Since the beginning of his term, state and local governments have shed 611,000 employees -- including 196,000 educators -- according to government statistics. Unlike the recovery in private-sector employment that Obama and his reelection campaign often cite -- with businesses adding 4 million jobs since hiring hit its low point in 2010 -- the jobs crisis at the state and local level has continued throughout his term.
In contrast to Obamacare, however, the Bush plan would have turbocharged the market for consumer-driven health plans, tied to health savings accounts, because the most economically efficient use of the deduction would be to purchase a sufficiently generous consumer-driven plan that allowed individuals to put a maximal amount of money into HSAs. Obamacare significantly constrains the use of HSAs in its regulated insurance markets.President Bush also proposed an "Affordable Choices Initiative," which would redirect existing federal spending in states that sought to expand coverage to the uninsured.As you'll remember, the 1986 EMTALA law forces hospital emergency rooms to care for anyone who shows up, regardless of their ability to pay. In order to partially compensate for this mandate, and underpayments from Medicaid and Medicare, the federal government gives most urban hospitals "disproportionate share hospital," or DSH, payments. Bush proposed to shift these dollars away from hospitals and toward uninsured individuals directly.States would design their own programs for expanding coverage, subject to approval by the HHS secretary, such as offering direct subsidies for insurance premiums, expanding or creating high-risk pools, or setting up Massachusetts-style exchanges. "Rather than perpetually pay the bills of uninsured people," said then-HHS Secretary Mike Leavitt, "it's better to use part of the money to help them get a basic insurance policy. They get better care and the money ultimately goes further." [...]The Bush plan would have expanded coverage and reduced the deficitThe Lewin Group analyzed the Bush tax reform using its Health Benefits Simulation Model, and estimated that equalizing the tax treatment of health insurance would expand coverage by 9.2 million people. In addition, the Bush administration estimated that the Affordable Choices Initiative would expand coverage by an additional 2 million or so, for a total of about 11 million. That's not as large a coverage expansion of Obamacare, at 33 million, but that 11 million is achieved with zero increase in federal spending commitments: a pretty impressive bang for the buck.In addition, Obamacare's 30-million coverage expansion figure may be substantially inflated. If the individual mandate gets struck down by the Supreme Court, the Congressional Budget Office projects that the law would expand coverage by only about 17 million, despite trillions of additional federal spending.Even more impressively, the Joint Committee on Taxation--the government agency responsible for the CBO's estimates of the impact of tax legislation--projected that the Bush proposal would reduce the deficit by $334 billion from 2008 to 2017, and by trillions more in later decades, because the tax deduction would grow at the rate of inflation, whereas the tax exclusion of employer-sponsored health insurance isn't capped by law, and grows along with overall, and higher, health inflation.These savings could have been used by the Bush administration to reduce the deficit, or alternatively, to create a $5,000 tax credit to for the uninsured to purchase health care, as George H.W. Bush had proposed. "This would be preferable to raising the $15,000 deduction" in the 2007 plan, the Wall Street Journal noted, "because the lower the deduction, the greater incentive for judicious consumption of health dollars."
In his TedMed talk last week, where he called for a renewed focus on improving root causes of health problems rather than waiting until they cause full blown illnesses, Sandeep Kishore noted this somewhat startling statistic: Of the 30 years of average life-expectancy gains the United States made in the last century, a surprisingly small amount of that average increase--just five years--stems from improvements in the sort of medical care we get in hospitals. The rest of those gains came from other sources, like improvements in water quality and sanitation, vaccinations, and other improvements in public health.And while that may sound surprising, it's consistent with a lot of what we know about health. For example, Steven Schroeder, the past president of the Robert Wood Johnson Foundation, has estimated that only about 10% of how healthy we are and how long we live is determined by health care. Instead, how we live our lives--our choices and behaviors, our physical surroundings, our socioeconomic circumstances--turn out to be far more important over the long run.
A review of the F-35's cost, schedule, and performance -- three essential measures of any Pentagon program -- shows the problems are fundamental and still growing.First, with regard to cost -- a particularly important factor in what politicians keep saying is an austere defense budget environment -- the F-35 is simply unaffordable. Although the plane was originally billed as a low-cost solution, major cost increases have plagued the program throughout the last decade. Last year, Pentagon leadership told Congress the acquisition price had increased another 16 percent, from $328.3 billion to $379.4 billion for the 2,457 aircraft to be bought. Not to worry, however -- they pledged to finally reverse the growth.The result? This February, the price increased another 4 percent to $395.7 billion and then even further in April. Don't expect the cost overruns to end there: The test program is only 20 percent complete, the Government Accountability Office has reported, and the toughest tests are yet to come. Overall, the program's cost has grown 75 percent from its original 2001 estimate of $226.5 billion -- and that was for a larger buy of 2,866 aircraft.Hundreds of F-35s will be built before 2019, when initial testing is complete. The additional cost to engineer modifications to fix the inevitable deficiencies that will be uncovered is unknown, but it is sure to exceed the $534 million already known from tests so far. The total program unit cost for each individual F-35, now at $161 million, is only a temporary plateau. Expect yet another increase in early 2013, when a new round of budget restrictions is sure to hit the Pentagon, and the F-35 will take more hits in the form of reducing the numbers to be bought, thereby increasing the unit cost of each plane.A final note on expense: The F-35 will actually cost multiples of the $395.7 billion cited above. That is the current estimate only to acquire it, not the full life-cycle cost to operate it. The current appraisal for operations and support is $1.1 trillion -- making for a grand total of $1.5 trillion, or more than the annual GDP of Spain. And that estimate is wildly optimistic: It assumes the F-35 will only be 42 percent more expensive to operate than an F-16, but the F-35 is much more complex. The only other "fifth generation" aircraft, the F-22 from the same manufacturer, is in some respects less complex than the F-35, but in 2010, it cost 300 percent more to operate per hour than the F-16. To be very conservative, expect the F-35 to be twice the operating and support cost of the F-16.Already unaffordable, the F-35's price is headed in one direction -- due north.
Obviousness is no bar to hysteria.Could American medicine be changing?For years, medical organizations have been developing recommendations and guidelines focused on things doctors should do. The specialty societies have been focused on protecting the financial interests of their most profligate members and have been reluctant to acknowledge the problem of overuse. Maybe they are now owning up to the problem.And judging from the content of the list, testing is a big part of that problem. Only a quarter of the recommendations fell in the category of "don't treat" -- as in, don't prescribe more chemotherapy for end-stage cancer that is beyond hope. The remainder fell in the category of "don't test."Because it can be the first step in a cascade of medical interventions, the focus on testing makes good sense. The specialty boards seem to now recognize that the results of testing include both signals (useful information) and noise (false and distracting information). For patients with symptoms the signal predominates. But for those without symptoms the noise predominates. And the noise is not harmless, it can trigger overdiagnosis and overtreatment. "Routine" chestX-rays, for example, have a way of unearthing multiple abnormalities. This raises questions in physicians' minds -- triggering CT scans, needle biopsies, bronchoscopies and even surgery in an effort to answer them.That's why multiple recommendations have argued against routine use of tests such as cardiograms (EKGs), ECHO and CT scans in asymptomatic patients -- and against repetitive testing in patients whose symptoms have not changed.Admittedly, some of the recommendations seem brain-dead obvious.
In the last few months, Israel's security and strategic options have changed dramatically. Against the backdrop of the Arab uprisings, Netanyahu's campaign to force Obama's hand on Iran has failed. Obama made it clear in March that he would not go to war with Iran over uranium enrichment, as Bibi had requested.Instead, he would reinvest in diplomacy and opt for a solution based on limiting and inspecting--not eliminating--Iran's enrichment program. And if diplomacy succeeds, Obama won't go to war with Iran at all. Rather, a reduction of US-Iran tensions will follow, which may have significant repercussions throughout the region.As a stalwart opponent of US-Iran diplomacy, Netanyahu is putting Israel on the opposite side of the US. Israel must now make a choice: Either continue to obstruct Obama's diplomatic strategy and risk greater tensions with Israel's most important ally, or shift gears and opt to influence the talks instead.