The Independent Institute


Employer-Based Coverage Does Not Equalize Access to Health Care

One reason public policy favors employer-based health benefits instead of individually owned health insurance is that policymakers believe it equalizes access to health care among workers of all income levels. Insurers usually demand 75 percent of workers be covered, which leads to benefit design that attracts almost all workers to be covered.

Employers do this by charging the same premium for all workers but having workers pay only a small share of the premium through payroll deductions. Most coverage is paid by the firm. Last year, the average total premium for a single worker in an employer-based plan was $6,435, but the worker paid only $1,129 directly while the employer paid $5,306.

Although this suppresses workers’ wages, workers cannot go to their employers and demand money instead of the employers’ share of premium. The tax code also encourages this practice, by exempting employer-based benefits from taxable income.

Does this equalize access to care? No, according to new research:

When demographics and other characteristics were controlled for, employees in the lowest-wage group had half the usage of preventive care (19 percent versus 38 percent), nearly twice the hospital admission rate (31 individuals per 1,000 versus 17 per 1,000), more than four times the rate of avoidable admissions (4.3 individuals per 1,000 versus 0.9 per 1,000), and more than three times the rate of emergency department visits (370 individuals per 1,000 versus 120 per 1,000) relative to top-wage-group earners.

(Bruce W. Sherman, et al., “Health Care Use and Spending Patterns Vary by Wage Level in Employer-Sponsored Plans,” Health Affairs, vol. 26, no. 2 (February 2017): 250-257.)

The reasons for these differences are not fully explained. Nevertheless, this research suggests employer-based benefits are not a good equalizer of access to health care, and the tax code’s prejudice in favor of those benefits and against individual health insurance should be revisited.

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For the pivotal alternative to Obamacare, see Priceless: Curing the Healthcare Crisis and A Better Choice: Healthcare Solutions for America, by John C. Goodman, published by Independent Institute.

Why Health Coverage Does Not Equal Healthcare Access

Readers know I disagree with using measurements of “coverage” as measurements of access to health care. New data from the Louisiana Department of Health, which cheers the expansion of Medicaid dependency in the state, shows (unwittingly) exactly why.

Healthy Louisiana’s Dashboard shows that 402,557 adults became dependent on Medicaid as a result of Obamacare’s expansion. The Department notes benefits for some sick people. For example, screening resulted in 74 people being diagnosed with breast cancer and 64 diagnosed with colon cancer.

The Dashboard stops there, not telling us how those newly diagnosed were treated. (Medicaid patients often receive treatment later than privately insured.)

However, there is another, likely bigger problem. Of these almost half million newly dependent, only 62,742 received “preventive healthcare or new patient services.” As David Anderson of the Duke-Margolis explained to me on Twitter, this number excludes those who became dependent on Medicaid but who were already being treated or did not get any treatment. That is, the Medicaid enrollment resulted in zero change in access to health care for 339,815 of the newly dependent. That amounts to 84 percent of the population.

Why did these people enroll in Medicaid when they were already receiving care or did not want to receive care? Well, the Medicaid expansion involved a lot of promotion, including enrollment “fairs” in high-traffic areas, so why not sign up and get a balloon or lapel pin or whatever?

More seriously: Those receiving care either paid for it or received it as charity. If they paid for it themselves, we need better understanding of whether or not this drove them into financial distress. If they received charity care, taxpayer funding is unnecessary.

Of course, most of the privately insured population at any given time is healthy. However, they are paying for “insurance” and cannot just get it whenever they want. People who get Medicaid do not need to enroll in open season: They can sign up when they get sick.

So, measuring health reform’s success by the number of people covered by Medicaid expansion is a very, very poor way to estimate increased access to health care.

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For the pivotal alternative to Obamacare, see Priceless: Curing the Healthcare Crisis and A Better Choice: Healthcare Solutions for America, by John C. Goodman, published by Independent Institute.


I’m somewhat amused by the anti-Trump protests the nation has seen since Trump’s election. He’s been a big talker, but as far as actually doing things, so far the only substantial thing he’s done was to try to implement his immigration ban. While I understand why people oppose his immigration policies, for the most part they are protesting Trump, personally, and the things he’s said rather than what he’s done in his young presidency.

I’m not against the protests. I have a lot of sympathy for anyone who protests against the use of government power by the executive branch (and the other two branches as well, for that matter). Regardless of whether I support or oppose any particular policy views Trump has espoused, any pushback against government power is always a move in the right direction.

Over the last century we’ve seen continual growth in the power of the executive branch, which at one time or another everyone has thought was undesirable. Progressives liked it when Obama was president; they dislike the power the chief executive holds now.

The on-going threat is that when government power expands, someone is going to gain control of that power to use it for purposes we oppose. So regardless of whether we support or oppose the specific person who holds that power now, our long-run interest is always to oppose any expansion of that power.

These protesters overwhelmingly come from the political left—the supporters of big government. It’s even better when those who have traditionally supported big government protest against the government’s exercise of power.

I’m on board with the Trump protesters, not because they are resisting Trump specifically, but because they are resisting the power of the executive branch of government.

The USA—Best Not to Go There Unless You Have an Urgent Reason to Do So

I am a consistent defender of allowing free passage of peaceful people across national borders. I understand full well why someone from an impoverished Mexican village or a violent hellhole such as Tegucigalpa might wish to migrate to the USA, where wage rates are 5-10 times greater for unskilled labor and, for Hondurans, Salvadorans, Guatemalans, and many people from the Middle East, physical security is better.

However, if you are not in such desperate straits, I would strongly suggest that you avoid attempting to enter the USA, however legally you might try to do so. Those entering the country through government checkpoints, either at the border or at an airport, run a high risk of being treated with great contempt by the border thugs and are at considerable risk of worse, including not only being detained and interrogated at great length (and completely without a plausible basis) and being compelled to surrender computer, phone, and social media passwords along with the devices, but also being denied permission to enter and forced to return to their place of departure.

The USA is simply not a welcoming place. It is a police state, and a hostile one at that. It makes virtually no attempt to distinguish potentially threatening people from ordinary people who, to anyone with a trace of brain, obviously pose no threat to national security or the personal well-being of current U.S. residents. So, be smart, amigos: don’t go there unless your have a very important reason to do so.

I am now kicking myself for having agreed to attend a conference in Maui in April. I should have listened to my wiser angel. I doubt very much, however, that afterward I shall ever make the same mistake.

The State, No Friend of Harmony and Peace

Turmoil and conflict

Politics nourishes them

Nature of the beast

Private property

Free markets and firm contracts

Foster harmony

Human rights basic

State thrives on war and plunder

Freedom works better

Health Spending and Prices to Rise, 2018 through 2025

Before the Affordable Care Act passed in March 2010, President Obama repeatedly promised that the typical family’s health premiums would go down by $2,500 after implementing the expansion of health insurance we label Obamacare.

Nothing of the sort has happened, of course. For the past few years, prices and spending have appeared moderate by historical standards. However, that is largely because they are reported in nominal terms, not real (inflation-adjusted) terms. From the Great Recession until very recently, general measures of inflation were about zero. An increase of premiums of eight percent when general measures of inflation are about zero is a lot more than an increase of eight percent when general measures of inflation are about three percent.

Actuaries at the Centers for Medicare & Medicaid Services, a government agency, have just updated their estimate of future health spending:

For 2018 and beyond, both Medicare and Medicaid expenditures are projected to grow faster than in the 2016–17 period, and more rapidly than private health insurance spending, for several reasons. First, growth in the use of Medicare services is expected to increase from its recent historical lows (though still remain below longer-term averages). Second, the Medicaid population mix is projected to trend more toward somewhat older, sicker, and therefore costlier beneficiaries. Third, baby boomers will continue to age into Medicare, with some of them dropping private health insurance as a result. And finally, growth in the demand for health care for those with private coverage is projected to slow as the relative price of health care—the difference between medical prices and economywide prices—is expected to begin gradually increasing in 2018 and as income growth slows in the later years of the projection period.

The vanity of Obamacare was that more central planning would reduce wasteful use of resources through “value-based” and “accountable” care. In fact, demand for health services by the privately insured will shrink only because prices outpace our ability to pay for them as government weighs down our prosperity.

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For the pivotal alternative to Obamacare, see Priceless: Curing the Healthcare Crisis and A Better Choice: Healthcare Solutions for America, by John C. Goodman, published by Independent Institute.

Medicare, Medicaid and VA at High Risk for Waste, Fraud and Abuse, Says GAO

The Government Accountability Office (GAO) has published its biennial update of federal programs “that it identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and mismanagement...”

Healthcare programs feature high on the list. Medicare, the entitlement program for seniors, and Medicaid, the joint state-federal welfare program for low-income households, are longstanding members of the list; and the GAO notes that legislation will be required to fix them:

We designated Medicare as a high-risk program in 1990 due to its size, complexity, and susceptibility to mismanagement and improper payments.

We designated Medicaid as a high-risk program in 2003 due to its size, growth, diversity of programs, and concerns about the adequacy of fiscal oversight.

Michael John Novak, Jr., 1933-2017

Our very dear friend and Founding Member of the Board of Advisors of the Independent Institute, Michael Novak, passed away at the age of 83, on February 17th. A man of immense generosity, integrity, joyfulness, and good will, Michael was one of the most important scholars, theologians, prolific authors, and public intellectuals of the post-World War II period. As a brilliant Catholic writer with a far-reaching, ecumenical influence across both religious and secular worlds, he championed the ideas and institutions of individual liberty, personal responsibility, free markets, civic virtue, religious freedom, private charity, entrepreneurship, family and community, and the rule of law, showing their roots in Judeo-Christian teachings. In the process, he thoroughly critiqued the tyranny and horrors of communism and fascism and the disasters of socialism/statism in creating massive poverty, environmental ruin, human depravity, and spiritual hopelessness.

The author of more than 50 books, including his pioneering volume, The Spirit of Democratic Capitalism (1982), he was the 1994 Templeton Prize Laureate for Progress in Religion. His books have been translated into most all major Western languages, plus Chinese, Korean, Japanese, and Bengali.

Was Hillary Clinton’s Progressive Presidential Bid Doomed from the Start?

Hundreds of thousands of people protested Donald Trump’s presidential election win, many believing he “stole” the presidency because Clinton “won” the popular vote. Digging below the surface of the November 2016 election results, however, suggests that Clinton’s presidential bid was doomed from the beginning. Moreover, the popular vote “win” may actually have been a result of conservatives in the “never Trump” camp crossing party lines, raising intriguing questions about whether she could have even governed successfully if she had won.

Most Americans, including those at the top levels of the Trump campaign, were shocked as Hillary Clinton’s presidential bid crumbled at the polls. She ended up with a popular win of 3 million votes, but this still represented a minority, just 48 percent, of the voting public. Most national polls failed to predict the outcome, prompting industry experts to do some serious soul searching. Their problem, however, may have been less methodological (e.g., sampling bias, survey design, or other technical issues) and more a failure to pay attention to fundamentals.

Review: Moonlight’s Focus on Drugs, Sexuality Make It a Film for Our Times

On the surface, Moonlight is a heart-wrenching film about a young African-American boy coming to terms with his sexuality while growing up in the impoverished public housing projects of Miami. But the Golden Globe winner (Best Motion Picture—Drama) is much more than a compelling, poignant, and uncompromisingly relevant movie; it’s a provocative portrayal of the complex underbelly of American cities.

In artistic terms, the film is outstanding, earning its eight Academy Award nominations, including Best Director, Best Picture, and Best Adapted Screenplay, even if its pacing seems a bit too deliberate at times. Filmed on-site in Miami over 25 days, many scenes were shot in Liberty City housing projects where director/screenwriter (and Florida State University film school graduate) Barry Jenkins grew up. The film is tight, brooding, engrossing, and focused.

Adapted from the semi-autobiographical book In Moonlight Black Boys Looks Blue by Tarell Alvin McCraney, the film doesn’t shy away from the complexities of the real-world dystopia that traps denizens of urban neighborhoods in big cities across the nation. For this reason the film speaks to a more universal condition and social problem.