Hearing on Health Tax Credits to Decrease the Number of Uninsured
United States House of Representatives
Committee on Ways and Means
February 13, 2002
(Dr. Stuart Butler, Vice President of the Heritage Foundation, and others provided extensive testimony on the use of tax credits to assist with the purchase of health insurance in the private market.)
The testimony continues:
Chairman Bill Thomas (R-CA): Mr. Stark? We only have about four minutes.
Rep. Pete Stark (D-CA): ... I'm gonna guess that we could provide Medicare for the under 65 population for probably 3,000 bucks a year. It was 4,000 for the 55 to 65 for the buy-in, so I'm extrapolating. Kids are only about 1,000 bucks, so you can fuss with me about the 3,000. But, I'm pretty close. If you add a maximum co-pay of 1,000 bucks, one day in the--one exposure to the hospital and 100 bucks for the doctor, you're talking about, at most, $4,000 for a plan that--I handed out this list of benefits that I got off the e-group--that's probably just as good as that, and if you--most of those had a $3,000 premium and a $1,000 co-pay. So, you could have Medicare with completely open enrollment and community rating, and why would anyone, therefore, object if using this tax credit, we allow people to purchase Medicare as an alternative? That's all we'd need to keep the insurance companies honest. If they want to compete, let 'em compete. And we already have it for the seniors where, obviously, the private insurance didn't want to compete. And so, I'd be perfectly willing to say, "Okay, let's do it," but just let Medicare offer a plan at budget net--cost as we do now with the subsidy for Part B, no higher, and provide it that way? Who'd object to that?
Dr. Stuart Butler (V.P. - Heritage Foundation): Well, I think you'd immediately see, of course, the adverse selection against Medicare, which is one of the big concerns with that. The people who would quickly and immediately take that option would be the people with the highest cost--.
Rep. Stark: Yeah, but adverse concern is the guy who doesn't get any insurance through the private market.
Dr. Butler: Well, I understand that. But, I'm just trying to point out that the cost of providing that coverage is--.
Rep. Stark: It's interesting how the (inaudible) is always worried about the poor people and the sick people first, as they're jamming it to us rich, healthy people? I like that, Stuart. You're true to form, always worrying about the rich people, never give a hoot for the poor.
Dr. Butler: Well, I--.
Rep. Stark: --At least you're consistent.
Dr. Butler: I think my record's very clear on that, Congressman.
Rep. Stark: Yes, your record is very clear. You don't give a rat's behind for the poor and the indigent. All you worry about is rich people getting their tax breaks.
Dr. Butler: Well, Congressman, I've actually--.
Rep. Stark: --Your career is outstanding in that regard.
Dr. Butler: If you look at the proposal--actually--.
Rep. Stark: --God bless you. Keep it up.
<http://www.kaisernetwork.org/health_cast/uploaded_files/hwa021302.pdf>http://www.kaisernetwork.org/health_cast/uploaded_files/hwa021302.pdf
Comment: Mr. Stark, in his mastery of the eloquence of the lay language, has left no doubt as to the fundamental issue that lies behind the debate on health care reform. Maybe we should proceed with this debate. Let's decide once and for all whether we, as a nation, give a rat's behind. If we don't, let's not waste more time and effort on health care reform. But, if we do, let's quit wasting our time trying to incrementally create a system that can be accepted by those that don't give a rat's behind. There is no such system. The enemies of reform will always try to silence the hoot that we want to give to the poor. If you doubt this, then ask yourself why a few decades of incremental reform have resulted in more uninsured, higher costs, and greater impairment of access to health care. The collectors of rat's behinds have silenced almost every hoot of each reform measure.
Single payer reform would provide comprehensive care for everyone and effectively address the cost issue. Let's leave the enemies of reform in their vaults, counting their rat's behinds, while we move on with real reform. Let's fix the damn thing now. Let's enact a single payer system.
Joshua Freeman, M.D., Professor and Chair, Department of Family Medicine, University of Kansas Medical Center, responds to Kip Sullivan on the Wennberg proposal:
I agree pretty much with Sullivan. Two comments:
1. The biggest problem with Wennberg, Ellwood and others is that the ownership of the care providers by private, corporate, for profit entities precludes not only privacy, but true cost-effectiveness, as it inescapably alters the motivation for everything that such providers do. This, not prospective payment, large groups, etc., is the problem with HMOs-in-their-current-form.
2. Sullivan is correct of course about prospective studies. My concern is that new IRB regulations, with the intention of protecting privacy of patients, will preclude a lot of people-based (as opposed to lab-based) research. Thus, it will not hurt those currently most NIH funded whose work is least likely and with the longest time lag to benefit people (but has the highest status, since it isn't susceptible to as much variation as studies involving actual people, with their undisciplined habits of variation!) but will be a real threat to clinical and in particular social science research on things that may be of greater immediate benefit (this has nothing to do with Wennberg or really Sullivan, but is a thought I had on reading Sullivan).
Uwe Reinhardt, Ph.D., responds to the Pete Stark - Stuart Butler exchange during the House Ways and Means hearing:
I do understand Pete's frustration and anger, and I share the sentiment. Pete has been a constant champion of the poor over the years and he must be deeply saddened at the 1990s. But I do not think that he was being fair to Stuart Butler.
To be sure, Stuart has a strong bias in favor of private market solutions--he, like Mark Pauly, has a deep-seated belief that government solutions invariably breed inefficiency and corruption, just as others have a deep-seated belief that private, for -profit enterprise is inherently anti-social. On the other hand, I know that both Mark and Stuart do care deeply about the welfare of low-income people, would very much like to see them all insured, and have worked hard over the years to work out politically feasible proposals to achieve that goal--proposals that have varied with the political temper of the times. They are not callous people. There really is such a thing as a compassionate conservative, and these two fall into that class (as President Bush does not--for he lacks the first of the "c's").
In fact, none other than former New Republic editor Michael Kinsley (recently retired from Slate) called Stuart Butler's original proposal (JAMA, around 1992) the most liberal proposal at the time, measured by the ultimate incidence of the fiscal burden and the degree of protection it offered. It may be recalled that the Urban Institute judged the financing of the Clinton Plan regressive in its incidence.
It is worth re-reading that old Heritage Foundation proposal to appreciate just how far we have sunk in terms of social ethics. Today it would be dead on arrival. Even Al Gore would have decried Stuart's proposal as "reckless spending."
Uwe