The Urgent Need to Lower the Cost of American Healthcare

 

Our country faces many serious problems (terrorism, global warming, income inequality, etc.) but the most serious of all in the long run is our rapidly growing national debt and the inability (unwillingness?) of our national leaders to address it.
Furthermore, the fundamental driver of our debt problem is the cost of healthcare, public and private.  The Affordable Care Act, established in 2010, expands access to healthcare but does not address the cost problem (see chart below).


I have previously discussed how to repair the ACA to make it more cost efficient, by, for example, repealing both the individual and employer mandates, establishing a universal (and refundable) tax credit for catastrophic care, migrating Medicare and Medicaid to the new universal system, etc.
But there are lots of other things, less political contentious, that we can do as well.  I have just read an astonishing new book, “An American Sickness” by Elizabeth Rosenthal, an MD who works as a healthcare journalist, which provides a vivid and compelling description of our overly expensive and dysfunctional healthcare system. According to Ms. Rosenthal here are a few of the things we could do collectively to get costs under much better control:

  • Reform malpractice insurance to place limits on noneconomic damages.
  • Breakup oversize hospital conglomerates so that hospitals don’t have such huge monopoly pricing power.
  • State insurance regulators could do a much better job of enforcing transparency and accuracy for provider directories, in-network and out-network fees, etc.
  • Insurance companies could do a better job on reference (i.e. standardized) pricing, encouraging bundling of services, tying the size of co-payments to a procedure’s medical worth and urgency, etc.
  • Congress should permit Medicare to negotiate national drug prices.

Conclusion. Repairing the ACA, as is now being done in Congress, will go a long way towards much better cost control of healthcare. But there are many other common sense steps which can also be taken towards this goal.

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What Should the Federal Government Do about Infrastructure?

 

President Trump has proposed spending $1 trillion over the next decade on public and private investment in infrastructure. The CATO Institute’s Ryan Bourne has just published an excellent analysis of the whole issue.  Here are the highlights:

  • Any new federal spending must take into account that federal public debt now stands at 77% of GDP and is likely to keep rising given the demographic pressures on entitlement spending. This means that the long-term outlook for public finances is dire.
  • With a current low unemployment rate of 4.4% and a high of 6 million job openings, the economy does not need more government stimulus at the present time.

  • Bridge quality has improved substantially since 1990 (see chart) although roadway congestion has become more acute (second chart). Rail and transit systems appear to be the main areas with observable deterioration.

  • The difference between state highways (which are in good condition), local roads (which are in fair condition) and transit systems (which are in poor condition) is simple: state road maintenance is paid almost entirely out of user fees (gasoline taxes), local road maintenance is paid for by a combination of taxes and user fees (motor vehicle registrations and parking meters) while transit maintenance is paid for almost entirely out of taxes.

The above indicates that the following policy framework should be followed:

  • Privatize areas where government is not needed such as airports, air traffic control systems and railways (Amtrak).
  • Localize decision making as far as possible such as decentralizing responsibility for transportation infrastructure back to the states.
  • Remove payment barriers for charging users. This could reduce the cost of capital investment required for highway systems by 30%.
  • Level the playing field for private sector funding. Currently interest income received for investing in municipal bonds is tax free which is not the case for private debt.

Conclusion. “Rather than imposing further costs on taxpayers, the Trump Administration should prioritize localizing decision making, removing regulatory barriers to private investment, encouraging use of user fees and removing tax exemptions for public investment.”

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The Growing Skills Gap

 

Donald Trump was elected President because of strong blue-collar support. Many blue collar workers feel left out of the American dream because of stagnant incomes and/or job loss.
At the same time there is a huge national focus on the high cost of college and the associated huge student loan debt.  But student loan debt is a fixable problem and is not what is holding our economy back.
Take a look at the two charts below from recent issues of the Wall Street Journal, here  and here.


The first chart shows the last four growth cycles and how wages eventually tick up as unemployment continues to fall.  Missing this time is hardly any growth in wages towards the end of the cycle (Of course, the current cycle won’t be over until we have the next recession).


The second chart shows that there are now more job openings (6 million) than job hires for the first time since 2001.  Furthermore there were only a low of 138,000 jobs added in May with an average of 121,000 per month for the past three months.  This suggests that employers are having a hard time finding qualified workers.
Obviously, what is badly needed is a renewed emphasis on workforce training.  Interestingly enough, the Business Roundtable has just issued an extensive report  detailing what many major corporations are doing to close America’s skills gap.

Conclusion. Lots of people, certainly including President Trump and the Republican Congress, would like to see faster economic growth.  Clearly there are practical and useful ways to achieve this and many people are already trying to make it happen.

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Why the U.S. Should Adopt a (Revenue Neutral) Carbon Tax

 

As I have discussed previously, the evidence for global warming is overwhelming.  I had hoped that President Trump would publicly recognize this scientific reality and decide to stay in the Paris Climate Agreement.  Nevertheless, it will take more than three years for the U.S. to completely withdraw.
But in or out of the Paris Agreement, the best way for the U.S. to show leadership on this critical issue is to adopt a (revenue neutral) carbon tax.  The American Enterprise Institute has just issued a comprehensive report  on the desirability and feasibility of doing this.


Here is the gist of the AEI argument:

  • $40 per ton is often taken to be the social cost of carbon in the atmosphere. A carbon tax at this level would raise the cost of gasoline by 36 cents per gallon.
  • A carbon tax is a consumption tax. Taxing consumption rather than income promotes economic growth. The revenue neutral offset would likely be an income tax such as the payroll tax or corporate income tax.
  • A carbon tax need not disadvantage the U.S. globally since a border adjustment tax could be imposed on imports from countries without a carbon price regime.
  • Replacing arbitrary regulations. The primary carbon-reduction regulations currently in effect are the 1) Corporate Average Fuel Economy (CAFE) standards for vehicles and 2) Clean Power Plan which limits power-sector carbon emissions at the state level. Leaving carbon abatement decisions to carbon producers is far more efficient than leaving it up to regulators.
  • Growing public acceptance. 84% of registered voters, including 72% of Republicans, support actions to accelerate the development and use of clean energy. Even 49% of conservative Republicans say that “Americans will make major changes to their way of life to address climate change.”

Conclusion. For the U.S. to adopt a carbon tax would be an even stronger statement of world leadership than participating in the Paris Agreement.

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An Emerging Democratic Agenda?

 

I am just as personally embarrassed by President Donald Trump as most other people I know. He is rude towards other world leaders and especially our own allies.  His destructive behavior endangers even his own policy initiatives.  He was elected by blue-collar workers who feel left behind in today’s global economy.  But how can he possibly lead others in implementing policies to help even his most avid supporters?


What is the Democratic Party doing about this?  First of all, they are trying to stop acting so elitist toward the working class.  But more fundamentally a new progressive social agenda apparently is emerging, here and here.  It has many attractive features but there is one big thing missing, namely fiscal responsibility:

  • A “public apprenticeship” jobs program. The idea here is to maintain the employment rate for prime-age workers without a bachelor’s degree at the 2000 level of 79%. This would require the creation of 4.4 million jobs, ideally at a living wage of $15 per hour plus Social Security and Medicare payroll taxes, and therefore at a wage of $36,000 per year. This would cost $158 billion per year.
  • A universal child allowance of $250 per month. This would cost $190 billion per year, although half could be offset by consolidating less-efficient existing programs. This would cut child poverty by 40%.
  • An expansion of the earned income tax credit. A family of four making $40,000 per year would get a tax credit of $6000 instead of the current credit of $2000. This would cost $1 trillion over ten years. The idea here is extra motivation to hold a job.

 

Conclusion. Who is opposed to creating millions of new living wage jobs to put the unemployed and underemployed back to work? Such a program would give our economy a huge boost.  Who is opposed to cutting child poverty in half (or doing even better)?  But how in the world would we make room for such new programs in the federal budget?  With $500 billion annual deficit spending already, we need to curtail federal spending, not increase it.

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The Only Way America Can Be Great Is To Provide Leadership

 

Like many other people I am upset that President Trump has decided to withdraw from the Paris Climate Accord.  It’s not that Paris solves the global warming problem but it is a major step in the right direction.  We’re the biggest contributor of carbon emissions  so it is our responsibility to lead in reducing them.


Here are some other major issues that need leadership:

  • Trade. The Trans-Pacific Partnership would have been a big win for the U.S.  But it is with China, responsible for two-thirds of our trade deficit, that we need a major rebalance.
  • NATO. Mr. Trump has withdrawn his campaign statement that NATO is “obsolete.” His criticism of NATO could turn out to be useful if it leads to an increase in NATO defense spending.

  • Faster Economic Growth. Economic strength is the backbone of our influence in world affairs. Lower corporate tax rates will encourage our multinational companies to bring their profits back home for reinvestment in the U.S. Administration efforts already under way to deregulate various aspects of the U.S. economy should soon lead to faster growth.
  • U.S. Budget. Mr. Trump has proposed to balance the U.S. budget within ten years which is hugely important. Unfortunately many of his specific proposals on spending and growth are not realistic.
  • Infrastructure Spending. This is an excellent idea if it is paid for directly and does not add to the federal deficit. Apparently Mr. Trump will soon announce a plan for private industry, cities and states to take the lead in new infrastructure spending with possible contributions from the federal government.

Conclusion. Although Paris is a disappointment, Mr. Trump will have many opportunities to redeem himself.

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PLEASE, Mr. President, Don’t Withdraw from the Paris Climate Accord

 

When Barack Obama was President I described our country’s two biggest long range problems as:

  • Massive Debt, now 77% of GDP (for the public part on which we pay interest) and predicted by the CBO to keep steadily getting worse.
  • Slow economic growth, averaging just 2% since the end of the Great Recession in June 2009. This means fewer new jobs are created and lower raises for existing jobs.

Now, under President Trump, I have modified this list to read:

  • Massive Debt, etc.
  • Global Warming, for which the evidence is overwhelming.

All three of these issues are large and urgent problems but President Obama was insufficiently concerned about both debt and economic growth while President Trump is insufficiently concerned about both debt and global warming.
Today’s Wall Street Journal, “Paris Climate Discord” has perhaps the best possible argument for withdrawing from the Paris Accord but it is ultimately unpersuasive.  Even if full implementation of the Paris standards would have only a tiny effect on global temperatures by 2100, and even if other countries aren’t contributing their fair share, Paris represents a big step in the right direction.
Global warming is real and if the U.S. is the world leader which it needs to be, and often purports to be, then it needs to be part of the Paris Accord.  Adjustments to our own domestic energy policies (such as adopting a revenue neutral carbon tax) will enable us to decrease carbon emissions much more efficiently than we are currently doing.

Conclusion. Global warming presents an opportunity for President Trump to show real leadership. I hope he is up to it.

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