Paul Krugman asks whether health insurance is purely parasitical; doesn't quite answer

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Paul Krugman, noting that most U.S. healthcare spending is filtered through private insurers, takes aim (in his new post-NYT retirement Substack) at private health insurance in the U.S.:

Let me offer a somewhat, but only somewhat, caricatured view of U.S. health care: It’s a system in which taxpayers bear the cost of major medical care, but this taxpayer money flows through private companies that take a cut, spend a lot on administration, and do their best to deny care to people who need it.

His argument as to whether private insurers add value is sketched in lightly, and focused entirely on Medicare Advantage:

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What service do private insurers provide in return for the tolls they in effect collect on a largely taxpayer-financed system? Medicare Advantage plans generally offer more extensive coverage than traditional Medicare. But there doesn’t seem to be any clear evidence that this is because private insurers provide efficiency gains the public sector doesn’t. What happens instead is that Medicare Advantage plans appear to be able to game the system sufficiently that they receive more taxpayer funding per enrollee than traditional Medicare spends on recipients in equivalent health…So you could make the case that at this point private health insurance is, in large part, a parasitical racket.

You could make that case, but leading with “you could” is a pretty equivocal way to make it. My take on the evidence (adapted from my comment on Krugman’s post) is below. The first point is a footnote to Krugman’s overview of private insurance’s share of U.S. healthcare spending.

1) Most Medicaid coverage is now also administered through private insurance companies (MCOs). Per KFF, 74% of Medicaid enrollees are in MCOs.

2) According to a KFF literature review, including a review of enrollee satisfaction surveys, Medicare Advantage enrollees are about as satisfied as traditional Medicare enrollees. By all accounts, problems in MA tend to come when you need serious care (especially post-acute care) — and denials appear to be on the increase. According to a Senate investigative report (inspired by reporting from STAT’s Bob Herman and Casey Ross), coverage denials from UnitedHealthcare MA plans for acute care more than doubled between 2020 and 2022 after the company adopted an AI tool (owned by UHC subsidiary NaviHealth, and also used by Humana and CVS Aetna) to assess claims.

3) Insurers "save" healthcare spending by denying not only needed but unneeded care -- and it's difficult to parse out the proportions of each. Surveys indicate that MA plans do encourage people to get screenings and so may prevent more acute care down the road. According to the KFF literature review, “The analyses consistently found that Medicare Advantage enrollees had higher utilization of preventive services and lower utilization of post-acute care and home health services.”

4) Some healthcare economists (e.g., Austin Frakt) find evidence that Medicare Advantage treatment protocols "spill over' into traditional Medicare and so save money there.

5) Private companies (MACs) also administer traditional Medicare, but with a very broad coverage grant and few coverage denials. MACs have no incentive to deny coverage.

6) In countries that deliver universal healthcare through private insurers, such as Germany and Japan, major medical insurers must be nonprofit. Germans can opt out of the nonprofit Statutory Health Insurance system into private plans, as 11% of the population did in 2019. But the government sets provider payment rates for private plans and limits premium increases. In Japan, as in many countries that deliver universal coverage through private plans, supplemental insurance can be for-profit.

7) In the U.S. whatever money insurers save by managing (denying) care is swamped by overpaying providers, which happens because we have no uniform payment rates, so providers divide and conquer. In the case of Medicare Advantage, where providers are paid Medicare rates or less, the savings are negated by payment formulas that overpay MA plans on a capitated basis, via a) a ridiculous risk adjustment system that incentivizes massive gaming, b) over-generous payment benchmarks, and c) bonus payments based on quality ratings that don't measure quality effectively.

8) Private insurers probably do have the capacity or potential to add administrative and care management value. But in the U.S., profit skews the incentives. In fact, it skews incentives for providers as much as for insurers. Almost all participants (e.g., those owned by giant insurers or private equity) are geared toward revenue maximization ("nonprofit" or not).

P.S. My own two-part assessment of Medicare Advantage (from 2022) starts here.

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Photo by Arthur Uzoagba 

Does marketplace resilience show creator brilliance? Not quite, Krugman

Paul Krugman crows a bit about the ACA's relative resilience:

What’s the secret of Obamacare’s stability? The answer, although nobody will believe it, is that the people who designed the program were extremely smart. Political reality forced them to build a Rube Goldberg device, a complex scheme to achieve basically simple goals; every progressive health expert I know would have been happy to extend Medicare to everyone, but that just wasn’t going to happen. But they did manage to create a system that’s pretty robust to shocks, including the shock of a White House that wants to destroy it.

Um, maybe, sort of. The perspective is a useful corrective to those of us prone to lamenting the ACA's many design flaws and susceptibility to sabotage. And Krugman does highlight a resilience-making feature that I suppose could have been otherwise:

Those subsidies aren’t fixed. Instead, the formula sets the subsidy high enough to put a limit on how high premium payments can go as a percentage of income.

Yes, the subsidy-eligible are insulated from the massive premium hikes of the past two years -- averaging well over 20% in each year -- and that would not be the case if they were not benchmarked to income. The Trump administration even added some accidental extra resilience in an act of spite -- cutting off federal CSR reimbursements to insurers -- which simply boosted the subsidies, and allowed many enrollees to leverage the increase by buying bronze or gold plan (since in most states insurers concentrated the un-reimbursed price of CSR in silver plans, against which subsidies are set).  So the subsidy structure seems to preserve a pool of 8 million subsidized -- if erosion among the unsubsidized, and the Trump administration's fostering of a lightly regulated, medically underwritten alternative market for the healthy among them -- doesn't drive large numbers of insurers out.

But Krugman overstates the case on several fronts -- the most notorious being a straight factual fudge. Noting that 83% of enrollees on the exchanges are subsidized, he concludes:

In a fraudster's grip

This is just to note that today Paul Krugman caught the essence of the Trump presidency in 80 words:

Our government hasn’t always done the right thing. But it has kept its promises, to nations and individuals alike.

Now all of that is in question. Everyone, from small nations who thought they were protected against Russian aggression, to Mexican entrepreneurs who thought they had guaranteed access to our markets, to Iraqi interpreters who thought their service with the U.S. meant an assurance of sanctuary, now has to wonder whether they’ll be treated like stiffed contractors at a Trump hotel.

Anyone over the age of five, regardless of political propensity or education level, should have been able to see that this is what Trump would deliver. Those who couldn't see it, driven by whatever passion or need, willfully shut their ears and eyes. His depravity was as manifest as Hitler's. Whether his will to evil is as intense, we'll learn.

Attention, Paul Krugman: Not everyone votes

Am I crazy or is Paul Krugman making a really elemental mistake here?

As Greg Sargent points out, the choice of Tom Price for HHS probably means the death of Obamacare. Never mind the supposed replacement; it will be a bust. So here’s the question: how many people just shot themselves in the face?

My first pass answer is, between 3.5 and 4 million. But someone who’s better at trawling through Census data can no doubt do better.

Here’s my calculation: we start with the Census-measured decline in uninsurance among non-Hispanic whites, which was 6 million between 2013 and 2015. Essentially all of those gains will be lost if Price gets his way.

How many of those white insurance-losers voted for Trump? Whites in general gave him 57 percent of their votes. Whites without a college degree — much more likely to have been uninsured pre-Obama — gave him 66 percent. Apportioning the insurance-losers using these numbers gives us 3.42 million if we use the overall vote share, or 3.96 million if we use the non-college vote share.

The assumption appears to be that everyone votes. Turnout this year is currently reported at 58.6%. It's probably lower for most of those who gained insurance via the ACA, as their incomes are below median: according to the Current Population Survey, almost three quarters of those who gained insurance in both 2014 and 2015 have incomes below twice the Federal Poverty Level, and nearly all have incomes under 300% FPL. Lower income people have lower turnout rates.  It would appear that Krugman's total needs to be sliced almost in half.

Paul Krugman agrees with me

Back when  Paul "the stimulus was too small!" Krugman was in full Cassandra mode, just after the November 2010 shellacking, I took issue with one of his numerous whacks at Obama:

...take this sideswipe at the stimulus in Krugman's latest crie de coeur about the Fed's refusal to raise its inflation target:

...fearing opposition in Congress, the Obama administration offered an inadequate plan, only to see the plan weakened further in the Senate. In the end, the small rise in federal spending was effectively offset by cuts at the state and local level, so that there was no real stimulus to the economy.

Wasn't one of the core purposes of the stimulus to offset spending cuts by state and local governments? That's what stimulus does -- offset drops in demand. Of course, Krugman believes that there was too little state aid, along with too little of everything, in the Recovery Act, and naturally a stimulus should do more than offset other government spending cuts. But still, offsetting those cuts is a "real stimulus to the economy." The Recovery Act unquestionably preserved hundreds of thousands of state and local government jobs, and GDP would have been lower if this hadn't been done.

This may seem a semantic quibble. But it's a symptom, I think, of an oversimplified narrative. Krugman has implied elsewhere that the right-sized stimulus would have set the economy roaring back to life (as has Martin Wolf). To what degree is that credible? If Obama had asked for $1.2 trillion and got $950 billion, what's the math on the counterfactual? Unemployment at 8.3%?  And the effect of such a drop on the electorate? I confess it could be substantial. But there's an awful lot of what-ifs there, beginning with the premise that a substantially larger stimulus could have got through the Senate. And the narrative leaves out some externalities, such as the Euro sovereign debt crisis, which seemed to stop a decent-looking recovery in its tracks. Not to mention the credible possibility, forecast now by a growing number of economists and business leaders (e.g., here and here), that a substantial recovery may be on the horizon now. 

Some time in 2012, Krugman had a change of heart about Obama, and now he is out with a defense of Obama's record just as a host of ex-cabinet members and in-office Democrats is piling on (he himself notes the irony in this). Now behold his retrospective view of the (still too-small) stimulus:

In which Krugman borrows Martin Wolf's scalpel, possibly via Geithner

[n.b. see update in mid-post. I seem to have misread...]

In October 2010, Financial Times columnist Martin Wolf led off a column with a heroic simile to describe Obama's economic performance:

An ambulance stops by the roadside to help a man suffering from a heart attack. After desperate measures, the patient survives. Brought into hospital, he then makes a protracted and partial recovery. Then, two years later, far from feeling grateful, he sues the paramedics and doctors. If it were not for their interference, he insists, he would be as good as new. As for the heart attack, it was a minor event. He would have been far better off if he had been left alone.

That is the situation in which Dr Barack Obama finds himself...more stimulus was needed. After all, it was quite modest: fiscal stimulus was less than 6 per cent of GDP and so accounts for less than a fifth of the cumulative deficits of 2009, 2010 and 2011, while monetary policy is caught in a liquidity trap.

The truth is not that policy was foolhardy and failed, but that it was too timid and so could not succeed.

Lo, now cometh Paul Krugman to review Tim Geithner's memoir:

The long and the short of income inequality

Ezra Klein made a splash a few days ago by arguing that Obama is wrong to call rising inequality the defining challenge of our time, asserting that jobs should take precedence: "Growth simply isn't producing enough jobs. This is a more severe and more urgent problem than inequality.

Today, Paul Krugman counters that inequality that the president was right -- first because stagnant incomes may have contributed to the debt crisis and are now depressing consumer demand, but more fundamentally, because the wealthiest have converted their disproportionate economic power into disproportionate political power, corrupting the country's ability to address its policy challenges.  The  the super-0rich, Krugman charges, triggered the financial meltdown by building a bipartisan consensus for financial regulation -- and have crippled the recovery by demanding austerity.

Klein's binary choice between addressing unemployment or austerity seems fundamentally mistaken to me, I would supplement Krugman's analysis with research by Peter Turchin (thanks, T. Greer), who has identified very long-term cycles of expanding and contracting inequality, and tied them chiefly to the supply of labor:

The GOP is drunk on the proven power of extortion

I am looking past the pending government shutdown to the looming debt ceiling standoff -- the point in late October when Republicans can, worst case, cause a global economic cataclysm, or, second worst, hamper U.S. economic growth for decades to come.

As Republicans keep cramming more fantastic demands into their debt ceiling ransom note, Obama is saying now what he should have said the first time they made fantastic demands ($2.5 trillion in spending cuts over ten years with no tax increases) a condition of raising the debt ceiling in spring/summer 2011. On Friday, he said:

I will not negotiate over Congress’s responsibility to pay the bills that have already been racked up.  Voting for the Treasury to pay America’s bills is not a concession to me.  That’s not doing me a favor.  That’s simply carrying out the solemn responsibilities that come with holding office up there.  I don’t know how I can be more clear about this.  Nobody gets to threaten the full faith and credit of the United States just to extract political concessions.  No one gets to hurt our economy and millions of innocent people just because there are a couple of laws that you do not like.

The continuation, though, rather airbrushed Obama's own history on this question:

Paul Krugman's moment of truthiness

I suffered cognitive dissonance this morning when I read this from Krugman:

We also all know that the reality [of how democracy in America functions] falls far short of the ideal. Voters are often misinformed, and politicians aren’t reliably truthful. Still, we like to imagine that voters generally get it right in the end, and that politicians are eventually held accountable for what they do. 

But is even this modified, more realistic vision of democracy in action still relevant? Or has our political system been so degraded by misinformation and disinformation that it can no longer function? 

He goes on to fulminate about Exhibit A: Americans do not know that the deficit has been dropping throughout the Obama years, as they did not know that the deficit was falling through Clinton's first term.

Why am I disconcerted by Krugman's consternation? Of course I share his frustration at the "outright falsehoods" that Republican leaders routinely mouth about the deficit. I agree, as he laments in this column, that our political discourse is shot through with truthiness.

But unlike Krugman (apparently), I recall what Krugman wrote..yesterday. Reacting to a recent morsel of egregious economic misinformation in a Robert Samuelson column, he opined:

OK, Krugman: How will hypocrisy help us?

Paul Krugman, Jeremiah of galloping income inequality in the United States, today manages a rather half-hearted tribute to the nation's long-term fidelity to its founding ideals. Half-hearted, because seeing those ideals subverted by encroaching oligarchy, he takes rueful solace only in our national hypocrisy:

Of course, our democratic ideal has always been accompanied by enormous hypocrisy, starting with the many founding fathers who espoused the rights of man, then went back to enjoying the fruits of slave labor. Today’s America is a place where everyone claims to support equality of opportunity, yet we are, objectively, the most class-ridden nation in the Western world — the country where children of the wealthy are most likely to inherit their parents’ status. It’s also a place where everyone celebrates the right to vote, yet many politicians work hard to disenfranchise the poor and nonwhite. 

But that very hypocrisy is, in a way, a good sign. The wealthy may defend their privileges, but given the temper of America, they have to pretend that they’re doing no such thing. The block-the-vote people know what they’re doing, but they also know that they mustn’t say it in so many words. In effect, both groups know that the nation will view them as un-American unless they pay at least lip service to democratic ideals — and in that fact lies the hope of redemption. 

So, yes, we are still, in a deep sense, the nation that declared independence and, more important, declared that all men have rights. Let’s all raise our hot dogs in salute.

Left unspoken here is how hypocrisy helps. It's said that hypocrisy is the tribute that vice pays to virtue -- bad conscience with a cover. The question is, how productive will our ethical unease prove? Now that our income distribution (and opportunity distribution) has reverted to roughly where it was before the Great Depression and the New Deal, will this retrogression prove, to borrow a bit of econ-speak, 'secular or cyclical'?  That is, will we readjust, as Obama in '08 argued we must, from a 30-year Reaganite right turn turbo-charging pressure on wages powered by automation and globalization? Will we find means to train our youth to create and fill "good-paying jobs of the future"? Or was the relatively weak American version of the welfare state merely a one-time strategic retreat by elites that have more recently tightened a now unshakable proprietary grip on the means to prosperity?

Ben Bernanke's over-the-cliff notes

No one needs me to add my wonder to that of everyone encountering Ben Bernanke's remarkable commencement speech at Princeton debunking the concept of meritocracy as defined by nearly every politician in America who pays lip service to it. No one needs me either to highlight the implicit rebuke to a party fanatically devoted to preserving low taxes for the rich and benefit cuts for the poor. 

I will only gild the lily so far as to note how thoroughly Bernanke set up the climactic credo from the moment he opened his mouth.  With caustic good humor, he repeatedly struck notes that eventually merged in the climactic chord: Life is unpredictable; merit is a product of chance; you are collectively the luckiest of the lucky; and your only instrument of meaningful control is a determination to do well by others. To wit:

In which Paul Krugman gets cutesy with causality

ICYMI, this week serious questions were raised about a controversial and influential paper by Harvard economists Carmen Reinhart and Kenneth Rogoff that purported to show -- or at least has been taken to show -- that when a country's national debt reaches about 90% of GDP, that debt acts as a significant drag on growth.  On April 15, Thomas Herndon, Michael Ash and Robert Polin published a paper alleging that Reinhart and Rogoff's paper contained, along with various methodological errors, a coding error in an Excel spread sheet. In response,  Reinhart and Rogoff acknowledge the error, but defend their methodology and  maintain that the error does not materially affect their conclusions. They also claim that they never stated categorically that higher debt caused lower growth. It's that question of how a politically freighted point is communicated and received that interests me here.

On his blog, Paul Krugman cried "casuistry" on that last point:

And the everyone hyping Reinhart-Rogoff very much included Reinhart and Rogoff themselves. Matt O’Brien has the goods. It’s true that their papers never said outright that the relationship was causal, but they weren’t anywhere near that scrupulous in op-eds and other media presentations. And the truth is that the papers may not have stated causation flatly, but it was clearly insinuated. By trying to claim now that they never meant to imply such a thing, R-R are falling down seriously in the menschhood test.

Today, Krugman, austerity's most stalwart enemy, devoted a whole column to the kerfuffle. And while I'm happy to see him hammer away at the foundations of the case for austerity, I must say that he replicates the alleged rhetorical error. That is, he gets cutesy with causality. The whole essay is set up to convey a conclusion that he somewhat airily dismisses in the final sentence.

The opening paragraph poses a pretty grandiose premise: 

You want real deficit reduction? Try this...

Like most progressives, I've been pleased to witness Obama thus far refusing to negotiate with himself in the fiscal cliff battle. With his tax proposals and modest proposed spending cuts on the table -- a package derived from his 2013 budget -- it would seem to make sense to let Republicans detail the deeper entitlement cuts they say they want. As Paul Krugman highlights today, the Republican leadership seems unwilling to go on record proposing deep, substantive cuts to Medicare, Medicaid, and Social Security. So the progressive consensus is clear: let them put up or shut up.

Nonetheless, there remain calls among some Obama supporters -- e.g., natch, Andrew Sullivan -- for Obama to "seize the center" and propose more thoroughgoing plans to restrain long-term spending.  And there may in fact be political opportunity for him in doing so -- on his own terms.

The benefits of union

An excellent article by the AP's Adam Geller on New York's massive flood protection challenges holds up Houston's Texas Medical Center, which was devastated by Hurricane Allison in 2001, as a shining example of an institution that learned from experience:

A review of the area's flood weaknesses led officials to create a list of 112 projects, including widening the bayou and building culverts that funnel water away from the campus. But many of the projects were based on acknowledging that even if planners couldn't ensure that all the water from a future storm would stay out, they could at least work to limit the damage.

TMC's member hospitals moved their electrical vaults and backup generators out of basements to areas above flood level. They rejiggered the way they used their space, rebuilding and moving facilities like research labs, many of which were destroyed by the flood, to higher floors. Scores of existing buildings were fitted with flood gates, and new buildings were built surrounded by berms. Underground tunnels were outfitted with 100 submarine doors, some 12 feet tall.

 Nice planning, guys!  And who paid?

Notes from the bully pulpit: no one hears you when unemployment is at 10%

As Obama gears up for the fiscal cliff end game, David Corn is out with a timely reminder that the deal Obama struck in December 2010, trading extension of the Bush tax cuts for the wealthy for a payroll tax cut, unemployment benefit extension and other stimulus, was far from the cave-in that liberal allies portrayed it as. Rather, it was a successful a bid to win "something bigger and better: more stimulus to aid the ailing economy."

This was actually obvious at the time, for those with eyes to see. According to Mark Zandi, the Democratic proposals that became part of the deal yielded $336 billion worth of stimulus from 2010-2012.  Even Paul Krugman admitted at the time that the provisions Obama fought for were likely to provide significant help to the economy. In concert with the payroll tax cut and and unemployment benefits extension Obama bludgeoned the GOP into accepting in early 2012, those stimulative measures probably secured his reelection.

While debunking the tax-deal-as-cave-in myth, Corn does subscribe to another narrative that does have some truth to it over the long haul but in my view is also exaggerated:  that Obama was ineffective at communicating his policy.  Here's Corn's read:

The tribute Obama deserves

has been delivered by Jonathan Chait:

What can be said without equivocation is that Obama has proven himself morally, intellectually, temperamentally, and strategically. In my lifetime, or my parents’, he is easily the best president. On his own terms, and not merely as a contrast to an unacceptable alternative, he overwhelmingly deserves reelection.

Chait understands that true pragmatism is the rarest and most powerful lever of leadership:

Obama’s résumé of accomplishments is broad and deep, running the gamut from economic to social to foreign policy. The general thrust of his reforms, especially in economic policy, has been a combination of politically radical and ideologically moderate. The combination has confused liberals into thinking of Obamaism as a series of sad half-measures, and conservatives to deem it socialism, but the truth is neither. Obama’s agenda has generally hewed to the consensus of mainstream economists and policy experts. What makes the agenda radical is that, historically, vast realms of policy had been shaped by special interests for their own benefit. Plans to rationalize those things, to write laws that make sense, molder on think-tank shelves for years, even generations. They are often boring. But then Obama, in a frenetic burst of activity, made many of them happen all at once.

Paul Krugman closes his own private enthusiasm gap

No one on the more or less mainstream left has been harder on Obama than Paul Krugman, who began tearing out his hair at the proposed size of the stimulus before Obama took office and did not let up for almost three years thereafter. The nadir came as details of the debt ceiling deal emerged last summer: Krugman's July 31, 2011 column was originally titled "Capitulation" and lives on online as The President Surrenders.  His bitterness reached this crescendo:

In fact, Republicans will surely be emboldened by the way Mr. Obama keeps folding in the face of their threats. He surrendered last December, extending all the Bush tax cuts; he surrendered in the spring when they threatened to shut down the government; and he has now surrendered on a grand scale to raw extortion over the debt ceiling. Maybe it’s just me, but I see a pattern here.

Yes, the debt ceiling deal was disillusioning, and droves of Democrats followed Krugman into the slough of despond.  Nine days later, the disgust peaked with Drew Westen's What Happened to Obama, a 3000-word screed on the front page of the New York Times Sunday Review that portrayed Obama as a craven conflict-averse surrender monkey while belittling his legislative accomplishments.  As I pointed out at the time, this rhetorical nuke dropped on ground zero in the liberal heartland relied almost entirely on Krugman's critique of the stimulus for its substantive attack on Obama's record.

Yet Krugman has had a change of heart over the past year. His esteem for the president has grown more swiftly than the economy -- to the point where, if Obama's base followed Krugman's lead, there would be no enthusiasm gap. Perhaps it's an accelerating case of 'you don't know what you've got till it's [almost] gone.

Mitt's standing prescription for America: Go (hardware) shopping

As Romney, in his nomination acceptance speech, hit Obama first for his Medicare cuts and then for the defense cuts triggered by the Budget Control Act, I tweeted that he was attacking Obama for cutting $1.2 trillion in spending - pretty funny for someone supporting a Balanced Budget Amendment to the Constitution.

Paul Krugman made the same point last week -- "OK, so deficit spending hurts the economy — unless it’s spending on the military (or on the medical-industrial complex), in which case cutting spending destroys jobs." Today, he elaborates:

Can the Competition Fairy control healthcare costs?

As I've explored in the last three posts, the Medicare reform plan in Ryan's 2013 budget blurs Democratic attack lines because it looks very much like an Affordable Care Act for seniors (who, er, already have affordable care) while staking an at least ostensibly credible claim to preserve the Medicare guarantee.

The simplest counterargument was just voiced by a Florida voter to Washington Post reporter Felicia Sonmez: if it ain't broke, don't fix it. The counterargument is that Medicare is broken insofar as its cost to taxpayers has wildly outrun inflation and threatens to bankrupt the federal government.  The debate boils down to the best means to control costs while preserving the Medicare guarantee.

A little distance on the post-truth campaign

I've been on vacation with my wife in the Finger Lakes and fell off the grid for reasons I won't bore you with -- off completely for one day, near-completely for three. When we get away, usually, I'm eager to dive back into the political/policy news when I can, but this time, my brief forays have felt like dropping into a coal mine.  A bit of distance defamiliarizes our degraded politics and brings home what a high-stakes, dangerous and disgusting contest it is.

Reconnecting for a bit last night, I caught up with this elevated argument from the Romney campaign: