One of the founders of the evidence-based medicine movement, Muir Gray
Fascinating, how in the same week two giants of evidence-based medicine have given such divergent views on the future of quality improvement. Here (free subscription required), Donald Berwick, the CMS administrator and founder and former head of the Institute for Healthcare Improvement, emphasizes the need for quality as the strategy for success in our healthcare system. But here, one of the fathers of EBM, Muir Gray, states that quality is so 20th century, and we need instead to shine the light on value. So, who is right?
Well, let’s define the terms. The Merriam-Webster dictionary defines quality as “the degree of excellence.” The same source tells us that value is “a fair return or equivalent in goods, services or money for something exchanged.” To me “value” is a holistic measure of cost for quality, painting a fuller picture of the investment vis-a-vis the returns on this investment. What do I mean by that?
Simply put, the idea behind value is to establish what is a reasonable amount to pay for a unit of quality. Let’s take my used 1999 VW Passat as an example. If my mechanic tells me that it needs to have some hoses replaced, and it will cost me under $100, and the car will run perfectly, I will consider that to be a good value. However, if my transmission has fallen out in the middle of Brookline Ave. in Boston (really happened to me once, many years ago and with a different car), and it will cost me $5,000 to fix, I may say that the value proposition is just not there, particularly given that the car itself is worth much less than $5,000. Given that my budget is not unlimited, I have to make trade-off decisions about where to put my money, so I may instead spend the money on another used Passat that has good prospects.
But in medicine, we routinely avoid thinking about value. There seems to be an overall impression that if it out there on the market, and especially if it is new, it is good and I am worth all of it. This impression is further enabled by the fact that CMS has no statutory power to make decisions based on value of interventions — they are legislatively mandated to turn a blind eye to the costs. Does this make sense? How toothless is our comparative effectiveness effort likely to be if it has to ignore half of the story?
Let us now look at my favorite sticky wicket, ventilator-associated pneumonia, or VAP. Now, the IHI bundle aimed at eliminating VAP consists of 5 points of intervention: 1). semi-recumbent positioning, 2). daily screen for readiness to get off mechanical ventilation, 3). daily sedation vacation, 4). prophylaxis against GI bleeding, and 5). prevention of clots. As I have mentioned before elsewhere, adherence of 95% to all these measures is deemed compliance and may be ultimately used as a quality measure by payers to determine levels of reimbursement. And while each of these interventions is basically “motherhood and apple pie”, applying them blindly and in toto to 95% of intubated patients may be a strategy for disaster. But what is even clearer is that, in order to implement this and all of the other quality improvement strategies, systems need to be put in place that will safeguard against failing to implement these quality measures. The time and resource expenditures needed to institute and maintain these systems, which have not been described in great enough detail as far as I am concerned, have never been quantified. So, what we are left with is a bunch of interventions that, while looking OK individually in clinical trials (until you really start looking at them critically), are likely providing small, if any, gains in quality at the margins, whose investment-return equation has not even been disclosed, let alone balanced. And because budgets are necessarily limited, as are clinicians’ time and cognitive capacities, we need to select a sensible menu of interventions from this practically unlimited feast.
This is the quality conundrum, a clear case of chasing our tails to achieve perfection at the expense of good enough. And while no one in their right mind will argue with the language of improved quality in healthcare, I do think that Muir Gray and his camp are on to something that has been a long time coming. At this time of shrinking budgets, competing priorities and tightening resources, does it not make sense to look at value as a package deal, rather than merely at quality in isolation from its context? Instead of being bombarded by ever-increasing volume of quality measures coming from many directions, would it not be more sensible to prioritize these interventions based on the value that they bring rather than merely on their projected outcomes benefits, so frequently estimated based on data that have very little applicability to the real world? Let’s start asking the question: how much quality and at what price? Without paying attention to this critical balance, we will not only bankrupt the system, but also worsen outcomes paradoxically, as we continue to overwhelm clinicians with infinite minutia that may or may not be generating helpful outcomes.
So, in my book, Muir Gray: score; Berwick: keep trying.
Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. Dr. Zilbergerg is also a professor of Epidemiology at the University of Massachusetts, Amherst. She blogs at Healthcare, etc.
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perceived value, different people will rate quality different but for the most part yes
I’ll be short and just say: quality is the measure for value. Isn’t that right?
So, in my book, Muir Gray: score; Berwick: keep trying.
I second
This is a false choice. What earthly good is quality without value or value without quality? There’s no “value” (which people interpret as low-cost) without a minimum level of quality.
The point of having choices is being able to find the “sweet spot” for each person that balances the quality they can get with the value they can afford.
And when it comes to health care, that’s almost always going to be what does the most good for the most people, not the tail ends of the bell curve.
There would be no distinction here if each and every provider had to have a cost discussion with each and every patient: How much is it? Do I really need it? Is there an alternative?
This is where 3rd-party payers have actually done a disservice, by inadvertently short-circuiting those discussions for the past 30 years.
Margalit,
I’m for option number 3. Costs can be reduced in a fair and equitable way. I’m a primary care physician that launched http://www.HealthScepter.com to help patients shop in the forming cash medicine markets. Medication, lab, and imaging costs can all be lowered significantly in the cash markets by up to 80%. One local imaging center (ACR-certified of course) will do MRI’s for $400. Reducing the cost of the same MRI service from $3,000 to $400 = value for the patient, reduced costs for insurers and reduced cost for the system. My work on HealthScepter is “an honest attempt to come up with an equitable solution.”
Ask questions of your provider to find out about the value and to determine if you’re paying too much or getting unnecessary treatments. Here’s some ideas: http://whatstherealcost.org/video.php?post=five-questions
I am not MD as Hell, but this commenter and I seem to think alike on most issues, because while I cannot and will not speak for anyone else but myself, doctors who think like me take the stands we do because they probably had a strong, solid training experience and gravitated to supervisors/mentors who did not believe physicians sell out to non providers for direction/control.
Unfortunately, that it not the case for what I believe is the majority of colleagues, and certainly not of the graduates from medicine in general these past 10 or more years!
Thank you Mr Holt for noting to Mr G to cease and desist his ridiculous accusations!
haven’t seen nearly as many spam post, haven’t been uncontrolably tempted to buy any vitamins read alternative medicine sites since the new system.
Are the Winstom Sock Pupperty trials over now or just beginning? Wouldn’t any self respecting sock puppet at least put in the effort to set up a dummy email account and spoof an IP? I think any dissenters from the prevailling ideology should be required to provide DNA at that least, right BobbyG? Either that or public dippings in NYT and Daily Kos to see if they float or sink.
BobbyG–Determind MD and MD as Hell are different people (or at least have different emails and different IP addresses!)
Guys. Sorry about the issues with comments. The new WordPress system shunts suspected spam into a “needs to be approved” file. Somehow it captured about 20 or so from your regulars (as well as a ton of spam). The new system is easier to manage than the old one, but it’s not perfect yet. Hang in there please! Lots more improvements will arrive….
“To bad Stupidty can’t get you banned.”
___
You’d be gone, that’s for certain. I know that “excapes” you and your own brand of “Stupidty.”
“As far as I know, Dr. D, illegal immigrants cannot vote, Democrat or otherwise, whether they have access to health care or not.”
Their kids can, and they have the highest birthrate of any Americans. Further they have engaged in election activity, while not the same as voting enfluencing voting should also be a problem, foreigners should not be impacting our elections.
While the legally can’t vote that hasn’t stopped them from doing so
http://www.fairus.org/site/News2?page=NewsArticle&id=16957&security=1601&news_iv_ctrl=1010
To bad Stupidty can’t get you banned. For Determind MD and MD as Hell to be the same person they would beed to be bi-polar or suffer from multipersonality disorder. Their writing styles, diction, and experiences are noticebly different. Finally its THCB and they are just posters why the heck would they need to engage in sock puppetry? Its common when people are posters and use it to agree or advance their original post or they use it to make it appear like multiple people feel the same way. How often do you see the two of them post in the same thread let alone agree?
Now certain commentors that keep making pointless ignorant comments that don’t advance the subject or even address the subject, if we could get rid of them….
“We” don;t need to decide anything if the patient holds his/her money and uses it as he/she sees fit.
The boomers are toast once the genX and etc. voters get a majority; they will reform Medicare in a moment of time.
Only the payor can decide value. But if the patient is not the payor, then there is a dissonance that is intolerable in the long run.
I would also like them to look into whether the always hyperbolic and untraceable “Determined MD” and “MD-as-Hell” are a Sock Puppet duo (i.e., the same person posing as different posters). That will get you banned from most reputable blogs.
“So far, no”
LOL, I would think Nate, above anyone, would have to have his comments reviewed for “moderation”.
No, but I had a problem with comments vanishing into thin air. I rebooted my router, thus obtaining a new IP address and the problem was resolved.
” Anyone else had this problem?”
So far, no but I liked the old format better.
Can somebody tell me why my comment is not being posted and has this at the top: “Your comment is awaiting moderation”
Moderation from what? I’m assuming there is a site “moderator” or administrator? Why has this happened more than once? There is no way to report site problems with this new format. Anyone else had this problem?
As far as I know, Dr. D, illegal immigrants cannot vote, Democrat or otherwise, whether they have access to health care or not.
“…asking providers to provide care for slave labor fees”
Since you said “providers”, I assume this goes beyond physicians and it includes hospitals. I would say that there is a huge area of acceptable fees between current provider fees and slave labor. Primary care excluded from this statement.
You want to talk about freeloaders, then what is the agenda of the Democrat Party wanting to provide what is basically amnesty to illegal immigrants and then allow them to be in our health care system? I’ll tell you what the agenda is in 3 words: More Democrat Voters. After all, who ya gonna thank for accessing our health care system for what will amount to free, because you think the majority of illegal immigrants are going to access private insurance? No, they will not, they will go on Medicaid rolls, and anyone who argues otherwise is either as insincere as the term comes or is so clueless and mesmerized by the Democrat false rhetoric that they would believe the sky is green if the Democrats said so.
Ms G-A’s comment of abetting 99 bums to avoid hurting one honest person is in fact that lame Democrat logic, even if she herself is not a Democrat. You are only aiding and abetting dependency, by believing we have to help every single person irregardless of cost for every issue that comes through health care provider doors, and that is not realistic in this day and age. Again, I am not advocating for abandonment or “death panel” ideology, but, something has go to give, and just asking providers to provide care for slave labor fees is not going to encourage or motivate the majority of honest, caring health care workers to stay in such a system.
The usual suspects will just add in their usual insults and demeaning perspectives of providers, especially physicians, and that is because they have their agenda to force this mind set on the public.
Wanna bet the loudest advocates for slave labor on physicians themselves go to boutique practices, and not only expect but demand the best and most up to date interventions? That is because the advocates and defenders of Obamacare are the textbook examples of hypocrisy. Just don’t expect them to tell you so.
To focus on Medicare and Medicaid for a moment, I think there are different forces driving the costs of these two programs. Prices per procedure, which is a huge issue for commercial insurance, is less of an issue in the two government programs because both use administered or dictated pricing which, supposedly, bear some relationship to the actual cost of providing care. However, even Medicare pays more per procedure than is typically paid in other developed countries.
Medicaid is really two separate programs – TANF + SCHIP and ABD. Children beyond the age of one year are comparatively cheap to cover. I’m told that over 35% of the costs to provide care to the TANF (Temporary Aid to Needy Families) population are for maternity care including labor and delivery. These two programs combined account for 25%-30% of Medicaid costs. The real money is in the ABD (Aged, Blind and Disabled) program. Here, we’re talking about huge outlays for skilled nursing care and home health care. There are big opportunities for fraud, including the provision of clearly unnecessary care to drive revenue for nursing homes. These providers need to be subject to rigorous utilization review.
Medicare, which serves the 65 and older population plus certain disabled people and those who need kidney dialysis, needs a different focus. Here, hospital based care is a more significant cost factor and we need good utilization review as well. There also seems to be a lot of fraud in the areas of durable medical equipment, like power wheel chairs, home health care, physical therapy and simply billing for care that was never provided for care for people who have already died. Access to the Medicare claims database, including aggregate billing by individual providers, could help to expose abuses on a more timely basis and eliminate many of the crooks from the Medicare system altogether.
To drive more cost-effective care generally, I think we need disclosure of actual contract reimbursement rates paid by private insurers, bundled pricing for surgical procedures and risk adjusted capitation for primary care. The faster we can move away from the fee for service payment model, the better.
Separately, I would be interested if Steve could provide some examples of lower tier care that the poor would not be eligible for. Are we talking more limited access to expensive specialty drugs, fewer care options at the end of life, or a basically similar benefits package but provided by less experienced physicians and other medical personnel than those who would typically serve the middle class and the wealthy? I think the concept is reasonable but I would like to better understand how you envision it working.
Steve, I would agree with a multi-tiered approach, if the tiers were differentiated by amenities, such as private rooms, orchestras in the lobby and private waiting rooms with personal Bose surround sound.
I would not favor multi-tiered standards of care though.
I think I started by saying that I have no objection to Barry’s suggested anti-fraud measures, so why mix apples and oranges?
Medicare fraud has nothing to do with somebody signing up their kid for a free school lunch. Those who fraudulently extract large sums of money from federal programs are usually not in need for a fake pass at the lunch counter.
You are again going to extremes. How many folks on food stamps drive BMWs?
The reason these programs are so expensive has very little to do with impoverished citizens trying to get a literal free lunch.
Barry, I also think taxes should go up, but they should be used to provide national health care coverage to all, automatically, so nobody has to cheat their way into the exquisite Medicaid system.
“My problem is liberals never admit there are free riders, welfare queens, and bums. ”
I work at a trauma center on the wrong side of the tracks. I work with the scum of the earth, if it is ok to be non-PC. I see some of these people almost every day. But, it is not like the old AFDC days. Most of the people on Medicaid, the poor people, are the working poor. Also, even the scum have kids, unfortunately. Rather than obsess over the minority of bad people, I would like to address the needs of the majority of these folks who are decent folks who dont make enough money to pay for health care. I have no problem in principle with not providing care for some of those truly awful people, but tell me how we can realistically do it? (BTW, the last time I looked, welfare moms, on average, have about the same number of kids as everyone else.)
So much of first world medicine is going to be expensive no matter what we do. Premie care, just to take one example, is expensive everywhere. It takes too many people and too much specialized equipment. If you make $6,000 a year, even a $1,000 CT scan is a big deal.
You are correct that we cannot afford care for everyone on our current path. The problem is that the percentage of people who cannot afford care will just keep growing. We need to bring down costs for everyone. We know it can be done since it is done in every other first world country. If, as part of that solution, we have a two (multi) tiered approach so that those who are not paying for their care get a lower level of care, I have no real problem with that. My caveat wold be that it not actually add to costs in the long run by delaying needed care. Here I am thinking HTN and DM and fending off ESRD and CAD/CHF in particular.
Steve
so its even worse, great way to ruin a sunday Barry.
I’m giving up, I’m going to the sugar shack to join the underground economy. Medicaid, Food stamps, and welfare for me, then with all my maple syrup money I never claim I can buy the BMW and my 10 month vacation when the sap isn’t flowing. Why work when Margalit is begging for the chance to give it all to me for free.
Nate — Actually the total cost of Medicaid is north of $400 billion including both the federal and the states’ share.
To follow up on my last comment, I think we need to do the following with respect to the entitlement programs:
The big potential savings in Medicare and Medicaid gaming is reducing provider fraud – mainly by doctors and hospitals. It would also be helpful if the extensive Medicare claims database, including aggregate payments to individual physicians, were made available to outside analysts. This is currently prohibited by a 1979 court decision but appropriate legislation could presumably change that.
For the means tested entitlement programs like Medicaid, food stamps, housing vouchers, subsidized school lunches, etc. we need to go after the individual gamers using the strategies I mentioned previously – national ID cards and rigorous income verification by the IRS.
Many people say they would be fine with government programs and spending and the taxes to finance them if they perceived that the money is spent wisely. The fraud and gaming makes taxpayers cynical and resentful which has a corrosive effect on the society and the culture. They feel like they are being played for chumps. Liberals, I think, would help their cause if they were more on board with reducing excessive or inappropriate payments to the gamers and fraudsters.
Finally, to bring government spending and the revenues to pay for them into closer alignment, taxes need to increase, not just on higher income people but the broad middle class as well. Since I said I would prefer a broad income base with lower marginal rates, here is a list of the major changes I would recommend, most of which affect me personally.
1. Phase out the tax preference for employer provided health insurance over five years.
2. Phase out the mortgage interest deduction over ten years.
3. Limit the charitable deduction to the extent that it exceeds 2% of adjusted gross income. Personally, I would give just as much to charity without the deduction.
4. Limit the deduction for state and local income and sales taxes and local property taxes to the extent that they exceed 5% of adjusted gross income.
5. As long as the top marginal rate is 28% (the 1986 Tax Reform Act level) or lower, income from capital gains and qualified dividends should be taxed at the same rate as ordinary income.
6. The middle class and lower middle class could be protected, at least for the most part, by raising the standard deduction while, if necessary, the Earned Income Tax Credit for the working poor could be increased as well.
When we are young and idealistic its common for our beliefs to make no sense, by the time we are tax paying adults and voting we better have our S*#$ together.
” better 100 bums get a free ride than one honest person suffering unnecessarily.”
” I do agree that we are wasting resources on two bit gamers and small time thieves, but I hardly think they are the main driver to the financial collapse of health care financing.”
Have you ever taken the time Margalit to actually think this out? To do the math on your beliefs?
If 100 bums get benefits for every honest person that is 99% waste. Obviously you were being rhetorical but where is the number you are ok with? Right now we have documented 10% of Medicare benefits are outright fraudulent and much more is wastes or paid to non deserving people. Medicaid eligibility, which is in such terrible shape most states can’t even do an accurate audit, the known number is 13%+.
Medicare is over 500 billion a year, that means we know we are losing 50 billion for sure with the true number closer to or over 100 billion.
Medicaid is around a 200 billion program meaning we are losing at least an additional 26 to 50 billion.
No white collar crime even begins to get close to 80 to 150 billion a year. Do you think 80 billion a year wouldn’t make a difference in our healthcare system? What we lose in fraud would have balanced our budget in a number of years.
If you’re OK with the current waste and fraud how hi are you willing to let it go before you admit it is a problem?
“I am not willing to sit in judgment on who is, or is not, deserving.”
You already do.
“those who seriously raid the tax payers’ cookie jar are more of the five-thousand-dollars suit & tie type than the hoodie and flannel shirt type.”
You clearly have decided the hoodie and flannel shirt type are deserving and those that have been successful are not. You are willing to turn a blind eye to fraud committed by those you deem deserving but will be the first to arms when you think someone successful is benefiting. What’s amazing is how you have brainwashed yourself to not see the hypocrisy. This is exactly why we will never find a solution as long as Liberals have a voice. No system built on abuse and graft will ever be sustainable and Liberals won’t allow any system not built on such. If you can’t feed your preferred classes and buy votes you rather everyone suffer, honest and crooks.
Margalit – I don’t have any love for the lobbying aristocracy either, but we have a money driven political system and structure and what the lobbyist are doing is not illegal, at least for the most part. The more government programs and tax preferences we have and create in the future, the more constituencies we will have that fight to protect them with lobbying money. On the tax side, I’ll take a broad base and lower rates like we had from 1987-1989. On the discretionary spending side, we should shrink the scope of government and get rid of programs that have outlived their usefulness or were never effective in the first place starting with ethanol subsidies.
Regarding your comment that waste and fraud in benefit programs is mere collateral damage and it’s better to tolerate a hundred freeloaders and bums than risk one honest person going without benefits I think is exactly the mentality that makes these programs as expensive and fraud ridden as they are. The attitude among too many of the federal, state and local government employees who are in charge of determining eligibility seems to be: If it doubt, put the money out. After all, we mean well and besides, it’s not our money anyway. By contrast, a relative of mine sees who works for the Social Security Administration sees himself as a guardian of taxpayer resources. His objective is to ensure that the right claimants get the right amount of benefits at the right time. We need more like him in that role.
“I think a lot of that has come from the taxpayer and was not earned.”
The financial bailouts proved this. If this was honestly earned then we wouldn’t be in this mess now. What also comes from the taxpayer to prop up dishonest unregulated money flipping is, unemployment benefits, massive un-collectible property taxes, welfare payments, food stamps, education layoffs, etc. If we did not pay for these things then how would we measure corporate failure? There is a lot of history in bailouts for the unregulated wealthy as well as local tax breaks to corporations. Part of why the health care uninsured remain hidden is there is no way to measure the collateral damage.
“what about those that don’t work or work poorly? Unless your mentally or physically incapable I don’t think we should have any handouts.”
http://money.cnn.com/news/specials/storysupplement/bankbailout/
http://articles.cnn.com/2008-12-22/us/bailout.accountability_1_tarp-money-bailout-money-troubled-assets-relief-program?_s=PM:US
http://projects.propublica.org/bailout/list
“Welfare, foodstamps, Medicaid, public housing should all require labor paid at the rate of $5.00 an hour to get them.”
Labor where and paid by whom? And do you expect the children to also work for $5/hr? Have you looked at the ratio of line ups to jobs offered? Tell you what, in order for the high paid benefactors of all the above bailouts why shouldn’t they work for $5 an hour, or donate labor to stand in front of all the people they’ve hurt?
I disagree, Nate. I am not willing to sit in judgment on who is, or is not, deserving.
To your point and Barry’s point, I do agree that we are wasting resources on two bit gamers and small time thieves, but I hardly think they are the main driver to the financial collapse of health care financing. I think Bobby’s assessment is correct in that those who seriously raid the tax payers’ cookie jar are more of the five-thousand-dollars suit & tie type than the hoodie and flannel shirt type.
I would be fine with anti fraud measures like the ones you describe Barry, but I have to confess that my tolerance for the lobbying aristocracy robbing us all blind for no particular reason other than sheer greed is much lower than my tolerance for someone buying a pint of liquor with food stamps worth a few bucks.
I think we need to deal with whatever provides the biggest bang for the buck first.
“My problem is that I see gaming of the system everywhere.”
This is precisely why Libertarianism has thus far been proven full of [bleep], empirically.
The United States of Scamerica. Shortly to again be on visible display by the grifters working as we speak to cash in big-time on the Japan Earthquake / tsunami tragedy.
And, in coda, I would readily proffer a BET that the clean-nails, top-shelf, politically connected scammers virtually obliterate by dollar volume any ill-gotten gains, in the aggregate, of those totemitc Welfare Queens and other “moochers.”
Margalit – I, for one, have absolutely no problem in paying taxes to help people who genuinely need help. My problem is that I see gaming of the system everywhere. It includes doctors and other medical providers who commit fraud against Medicare and Medicaid. It extends to people who claim dubious injuries to qualify for Social Security disability benefits. Then there are those who hide or understate income to qualify for more food stamps, housing vouchers and subsidized lunch for their kids than they are legitimately eligible for if they are eligible at all. Tax fraud by people who earn income that is not reflected on W-2 or 1099 forms is a huge problem. With modern technology, we should require everyone, at least over the age of 16, to have a national ID card with a name and address, a picture and a finger print or some other biometric identifier. As a taxpayer, I don’t think it’s too much to ask people who are applying for government benefits to at least prove that they are who they say they are and to expect their income to be verified by the IRS before benefits are approved. It’s amazing to me that there are people who are barely literate, yet when it comes to applying for government benefit programs, they seem to have PHD’s in gaming the system.
“better 100 bums get a free ride than one honest person suffering unnecessarily.”
Problem Margalit is all the free rides are causing honest people to suffer unnecessarily. You would be the first to say the poor need better healthcare, why aren’t they getting it? Because we can’t afford it. Why can’t we afford it? Becuase all the money spent on people who don’t deserve it. For some reason the Democrats always pick the free loaders over the honest people.
You know Nate, I think the hand-outs to free-riders and bums is just collateral damage of liberal programs, just like tax cuts to wealthy thieves, who never created a job in their life, is collateral damage of conservative policies.
Nothing can ever be perfect, but to borrow from the legal system, better 100 bums get a free ride than one honest person suffering unnecessarily.
Yes and we should do everything we can to help those people. My problem is liberals never admit there are free riders, welfare queens, and bums. None of the liberal programs ever address the problem of those that don’t earn help or do anything to prevent these programs from being abused. If liberals didn’t waste so much money on those that don’t deserve it we would have more then enough money to help those that do
Nate, whichever way we go, we always end up at the same point: hand-outs.
I am not going to debate your aversion to free-riders and bums, but I want to ask an honest question and I want an honest answer.
Do you understand that there are many decent, law-abiding, God fearing, hard working people, holding sometimes 2 or 3 jobs, and working as hard if not harder than most, who cannot afford comprehensive medical care?
On the last point not at all. I disagree with a large portion of Wall Street Activity. I think the way people manipulate the market and bet for corporate failure is contradictory to the original concept of corporations selling stock. The way George Soros made his money is even worse, I count on there being a special place in hell for people like him.
” I think that if you work more, or work better, you should make more.”
Does that apply to the converse, what about those that don’t work or work poorly? Unless your mentally or physically incapable I don’t think we should have any handouts. Welfare, foodstamps, Medicaid, public housing should all require labor paid at the rate of $5.00 an hour to get them. Oddly people always want to complain about and demand more from those that are working but never ask anything of those that aren’t?
How does income distribution matter in a discussion of poor not paying anything for their benefits?
If we discuss broad tax issues or funding of benefits paid with local and state taxes then I would agree. If you are discussing Federal matters and matters specific to federal taxation then local and state taxes are not relevant.
Yes, Steve, corporate profits peaked at about 40% from the financial services sector during the last decade at the height of the bubble — about 3 times what one could legitimately expect from an “agency function.”
This was accomplished by recursively bundling and flipping/re-flipping increasingly “bad paper” gussied up to look like just swell securities. The business model became all about an unsustainable combination of transaction fee income while concomitantly shoveling risk out the door. I worked in subprime risk modeling and management from 2000 to 2005, so I saw this stuff up close.
The upshot of all that huge swindle is to a large degree why we now have this intractable economic mess. Humanity in general has been running an increasing sustainability deficit since the mid-1980’s, but, given the very loose coupling of cause and effect and long boomerang times, it “excapes” most people.
“If you really want to go to school Steve I can drop you off.”
This is what I said. ” At present, payroll taxes, in terms of revenue collected”
http://www.whitehouse.gov/omb/budget/Historicals/
Table 2.1, Receipts by source. I will round off. In 2010 income tax revenue was $900 billion. Payroll tax was $864 billion. (If you prefer links to CBO data or BEA those easily found or I have them archived.)
“When I specifically discuss federal taxes why do you bring up local and state taxes? ”
I think that total tax burden is important. You are free to disagree and only state federal income tax numbers, but from my POV, that gives an incomplete picture. I think all taxes matter.
“Or maybe you just never knew that fact has nothing to do with the argument? Maybe the logic excapes you but we should expect people that work to have more income and wealth then those that don’t. ”
I thought you worked with numbers? If the top 1% makes 25% of the income, then if they were paying taxes at the same rate as everyone else, we would expect them to pay 25% of the tax. The denominator always matters. Feel free to make an argument against a progressive tax structure, but income distribution always matters.
I run a group that pays itself based upon productivity. I think that if you work more, or work better, you should make more. However, I do not believe that all of that growth at the top over the last few years came from productive work. IIRC, 40% of growth in the aughts was in the financial sector. I think a lot of that has come from the taxpayer and was not earned. I assume you disagree. I think that those who rent seek effectively are not really earning their money. Those who get special tax deals, are not really earning their wealth.
Steve
Welfare Queen myth? You mean there never were any welfare queens?
http://healthinpublichousing.org/aboutresidents.html
Over 21% of residents remain in public housing more than 5 years and nearly 17% of residents remain in Section 8 housing for more than 5 years.
“The primary source of income for 30% of public housing resident households, 15% of residents of Section 8 housing and 32% of Housing Choice Voucher residents is through wages.”
If 30% are earning income from wages then that means 70% aren’t. If 70% aren’t earning much income then they aren’t paying payroll taxes. Sort of kills your first argument Steve.
http://www.libraryindex.com/pages/2309/Federal-Government-Aid-Homeless-PUBLIC-HOUSING.html
“Thirteen percent of the population had been in public housing for more than twenty years, 17% for ten to twenty years, 21% for five to ten years, 23% for two to five years, 11% for a year or two, and 16% had moved during the past year.”
13% 20+ years, thats a lot of welfare