There are better solutions than wealth taxes, ‘Medicare for all’ or universal basic income.
American capitalism is at a serious inflection point. Many Americans, including the two of us, are alarmed by enormous levels of inequality and by declining economic mobility. We are concerned that in many cases American markets are no longer the most competitive in the world. And, we worry that our country’s long-term economic strength will slowly deteriorate because of an unsustainable fiscal trajectory that leaves future generations worse off.
The solution is not to upend the system. A market-based economy, for all its flaws, is still the best way to achieve broad economic prosperity and to ensure that living standards continue to rise over time. But the answer is not to maintain the status quo, either.
Radical change or complete inaction seem to be the only types of solutions that are being debated in today’s marketplace of ideas. Americans can’t afford to restrict our thinking based on political ideology and the false equivalency of having to pick one extreme or the other. That’s a recipe for stalemate.
Since founding the bipartisan Aspen Economic Strategy Group more than two years ago, our focus has been on bringing together leaders with different perspectives to highlight the importance of evidence-based policymaking. Earlier this week, 38 of our members signed on to a statement of principles that should guide the development of a new economic policy agenda. We also believe we must rigorously analyze some of the proposals that are being put forward in today’s policy debates, including universal basic income, “Medicare for all” and direct taxes on wealth.
Based on research from the newest book from the Aspen Economic Strategy Group, the two of us are more convinced than ever that those policies are fundamentally misguided and would result in economically harmful outcomes that could put our economy on an unstable and precarious path, harming the very people they are intended to help.
The collective work to identify specific policy solutions, however, also suggests to us that there are still many ways to ensure more that many more people can participate in America’s successes. And while there are no silver bullets, nor will there ever be complete agreement about every policy detail, we see many excellent ideas that are ripe for bipartisan collaboration and that can begin the process of adapting our economic policies so that they work for far more people.
First, we must aggressively invest in our human capital. That starts with addressing the supply side of the education market, including investments in community colleges to provide more students the option to obtain a high-quality education and complete their degree. This ensures that more American workers have the skills they need to compete in a global economy. Just as important, investing in education will increase economic productivity, which will help drive the wage growth needed to reduce income inequality.
There are other steps we can take to further address the distribution of economic opportunity and wage growth. But as Melissa Kearney and Magne Mogstad have argued, universal basic income is not a viable solution. It directs resources away from the neediest individuals and fails to address the underlying factors that contribute to inequality. Instead, we should look at more targeted and efficient approaches to encouraging work by supplementing the wages of low- and middle-income Americans, such as expanding the earned -income tax credit or enacting a wage -subsidy program.
Finally, we have to confront the uncomfortable truth that our country is on an unsustainable fiscal trajectory. Spending priorities such as education, infrastructure, and high-value research and development are underfunded, while our commitments to entitlements continue to rise indefinitely. Restoring the sanity of our fiscal position will require raising more revenue, slowing the rate of growth in health care spending, and making Social Security sustainably solvent.
Returning to fiscal responsibility through spending reform alone is neither just nor possible. The United States needs to reform its tax code in a manner that is more progressive and produces more revenue. But there are better approaches than a wealth tax, which would be highly distortionary and is unlikely to capture nearly as much revenue as its proponents claim. Making the income tax code more progressive and reforming estate and gift taxes to eliminate the loopholes that allow wealthy Americans to pass on wealth to their children at very low tax rates would be a better first step.
Whatever path policymakers choose, it is clear that we need to move away from theoretical arguments and wishful thinking and into the arena of pragmatic policy solutions that can actually be enacted. There is a plethora of policies that already enjoy broad bipartisan support, and these policies can be enacted only through effective government, which will require leaders to engage in principled compromise and make decisions grounded in facts and analyses.
The cost of inaction is severe and grows each day, as inequality undermines our economic strength and more Americans become disillusioned with the capitalist system that has made upward mobility a pillar of the country’s identity since its founding.
Democrats mislead voters by appropriating the name of a popular program they actually seek to abolish.
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More than 100 House Democrats have endorsed Rep. Pramila Jayapal’s Medicare for All Act of 2019. Fourteen Democratic senators have co-sponsored a similar bill from Sen. Bernie Sanders.
The title is deeply misleading. It implies that the current Medicare system would be extended to all Americans. In fact, Medicare for All differs from Medicare in fundamental ways—with much broader coverage, no cost sharing, and fewer choices of health-care plans. While America needs a debate about health care, it should be based on an accurate description of the alternatives.
Medicare for All would cover a panoply of dental, vision and mental-health services not covered by Medicare. Under the latest version of the House bill, the federal government would also pay for all long-term nursing and home care—estimated by the Urban Institute to cost roughly $3 trillion over the next decade.
The program would replace Medicare, Medicaid and the Children’s Health Insurance Program, as well as all employer-sponsored insurance and direct individual insurance (including the ObamaCare exchanges). It would cover not only uninsured American citizens but every U.S. resident—potentially including illegal as well as legal immigrants.
Despite this substantial expansion of coverage, Medicare for All would not require beneficiaries to contribute premiums, deductibles or copayments. By contrast, most parts of Medicare require some form of cost sharing by patients. Medicare Part B, for outpatient medical expenses, has a standard premium of $1,626 a year with an annual deductible of $185, plus a 20% copayment, according to the official Medicare website.
Because of the broad coverage of services and patients without cost sharing, Medicare for All would entail dramatically higher federal spending on health care than Medicare and other programs. There have been several estimates of the incremental cost over 10 years of Mr. Sanders’s 2016 proposal, which did not include long-term care—$27.3 trillion by the Center for Health and Economy, $28 trillion to $32 trillion by former Social Security and Medicare trustee Charles Blahous, and $24.7 trillion by Emory Professor Kenneth Thorpe. The Urban Institute estimate, which included long-term care, was $32 trillion over 10 years.
Proponents counter that the proposal would reduce federal health-care spending in three main ways—lower drug prices through government negotiations, lower reimbursement rates for medical services, and lower administrative costs by eliminating insurance companies. They also argue the proposal would increase federal tax revenue by repealing the deduction for employer-provided insurance. But these four factors are already built into the previous estimates. However you cut it, Medicare for All would inevitably lead to massive tax increases.
Neither the House nor the Senate bill includes much detail on financing higher federal spending. Mr. Sanders’s staff released a paper in April with revenue options—imposing a premium tax on employers and employees, increasing the top income-tax rate, imposing a wealth tax, closing tax loopholes and so on. But the paper does not address the budget implications of these options or the challenges of getting them through Congress.
Medicare for All would also replace Medicare’s current method of paying fees for services to every hospital, nursing home and other institutional provider. Instead, a new federal board would set an annual budget for each provider, which would receive one lump sum for current operations and another for capital expenditures. That board would be expressly forbidden by current Medicare for All bills from using quality metrics—which would be necessary to prevent providers from skimping on quality with lump-sum payments.
All this would force a radical change in the current business models of most hospitals and other Medicare providers. Although they would generally have discretion over how to spend their lump-sum payments, they could not use them to make “profit or net revenues.” Yet each provider would bear the risk if these payments were insufficient to cover actual costs. Many hospitals would limit the volume or scope of their services until they were sure they would break even for the year.
Finally, Medicare for All would eliminate the plan choices Medicare now allows. Elderly Americans don’t have to get outpatient or drug coverage from the government. Some opt to stay with their employer plans and others choose private providers through Medicare Advantage. Medicare for All would prohibit any insurer or employer from privately offering any services covered by this legislation—which means essentially all medical services.
Medicare for All allows even less in the way of plan choice than other single-payer systems. In the United Kingdom, patients may purchase private insurance for medical services even if they are available through the National Health Service. Canada does not cover dental, vision or long-term care, so two-thirds of Canadians purchase these services through private health insurance.
In the coming debate over health care, the label “Medicare” should be reserved for proposals that are built on the existing structure of this successful program. Whatever else “Medicare for All” may be, it isn’t Medicare.
A Fraser Institute study published in November examined 28 universal health-care systems across 45 indicators of performance. After adjusting for differences in the proportion of seniors, Canada ranked among the top spenders—fourth-highest as a percentage of gross domestic product and 10th-highest per capita. Yet it had less medical resources available for patients and painfully long wait times for specialists. Canada ranked 26th out of 28 for number of physicians, 22nd out of 27 for MRI units, and 25th out of 26 for hospital beds.
In Commonwealth Fund data comparing 11 developed countries, Canada reported the most patients waiting more than four weeks for a specialist appointment (56%), vs. only 22% for Switzerland and 23% for the Netherlands, the top performers. The proportion of patients waiting more than four months for elective surgery was 18% for Canadians, 2% for the French and zero for Germans. Canada performed well on only five of the 12 indicators of clinical performance and quality included in the Fraser Institute’s study. Its performance on the other seven—including obstetric traumas and diabetes-related amputations—was poor or average.
Overall, Canada performs worse than other universal-coverage countries, particularly Switzerland, the Netherlands and Germany. Why? Unlike Canada’s single-payer system, the Swiss, Dutch and German systems rely on private insurers, whether nonprofit or for-profit. Government helps the needy make premium payments.