Summary

Not exactly a blog, but maybe if I write some of this stuff down I won't be tempted to start visiting political chat sites to vent. And maybe just knowing that this page exists is enough to scare me into spending my time more productively. (I am way too emotionally invested in the direction that my country is taking. Funny how the needless deaths of thousands abroad can do that to you.)

-- cbu (09/05/2004)

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As I've proved many times in the past, I'm kind of lousy at political predictions. I often allow my wishful thinking to ignore unpleasant realities.

For example, I seriously over-estimated the egos of Rudy Guiliani and Fred Thompson when I predicted that even a display of weak support for their Republican nomination candidacies would cause them to ignore their shelf-life expiration dates. I'm also mildly impressed that Mitt Romney turned out to be more of a fiscal conservative than I imagined, at least as far as squandering his children's inheritance. Those miscalculations on my part, along with underestimating how quickly the GOP "winner takes all" primary system would winnow the field, helps explain why there was no brokered convention in St. Paul this year.

Given that, I think that we'll find out in the next two/three days how far McCain is willing to go down his current path. He's at the precipice now, looking over campaign rally supporters shouting Treason and Traitor. At some point he is going to figure out that he got punkt

1. by his Rove-tutored campaign manager who convinced him to cash in all of political capital culminating in the Palin pick, and
   
2. by Obama who feinted joining a head-first dive into a bunch of rabbit holes but then pulled back at the last minute.

All that McCain had going for him into this campaign was his reputation. He let himself get talked into sacrificing that for the sake of winning an election on behalf of an ungrateful and suspicious base of Republicans.

So my prediction is that McCain will soon realize he only has three weeks left in the national spotlight, three weeks to salvage his credibility. He doesn't even have a shot of being an opposition leader -- not that he really wants that -- so now all he has to play for is his legacy, his brand. I'm guessing that all of this Ayers crap will disappear from his campaign by the weekend, as he rolls out his last new campaign slogan: Down with Dignity.

-- cbu (10/09/2008)

Imagine, if you can, these three developments in the 2008 campaign:

1. Several individual states, all operating rationally to promote their self-interest, move up their primary elections in order to get more attention from both the candidates and the national media. More than 40% of each party's delegates are scheduled to be selected by "Super Duper Tuesday," 05 February.
   
   
2. The national parties both assume their conventions will only serve as a formality for the pre-determined nominee. Hoping to reserve general election campaign funds for the last few months of the campaign, they move back their conventions to the end of the summer (only three months before 04 November).
   
   
3. No definitive GOP frontrunner emerges at the conclusion of Super Tuesday, and all of Romney, Guiliani, McCain, Huckabee, and Paul secure either enough delegates or enough financing to maintain their status as viable candidates. This pattern continues in the remaining primaries, and the party waits seven months between Super Tuesday and its national convention before settling on its ultimate nominee.

The first two hypotheticals have obviously formed the reality of the 2008 campaign season; with every passing day the third is looming as a more likely possibility. Each of the top five candidates appeals to a limited ideological or geopolitical bloc of the Republican party. If the GOP is confronted with the first brokered convention in its memory, it will be preceded by a seven-month period of Republican in-fighting and negative attacks from increasingly desperate and financially strapped candidates. It then has the daunting tasks of not only reconciling their own members to their nominee, but also undoing the damage caused by the other candidates leading up to the convention. All in three months. Meanwhile, the Democratic nominee has been preparing for the general election for the previous six months.

In this scenario, the rational pursuit of self-interest from multiple actors with competing agendas is likely to result in an election nightmare for the Republicans, no matter who eventually secures the nomination. Of course, the Democrats face this possibility as well, though I believe that with a smaller slate of top-tier candidates (essentially Clinton vs. Obama) the party's nominee will be evident by the end of March.

-- cbu (12/18/2007)

While I was firing off letters to my congressional representatives last week pushing for universal health care, I was amused by how many times I use the term "Americans." While wondering if there was any other way to describe U.S. citizens, I thought about the term "North Americans" and it struck me that adjectives usually create a subset for a grouping. West Africans, political sociologists, graduate students, paperback books...

But in this case "Americans" are a subset of "North Americans." Curious, no?

And I can't think of any other examples. (I never did come up with a synonym for Americans, either.)

Unrelated note: the posts from 24 to 28 July all deal with a proposal for a "National Health Program for Infants and Children." On the main page these are listed in reverse chronological order. If you would prefer to read them in the order in which they were posted (since they really are sequential), take a look at the 2007 archives instead.

-- cbu (07/29/2007)

In earlier posts I provided a quick description and a brief rationale of a single-payer health care plan that I'm calling the National Health Program for Infants and Children (NHPIC), as well as an explanation of why pregnant women and children should be the first group covered as we progress towards universal care for the entire population. I also proposed a method for paying for such a program.

Representative John Conyers (D - Michigan) has introduced House Resolution 676, The United States National Health Insurance Act, and he is to be commended for this. His web site provides many good resources to obtain more information about universal health care and a single-payer system. Unfortunately, the probability that H.R. 676 will receive a full hearing and be passed by this Congress are exactly 0%. (Curiously, these are the same chances that the Minnesota Twins have of reaching the World Series. I seem to be a sucker for the underdog causes this year.)

The prospects for serious reform in our nation's health-care system remain dim. So long as we have a president who cares more about the short-term profits of health insurance companies than the long-term health of its citizenry, we will only see proposals that reshuffle the deck. Even our best intentioned leaders who pursue greater access to and affordability in health care have confused enrollment in insurance plans with actual treatment and care.

Insurance companies learned a long time ago that the only way to make the health-care system work with a limited financial investment is to redirect revenue flows away from those areas that cost them the most money. As citizens and as policy makers, we need to apply that lesson to the entire system.

To make better use of our health-care dollars, we must remove unnecessary actors that divert funds from providing care. The only way to make fundamental change, to provide expanded and improved coverage without increasing monetary outlays, is to eliminate the gate-keeping role provided to those insurance companies.

Opportunities for meaningful reform will have to wait until after the next election. Until then, however, we can at least debate the principles of what type of nation we want to be. I therefore humbly ask the U.S. Congress to consider and adopt the following non-binding resolution.

Whereas raising a family is one of the most important responsibilities of any person, regardless of their position or stature in life, deserving the full support of their government, and

Whereas providing proper pre-natal care to pregnant women has a tremendous impact on the lives of their children, and

Whereas the long-term health of any person is highly dependent on the care they receive in the first years of their lives, and

Whereas the health care of infants and children should never be dependent on the employment status or benefits of their parents, and

Whereas the United States is the only industrialized nation that does not guarantee health care for its most vulnerable citizens,

Be it resolved that the United States should adopt a National Health Program for Infants and Children (NHPIC), in which

All pregnant women who are American citizens shall be automatically enrolled in the NHPIC, and shall receive care up to 90 days following the end of their pregnancy, and

All American children shall be automatically enrolled in the NHPIC from the moment of their birth, and shall receive care up to the age of six, and

Any health-care treatment facility that receives any form of federal funding shall be required to accept and treat any participant in the NHPIC, and

All available treatment options shall be informed by a published list of standard accepted practices maintained by the National Institute of Health, and

No accepted treatment suggested by a licensed health-care practitioner shall be subject to the approval of any agent of the NHPIC for any reason, and

All enrolled participants shall pay a nominal per-visit charge to a licensed health-care treatment facility, shall pay a nominal fee for any prescription, and

Reimbursement for all treatments and prescriptions beyond these nominal fees shall be negotiated solely by care providers and the NHPIC without involving the patients or their families.

It is a simple idea, but one that would have an enormous impact on the lives of the 4 million American families that bring new children into the world each year, and on the health of their 25 million children under the age of six.

Could we afford such a national health program to cover pregnant women, infants, and children? Every other industrialized country has already find a way to do so. If this is a policy that we as a nation wish to pursue, we will find the funding to implement it.

Our nation has suffered long enough under the delusion that insurance companies are looking out for our best interests. Rather than lobby for greater access to the profit-seeking gate-keepers, we should remind our elected leaders that we simply want to see a doctor when we are sick. The least we can do is take care of the children first.

Over the last few weeks I have contacted all of my Senate and House representatives informing them of my plan. For an example of what I have been telling them, you can take a look at the letter I sent to Senator Norm Coleman.

I have also pitched my proposal to all of the major candidates for the Democratic Party nomination to be president: Barack Obama, Hillary Clinton, John Edwards, Chris Dodd, and Joe Biden. It is my firm belief that any candidate who proposes that the federal government cover all childbirth expenses will be easily elected president.

I have also contacted all senators on the Senate Subcommittee on Children and Families, asking that they introduce my proposed non-binding resolution. I also submitted a version of this post to the New York Times as a commentary for their Opinion pages, but I suspect that the probability of anyone seeing that in print are only slightly better than seeing H.R. 676 passed into law.

Still, a boy can dream...

And with that, I believe that my personal lobbying and posting efforts are now at an end. Maybe next week I'll try to fix the impending Social Security trust shortfall. (Hint: try incrementally raising the Social Security wage base from the current (2007) limit of $97,500 to $200,000 over the course of the next ten years.)

cheers,

-- cbu (07/28/2007)

In earlier posts I provided a quick description and a brief rationale of a single-payer health care plan that I'm calling the National Health Program for Infants and Children (NHPIC), as well as an explanation of why pregnant women and children should be the first group covered as we progress towards universal care for the entire population. Now I'll propose a method for paying for such a program.

Yes, cover your ears if you must, but this will involve taxes. We need to ask all American citizens to contribute some of their earnings in order for their government to provide services that benefit the common good. No, you can't fund universal health care with a tax cut.

The key towards winning acceptance is complete transparency. The public must be fully aware of how much this program costs, but they also need some assurance that it is not going to disappear the next time that two parties in Congress get into a spitting match. I believe that in order for this to work, we need to create a National Health Trust (NHT) funded by payroll taxes. A percentage of each worker's paycheck would be automatically deducted, just as is the case for FICA (Social Security) and the current Medicare tax. All revenue would be deposited in the NHT, and the funds would not be available to or allocated by the general federal budget. All employee contributions would need to be matched by their employers.

So how much would this cost, and what would be the initial percentages deducted from payroll checks? Because the ultimate goal is to expand the NHPIC and the NHT to cover all Americans, it is useful to consider what those needs would be, and then scale back. Please keep in mind that I don't have the General Accounting Office available to determine exact costs; I'm using publicly available information to create some close estimates.

Each year the Office of the Actuary at the Centers for Medicare and Medicaid Services (an agency of the U.S. Department of Health and Human Services) estimates national expenditures on health care. The estimated total amount spent on health care in 2004 was 1.86 trillion dollars. Per-capita expenditures were $6,322 . These figures include everything: hospitalization, dental care, prescription drugs, the cost of nursing homes, research, investments in structures and equipment, etc. For the sake of a high-end estimate, we'll use this per-capita figure without making any reductions, even though we also know that a single-payer plan would vastly reduce administrative costs and that preventative medicine will make many people healthier and allow them to avoid or at least put off major (costly) medical procedures.

Current funding sources run the gamut from private insurers to personal out-of-pocket payments, the Medicare payroll tax, and all of the taxes collected for the general budgets at federal and state levels for programs like SCHIP.

So the question is this: if the NHT had to pay for all national health care expenditures itself, without relying on other state or federal funding for any program, where would the money come from? Taxpayers, of course, both individuals and corporations. That's only real source for generating revenue at this level, and that's ultimately where most of the 1.86 trillion is coming from already. All of this could (and would have to) be raised through payroll deductions, to be matched by employer contributions.

In 2004 (the last year in which figures are available, which is why we're using that year's estimated health expenditures), total reported wages and salaries in this country amounted to 4.9 trillion dollars. If individual payroll deductions fully funded the NHT, we would need to be taxing people at the rate of 38%. That's not going to go over very well. Employers will be picking up part of the tab as well, it's just a question of how much. I think that even proposing that individuals pick up half the costs, i.e. taxing their wages and salaries at 19%, is going to create a huge uproar. Employers are going to have to do more. That actually makes sense, since they will be receiving a huge benefit by being freed from the obligation to pay for employee insurance plans, and they'll benefit from a healthier labor pool whose members aren't stressed about how they're going to pay for their families' medical bills. So let's have a 1/3 employee contribution, and a 2/3 employer contribution. For every dollar deducted from a paycheck, the employer kicks in two. That leaves us with approximately 12.7% and 25.4% tax rates on wages and salaries to fully fund the NHT and provide universal health care.

And that seems huge! That is, until you start to figure in how universal care will help the tax burden in other areas. The current Medicare payroll deduction would disappear for both employees and employers, and that is currently at 1.45%, reducing the net change for employee deductions to a more slightly more respectable 11.25%. Medicaid and Medicare would be superceded, as would SCHIP and a host of other programs. This would reduce federal and state budgets, opening the possibility for reducing the "normal" tax rate on adjusted gross income. And of course employees would no longer need to be spending huge amounts of their personal, pre- or post-tax income on health care costs. This is what I meant by making the funding scheme transparent -- funding SCHIP by raising tobacco taxes, for example, is a totally obscure and convoluted revenue generation scheme that would no longer be necessary.

So that's what it would take to fully fund the NHT. We went through this exercise, however, because we want to create a more limited program, initially only covering pregnant women and children, but we want to set it up to allow for easy and incremental expansion. Once the framework is in place, all we need to do to cover, say, all children up to the age of 10, is determine how much the NHT payroll deduction percentage needs to be raised to generate the necessary revenue. And then do the same to cover children up to the age of 18... In this way we incrementally implement true universal coverage, by gradually shifting current tax burdens to the NHT payroll deduction.

Again, I don't have exact figures for what the health costs would be for the initial set of enrollees, but let's assume that the average per-capita health-care expenditure applies to them as well. We're attempting to cover about 29 million people, so in 2004 we would have need to raise 183 billion dollars. Using the 2 to 1 employer to employee contribution ratio, that would have required a 1.25% deduction on each paycheck, with a 2.5% match from employers.

Still with me? Wondering how much that would cost the "average" taxpayer? More than 2/3 of Americans had total reported wages and salaries below $50,000 in 2004. If you were lucky enough to reach that plateau, you would have had to shell out $625 in order to provide one year of health care to every pregnant woman in America, and to cover every child under the age of six. If you made $30,000, your contribution would have been $375. That sounds perfectly reasonable to me, and apparently it did to the majority of Americans in that New York Times poll on health care issues mentioned earlier.

In conclusion, the costs for the NHPIC to individual taxpayers would not be excessive, but by making them transparent it becomes much easier for them to think about how much we would want to expand the program and how much they would have to contribute. All it takes is an honest politician who is willing to explain that you're not going to truly address accessibility and affordability issues in the health care system with a tax cut. Yes, this will require a tax increase, but it won't be as bad as you've been lead to believe, and you'll be able to go to bed at night with a clean conscience.

-- cbu (07/27/2007)

If we were to create a single-payer system of universal health care, and if we could initially only cover 10% of the population, which group should be first in line?

Perhaps the 45 million Americans currently without health insurance? Sure, that represents 15% of the population rather than 10, but that percentage was chosen arbitrarily anyway. Unfortunately, this is a moving target; as soon as you tell the country that we're going to provide free health care so long as you don't have insurance, you're going to see those ranks swelling rapidly and you'll overwhelm the system.

Should we target the poor, and have an income eligibility limit? Not only is this also a highly variable population, but you immediately have to confront moral subtexts and arguments about helping the deserving vs. the undeserving poor. You'll also create enormous resentment amongst those who earn just a little more about the cutoff and end up with nothing. (Any plan based on income eligibility must have sliding benefits or fee schedules to avoid this last issue, and that is contrary to the ultimate goal of universal single-payer coverage.)

Complete transparency is required in all aspects of this plan, and that includes clear, distinct, unimpeachable eligibility guidelines. And that leads to carving up the population by age. The two populations that would benefit most from universal coverage are the elderly and the young. There are about 37 million seniors over the age of 65 (12% of the population), and about 20 million children under the age of five (6%).

The federal government already provides subsidized health plans, flawed as they might be, for both the elderly and the young: Medicare and the federally-funded State Children's Health Insurance Program (SCHIP). Any new plan is going to supercede, in whole or in part, one of these programs, which introduces new interested political actors into the equation.

Of the two, Medicare is much more entrenched in American society. Enacted in 1965 during the Johnson administration as an amendment to Social Security legislation, Medicare is actually administered by private insurance companies. SCHIP, also enacted as a separate Title in the Social Security Act, was implemented in 1997. It provides federal funds to individual states allowing them to help subsidize health insurance for families that exceed the maximum eligibility requirements for Medicaid. States generally act as insurance brokers, directing participants to private insurers.

If you're going to take on the insurance lobby, you don't want to start with Medicare. This is their primary federal feeding trough, in which they get to channel more than 250 billion dollars through their accounting systems. SCHIP, on the other hand, was alloted just 5.6 billion from the federal government in 2007 (as grants to be matched by the states). Continuation and expansion of SCHIP has recently proved to be a contentious issue for Congress, even though it has bipartisan support, with the president promising to veto increased allocations. It is, however, that bipartisan support of SCHIP which suggests that a program like the NHPIC might at least get a hearing in Congress.

Another political consideration is the prospect of public support for providing universal health care to infants and children. Americans believe in the notion of the "common good." We are willing to make personal sacrifices to help others in need. We support policies that strengthen families, realizing that healthy, educated, well-fed children make all of our communities safer and more secure. These are the social values that we expect our elected representatives to bring to the fore as they formulate policies on health care.

In a recent New York Times poll on health care issues (conducted February 2007), a majority of Americans stated that the President and Congress should concentrate on ensuring universal health care coverage. This easily trumped issues of immigration laws, "traditional values," and reducing taxes. Three out of four stated that making health care available to all was more important than retaining any recent tax cuts. When asked specifically about expanding SCHIP to cover all uninsured children, the results were even more stunning:

34. Currently, a government program provides health insurance for some children in low 
and moderate income families.  Would you favor or oppose expanding this program to 
include ALL uninsured children?  
 
          Favor      Oppose      DK/NA 
          
2/23-27/07  84        11          5 
        

Beyond political considerations, a program like NHPIC is just good social policy, which I believe is reflected in these poll results. One of the cornerstones of universal care is an emphasis on preventative medicine, the idea that if you make it easy for patients to see a doctor before a problem becomes more serious, you will have large cost savings down the line. Providing all of the care required by infants and young children will, quite naturally, lead to healthier older children. Similarly, providing proper pre-natal care to pregnant women has been shown over and over to lead to healthier babies. Most Americans (well, most humans, actually) understand this implicitly, which is one reason they are so willing to volunteer more of their own income in taxes to ensure health care for families that they don't even know.

35. IF ANSWERED "FAVOR" TO Q34, ASK: What if that meant you would have to pay more 
in taxes? Then, would you favor or oppose expanding the government program to include all 
uninsured children? 
 
          Favor      Oppose     DK/NA 
          
2/23-27/07  67        12          4 
        

Finally, providing guaranteed, universal health care to infants and children makes for good social policy because it provides a huge benefit to their parents as well. Beyond the monetary benefits, which would be huge for a new family, the NHPIC would provide a measure of security allowing them to focus on raising their young families. If you haven't noticed, bringing babies into the world is a tremendous life transition in which priorities are re-arranged in ways these parents never anticipated, no matter how much they were told it would. Many of them feel obligated to retain their old employment statuses and patterns because suddenly maintaining that company insurance policy (even with its rising premiums) is crucial.

So, if you are only going to initially cover one segment of the population with a universal single-payer system, it just makes sense to start with pregnant women and children first. Then let's ask how they like it, if they think that their five-to-ten year-olds should be covered as well. So long as we design a program with the possibilities for easy expansion and a transparent financing scheme, we'll be on the road to eventually resolving this issue once and for all.

-- cbu (07/26/2007)

I have a lot to do for my professional work this month, including preparing two new classes that I will be teaching in the Fall and this pesky little dissertation that I'm writing, so I really don't have that much time to spend on political issues. But I'll allow myself ten minutes a day to think about how we can create a more just society. Reforming the national health care system is at the top of my list this week.

It is obvious (to me, at least) that if we really want to provide universal health care in this country, the only reasonable way to implement it is with a single-payer system. The current system in which some (but not all) employers offer health insurance with highly variable benefits and employee costs, in which the state subsidizes some (but not all) unemployed/underemployed/uncovered citizens through programs like Medicaid and the Children's Health Insurance Program, in which the elderly are eligible for Medicare but still need supplementary insurance and still pay for many expenses out of their own pockets, ... This system doesn't work. It is too complicated, the illusion of "choice" makes everything more rather than less confusing, and every new program only adds a new layer of bureaucracy driving up administrative costs.

Most major presidential candidates have proposed some plan that pretends to approach universal coverage, but they all still rely on the "insurance" model and none will actually guarantee that every American will receive the health care that they need. Unfortunately, most of our political leaders -- like many in the electorate -- tend to equate the option to enroll in insurance plans with actually receiving care. In many cases, insurance companies act as gate-keepers to our nation's doctors, clinics, and hospitals. Providing greater access to a dysfunctional, costly system does not represent true reform.

Insurance companies learned a long time ago that the only way to make the health-care system work with a limited financial investment is to redirect revenue flows away from those areas that cost them the most money. As citizens and as policy makers, we need to apply that lesson to the entire system. To make better use of our health-care dollars, we must remove unnecessary actors that divert funds from providing care. The only way to make fundamental change, to provide expanded and improved coverage without increasing monetary outlays, is to eliminate those insurance companies.

We must institute a single-payer system in which the government automatically enrolls every citizen and pays for all medical expenses. So long as profit-maximization remains a primary incentive in the health-care system, the needs of the citizenry cannot be sufficiently met. However well intentioned insurance companies might be, they inherently divert resources away from patient care. Every dollar spent on lobbying or advertising for an insurance company is a reckless abuse of limited resources. Every dividend paid to a company stockholder is money that could have been spent providing pre-natal care to an expecting mother. Every doctor employed by an insurance company to review claims is a doctor who is not in a neighborhood clinic diagnosing disease. The only way to address the havoc that private insurance companies have wreaked on the health-care system is to make them irrelevant, take them out of the equation.

Getting us from here to there is a great challenge. There are political parameters to be dealt with. The insurance lobby is obviously very powerful, and won't take too kindly to proposals that render them obsolete. There are also logistical parameters: how could we possibly create a program that enrolls all 301 million Americans overnight? This is simply not going to happen, and attempts to do this all in one fell swoop will undoubtedly fail.

After thinking about this for an hour or so over my lunch break last Monday, I figured out the solution. We propose a single-payer plan with universal coverage for a subset of the population. Create a limited program that is designed to be expanded in a logical, orderly way, but will also be effective for those it enrolls. Spend a few years working out the bureaucratic bugs, and if it proves to be popular then the public will demand that the program's coverage population be increased.

More tomorrow on why this first subset should be infants and children, just in case that isn't readily apparent.

-- cbu (07/25/2007)

I've been obsessing about national health care lately, or more accurately about the lack thereof. I finally decided to create my own proposal and send it to Congress for approval.

Raising a family is hard enough; the least we can do as a nation is to help parents receive the care they need for their children. To guarantee that any child who walks into a clinic or hospital will never be turned away, the federal government should create a National Health Program for Infants and Children (NHPIC). You could think of this as a national insurance program, but it would cover all pregnant women and children up to the age of six, and it would have no premiums or deductibles. The only costs to the participants would be a $20 co-pay per visit and a $10 flat fee for medications. Upon enrollment in the NHPIC a family could apply for a percentage reduction in the co-pays and prescription fees based on annual income.

Any health clinic or hospital that receives any form of federal funding would be required to accept and treat a patient enrolled in the NHPIC. The list of available treatment options would be transparent and determined in advance, perhaps informed by the National Institute of Health's guidelines. Health-care providers would have to negotiate reimbursement costs with the NHPIC, but this would never involve the patient or his/her parents -- no bills would ever be sent to the family household. The NHPIC would also cover all pregnant women to ensure proper pre-natal care, and include their post-natal care up to 90 days following childbirth. All children would continue to receive free coverage up to the age of six.

We'll see how far that gets us. More later...

-- cbu (07/24/2007)

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