Hardly anyone wants to endorse means-testing but almost everyone is for it. Of course Medicaid, food stamps, HUD housing assistance, and many other programs are already means-tested.
Furthermore most people want to extend the scope of the principle.
A few days ago Greg Mankiw described means testing (negatively) as "an income tax surcharge on old, sick people." But last year Greg seemed to endorse a proposal for means-tested subsidies for the purchase of health insurance, involving a corresponding limitation on the tax break for the relatively wealthy.
Paul Krugman writes:
If we’re serious about controlling Medicare costs, Peter Orszag and his staff at CBO have had a lot to say about this. Means-testing isn’t the answer; setting priorities for care is.
Of course the big health care priorities — most of all in Krugman’s eyes — involve greater access for poor people. The prioritization process, if it is to save money, will in some way discriminate against higher-income users, even if the changes are not labeled as such. The people with "too many doctor visits" or "too much wasteful use of capital equipment" are not in general the poor.
The real question is means-testing at which margin and in which manner. In the meantime, beware of arguments which insist that means-testing is good or bad per se.
Since you like to refer often to Krugman, you may want to comment on this story
http://online.wsj.com/article/SB121677050160675397.html?mod=opinion_main_commentaries
The reader can decide whether or not Mankiw’s characterization is “negative”. That partial derivatives commute is a fact; if you think you like an idea characterized one way and dislike it in mathematically identical terms, your set of preferences is inconsistent, and it’s worth resolving the inconsistency.
BTW though, when you talk about means testing, especially the retired, it is really about net-worth, which becomes more problematic. I’m not sure I’m ready for any intrusive measures of NW for means testing. [some hiccups in posting, retry]
Shneezy, what do you think my reaction as a moderate is to you going off on “liberals?”
(If you’ve got a comic book in your head you’re less well set up to grapple with real problems.)
odograph: “It is very easy to say that no one with double the median US income should receive any form of “assistance” whatsoever.”
It is also very easy to say that those who contributed 5 or 10 times the national average to medicare and medicaid funding should be entitled to get something back.
“From each according to his ability, to each according to his need” is a proven failure.
It is also very easy to say that the majority voting themselves the right to the wealth of the minority is a very clear assault on personal liberty. But those who promote the Marxist philosophies don’t give a damn about liberty, do they?
I think you just split the goal. Are Med* about getting medical care to people who need it, or are they also savings plans for the high end earners?
When you say “get something back” it sounds like you want the savings plan aspect.
odograph: “Are Med* about getting medical care to people who need it, or are they also savings plans for the high end earners?”
The Medicare program as voted on by our representatives has been prepaid medical insurance for everyone who contributed. That was the promise made for all those years in which we gave up our wealth. It is you, and those who favor Marxist philosophies, who would change it to welfare.
Right now, today, I have a claim to some fraction of the Medicare funds which will be collected after I’m 65. You would invalidate that claim – a portion of my wealth – because you feel the program should be “From each according to his ability, to each according to his need”
If Medicare cannot fund medical care for all retirees, then everyone in the program should suffer the same loss. It should not be some sufferring 100% loss and others sufferring 0% loss.
But honoring promises has never been a Marxist principle, has it?
John, I think the big double-take I give your Med* comments is that you favor bigger programs, with more cash, and more contributions from high wage earners.
If the goal is to help those who cannot afford it, we drop that pox on the budget: aid to the middle class.
If we stopped giving aid to the un-needy, how much of your “5 or 10 times the national average” do you think would fall away?
It’s perverse (but funny in a laugh at the talking point way) that you call “marxist” while asking for bigger government and bigger programs.
Oh, a tidbit on education and means testing … 99.999% of all “kids” are poor. Their parents may or may not be rich, but we don’t really know their commitment to education. I’m sure we all know median+ families who pay for kids college, and others who say “I did it myself, so can you.”
odograph,
I’ve not asked even once in my life for bigger government and bigger programs.
Had I been a voter when Medicare was started, I would have voted against it. But now that I’ve been paying Medicare taxes for 40 years, I expect this nation to live up to its promise to me. I did ask – on a number of occasions – that my representatives not increase Medicare programs.
Means testing is an idiotic thing to spring on folks approaching retirement. Socialists in this nation have prevented the formation of health insurance for seniors, so that almost nothing exists outside of medicare. Those who have “uninsurable” diseases, such as diabetes, have no options right now other than Medicare or self-insurance. Some of those “uninsurable” diseases can be so expensive to treat that self-insurance is just not feasible, even for millionaires.
I don’t really care what you find to be perverse or what you decide is a “pox on the budget”. I expect this nation to live up to the promises it made to its citizens.
The issue w/means testing is not good or bad. We already have means-testing. Medicare is partly financed with income tax and partly with uncapped payroll tax. The issue is more, less, or the same level of means-testing. I’m for more, via the income tax.
How about replacing health insurance with low interest loans with deferment options for periods of incapacitation.
Wouldn’t it be “an income tax surcharge on old, sick rich people.”?
With the original perspective any co-pay is a surcharge on sick people and on average any health cost will tend to be a surcharge on old people.
Given the choice between paying for universal health care and health care for those who can’t afford even basic coverage (and no other choice), I would go for the latter choice. The only difference between universal health care and universal Medicare is the latter makes you wait until you are old and most in need of coverage: hence not much difference.
To be fair I don’t think much of this was straight-up democratic voting. IMO a lot grew out of the two-party congressional dynamic.
To many patch-ups an not enough architecture.
There is means testing and means testing. Those suggesting it have a duty to define what them mean by it. Means testing by the income tax can be reasonable; it is the basis of taxation after all. Means testing which confuses income and wealth is generally not.
I’m with you. There is no reason we should repeat the mistakes of the past just because we are going to be the ones to pay for them. Medicare and Social Security are dumb programs, but we probably can’t totally pull the rug out from under people who are counting on them. We can make sure that we don’t put our children in the same position our parents and grandparents put us.
Peter,
It’s not just an “attitude of entitlement”. It’s a matter of staying alive. For those over 65 – especially those with uninsurable diseases such as diabetes – there is no alternative to Medicare. Because this evil program was set up two generations ago – and expanded over the past 40 years – there is no private insurance alternative for those seniors who lost in the health lottery.
For means-testing to solve the shortfall, it will require not just billionaires but probably 1/3 the retiree population to be shoved off the Medicare rolls. Millions of those retirees will have no alternative other than self-insurance. Self-insurance cannot work for anyone with a net worth below $5 million. Without medicare, the risk of running out of money is very real even for those of us who have accumulated a million or two.
Boomers are not going to end Medicare. You guys are dreaming if you think that will happen. There’s just too many of us and not enough of you to end the program.
Come up with an alternative to Medicare, and return to retirees what they have put in to this system, and Boomers may pay attention to your talk. Start playing the wealth vs poor game – rewarding those who screwed off for 40 years by penalizing those who worked hard and saved – and you’re just going to create the worst sort of class warfare.
Not a difficult issue for me.
Should Warren Buffet get Medicare coverage when he retires? Bill Gates? Derek Jeter? Jack Nicholson? I would mention politicians, but they’ve left nothing to chance with the sweetheart deal they’ve given themselves.
floccina: “you did not contribute to Medicare of your own volition, you did not even vote for it, it was taken from you therefore IMO you do not have a claim on others contributions”
You and I almost always agree, floccina. But not on this issue.
In the first place, only our elected representatives voted on medicare, and they did represent all Americans – not just those of voting age. Those 1960′s elected representatives imposed an obligation on not just the workers of the 1960′s but on all future income earners on American soil. Until such time as the terms of that obligation are changed, I do have a claim on future contributions. As I said earlier, younger generations do not have the voting power to eliminate either Medicare or Social Security. Together with older but poorer retirees, they may have the voting power to change the terms and invalidate the claim I, as an upper middle class person, have on future Medicare funds. But if we start down that slippery slope of taking more from the top half to pay more to the bottom half, we will end up with a class warfare disaster.
Your generation – I’m assuming we are different ages – can rant all you wish about the unfairness of intergenerational Social Security and Medicare taxes. I did when I was younger. I know now that there is no solution.
It’s interesting that nobody has asked WHY “means testing” is not politic to endorse.
The phrase (and practice) is perfectly accepted in other anglospheric countries (eg. Australia). So why is the USA more in favour of middle and upperclass wealthfare?
There was an old folk song, was it Peter Paul & Mary? Something like “All my troubles, long time going.” It had the lines
“If life was a thing that money could buyyyyy…
The rich would live, and the poor would diiieeeeeee”
And that’s what we’re talking about. People don’t want to die for not being rich.
So OK, rich people do live longer. It’s probably due more to eating better (except the ones who choose to eat expensive stuff that isn’t good for them) and generally getting taken care of. (A few days after a cold snap death rates go up for old people. They go out in the cold without good enough coats etc, and get too cold, and don’t recover properly. Any bets whether wealthy or less wealthy people do that more?)
Likely not so much of it is medical care. There are a few expensive things that probably make a big difference, sometimes. People who eat the wrong things wind up with blood-vessel sludge that can be removed from blood vessels that supply the heart. (Maybe there’s some other reason that happens.) People who eat the wrong things join the diabetes epidemic, and may benefit from expensive help. (Again, other reasons may apply.) Occasionally people who have cancer get remissions, and this might possibly be attributed to the unpleasant medical treatments they receive.
I don’t have good numbers on it, and I predict that if such numbers can be found they will show that rich people live longer than poor people mostly because they have less unpleasant lives generally, and not because their medical care keeps them alive longer.
If we had good statistics about this sort of thing, I believe a lot of the anxiety about paying for medical care would dissipate.
So we should make the data available, maybe sanitized to make it hard to figure out individual people’s medical records. And we could do things like — temporarily, for things that look lethal, offer to pay the patient the difference between what the treatment would cost and what hospice care would cost, if he chooses not to accept treatment. More poor people would accept that than otherwise, but we’d at least start to get some sort of baseline to show the effects of current best practice.
So, get a single-payer system and display the records. And allow whatever private practices people want to pay for, and display the records on those too. As it gets more obvious that most of it doesn’t actually make much difference, people will calm down.
So for example, after a woman has been diagnosed with breast cancer and had the tumor removed, and it hasn’t obviously moved into her lymph nodes, she has about 11% chance the cancer will recur in the same breast. MDs recommended radiation treatment to reduce that chance essentially to zero, at the expense of severe damage to the breast. She has about 8% chance to get cancer in the other breast, for which they did not recommend radiation treatment. I think if people looked at the details, they would decide this did not quite make sense.
The more of our health care system people understood in detail, the less they would choose to use it. Health costs would go down.
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