U.S. healthcare policy is now in limbo. The Affordable Care Act has withstood Congressional attempts to repeal it, but it has many flaws which need to be repaired. Primarily, the ACA expands access to healthcare in the U.S. (good) but does nothing to control burgeoning costs for both individuals and the federal budget (bad).
One option for both further expansion of access as well as cost control is Bernie Sanders’ single-payer “Medicare for All” plan. A different option is universal catastrophic care for all Americans not already covered by Medicare or Medicaid (including those receiving employer provided health insurance).
A different perspective is provided by an editorial in the New England Journal of Medicine. According to the authors, Eric Schneider and David Squires, the U.S. also faces (in addition to the challenge of much better cost control) several performance challenges such as:
Lack of access to affordable and comprehensive insurance coverage for too many people.
Relative underinvestment in primary care. Other developed countries have a higher percentage of their professional workforces dedicated to primary rather than specialty care and deliver a wider range of services at first contact.
Administrative inefficiency of the U.S. healthcare system. The solution here is to change our reimbursement systems to use global payments, fee schedules, formularies and defined benefits.
Disparities in the delivery of care. People with low incomes, low educational attainment, and other social and economic challenges face greater health risks and thus need even greater access to primary healthcare.
Conclusion. The U.S. compares poorly with other advanced countries in both the quality and cost efficiency of its healthcare system. Healthcare costs in the U.S, are a huge drain on the economy and will ultimately cause huge fiscal problems if not brought under much greater control.
Congress has just postponed the debt ceiling until December 8 but at least they didn’t repeal it. It is crucial to retain regular and explicit debt ceilings as a reminder of the urgency of putting our debt on a downward course (as a percentage of GDP).
As a reminder:
The debt now stands at 77% of GDP (for the public part on which we pay interest), the highest it has been since right after WWII. The $15 trillion public debt right now is essentially “free” money because interest rates are so low. But interest rates will inevitably return to more normal, and higher, historical levels and, when this happens, interest payments on the debt will skyrocket.
The entitlementprograms of Social Security. Medicare and Medicaid are the drivers of our debt problem because their costs are increasing so rapidly. Medicaid costs the federal government almost $400 billion per year. Medicare costs the federal government $400 billion per year more than it receives in FICA taxes and premiums paid.
The attached chart demonstrates the scope and urgency of the problem. By 2032, just fifteen years from now, all federal tax revenues will be required to pay for Social Security, Medicare, Medicaid and interest payments on the debt. This means that all of ordinary discretionary spending: on defense, various government operations and social welfare programs will be paid for entirely from new deficit spending and, in the process, will almost inevitably suffer huge cutbacks. The lower-income and poor people, who are the most reliant on government programs to get by, will be the most adversely affected.
Conclusion. Such a dreary scenario of drastically tightened government spending does not have to occur. It can be avoided by immediately starting to make sensible curtailments, not actual spending cuts, all along the line. Do our national leaders have the common sense and fortitude to do this?
I am a non-ideological fiscal conservative and social moderate. I agree with Republicans on some issues and Democrats on others. It seems to me that there is a lot of common ground between the two national parties and plenty of opportunity for working together.
The economy. Donald Trump was elected President with the support of blue-collar workers. He wants to help them out by speeding up economic growth. But the Democrats also want to give a boost to the working class. Why not lower the corporate tax rate to encourage multi-national companies to bring their profits back to the U.S.? Why not exempt small community banks from Dodd-Frank so they can lend more money to main street businesses?
Sustainable healthcare. After failing to repeal and replace the ACA, Republicans now have to accept that universal health insurance is here to stay even though it needs much better cost control. The popularity of employer provided health insurance makes single payer healthcare unacceptable to many. Two major changes are needed to lower healthcare costs. The ACA Cadillac tax should be replaced by an upper limit on the tax exemption for employer provided insurance. The Medicare Part B premium covers only 25% of the cost of that program and should be increased on a means adjusted basis.
Immigration policy. With the unemployment rate now 4.4% and dropping, a huge labor shortage is beginning to develop which will retard economic growth. We now need more skilled and unskilled immigrants alike. An expanded guest-worker program to meet the needs of employers should be created. Enhanced border security can be part of the mix.
Military spending. In a dangerous world we need a strong military defense. But there is a lot of waste in the Pentagon budget. Do we really need 800 foreign bases in over 70 different countries? Nebraska’s own Chuck Hagel identified $25 billion a year in military waste while he was Secretary of Defense.
Conclusion. Here are just a few ways that the two parties can work together to address some of our biggest national problems. Faster economic growth and fiscal restraint just make common sense.
Three devastating hurricanes have struck the U.S. in recent years: Katrina (2005), Sandy (2012) and now Harvey (2017). Hurricanes and tropical storms are natural events which have occurred since the distant past, long before global warming became a problem.
What has changed is that the oceans are now steadily getting warmer by absorbing much of the heat reflected back to earth by greenhouse gases (see chart). Warmer water has more latent energy and this makes hurricanes more severe. The warmer the oceans become, the more devastating future hurricanes will be.
It is (past) time to get serious about global warming. As the world’s strongest country, it is up to the U.S. to provide leadership on this very serious problem. The best way we can respond is by adopting a (revenue neutral) carbon tax to discourage future carbon emissions as much as possible. This problem is not going to disappear but it is within our power to limit the damage it causes before it gets a lot worse.
The exact same thing is true about our national debt. At 77% of GDP (for the public part on which we pay interest), it is the highest it has been since the end of WWII. Right now interest rates are so low that our debt is almost “free money.” But interest rates will eventually return to more historically normal levels. When this happens, interest payments on the debt will rise by hundreds of billions of dollars per year. At that point a severe Fiscal Crisis will not be far behind.
Again, debt is a solvable problem if only our national leaders will take it seriously. All it requires (so to speak, because it won’t be easy!) is to limit future federal spending in sensible ways.
Conclusion. Both global warming and national debt are serious, urgent problems. The sooner we get started on addressing them, the better off we will be.
Americans are a very fortunate people. We are protected by two oceans and friendly neighbors to our north and south. We are the strongest country in the world, both economically and militarily. We provide the world with cutting edge leadership in many areas such as technology, finance, energy production, scientific research and university education.
In short we live in a very successful, prosperous and complex society. We do have serious problems but they are being addressed by our elaborate legal and governmental processes and structures. Slowly but surely life in America is getting better and better all the time.
Given our country’s size, complexity and dominance in the world, it is inevitable that government will also grow in size and structure in order to take on new responsibilities. It is completely unrealistic to think that we can return to a more limited form of government that existed in the past.
When I say, then, that I’m a fiscal conservative, I am not advocating for less government but merely that we pay for the government that we have, in other words, act in a fiscally responsible manner.
And we are not doing this at the present time:
Our national debt, now 77% of GDP (for the public debt on which we pay interest), is the highest since right after WWII. It is predicted by the Congressional Budget Office that it will keep steadily getting worse without major changes in current policy.
The urgency of the debt problem is based on the fact that interest rates are now so low that it is almost “free” money. But interest rates will inevitably return to more normal historical levels and, when this happens, interest payments on the debt will skyrocket. Eventually this will lead to a Fiscal Crisis, much worse than the Financial Crisis of 2008.
The solution to this problem need not be drastic. Federal spending is growing by 5% per year while tax revenues are growing by 3% per year. If we would just hold spending increases down to 2.5% per year, the federal budget would be balanced in a few years and our debt would start shrinking as a percentage of GDP.
Conclusion. Spending restraint, with very few actual spending cuts, is all that it will take to put our debt problem on a path to solution. Surely we are capable of acting in a fiscally responsible manner like this!
For the past almost five years, beginning in November 2012, I have been blogging about fiscal and economic issues facing the United States. With the unemployment rate now down to 4.3%, and the economy growing at 2% annually and likely to pick up speed, our biggest problem by far is an exploding national debt, currently 77% of GDP (for the public debt on which we pay interest), the highest since the end of WWII.
There are two announced candidates so far for the Nebraska Senate seat which becomes open in January 2019:
The incumbent, Senator Deb Fischer, a Republican
Jane Raybould, Lincoln City Councilwoman, a Democrat.
There is always enormous pressure on members of Congress to maintain or increase spending for popular projects and little pressure to cut anything. In general, Republicans deplore large deficits and debt but are ineffective in implementing fiscal restraint while Democrats simply don’t want to talk about the debt problem at all. I am a non-ideological (registered independent) fiscal conservative and social moderate, highly focused on substantially shrinking our annual deficits over a short time period.
Here are my options for the Senate race:
Enter the Republican Primary. I would get almost no traction running against the incumbent Republican in the Primary, even though she is a big spender, all the more so since she is pro-life and I am pro-choice (with a 20 week cutoff for most abortions).
Run as an independent. This is futile without huge name recognition or financial resources, of which I have neither.
Enter the Democratic Primary. The announced candidate has a strong party affiliation which I lack. But she has little chance of defeating Senator Fischer in the general election whereas I could by credibly hammering Fischer as a big spender.
Please respond! Please give me you input on this matter one way or another. My email address is firstname.lastname@example.org. Would you support me as a Senate candidate? Congress badly needs more members who are serious about shrinking our debt and I am such a person. More later!
This blog is devoted to fiscal and economic issues facing the U.S. Both the Trump Administration and the Democrats are working to speed up economic growth and I believe there is a good chance that this will happen.
However there is not nearly enough interest in addressing an even bigger problem: our national debt, is now larger, in relative terms, than at any time since the end of WWII.
This is a very difficult political problem because elected representatives would much rather say yes than say no to new programs and more spending. It is even more difficult to try to restrain the growth of, let alone cut, existing programs.
The Congressional Budget Office has recently published a long list of possible ways to decrease federal spending (or increase federal revenues) over the next ten years. It is interesting to pull out several of these suggestions to see what can be accomplished:
Program 10 year savings
Eliminate concurrent receipt of retirement pay and disability $139 billion for veterans.
Use an alternative measure of inflation to index mandatory $182 billion
Reduce funding for International Affairs Programs. $117 billion
Limit highway funding to expected highway revenues. $40 billion
Reduce the size of the federal workforce through attrition $50 billion
Reduce funding for grants to state and local governments $56 billion
Impose caps on federal spending for Medicaid $680 billion
Increase premiums for Medicare Parts B and D from 25% to $331 billion 35% of cost. Total $1595 billion
Conclusion. This brief list of budget restraints would reduce deficit spending by about $160 billion per year. This is significant but not nearly enough compared to the projected deficit of $685 billion for just the 2017 fiscal year alone. About 2/3 of the savings come from the two entitlement programs of Medicare and Medicaid. The idea here is to give specific examples of the sort of changes which will be necessary to seriously confront our debt problem.