In response to that question and assertions by Kevin Drum, at Bloomberg View Megan McArdle answers it in the negative:

I agree that higher subsidies and a stronger mandate would have made Obamacare less of a policy train wreck; we probably wouldn’t be so worried about a death spiral if they had passed. On the other hand, it would have made the program much more of a fiscal train wreck. Kevin suggests that they should have just raised taxes on the rich, but for reference, the total repeal of the Bush tax cuts was projected to raise only about two-thirds of the amount needed. And since they were projected to expire, that was not a source of revenue that Democrats could use to fund Obamacare.

Funding this extra entitlement by tapping the rich would have been, to put it mildly, unpopular with an important part of the Democratic base: urban professionals. They would have, in the course of a few years, seen about 10 percent of their gross income, and a considerably larger fraction of their take-home pay, vanish. Nor would they be excited when politicians came back to them for even more money to pay for little incidentals like our growing entitlement gap.

Nor, as Kevin suggests, could Democrats have simply hand-waved the cost away. Bills have to be scored by the Congressional Budget Office. The Congressional Budget Office would not have scored heartfelt paeans to the economic benefits of broader health coverage (and to the extent that they would have, most of those benefits were already in the score the bill got.) If Democrats had tried to pass a bill that cost $2 trillion over 10 years, the Congressional Budget Office would have scored it as such, and that is the cost that the media would have reported. This — not a tragic surfeit of honesty — is why Democrats didn’t take the-time-honored approach of telling wild lies about what their plans would cost.

The Affordable Care Act is built on certain principles: guaranteed issue (everybody should be able to get insurance) and community rating (people living in the same area and in the same age cohort should pay the same premiums). Either one of those principles can exist within the insurance framework but together they can’t. For a program to be insurance, premiums must be proportional to risk.

Kevin’s strategy rests on some assumptions: that a plan of any cost can be financed by taxing “the rich” and that there is no limit to the political acceptability of such a plan. In her article Megan calls the latter assumption into question.

But there’s another problem. With healthcare costs rising at a multiple of the increase in other costs and, importantly, at a multiple of the increase in incomes, it wouldn’t be a case of increasing taxes once and forget it. It would be increasing taxes again and again and again to finance a hungry healthcare system which I characterized in my last post as “writing providers a blank check”. Can you envision politicians doing that? Me, neither.

If J. D. LeDell’s prediction at The Moderate Voice is correct, the incoming Congress may not need to repeal the Affordable Care Act. It may have become inoperative long before then:

In the meantime, if Republicans vote to repeal Obamacare(either right away or at some future effective date) without a replacement ready to implement, Obamacare as we know it will cease to exist no later than January 1, 2017 as every insurance carrier will flee the market.

I think he may mean January 1, 2018 but either way is not particularly good news for the program. Mr. LeDell’s expressed preference is for the federal government to underwrite the entire healthcare insurance market, in full or part.

His diagnosis of the problem, essentially, is that the constraints of the ACA make it impossible for private insurers to make a profit:

What should be done to cure Obamacare’s ills? Quite simply make rates reflect expected health care costs by age. Obamacare mandates that the difference in rates between a 63 year old can be no more than 3 times the rate for a young healthy 20 year old. In actuality, the 63 year old rates should be 10 times that rate for the 20 year old. In fact one of Obamacare’s biggest problems is that a 20 year old can find costs in the regular individual market that are half of Obamacare’s rates while the 63 year old will never ever find a rate as good as he can under Obamacare. Unfortunately, the designers of Obamacare took too much of what makes borrowed community rating practices from HMO’s and modified them without understanding the fundamental differences of the two. You can be sure that the 13 million people covered by non-Obamacare individual health policies are young and healthy since their rates are lower than Obamacare.

which is another way of saying that the ACA requires that healthcare insurance not be insurance. For a plan to be insurance premiums must be proportional to risk.

Once you’ve rejected the idea of healthcare insurance as insurance, keeping the system financially viable is a real challenge. Whether underwritten by the federal government or not, the system must be financially viable. Either we must be prepared to write providers a blank check, costs must be reduced, or rationing imposed. There really is no other alternative.

Debbie Reynolds has died, just a day after the death of her daughter, Carrie Fisher. Variety reports:

Debbie Reynolds, the Oscar-nominated singer-actress who was the mother of late actress Carrie Fisher, has died at Cedars-Sinai hospital. She was 84.

“She wanted to be with Carrie,” her son Todd Fisher told Variety.

She was taken to the hospital from Carrie Fisher’s Beverly Hills house Wednesday after suffering a stroke, the day after her daughter Carrie Fisher died.

The vivacious blonde, who had a close but sometimes tempestuous relationship with her daughter, was one of MGM’s principal stars of the 1950s and ’60s in such films as the 1952 classic “Singin’ in the Rain” and 1964’s “The Unsinkable Molly Brown,” for which she received an Oscar nomination as best actress.

The death of a child can be a terrible strain for a parent, I’m told.

Ms. Reynolds brought an enormous, youthful energy to all her roles. She was one of the younger representatives of the post-war cohort of studio contract players that included stars like Marlon Brando, Marilyn Monroe, Tony Curtis, and Janet Leigh.

I recognize that you can’t include every aspect of a story in every article about the story. But some stories leave so much out that, like a fan dancer’s fan, they appear to be intended to reveal but are actually intended to conceal.

That’s how I felt about this story at RealClearHealth:

The cost of keeping American kids physically and mentally healthy increased 56 percent between 1996 and 2013, a new study finds.

Health care expenditures jumped from nearly $150 billion in 1996 to more than $233 billion in 2013 for those 19 and younger, researchers found.

Here’s what’s left out: they never define whether they’re talking about real or nominal spending. Without that you can’t tell whether spending is going up, down, or staying the same. $150 billion in 1996 is about $230 billion today which would mean that if they’re talking in terms of nominal dollars spending is unchanged. In per capita terms $1,915 in 1996 dollars is about $2,946 today so per capita spending of $2,777 would mean that per capita spending has actually gone down.

I could determine that by searching out the original study and purchasing it but I shouldn’t have to. That information is basic in good economics reporting.

Since there are as many as 4 million more children 13 and under than there were in 1996 and the total spending is unchanged in real dollars that would mean that per capita spending is actually going down which is supported by the figure reported.

Here are some other things left out of the report:

• Is the difference mostly in private or public spending?
• How has the change in spending affected outcomes?
• What is the difference in procedures performed per patient?
• How does that spending break down by the income quintile of the parents?

There’s a vague statement about outcomes but not nearly enough to draw any conclusions from.

Maybe this should be filed under “Why, oh why isn’t there better healthcare reporting?”

There is one interesting little snippet in the article:

By 2013, nearly $28 billion went to newborns in the hospital. Spending on ADHD reached almost $21 billion. Dental care commanded $18 billion, and asthma reached $9 billion, Dieleman said.

By contrast, spending on childhood ADHD in 1996 was just under $8 billion, Dieleman said.

That’s a sharp increase whether nominal or real and, honestly, it touched a nerve. I wonder how much of that additional spending on ADHD is targeted at making little boys behave like little girls, i.e. sitting still and playing quietly?

Here are some other little factoids, not from the article. In the United States we spend less on children and young adults’ health as a share of total healthcare spending than any other OECD country. And we spend a lot more on elder care.

If you feel the need for a backgrounder on the conflict between the Israelis and Palestinians, brought into the news for the umpteenth time by the Obama Administration’s decision not to veto a United Nations Security Council resolution condemning the Israelis’ settlements in the West Bank, you could do worse than George Friedman’s at RealClearWorld. On the competing claims which he characterizes as “moral arguments”, he writes:

Moral arguments are made, of course. The moral argument for the existence of the state of Israel is that it rectifies an injustice committed by the Romans 2,000 years ago. But 2,000 years is a long time, and the half-life for moral rectification seems past. The claim that the Israelis wanted peaceful coexistence with the Arabs was true, but limited by the fact that they wanted that peace to be on Israeli terms. The claim that this was merely the return of a people to a land where their rights were morally unambiguous strains credibility.

The Arabs’ moral argument is that Israel was made up of European people occupying Arab lands and displacing and oppressing the native population. The problem with this argument is that the history of Islamic expansion was the history of the imposition of its religion and political control on other people. Moreover, the history of the immediate region is one of violence, population displacement and oppression. The state of Jordan was created by the British-supported Hashemite tribe that was forced to leave the west coast of what is now Saudi Arabia and settled there. As for the argument that the creation of settlements in the West Bank is uniquely oppressive, that can only be made by willfully ignoring the slaughter and oppression in the rest of the Arab world.

There are some deficiencies in that account, of course. The modern colonization of Israel by Jews began just about a century earlier while the Ottoman still ruled Palestine. European, African, and Asian Jews began coming to Palestine to live in land that had been purchased from its owner, the state, much of it with money from the Rothschilds.

There is no really good accounting of the countries of origin of the present Jews of the land of Israel but they appear to descend in roughly equal thirds from Jews of Europe, Jews of Africa and Asia, and descendants of Jews who’ve lived there for a couple of millennia.

Similarly, there is no good accounting of the origins of the non-Jewish people of Palestine. Some are Arabs, some are Egyptians, some are from other places.

Genetic studies have found that the people who most closely resemble the ancient people of Palestine are the Maronites of Lebanon. In other words, neither side has a really good historic claim and what good is a historic claim anyway?

Here’s his account of present Israeli and Palestinian nationalism:

Israel is a settler nation, as are the United States and New Zealand. It settled in a stretch of the eastern Mediterranean coast that Israelis had some historic connection to. Part of it was a response to the rise of nationalism in Europe. If every European cultural entity had a moral claim to a state, so should the Jews. The theoretical position turned into a practical one in World War II. They had thought they were simply Europeans with a different religion and discovered that wasn’t true. The theoretical argument for nationhood and statehood surged. The Jews were a nation. They needed a land on which to build a state. They migrated, partially displaced a population and created a state.

Palestinian nationalism had the same origin in European nationalism. Palestinians had two identities. One was Muslim. The other was Arab. But until the fall of the Ottomans, they were subjects of the Turks. When the Ottomans fell and the Jews began to arrive, so did the idea that they were a distinct people requiring an independent state. Their claims against the Jews were at first ambiguous and based primarily on Muslim or Arab identity. Over time, as with the Jews, the objection to Israel and the basis of their claims against Israel were refined into the idea of nationhood and statehood. They had a land, and they needed to be a nation and build a state. To understand the region, therefore, a historical, not a moral, perspective is needed.

Here’s his account of the situation on the ground now:

There are now two realities. The first is that the Palestinians are weak. No great power or Arab state has an overriding interest in the creation of a Palestinian state. The Russians are indifferent and the Arabs are concerned about the radicalism of such a state. The Palestinians are also divided, split into the relatively secular West Bank and religious Gaza – the Palestinian National Authority and Hamas. Without unity among the Palestinians, no one can sign an agreement authoritatively or coordinate resistance to the Israelis.

The second reality is that it is impossible to create two states. The Israelis cannot give up the Jordan River line since it is their main defensive position. Nor can they accept a westward shift of the border toward the 1948 lines, as it would make the Israeli heartland (the Tel Aviv-Haifa-Jerusalem triangle) vulnerable to the kinds of rockets fired from Gaza.

The Palestinians can’t accept a state divided between Gaza and the West Bank, without any transport under their control. Nor can they accept Israeli control of the Jordan River line, as that would mean that they remain isolated except for Israel permitting movement – and would mean the Israeli army moving through Palestinian territory. Finally, such a geography would be economic insanity. Palestine would remain dependent on Israel, with its population employed in menial jobs in Israel, passing through Israeli checkpoints.

In other words it’s an intractable mess with no fair, foreseeable solution. As long as the Israelis continue forcible resistance, they can hold the land. As long as the Palestinians continue forcible resistance, mayhem continues.

I understand the Israelis’ position. I understand the Palestinians’ position. The one thing I don’t understand is why it’s our problem to solve.

At National Journal Charlie Cook suggests that the reason that Hillary Clinton lost the election was less because of bigotry, James Comey, or Russian hacking than because she believed her data analysts:

The re­li­ance, or per­haps over­re­li­ance on ana­lyt­ics, may be one of the factors con­trib­ut­ing to Clin­ton’s sur­prise de­feat. The Clin­ton team was so con­fid­ent in its ana­lyt­ic­al mod­els that it op­ted not to con­duct track­ing polls in a num­ber of states dur­ing the last month of the cam­paign. As a con­sequence, de­teri­or­at­ing sup­port in states such as Michigan and Wis­con­sin fell be­low the radar screen, slip­page that that tra­di­tion­al track­ing polls would have cer­tainly caught.

Ac­cord­ing to Kantar Me­dia/CMAG data, the Clin­ton cam­paign did not go on the air with tele­vi­sion ads in Wis­con­sin un­til the weeks of Oct. 25 and Nov. 1, spend­ing in the end just $2.6 mil­lion. Su­per PACs back­ing Clin­ton didn’t air ads in Wis­con­sin un­til the last week of the cam­paign. In Michigan, aside from a tiny $16,000 buy by the cam­paign and a party com­mit­tee the week of Oct. 25, the Clin­ton cam­paign and its al­lied groups didn’t con­duct a con­cer­ted ad­vert­ising ef­fort un­til a week be­fore the elec­tion.

In fact, the Clin­ton cam­paign spent more money on tele­vi­sion ad­vert­ising in Ari­zona, Geor­gia, and the Omaha, Neb­raska mar­kets than in Michigan and Wis­con­sin com­bined. It was Michigan and Wis­con­sin, along with Pennsylvania (the Clin­ton cam­paign and al­lied groups did spend $42 mil­lion on tele­vi­sion in the Key­stone State), that ef­fect­ively cost Demo­crats the pres­id­ency.

That, along with the observations Mr. Cook makes in the article about the irrelevance of polling, provides at least a little support for the point I’ve been making around here for some time. Election consultants really don’t have as much to offer as they used to. If they ever did.

Carrie Fisher has died:

Carrie Fisher died Tuesday morning … days after suffering a massive heart attack on board a flight from London to LAX … a family spokesperson has confirmed.
TMZ broke the story … Fisher was on a flight from London to LAX Friday when she suffered the heart attack 15 minutes before landing. People on the plane tell TMZ she appeared lifeless.
A passenger who’s an EMT performed CPR on Carrie and once the flight landed, paramedics rushed her to UCLA Medical Center where she remained in intensive care until her death.

I predict that Disney will cut a deal with her estate for a digital version of her to appear in upcoming movies in the Star Wars franchise, much as a digital version of Peter Cushing appeared in Rogue One.

It being the end of the year and the Obama presidency is drawing to a close, there are all sorts of retrospectives being performed. Many of them are retrospectives of President Obama’s foreign policy.

Since there doesn’t seem to be any consensus on what that foreign policy accomplished, what President Obama wanted to accomplish, or what he should have wanted to accomplish, I think that most of these retrospectives are in vain or, at the very least, incomplete.

How should President Obama’s foreign policy be judged and using that yardstick how is it to be evaluated?

I think there’s one thing on which all of us should agree. If the yardstick is “don’t do stupid sh*t”, his foreign policy was a failure and in all likelihood all past presidents’ have been and any future president’s foreign policy will be. They each do their own stupid sh*t.

We might be more charitable towards presidents if we took that into account.

Hidden in Jason Fodeman’s post at RealClearHealth on reforming the healthcare system is the too unappreciated key:

In repealing and replacing the ACA, the Trump administration should work to create a simpler government physician reimbursement system that better aligns scarce resources with demand.

Compensation is key. Very little can be accomplished in reforming healthcare without addressing the who, how much, and when of compensation.

The balance of the article is full of misconceptions. For example, in the providing of healthcare services the patient is not the buyer and frequently the physician or other service provider is not the seller. Since neither the buyer nor the seller have any commitment to cost control, there is no cost control. Since the interests of the patient, the provider, the buyer, and the seller are improperly aligned, nobody’s objectives are accomplished in a satisfactory manner.

Some day we will realize that the fee for services model is unworkable by anybody anywhere. Until then healthcare reform will remain beyond our reach.