Wednesday, September 30, 2009

Wall Street Needs More Skin in the Game - Partnerships were one way of aligning the interests of money managers and investors

Wall Street Needs More Skin in the Game. By PETER WEINBERG
Partnerships were one way of aligning the interests of money managers and investors.
WSJ, Oct 01, 2009

The debate about bonuses and Wall Street pay rages on, and for good reason. Compensation is a complex issue that is essential to managing systemic risk. The asymmetrical structure of pay packages—a "heads I win, tails I win less" approach—was wrong. But overly prescriptive government intervention to solve the problem poses its own challenges and might not help us get the incentives right, either. So what can we do?

Prior to 1970, the New York Stock Exchange had a rule prohibiting brokerage firms from being publicly traded companies. There was a genius to this rule. It aligned the interest of the partners of old Wall Street with that of the securities markets themselves. Today, all the large firms are publicly traded. This has given these firms needed permanent capital, but has also served to distort incentives.

We can't snap our fingers and turn public financial institutions back into private partnerships, but we can realign interests by restructuring executive pay.

The only private partnership I can talk about authoritatively is the one in which I was a partner from 1992 to 1999, when the firm went public: Goldman Sachs. Partners there owned the equity of the firm. When elected a partner, you were required to make a cash investment into the firm that was large enough to be material to your net worth. Each partner had a percentage ownership of the earnings every year, but the earnings would remain in the firm. A partner's annual cash compensation amounted only to a small salary and a modest cash return on his or her capital account. A partner was not allowed to withdraw any capital from the firm until retirement, at which time typically 75%-80% of one's net worth was still in the firm. Even then, a retired ("limited") partner could only withdraw his or her capital over a three-year period. Finally, and perhaps most importantly, all partners had personal liability for the exposure of the firm, right down to their homes and cars.

The focus on risk was intense, and wealth creation was more like a career bonus rather than a series of annual bonuses. Other private Wall Street firms had similar pay structures.

Here are two ideas that could help us replicate the discipline instilled by the old pay packages of private partnerships:

First, institute what is called a "10/20/30/40" plan. Under such a plan, junior employees would receive regular competitive pay, but senior employees would be paid as follows: 10% of annual compensation in cash now; 20% of annual compensation in cash later; 30% of annual compensation in stock now (with a required holding period); and 40% of annual compensation in stock later.

"Now" means paid immediately at the end of a compensation period. "Later" means after a period during which a cycle can be evaluated. During that evaluation, the firm's compensation committee would perform a "look back" in which it can adjust the award or leave it at a predetermined level. This function should not be used to micromanage past bonuses but simply to make sure success in a specific year was still viewed to be success in hindsight.

Second, create a "Skin in the Game" plan. When an executive or a senior employee manages a trading or asset-management business which can be measured by its own profit and loss statement, those executives or employees should invest a significant amount of their own capital in that business or fund. The compensation committee of the company's board would determine who qualifies for this plan and the definition of a material commitment.

What would these two plans achieve? The first would back-end wealth creation to ensure that through-the-cycle compensation was linked to through-the-cycle value creation. The second would increase stock ownership and personal financial commitment to better align the pocketbooks of Wall Street with the pocketbooks of financial markets and our economy.

Beyond more prudent capital requirements, regulators and politicians likely won't gain much if they are too prescriptive. Writing new rules could spark a cat-and-mouse game that would not benefit anyone. If the private sector can align its incentives and risk management with the interests of the global marketplace, we will all be pulling in the same direction. That has worked before.

Mr. Weinberg is a founding partner of Perella Weinberg Partners, an advisory and asset-management firm based in New York and London.

How the U.S. Government Rations Health Care

How the U.S. Government Rations Health Care. By SCOTT GOTTLIEB
The agency that would likely run the 'public option' was slow to pay for implantable cardiac defibrillators.
WSJ, Oct 01, 2009

President Barack Obama deflects criticism that his health-care plan will bring on government rationing of medical care by arguing that insurance companies ration care. Everyone knows private payers limit access to some health care. But government does it in far more byzantine and arbitrary ways.

Consider the $450 billion Medicare program. It provides a model for—indeed its bureaucracy could well end up running—the "public option" health plan that Mr. Obama wants to offer all Americans under the age of 65. In recent years, Medicare's staff has been aggressively restricting coverage for costly treatments. Looking for ways to control spending on medical products—and preserve the illusory "trust fund" that pays Medicare claims—is what shapes the culture of the organization and motivates the agency's staff.

This often means limiting access to the costliest technologies. To do this Medicare relies on its rationing and pricing systems. National coverage decisions (NCDs) are assessments issued by Medicare's medical staff that define who is eligible for new but often expensive treatments. Medicare then assigns medical products and procedures with "codes" that determine which regulated category they fall into. Finally, price "schedules" are developed by Medicare's staff each year to assign each unique code with its own updated payment rate. The process for getting a favorable code on a new product is a source of intense lobbying. It can make or break a technology.

For a remote agency like Medicare, far removed from clinical practice, it's easier to try and manage the use of a high-cost but specialty treatment than a much lower-cost but very widely used product. Yet cheaper, more commonly used products can still be mispriced and account for more total cost to the agency. For example, low-tech orthotic devices and other "durable medical equipment" are a known source of wasteful spending. These medical products often evade Medicare's attention in favor of less used but more expensive items such as a biological cancer drug.

Take the agency's tortured decisions concerning the use of implantable defibrillators that jump-start stopped hearts during cardiac arrest. Medicare sharply restricted their use in the 1990s. Mounting research proved that the $30,000 devices could be saving many more lives. So in 2003 Medicare adopted a novel theory to expand coverage to some, but not everyone, who needed one. The agency said only patients with certain measures on their electrocardiograms (called "wide QRS") seemed to benefit.

It was an easily measurable but ultimately imprecise way to allocate the devices. After another major study firmly refuted the QRS theory, Medicare expanded coverage again in 2005, potentially saving 2,500 additional lives according to a press release issued with that decision.
That experience wasn't unique. From 1999 to 2007, Medicare denied access in a third of the treatments it evaluated through its coverage process, taking an average of eight months to complete its reviews. When coverage was granted, in 85% of cases the treatments were restricted, usually to patients with more advanced illnesses.

Medicare is lately increasing its use of the national coverage process and is becoming more tightfisted. Since 2008, according to my review of Medicare data, it conditioned access in 29% of its reviews and denied new or expanded coverage in fully 53% of cases.

Medicare's methods can also be arbitrary. Take the travails of the pharmaceutical company Sepracor and its drug Xopenex, an innovative respiratory medicine that competes with the chemically distinct and much cheaper generic albuterol. Both are inhaled aerosols used to treat asthma and chronic obstructive pulmonary disease. Xopenex has the same benefits as albuterol, but some believe fewer of its cardiac side effects. Medicare didn't agree.

The agency tried to make a "national coverage decision" on Xopenex but couldn't come up with a clinical justification to limit the drug's usage. So Medicare manipulated its payment process, saying it would pay Xopenex a price equivalent to the "least costly alternative" form of generic albuterol, 10 cents a treatment compared to about $2.50 for Xopenex. Then Medicare was sued by a patient, and a Federal court recently ruled the agency exceeded its authority.

Medicare finally succeeded in reigning in the use of Xopenex with its coding system. By issuing Xopenex the same classification as generic albuterol, it was able to pay both products the same "blended" price—an average of the cost of each individual drug. That lowered the price on Xopenex, but ironically increased what Medicare paid for the generics.

It's not a stretch to say that Medicare spent hundreds of cumulative man-hours focusing on Xopenex while other priorities languished. The question is why? There weren't safety concerns. Xopenex may have been used in lieu of a cheaper alternative, but at peak Medicare sales of about $300 million it represented far less than one one-thousandth of the agency's budget. Simply put, a few staffers inside Medicare were consumed with the drug and its higher price—revealing a process that is capricious and often disconnected from science.

Worse still is how impenetrable these programs have become. Drug and device companies spend millions of dollars trying to influence Medicare decisions. The hundreds of consultants they hire to advise them typically command $20,000-a-month retainers.

Formal patient and provider appeals to Medicare took an average of 21 months, according to a report issued in 2003 by the Government Accountability Office (using 2001 data), with delays in "administrative processing" due to "inefficiencies and incompatibility" of data systems eating up 70% of the time spent processing appeals.

There's nothing inherently wrong with a program like Medicare seeking value for taxpayers. But it shouldn't make up the rules as it goes. When private plans ration care, patients can appeal directly to an insurer's medical staff. Only a small fraction of Medicare's denied claims—about 5%—are ever formally appealed because its process is so impenetrable. People can also switch insurers, and in many cases patients chose a policy because it matched their preferences in the first place. These options don't exist in a government health program.

Dr. Gottlieb is a resident fellow at the American Enterprise Institute and a former senior official at the Centers for Medicare and Medicaid Services. He is partner to a firm that invests in health-care companies, and he advises health plans.

Biologics: Diverse and Dramatic Advances

Biologics: Diverse and Dramatic Advances, September 3, 2009

Research in biologics offers huge promise to patients. As scientists learn more of the molecular underpinnings of disease, our ability to treat diseases with biologics in new and innovative ways rapidly grows. A recent article in the Journal of the American Medical Association stated that biologics “represent an important and growing part of the therapeutic arsenal.”[i]

Biologics are medicines made from living material (plant, animal or microorganism) and may be derived from natural sources or engineered in a laboratory. Because they are structurally so different from most existing treatments and allow for very precise targeting, they have revolutionized treatment for many diseases. In many cases biologics are the first treatment available for a disease or they offer a significantly better way to treat a given disease. And many believe that, with more research, the near future holds many more breakthrough biologics.

Here are just a few examples of biologics that are making an enormous difference for patients:

Bevacizumab (Avastin) represents a completely new approach to attacking cancer tumors by cutting off the blood supply that feeds them. Following three decades of research in this promising area, bevacizumab was approved in 2004 to treat metastatic colorectal cancer. Since then bevacizumab has proved effective against several other forms of cancer.

Approved in 2008 to treat metastatic breast cancer, bevacizumab, in combination with paclitaxel, was shown to double progression-free survival time for women with metastatic breast cancer. The American Society for Clinical Oncology (ASCO) highlighted this a major advance of 2008.[ii]

Another recent study presented at the 2009 American Society for Clinical Oncology annual meeting found that for non-small cell lung cancer patients, bevacizumab combined with chemotherapies can slow cancer growth by up to 25%. According to the study author, "This cancer is very hard to treat. There have been some advances, but we have reached a treatment plateau and we need more agents which may help us to offer better treatment to patients…We were able to confirm that bevacizumab adds efficacy to standard chemotherapy and provides hope for patients suffering from a deadly disease."[iii]

Etanercept (Enbrel), originally approved for treatment of moderate to severe rheumatoid arthritis in 1998,[iv] has since been approved for several other autoimmune diseases, including: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis.[v]

Etanercept has contributed to great strides in treating rheumatoid arthritis. A recent study found that patients treated with combination therapy including etanercept had a 50% chance of complete clinical remission after 52 weeks of treatment, compared with 28% taking an older medicine.[vi] According to an editorial in The Lancet, these results would have been “unthinkable in the 20th century” prior to new disease-modifying biological medicines.[vii]

Trastuzumab (Herceptin) is one of the earliest and most common examples of personalized medicine. About 30% of women have a form of breast cancer that over-expresses a protein called HER2, which is not responsive to standard therapy. Trastuzumab was approved for patients with HER2 positive tumors in 1998 and further research showed in 2005, that it reduced recurrence by 52% in combination with chemotherapy.[viii] A commentary in the New England Journal of Medicine concluded that findings suggested “a dramatic and perhaps permanent perturbation of the natural history of the disease, maybe even a cure.”[ix]

These are just three examples of advances that are already benefiting patients. Based on progress like this, many experts believe that biologics are a key source for potential future advances. According to the Association of American Universities, “Biologics have enormous potential to provide breakthrough medical treatments.”[x] Researchers continue to explore the possibilities of new biologics and the promise for patients is enormous. By fostering such research we can deliver on the potential of biologics for more patients in the coming years.


[i]T.J. Giezen, “Safety-Related Regulatory Actions for Biologicals Approved in the United States and the European Union,” Journal of the American Medical Association, 300 (October 2008): 16, 1887-1896.
[ii]American Society of Clinical Oncology, “Clinical Cancer Advances 2008: Major Research Advances in Cancer Treatment, Prevention and Screening,” Journal of Clinical Oncology, 22 December 2008.
[iii]A. Gardner, “New Treatments for Tough Cancers Show Promise,” 23 March 2007, HealthDay, (Accessed 21 July 2009).
[iv]Food and Drug Administration, Approval Letter, 2 November 1998,, (Accessed 21 July 2009).
[v]Food and Drug Administration, Drugs @ FDA, (Accessed 21 July 2009).
[vi]P. Emery, et. al., “Comparison of Methotrexate Monotherapy with a Combination of Methotrexate and Etanercept in Active, Early, Moderate to Severe Rheumatoid Arthritis (COMET): A Randomized, Double-Blind, Parallel Treatment Trial,” The Lancet, 372 (August 2008): 9636, 375-382.
[vii]J.M. Kremer, “COMET’s Path, and the New Biologicals in Rheumatoid Arthritis,” The Lancet, 372 (August 2008): 9636, 347-348.
[viii]Personalized Medicine Coalition, “The Case for Personalized Medicine,” May 2009, (Accessed 21 July 2009); Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after Adjuvant Chemotherapy in HER2-positive Breast Cancer. New England Journal of Medicine, 353 (20 October 2005):1659-72; Romond EH, Perez EA, Bryant J, et al. Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-positive Breast Cancer. New England Journal of Medicine 2005; 353 (20 October 2005):1673-84.
[ix]G. Hortobagyi, “Trastuzumab in the Treatment of Breast Cancer,” New England Journal of Medicine, 353 (20 October 2005): 16, 1734-1736.
[x]R. M. Berdahl, Association of American Universities, Letter to Representative Anna Eshoo, 20 July 2009.

Libertarian: protectionist policies hurting low-income Americans

Obama's protectionist policies hurting low-income Americans. By Daniel Griswold
Washington Times, Sep 30, 2009

President Obama and the other Group of 20 leaders delivered their obligatory warning against protectionism at last week's summit in Pittsburgh. But at home the U.S. president continues to conduct his own trade war, not only against imports from China and other developing countries, but against the most vulnerable of American consumers.

America's highest remaining trade barriers are aimed at products mostly grown and made by poor people abroad and disproportionately consumed by poor people at home. While industrial goods and luxury products typically enter under low or zero tariffs, the U.S. government imposes duties of 30 percent or more on food and lower-end clothing and shoes - staple goods that loom large in the budgets of poor families.

To win favor with organized labor and other opponents of trade liberalization, Mr. Obama has either defended or actually raised barriers on precisely those products of most interest to poor households.

The tariff the president imposed on Chinese tires earlier this month was heavily biased against low-income American families. The affected tires typically cost $50 to $60 each, as compared with the unaffected tires that sell for $200 each. The result of the tariff will be an increase in lower-end tire prices of 20 percent to 30 percent. Low-income families struggling to keep their cars on the road will be forced to postpone replacing old and worn tires, putting their families at greater risk.

The "cash for clunkers" program the president championed, while not a trade measure, betrays the same indifference to markets that serve the poor. The program forced the disposal of the 700,000 cars and light trucks that were traded in, reducing supply and raising prices of used vehicles for families that cannot afford to buy new. Because of this president's policies, low-income drivers will find it more difficult to buy a car and to keep it running safely. The president's policy appears to be to let the rich drive their new, subsidized hybrid cars while the poor walk or take a bus.

Mr. Obama also displays no concern for the anti-poor nature of tariffs on food and clothing. As a senator and presidential candidate, he embraced the 2008 farm bill, which subsidizes farmers whose average incomes and wealth are higher than the typical non-farm family. The farm bill imposes anti-competitive tariffs and quotas on imported sugar, milk and cheese - a food tax that falls disproportionately hard on the poor, who spend a larger share of their budgets on food.

This summer, a group of sugar-using industries asked the Obama administration to relax quotas on imported sugar to avoid potential domestic shortages in the face of globally high prices. The administration refused, not only placing jobs at risk in the confectionery and food-processing sectors, but also forcing working families to continue paying higher prices than they should for candy, breakfast cereals, bakery goods and other sugar-containing products.

When he was running for president, Mr. Obama explicitly endorsed higher prices for T-shirts for every American family to save jobs in the small and declining apparel sector. At a debate before union members in Chicago in August 2007, he said, "People don't want a cheaper T-shirt if they're losing a job in the process. They would rather have the job and pay a little bit more for a T-shirt."

The future president ignored the fact that every poor family must buy those shirts to keep themselves clothed, yet only one-third of 1 percent of American workers make clothing or textiles of any kind. A wealthy politician or TV commentator need not care about the price of a T-shirt or other everyday consumer items, but millions of poor and middle-class American families do care.

A few liberal Democrats still care, too. Edward Gresser of the Democratic Leadership Council has done more than anyone to expose the unfair, anti-poor bias of the U.S. tariff code.
In his 2007 book "Freedom From Want: American Liberalism and the Global Economy," he calculated that a single mother earning $15,000 a year as a maid in a hotel will forfeit about a week's worth of her annual pay to the U.S. tariff system, while the hotel's $100,000-a-year manager will give up only two or three hours of pay.

The $25 billion in revenue raised each year from import duties represent by far the most regressive tax the federal government imposes. Yet the Obama administration and the Democratic Congress have refused to move forward with trade agreements that would lower trade taxes that fall most heavily on the poor. By supporting the farm bill, but not new trade agreements, the president has embraced the status quo rather than change.

This is the status quo that so many "progressives" in America, from Public Citizen to the AFL-CIO, are expending millions of dollars to defend. They reflexively oppose any trade agreements that would reduce those regressive tariffs. In contrast to what he says on the public stage, Mr. Obama so far has taken their side in the trade debate at the expense of poor American families struggling to keep their cars on the road, shirts in the closet and food on the table.

Daniel Griswold is director of the Center for Trade Policy Studies at the Cato Institute and author of a new book, "Mad About Trade: Why Main Street America Should Embrace Globalization" (Washington: Cato Institute, 2009).

Libertarians: A catalog of untruths in health insurance reform

You Mislead!, by Michael F. Cannon and Ramesh Ponnuru
Cato, Sep 29, 2009
This article appeared in the National Review (Online) on September 28, 2009.

It is a good thing that other congressmen did not follow Rep. Joe Wilson's lead. If they yelled out every time President Obama said something untrue about health care, they would quickly find themselves growing hoarse.

By our count, the president made more than 20 inaccurate claims in his speech to Congress. We have excluded several comments that are deeply misleading but not outright false. (For example: Obama pledged not to tap the Medicare trust fund to pay for reform. But there is no money in that "trust fund," anyway, so the pledge is meaningless.) Even so, we may have missed one or more false statements by the president. Our failure to include one of his comments in the following list should not be taken to constitute an endorsement of its accuracy, let alone wisdom.

1. "Buying insurance on your own costs you three times as much as the coverage you get from your employer." The Congressional Budget Office writes, "Premiums for policies purchased in the individual insurance market are, on average, much lower — about one-third lower for single coverage and one-half lower for family policies." It is true that individual insurance policies are generally 30 percent less comprehensive than employer-provided insurance, and comparable individual policies are about twice as expensive. But much of the extra cost is a function of the tax penalty on purchasing such insurance and the stunted market that penalty has yielded.

2. "There are now more than 30 million American citizens who cannot get coverage." An outright falsehood, whether you use the president's noncitizen-free estimate or the standard, questionable estimate of 46 million uninsured residents.

A study prepared for the federal government estimates that 9 million people counted as "uninsured" in the standard estimate are in fact enrolled in Medicaid. The left-leaning Urban Institute estimates that 12 million are eligible but not enrolled, meaning they could get coverage at any time. Health economists Mark Pauly of the University of Pennsylvania and Kate Bundorf of Stanford estimate that one quarter to three quarters of the uninsured can afford to purchase coverage, but choose not to do so.

3."And every day, 14,000 Americans lose their coverage." The paper that generated this estimate assumed that two months of severe job losses would continue forever. Applying that paper's methodology to a broader period of rising unemployment (January 2008 through August 2009) produces a figure below 9,000.

It also assumes those coverage losses are permanent. Like many of the 46 million Americans we label "uninsured," many of those 9,000 will regain coverage after a number of months. (David Freddoso illustrates the absurdity of assuming that all coverage losses are permanent.)

4. "One man from Illinois lost his coverage in the middle of chemotherapy... They delayed his treatment, and he died because of it." He didn't die because of it. The originator of this false claim, a writer for Slate named Timothy Noah, has admitted he got it wrong.

5. "Another woman from Texas was about to get a double mastectomy when her insurance company canceled her policy because she forgot to declare a case of acne." Scott Harrington supplied more facts in the Wall Street Journal: "The woman's testimony at the June 16 hearing confirms that her surgery was delayed several months. It also suggests that the dermatologist's chart may have described her skin condition as precancerous, that the insurer also took issue with an apparent failure to disclose an earlier problem with an irregular heartbeat, and that she knowingly underreported her weight on the application." The woman deserves sympathy, but Obama has stretched the truth here.

6. Rising costs are "why so many employers . . . are forcing their employees to pay more for insurance." Perhaps no other issue generates as much of a consensus among health-care economists as this one: The "employer's share" of employees' health-care costs comes out of those employees' wages, not out of profits. In this comment and in five others in his speech, Obama contradicts that basic truth. Employers aren't forcing their employees to pick up a larger share of the bill because they can't. Workers are already paying the entire bill.

7. Rising costs are "why American business that compete internationally... are at a huge disadvantage." False. The rising cost of health benefits does not increase employers' labor costs because, again, wages adjust downward to compensate. The Congressional Budget Office, under the leadership of Obama's OMB director, Peter Orszag, confirmed that health-care costs do not hinder competitiveness. Obama economic aide Christina Romer has called this competitiveness argument "schlocky."

8. "Those of us with health insurance are also paying a hidden and growing tax for those without it — about $1,000 per year that pays for somebody else's emergency room and charitable care." That number comes from a left-wing advocacy group. A Kaiser Family Foundation study debunked the group's analysis, reaching an estimate closer to $200 per year for a family. The CBO report mentioned above reached the same conclusion.

9. At this point, Obama said, "These are the facts. Nobody disputes them." This comment continues Obama's already long tradition of trying to curtail debate by denying that anyone disagrees with him.

10. "[Reform] will slow the growth of health-care costs for our families, our businesses, and our government." In July, CBO director Douglas Elmendorf said, "In the legislation that has been reported we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health-care costs." The CBO projects that the legislation that Sen. Max Baucus (D., Mont.) has since introduced "would reduce the federal budgetary commitment to health care, relative to that under current law, during the decade following the 10-year budget window," but hints that the 40 percent cut in Medicare's reimbursement rates, which helps Baucus achieve that feat, is politically unrealistic. (More on that below.) Health economist Victor Fuchs writes that the proposals before Congress "aim at cost shifting rather than cost reduction." Obama and his allies have yet to demonstrate anything to the contrary.

11. "Nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: Nothing in our plan requires you to change what you have." Obama's wording is lawyerly: While not denying that his plan would cause people to lose existing coverage with which they are satisfied, he leads us to believe that he is denying it. But even on its own terms, Obama's claim is false. The CBO estimates that slashing payments to Medicare Advantage, as Obama advocates, "would reduce the extra benefits that would be made available to beneficiaries through Medicare Advantage plans." It would also cause some people to lose their coverage.

12. Requiring insurers to cover preventive care "saves money." Nope. According to a review in the New England Journal of Medicine, "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not."

13. "The [bogus] claim... that we plan to set up panels of bureaucrats with the power to kill off senior citizens... is a lie, plain and simple." Sarah Palin claimed that Obama's "death panels" would deny people medical care, not actively kill them. If Palin believes her claim, it is not "a lie, plain and simple." Most important, the substance of Palin's claim is, in fact, true. Obama himself proposed a new Independent Medicare Advisory Council with the authority to deny life-extending care to the elderly and disabled.

14. "There are also those who claim that our reform efforts would insure illegal immigrants. This, too, is false. The reforms I'm proposing would not apply to those who are here illegally." For better or worse, the president's plan would, in his words, insure illegal immigrants. Various federal agencies, immigration critics, and the media all acknowledge that a small number of undocumented aliens obtain Medicaid benefits despite being ineligible. The president seeks to expand Medicaid, which would create greater opportunities for ineligible aliens to enroll.

The House Democrats' health-insurance exchange, which Obama supports, would "apply to" undocumented aliens. The CRS writes that the House legislation "does not contain any restrictions on noncitizens participating in the Exchange — whether the noncitizens are legally or illegally present." Nor does it require that the legal status of people receiving subsidies be verified.

Finally, Obama supports granting legal status to millions of illegal immigrants, which would make them eligible for government benefits under his health plan.

15. "Under our plan, no federal dollars will be used to fund abortions." Unless Obama refers to some draft legislation inside his head, this claim is false. The House bill allows the "government option" to pay for abortions directly from the U.S. Treasury. Both the House and Baucus bills would subsidize private insurance that cover abortions. (See Douglas Johnson's comment on this article.)

16. Critics of the public option would "be right if taxpayers were subsidizing this public insurance option. But they won't be. I've insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects." How quickly we forget the example of Fannie Mae and Freddie Mac. Like those institutions, the public option would benefit from an implicit subsidy: Everyone would know that Washington would not allow the program to fail, and financial institutions would therefore offer it better rates. (During the Clinton administration, Obama adviser Larry Summers reported that a similar implicit guarantee was worth $6 billion per year to Fannie and Freddie.) The public option would thus be able to undercut its less-subsidized competitors.

17. "And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need." Unless the president proposes to abolish insurance, or abolish all care management, there will always be tension between patients, doctors, and public/private insurers over what patients "need." Such tensions are sure to arise under the president's IMAC proposal.

But even if a new program would be "administered by the government, just like Medicaid or Medicare," it would interfere in those decisions. As an administrative-law judge wrote to one of us after Obama's address: "I am a government bureaucrat . . . and I just happen to be reviewing [six] cases, albeit involving Medicare and Medicaid, where the government has inserted itself between the patient and the care prescribed by the physician."

18. "I will not sign a plan that adds one dime to our deficits — either now or in the future." "The plan will not add to our deficit." None of the bills before Congress can credibly claim to keep the deficit from rising. The one that comes closest, the Baucus bill, does so by making the wildly implausible assumption that Congress will allow 40 percent cuts in physician payments under Medicare to take place in 2012. Congress has routinely refused to support much smaller cuts.

19. "Now, add it all up, and the plan I'm proposing will cost around $900 billion over ten years." Even the supposedly parsimonious Baucus bill would cost closer to $2 trillion than $1 trillion once we "add it all up." The CBO says that bill would spend a mere $774 billion over ten years, in part because the spending begins late in that ten-year window. Republican staffers on the Senate Budget Committee estimate that the Baucus bill would cost $1.7 trillion over the first ten years of full implementation.

Moreover, the preliminary CBO score does not measure the full cost of the bill because it does not include the mandates Baucus would impose on states (about $37 billion) and the private sector (not yet estimated, but 60 percent of total costs in Massachusetts). The other bills would cost even more.

20. "The middle class will realize greater security, not higher taxes." Obama would make health insurance compulsory for the middle class (and everyone else). If he thinks that isn't a tax, he should listen to his economic adviser Larry Summers, or his nominee for assistant secretary for planning and evaluation at HHS, Sherry Glied. Both liken the "individual mandate" to a tax, as do other prominent health economists like Uwe Reinhardt (Princeton) and Jonathan Gruber (MIT). The CBO affirms that the penalties for non-compliance "would be equivalent to a tax or fine."
If Obama thinks the middle class wouldn't pay the taxes he wants to impose on the "drug and insurance companies," he should read this CBO report or talk to the junior senator from West Virginia, who accurately describes those levies as a "big, big tax" on middle-class coalminers.

21. "I won't stand by while the special interests use the same old tactics to keep things exactly the way they are." Who are these special interests? In case Obama hadn't noticed, everyone from the drug-makers to the unions to the insurance companies he demonizes are spending millions to build momentum for his version of reform — in no small part because Obama has promised to buy them off with middle-class tax dollars.

When President Obama makes a factual claim about health-care policy, he does not deserve the benefit of the doubt about its accuracy. We do not know whether he has been badly misinformed or is deliberately trying to mislead. Either way, he cannot be trusted to reform American health care.

Michael F. Cannon is director of health policy studies at the Cato Institute and coauthor of Healthy Competition: What's Holding Back Health Care and How to Free It. Ramesh Ponnuru is a senior editor at National Review.