How beneficial is healthcare?

Mar 22 JDN 2458931

Healthcare has been a contentious issue in the US for generations, but became especially so during the Obama administration with the passage of the Affordable Care Act. To be honest, I never quite understood the opposition to transitioning to a single-payer healthcare system; we already spend as much public funds on healthcare as most other First World countries spend in their entire healthcare system (plus we spend even more than that on private spending!), so not only can we afford it—it would in fact save us trillions of dollars a year. We might not even have to raise taxes, but even if we did, we’d pay so much less out of pocket that most of us would end up with more money. I understand why the corporations that run HMOs don’t want single-payer; but why does anyone else oppose it?

It’s not as if there are no models to follow; we could literally just copy the Canadian system (or the British system, or the French system…). It’s always amusing to me when conservatives respond to the suggestion by: “But that’s socialism! Do you want to end up like Cuba?” First of all, I said copy Canada, not copy Cuba. But even if we did copy Cuba, healthcare is one of the few things that Cuba actually does extremely well. On a QALY-per-dollar basis, it’s probably the most cost-effective healthcare system in the world (and the US is probably the least). So yeah, you know what? I kinda do want to end up like Cuba.

And no, countries with single-payer healthcare systems do not have longer wait times. Even by standard measures, our wait types are in the middle of the pack. But in fact these standard measures are clearly biased in our favor. The main way that we reduce wait times is by excluding people from care entirely. That’s not a wait time of zero; it’s a wait time of the rest of your life. If we measured properly, we would clearly have the longest wait times in the First World, because of all those people who never get care at all.

But today I’m going to ask a different question:

How much harm is done by our awful healthcare system?

Or conversely:

How much benefit would we get from insuring everyone?

The largest randomized controlled experiment on health insurance in the United States was the RAND Health Insurance Experiment, and its results were quite surprising: The marginal benefit of better health insurance for most people was very small, in many cases statistically negligible. People who were very poor or very sick benefited from having health insurance, but everyone else used more medical care without getting much apparent benefit. Since this was a large randomized controlled experiment, it should probably be considered our most credible evidence.

On the other hand, the RAND study was done before I was born, so maybe it’s time for a new study?

More recent studies have used regression discontinuity analysis, looking to see if going on Medicare seems to change the trendline in your mortality rate. It doesn’t.Of course mortality rates go up as you get older, and people become eligible for Medicare by getting older… but still, if Medicare is helping, you’d think there would be some kind of kink in the trend, and as far as we can tell, there isn’t. Perhaps people are simply transitioning from one form of adequate health insurance (e.g. employer-provided insurance) to another.

There is some evidence that healthcare saves lives, if we restrict attention specifically to what is called mortality amenable to healthcare, deaths caused by diseases that we know can be effectively treated by medical intervention. (It’s really a continuum, with malaria at one end, and airstrikes at the other. Both kill thousands of people every year, but malaria can be treated with a few doses of quinine, while there’s nothing anyone can do for you if you were in the blast center of a Hellfire missile. In between we have diseases like cancer, which medicine can sometimes save you from but not always.) By this measure, the United States clearly lags behind other First World countries, and the reason is clearly that we deny a lot of people healthcare.

However, I think mortality is really the wrong measure to use, for the following reason: We already have a universal healthcare system when it’s literally a question of life or death, and that’s the ER system. The Emergency Medical Treatment and Labor Act, signed by Ronald Reagan (yes, Republicans also used to like saving poor people from diseases, not so long ago!), guarantees that anyone who needs emergency care can get it immediately, regardless of their ability to pay. They can still bill you later, which may be a big reason why medical costs are the leading cause of bankruptcy in the United States (and literally nowhere else in the world). But at least you won’t die.

A lot of it actually comes down to how we measure health. Self-reported measures are notoriously unreliable in various ways, yet ultimately I don’t see how we can tell whether someone is sleeping well, feeling energetic, or being in pain without asking them. Correlating self-reported measures with objective measures like records of doctor visits shows pretty good correspondence, albeit by no means perfect.

As healthcare spending has increased and medical technology has advanced, there has been a worldwide trend of reduced disability and mortality, and the US is no exception. Clearly healthcare is doing something.

Yet it remains a fair question whether most people need more healthcare—maybe we’re actually getting enough. Maybe most people’s health insurance is already adequate, and we don’t need to improve it in any substantial way.

On balance, I think the best evidence we have says that people who have no insurance at all, or really awful insurance, would strongly benefit from improved access to healthcare. There’s also evidence that people with severe chronic conditions benefit from having steady healthcare. But for most people most of the time, the benefits of more health insurance would be quite small.

Does this mean we should get rid of health insurance? Of course not. But it does mean that future reforms should be focused on getting it to people who have none, not improving it for people who already have it. We don’t need to lower co-pays or deductibles; we may not even need to raise or remove coverage caps. But we do need to get some kind of health insurance to people who don’t have any at all.
To this end, Obamacare has done fairly well: You can just look at a graph of the number of uninsured people in the US and see that not only did Obamacare reduce that number, the steady attempts to undermine Obamacare are starting to bring it back up.

Then again, a single-payer system would clearly do even better, maybe even get that number to zero… so explain to me again why we’re not doing this?

The cost of illness

Feb 2 JDN 2458882

As I write this I am suffering from some sort of sinus infection, most likely some strain of rhinovirus. So far it has just been basically a bad cold, so there isn’t much to do aside from resting and waiting it out. But it did get me thinking about healthcare—we’re so focused on the costs of providing it that we often forget the costs of not providing it.

The United States is the only First World country without a universal healthcare system. It is not a coincidence that we also have some of the highest rates of preventable mortality and burden of disease.

We in the United States spend about $3.5 trillion per year on healthcare, the most of any country in the world, even as a proportion of GDP. Yet this is not the cost of disease; this is how much we were willing to pay to avoid the cost of disease. Whatever harm that would have been caused without all that treatment must actually be worth more than $3.5 trillion to us—because we paid that much to avoid it.

Globally, the disease burden is about 30,000 disability-adjusted life-years (DALY) per 100,000 people per year—that is to say, the average person is about 30% disabled by disease. I’ve spoken previously about quality-adjusted life years (QALY); the two measures take slightly different approaches to the same overall goal, and are largely interchangeable for most purposes.

Of course this result relies upon the disability weights; it’s not so obvious how we should be comparing across different conditions. How many years would you be willing to trade of normal life to avoid ten years of Alzheimer’s? But it’s probably not too far off to say that if we could somehow wave a magic wand and cure all disease, we would really increase our GDP by something like 30%. This would be over $6 trillion in the US, and over $26 trillion worldwide.

Of course, we can’t actually do that. But we can ask what kinds of policies are most likely to promote health in a cost-effective way.

Unsurprisingly, the biggest improvements to be made are in the poorest countries, where it can be astonishingly cheap to improve health. Malaria prevention has a cost of around $30 per DALY—by donating to the Against Malaria Foundation you can buy a year of life for less than the price of a new video game. Compare this to the standard threshold in the US of $50,000 per QALY: Targeting healthcare in the poorest countries can increase cost-effectiveness a thousandfold. In humanitarian terms, it would be well worth diverting spending from our own healthcare to provide public health interventions in poor countries. (Fortunately, we have even better options than that, like raising taxes on billionaires or diverting military spending instead.)

We in the United States spend about twice as much (per person per year) on healthcare as other First World countries. Are our health outcomes twice as good? Clearly not. Are they any better at all? That really isn’t clear. We certainly don’t have a particularly high life expectancy. We spend more on administrative costs than we do on preventative care—unlike every other First World country except Australia. Almost all of our drugs and therapies are more expensive here than they are everywhere else in the world.

The obvious answer here is to make our own healthcare system more like those of other First World countries. There are a variety of universal health care systems in the world that we could model ourselves on, ranging from the single-payer government-run system in the UK to the universal mandate system of Switzerland. The amazing thing is that it almost doesn’t matter which one we choose: We could copy basically any other First World country and get better healthcare for less spending. Obamacare was in many ways similar to the Swiss system, but we never fully implemented it and the Republicans have been undermining it every way they can. Under President Trump, they have made significant progress in undermining it, and as a result, there are now 3 million more Americans without health insurance than there were before Trump took office. The Republican Party is intentionally increasing the harm of disease.

Subsidies can’t make things unaffordable

May 12 2458616

In last week’s post I talked about a supposed benefit of subsidies that almost never materializes. In this week, I’m going to talk about a supposed harm of subsidies that is literally impossible.

The American Enterprise Institute (a libertarian think-tank) has been sending around a graph of price increases over the last 20 years by sector, showing what everyone already intuitively knows: healthcare and education have gotten wildly more expensive, while high-tech products have gotten extremely cheap. Actually I was a surprised how little they found housing prices had increased (enough to make me wonder what metric they are using for housing prices).

They argue that it is government intervention which has created these rising prices:

Blue lines = prices subject to free market forces. Red lines = prices subject to regulatory capture by government.

Along similar lines, Grey Gordon and Aaron Hedlund published a book chapter presenting evidence that student loans and federal subsidies are responsible for increases in college tuition. They are professional economists, so I feel like I ought to take their argument seriously… but it’s really hard to do, because it’s such a silly concept at the most basic level. I could nitpick their assumptions about elasticity of demand and monopoly power, but the whole argument just doesn’t pass the smell test.

Subsidies always make things more affordable for the person being subsidized.

It’s possible for subsidies to create other distortions, and make things more expensive for those who aren’t subsidized. But it’s literally impossible for subsidies to make something unaffordable to the person being subsidized.

That result is absolutely fundamental, and it comes directly from the Law of Supply and Law of Demand.

Subsidies

On this graph, the blue line is the demand curve. The red line is the supply curve. The thick green line is where they intersect, at the competitive equilibrium price. In this case, that equilibrium means we sell 6 units at a price of $3 each.

The thin green lines show what happen if we introduce a subsidy. Here the subsidy is $3. The sticker price can be read off of the supply curve: It will rise to $4. But the actual price paid by consumers is read off the demand curve: It will fall to $1. Total sales will rise to 8 units. The total cost to the government is then 8($3) = $24.

These exact numbers are of course specific to the example I chose. But the overall direction is not.

We can go ahead and draw this with all sorts of different supply and demand curves, and we’ll keep getting the same result.

Here’s one where I didn’t even make the curves linear:

Subsidies_2

In this case, a subsidy of $5.40 raises the sticker price from $6.10 to $11.20, only reducing the price for consumers to $5.80, while increasing the quantity sold from 3.5 to 4.8. The total cost of the subsidy is $25.92. The price effects are very different in magnitude from the previous example, and yet all the directions are exactly the same—and they will continue to be the same, however you draw the curves.

And here’s yet another example:

Subsidies_3

Here, a subsidy of $2.30 raises the sticker price from $4 to $5.30, lowers the cost to consumers to $3, increases the quantity sold from 4 to 7 units, and costs $16.10.

If you’re still not convinced, try drawing some more of the same diagrams yourself. As long as you make the supply curve slope upward and the demand curve slope downward, you’ll keep getting the same results.
A subsidy will always do four things:

  1. Increase the sticker price, benefiting sellers.
  2. Decrease the price that subsidized consumers actually pay, benefiting those consumers.
  3. Increase the quantity sold.
  4. Cost the government money.

The intuition here is quite simple: If I give you free money every time you buy a thing, you’ll buy more of that thing (3) because it costs you less to do so (2). Because you buy more of the thing, the price will go up (1), but not enough to cancel out the reduced cost to you (or else you’d stop). Since I’m giving you free money, that will cost me money (4). This intuition is fully general: It doesn’t matter what kind of product we are talking about, you’re never going to buy less or have to pay more for each one because I gave you free money.

The size of each effect depends upon elasticity of demand and supply, in basically the same way as tax incidence. The more inelastic side of the market is harmed less by the tax and also benefits less from the subsidy. For any given change in quantity, more inelastic markets raise more tax revenue and cost more subsidy spending.

If we allow elasticities of demand or supply to be zero or infinite (which is almost never the case in real life), then some of these effects might be zero. But they will never go the opposite direction, not as long as the supply curve slopes upward and the demand curve slopes downward.

I suspect that education has relatively inelastic demand and relatively elastic supply, which would mean that the subsidies are actually largely felt by the consumer, not the seller. But that’s actually a legitimate economic question: I might be overestimating the elasticity of supply.

There are other legitimate economic questions here as well, such as how much benefit we get out of a given subsidy versus other ways we might spend that money, and how subsidies may hurt others in the same market who aren’t subsidized.

What is not a legitimate question is the one that these libertarian think-tanks seem to be asking, which is “If you give people money, will they end up with less stuff?” No, they won’t. That’s not how any of this works.

And I’m pretty sure the people in these think-tanks are smart enough to know that. They might be blinded by their anti-government ideology, but I actually suspect it’s more sinister than that: They know that what they are saying isn’t true, but they consider it a “noble lie”: A falsehood told to the common folk in the service of a higher good.

They are clever enough to not simply state the lie outright, but instead imply it through misleading presentation of real facts. Yes, it’s true that subsidies will raise the sticker price—so they can say that this was all they were asserting. But not only is that obvious and trivial: It wouldn’t even support the argument they are obviously trying to make. Nobody cares about the sticker price. They care about what people actually pay. And a subsidy, by construction, as a law of economics, cannot possibly increase the amount paid by the buyer who is subsidized.

What they obviously want you to think is that the reason healthcare and education are so unaffordable is because the government has been subsidizing them. But this is basically the opposite of the truth: These things became unaffordable for various reasons, and the government stepped in to subsidize them in order to stop the bleeding. Is that a permanent solution? No, it’s not. But it does actually help keep them affordable for the time being—and it could not have done otherwise. There’s simply no way to give someone free money and make them poorer. (Of course, fully socialized healthcare and education might be permanent solutions, so if the libertarians aren’t careful what they wish for….)

Green New Deal Part 3: Guaranteeing education and healthcare is easy—why aren’t we doing it?

Apr 21 JDN 2458595

Last week was one of the “hard parts” of the Green New Deal. Today it’s back to one of the “easy parts”: Guaranteed education and healthcare.

“Providing all people of the United States with – (i) high-quality health care; […]

“Providing resources, training, and high-quality education, including higher education, to all people of the United States.”

Many Americans seem to think that providing universal healthcare would be prohibitively expensive. In fact, it would have literally negative net cost.
The US currently has the most bloated, expensive, inefficient healthcare system in the entire world. We spend almost $10,000 per person per year on healthcare, and get outcomes no better than France or the UK where they spend less than $5,000.
In fact, our public healthcare expenditures are currently higher than almost every other country. Our private expenditures are therefore pure waste; all they are doing is providing returns for the shareholders of corporations. If we were to simply copy the UK National Health Service and spend money in exactly the same way as they do, we would spend the same amount in public funds and almost nothing in private funds—and the UK has a higher mean lifespan than the US.
This is absolutely a no-brainer. Burn the whole system of private insurance down. Copy a healthcare system that actually works, like they use in every other First World country.
It wouldn’t even be that complicated to implement: We already have a single-payer healthcare system in the US; it’s called Medicare. Currently only old people get it; but old people use the most healthcare anyway. Hence, Medicare for All: Just lower the eligibility age for Medicare to 18 (if not zero). In the short run there would be additional costs for the transition, but in the long run we would save mind-boggling amounts of money, all while improving healthcare outcomes and extending our lifespans. Current estimates say that the net savings of Medicare for All would be about $5 trillion over the next 10 years. We can afford this. Indeed, the question is, as it was for infrastructure: How can we afford not to do this?
Isn’t this socialism? Yeah, I suppose it is. But healthcare is one of the few things that socialist countries consistently do extremely well. Cuba is a socialist country—a real socialist country, not a social democratic welfare state like Norway but a genuinely authoritarian centrally-planned economy. Cuba’s per-capita GDP PPP is a third of ours. Yet their life expectancy is actually higher than ours, because their healthcare system is just that good. Their per-capita healthcare spending is one-fourth of ours, and their health outcomes are better. So yeah, let’s be socialist in our healthcare. Socialists seem really good at healthcare.
And this makes sense, if you think about it. Doctors can do their jobs a lot better when they’re focused on just treating everyone who needs help, rather than arguing with insurance companies over what should and shouldn’t be covered. Preventative medicine is extremely cost-effective, yet it’s usually the first thing that people skimp on when trying to save money on health insurance. A variety of public health measures (such as vaccination and air quality regulation) are extremely cost-effective, but they are public goods that the private sector would not pay for by itself.
It’s not as if healthcare was ever really a competitive market anyway: When you get sick or injured, do you shop around for the best or cheapest hospital? How would you even go about that, when they don’t even post most of their prices and what prices they post are often wildly different than what you’ll actually pay?
The only serious argument I’ve heard against single-payer healthcare is a moral one: “Why should I have to pay for other people’s healthcare?” Well, I guess, because… you’re a human being? You should care about other human beings, and not want them to suffer and die from easily treatable diseases?
I don’t know how to explain to you that you should care about other people.

Single-payer healthcare is not only affordable: It would be cheaper and better than what we are currently doing. (In fact, almost anything would be cheaper and better than what we are currently doing—Obamacare was an improvement over the previous mess, but it’s still a mess.)
What about public education? Well, we already have that up to the high school level, and it works quite well.
Contrary to popular belief, the average public high school has better outcomes in terms of test scores and college placements than the average private high school. There are some elite private schools that do better, but they are extraordinarily expensive and they self-select only the best students. Public schools have to take all students, and they have a limited budget; but they have high quality standards and they require their teachers to be certified.
The flaws in our public school system are largely from it being not public enough, which is to say that schools are funded by their local property taxes instead of having their costs equally shared across whole states. This gives them the same basic problem as private schools: Rich kids get better schools.
If we removed that inequality, our educational outcomes would probably be among the best in the world—indeed, in our most well-funded school districts, they are. The state of Massachusetts which actually funds their public schools equally and well, gets international test scores just as good as the supposedly “superior” educational systems of Asian countries. In fact, this is probably even unfair to Massachusetts, as we know that China specifically selects the regions that have the best students to be the ones to take these international tests. Massachusetts is the best the US has to offer, but Shanghai is also the best China has to offer, so it’s only fair we compare apples to apples.
Public education has benefits for our whole society. We want to have a population of citizens, workers, and consumers who are well-educated. There are enormous benefits of primary and secondary education in terms of reducing poverty, improving public health, and increased economic growth.
So there’s my impassioned argument for why we should continue to support free, universal public education up to high school.
When it comes to college, I can’t be quite so enthusiastic. While there are societal benefits of college education, most of the benefits of college accrue to the individuals who go to college themselves.
The median weekly income of someone with a high school diploma is about $730; with a bachelor’s degree this rises to $1200; and with a doctoral or professional degree it gets over $1800. Higher education also greatly reduces your risk of being unemployed; while about 4% of the general population is unemployed, only 1.5% of people with doctorates or professional degrees are. Add that up over all the weeks of your life, and it’s a lot of money.
The net present value of a college education has been estimated at approximately $1 million. This result is quite sensitive to the choice of discount rate; at a higher discount rate you can get the net present value as “low” as $250,000.
With this in mind, the fact that the median student loan debt for a college graduate is about $30,000 doesn’t sound so terrible, does it? You’re taking out a loan for $30,000 to get something that will earn you between $250,000 and $1 million over the course of your life.
There is some evidence that having student loans delays homeownership; but this is a problem with our mortgage system, not our education system. It’s mainly the inability to finance a down payment that prevents people from buying homes. We should implement a system of block grants for first-time homeowners that gives them a chunk of money to make a down payment, perhaps $50,000. This would cost about as much as the mortgage interest tax deduction which mainly benefits the upper-middle class.
Higher education does have societal benefits as well. Perhaps the starkest I’ve noticed is how categorically higher education decided people’s votes on Donald Trump: Counties with high rates of college education almost all voted for Clinton, and counties with low rates of college education almost all voted for Trump. This was true even controlling for income and a lot of other demographic factors. Only authoritarianism, sexism and racism were better predictors of voting for Trump—and those could very well be mediating variables, if education reduces such attitudes.
If indeed it’s true that higher education makes people less sexist, less racist, less authoritarian, and overall better citizens, then it would be worth every penny to provide universal free college.
But it’s worth noting that even countries like Germany and Sweden which ostensibly do that don’t really do that: While college tuition is free for Swedish citizens and Germany provides free college for all students of any nationality, nevertheless the proportion of people in Sweden and Germany with bachelor’s degrees is actually lower than that of the United States. In Sweden the gap largely disappears if you restrict to younger cohorts—but in Germany it’s still there.
Indeed, from where I’m sitting, “universal free college” looks an awful lot like “the lower-middle class pays for the upper-middle class to go to college”. Social class is still a strong predictor of education level in Sweden. Among OECD countries, education seems to be the best at promoting upward mobility in Australia, and average college tuition in Australia is actually higher than average college tuition in the US (yes, even adjusting for currency exchange: Australian dollars are worth only slightly less than US dollars).
What does Australia do? They have a really good student loan system. You have to reach an annual income of about $40,000 per year before you need to make payments at all, and the loans are subsidized to be interest-free. Once you do owe payments, the debt is repaid at a rate proportional to your income—so effectively it’s not a debt at all but an equity stake.
In the US, students have been taking the desperate (and very cyberpunk) route of selling literal equity stakes in their education to Wall Street banks; this is a terrible idea for a hundred reasons. But having the government have something like an equity stake in students makes a lot of sense.
Because of the subsidies and generous repayment plans, the Australian government loses money on their student loan system, but so what? In order to implement universal free college, they would have spent an awful lot more than they are losing now. This way, the losses are specifically on students who got a lot of education but never managed to raise their income high enough—which means the government is actually incentivized to improve the quality of education or job-matching.
The cost of universal free college is considerable: That $1.3 trillion currently owed as student loans would be additional government debt or tax liability instead. Is this utterly unaffordable? No. But it’s not trivial either. We’re talking about roughly $60 billion per year in additional government spending, a bit less than what we currently spend on food stamps. An expenditure like that should have a large public benefit (as food stamps absolutely, definitely do!); I’m not convinced that free college would have such a benefit.
It would benefit me personally enormously: I currently owe over $100,000 in debt (about half from my undergrad and half from my first master’s). But I’m fairly privileged. Once I finally make it through this PhD, I can expect to make something like $100,000 per year until I retire. I’m not sure that benefiting people like me should be a major goal of public policy.
That said, I don’t think universal free college is a terrible policy. Done well, it could be a good thing. But it isn’t the no-brainer that single-payer healthcare is. We can still make sure that students are not overburdened by debt without making college tuition actually free.

You know what? Let’s repeal Obamacare. Here’s my replacement.

Feb 18 JDN 2458168

By all reasonable measures, Obamacare has been a success. Healthcare costs are down but coverage rates are up. It reduced both the federal deficit and after-tax income inequality.

But Republicans have hated it the whole time, and in particular the individual mandate provision has always been unpopular. Under the Trump administration, the individual mandate has now been repealed.

By itself, this can only be disastrous. It threatens to undermine all the successes of the entire Obamacare system. Without the individual mandate, covering pre-existing conditions means that people can simply wait to get insurance until they need it—at which point it’s not insurance anymore. The risks stop being shared and end up concentrated on whoever gets sick, then we go back to people going bankrupt because they were unlucky enough to get cancer. The individual mandate was vital to making Obamacare work.

But I do actually understand why the individual mandate is unpopular: Nobody likes being forced into buying anything.

John Roberts ruled that the individual mandate was Constitutional on the grounds that it is economically equivalent to a tax. This is absolutely correct, and I applaud his sound reasoning.

That said, the individual mandate is not in fact psychologically equivalent to a tax.

Psychologically, being forced to specifically buy something or face punishment feels a lot more coercive than simply owing a certain amount of money that the government will use to buy something. Roberts is right; economically, these two things are equivalent. The same real goods get purchased, at the same people’s expense; the accounts balance in the same way. But it feels different.

And it would feel different to me too, if I were required to actually shop for that particular avionic component on that Apache helicopter my taxes paid for, or if I had to write a check for that particular section of Highway 405 that my taxes helped maintain. Yes, I know that I give the government a certain amount of money that they spent on salaries for US military personnel; but I’d find it pretty weird if they required me to actually hand over the money in cash to some specific Marine. (On the other hand, this sort of thing might actually give people a more visceral feel for the benefits of taxes, much as microfinance agencies like to show you the faces of particular people as you give them loans, whether or not those people are actually the ones getting your money.)

There’s another reason it feels different as well: We have framed the individual mandate as a penalty, as a loss. Human beings are loss averse; losing $10 feels about twice as bad as not getting $10. That makes the mandate more unpleasant, hence more unpopular.

What could we do instead? Well, obviously, we could implement a single-payer healthcare system like we already have in Medicare, like they have in Canada and the UK, or like they have in Scandinavia (#ScandinaviaIsBetter). And that’s really what we should do.

But since that doesn’t seem to be on the table right now, here’s my compromise proposal. Okay, yes, let’s repeal Obamacare. No more individual mandate. No fines for not having health insurance.

Here’s what we would do instead: You get a bonus refundable tax credit for having health insurance.

We top off the income tax rate to adjust so that revenue ends up the same.

Say goodbye to the “individual mandate” and welcome the “health care bonus rebate”.

Most of you reading this are economically savvy enough to realize that’s the same thing. If I tax you $100, then refund $100 if you have health insurance, that’s completely equivalent to charging you a fine of $100 if you don’t have health insurance.

But it doesn’t feel the same to most people. A fine feels like a punishment, like a loss. It hurts more than a mere foregone bonus, and it contains an element of disapproval and public shame.

Whereas, we forgo refundable tax credits all the time. You’ve probably forgone dozens of refundable tax credits you could have gotten, either because you didn’t know about them or because you realized they weren’t worth it to you.

Now instead of the government punishing you for such a petty crime as not having health insurance, the government is rewarding you for the responsible civic choice of having health insurance. We have replaced a mean, vindictive government with a friendly, supportive government.

Positive reinforcement is more reliable anyway. (Any child psychologist will tell you that while punishment is largely ineffective and corporal punishment is outright counterproductive, reward systems absolutely do work.) Uptake of health insurance should be at least as good as before, but the policy will be much more popular.

It’s a very simple change to make. It could be done in a single tax bill. Economically, it makes no difference at all. But psychologically—and politically—it could make all the difference in the world.

Our government just voted to let thousands of people die for no reason

May 14, JDN 2457888

The US House of Representatives just voted to pass a bill that will let thousands of Americans die for no reason. At the time of writing it hasn’t yet passed the Senate, but it may yet do so. And if it does, there can be little doubt that President Trump (a phrase I still feel nauseous saying) will sign it.

Some already call it Trumpcare (or “Trump-doesn’t-care”); but officially they call it the American Health Care Act. I think we should use the formal name, because it is a name which is already beginning to take on a dark irony; yes, only in America would such a terrible health care act be considered. Every other highly-developed country has a universal healthcare system; most of them have single-payer systems (and this has been true for over two decades).
The Congressional Budget Office estimates that the AHCA will increase the number of uninsured Americans by 24 million. Of these, 14 million will be people near the poverty line who lose access to Medicaid.

In 2009, a Harvard study estimated that 45,000 Americans die each year because they don’t have health insurance. This is on the higher end; other studies have estimated more like 20,000. But based on the increases in health insurance rates under Obamacare, somewhere between 5,000 and 10,000 American lives have been saved each year since it was enacted. That reduction came from insuring about 10 million people who weren’t insured before.

Making a linear projection, we can roughly estimate the number of additional Americans who will die every year if this American Health Care Act is implemented. (24 million/10 million)(5,000 to 10,000) = 12,000 to 24,000 deaths per year. For comparison, there are about 14,000 total homicides in the United States each year (and we have an exceptionally high homicide rate for a highly-developed country).
Indeed, morally, it might make sense to count these deaths as homicides (by the principle of “depraved indifference”); Trump therefore intends to double our homicide rate.

Of course, it will not be prosecuted this way. And one can even make an ethical case for why it shouldn’t be, why it would be impossible to make policy if every lawmaker had to face the consequences of every policy choice. (Start a war? A hundred thousand deaths. Fail to start a war in response to a genocide? A different hundred thousand deaths.)

But for once, I might want to make an exception. Because these deaths will not be the result of a complex policy trade-off with merits and demerits on both sides. They will not be the result of honest mistakes or unforeseen disasters. These people will die out of pure depraved indifference.

We had a healthcare bill that was working. Indeed, Obamacare was remarkably successful. It increased insurance rates and reduced mortality rates while still managing to slow the growth in healthcare expenditure.

The only real cost was an increase in taxes on the top 5% (and particularly the top 1%) of the income distribution. But the Republican Party—and make no mistake, the vote was on almost completely partisan lines, and not a single Democrat supported it—has now made it a matter of official policy that they care more about cutting taxes on millionaires than they do about poor people dying from lack of healthcare.

Yet there may be a silver lining in all of this: Once people saw that Obamacare could work, the idea of universal healthcare in the United States began to seem like a serious political position. The Overton Window has grown. Indeed, it may even have shifted to the left for once; the responses to the American Health Care Act have been almost uniformly comprised of shock and outrage, when really what the bill does is goes back to the same awful system we had before. Going backward and letting thousands of people die for no reason should appall people—but I feared that it might not, because it would seem “normal”. We in America have grown very accustomed to letting poor people die in order to slightly increase the profits of billionaires, and I thought this time might be no different—but it was different. Once Obamacare actually passed and began to work, people really saw what was happening—that all this suffering and death wasn’t necessary, it wasn’t an inextricable part of having a functioning economy. And now that they see that, they aren’t willing to go back.

Tax plan possibilities

Mar 26, JDN 2457839

Recently President Trump (that phrase may never quite feel right) began presenting his new tax plan. To be honest, it’s not as ridiculous as I had imagined it might be. I mean, it’s still not very good, but it’s probably better than Reagan’s tax plan his last year in office, and it’s not nearly as absurd as the half-baked plan Trump originally proposed during the campaign.

But it got me thinking about the incredible untapped potential of our tax system—the things we could achieve as a nation, if we were willing to really commit to them and raise taxes accordingly.

A few years back I proposed a progressive tax system based upon logarithmic utility. I now have a catchy name for that tax proposal; I call it the logtax. It depends on two parameters—a poverty level, at which the tax rate goes to zero; and what I like to call a metarate—the fundamental rate that sets all the actual tax rates by the formula.

For the poverty level, I suggest we use the highest 2-household poverty level set by the Department of Health and Human Services: Because of Alaska’s high prices, that’s the Alaska poverty level, and the resulting figure is $20,290—let’s round to $20,000.

I would actually prefer to calculate taxes on an individual basis—I see no reason to incentivize particular household arrangements—but as current taxes are calculated on a household basis, I’m going to use that for now.

The metarate can be varied, and in the plans below I will compare different options for the metarate.

I will compare six different tax plans:

  1. Our existing tax plan, set under the Obama administration
  2. Trump’s proposed tax plan
  3. A flat rate of 30% with a basic income of $12,000, replacing welfare programs and Medicaid
  4. A flat rate of 40% with a basic income of $15,000, replacing welfare programs and Medicaid
  5. A logtax with a metarate of 20%, all spending intact
  6. A logtax with a metarate of 25% and a basic income of $12,000, replacing welfare programs and Medicaid
  7. A logtax with a metarate of 35% and a basic income of $15,000, cutting military spending by 50% and expanding Medicare to the entire population while eliminating Medicare payroll taxes

To do a proper comparison, I need estimates of the income distribution in the United States, in order to properly estimate the revenue from each type of tax. For that I used US Census data for most of the income data, supplementing with the World Top Incomes database for the very highest income brackets. The household data is broken up into brackets of $5,000 and only goes up to $250,000, so it’s a rough approximation to use the average household income for each bracket, but it’s all I’ve got.

The current brackets are 10%, 15%, 25%, 28%, 33%, 35%, and 39.6%. These are actually marginal rates, not average rates, which makes the calculation a lot more complicated. I did it properly though; for example, when you start paying the marginal rate of 28%, your average rate is really only 20.4%.

Worst of all, I used static scoring—that is, I ignored the Laffer Effect by which increasing taxes changes incentives and can change pre-tax incomes. To really do this analysis properly, one should use dynamic scoring, taking these effects into account—but proper dynamic scoring is an enormous undertaking, and this is a blog post, not my dissertation.

Still, I was able to get pretty close to the true figures. The actual federal budget shows total revenue net of payroll taxes to be $2.397 trillion, whereas I estimated $2.326 trillion; the true deficit is $608 billion and I estimated $682 billion.

Under Trump’s tax plan, almost all rates are cut. He also plans to remove some deductions, but all reports I could find on the plan were vague as to which ones, and with data this coarse it’s very hard to get any good figures on deduction amounts anyway. I also want to give him credit where it’s due: It was a lot easier to calculate the tax rates under Trump’s plan (but still harder than under mine…). But in general what I found was the following:

Almost everyone pays less income tax under Trump’s plan, by generally about 4-5% of their income. The poor benefit less or are slightly harmed; the rich benefit a bit more.

For example, a household in poverty making $12,300 would pay $1,384 currently, but $1,478 under Trump’s plan, losing $94 or 0.8% of their income. An average household making $52,000 would pay $8,768 currently but only $6,238 under Trump’s plan, saving $2,530 or about 4.8% of their income. A household making $152,000 would pay $35,580 currently but only $28,235 under Trump’s plan, saving $7,345 or again about 4.8%. A top 1% household making $781,000 would pay $265,625 currently, but only $230,158 under Trump’s plan, saving $35,467 or about 4.5%. A top 0.1% household making $2,037,000 would pay $762,656 currently, but only $644,350 under Trump’s plan, saving $118,306 or 5.8% of their income. A top 0.01% household making $9,936,000 would pay $3,890,736 currently, but only $3,251,083 under Trump’s plan, saving $639,653 or 6.4% of their income.

Because taxes are cut across the board, Trump’s plan would raise less revenue. My static scoring will exaggerate this effect, but only moderately; my estimate says we would lose over $470 billion in annual revenue, while the true figure might be $300 billion. In any case, Trump will definitely increase the deficit substantially unless he finds a way to cut an awful lot of spending elsewhere—and his pet $54 billion increase to the military isn’t helping in that regard. My estimate of the new deficit under Trump’s plan is $1.155 trillion—definitely not the sort of deficit you should be running during a peacetime economic expansion.

Let’s see what we might have done instead.

If we value simplicity and ease of calculation, it’s hard to beat a flat tax plus basic income. With a flat tax of 30% and a basic income of $12,000 per household, the poor do much better off because of the basic income, while the rich do a little better because of the flat tax, and the middle class feels about the same because the two effects largely cancel. Calculating your tax liability now couldn’t be easier; multiply your income by 3, remove a zero—that’s what you owe in taxes. And how much do you get in basic income? The same as everyone else, $12,000.

Using the same comparison households: The poor household making $12,300 would now receive $8,305—increasing their income by $9,689 or 78.8% relative to the current system. The middle-class household making $52,000 would pay $3,596, saving $5,172 or 10% of their income. The upper-middle-class household making $152,000 would now pay $33,582, saving only $1998 or 1.3% of their income. The top 1% household making $782,000 would pay $234,461, saving $31,164 or 4.0%. The top 0.1% household making $2,037,000 would pay $611,000, saving $151,656 or 7.4%. Finally, the top 0.01% household making $9,936,000 would pay $2,980,757, saving $910,000 or 9.1%.

Thus, like Trump’s plan, the tax cut almost across the board results in less revenue. However, because of the basic income, we can now justify cutting a lot of spending on social welfare programs. I estimated we could reasonably save about $630 billion by cutting Medicaid and other social welfare programs, while still not making poor people worse off because of the basic income. The resulting estimated deficit comes in at $1.085 trillion, which is still too large—but less than what Trump is proposing.

If I raise the flat rate to 40%—just as easy to calculate—I can bring that deficit down, even if I raise the basic income to $15,000 to compensate. The poverty household now receives $10,073, and the other representative households pay $5,974; $45,776; $297,615; $799,666; and $3,959,343 respectively. This means that the poor are again much better off, the middle class are about the same, and the rich are now substantially worse off. But what’s our deficit now? $180 billion—that’s about 1% of GDP, the sort of thing you can maintain indefinitely with a strong currency.

Can we do better than this? I think we can, with my logtax.

I confess that the logtax is not quite as easy to calculate as the flat tax. It does require taking exponents, and you can’t do it in your head. But it’s actually still easier than the current system, because there are no brackets to keep track of, no discontinuous shifts in the marginal rate. It is continuously progressive for all incomes, and the same formula can be used for all incomes from zero to infinity.
The simplest plan just replaces the income tax with a logtax of 20%. The poor household now receives $1,254, just from the automatic calculation of the tax—no basic income was added. The middle-class household pays $9,041, slightly more than what they are currently paying. Above that, people start paying more for sure: $50,655; $406,076; $1,228,795; and $7,065,274 respectively.

This system is obviously more progressive, but does it raise sufficient revenue? Why, as a matter of fact it removes the deficit entirely. The model estimates that the budget would now be at surplus of $110 billion. This is probably too optimistic; under dynamic scoring the distortions are probably going to cut the revenue a little. But it would almost certainly reduce the deficit, and very likely eliminate it altogether—without any changes in spending.

The next logtax plan adds a basic income of $12,000. To cover this, I raised the metarate to 25%. Now the poor household is receiving $11,413, the middle-class household is paying a mere $1,115, and the other households are paying $50,144; $458,140; $1,384,475; and $7,819,932 respectively. That top 0.01% household isn’t going to be happy, as they are now paying 78% of their income where in our current system they would pay only 39%. But their after-tax income is still over $2 million.

How does the budget look now? As with the flat tax plan, we can save about $630 billion by cutting redundant social welfare programs. So we are once again looking at a surplus, this time of about $63 billion. Again, the dynamic scoring might show some deficit, but definitely not a large one.

Finally, what if I raise the basic income to $15,000 and raise the metarate to 35%? The poor household now receives $14,186, while the median household pays $2,383. The richer households of course foot the bill, paying $64,180; $551,031; $1,618,703; and $8,790,124 respectively. Oh no, the top 0.01% household will have to make do with only $1.2 million; how will they survive!?

This raises enough revenue that it allows me to do some even more exciting things. With a $15,000 basic income, I can eliminate social welfare programs for sure. But then I can also cut military spending, say in half—still leaving us the largest military in the world. I can move funds around to give Medicare to every single American, an additional cost of about twice what we currently pay for Medicare. Then Medicaid doesn’t just get cut; it can be eliminated entirely, folded into Medicare. Assuming that the net effect on total spending is zero, the resulting deficit is estimated at only $168 billion, well within the range of what can be sustained indefinitely.

And really, that’s only the start. Once you consider all the savings on healthcare spending—an average of $4000 per person per year, if switching to single-payer brings us down to the average of other highly-developed countries. This is more than what the majority of the population would be paying in taxes under this plan—meaning that once you include the healthcare benefits, the majority of Americans would net receive money from the government. Compared to our current system, everyone making under about $80,000 would be better off. That is what we could be doing right now—free healthcare for everyone, a balanced budget (or close enough), and the majority of Americans receiving more from the government than they pay in taxes.

These results are summarized in the table below. (I also added several more rows of representative households—though still not all the brackets I used!) I’ve color-coded who would be paying less in tax in green and who would be more in tax in red under each plan, compared to our current system. This color-coding is overly generous to Trump’s plan and the 30% flat tax plan, because it doesn’t account for the increased government deficit (though I did color-code those as well, again relative to the current system). And yet, over 50% of households make less than $51,986, putting the poorest half of Americans in the green zone for every plan except Trump’s. For the last plan, I also color-coded those between $52,000 and $82,000 who would pay additional taxes, but less than they save on healthcare, thus net saving money in blue. Including those folks, we’re benefiting over 69% of Americans.

Household

pre-tax income

Current tax system Trump’s tax plan Flat 30% tax with $12k basic income Flat 40% tax with $15k basic income Logtax 20% Logtax 25% with $12k basic income Logtax 35% with $15k basic income, single-payer healthcare
$1,080 $108 $130 -$11,676 -$14,568 -$856 -$12,121 -$15,173
$12,317 $1,384 $1,478 -$8,305 -$10,073 -$1,254 -$11,413 -$14,186
$22,162 $2,861 $2,659 -$5,351 -$6,135 $450 -$9,224 -$11,213
$32,058 $4,345 $3,847 -$2,383 -$2,177 $2,887 -$6,256 -$7,258
$51,986 $8,768 $6,238 $3,596 $5,794 $9,041 $1,115 $2,383
$77,023 $15,027 $9,506 $11,107 $15,809 $18,206 $11,995 $16,350
$81,966 $16,263 $10,742 $12,590 $17,786 $20,148 $14,292 $17,786
$97,161 $20,242 $14,540 $17,148 $23,864 $26,334 $21,594 $28,516
$101,921 $21,575 $15,730 $18,576 $27,875 $30,571 $23,947 $31,482
$151,940 $35,580 $28,235 $33,582 $45,776 $50,655 $50,144 $64,180
$781,538 $265,625 $230,158 $222,461 $297,615 $406,076 $458,140 $551,031
$2,036,666 $762,656 $644,350 $599,000 $799,666 $1,228,795 $1,384,475 $1,618,703
$9,935,858 $3,890,736 $3,251,083 $2,968,757 $3,959,343 $7,065,274 $7,819,932 $8,790,124
Change in federal spending $0 $0 -$630 billion -$630 billion $0 -$630 billion $0
Estimated federal surplus -$682 billion -$1,155 billion -$822 billion -$180 billion $110 billion $63 billion -$168 billion