s purchase of health insurance. This is in line with the approach taken by Health and Human Services Secretary Tom Price, when he was in Congress, and by the House Republican leadership.

Some self-styled conservatives, however, oppose a refundable tax credit because it would cost taxpayers a lot of money. That which we currently understand to be the Republican replacement bill would offer a tax credit to individuals based on age but not on income, if they do not get employer-based health benefits.

That may be changing to a means-tested tax credit in order to win the support of conservative Republican lawmakers. “Oh, the irony,” exclaims one journalist: Don’t those Republicans know Obamacare contains means-tested tax credits? It’s still Obamacare-Lite!

No, it would not be.

Politics without Romance? Yes and No

James Buchanan, a pioneer in the development of public choice, viewed his approach to the study of government and politics as the analysis of “politics without romance.” But Jim couldn’t really live without the romance, and no sooner had he expelled it out the front door than he let it in the back door, calling it “constitutional political economy” and supposing that “constitutional level” politics, related to the most basic rules for collective decision making, could be separated from and made more durable than the “rent-seeking” decision-making related to ordinary politics.

My understanding of political history led me to conclude that Jim was engaged in wishful thinking in the “constitutional political economy” phase of his project. In my view, constitutional issues are as constantly and as hotly contested as the issues of ordinary politics—politics is politics, and political actors seize every instrument available for attaining their ends.

Yes, one can adopt a constitution that makes its amendment difficult, but that very feature explains why, from the outset, political actors in the United States of America usually undertook to amend the U.S. Constitution not by explicit, formal amendment in accordance with the stipulations expressed in the original document, but by judicial reinterpretation of legal and constitutional meanings. Judges that make law, as opposed to merely interpreting it, are not, as many conservatives imagine, a relatively recent occurrence for which Progressives or New Dealers are to blame. Such judicial law making goes back at least to the Marshall court of more than 200 years ago, and conservative justices practice it as well as progressive ones.

Notice how, today, appointments to the Supreme Court elicit such fierce politicking. (Indeed, this heated wrangling has been the case for a long time.) Such would not be the case if there were no judicial law making. All sides expect it, however, and act accordingly.

Charles Murray and Middlebury College

The Atlantic, not a place to find conservative or libertarian views, has a good essay from a self-proclaimed liberal on the events at Middlebury College. Just as a recap, a student group at Middlebury College invited Dr. Charles Murray to speak on his book Coming Apart: The State of White America, 1960-2010. Also invited to this event was Allison Stanger, a progressive professor at the college, to engage Murray in a public conversation following his talk. But no talk or conversation was allowed to take place. Instead, students shouted Murray down and then launched an attack. Here is how The Atlantic summarizes the events:

[Murray and Stanger] found themselves surrounded by protesters. The protesters—some of whom were wearing masks and may not have been Middlebury students—began pushing them. When Stanger tried to shield Murray, according a Middlebury spokesman, a protester grabbed her hair and twisted her neck.

Murray, Stanger and their escorts made it to a waiting car, but the protesters “pounded on it, rocked it back and forth, and jumped onto the hood. . . . One took a large traffic sign, attached to a concrete base, and placed it in front of the car to prevent it from leaving.

Finally, Murray and Stanger got away. They had planned to eat dinner at a local restaurant, but, upon learning that the protesters planned to disrupt their meal, left town altogether. Stanger later went to the hospital, where she received a neck brace.

Unbelievable. A liberal professor defending the idea of debate and speech is injured by a crowd of student radicals when she tried to shield a conservative writer from physical attack. What will be of our country in 10 or 20 years when these young “social justice warriors” start to take positions of authority in government and business? They fear discussing ideas and resort to violence when someone disagrees with them. They have a sense of entitlement that they are the only proper judges of which opinions are acceptable and which may be voiced. What awaits us??

Review: Logan Shows Superhero Films Can Also Have Soul

Logan is the kind of movie that restores my faith in superhero action films. The story is layered, the characters have defined arcs, and the suspense keeps the audience engaged. Its R rating is well earned, with gruesome violence and disturbing situations involving children. The Hunger Games looks like a playground dust-up compared to what the mutant children in Logan deal with—and respond to in kind.

The violence may seem gratuitous to some viewers, but mostly it serves the purpose of the story. James “Logan” Howlett is the mutant Wolverine of Marvel Comics fame, and his personality is volatile and emotional. He also has a conscience. These dimensions—including the guilt that comes with the curse of having steel claws that decapitate, impale, and slash his attackers—are portrayed well by Hugh Jackman (his ninth movie performance as Wolverine). Logan’s mutant powers are used defensively, not offensively. The violence is not portrayed as honorable or noble, and this becomes an integral part of a very thoughtful film.

The story picks up on the tail end of a purge of mutants in a somewhat dystopian America of 2029. Logan is holed up in an abandoned factory, just over Texas’s border with Mexico, caring for Charles Xavier, a.k.a. “Professor X” (Patrick Stewart, Star Trek: The Next Generation), and assisted by the albino mutant Caliban (Stephen Merchant). Both Logan and Xavier are dying. Logan has been poisoned by the adamantium alloy fused into his bones to make his claws. Professor X is suffering from a degenerative neurological disease that unpredictably unleashes devastating telepathic powers.

Meanwhile, the evil global corporation Transigen is tracking down all the remaining mutants and replacing them with the new X-24 breed cloned from the DNA of first-generation mutants. The program is run by Transigen’s brilliant if authority-hungry surgical head Zander Rice (Richard E. Grant, Bram Stoker’s DraculaThe Iron LadyJackie), whose father was killed by Logan at the end of X-Men: Apocalypse. Assisting Rice are the “cyber-enhanced” (non-mutant human) chief of security Donald Pierce (Boyd Holbrook, Milk, Gone Girl) and a small army of cyber-enhanced “enforcers” called “reavers.”

Xavier, Logan, and Caliban live below the radar until Gabriella (Elizabeth Rodriguez, Orange is the New BlackFear the Walking Dead), a former nurse for Transigen, tracks them down in an effort to save 11-year-old Laura (Dafne Keen, The Refugees), part of a new generation of X-23 warriors cloned from mutant DNA. Gabriella implores Logan to transport Laura to safety in Canada. Transigen, having determined that the X-23 children were too hard to control, had killed them after another breed of mutant, the X-24, was perfected. Gabriella sees the humanity in the children and helps several to escape, but Laura is the only one who makes it to Logan’s compound. Gabriella also reveals that Laura was cloned from the DNA of Logan and thus is his daughter.

In the hands of a lesser filmmaker, the father-daughter twist could easily have been nothing more than a cinematic cliché. But in the hands of writer-director James Mangold (Walk the LineGirl, Interrupted, 3:10 to Yuma) the revelation becomes central to the film’s psychological theme: how violence affects the human mind. Logan’s relationship with Laura rekindles a fundamental humanity in him. The real story, however, is his role in teaching the undisciplined, intense, and volatile Laura the value of preserving life rather than taking it. Logan’s internal torment is driven by his guilt from having killed people, not all of whom were evil. Teaching warrior Laura a moral lesson—the dangers and responsibilities that come with her mutant powers—provides Logan with a path to redemption as he grapples with his own impending death.

As his healing powers weaken and his life grows increasingly precarious, Logan experiences his humanity resurfacing long enough for him to awkwardly but effectively teach Laura the value of life. Dafne Keen’s portrayal of Laura is riveting and compelling. The young actress convincingly shows us how Laura evolves, from a darkly unstable and violent warrior into an inquisitive and contemplative child who has genuinely bonded with Logan. Mangold deftly uses Laura’s Spanish-English bilingualism to pull back the layers of her character and eventually reveal her complexity and compassion.

Through Logan’s torturous self-loathing from having blood on his claws, the film shows how violence traps and degrades humanity. But it also imparts a hopeful vision, by showing Laura’s growing understanding of the value of human life and connection to her father. This message is not just one of many interpretations of the events unfolding on the screen—it is unavoidable. As the mutant children make their way to Canada, Laura quotes the 1953 western movie Shane. “A man has to be what he is, Joey,” says Shane to the young boy who idolizes the gunslinger turned protector.

“You can’t break the mould... I tried it and it didn’t work for me.... Joey, there’s no living with a killing. There’s no going back from one. Right or wrong, it’s a brand. A brand sticks. There’s no going back. Now you run on home to your mother, and tell her...tell her everything’s all right and there aren’t any more guns in the valley.”

Logan is a superhero action film with soul. It provides entertaining escape, but it also provokes meditations for viewers hoping for more depth.

Why Do Late Middle-Aged Women Allow Obamacare to Gouge Them?

In February, Professor Mark Pauly of the Wharton Business School wrote a short article proposing reforms to individual health insurance, in which he reminded us the biggest premium hike in the market for individual insurance consequent to Obamacare was among women in their 60s. His actual research was published in 2014, but I have wondered about it ever since.

Obamacare prevents insurers from charging premiums for 64-year olds that are more than three times those charged to 18-year olds. (A multiple of about five would be fairer, according to actuaries’ consensus.) Intuition tells us that should reduce premiums for older people. That intuition is wrong. Nevertheless, if politicians can convince people it is true, it makes political sense to impose the rule, because older people are much more likely to vote than younger people.

However, Obamacare also prevents insurers from charging different premiums to men and women of the same age. Pro-Obamacare politicians have a provocative slogan: “Being a woman should not be a pre-existing condition.”

Because Obamacare mandates maternity benefits, women of childbearing age cost a lot more than men. So the rule hikes young men’s premiums. Because men in late middle age have “bad habits” (according to Pauly), their health care costs more than older women’s health care does. So, it hikes those women’s premiums.

Politically, this is hard to figure out. Pre-election polling indicated 69 percent of women aged 18 to 34 supported Hillary Clinton, but only 60 percent of women aged 50 to 64 did. That alone suggests Democratic (therefore pro-Obamacare) politicians would seek younger women’s support by imposing a rule that favors them but punishes older women.

But does this overwhelm voter turnout? In the 2012 election, only 44.5 percent of women aged 18 to 24 voted, while 69.5 percent of those aged 45 to 64 voted. So, in raw numbers, there are surely more late middle-aged women who vote Democrat than young women.