I’ve been having a back-and-forth on another blog about the prospects for a single-payer healthcare system in the United States and I wanted to solicit some opinions here. One of the arguments made for a single-payer system is that having everyone within a single-payer system will reduce costs. My view is that under certain rather stringent circumstances that might be the case:
Providers accept a pay cut.
There is enough unused capacity in our healthcare system to provide care of at least present quality to everyone.
We close our borders, particularly our southern border.
The will to constrain costs emerges.
but, since those are vanishingly unlikely, I seriously doubt that will happen. My own view is that the reason that healthcare is so expensive in the United States is not because we’re not all covered under the same system but that prices are too darned high and no one has the incentives to cut costs. Getting private insurance out of the picture might help a little but in the absence of real will to control costs it would only be a litte.
Let me explain just one of those. I don’t mention closing the border out of any prejudice against migrants. Will this single-payer system cover everyone in the United States or just some of the people in the United States and what percentage of the people need to be covered by it before the economies kick in?
Consider Illinois. In Illinois something between 5% and 15% of the population consists of illegal immigrants. Will they be covered under this single-payer system? If they are not, everyone in the country will not be covered by a single system. If they are it seems to me that the costs will be significantly higher than has been estimated (and the estimates are high as it is) plus is will add yet another “pull” force to attract illegal immigration.
It’s not just Illinois. California, Oregon, Washington, Colorado, and New York have large populations of illegal migrants as well. That may be part of the explanation for why those states’ Medicaid systems support illegal migrants.
I have a question. Israel is moving troops into Syria from the south. I’ve read some reports that Israel is planning to increase its settlement of the Golan substantially. There are fears that Turkey’s buildup of troops at the border may signal an incursion by Turkey is immanent. There are also some reports that Iraq is considering an incursion into Syria.
Lots of people are speculating about Syria’s future. Does Syria as we have understood it have a future? Today’s Syria is made up of a number of different Ottoman sanjaks and vilayets that have never cohered particularly well. Will Syria disintegrate?
The UN Special Envoy for Syria concluded talks in Damascus on Wednesday, expressing optimism that the fall of the Assad regime could mark the start of a peaceful and democratic transition for the shattered country, while acknowledging challenges remain.
and
Members of the UN Security Council also highlighted the importance of an inclusive and Syrian-led political process based on resolution 2254 (2015) that is facilitated by the United Nations.
In a press statement issued late on Tuesday, ambassadors reaffirmed their strong commitment to Syria’s sovereignty and territorial integrity while urging all nations to respect these principles.
“They also underlined the need for Syria and its neighbours to mutually refrain from any action or interference that could undermine each other’s security,” the statement noted, emphasising the need to combat terrorism and prevent extremist groups like ISIL/Da’esh from regaining a foothold in the country – where they have been active for years.
Council members also reiterated the obligation to respect human rights, including the right to seek justice, and international humanitarian law in all circumstances.
That strikes me as at best aspirational and at worst fantasizing.
For the last couple of weeks there has been increased interest in reforming the U. S. healthcare system. I think many of the pieces I’ve read have been well-intentioned but miss a key point. This piece by Deane Waldman at RealClearHealth certainly fits that description. Here’s a snippet:
News media are replete with stories about the killing of UnitedHealthcare CEO, Brian Thompson. While the murder mystery elements still dominate, a constant subtext is the perpetrator was angry at greedy insurance companies like UnitedHealthcare and frustrated that care is unaffordable and inaccessible.
With Trump in the White House and with the DOGE (Department of Government Efficiency) advising him how to improve efficiency of federal activities, radical reform may be possible, transforming healthcare to become affordable and accessible. Might there be anyone opposed to such transformation?” The surprising answer is, YES!
Who are these people? There are three reasons why some would resist: self-interest, wrong reform, and fear of change.
I think there’s actually other reasons, even a group of related reasons, that there would be resistance to change in our healthcare system including longterm trends within the practice of medicine. Dr. Waldman is pretty forthright about how he thinks our system should be reformed. I think he’s engaging in wishful thinking and introducing advertising and price competition into healthcare are unlikely to result in the cost savings that are necessary.
I would like to open this post up to a conversation about reforming healthcare and air some of my own prejudices about it. I don’t believe that any conceivable reform will result in more, better healthcare at a price we can afford unless the incentives are changed and any attempt at changing the incentives in healthcare will be fought to the death by all of the stakeholders, e.g. patients, providers, insurers, employers, etc.
Please don’t say “well, other countries pay less for equivalent care so it must be possible”. That’s a cop out. Say what you think should be done and how it can be done. There are a number of things that should be kept in mind. First, there is no country that is actually comparable to the United States. There is no country that is as large as the U. S. and as rich as the U. S. and shares a 1,600 mile land border with a country with a median household income a quarter its own.
Growth in staff size and the proliferation of unneeded headquarters is accompanied by a strong tendency to “over-officer” the force, one factor in the explosion of personnel costs since 9/11. In 2024, one in six soldiers is a commissioned officer (a 21 percent increase since 2000). About one-third of the Army’s personnel budget goes to officer pay and allowances. Between 1965 and 2018, the number of general and flag officers in the U.S. military as a percentage of the total force increased by 46 percent; of 4-stars by 114 percent; and of 3-stars by 149 percent. Such deliberate rank-inflation and over-staffing contributes to a bureaucratic culture that demands constant reporting from junior commanders, so much so that one authoritative Army War College study found a “suffocating amount of mandatory requirements” they are “literally unable to complete…forcing them to resort to dishonesty evasion.” Almost certainly, this environment contributes to an exodus of young officers who are frustrated by crushing administrative burdens they cannot reconcile with their duty to train their soldiers for war.
In short, the Army should shutter those organizations not deemed essential, reduce the officer-to-enlisted ratio, and streamline its bloated staffs. These measures will increase the number of billets available to operational units, decrease unnecessary reporting requirements on them, reduce personnel costs and increase the productivity and efficiency of those headquarters that remain. Leaner and flatter are watchwords in the private sector—and are clearly priorities for the incoming administration. America’s Army should adopt them as well.
That will have beneficial run-on effects that go far beyond remaining within its authorized end strength. The focus must be unswervingly on readiness and lethality.
In 2013 Rita Crundwell, the city comptroller of Dixon, Illinois, pled guilty to embezzlement in what has been called “the largest municipal fraud in United States history”. She was sentenced to 19 years in prison. As part of his mass pardon, President Joe Biden has commuted her sentence. NBC 5 Chicago reports:
Rita Crundwell, the former Dixon comptroller who stole more than $50 million in what some publications called “the largest municipal fraud in United States history,” had her sentence commuted by President Joe Biden Thursday.
Crundwell was one of nearly 1,500 individuals who had their sentences commuted by the president in one of the largest single-day actions in U.S. history, with the president also issuing more than three dozen pardons.
Crundwell served as Dixon’s comptroller for more than 20 years, and pleaded guilty in 2013 to embezzling more than $50 million from the city over the course of that time. She used the funds to build a massive championship-winning horse breeding and show operation, according to prosecutors.
Pardoning her is certainly clement but I believe it is a miscarriage of justice. She should serve her full sentence and not under home confinement.
Is pardoning her just part of a mass pardon? If so it illustrates the injustices of mass pardons. If not did someone advocate for her pardon? I believe the voters of Illinois deserve to know if their elected officials are advocating the pardon of their corrupt peers.
There’s quite a bit of whinging about FBI Director Christopher Wray’s giving notice that he will resign his post at the end of President Biden’s term. Wasn’t that inevitable after Sen. Chuck Grassley’s letter?
To save you the trouble of reading it, in the letter Sen. Grassley makes a prima facie case that Director Wray has been nonfeasant, misfeasant, malfeasant or all of the above.
You may disagree. You may think that Kash Patel is unfit to rectify the situation at the Federal Bureau of Investigation. Maybe the Bureau is unmanageable at this point. But it’s pretty clear that something is very, very wrong with the FBI.
As I’ve said before I think the Bureau is redundant at this point. When the FBI was founded more than a century ago the federal government didn’t have dozens of armed agencies with police powers as is the case now. I don’t know that there’s a better illustration of the need for a major reorganization of the federal government than that. The left hand doesn’t know what the right hand is doing.
The graph above was produced by economist Mark Perry. What about healthcare insurance costs? (That was my immediate question.) Fortunately, Statista has that for me.
As you can see individual healthcare insurance prices have more than trebled since 2020. Not just fast but faster than hospital costs or medical service costs. Both of the latter have increased faster than wages in general.
Some are concluding from the above that the Affordable Care Act has failed in slowing the increase in healthcare costs and while that’s certainly the case it wasn’t my conclusion. My conclusion is, I have said many times, that the incentives in healthcare are completely out of whack. A change to single payer is not merely unaffordable and unsustainable in the absence of the will to constrain costs which is demonstrably absent, insurance isn’t the primary problem.
Please, please don’t tell me that other countries do it so it must be possible, particularly not if you’re pointing to tiny countries with high social cohesion. We are starting from too high a baseline. Pointing to insurance is misdirection. It’s the prices, stupid.
As I’ve also said before, I have all sorts of proposals for fixing the situation but everybody hates them so they’re not worth repeating.
IMO abolition or reform of birthright citizenship should be wayyy down on the priority list of changes to immigration. Just off the top of my head my priorities would be:
Expel security risks and prevent them from returning
Expel public safety risks and prevent them from returning, i.e. known felons
Reduce the number of asylum applications accepted on an annual basis to the number we can actually process
Require that asylum applications be made before entering the United States
Expand the number of work visas issued, particularly for people living in Mexico
Make it at least as difficult to work without authorization (citizenship, green card, or other) in the United States as it is in Canada, Australia, and New Zealand, countries with which we have much in common
That would be a start.
That’s not to say that I think that birthright citizenship is a complete non-issue. I think its urgency as an issue would be greatly diminished of the reforms above were adopted. I suspect the reason it has been brought up at all is the inevitable appeals to emotion on behalf of the first two categories I’ve listed above.
I want the U.S. to have the greatest military in the world and the resources to counter increasingly sophisticated threats from our adversaries, but we need a more sensible approach. That is why I have been the only member on the House Armed Services Committee to vote against the bloated defense budget.
And that is why I look forward to working with the Department of Government Efficiency (DOGE) to reduce waste and fraud at the Pentagon, while strongly opposing any cuts to programs like Social Security, Medicare, the Department of Veterans Affairs or the Consumer Financial Protection Bureau. There are several areas of waste and abuse that I hope DOGE will address.
As a starter, consolidation in the defense industry has allowed companies to drive up prices. When I was a freshman member of Congress, I led an investigation on the House Oversight Committee into the defense contractor TransDigm, which through mergers had acquired exclusive rights to sole-source aircraft parts. A report from the Defense Department’s inspector general revealed the company had exploited the American people by overcharging over 4,000 percent on those sole-source parts. In the end, TransDigm returned $16.1 million to the Pentagon. Equally outrageous, a “60 Minutes” report found that the price of stinger missiles has increased from $25,000 in 1991 to $480,000 today. One reason is that Raytheon became the sole supplier and can drive up costs.
He goes on to single out the F-35, oppose sole source contracts, oppose cost-plus contracts, support divesting excessive military property, thereby reducing maintenance costs, and canceling projects the DoD no longer wants. Here’s a reform that hasn’t been on my radar:
One ingredient for effective price monitoring is better communication across the federal government to ensure the Pentagon isn’t paying more than any other department. The Defense Health Agency overpaid by $16.2 million for electric breast pumps, spending as much as $1,400 for pumps that are $192 in stores. The department’s acquisition processes lacks sufficient controls for defense contractors who can get away with overcharging the government. We have a phenomenal workforce, but they must be paired with state-of-the-art systems and policies to ensure contracts only go to qualified contractors with reasonable prices.
My own pet reform to our defense spending is that I believe that we need to reduce the number of flag officers substantially. That will do a lot more than the obvious saving in costs. Nearly every flag officer has a pet project he or she carries with her or him throughout their career and frequently even beyond. Reducing the number of flag officers will organically result in substantial cost savings.
