OP-ED

The Leaning Tower of Jello: Why No-one Believes Health Reform will be Deficit Neutral

President Obama has promised not to sign any health reform legislation that increases the federal deficit. This promise recognized rising public concern about an Argentinean fiscal trend that, unchecked, could leave us with $19 trillion in federal debt in a decade.

Without that pledge, given the current economic climate, health reform would be one dead mackerel.

Some clarifications are essential here. I’m a Democrat and fervent Obama supporter. I voted for him twice (and that was just in the Virginia primary). I’m proud of our President. He has first class economic and healthcare teams. He deserves credit for not postponing health reform. He’s right: it’s simply not tolerable, morally or economically, for a wealthy nation to continue having close to 50 million uninsured people.

The problem is, despite his great personal popularity, the vast majority of Americans do not believe his deficit pledge. A mid November Quinnipiac poll found that only 19% of Americans and 35% of his own political party believe health reform will not add to the deficit. The problem isn’t the President; it’s our sorry fiscal history, and his partnership with an increasingly discredited Congress.

Americans are having trouble understanding how, if it’s unhealthy for their households to have too much debt- the reason why we’re in so much economic trouble- it is prudent to cure our economic and social problems by plunging even more deeply into public debt. It’s kind of hard to swallow that the solution to a terrible economic hangover is drinking another case of Jack Daniels. America is on an epic fiscal bender, and the world’s collective tolerance for our drunkard’s excuses is wearing thin.

The reason almost no one believes health reform will be deficit neutral is our political system’s lavishly demonstrated inability to say no to anyone. American health care is a vast enterprise: we’ll spend more in 2014 on healthcare in the US than the entire GDP of Germany! Powerful political interests intersect in the health benefit: organized labor, capital markets, major manufacturers, doctors, lawyers, hospitals, pharmaceutical companies, health insurers, state governments, employers large and small. Have I left anybody out?

It is, in other words, a not-so-micro-cosm of the whole economy. Logically, if each one of the above named constituencies pitched in a little bit, we could cobble together $900 billion over a decade to accomplish an important social goal. Some have thrown in- pharmaceutical companies and hospitals willingly, insurers reluctantly but still significantly. A lot of other wealthy interests- technology manufacturers, physicians, the plaintiff’s bar and the unions most notably- don’t want to contribute anything and may skate away clean.

Exhibit A for the prosecution’s case about the inability of our political system to demand sacrifice is the so-called Doctor Fix problem. This is a legacy of an otherwise successful effort to balance the federal budget twelve years ago. In the Balanced Budget Act of 1997, Congress imposed what was, in effect, a global budget on the fastest growing part of Medicare- Part B, which covers physician care, home care, hospital outpatient care and a lot of new technology like medical imaging. If Part B spending grew faster than the nation’s economic output, the BBA required both beneficiary premium increases and across the board cuts on doctor fees.

This spending cap was a well meaning but comprehensive failure. After a couple of remarkably docile years, medical costs simply resumed rising as they had for the past thirty plus years. Every year except once (2002), Congress has declined to cut physician fees. The result is a fiscal crater more than $300 billion deep- the equivalent of a huge bad mortgage on the federal balance sheet. To substitute a ten-year fee freeze (an equally absurd solution) for the mandated cuts would “cost” about $318 billion in fictitious savings.

To let fees grow at the rate of medical inflation, a more realistic constraint give past history, would “cost” $439 billion, and to do that, and exempt beneficiaries from increases in their premiums would “cost” a magnificent $556 billion. What we’re doing now with Medicare spending is practicing a public sector form of Enron accounting, booking “savings” that do not exist. There’s an unfortunate amount of Enron accounting in the CBO “deficit neutrality” analyses, because CBO is required blindly to assume in its analyses that laws are, in fact, enforced, politics be damned.

Health reform adds a heap of new cost saving political obligations on Congress. A partial list:

1)that Congress not extend the five-year shelter for states from their share of the cost of a 15 million person Medicaid expansion (e.g. more than a 30% increase). Presently, states are sheltered from Medicaid cost sharing for this expansion until 2014, but then have to find $34 billion in new money to pay their share. States, who are drowning in Medicaid costs already, will press hard to have their existing matching requirements reduced, as they have been for S/CHIP in the two bills.

2)that any “public option” health plan be self-supporting after an initial start up investment, which must be repaid. Recent CBO analysis suggested that because it will attract a ton of sick people, public plan premiums may end up costing more than private insurance unless they are either heavily subsidized or else impose Medicare rates unilaterally. Who will sign up if it’s so expensive?

3)that premium subsidies to help support a 21 million-person expansion in private insurance coverage not rise if health insurance premium growth exceeds present estimates. The premium subsidies are a huge new entitlement- $574 billion over a decade in the more generous House bill. Neither Congress nor the CBO have the faintest idea how health insurers’ costs will be affected by all the proposed restrictions on their underwriting practices. The subsidy cost estimates are, therefore, a Jules Verne moon shot. What happens if, as seems likely, they are way too low?

4)that Congress let stand recommendations of the proposed (by the Senate anyway) “independent” Medicare Commission that would reduce spending below a target (and not fiddle with the deficit neutrality rule which requires them to find offsetting revenues if the cuts are not implemented). This Commission was forbidden by Senate charter from affecting hospital payments (45.5% of the program’s cost in 2007!), not an auspicious beginning. The House has thus far predictably refused to let go of Medicare’s reins.

5)that Congress not tamper with the health benefit package employers are mandated to provide or individuals are mandated to carry. In both bills, the relatively restrained “opening” benefit package is left under the (political) control of the Secretary of Health and Human Services. If there is benefit creep (chiropractic, podiatry, in vitro fertilization, massage therapy, reiki, you name it), the required premium subsidies will have to increase apace.

How confident are you that Congress will bite all these bullets and exercise fiscal restraint when confronted with organized advocacy? The CBO kabuki dance on health reform’s deficit neutrality has pivoted around the risible assumption that Congress will actually enforce laws, like the Part B cap, that require, at some future point, fiscal discipline.

So thank you, Thomas Jefferson (the patron saint of the town I live in- Charlottesville)! You wanted to forestall tyranny by designing a weak and divided central government. Little did Jefferson realize that 220 years later, we’d be trying to manage a $14 trillion economy or a $2.5 trillion health system with our founding fathers’ deliberately crippled political system.

Add to the mix a bitterly polarized and poorly informed electorate and weak Congressional leadership and you have a recipe for fiscal incontinence on a grand scale.

Appointing a Deficit Commission, as some have recently advocated, seems like an entirely predictable substitute for actually demanding sacrifice. This is how great civilizations end- not with foreign invasion, but rather creeping internal rot, not with a bang, but with pandering to factions and to the mob.

The capacity to execute a fiscally responsible health reform rests in sweaty, shaky hands. Lyndon Johnson once famously said of the special interests: “If you can’t take their money, drink their liquor, sleep with their women and then vote against them when you need to, you don’t belong in Congress.” No Johnsons or Rayburns, or for that matter, Mitchells or Tip O’Neills presently wield the gavel. The Republicans, of course did no better when they ran things, and have made a truly pathetic contribution to the present health reform debate. It is a bipartisan failure we have here. Against powerful focused economic interests, the American political system is a leaning tower of jello. Let’s hope it’s not strawberry, because the odds are we’re going to be swimming in it!

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42 replies »

  1. Hey Jeff, I am a week late on the draw here, but I would like to add some logs to the fire.
    1. While it is admirable to be so concerned about the fiscal issues, really, what does the government do when it needs money? It prints more. Federal money is not the same as cash in your pocket, which runs out. Yes the world is flatter than it used to be, but a large portion of the known world still depends on U.S. consumerism. Neither China nor Europe is anywhere close to replacing us as the world’s economic engine.
    2. The long-term benefits (long-long-term) of having people be well, of having children develop with pre-natal and pediatric care, of having parents counseled on nutrition and parenting and education, of having illness treated before it becomes acute and requires a LOT more care — these benefits will contribute an incalculable new resource and retro-fit a declining resource — a smarter, healthier workforce. Why should we (taxpayers, country, workers, businessmen) pay for healthcare for them (the poor and their children)??? Because it will give OUR children a much more competitive U.S.
    3. Grassroots healthcare reform is taking place all around us. We are doing our small part at Health Care Hiring (http://www.healthcarehiring.com), offering free resources to help people find jobs and careers in the health and medical sector. Others such as Cleveland Clinic, Renaissance Health and Practice Fusion are making major strides to reduce costs, redesign delivery models and provide more efficient care. Extending the healthcare system to the millions now unserved is only a piece of the puzzle — do we really want that swept under the rug again?
    Cheers
    Mike Clark

  2. Oh, Nate, are we ranting about what. The fact I Don’t Consider writing off Debt because the debt is no longer collectible; is any where near a agreement struck between the Doctor and Patient. Rather it is a business choice to be decided by the business Manager and /or Doctor. In this case it is not a negotiable Instrument but rather a business practice for debts that are Non Collectible.
    Well Nate you got me on a portion of this argument, but these doctors who give services for the uninsured , I would think are subsidized in some manner.However,You are not going to convince me a write off is a Negotiable Instrument for the Patient after the fact. The power of persuasion has nothing to do with Insults and abusive behavior that appears to be your personality. Even if you were right on all counts.Your demeanor grates against that very principle of persuasion . How to influence people and Win friends by Dale Carnagie would be a terrific Book for You.
    So what is your carear; Doctor , Nurse , RT and or Insurance agent? I’ will take a guess Insurance agent.If this is your true nature, then I would Have concerns for welfare of those around you. Tell me who you represent in the Field of Health Care or insurance,so I can choose otherwise. Well kid , I bid you farewell on this subject that brings out your primal animal and verbal hostility. May God Bless You and Keep You.

  3. Hey Moron, came across this on another blog, really just wanted to point out again how wring you are…
    Two, investigate a company called Simplecare. The SimpleCare story has appeared in U.S. News & World Report, in Forbes, and on NBC News. SimpleCare , a fee-for-service organization, accepts money for medical treatment without the bother and hassle of insurance forms, co-payments, and other third-party payment related procedures. SimpleCare has an alliance of doctors offering cash discounts. Itsmembership includes 38,000 patient members working with 1,500 doctors nationwide. Discounts range from 15 percent to 50 percent for patients paying in cash.
    well looky there an entire company that according to Gary doesn’t exist doing things Gary says are impossible. Is that a 50% discount I see, but Gary you said….

  4. Gary you just don’t know when to shut up and admit your wrong,
    “It is not a Standard Practices to give 50 to 80 percent discounts for Hospitals or Doctors Services.”
    Actually it is, everyone that treats Medicaid patients gives that discount and most major metro facilities give 50-70 discounts. I see the bills every day, you just make things up in your head.
    “Doctors are not going to get caught in Bidding wars when Health Care is competition Free.”
    Again your an idiot. Cosmetic, dental, and other services primarily paid by the patient are full of competition and doctors big aginst each other. There are also now companies that big out surgeries to facilities to see who gives the best price.
    wow you are clueless Gary
    I have flyers, brochures, cashed checks, and real world experience with all this for thousands of people. Your one person that apparetently isn’t very succesful at solving problems. just becuase you failed doesn’t mean everyone else did.
    every day doctors agree to write off portions of their bill both pre and post service. It’s a common pratice and takes very little inteligence to do.

  5. Well, God Almighty,I see you are a pompous Anal Pore.Who apparently works directly for Insurance or not? It is not a Standard Practices to give 50 to 80 percent discounts for Hospitals or Doctors Services.Doctors are not going to get caught in Bidding wars when Health Care is competition Free. The write off as you speak of it is the decision of the Doctor. The Patient does NOT CHOOSE TO RIGHT OFF THEIR BILL!!!! Who are you calling a Idiot Nate!!!! How many are in Collections because they missed a payment! I’m NOT Buying the write off is a form of Negotiation! To negotiate is a up front Agreement and not a last resort! I have tried to get a rate that reflected my doctors actual Cost and he claimed that the Insurance rate is firm and non negotiable. Hey, if your getting 80 percent off for paying Cash.Good for You! By the Way, I don’t rate dentist as medical Doctors and some of the others you speak of are superficial elective surgeries that most people would not need and some insurance policies would not pay to have. So back it up with some life experiences that take your random assumptions out of the equation. Certainly, no snot nosed kid is going to impress me with his condescending, arrogant and abusive behavior.

  6. no idiot, er lampman the answer is every day. I see sales on lazik surgey EVERY day, cosometic surgery every day. Eye exams and dental cleanings on sale every day.
    How do I and millions of people get a lower price for a procedure. Doctor #2 I called Dr #1 and he said he can do it for $x can you match that as I really don’t want to change doctors.
    Example number 2, Hey doc I don’t have insuance, if I paid cash could you give me a discount.
    It happens hundreds of thousands of times a week.
    LOL Gary you really are stupid, before I thought maybe you just weren’t very brite but no I almost feel bad, you have a seriously low inteligence.
    Health Insurance conracts do not allow you to make payments or set out of pocket expenses. Your utilizatrion and choices determine your out of pocket expense, contracts only limit what one plan will pay towards your decisions.
    small discount? For someone that didn’t even know you could call and get a discount how do you know the size? I have seen providers offer 50-80% discounts for cash, not what most people would call small.
    LOL Individuals have all the leverage, if you don’t like the deal your provider offers go to another provider….how mush easier can that be?
    LOL Gary Gary if the doctor wanted to collect he could take them to court and firce the issue, most write offs are the doctor agreeing to not pursue collection which is a mutual agreement between patient and provider.
    Good luck to you Gary, your going to have a long hard life.

  7. Well Nate, your arrogance proceeds you and so does your ignorance. Explain to me how you can claim that you can negotiate lower cost for a procedure? Explain to me Why the cost of any given procedure is not provided by any given provider? Tell me why,we are unable to shop for lower costs by comparison shopping by phone. When in your lifetime have you seen a sale on medical procedures?
    The answer to all above is Never! Health Insurance Contracts set your premiums and out of pocket expenses.Its true they will allow you to make payments on out of pocket,and give a small discount if your uninsured. However, Individuals are not the negotiators and have no Leverage to cut expenses with Insurance or providers. If I’m uninsured at the time of the office visit. I pay $125.00 dollars because of insurance anti trust waivers. When insured my Co pay is 30 dollars and the insurance pays 25 dollars based on their rate of Inflation. Charge $125.00 to collect $55.00. Retarded!
    You also should be careful of arbitrarily putting words in my mouth. I never said that ” By your theory Lampman all these doctors would be in jail”Its not the Doctors that I’m pressing. Rather it is Health Insurance that exploits and manipulates markets.
    Write offs for noncollectable debt doesn’t qualify as being negotiable.This is between the doctor and his accountant. Not between the doctor and patient! These are Debts that are noncollectable because for the most part , you have priced yourselves out of the Market.However,under no circumstance that this argument should be construed as a negotiable instrument.
    Private industry in the real free market often project far larger losses because of negotiation and failure to Pay. The difference between private industry and Health Providers are that private business are accountable to their clients.
    To sum it up in your twisted understanding of negotiation and the ability to lower cost of the individuals. Is erroneous and misleading.I would thank you for taking the time to search the internet yourself.Certainly, you are conflicted in understanding the rudimentary principles of negotiation.

  8. I’m a very slow typist, Nate.
    I don’t know, being a liberal and such, but our previous excellent President of these United States told us to go shopping after 9-11. It was supposed to be the patriotic thing to do then, and I assume it still must be. I don’t think he meant that we should go shopping at the hospital.
    Shortage of shoppers may very well hurt China, and we shouldn’t be doing that right now either, but it will also hurt Walmart and Amazon and GM and all other true blue purveyors of cheap imported goods. This of course translates into less jobs and smaller salaries for your potential health insurance shoppers and probably more mental disease. The world is very flat nowadays.

  9. it’s like the left never learned to use the internet for basic research, if Maggie or Ezra or some other agenda driven liberal doesn;t hand it to them they have no idea how to find it themselves let alone if it is correct.
    By your theory Lampman all these doctors would be in jail;
    Write-offs for uncollectible accounts (including contractual write-offs) on private-pay patients can be 5 percent to 15 percent in some affluent communities and 75 percent or more in some poorer communities.
    The changes cut the write-offs from 5.5 percent to 0.65
    If “by law” they can’t negotate then they couldn’t be writing off bills now could they……

  10. Marglit easy place is go to yahoo finance enter any insurance company and see what their annual profit margin is.
    Health Insurance doesn’t need to cost $1200 a month, not every family needs to have a Cadalic plan. Their are plenty of options for far less cost. Further if they spent half as much time learing their insurance policy as they did their new cell phone they could substantially drive down cost.
    I think China would be in a world of trouble and the US would be much better off. Domestic consumption of services, like healthcare, are far mroe beneficial to our economy then buying cheap china goods. I hope you know this and where just typing faster then you where thinking.
    Lampman your an idiot, every hospital in the country negotates with patients and most providers do as well. You have no clue what your talking about.

  11. I have never heard of such BS Barry.Profit driven Medicine certainly drains resources,takes risks and subjects patients to excessive testing to produce Profits and the dividend returns to investors.
    Its easy to make the math fit your ideals .Just cook the Books and that is just what providers are doing. All this information is proprietary and it would take a team of accountants to unravel.
    Bill Frist,the same one who said what is wrong with Health Care is Individuals do not Negotiate for Lower Prices? It is illegal for providers negotate with patients! Did I not tell you he is delusional and lacking the understanding from a middle class point of View. He is also Wrong about the Doctors Pen as Health Care is Dictated by insurance!

  12. Margalit,
    The 1%-2% figure refers to the non-profit sector including companies like Kaiser, Harvard-Pilgrim and the Blues other than the 14 Blues plans owned by Wellpoint. You might be able to access the annual reports for Kaiser and Harvard Pilgrim from their websites. The Blue Cross and Blue Shield Association may have data on the non-profit Blues. There are 39 Blues plans altogether of which 25 are non-profit or member owned. The largest of those is Healthcare Services Corporation (HCSC) which insurers people in IL, TX, NM, and OK. There is also an analyst who used to be at Bear Stearns and is now at J.P. Morgan Chase who publishes a compendium of managed care insurer data based on state regulatory filings.
    The bottom line is that insurer profits and executive compensation are not material contributors to high healthcare costs. At the end of day, according to former Tennessee Senator and heart transplant surgeon, Bill Frist, the biggest driver of healthcare costs in the U.S. is the doctor’s pen.

  13. Nate,
    families that make $75K to $100K cannot afford $1200 per month for health insurance, unless as you say, the stop consuming products like TVs, cars, phones, etc.
    Please tell me what you think will happen to the economy if the entire middle class, and all others below, were to drastically reduce purchases of goods and services?
    Barry,
    I am aware of single digit NET profits for most insurers, but I haven’t seen 1% – 2% anywhere. Is there a good source I could look at?
    I know Senator Rockefeller and his committee are trying very hard to get some real numbers from these folks and it’s not as easy as it should be.

  14. see key fact at the end, even back in 1965 you liberals where dishonest snake oil salesman.
    Another important underpinning of the “avoiding dependency” rationale was the widely trumpeted portrait of elderly Americans as an impoverished group whose plight made them a sympathetic object of tax-supported medical insurance. Misrepresentation of the financial condition of the elderly helped to paint this portrait, as government officials advocating Medicare repeatedly cited statistics showing lower incomes received by the elderly in comparison with other age groups. Yet the income statistics by themselves were misleading because they did not include asset ownership, and the elderly as a group had more substantial assets than other segments of the populace. Rep. Thomas B. Curtis (R., Mo.) repeatedly challenged HEW officials regarding the “incompleteness of the income statistic,” noting that “just as they have relatively low incomes as a group because they are on retirement, so they have more wealth than any other age group” since “they have been saving longer” (U.S. House Hearings 1963-64: 96).
    Notice how th eleft ignored the opportunity to actually help the 15-20% that needed it and instead decided to destory the whole sytsem
    However, data submitted for the record from a 1960 University of Michigan study showed that “87 percent of all spending units headed by persons aged 65 or older” had assets whose median value matched asset ownership of people aged 45-64 and exceeded the asset ownership of people under age 45 (U.S. House Hearings 1963-64: 242-43). While HEW Secretary Celebrezze waxed eloquent about the necessity to furnish protection “as a right and in a way which fully safeguards the dignity and independence of our older people,” Rep. Curtis questioned whether it was appropriate to “change the basic system” when 80 to 85 percent of the aged were able to take care of themselves under the existing system, recommending instead that we “direct our attention to the problems of the 15 percent, rather than this compulsory program that would cover everybody” (U.S. House Hearings 1963-64: 31, 392).

  15. 59 million people, including over 18% of those with insurance, are having trouble paying their medical bills
    The problem is Liberals aren’t inteligent to look past the obvious problem and see what causes it, this is why your reforms never work. Poor mothers need money, lets pay them for each kid they ave, poor are homeless lets build public housing, etc etc etc, that is why everything you do is such a complete and total failure.
    How many of those have a cell phone?
    “According to the CTIA-Wireless Association, over 250 million Americans now subscribe to a cellular-phone service. places the penetration rate at 82.4 percent”
    in 2001 “In Figure 2, the percent of households with a large screen television increased from about 25 percent for the lowest income bracket to 43 percent for the highest income bracket.”
    25% of people making less then 15K had a big screen TV.
    What percentage smokes? What percentage drinks?
    Your claims are BS and show complete lack of basic reasoning. If they can afford the cell phone, new TVs, and everything else they could afford their Medical bills. THEY CHOOSE NOT TO PAY, which is completly different from your claim.
    Someone making 75-100K that took on to much debt to pay their responsibilites is not my fault, they need to clean up their own house. Further it is not a failure of our insurance or healthcare system they got in over their head and chose to gave up their medical insurance before the SUV, cable or cell phone.
    It’s my fault you can’t budget your money? I should pay more becuase your illresponsible? That is what this is all about, you can’t afford your lifestyle and want me to pay for it. If you can’t afford them maybe you shouldn’t have had kids. As a responsible person I am going to wait and have kids when I am financially able to support them. Congrats Jeff you started a whole new class of welfare, rich liberals that think the rest of society should pay for their choices.

  16. 43% of people over 65 lacked health insurance in 1963,
    They didn’t need health insurance becuase they could afford to pay 100% of their bills. Read your history and you would know what the public wanted from Medicare was a catostrophic plan in case grandma spent 6 months in the hospital it wouldn’t bankrupt her. What they got was a plan that covered that exact opposite.
    “Moreover, a Gallup poll released on January 3, 1965, showed that efforts to sway public opinion on the national health insurance issue had been at least superficially successful: 63 percent of respondents now approved of the idea of a “compulsory medical insurance program covering hospital and nursing home care for the elderly … financed out of increased social security taxes”
    “The most pressing rationale for compulsory health insurance continually put forward by government officials and echoed by the public was the specter that responsible older people could be ruined financially by catastrophic illness. Yet neither the 1963 nor the 1965 proposal provided coverage for catastrophic illness. During the 1965 Senate Finance Committee hearings, Chairman Russell Long (D., La.) asked HEW Secretary Anthony Celebrezze, whose department had written the bill, “Why do you leave out the real catastrophes, the catastrophic illnesses?” (U.S. Senate Hearings 1965: 182). When Celebrezze replied that it was “not intended for those that are going to stay in institutions year-in and year-out,” Senator Long countered: “Well, in arguing for your plan you say let’s not strip poor old grandma of the last dress she has and of her home and what little resources she has and you bring us a plan that does exactly that unless she gets well in 60 days.”
    Typical lefty Jeff no clue of the facts and lie your ass of to trick the public into supporting you. NO ONE WANTED 60 DAYS OF COVERAGE, people didn’t need 60 days of coverage. Democrats wanted the money though and there isn’t any money in catostrophic insurance.
    “When Rep. Albert Ullman (D., Ore.) cited allegations that the “public is somehow being hoodwinked” and “being misled” and asked HEW’s Wilbur Cohen about the degree to which the public misunderstood the program, Cohen stated that “we do recognize this problem and I think it has been complicated by the use of the term ‘medicare’ which is an erroneous term when applied to this program” (U.S. House Hearings 1965: 104). Although government officials sometimes expressed dismay about this public misimpression, the misinformation nonetheless fueled support for passage of a bill they strongly supported.”
    Want me to post the entire congressional record from 64-65 so everyone can see how full of %^@! you are? Medicare was a lie and is a complete failure. It never delivered what we where promised and doesn’t deliver what it was intended.

  17. John Winkelman,
    You’re the one that’s peddling a “pile of manure.” The net after tax profit margin of the large publicly traded for profit private insurers is in the 4% range over the last couple of years while the non-profits, which cover over 40% of the privately insured membership, earn 1%-2%. The total net profit for the entire industry in the most recent year is roughly $20 billion or less than 1% of healthcare costs, not the 30% that you wrongly assert. Moreover, according to the Congressional Research Service, large self-funded employer plans, which cover a bit over half of the 160 million people who get their health insurance through their employer, have administrative costs of between 5% and 11% of their total healthcare spend. Finally, according to CMS, about 35% of healthcare spending is paid for by private insurers or north of $800 billion including payments by the self-funded plans for which the insurers just provide administrative services including access to their networks and claims processing. If we wanted to replace that sum with a tax to finance Medicare for all, the tax rate would need to be about equal to the current combined Social Security and Medicare tax or 12.2% of the first $106,800 of wages (half paid by the employee and half nominally paid by the employer) and 2.9% on all wages without limit, again evenly split between the employee and the employer. Most economists will tell you that the employee actually pays both halves in the form of lower wages that would have been paid if the tax were not there.

  18. Jeff,
    Thank you for clarifying your studies in an attempt to put Nate in his place. Unfortunately the ideologues are winning this battle with the result being a pile of manure masquerading as health care reform.
    I strongly agree with Rep. Anthony Weiner (D-NY) that the health care insurance industry doesn’t actually provide any value in the delivery of health care services. With a profit margin of 30% this effectively means that 30 cents of every dollar spent on premiums goes to the bottom line, not to delivering services. Add onto that an additional 20-30 cents for the administrative burden of processing claims, paying providers, approving or denying benefits, validating coverage, etc., that doesn’t leave much for actual care delivery. Hence the heavy handed payment negotiations with providers that has driven a multitude of providers to drop their participation in certain health plans.
    It certainly seems to me that the simplest solution is to provide basic universal coverage for every American, similar to coverage under Medicare. The insurance industry could continue to stay in business by providing supplemental benefits, just like they do now for most Medicare recipients.
    Corporate America would benefit by no longer having to pay for insurance coverage separately, unless employers wanted to contribute to supplemental coverage. The savings to corporate America would be just like the tax cut Republicans so strongly believe would stimulate growth. We taxpayers would trade our current premium costs for a new tax, but I’m pretty certain it would be less than what’s currently paid in as premiums now.
    I don’t know where to find out how much is currently spent on health care premiums, but it has to be more than what it currently takes to cover everyone but the 50 million or so uninsured since at least 30% of those premium dollars are not used to pay for care delivery.
    The government may not be the best at managing any business activity, but one thing I do know is that government run health insurance will not be looking to make a 30% profit on every dollar they collect in premiums. That alone should be a significant reduction in total health care costs.

  19. Nate source list:
    40% of people over 65 in poverty before Social Security, see Arthur Schlesinger’s history of the Great Depression. Half of them were on some form of local relief.
    43% of people over 65 lacked health insurance in 1963, see Marilyn Moon’s retrospective What Medicare has Meant to Older Americans http://www.socialsecurity.gov/history/pdf/WhatMedicareMeant.pdf
    59 million people, including over 18% of those with insurance, are having trouble paying their medical bills, see Center for Studying Health System Change “Living on the Edge: Medical Expenses Strain Household Budgets”
    http://www.hschange.com/CONTENT/1034/?topic=topic05
    On who the uninsured are, see Census Bureau report:
    http://www.census.gov/prod/2008pubs/p60-235.pdf
    Fastest growing segment is the 21% of the uninsured with incomes over 75 thousand in income. In Pahrump, Nevada, that’s a ton of money. In Chicago or Los Angeles, not so much. Big problem with people in the $50-100 thousand range, a crushing consumer debt people were too imprudent to accumulate- $14 trillion for all of us, which is why we’re drowning economically.
    I guess if you wipe out their household debt, default on those pesky mortgages and get on food stamps, you could free up $13,375 a year for family coverage.
    (How much free cash do you have in your household budget, Nate? I’m sure I make more than you do and I don’t have any. I have a kid in college and pay $1580 a month for my family coverage.)
    On what family coverage cost in 2009, see the Kaiser Family Foundation Report http://ehbs.kff.org/ That’s where the $13,375 estimate of the cost of family coverage came from. I’m sure they’re lying, or got their data from the wrong place.
    Why did I bother with the “studies” Nate asked for? Good question. IF you argue with Glenn Beck or Lou Dobbs, you mostly end up covered with spittle. Remember dear readers that 25% of the electorate in 1974 thought Richard Nixon was framed, and that a huge fraction of the Arab world thinks the Jews bombed the World Trade Center to justify a crusade against Islam (and everybody got a phone call telling them not to come to work). This isn’t about facts, it’s about ideology.
    The correct number for the % of uninsured eligible for Medicaid or SCHIP but not enrolled was about 25% in 2007, so there are benefits available that are not being used, but believe me, lots of the uninsured are uninsured because health care and health coverage is just too damned expensive.

  20. You complain about Jefferson’s broken government model. The only problem is that this model of a weak central government is a feature, not a bug.
    If you look at Madison’s Federalist Paper on the subject, one of the arguments against the generality of the Commerce and the “Health and Welfare” clauses, was that Congress would use these generalities to grow the Federal Government into tyranny. Madison argued that this couldn’t happen. Guess what folks? It appears that Madison was wrong on that score.
    As many in the posts above have waxed eloquent over the need to restrict the Federal Government, I will spare you the details. The fact remains that we need to provide charity out of our abundance rather than out of our poverty. It’s hard to give away your last crust of bread, when that’s all you have for the week. That is where our public trough now sits. We have made enough promises to put us in the poorhouse 4 times over. The solution being proposed is to borrow more money, and slice up the promise into smaller pieces and scatter those pieces to all the citizenry. The cry “let them eat cake!” has morphed into “Let them have healthcare!”.
    My sensibilities tell me that the same fate that awaited the former, need to be dispensed politically to the latter. We are in dire need of a bloodless revolution, before we are in total default. Are we past the point of no return? We will see…

  21. Jeff do you really think you can cite such utter BS and I won’t call you out on it?
    40% seniors in poverty BS it was 13% prior to Medicare and now 19% of seniors are on Medicare it got worse. You also need to learn how to comapre your stats, your 40% BS might be close to correct if your measureing it on income. Obviously a retired person doesn’t have an income so it is a BS analysis. 87% of seniors had no problem paying 100% of their medical bills, strait out of the congressional record during the debates.
    Insurance $1000 per month, again BS no where close. The average cost of an individual policy is a couple hundred. Average family still well below $1000 and not every uninsured person is a family.
    Stop with the statical games and go strait to any study of the uninsured. Half are eligibile for free insurance now and choose not to take it. 20-30% make 50k+ and could afford it but choose not to buy it. Only 3-5 million americans want insurance and can’t afford it.
    “A huge fraction of uninsured are uninsured because they cannot afford coverage, or their share of employer based coverage.”
    unless you define huge as 10% its BS and you can’t out up a single study to support that claim. Read KFF and they will shot your theory to hell.
    If you want to discuss cost that is almost 100% the fault of congress, repeal Medicre, COBRA, HIPAA, and 45 years of other stupid laws and 90% of americans would still be able to afford all the care they needed. h

  22. Jeff Goldsmith is absolutely right to be disgusted with the Dems in Congress. We had the market based solution to the healthcare mess and it was bi-partisan. It was the Healthy Americans Act (S. 334) and it was co-sponsored by Bob Bennett from Utah. (How can you get more bipartisan?) It would make our healthcare financing system look more like Switzerland (which spends about 10% of GDP on healthcare). The problem seemed to be that it was not pleasing to our labor union leaders as it would have removed a tax break for healthplans.
    The bottom line seems to be that special interests always trump the public interest. We should all be disgusted, not to mention worried for our future.

  23. Interesting that amidst all of this he just sent another whack of troops to Afghanistan! I never did consider the amount of debt the us already has in comparison to what it is trying to take on. However I am sure that the republicans spent money on all kinds of useless things that can be cut. Though this will nowhere near even out the debt they will take on. Either way it will be interesting to see how they plan on going about this without further detriment to the current economy.

  24. Lots of great comments above. Some reactions in random order. To Nate, it’s worth perusing the Census Bureau’s analysis of the uninsured that comes out every year. I’ve become a scholar of this single, telling table. You ought to read it sometime. The reason we’re in a recession is that the typical American household simply ran out of cash. At a grand a month (maybe your lucky clients can get it cheaper), health insurance is simply unaffordable for most people who do not get it through their employers or the government. Lack of health coverage is resulting in premature death and bankruptcy for many people, and, pragmatically, is costing us both jobs and tax revenues. I think the assertion that most of the people who don’t have coverage have “voluntarily” decided not to buy it is abject bullshit.
    I also do not agree that Social Security and Medicare have been failures-40% of the “elderly” were in poverty before they were enacted. A chasm has arisen in our system between those who get their insurance from public sources and those who buy it for themselves or their employees. A huge fraction of uninsured are uninsured because they cannot afford coverage, or their share of employer based coverage.
    The market ain’t going to fix this. I taught at the University of Chicago’s Graduate School of Business for eleven years and Wharton for eight, so I don’t feel a need to be lectured about markets. Analyzing the healthcare market (and investing in it) is what I do for a living. Our present health insurance system is an antique and needs to be modernized and humanized, not by replacing markets but by using them to make healthcare more affordable. Too many people are falling between the cracks.
    The President was right during the campaign: we cannot force people to buy something they cannot afford. These bills abjectly fail this test: they do virtually nothing tangible to make it more affordable. So I semi-agree with the comments on compulsion. But if health insurance is out of reach for maybe 30 million of the presently uninsured, and a major source of cash flow problems for perhaps another 30 million WITH insurance, we have to take some type of thoughtful action.
    Margalit has nailed the central: representative democracy has broken down. It is less excusable, perhaps, for the Republicans who have always represented the wealthy and powerful, but completely inexcusable for Democrats, who allegedly represent society’s underdogs, for our political system to be an abject slave to special interests. The Democratic Party has “evolved” into a bunch of fat cats (Terry McAuliffe, anyone?) who wear $2000 suits and fly around in peoples’ private jets.
    The inability of Congress, under either party, to sort out the strong from the weak claims- to say command sacrifice from the powerful and to advocate on behalf of those who have no political action committees or lobbyists- is the scandal here. Health care is the most powerful constellation of private interests in our economy: it should be a great test of the government’s capacity to act in a humane and thoughtful way to help ordinary citizens.
    If it cannot do that, we’ll keep replacing our elected leadership until we find someone we can trust with that job- it’s why I voted for Obama, because I trusted him to do this. It’s early yet to judge if I made a mistake or not, but I still believe he wants to do the right thing, not just “check the box” and say he “did” health reform.
    Finally, to those Jefferson scholars, I agree with his basic premise. I’ve been to Monticello about fifteen times, and get goosebumps every time. We don’t want tyranny, or a powerful central government running our lives. I believe in limited government and think that markets, individual and collective initiative can accomplish most things.
    The hard things we cannot do for ourselves is defend our country and sort out instances of market failure where people are being genuinely hurt- like by our bonus-addicted financial system and our health system. In these limited instances, government needs to act wisely and thoughtfully, and then get the hell out of the way.
    I have no confidence that the present political system can do this with health reform, and have trouble believing that buried in the hairball Congress is creating, the ordinary citizen’s interests will be furthered or protected, or that we won’t, by protecting the lawyers, the unions, the “health system’s” moneyed interests, create more problems than the important one we’re trying to solve. We don’t need a “Health Choices Commissioner” to sort this out.

  25. “Little did Jefferson realize that 220 years later, we’d be trying to manage a $14 trillion economy or a $2.5 trillion health system with our founding fathers’ deliberately crippled political system.”
    Our political design was almost perfect, the failure came in the inability and desire of the public to restrain federal politicians from encroaching on state rights. It is not the role of the federal government to fund education, healthcare, or half of what it does. If MA, CA, or some State wished to create a mandatory health plan then that is within the State’s right. Our system was designed as such specifically to protect us from dangerous thinking like yours. If CA, NY, and MA want to run head long off a fiscal cliff then so be it, our limited federal government was designed so they didn’t take the rest of us with them.
    Carl are you unaware that every other nation you refer to is also headed to financial collapse of their healthcare system, no nation has a sustainable universal system.
    “Just like Social Security works.” Um Joel FYI SS doesn’t work, it has already informed me there will not be enough money to pay the benefits I have been promised and there will be zero money to pay the benefits of those just entering the system. I think your definition of works is different then the average persons.
    “It isn’t as though the same level of irresponsibility and ignorance will continue for the next 10 years.”
    This is what they said before they passed Medicare in 1965. This was the argument when they mandated HMOs in 1973. This was the excuse with reform in 1986. And basically the same thing was said in early 90s and 00s. JD…notice a trend? It does continue and it always will with socialist programs. Socialism/Communism never starts to work magically after a couple decades, look around it ALWAYS fails. What’s with rewriting history and claiming we had a Democrat Congress from 1992 – 2000, you never heard of Newt? Let me update your facts for you;
    When the 104th Congress opens this week (Jan. 4), the Republicans will be in control of both houses of Congress for the first time since 1946.
    The new U.S. Senate has 53 Republicans and 47 Democrats. The new U.S. House of Representatives now has 227 Republicans and 199 Democrats. (Eight House seats remain undecided.
    Facts would seem to show a Democratic congress leads to fiscal illresponsibility. How odd that the body of US government actually responsible for writing and passing spending bills would have such an impact on spending. The President steers the desires to spend but Congress writes the checks. With the exception of a few recent years where Liberal Republican’s took over the party the spending problem has always been on the left.

  26. “He’s right: it’s simply not tolerable, morally or economically, for a wealthy nation to continue having close to 50 million uninsured people.”
    Jeff can you please explain how in a country born on the principal of freedom it is morally tolerable to force people that have chosen to not have insurance purchase it. You conveniently ignore that most uninsured are so by choice. We have a constitution expressly for preventing thinking like yours. You have no right to tell me I must carry health insurance. It is intolerable that you try to impose your communist ideology on me. I don’t want to participate in another one of your failed social experiments. After your dogma’s failure with public housing, SS, Medicare, and Medicaid there is no question it hasn’t, doesn’t and won’t work.

  27. jd,
    While I give the Clinton administration credit for raising taxes in 2003 to mitigate the budget deficit, he also benefited from the ability to reduce defense spending massively during his term following the disintegration of the former Soviet Union. I think the Reagan (partly deficit financed) defense buildup following the Carter years contributed significantly to the 1990’s sharp reduction in the defense force structure. Moreover, he was also lucky to be President during a rare burst of innovation centered on technology and telecommunications. He vetoed welfare reform twice before he finally signed a bill that never would have passed at all if it weren’t for the Republican Congress. While he originally expressed an intention to do so, he never followed through on entitlement reform. Entitlement reform should be easier to take on for a Democratic president because of better perceived credibility and moral authority among the poor and, working classes just as it was easier for Nixon to go to China than it would have been for a Democrat. Going to China was probably Nixon’s finest hour while the failure to tackle entitlement reform was, aside from the Monica Lewinsky scandal, Clinton’s worst.

  28. JD,
    I would agree that spending under Clinton was remarkably restrained. My comments were directed at voters, who in general vote for expansive unfunded spending to address the never-ending list of issues that each party feels take priority over the budget. And, I don’t think anyone believes we have to wait 4-8 years to see where Obama will rank in terms of fiscal responsibility.

  29. Sean M,
    When you say “But I am truly shocked by the extent to which constituents of each party have shown time and again their total lack of fiscal discipline and concern for future generations.”
    Don’t forget that a Democratic president and congress from 1992 to 2000 was a model of fiscal responsibility. Republicans Reagan and Bush II, with Democratic or Republican congresses, were models of fiscal irresponsibility. We’ll see what happens with Obama over the next 4-8 years.

  30. Hi Jeff,
    I came across your post while trying to look at current attitudes surrounding health care reform. As a current senior at Bentley University I am currently conducting a survey (8 multiple choice questions, 4 of which are demographic) for my honors capstone project. I am really hoping to get a decent number of respondents and would really appreciate your response and any passing on of the word you could:
    https://bentley.qualtrics.com/SE?SID=SV_2hKBQJ94wIRC48k&SVID=Prod
    Kind Regards,
    Eager Reader

  31. Let’s hope our investors (China and others) don’t loose confidence in our ability to afford our debt and raise interest rates, which as we have seen in the personal credit markets, makes our position worse and possibly impossible. Death spiral anyone?

  32. Jeff,
    Great article. A total collapse of the U.S. economy seems all but inevitable now as a result of the enormous debts we have incurred. The current healthcare reform effort is only the last big heavy bundle of straw. The only questions are how soon, and how will each side recast history to absolve themselves of any blame. This reckless behavior by our representatives at all levels of government is sad but predictable. But I am truly shocked by the extent to which constituents of each party have shown time and again their total lack of fiscal discipline and concern for future generations.
    I am very disturbed by a tactic used over the years by Republicans and Democrats alike that has become rampant. The party in power cites past indiscretions of the opposition, not so that corrective action can be taken, but as some twisted justification for equally reckless spending on their own party’s behalf.

  33. This analysis ignores what so many analyses ignore: when universal health care is enacted, there will be a new urgency on containing costs for many reasons. It isn’t as though the same level of irresponsibility and ignorance will continue for the next 10 years. It can’t and won’t, and we can point to some of the reasons why:
    1. The access issue will recede in importance because it will have been mostly solved. The cost and quality issues will take greater prominence because they won’t be crowded out as much by access issues. If we had a responsible media, cost and quality would become overwhelmingly dominant stories. In reality, I expect we’ll still get a lot of nitpicky gotcha-type stories explaining how some people still aren’t covered, sucking oxygen from the more critical stories. But the weight will shift in the needed direction to bring greater awareness among the public of the real drivers of high costs and why we pay more than the rest of the world. This is essential to getting solid support from the public for reforms that cut into the money-train of special interests.
    2. Universal healthcare will create a greater sense of ownership over healthcare costs than currently exists among the left and middle class. Right now we all know that the true cost of care is invisible to most people. That will be less true when the individual market grows by tens of millions (even the subsidies will be highly visible and not hidden like most employer-based health insurance). In addition, mandates for individuals and groups will make the cost of health care less avoidable for some who avoid getting insurance. Finally, increased taxes will make the high cost of care more painful to those whom the taxes impact (high income citizens and/or those in rich benefit plans).
    3. While the right won’t feel a greater sense of ownership responsibility, it will feel a greater sense of agitation over high costs. Right now, there is a reflexive desire to defend our high costs among many on the right. If you look at a commenter like Nate, for example, the only high costs he’ll moan about are those he can blame on government benefit mandates or a lack of caps on pain and suffering awards. He won’t complain or criticize the fact that medical fees are twice as high in the US as they are in other nations, or even admit that the comparison is meaningful. This is a typical attitude, and it will flip once universal health care passes. Within months, the right will be in favor of reforms that control costs not just by reducing benefits (the standard response) but by delivery system reforms. This will be framed in terms of entitlement reform, especially for the new expanded Medicaid.
    4. As Jeff Goldsmith noted, there are a lot of mechanisms and organizations created by the current bills that could be used to control costs. They won’t be strong out of the gate, given our culture and the power of special interests, but I now tend to agree with Maggie Mahar that within a few years after universal health care starts they will become effective at bending the trend. If they aren’t effective enough, new legislation will appear for the reasons cited above.

  34. What people need to realize is they are being sold a lot of crtap out of fear. Freedom from fear is more valuable than healthcare. Twll the government to drop dead. They cannot make your life better. They only make there own lives better by selling you on something you don’t want!

  35. What people need to realize is that reform needs to happen, but that it might not come in a perfect self contained box. Similar to the way many American’s are reacting to Obama’s presidency, expecting a silver bullet to fix the economy, health care, multiple wars, federal deficit, foreign relations be changed within just ten short months. Health care reform is also likely to come in stages, and will require patience and persistence.The first stage will seek to extend coverage to millions of Americans, while the second stage should aim to reform the system by which we pay physicians. Time, money, effort, and unforeseen problems will be involved. However, in the long run, health care reform will not only extend coverage to many uninsured Americans, but will also reduce overall health care costs within the United States.

  36. Powerful political interests intersect in the health benefit: organized labor, capital markets, major manufacturers, doctors, lawyers, hospitals, pharmaceutical companies, health insurers, state governments, employers large and small. Have I left anybody out?

    Uh, the 90% or so of our citizens who are not in any of these groups.
    What everybody needs, whether or not they are smart enough to realize it or not, is 7-9% taken out of their paycheck to pay for everyone’s medical care. Just like Social Security works. That would provides medical care for everyone at half what we pay now.
    Of course, that does not provide unjustified and indecent extra revenue for the groups mentioned above. I guess that is more important to us Americans.

  37. Making such a grand change to health care cannot possibly be deficit-neutral. With that said, I believe that something MUST be done to provide care to those who are lacking. The employer-based health care system is a failure, especially when unemployment numbers are high.

  38. Beautiful article…..but…..
    National debt is not the same as personal debt, as Mr. Jefferson surely was aware of. While his mounting personal debt indeed proved disastrous, his equally disastrous attempt to reduce the national debt lead to the burning of the capital.
    Mr. Jefferson was also of the opinion that a little rebellion here and there is a good thing and that every generation should be free to choose its preferred form of government and not be bounded by decisions made by deceased people. Maybe its time to heed to Mr. Jefferson’s advice. Not to mention that Mr. Jefferson himself was perfectly willing to cut some corners and depart from the feebleness of his preferred form of government, when the circumstances required that he did (i.e. Louisiana).
    The current health care debacle is merely a symptom of our real problems in this country, the main one being that representative government is dead.

  39. “…You wanted to forestall tyranny by designing a weak and divided central government. Little did Jefferson realize that 220 years later, we’d be trying to manage a $14 trillion economy or a $2.5 trillion health system with our founding fathers’ deliberately crippled political system.”
    Wow. Talk about struggling over the obvious.
    I guess I’ll go ahead and point out that the entire point of the weak and divided central government was to keep it from things like managing the economy or the health care of the citizens. The Founders had the quaint notion that “control” and “manage” were synonyms for, well, “tyranny”.
    You can disagree with the 18th century result of the Constitutional convention if you like, but can anyone seriously not grasp at this point that they broke it on purpose?

  40. As a Republican who did not vote for Obama, I wish to congratulate Jeff Goldsmith , a self-proclaimed “fervent” Democrat, on a splendid piece of writing.
    I’m particularly taken by these insights into,
    • American health care as a” vast enterprise where powerful political interests intersect: organized labor, capital markets, major manufacturers, doctors, lawyers, hospitals, pharmaceutical companies, health insurers, state governments, employers large and small. “
    • Thomas Jefferson who sought to “forestall tyranny by “designing a weak and divided central government” that “deliberately crippled “ the political system.
    • A” bitterly polarized and poorly informed electorate and weak Congressional leadership as a “recipe for fiscal incontinence on a grand scale.”
    • The Democratic attitude towards the special interests, which he explained with this Lyndon Johnson quote, “ If you can’t take their money, drink their liquor, sleep with their women and then vote against them when you need to, you don’t belong in Congress.”
    As any faithful Democrat should, Jeff argues our political legacy is a weak and divided government, and what we need is a powerful central government with a series of legislative teeth to make special interests bite a series of bullets for the common good.
    As a Republican, I would counter,
    • It is a good thing we have powerful political interests to protect the economic “vitality” of business and professional interests to protect us against the most powerful political interest in the country, the Democratic party, that promises economic “security” for all – an impossible dream.
    • Thomas Jefferson was right. He believed the people, rather than being a “poorly informed electorate,” collectively had a practical wisdom that would serve as a bulwark against government infringements on individual liberties. Public uprisings in town hall meetings, capitol protest marches, and tea parties against mounting federal deficits, the false promise of deficit neutralities, and the threat of invasive government controls over health care,
    • The federal government is already taking a huge bite out of society and the economy. It is running enormous deficits, and as a percent of GDP at 28.5% is spending money at a record pace since World War II without any visible impact on unemployment or other economic woes.
    What we need are tax cuts to stimulate investment, hiring, and government revenues; health care tax credits for all including making patients responsible for spending more of their own money with more cost transparency; expanding health plan choice across state lines; instituting tort reform and neutralizing the American Trial Lawyers influence on the Democratic Party; and wider recognition that the current health bills being taxing immediately while delaying benefits until 2014.
    Let the debate begin in earnest.
    As David Brooks argued in a recent New York Times column, “The Values Question, “
    “Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one.”
    “We all have to decide what we want at this moment in history, vitality or security. We can debate this or that provision, but where we come down will depend on that moral preference. Don’t get stupefied by technical details. This debate is about values.”
    We shall soon see whose values prevail.

  41. Well you may be right about it not being deficit neutral. I for one am still on board. How do other countries do it. Remember the US is in the minority when it comes to some kind of universal health care plan. The US should take the best of what others have done and tailor it to the US landscape. Carl Parisien Natick MA

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