Sinking SCHIP: A First Step toward Stopping the Growth of Government Health Programs

Federal lawmakers are considering legislation that could result in millions more middle income families obtaining health insurance from government. Unfortunately, the debate over expansion of the State Children's Health Insurance Program is divorced from the reality of who truly needs assistance and the forces that are making health insurance increasingly unaffordable. SCHIP and its larger sibling Medicaid currently enroll many people who do not need government assistance, including some families of four earning up to $72,000 per year. That is a direct result of federal funding rules that reward states for making more Americans dependent on government for their health care. Rather than expand SCHIP, Congress should (1) make private health insurance more affordable by allowing consumers and employers to purchase less expensive policies from other states, and (2) fold federal Medicaid and SCHIP funding into block grants that no longer encourage states to open taxpayer-financed health care to nonneedy families. With more Americans able to afford private insurance and no incentive for states to expand government programs beyond the truly needy, federal and state governments could reduce spending on those programs

Does Barack Obama Support Socialized Medicine?

Democratic presidential nominee Sen. Barack Obama (IL) has proposed an ambitious plan to restructure America's health care sector. Rather than engage in a detailed critique of Obama's health care plan, many critics prefer to label it "socialized medicine." Is that a fair description of the Obama plan and similar plans? Over the past year, prominent media outlets and respectable think tanks have investigated that question and come to a unanimous answer: no. Those investigations leave much to be desired. Indeed, they are little more than attempts to convince the public that policies generally considered socialist really aren't. A reasonable definition of socialized medicine is possible. Socialized medicine exists to the extent that government controls medical resources and socializes the costs. Notice that under this definition, it is irrelevant whether we describe medical resources (e.g., hospitals, employees) as "public" or "private." What matters-what determines real as opposed to nominal ownership-is who controls the resources. By that definition, America's health sector is already more than half socialized, and Obama's health care plan would socialize medicine even further. Reasonable people can disagree over whether Obama's health plan would be good or bad. But to suggest that it is not a step toward socialized medicine is absurd

A Better Way to Generate and Use Comparative-Effectiveness Research

President Barack Obama, former U.S. Senate majority leader Tom Daschle, and others propose a new government agency that would evaluate the relative effectiveness of medical treatments. The need for "comparative-effectiveness research" is great. Evidence suggests Americans spend $700 billion annually on medical care that provides no value. Yet patients, providers, and purchasers typically lack the necessary information to distinguish between high- and low-value services. Advocates of such an agency argue that comparative- effectiveness information has characteristics of a "public good," therefore markets will not generate the efficiency-maximizing quantity. While that is correct, economic theory does not conclude that government should provide comparative-effectiveness research, nor that government provision would increase social welfare. Conservatives warn that a federal comparative- effectiveness agency would lead to government rationing of medical care -- indeed, that's the whole idea. If history is any guide, the more likely outcome is that the agency would be completely ineffective: political pressure from the industry will prevent the agency from conducting useful research and prevent purchasers from using such research to eliminate low-value care. The current lack of comparative-effectiveness research is due more to government failure than to market failure. Federal tax and entitlement policies reduce consumer demand for such research. Those policies, as well as state licensing of health insurance and medical professionals, inhibit the types of health plans best equipped to generate comparative-effectiveness information. A better way to generate comparative-effectiveness information would be for Congress to eliminate government activities that suppress private production. Congress should let workers and Medicare enrollees control the money that purchases their health insurance. Further, Congress should require states to recognize other states' licenses for medical professionals and insurance products. That laissez-faire approach would both increase comparative-effectiveness research and increase the likelihood that patients and providers would use it

Does the Doctor Need a Boss?

The traditional model of medical delivery, in which the doctor is trained, respected, and compensated as an independent craftsman, is anachronistic. When a patient has multiple ailments, there is no longer a simple doctor-patient or doctor-patient-specialist relationship. Instead, there are multiple specialists who have an impact on the patient, each with a set of interdependencies and difficult coordination issues that increase exponentially with the number of ailments involved. Patients with multiple diagnoses require someone who can organize the efforts of multiple medical professionals. It is not unreasonable to imagine that delivering health care effectively, particularly for complex patients, could require a corporate model of organization. At least two forces stand in the way of robust competition from corporate health care providers. First is the regime of third-party fee-for-service payment, which is heavily entrenched by Medicare, Medicaid, and the regulatory and tax distortions that tilt private health insurance in the same direction. Consumers should control the money that purchases their health insurance, and should be free to choose their insurer and health care providers. Second, state licensing regulations make it difficult for corporations to design optimal work flows for health care delivery. Under institutional licensing, regulators would instead evaluate how well a corporation treats its patients, not the credentials of the corporation's employees. Alternatively, states could recognize clinician licenses issued by other states. That would let corporations operate in multiple states under a single set of rules and put pressure on states to eliminate unnecessarily restrictive regulations

Pay-for-Performance: Is Medicare a Good Candidate?

According to one prominent study, adults in the United States receive the generally accepted standard of preventive, acute, and chronic care only about 55% of the time. The likelihood that patients will receive recommended care varie[s] substantially according to the particular medical condition, ranging from 78.7 percent of recommended care . . . for senile cataract to 10.5 percent of recommended care ... for alcohol dependence. Evidence of low-quality care appears in Medicare, the federal health program for the elderly and disabled. Quality of care does not appear to be higher in areas where Medicare spending is higher. In fact, some studies point to the somewhat paradoxical conclusion that Medicare patients are often less likely to receive recommended care in regions where Medicare expenditures are highest. Third-party payment is a potential contributor to the under-provision of quality health care. Most health care payments in the United States are made by third parties, usually employers, insurers, or government. Those purchasers typically reimburse health care providers on the basis of the volume and intensity of the services provided, rather than the quality or cost-effectiveness of those services. The result is a financing system akin to paying academics on the basis of the volume and intensity of footnotes

King v. Burwell and the Triumph of Selective Contextualism

King v. Burwell presented the question of whether the Patient Protection and Affordable Care Act of 2010 (ACA) authorizes the Internal Revenue Service (IRS) to issue tax credits for the purchase of health insurance through Exchanges established by the federal government. The King plaintiffs alleged an IRS rule purporting to authorize tax credits in federal Exchanges was unlawful because the text of the ACA expressly authorizes tax credits only in Exchanges “established by the State.” The Supreme Court conceded the plain meaning of the operative text, and that Congress defined “State” to exclude the federal government. The Court nevertheless disagreed with the plaintiffs, explaining that “the context and structure of the Act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.” The Court reached its conclusion by disregarding portions of the ACA’s text and considering only selected elements of the ACA’s structure, context, and purpose. The King majority’s selective contextualism embraced an unexpressed congressional “plan” at the expense of the plan Congress actually enacted

Taxation Without Representation: The Illegal IRS Rule to Expand Tax Credits Under the PPACA

The Patient Protection and Affordable Care Act (PPACA) provides tax credits and subsidies for the purchase of qualifying health insurance plans on state-run insurance exchanges. Contrary to expectations, many states are refusing or otherwise failing to create such exchanges. An Internal Revenue Service (IRS) rule purports to extend these tax credits and subsidies to the purchase of health insurance in federal exchanges created in states without exchanges of their own. This rule lacks statutory authority. The text, structure, and history of the Act show that tax credits and subsidies are not available in federally run exchanges. The IRS rule is contrary to congressional intent and cannot be justified on other legal grounds. Because the granting of tax credits can trigger the imposition of fines on millions of individuals and employers, the IRS rule is likely to be challenged in court

King v. Burwell and the Triumph of Selective Contextualism

King v. Burwell presented the question of whether the Patient Protection and Affordable Care Act of 2010 (ACA) authorizes the Internal Revenue Service (IRS) to issue tax credits for the purchase of health insurance through Exchanges established by the federal government. The King plaintiffs alleged an IRS rule purporting to authorize tax credits in federal Exchanges was unlawful because the text of the ACA expressly authorizes tax credits only in Exchanges “established by the State.” The Supreme Court conceded the plain meaning of the operative text, and that Congress defined “State” to exclude the federal government. The Court nevertheless disagreed with the plaintiffs, explaining that “the context and structure of the Act compel us to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.” The Court reached its conclusion by disregarding portions of the ACA’s text and considering only selected elements of the ACA’s structure, context, and purpose. The King majority’s selective contextualism embraced an unexpressed congressional “plan” at the expense of the plan Congress actually enacted

The Amateur Sky Survey Mark III Project

The Amateur Sky Survey (TASS) is a loose confederation of amateur and professional astronomers. We describe the design and construction of our Mark III system, a set of wide-field drift-scan CCD cameras which monitor the celestial equator down to thirteenth magnitude in several passbands. We explain the methods by which images are gathered, processed, and reduced into lists of stellar positions and magnitudes. Over the period October, 1996, to November, 1998, we compiled a large database of photometric measurements. One of our results is the "tenxcat" catalog, which contains measurements on the standard Johnson-Cousins system for 367,241 stars; it contains links to the light curves of these stars as well.Comment: 20 pages, including 4 figures; additional JPEG files for Figures 1, 2. Submitted to PAS

A tectonic-rules-based mantle reference frame since 1 billion years ago - implications for supercontinent cycles and plate-mantle system evolution

Understanding the long-term evolution of Earth\u27s plate-mantle system is reliant on absolute plate motion models in a mantle reference frame, but such models are both difficult to construct and controversial. We present a tectonic-rules-based optimization approach to construct a plate motion model in a mantle reference frame covering the last billion years and use it as a constraint for mantle flow models. Our plate motion model results in net lithospheric rotation consistently below 0.25g g€Myr-1, in agreement with mantle flow models, while trench motions are confined to a relatively narrow range of -2 to +2g€cmg€yr-1 since 320g€Ma, during Pangea stability and dispersal. In contrast, the period from 600 to 320g€Ma, nicknamed the zippy tricentenary here, displays twice the trench motion scatter compared to more recent times, reflecting a predominance of short and highly mobile subduction zones. Our model supports an orthoversion evolution from Rodinia to Pangea with Pangea offset approximately 90g eastwards relative to Rodinia - this is the opposite sense of motion compared to a previous orthoversion hypothesis based on paleomagnetic data. In our coupled plate-mantle model a broad network of basal mantle ridges forms between 1000 and 600g€Ma, reflecting widely distributed subduction zones. Between 600 and 500g€Ma a short-lived degree-2 basal mantle structure forms in response to a band of subduction zones confined to low latitudes, generating extensive antipodal lower mantle upwellings centred at the poles. Subsequently, the northern basal structure migrates southward and evolves into a Pacific-centred upwelling, while the southern structure is dissected by subducting slabs, disintegrating into a network of ridges between 500 and 400g€Ma. From 400 to 200g€Ma, a stable Pacific-centred degree-1 convective planform emerges. It lacks an antipodal counterpart due to the closure of the Iapetus and Rheic oceans between Laurussia and Gondwana as well as due to coeval subduction between Baltica and Laurentia and around Siberia, populating the mantle with slabs until 320g€Ma when Pangea is assembled. A basal degree-2 structure forms subsequent to Pangea breakup, after the influence of previously subducted slabs in the African hemisphere on the lowermost mantle structure has faded away. This succession of mantle states is distinct from previously proposed mantle convection models. We show that the history of plume-related volcanism is consistent with deep plumes associated with evolving basal mantle structures. This Solid Earth Evolution Model for the last 1000 million years (SEEM1000) forms the foundation for a multitude of spatio-temporal data analysis approaches