We've convinced ourselves that everyone "deserves" to have high quality homes, health care, education, etc... It's demeaning to have "substandard" levels of quality, so we regulate them until providing bare bones versions is illegal.
Housing: We used to have boarding houses, SROs, hostels, etc... But middle-class activists got rid of those options via zoning codes. Unfortunately, middle-class+ legislators never got around to actually providing a cost effective alternative.
Health Care: Health insurance used to all be "catastrophic" only. Minor stuff was on you, but if you had a car accident or got leukemia, they'd step in to cover (most usually) of the costs. But we decided making sick people worry about price was icky, and after all, everyone deserves health care, so we did away with those. Obamacare was the final nail in the coffin of those plans. And not surprisingly, health care costs skyrocketed.
Education: Why couldn't we have small, public schools that replicate the 1-room schoolhouse (or 2-3 room if you like) model of 100 yers ago? We know it works. Less overhead. More parental involvement. More accountability both ways. But rules about school construction and red tape have effectively made that impossible. Oh, it still exists, but only for parents that can afford private or home education.
We need to learn to tolerate more diversity of quality in many things. One size fits all generally fits almost no one well.
healthcare inflation has slowed since the ACA was enacted. Though it still exists certainly, and except for a a couple years during the post-Pandemic general inflationary years it does outstrip general inflation.
Why would many smaller schools be cheaper? If anything the need for more infrastructure starting with the buildings themselves would push overall costs higher. As a general rule and up to a certain point consolidation in just about anything usually results in lower prices.
A question on "high quality" health care. Does it include being told the truth by our government regarding vaccines? Check the latest measles numbers as the loon RFK spreads his lunacy. Another legacy of the "new" right is a return to the Dark Ages on this front. Of course, establishment elites in the "new" right stay silent as children needlessly die. Don't wanna cross the mad king.
Good thing George Washington required smallpox vaccines for his army, or we might have lost the war...
Health insurance costs are driven by health care costs. One should not conflate the two. The margin is fairly thin. All sane employers try to reduce that margin in their negotiations with the insurance industry. CMS appears to do the same. Adding mandatory benefits greatly increases costs as more providers get to play. Initially, Obamacare did this big time but seem to have backed off a bit. Raising deductibles and copays has a pretty dramatic impact on premiums but that just offloads some of the costs to households. But the big influence on costs is financialization of the health care industry including medical practices, hospitals, nursing homes, physical therapy practices, pharmacies and even veterinary practices. Another large influence is the aging of the population for which there is no solution. The big influence on premiums is all the people getting free stuff. Basically Medicaid and the EMTALA. This drives up the costs for everyone else as providers seek to recover their losses. Medicare is a benefit paid for by a career's worth of mandatory deductions. This is buried in the FICA deductions so many don't realize it exists. There are also ongoing premiums for Parts B and D. And for tall poppies, there is IRMA. Health insurance has always subsided the sick at the expense of the healthy. It is a design feature. If you are healthy and subsidizing the sick, you are the winner. This feature is perverted when health insurance covers predictable, routine stuff.
Insurance should cover "predictable, routine stuff" and they don't just do it because it's the law. If they didn't cover predictable, routine stuff, there'd be more non-routine 'stuff' like hospital stays and ER visits, which would cost the system a lot more.
It's true EMTALA costs the system money because everyone can be treated at an ER without showing their papers, but I'd hate to live in a world where patients are allowed to bleed out because no one could find their insurance card in time.
Have you been to the ER lately? No one's "bleeding out for lack of an insurance card". At least here in CA, 3/4s of the waiting room is full of parents (mostly illegal likely) whose kids have runny noses and coughs.
There are all kinds of free or low cost clinics, but because the law says the ER has to treat them for free, they go to the ER. Even for the sniffles.
I try to avoid the ER so, no, I haven't been to one lately. The issue you're referring to isn't due to EMTALA -- EMTALA only requires hospitals to screen for and treat 'emergency medical conditions' -- it doesn't require them to treat runny noses. https://www.law.cornell.edu/uscode/text/42/1395dd
In practice though, screening for emergency conditions takes up an enormous amount of time, and the lawyers make it essentially impossible to say: "you're not an emergency, go home."
I was a foster parent for many years. I spent a lot of time in ERs and saw this problem first hand for a long time here in CA.
Interesting. Seems there ought to be a way to throw out the bathwater here without the baby, because you don't want people using the ER for primary care but you also don't want real emergency medical conditions being delayed or ignored due to a lack of funds, or even the inability of a (possibly unconscious, underage or insane) patient to prove he's insured.
Well said. EMTALA is really inside baseball in HC. People say "there's no right to HC" but there is a partial right if you read EMTALA.
All the talk about giving people $1500 to put in an HSA is ridiculous. What happens when they hit an emergency? They'll need $100k!
The right celebrates free markets and innovation but glosses over who pays. Even the WSJ was insisting that Medicare cover one of the dementia drugs despite really high cost and weak benefits. Same w/ Duchenne Muscular Dystrophy at $3mm a pop.
The HSA could be a solution for having routine care in insurance but not for the big buck stuff. Probably needs a separate insurance policy that would have to be public funded because no one this side of a billionaire can cover those costs. Problem is as we have seen in the UK an alternative is just letting them die. Medicare, Medicaid, Obamacare, and employer policies would cover the middle ground. This is just an interim plan though. Longer run we have to run private equity out, break the various cartels that strangle provider numbers, force foreign countries to pay a fair share of pharma research and figure out a way to induce people to stop killing themselves with lifestyle diseases. If we could get costs under control, we could design insurance plans that weren't crazy.
Medicare premiums and payroll deductions don’t cover the cost of care. Not close. It’s not just poor brown people getting “free stuff”. Wealthy white guys like me do too. MAGA devotees likely don’t understand this, hence the cuts inherent in Don’s signature legislation, the BBB. When the “new” right realizes that Medicaid recipients are now their base voters, this view may change.
Part A is covered by the payroll deductions. Premiums (including IRMA) cover about 25% of B and D. The comparable number for Medicaid is close to 0% with some individuals above Medicare eligibility levels but below 150% of FPL in some states.
Roughly half of Medicare funding comes from the general fund, not premiums or taxes. This increases as the population ages. It sounds like you are arguing for taking Medicare recipients, not just Medicaid recipients, off the dole, since "the big influence on premiums is all the people getting free stuff"...
It will not be easy to unwind the mess that LBJ, Bush and Obama made of the health care system. Problem is that much of the population now depends on those programs and just pulling the plug will upset everybody's financial situation. Probably the only way out is to run dual systems with everybody being grandfathered and a new system set up for new entrants. That will be very expensive and therefore will never happen. Most likely outcome is to ride the bomb down and then do something.
Plenty of bipartisan blame in the past. I'm more concerned about the future. Clearly Don will never take on either health care or entitlement reform, even with unified control, he's made that clear. Eschewing entitlement reform is another break his "new" right has made, they now explicitly oppose all entitlement reform and have effectively made common cause with the left in preserving the status quo. The most he can muster is cutting his base voters off Medicaid while still managing to run up record setting deficits.
Obamacare ended years ago in the individual market…what we have now is Kushnercare because of the reforms the Republicans have made over the years. Obamacare lives on in the very popular Medicaid expansion which is what Obamacare should have only been by expanding Medicaid to 250% FPL and then a $5000 refundable tax credit to those without employer benefits.
Health insurance, at least the way we have been doing it, creates a third party payer problem. The doctor provides the service, the patient gets the service but the employer or insurance company pays for the service. The doctor wants to get the most money he can, the patient wants to get the most healthcare he can, and the insurance company want to avoid paying for a much as it can. If health insurance was limited in the way that car insurance was, this wouldn't be a problem.
Then comes the tax laws. If you pay for healthcare out of pocket, it's with taxed earnings. If you pay for healthcare through your employer provided insurance, it's with none taxed earnings. Starting to see where things go off course. If you can get employer provided insurance to cover the cost of routine care, or prescriptions then you will in theory save money by not paying taxes on those earnings.
One simple example of this, was my wife asking for a prescription for vitamin C during her pregnancy. This made it covered by her insurance. I'm weird so I looked at the difference between what was paid for the prescription versus what the cost was off the self. $8 for the prescription for 100 tablets, $4.50 for 250 tablets off the self. Not surprising when you realize one was stocked by a basic employee and paid for at the register. The other needed to be filled by a pharmacy tech and billed through a series of accounts payable and receivable.
All that before you get to the many problems in Medicare. Copays and deductibles help because it makes people pay attention to what it's costing them to go to the doctor rather then look for an off the shelf remedy first, or trying to find a more affordable doctor.
There's a prescription form of Vitamin C? And health plans will pay for it? That's strange.
Back when the allergy med Zyrtec was Rx only my health insurance paid for it. Then they allowed it to go OTC and my health plan no longer paid for it even if a doctor wrote a script for it.
Obviously, it depends on you're insurance policy. At the time my wife worked in the banking industry and had one of the better insurance plans. That was the point of my post, those types of plans should have been getting tax subsidies but were and are still today.
Maternity has no business being part of what we refer to as health insurance. All health insurance in America is the wealthier can spread health care costs onto other Americans more easily. We pay for health care via a VAT meaning every product and service you purchase in America includes someone else’s health care costs.
Wow, let's start with that there are some people getting rich off our jacked up health care system, but that in no means that the average rich guy saves money because the rest of us have to deal with our jacked up health care system. In fact they are getting just as screwed as we are, if not more.
Then let's deal with, we don't have a Value Added Tax, you might mean that we are all paying more for health care in a number of way, but it usually comes from the employees getting less wages. We still pay attention to price signals so the company that tries to pass the cost onto the consumer will lose business.
Because the system is so jacked up, people are willing to take lower pay for better health insurance. Again a lot of that goes back to taxes. If your health insurance cost 10K a year, and taxes on your last dollar made is 25%, you have to make $13,350 before taxes to pay for it. So in other words you can save $3,350 by having your employer pay for your insurance.
You might be thinking, wait 25% of $10k is only $2,500, yes but you have to pay taxes on that, which is $625, but you have to pay taxes on that, which is 156.25, but you have to pay taxes on that which is $39.06, and on and on.
All this means that rather then shopping around for the best health insurance that fits your needs, or joining a health Co-op that negotiates things like maternity coverage in addition to having health insurance, we just demand it to be covered in everybody's health insurance.
Again, all that before you get to how we've messed up Medicare.
Large American corporations are “self insured” which means they pay for their employees’ health insurance as a line item in their budget—that’s exactly how a VAT is treated in a balance sheet!! So the way Bill Gates or a law firm partner’s health insurance is paid for is they include it as part of their business expenses which means everyone that buys something from Microsoft pays for Gates’ health care expenses AND they pay for the law firm partner’s health care expenses that Microsoft hires!! Right now you are paying for Gates’ health care expenses because by just going on the internet you are in some way using Microsoft!!!!
So in America the more you can spread health care costs around the better off you are. So obviously a maid that is self employed can’t spread around her $10k maternity bill but Gates’ wife certainly can because Microsoft picks up the tab and includes it in their budget!
You obviously don't understand how a Value Added tax works or what all the various nations that charge these taxes use the money for. I'll come back to that but first.
The fact that Bill Gates runs his healthcare through his employer doesn't in and of itself increase what you pay Microsoft. If he wasn't getting his overpriced health insurance through his employer he would just take the money instead. I know this because my customers don't pay my health insurance even though I run it through my own business. If I could charge more money I would do that and take the cash anyway. I buy my family's health insurance under my business because it then saves me about $3,350 a year in taxes.
Here is how a value added tax system works. If you buy Bauxite ore and make it into rolls of aluminum, you pay a tax on the difference between the value of the Bauxite ore and the aluminum roles. If you buy rolls of aluminum and turn it into soda cans, you pay a tax on the difference between the value of the rolls of aluminum and the the value of the cans. If you buy soda cans and fill them with soda, you pay a tax on the added value between the empty cans and the filled cans. If you buy cans of soda from the manufacture and then sell them to the retailer, you pay a tax on the value added by distributing the soda cans. If you are a retailer that buy soda from a wholesaler, you pay a tax on the value added.
So it's nothing like what you think it is. It's similar to a sales tax, just one that is calculated not on the purchase price at the final retail store, but rather, at every point it changes hands. The tax is calculated not on the total price that you're selling it for, but for the difference between the price you paid and the price you got. Countries that charge value added taxes use them to pay for all kinds of things just like income taxes, or property taxes. Not all countries with Value added taxes have government run healthcare. Not all countries with government run health care have a Value Added Tax. Quit using that as an argument. It make you sound thick to anyone that knows what a VAT is.
I think you are invested in a false narrative about how heath care in America is structured. Health care is a line item on a P&L statement and so for the vast majority of Americans it isn’t “insurance”. So when you engage in commerce in America you are literally paying for other Americans’ health care expenses….no “insurance” involved. So the wealthier an American is the more they can spread their health care expenses to other Americans…so that is the heath care system you defended against Obamacare…..oops. 😉
Yes, they are self-insured-- but only up to a certain dollar amount. Beyond that those plans are reinsured meaning that for someone who does run up a big bill an insurer in the background foots the bill (and the employer pays for that, generally rolled into the cost of having a benefits company administer the plan) When I was in that industry the cutoff was general 10K per member but it may be higher now.
I happened to meet a guy whose family was starting an insurance company and their business model was (and I have no clue what this means or if it even makes sense but iirc) ERISA + 20% and take it or leave it. Anyway, when I made the remark that the employer based market had the greatest risk pool of any market because everyone has to be healthy enough to have a full time job and their spouse and children have to be healthy enough that they can work full time he laughed in agreement.
Other than the tax thing, the patient always pays. Either they get less wages because the employer is paying for health insurance or they are paying insurance premiums directly. Having done collective bargaining, I have discovered that if you tell unions the total available for compensation, they will chose wages over health insurance every single time. In retirement, I have discovered that at least for basic stuff like blood pressure meds, you can use non-insurance products like Good RX to get prescriptions for the same price.
Your fundamentally right that the patient always pays in the end, but missing the way this tricks the patient into paying much more for less. Your example of using Good RX is a case in point. If Medicare part D simply covered all your prescriptions regardless of where they were purchased, you would go for the most convenient to you arrangement. Because of it's deductibles and the infamous donut hole, it rewards you for finding ways to save money instead.
But back to us non-retired persons, by tricking my wife into believing she was saving money by getting a prescription for an otherwise over the counter vitamin, that drives up demand for pharmacy tech and billing agents, which raises the price of wages, which in turn raises the price we all pay to get our prescriptions filled.
We have really and truly made an absolute mess of our healthcare system. Obama care was destined to fail because rather then increasing the supply of healthcare professionals, it increased the need for accountants, lawyers, and billing and receiving agents.
But attempts to restrict the tax exemptions or switch them to personal exemptions rather then employer exemption always run smack into a political wall of resistance. Same with copying the more successful voucher program in Medicare part D in the other parts that are currently fee for service.
Part D is fundamentally flawed. After my experiences with GoodRX, I am contemplating the thought that the whole thing was a trick to get retirees to bail out Medicare while thinking they were getting something for nothing. Adding Part D IRMA for the tall poppies reinforces that. A caveat to my opinion is that I have no experience (fortunately) with really expensive classes of meds and Part D may provide actual benefits to those who do.
The history of employer based insurance reinforces your point about trickery. It was initially instituted as a way to evade WW2 wage and price controls. When the war was over an attempt was made to count it as income. The unions (private sector unions were a lot more powerful then and it was the Truman administration) put on a big push to retain it and succeeded. Deductions for employers were the same either way and they lacked to foresight to see where it was going. To this day, many employers still don't understand total compensation theory. With the dominance of 401k plans, they have gotten there about retirement but health insurance not so much. If they did, they would have a fungible benefit allowance rather than piecemeal benefits.
One guy I used to know from the Lions club, was able to keep his house thanks to part D. Not that he would have got much for it, since he had already taken out a reverse mortgage some years before. So if you were on those expensive drugs, it would mean a lot more to you. That said, another scam has been the ban on re-importing drugs. That are own politicians would let the pharmaceuticals get way with charging us far more for the same drug they sell to the Canadians for much less is just an outright scandal. This doesn't get the coverage it should. That has as much to do with the Pharmaceuticals spending big on advertising with the same companies that are supposed to be honestly reporting on these issues.
Then you get into the countless other scams. My mom got mad enough that she quit taking one of her prescriptions for over a year because all the companies kept trying to make her rent a nebulizer. When she would complain, the response was "Medicare is paying for the nebulizer so why do you care?" She just couldn't get over the idea of paying $20 a month to rent a machine that she already had and could buy new for $45. If memory serves, she eventually found a Canadian pharmacy that would fill the prescription without requiring her to rent the machine. So my otherwise law abiding mom felt irritated enough to break the law rather then go along with what she thought was a scam. Most just accept it and don't bother to think about how much debt they are helping to pile their kids and grandkids in.
So again, we've made a real mess of our healthcare system.
Re: In practice, this means that those who could otherwise afford perfectly reasonable insurance premiums (and who tend to consume a limited amount of health care) are required to pay exorbitantly more—not as “taxes,” technically, just the “price” in the “market”—to hold down the cost for those who cannot possibly afford to cover their own costs.
This has existed in this country long before the ACA-- in workplace health plans. Community rating (everyone pays the same premium) is all but universal in such group plans, allowing only for small surcharges for smoking or maybe a couple other voluntary unhealthy habits. That means of course that healthy employees and their dependents who consume little healthcare are indirectly helping pay the premiums of other employees who do or whose dependents may have very high cost conditions. The premium cost however is partially disguised by the fact that the employer is paying part of it and rarely makes that transparent to the employees.
Excellent survey. On redistribution, the goal should be a fair and efficient way to transfer income from capital to labor that does not disincentivize saving and investment. Economists have known for decades the ideal way to attack this problem. It's called a graduated expenditure tax, essentially a progressive tax on personal consumption with net savings tax exempt. Here I describe a single parameter version of such a tax which is at once simple, transparent, and immune from lobbying on behalf of special interests: https://shorturl.at/cS4Kx
Many of you might remember Representative Paul Tsongas (D, MA) from the 80s. He got the reputation as an "eat your peas" Democrat for telling unpleasant truths. While Oren probably doesn't remember him firsthand, I get the feeling that Oren's parents would have been supporters.
"But to do that, we would need the government to pick up the tab, as it should, for the care we, as a nation, have decided we want to ensure everyone receives. And to do that, we would need to raise more tax revenue from higher-income households who are having no trouble making ends meet."
Yes, and we're getting very close to the point where we have to stop kicking the can and "eat our peas." The hand waving, finessing and insistence that every problem can be solved in a "win/win" way needs to stop if we are to actually solve the hardest problems.
Government redistribution is never the correct answer to any problem. Real "redistribution" comes from people being paid more for their work. That requires rebalancing the labor market in favor of employees, by reversing globalization. When the economy as a whole is shrinking due to massive trade deficits, as it has increasingly been for 35 years, tax and spend policies are not only rearranging the deck chairs on the Titanic, they are piling more weight on top of it. The actual problem has to be fixed. Inequality has exploded due to the exploitation of cheap foreign labor, driving down incomes across the board. Part of the money that used to go to American households goes out of the country, while the rest is pocketed by the employers. Anything that does not address that is worse than useless.
Bottom line: the correct way that a healthy economy “redistributes” wealth and reduces inequality is through employees being paid well for their jobs. End globalization, which exists for the purpose of exploiting the arbitrage of cheap foreign labor, and that happens. It is that simple.
I sort of agree on inequality. In 1980, before taxes the top 1% received 8% of GDP, it is now around 24%. This was not because they added more value, by 2004 TFP collasped from 2% to .5% annually. They used immigration, imports, and the Fed to crush any growth in US citizen median real wages. Changing this via tax policy ends growth. You need a cometitive capitalism focused on the top 10%.
The problems of the US economy, including affordability and inequality, are entirely the result of ~35 years of "globalization". Profits over that period of time, which have accrued to those at the top, have been almost entirely the product of arbitrage, and specifically the arbitrage of cheap foreign labor. The only true solution to these problems is a rebalancing of the labor market, in favor of domestic employees and job seekers.
What has happened is clear at this point. Starting in the 1990s, everything that could be outsourced was outsourced, while immigration, both legal and illegal, exploded. The consequence was the suppression of employee compensation, the explosion of the trade deficit, and the stagnation of the economy. Because globalization reduced the price of many goods and services, inflation was kept low, and interest rates were kept near zero, which encouraged debt. But as the economy as a whole hollowed out, that debt became unsustainable, and collapsed in 2008. Since then, the economy has limped at around 2% GDP growth, for 17 years. COVID, of course, made things much worse.
The (raw) "deal" of globalization was that it would provide cheap consumer goods at Walmart, which would make up for lower incomes. But the core expenses of a middle class life, as defined in this article, are things that are not subject to price reduction from globalization. Money, like water, seeks its own level, and as it flowed out to the Third World, and the Third World flowed in, things like housing, education and health care remained as untouched islands of the economy that used to be, continuing to rise in cost, while incomes did not keep pace.
Plentiful jobs for native-born Americans that pay well are the only actual answer to these problems. Employers paying employees more, and hiring more of them, is the true, legitimate "redistribution" that would actually make things right. Everything else is a band-aid. Reducing immigration to zero and reversing it will exert that kind of pressure. Tariffs that protect domestic jobs are the other half of the equation. Domestically, within the borders of the US economy, libertarian economic policy works. But it must stop at the water's edge. It is that simple.
NOTE: The impact of globalization on employment and compensation is not confined to blue collar work, or those without a college education. It increasingly impacts white collar work, which is already subject to technological pressures. The stories of companies firing their entire IT departments and replacing them with cheap labor imported from India have been happening for years. With few exceptions, you cannot call a customer service or technical support line and speak to an American. Those are reasons why college doesn't pay off for many, and it must all end.
On a macro level, the US economy has bled wealth through exponential increases in the trade deficit, suppressing GDP growth. During that time, "foreign investment" has been touted as the return of that wealth. Sending out massive amounts of money, and having it come back in the form of foreign purchase of US assets, has been ludicrously characterized as a "win". The malpractice and dishonesty in all of this is astounding. The country has effectively been strip mined, chopped up and sold off as parts, sold out from under the American people. A few have profited, while the country itself has disintegrated. It is a crime of historic proportions.
An other fine piece, but Ifeel compelled to make two comments. First, I agree with Oren wholeheartedly that explicit and implicit wealth redistribution will be required to bring middle class working families a decent standard of living. As I have pointed out previously Democratic Socialists, the Bernie faction of Democrats and frankly traditional New Dealers have long advocated such an approach. And yes, the Corporate Democrats have abandened the middle class. But why waste time on branding issues when one could make common cause for the greater good? Secondly, a bit of an issue on the reporting regarding GM leaves out that GM took a 28% drop from last year and as a result workers will be getting a much lower profit sharing check, while at the same time giving out the reported dividends reported in here. How do we incent good corporate behavior?
There is only one reason for the disparity of higher costs versus income. Supply and demand. We have an abundant supply of do-nothing people that are takers contributing zero to the necessities of life, while the worker bees are required to support them. Housing would be more affordable if Property taxes were not the equivalent of a mortgage payment. And where do property taxes go, to fund a bloat of do-nothing public employees.
I'd add to the question of "market preferences" the angle of regulatory demands. For example, no small part of that rise in university costs can be put down to expanding bureaucracy, which is itself often a byproduct of regulations and so on.
Or take a car - you /cannot/ buy a car without backup cameras, blind spot sensors, an infotainment system, and a bunch of airbags. We can argue about the merits of each item there, but the point is that these features are not universally present because of popular demand, or even because manufacturers find it unaffordable to include less-optioned models in their mix, but because of government fiat.
You're barking up the wrong tree when it comes to cars. There is strong demand for backup cameras and they are pretty cheap. Adding about a hundred dollars to manufactures costs. Have you noticed all the models sporting turbo chargers, that's not because of demand. That because the ever tightening emission controls keep forcing the auto makers go to increasingly expensive lengths to get us the power we want and need.
That is also why basic pickup trucks have grown to stupid sizes. They can't stick a powerful enough engine in a regular sized truck or car to pull the boat or haul a load of kids to boy scouts. So the car companies have to increase the width, height and length to give you what you want. Comparatively, the air bags are cheap and save far more money in the aggregate then they cost.
The really sad part is that building turbos, or making trucks bigger uses more power and creates more pollution then letting us buy what we want in the first place.
I’d like to see a cogent description, winners and losers, of a newly privatized health insurance system that covers the cost of ‘catastrophic’ medical care while leaving ‘routine and non-catastrophic care to the private sector outside of the insurance market.
A start might be repealing the signature economic policy achievement of Don, MAGA, and the "new" right-the BBB. After all, it shifts massive wealth from working stiffs to plutocrats along with its record setting deficits.
We've convinced ourselves that everyone "deserves" to have high quality homes, health care, education, etc... It's demeaning to have "substandard" levels of quality, so we regulate them until providing bare bones versions is illegal.
Housing: We used to have boarding houses, SROs, hostels, etc... But middle-class activists got rid of those options via zoning codes. Unfortunately, middle-class+ legislators never got around to actually providing a cost effective alternative.
Health Care: Health insurance used to all be "catastrophic" only. Minor stuff was on you, but if you had a car accident or got leukemia, they'd step in to cover (most usually) of the costs. But we decided making sick people worry about price was icky, and after all, everyone deserves health care, so we did away with those. Obamacare was the final nail in the coffin of those plans. And not surprisingly, health care costs skyrocketed.
Education: Why couldn't we have small, public schools that replicate the 1-room schoolhouse (or 2-3 room if you like) model of 100 yers ago? We know it works. Less overhead. More parental involvement. More accountability both ways. But rules about school construction and red tape have effectively made that impossible. Oh, it still exists, but only for parents that can afford private or home education.
We need to learn to tolerate more diversity of quality in many things. One size fits all generally fits almost no one well.
Bravo!
Brian,
healthcare inflation has slowed since the ACA was enacted. Though it still exists certainly, and except for a a couple years during the post-Pandemic general inflationary years it does outstrip general inflation.
Why would many smaller schools be cheaper? If anything the need for more infrastructure starting with the buildings themselves would push overall costs higher. As a general rule and up to a certain point consolidation in just about anything usually results in lower prices.
A question on "high quality" health care. Does it include being told the truth by our government regarding vaccines? Check the latest measles numbers as the loon RFK spreads his lunacy. Another legacy of the "new" right is a return to the Dark Ages on this front. Of course, establishment elites in the "new" right stay silent as children needlessly die. Don't wanna cross the mad king.
Good thing George Washington required smallpox vaccines for his army, or we might have lost the war...
Good luck America.
Health insurance costs are driven by health care costs. One should not conflate the two. The margin is fairly thin. All sane employers try to reduce that margin in their negotiations with the insurance industry. CMS appears to do the same. Adding mandatory benefits greatly increases costs as more providers get to play. Initially, Obamacare did this big time but seem to have backed off a bit. Raising deductibles and copays has a pretty dramatic impact on premiums but that just offloads some of the costs to households. But the big influence on costs is financialization of the health care industry including medical practices, hospitals, nursing homes, physical therapy practices, pharmacies and even veterinary practices. Another large influence is the aging of the population for which there is no solution. The big influence on premiums is all the people getting free stuff. Basically Medicaid and the EMTALA. This drives up the costs for everyone else as providers seek to recover their losses. Medicare is a benefit paid for by a career's worth of mandatory deductions. This is buried in the FICA deductions so many don't realize it exists. There are also ongoing premiums for Parts B and D. And for tall poppies, there is IRMA. Health insurance has always subsided the sick at the expense of the healthy. It is a design feature. If you are healthy and subsidizing the sick, you are the winner. This feature is perverted when health insurance covers predictable, routine stuff.
Insurance should cover "predictable, routine stuff" and they don't just do it because it's the law. If they didn't cover predictable, routine stuff, there'd be more non-routine 'stuff' like hospital stays and ER visits, which would cost the system a lot more.
It's true EMTALA costs the system money because everyone can be treated at an ER without showing their papers, but I'd hate to live in a world where patients are allowed to bleed out because no one could find their insurance card in time.
Have you been to the ER lately? No one's "bleeding out for lack of an insurance card". At least here in CA, 3/4s of the waiting room is full of parents (mostly illegal likely) whose kids have runny noses and coughs.
There are all kinds of free or low cost clinics, but because the law says the ER has to treat them for free, they go to the ER. Even for the sniffles.
I try to avoid the ER so, no, I haven't been to one lately. The issue you're referring to isn't due to EMTALA -- EMTALA only requires hospitals to screen for and treat 'emergency medical conditions' -- it doesn't require them to treat runny noses. https://www.law.cornell.edu/uscode/text/42/1395dd
In practice though, screening for emergency conditions takes up an enormous amount of time, and the lawyers make it essentially impossible to say: "you're not an emergency, go home."
I was a foster parent for many years. I spent a lot of time in ERs and saw this problem first hand for a long time here in CA.
Interesting. Seems there ought to be a way to throw out the bathwater here without the baby, because you don't want people using the ER for primary care but you also don't want real emergency medical conditions being delayed or ignored due to a lack of funds, or even the inability of a (possibly unconscious, underage or insane) patient to prove he's insured.
Well said. EMTALA is really inside baseball in HC. People say "there's no right to HC" but there is a partial right if you read EMTALA.
All the talk about giving people $1500 to put in an HSA is ridiculous. What happens when they hit an emergency? They'll need $100k!
The right celebrates free markets and innovation but glosses over who pays. Even the WSJ was insisting that Medicare cover one of the dementia drugs despite really high cost and weak benefits. Same w/ Duchenne Muscular Dystrophy at $3mm a pop.
The HSA could be a solution for having routine care in insurance but not for the big buck stuff. Probably needs a separate insurance policy that would have to be public funded because no one this side of a billionaire can cover those costs. Problem is as we have seen in the UK an alternative is just letting them die. Medicare, Medicaid, Obamacare, and employer policies would cover the middle ground. This is just an interim plan though. Longer run we have to run private equity out, break the various cartels that strangle provider numbers, force foreign countries to pay a fair share of pharma research and figure out a way to induce people to stop killing themselves with lifestyle diseases. If we could get costs under control, we could design insurance plans that weren't crazy.
Medicare premiums and payroll deductions don’t cover the cost of care. Not close. It’s not just poor brown people getting “free stuff”. Wealthy white guys like me do too. MAGA devotees likely don’t understand this, hence the cuts inherent in Don’s signature legislation, the BBB. When the “new” right realizes that Medicaid recipients are now their base voters, this view may change.
Part A is covered by the payroll deductions. Premiums (including IRMA) cover about 25% of B and D. The comparable number for Medicaid is close to 0% with some individuals above Medicare eligibility levels but below 150% of FPL in some states.
Roughly half of Medicare funding comes from the general fund, not premiums or taxes. This increases as the population ages. It sounds like you are arguing for taking Medicare recipients, not just Medicaid recipients, off the dole, since "the big influence on premiums is all the people getting free stuff"...
It will not be easy to unwind the mess that LBJ, Bush and Obama made of the health care system. Problem is that much of the population now depends on those programs and just pulling the plug will upset everybody's financial situation. Probably the only way out is to run dual systems with everybody being grandfathered and a new system set up for new entrants. That will be very expensive and therefore will never happen. Most likely outcome is to ride the bomb down and then do something.
Plenty of bipartisan blame in the past. I'm more concerned about the future. Clearly Don will never take on either health care or entitlement reform, even with unified control, he's made that clear. Eschewing entitlement reform is another break his "new" right has made, they now explicitly oppose all entitlement reform and have effectively made common cause with the left in preserving the status quo. The most he can muster is cutting his base voters off Medicaid while still managing to run up record setting deficits.
Obamacare ended years ago in the individual market…what we have now is Kushnercare because of the reforms the Republicans have made over the years. Obamacare lives on in the very popular Medicaid expansion which is what Obamacare should have only been by expanding Medicaid to 250% FPL and then a $5000 refundable tax credit to those without employer benefits.
Health insurance, at least the way we have been doing it, creates a third party payer problem. The doctor provides the service, the patient gets the service but the employer or insurance company pays for the service. The doctor wants to get the most money he can, the patient wants to get the most healthcare he can, and the insurance company want to avoid paying for a much as it can. If health insurance was limited in the way that car insurance was, this wouldn't be a problem.
Then comes the tax laws. If you pay for healthcare out of pocket, it's with taxed earnings. If you pay for healthcare through your employer provided insurance, it's with none taxed earnings. Starting to see where things go off course. If you can get employer provided insurance to cover the cost of routine care, or prescriptions then you will in theory save money by not paying taxes on those earnings.
One simple example of this, was my wife asking for a prescription for vitamin C during her pregnancy. This made it covered by her insurance. I'm weird so I looked at the difference between what was paid for the prescription versus what the cost was off the self. $8 for the prescription for 100 tablets, $4.50 for 250 tablets off the self. Not surprising when you realize one was stocked by a basic employee and paid for at the register. The other needed to be filled by a pharmacy tech and billed through a series of accounts payable and receivable.
All that before you get to the many problems in Medicare. Copays and deductibles help because it makes people pay attention to what it's costing them to go to the doctor rather then look for an off the shelf remedy first, or trying to find a more affordable doctor.
There's a prescription form of Vitamin C? And health plans will pay for it? That's strange.
Back when the allergy med Zyrtec was Rx only my health insurance paid for it. Then they allowed it to go OTC and my health plan no longer paid for it even if a doctor wrote a script for it.
Obviously, it depends on you're insurance policy. At the time my wife worked in the banking industry and had one of the better insurance plans. That was the point of my post, those types of plans should have been getting tax subsidies but were and are still today.
Maternity has no business being part of what we refer to as health insurance. All health insurance in America is the wealthier can spread health care costs onto other Americans more easily. We pay for health care via a VAT meaning every product and service you purchase in America includes someone else’s health care costs.
Wow, let's start with that there are some people getting rich off our jacked up health care system, but that in no means that the average rich guy saves money because the rest of us have to deal with our jacked up health care system. In fact they are getting just as screwed as we are, if not more.
Then let's deal with, we don't have a Value Added Tax, you might mean that we are all paying more for health care in a number of way, but it usually comes from the employees getting less wages. We still pay attention to price signals so the company that tries to pass the cost onto the consumer will lose business.
Because the system is so jacked up, people are willing to take lower pay for better health insurance. Again a lot of that goes back to taxes. If your health insurance cost 10K a year, and taxes on your last dollar made is 25%, you have to make $13,350 before taxes to pay for it. So in other words you can save $3,350 by having your employer pay for your insurance.
You might be thinking, wait 25% of $10k is only $2,500, yes but you have to pay taxes on that, which is $625, but you have to pay taxes on that, which is 156.25, but you have to pay taxes on that which is $39.06, and on and on.
All this means that rather then shopping around for the best health insurance that fits your needs, or joining a health Co-op that negotiates things like maternity coverage in addition to having health insurance, we just demand it to be covered in everybody's health insurance.
Again, all that before you get to how we've messed up Medicare.
Large American corporations are “self insured” which means they pay for their employees’ health insurance as a line item in their budget—that’s exactly how a VAT is treated in a balance sheet!! So the way Bill Gates or a law firm partner’s health insurance is paid for is they include it as part of their business expenses which means everyone that buys something from Microsoft pays for Gates’ health care expenses AND they pay for the law firm partner’s health care expenses that Microsoft hires!! Right now you are paying for Gates’ health care expenses because by just going on the internet you are in some way using Microsoft!!!!
So in America the more you can spread health care costs around the better off you are. So obviously a maid that is self employed can’t spread around her $10k maternity bill but Gates’ wife certainly can because Microsoft picks up the tab and includes it in their budget!
You obviously don't understand how a Value Added tax works or what all the various nations that charge these taxes use the money for. I'll come back to that but first.
The fact that Bill Gates runs his healthcare through his employer doesn't in and of itself increase what you pay Microsoft. If he wasn't getting his overpriced health insurance through his employer he would just take the money instead. I know this because my customers don't pay my health insurance even though I run it through my own business. If I could charge more money I would do that and take the cash anyway. I buy my family's health insurance under my business because it then saves me about $3,350 a year in taxes.
Here is how a value added tax system works. If you buy Bauxite ore and make it into rolls of aluminum, you pay a tax on the difference between the value of the Bauxite ore and the aluminum roles. If you buy rolls of aluminum and turn it into soda cans, you pay a tax on the difference between the value of the rolls of aluminum and the the value of the cans. If you buy soda cans and fill them with soda, you pay a tax on the added value between the empty cans and the filled cans. If you buy cans of soda from the manufacture and then sell them to the retailer, you pay a tax on the value added by distributing the soda cans. If you are a retailer that buy soda from a wholesaler, you pay a tax on the value added.
So it's nothing like what you think it is. It's similar to a sales tax, just one that is calculated not on the purchase price at the final retail store, but rather, at every point it changes hands. The tax is calculated not on the total price that you're selling it for, but for the difference between the price you paid and the price you got. Countries that charge value added taxes use them to pay for all kinds of things just like income taxes, or property taxes. Not all countries with Value added taxes have government run healthcare. Not all countries with government run health care have a Value Added Tax. Quit using that as an argument. It make you sound thick to anyone that knows what a VAT is.
I think you are invested in a false narrative about how heath care in America is structured. Health care is a line item on a P&L statement and so for the vast majority of Americans it isn’t “insurance”. So when you engage in commerce in America you are literally paying for other Americans’ health care expenses….no “insurance” involved. So the wealthier an American is the more they can spread their health care expenses to other Americans…so that is the heath care system you defended against Obamacare…..oops. 😉
Yes, they are self-insured-- but only up to a certain dollar amount. Beyond that those plans are reinsured meaning that for someone who does run up a big bill an insurer in the background foots the bill (and the employer pays for that, generally rolled into the cost of having a benefits company administer the plan) When I was in that industry the cutoff was general 10K per member but it may be higher now.
I happened to meet a guy whose family was starting an insurance company and their business model was (and I have no clue what this means or if it even makes sense but iirc) ERISA + 20% and take it or leave it. Anyway, when I made the remark that the employer based market had the greatest risk pool of any market because everyone has to be healthy enough to have a full time job and their spouse and children have to be healthy enough that they can work full time he laughed in agreement.
Other than the tax thing, the patient always pays. Either they get less wages because the employer is paying for health insurance or they are paying insurance premiums directly. Having done collective bargaining, I have discovered that if you tell unions the total available for compensation, they will chose wages over health insurance every single time. In retirement, I have discovered that at least for basic stuff like blood pressure meds, you can use non-insurance products like Good RX to get prescriptions for the same price.
Your fundamentally right that the patient always pays in the end, but missing the way this tricks the patient into paying much more for less. Your example of using Good RX is a case in point. If Medicare part D simply covered all your prescriptions regardless of where they were purchased, you would go for the most convenient to you arrangement. Because of it's deductibles and the infamous donut hole, it rewards you for finding ways to save money instead.
But back to us non-retired persons, by tricking my wife into believing she was saving money by getting a prescription for an otherwise over the counter vitamin, that drives up demand for pharmacy tech and billing agents, which raises the price of wages, which in turn raises the price we all pay to get our prescriptions filled.
We have really and truly made an absolute mess of our healthcare system. Obama care was destined to fail because rather then increasing the supply of healthcare professionals, it increased the need for accountants, lawyers, and billing and receiving agents.
But attempts to restrict the tax exemptions or switch them to personal exemptions rather then employer exemption always run smack into a political wall of resistance. Same with copying the more successful voucher program in Medicare part D in the other parts that are currently fee for service.
Part D is fundamentally flawed. After my experiences with GoodRX, I am contemplating the thought that the whole thing was a trick to get retirees to bail out Medicare while thinking they were getting something for nothing. Adding Part D IRMA for the tall poppies reinforces that. A caveat to my opinion is that I have no experience (fortunately) with really expensive classes of meds and Part D may provide actual benefits to those who do.
The history of employer based insurance reinforces your point about trickery. It was initially instituted as a way to evade WW2 wage and price controls. When the war was over an attempt was made to count it as income. The unions (private sector unions were a lot more powerful then and it was the Truman administration) put on a big push to retain it and succeeded. Deductions for employers were the same either way and they lacked to foresight to see where it was going. To this day, many employers still don't understand total compensation theory. With the dominance of 401k plans, they have gotten there about retirement but health insurance not so much. If they did, they would have a fungible benefit allowance rather than piecemeal benefits.
One guy I used to know from the Lions club, was able to keep his house thanks to part D. Not that he would have got much for it, since he had already taken out a reverse mortgage some years before. So if you were on those expensive drugs, it would mean a lot more to you. That said, another scam has been the ban on re-importing drugs. That are own politicians would let the pharmaceuticals get way with charging us far more for the same drug they sell to the Canadians for much less is just an outright scandal. This doesn't get the coverage it should. That has as much to do with the Pharmaceuticals spending big on advertising with the same companies that are supposed to be honestly reporting on these issues.
Then you get into the countless other scams. My mom got mad enough that she quit taking one of her prescriptions for over a year because all the companies kept trying to make her rent a nebulizer. When she would complain, the response was "Medicare is paying for the nebulizer so why do you care?" She just couldn't get over the idea of paying $20 a month to rent a machine that she already had and could buy new for $45. If memory serves, she eventually found a Canadian pharmacy that would fill the prescription without requiring her to rent the machine. So my otherwise law abiding mom felt irritated enough to break the law rather then go along with what she thought was a scam. Most just accept it and don't bother to think about how much debt they are helping to pile their kids and grandkids in.
So again, we've made a real mess of our healthcare system.
Renting the machine is a scam that goes well beyond health care. See Microsoft and automotive software.
I’m pretty confused what exact sky your healthcare policy is.
I dunno. This sounds a lot like what Kamala Harris was talking about during the campaign. It also makes a lot of sense. You sure Oren Cass wrote this?
Re: In practice, this means that those who could otherwise afford perfectly reasonable insurance premiums (and who tend to consume a limited amount of health care) are required to pay exorbitantly more—not as “taxes,” technically, just the “price” in the “market”—to hold down the cost for those who cannot possibly afford to cover their own costs.
This has existed in this country long before the ACA-- in workplace health plans. Community rating (everyone pays the same premium) is all but universal in such group plans, allowing only for small surcharges for smoking or maybe a couple other voluntary unhealthy habits. That means of course that healthy employees and their dependents who consume little healthcare are indirectly helping pay the premiums of other employees who do or whose dependents may have very high cost conditions. The premium cost however is partially disguised by the fact that the employer is paying part of it and rarely makes that transparent to the employees.
Excellent survey. On redistribution, the goal should be a fair and efficient way to transfer income from capital to labor that does not disincentivize saving and investment. Economists have known for decades the ideal way to attack this problem. It's called a graduated expenditure tax, essentially a progressive tax on personal consumption with net savings tax exempt. Here I describe a single parameter version of such a tax which is at once simple, transparent, and immune from lobbying on behalf of special interests: https://shorturl.at/cS4Kx
Many of you might remember Representative Paul Tsongas (D, MA) from the 80s. He got the reputation as an "eat your peas" Democrat for telling unpleasant truths. While Oren probably doesn't remember him firsthand, I get the feeling that Oren's parents would have been supporters.
"But to do that, we would need the government to pick up the tab, as it should, for the care we, as a nation, have decided we want to ensure everyone receives. And to do that, we would need to raise more tax revenue from higher-income households who are having no trouble making ends meet."
Yes, and we're getting very close to the point where we have to stop kicking the can and "eat our peas." The hand waving, finessing and insistence that every problem can be solved in a "win/win" way needs to stop if we are to actually solve the hardest problems.
Government redistribution is never the correct answer to any problem. Real "redistribution" comes from people being paid more for their work. That requires rebalancing the labor market in favor of employees, by reversing globalization. When the economy as a whole is shrinking due to massive trade deficits, as it has increasingly been for 35 years, tax and spend policies are not only rearranging the deck chairs on the Titanic, they are piling more weight on top of it. The actual problem has to be fixed. Inequality has exploded due to the exploitation of cheap foreign labor, driving down incomes across the board. Part of the money that used to go to American households goes out of the country, while the rest is pocketed by the employers. Anything that does not address that is worse than useless.
Bottom line: the correct way that a healthy economy “redistributes” wealth and reduces inequality is through employees being paid well for their jobs. End globalization, which exists for the purpose of exploiting the arbitrage of cheap foreign labor, and that happens. It is that simple.
I sort of agree on inequality. In 1980, before taxes the top 1% received 8% of GDP, it is now around 24%. This was not because they added more value, by 2004 TFP collasped from 2% to .5% annually. They used immigration, imports, and the Fed to crush any growth in US citizen median real wages. Changing this via tax policy ends growth. You need a cometitive capitalism focused on the top 10%.
The problems of the US economy, including affordability and inequality, are entirely the result of ~35 years of "globalization". Profits over that period of time, which have accrued to those at the top, have been almost entirely the product of arbitrage, and specifically the arbitrage of cheap foreign labor. The only true solution to these problems is a rebalancing of the labor market, in favor of domestic employees and job seekers.
What has happened is clear at this point. Starting in the 1990s, everything that could be outsourced was outsourced, while immigration, both legal and illegal, exploded. The consequence was the suppression of employee compensation, the explosion of the trade deficit, and the stagnation of the economy. Because globalization reduced the price of many goods and services, inflation was kept low, and interest rates were kept near zero, which encouraged debt. But as the economy as a whole hollowed out, that debt became unsustainable, and collapsed in 2008. Since then, the economy has limped at around 2% GDP growth, for 17 years. COVID, of course, made things much worse.
The (raw) "deal" of globalization was that it would provide cheap consumer goods at Walmart, which would make up for lower incomes. But the core expenses of a middle class life, as defined in this article, are things that are not subject to price reduction from globalization. Money, like water, seeks its own level, and as it flowed out to the Third World, and the Third World flowed in, things like housing, education and health care remained as untouched islands of the economy that used to be, continuing to rise in cost, while incomes did not keep pace.
Plentiful jobs for native-born Americans that pay well are the only actual answer to these problems. Employers paying employees more, and hiring more of them, is the true, legitimate "redistribution" that would actually make things right. Everything else is a band-aid. Reducing immigration to zero and reversing it will exert that kind of pressure. Tariffs that protect domestic jobs are the other half of the equation. Domestically, within the borders of the US economy, libertarian economic policy works. But it must stop at the water's edge. It is that simple.
NOTE: The impact of globalization on employment and compensation is not confined to blue collar work, or those without a college education. It increasingly impacts white collar work, which is already subject to technological pressures. The stories of companies firing their entire IT departments and replacing them with cheap labor imported from India have been happening for years. With few exceptions, you cannot call a customer service or technical support line and speak to an American. Those are reasons why college doesn't pay off for many, and it must all end.
On a macro level, the US economy has bled wealth through exponential increases in the trade deficit, suppressing GDP growth. During that time, "foreign investment" has been touted as the return of that wealth. Sending out massive amounts of money, and having it come back in the form of foreign purchase of US assets, has been ludicrously characterized as a "win". The malpractice and dishonesty in all of this is astounding. The country has effectively been strip mined, chopped up and sold off as parts, sold out from under the American people. A few have profited, while the country itself has disintegrated. It is a crime of historic proportions.
Great post, and great weekend reading - thanks!
An other fine piece, but Ifeel compelled to make two comments. First, I agree with Oren wholeheartedly that explicit and implicit wealth redistribution will be required to bring middle class working families a decent standard of living. As I have pointed out previously Democratic Socialists, the Bernie faction of Democrats and frankly traditional New Dealers have long advocated such an approach. And yes, the Corporate Democrats have abandened the middle class. But why waste time on branding issues when one could make common cause for the greater good? Secondly, a bit of an issue on the reporting regarding GM leaves out that GM took a 28% drop from last year and as a result workers will be getting a much lower profit sharing check, while at the same time giving out the reported dividends reported in here. How do we incent good corporate behavior?
There is only one reason for the disparity of higher costs versus income. Supply and demand. We have an abundant supply of do-nothing people that are takers contributing zero to the necessities of life, while the worker bees are required to support them. Housing would be more affordable if Property taxes were not the equivalent of a mortgage payment. And where do property taxes go, to fund a bloat of do-nothing public employees.
I'd add to the question of "market preferences" the angle of regulatory demands. For example, no small part of that rise in university costs can be put down to expanding bureaucracy, which is itself often a byproduct of regulations and so on.
Or take a car - you /cannot/ buy a car without backup cameras, blind spot sensors, an infotainment system, and a bunch of airbags. We can argue about the merits of each item there, but the point is that these features are not universally present because of popular demand, or even because manufacturers find it unaffordable to include less-optioned models in their mix, but because of government fiat.
You're barking up the wrong tree when it comes to cars. There is strong demand for backup cameras and they are pretty cheap. Adding about a hundred dollars to manufactures costs. Have you noticed all the models sporting turbo chargers, that's not because of demand. That because the ever tightening emission controls keep forcing the auto makers go to increasingly expensive lengths to get us the power we want and need.
That is also why basic pickup trucks have grown to stupid sizes. They can't stick a powerful enough engine in a regular sized truck or car to pull the boat or haul a load of kids to boy scouts. So the car companies have to increase the width, height and length to give you what you want. Comparatively, the air bags are cheap and save far more money in the aggregate then they cost.
The really sad part is that building turbos, or making trucks bigger uses more power and creates more pollution then letting us buy what we want in the first place.
I’d like to see a cogent description, winners and losers, of a newly privatized health insurance system that covers the cost of ‘catastrophic’ medical care while leaving ‘routine and non-catastrophic care to the private sector outside of the insurance market.
A start might be repealing the signature economic policy achievement of Don, MAGA, and the "new" right-the BBB. After all, it shifts massive wealth from working stiffs to plutocrats along with its record setting deficits.