How to slow the growth of health care costs.

Thanks to Susan Voss for her thoughtful essay about the complexities of our health care system, and how difficult it is to reduce costs. (See link to Register essay below.)   I don’t claim to have “the answer”, but I do suggest that the following cost saving ideas be given serious consideration.

  • Medicare, Medicaid and private insurance should not be required to cover every new drug, product, or procedure that is approved by the FDA. Some are very high cost but provide only marginal improvement over alternatives that cost much less.  Also, at least some covered products and procedures would likely be considered not medically necessary by most people.
  • Consider shortening the amount of time that government grants a monopoly for patents.  Patents are not natural property: humans have copied one another since the beginning of time.  Our U.S. Constitution allows patents to be granted to encourage inventiveness, but there is no objective reason why a patent must be granted for 20 years. Why won’t five or ten years work?  Maybe the length of the patent should be based on the cost to develop the patented item and whether or not government funds were used to help develop the item.
  • Don’t require limits on out-of-pocket payments such as co-payments, especially for very high cost items.  A person should have “skin-in-the-game” if they expect their insurance to cover very high cost items.  Today, we see the opposite: drug companies offer to help pay people’s out-of-pocket costs so there won’t be so much political pressure on them to lower their prices.
  • Allow both pharmacies and individuals to purchase drugs from sellers in other countries that are “deemed” to have sufficient safety procedures in place.  If drug companies are free to charge lower prices in other countries, then pharmacies and individuals should be free to purchase the drugs from those other countries.
  • Allow Medicare and Medicaid to negotiate with drug companies on prices they pay for the drugs that are covered by the programs.  Right along with that, Medicare and Medicaid should be allowed to develop formularies (lists of drugs that are preferred over other therapeutically similar drugs), that give beneficiaries a financial incentive to use the preferred drugs and a penalty for using higher cost drugs.

Our health care wants are unlimited.  Our ability to pay is not.  We, as citizens, should not expect private insurance or our government health care programs to cover everything, regardless of cost.  We should expect our government to NOT do things that increase costs, or reduce our choices.

Link to Register essay:  https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2018/09/19/dont-fooled-when-someone-claims-have-answer-soaring-health-care-costs/1355890002/

 

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Is getting rid of a special interest loophole the same as raising taxes? When general tax rates are being reduced?

The title to an essay by  A.J. Spiker’s recently published in the Des Moines Register was, “Republicans must ignore pleas to raise our taxes”. (11/262017 – see link below.)  The essay advocated for not raising tax rates on carried interest income – bonuses earned by hedge fund managers and real estate development managers. He urged our Senators to make sure the tax bill did not get rid of the special low capital gains tax rate for carried interest.  Regular people who earn the same type of bonuses pay taxes at ordinary Earned Income tax rates.  For years, carried interest has been tax at this lower special rate and those who benefit from it simply don’t want to lose it.  (The same seems to be true for people in every special interest group that gets politically favored tax breaks.  The ask our elected representatives to get rid of all the special tax breaks… except for mine…  which is vitally important to job creation!)

I thought that a stated goal for tax reform is to simplify our 70,000+ page the tax code.  In large part, this means getting rid of the many many special interest tax breaks, and then lowering the tax rates for all.  If certain individuals lose their precious special interest tax breaks and actually have to pay more in taxes, so be it.  They should feel lucky for what they got in the past.  This is part of “draining the swam” that our President has called for.  I urge our elected federal representatives to resist the tremendous pressure that they are under from those who received the tax breaks and their lobbyists, and proceed to get rid of the carried interest and many other special interest tax breaks, and lower general tax rates for all.

Link: https://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2017/11/24/gop-must-ignore-pleas-raise-taxes-carried-interest-capital-gains/887643001/

Trump’s proposed tax rate for “pass-through” businesses is unfair

President Trump has proposed a maximum 25% tax rate on income that individuals receive from “pass through entities”.  Pass through entities are businesses that don’t pay corporate income taxes, but rather pass their net income each year through to the owners to be taxed as part of the owners’ individual tax return.  These pass through entities include S-Corporations, partnerships, limited liability companies (LLCs), and sole proprietorships.  Currently, income from pass through entities is taxed at the same rate as any other ordinary income – up to a maximum rate of 39.5%.  (President Trump’s proposal for ordinary income for most taxpayers is a maximum tax rate of 35%.)  He justifies the lower tax rate for pass through entities because, he says, these pass through businesses are the job creators.

This begs at least two questions:  Do pass through entities really create more jobs than non-pass through entities?  Even if so, why should the income of an employer be taxed at a lower rate than an employee if they earn the same amount?  Tax fairness would dictate that two people with the same income would pay the same amount of tax, regardless of source.

Regarding job creation, it is important to know that pass through entities are not just manufacturers, wholesalers or retailers, who may or may not be job creators.  They are also professionals such as doctors, lawyers, accountants. Most hedge funds and private equity funds are pass through entities.  About 95% of all businesses are pass through entities.  Of those, about 99% have revenues of less than $10 million.  The 1% of pass through entities with revenues of more than $10 million earn about 83% of all profits!  So, some pass through entities are very large, and many owners of pass through entities have very high incomes.  Is it fair for business owners to pay at a 25% rate while regular workers with the same income pay at a 35% rate?  I don’t think so.

I expect to write several blog posts on President Trump’s tax proposal.  The idea of reducing tax rates is a good one – especially if the total plan is revenue neutral and doesn’t increase our $20 Trillion debt.  This means that tax reform that reduces rates must also reduce special tax breaks for politically favored groups and/or reduce spending.  I hope that Congress, which controls all tax legislation, will not “bet on the come” – that is assume future tax revenue will increase due to future growth in the economy.  Our government uses a 10 year look forward to determine the deficit/surplus effect of any change in taxing or spending.  In recent decades, it seems that all tax and spending changes have significant costs up front with the promise of savings toward the end the the 10 year period.  Let’s not keep doing that.

Source: https://www.brookings.edu/research/9-facts-about-pass-through-businesses/

Wellmark right to disclose cost of anonymous patient

The Des Moines Register recently reported that Wellmark Blue Cross Blue Shield has been accused of violating federal HIPAA privacy regulations in the case of a patient with severe hemophilia.  (See link to Register article below.)  As reported, a representative of Wellmark was discussing the high cost of health insurance at a Rotary Club meeting last March.  She gave an example of an extreme case that was costing $1 million per month.  (ACA – Obamacare – prohibits insurance companies from placing any limit on the amount it will pay for patients.)  She did not identify the patient by name, but described him as a 17 year old male with hemophilia.  Maybe she should not have mentioned the age or sex of the patient, but that information alone did not identify who the specific patient was, and should not be considered a violation of federal privacy regulations.

Wellmark and other insurance companies must be able to cite specific high cost cases that are causing health insurance premiums to rise to unaffordable amounts.  How can we openly debate ways to contain health care costs if we don’t know what is causing the high costs?  Can we really afford to require insurance companies to pay out unlimited amounts for any patient?  I recently heard that the last remaining company to offer individual health insurance policies in Iowa may charge more than $30,000 per year next year for a couple who are 55 years old.  Health care wants are unlimited.  Our ability to pay is not.  We need to debate whether or not government should prohibit health insurance policies from having limits on how much they pay out for individual patients.

Link to Register article: http://www.desmoinesregister.com/story/news/health/2017/08/21/wellmark-accused-violating-privacy-iowa-teen-severe-hemophilia-reportedly-costing-1-million-month/586702001/

 

 

Transgendered okay in the military, but sex change surgery should not be paid for by taxpayers.

A transgendered person should be eligible to serve in the military, just like just like every other man or women, and just like every other gay or straight person.  If they are qualified to do the job, then government should not discriminate against them based on their transgendered status.  That does not mean the military or taxpayers should foot the bill for sex change operations.  Just as being transgendered is not a disease, surgery to to change a person’s sex is not a medical necessity.  Transgendered folks will can be completely healthy without a sex change operation.  So, sex change operations should be considered elective, and not be required to be covered by any insurance plan, including that of the military.

Grassley wrong to not hold hearings on Supreme Court Justice nomination.

The announcement by Senator Grassley, (and other Senate Republican leaders), that the Senate Judiciary Committee would not even hold hearings on President Obama’s nominee to the Supreme Court, before a nominee is even announced, sets a bad precedent.  The Senate may have the power to not even consider a nominee, but what is to stop this kind of thing from getting even further out of control?  If a Democrat is elected President this November, and the Republicans maintain control of the Senate, will the Senate withhold its consent for four more years in order, “…to protect the will of the American people…”?  The Senate would have the power to do that too.  And the Democrats would do the same to a Republican President’s nominee just as soon as they got the chance.  The Republicans, and Senator Grassely, should hold the hearings and then vote the nominee up or down.

Corporate tax inversion is not cheating

The Register, today 11/27/2015, called corporations “tax cheats” when they try to avoid taxes by changing their “tax home” to a different country with lower rates.
These companies are not cheating. They are playing by the rules. This is what happens when the U.S. has the highest corporate tax rates in the world. We (the U.S.) don’t only tax U.S. based corporations on income earned in the U.S., we also tax them on income earned outside the U.S. – minus a credit for foreign taxes paid.  (That way, we make sure they pay the full U.S. rate on all income.)
This competition among countries to keep corporate income tax rates low is very much like competition among states to keep individual income taxes low. How many Iowans, who earned their wealth while living in Iowa, now live more than half of the year in Florida, South Dakota, or Texas, etc., because those states have no individual income tax? These people are not cheaters. They are following the laws. Tax competition among both states and countries is a good thing – it helps keep a check against ever increasing taxes and spending by governments.

 

Link to Register article:

http://www.desmoinesregister.com/story/opinion/editorials/2015/11/26/editorial-stop-rewarding-tax-cheats-taxpayer-funded-services/76341606/