A point-by-point exploration of their arguments would exceed the space allotted for this column by several thousand inches. But I think one can sum up the libertarian approach to Warren with a single question: How big a problem do you think billionaires, and the mega-successful corporations they helm, pose to the average American? Actually, come to think of it, I think that’s about how you’d sum up the question of Warren from any angle.
Which is why this debate ultimately matters to a lot more people than just some cranky libertarians: It speaks directly to a whole lot of young people who see that the economy doesn’t work for them the way it did for their parents and grandparents, and therefore conclude that somewhere along the way, the people it is working for — the barons of finance, the giants of Silicon Valley — must have rigged the system in their favor.
To be fair, they’re not entirely wrong. As Adam Smith once wrote, “People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.” Bankers and tech executives very much included. So I find myself nodding in agreement with Wilkinson — and, by extension, with the progressive base of the Democratic Party — when he says: “Warren’s general diagnosis of the problem — it’s a rigged system of anticompetitive rent-seeking enabled by insufficiently democratic and representative political institutions — is broadly similar to my own.”
Yet they’re not entirely right, either. Are big corporations, or billionaires, or banks, or tech giants, or health insurers and pharmaceutical firms — to name some of Warren’s favorite targets — really the reason that young people are struggling
- with enormous student loans? Are they the reason that millennial homeownership lags that of their parents? Are they the
- reason that recent college graduates are more likely than their elders to be underemployed? Have they
- driven the cost of health insurance to its current stratospheric levels?
Sure, Warren may be eager to sic her Consumer Financial Protection Bureau on your mortgage lender if you fall afoul of some obscure clause, but that’s not the problem for most Americans. They’re much more likely to struggle with finding affordable housing in prosperous cities. In fairness, Warren does have a plan to ease the zoning regulations that cause the shortage — but for some reason she rarely talks about it on the campaign trail, possibly because it’s constitutionally dubious, but more likely because it would alienate her affluent suburban base.
Similarly, Warren is eager to forgive student loans — a $1.6 trillion transfer to some of the most affluent members of society — but not to attack degree creep, which has walled off most of the best jobs for those who hold a bachelor of arts while enriching a lot of colleges. She targets insurers and drugmakers, but not the hospitals and medical workers who drive most of our health-care costs.
Too many of her proposals are like this; they focus on corporate villains or billionaires while ignoring the much broader class of people that Richard Reeves of the Brookings Institution dubbed the “Dream Hoarders” — the well-educated upper-middle-class people who are desperate to pass their privilege onto their kids, and are unhappy about the steadily mounting cost of doing so. They’re Warren’s base.
Unfortunately, the Dream Hoarders — and I include myself in their number — are a much bigger problem for the rest of America than the billionaires whose wealth Warren promises to expropriate. Those billionaires got that way by building companies that disrupted cozy local monopolies, and they fund coding camps for high-school dropouts; Dream Hoarders
- protect their professional licensing regimes and
- insist on ever more extensive and expensive educations in the people they hire. Dream Hoarders also
- pull every lever to keep their own housing prices high — and poorer kids out of their schools — while
- using their wealth to carefully guide their children over the hurdles they’ve erected.
Which may be why the best predictor of a neighborhood with a low degree of income mobility is not the gap between the top 1 percent and everyone else — the gap that Warren focuses on with all her talk of taxing billionaires — but
If you really want to unrig the system, you need to focus less on a handful of billionaires than on the iron grip that the Dream Hoarders have on America’s most powerful institutions — including, to all appearances, Elizabeth Warren’s campaign.
Donald Trump Did Something Right
As Donald Trump was fighting with Congress over the shutdown and funding for a border wall, his administration implemented a new rule that could be a game-changer for health care.
Starting this month, hospitals must publicly reveal the contents of their master price lists — called “chargemasters” — online. These are the prices that most patients never notice because their insurers negotiate them down or they appear buried as line items on hospital bills. What has long been shrouded in darkness is now being thrown into the light.
For the moment, these lists won’t seem very useful to the average patient — and they have been criticized for that reason. They are often hundreds of pages long, filled with medical codes and abbreviations. Each document is an overwhelming compendium listing a rack rate for every little item a hospital dispenses and every service it performs: A blood test for anemia. The price of lying in the operating suite and recovery room (billed in 15-minute intervals). The scalpel. The drill bit. The bag of IV salt water. The Tylenol pill. No item is too small to be bar coded and charged.
But don’t dismiss the lists as useless. Think of them as raw material to be mined for billing transparency and patient rights. For years, these prices have been a tightly guarded industrial secret. When advocates have tried to wrest them free, hospitals have argued that they are proprietary information. And, hospitals claim, these rates are irrelevant, since — after insurers whittle them down — no one actually pays them.
Of course, the argument is false, and our wallets know it.
First of all, hospitals routinely go after patients without insurance or whose insurer is not in their network. When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.
Second, those list prices form the starting point for negotiations, allowing hospitals and insurers to take credit for beneficence, when there is none.
I recently received an insurance statement for blood tests that were priced at $788.04; my insurer negotiated a “discount” of $725.35, for an agreed upon price of $62.69 “to help save you money.” My insurer’s price was around 8 percent of the charge. Since my 10 percent co-payment amounted to $6.27, my insurer happily informed me, “you saved 99 percent.”
.. Just as airlines have been shown to exaggerate flight times so they can boast about on-time arrivals, hospitals set prices crazy high so they can tout their generous discounts (while insurers tout their negotiating prowess).
Trump Has No Idea What His Tariffs Have Unleashed for Farmers
His trade war will hurt business at a time when the rural population is aging, and it will probably hollow out farm communities.
.. The president is here to trumpet a $12 billion plan to aid American farmers. Why do they need aid? For Iowans, it’s because 33 percent of our economy is tied, directly or indirectly, to agriculture, and Mr. Trump recklessly opened trade wars that will hit “Trump country” — rural America — hardest and that have already brought an avalanche of losses. Indeed, the impact of his tariffs will probably be felt by family farms and the area for generations... Once those markets are gone, they will be difficult to recover. Commodity prices continue to drop, and good weather suggests an excellent crop is in the making, which will drive prices further down... Rural America is going to be hollowed out very quickly. Farms will become consolidated, and towns that are already in trouble will certainly die.Iowa’s farmers are aging, and younger farmers aren’t replacing them proportionately. Sixty percent of Iowa farmland is owned by people 65 years or older, and 35 percent of farmland is owned by people 75 or older.
.. the average age of the American farmer was 58.3 years. This isn’t because young people in rural America don’t want to farm; it’s because, if it isn’t already the family business, the costs are much too high to allow many of them to get into it.
.. losses and farm consolidation accelerated by Mr. Trump’s tariffs will make the devastating 1980s farm crisis look like a bump in the road as it drives a significant rural-to-city migration.
.. Smaller operations don’t have the capital to weather a trade war and will be forced to sell, most likely to larger operations.
.. Another casualty: our community banks. As farms get larger, farm loans are less likely to be local. A big operation with farms in dozens of counties that maybe even cross state lines probably won’t use local banks for credit.
When our community banks are gone, one of the major economic engines of our small towns will be gone.
.. At a certain point, populations won’t be enough to support rural hospitals and clinics, and they, too, will be gone. Rural hospitals are one of the major employers in the community. Even if you have a good manufacturing company in town, if you lose the hospital, they won’t be able to attract the employees they need.
.. Some of the farmers I speak with are unwavering in support of the president; they’d vote Republican even if Mr. Trump personally slapped the heck out of the preacher at the church potluck. But others are starting to recognize how the economic impact of the tariffs is hitting them personally.
.. Farmers take out lines of credit in the spring — usually due the following Jan. 1 — to pay for seed and other input costs, and then pay the loans back after harvest. Like any other loan, there are consequences to not paying, including losing the farm. Farmers are going to know before the midterm elections if they are going to be able to pay back loans.
.. The larger farm operations and the larger agribusinesses will be hovering, looking for any weakness, and ready to purchase smaller farms. And rest assured, when the Trump payments are made to farmers, the larger operations will be the ones that gobble them up.
.. most rural Republicans aren’t farmers, and many are Fox News devotees. So when they turn on Tucker Carlson or Sean Hannity, the hosts will likely extol the “virtues” of Mr. Trump’s farm policies and tariffs rather than the reality of their failures.
Chasing millions in Medicaid dollars, hospitals buy up nursing homes
The nursing home can afford these multimillion-dollar improvements partly because it has, for the past five years, been collecting significantly higher reimbursement rates from Medicaid, the state-
federal health insurance program for the poor... A wrinkle in Medicaid’s complex funding formula gives Indiana nursing homes owned or leased by city or county governments a funding boost of 30 percent per Medicaid resident. The money is sent to the hospitals, which negotiate with the nursing homes over how to divvy it up.
.. Nearly 90 percent of Indiana’s 554 nursing homes have been leased or sold to county hospitals in the past 14 years
.. Today, more than two-thirds of Indiana’s Medicaid long-term care dollars go to nursing homes. The U.S. average is 47 percent.
.. they say, it has provided incentives to steer patients to nursing homes rather than lower-cost options, such as home health care or community-based day-care centers.
.. a bad deal for the poor because it takes a large portion of Medicaid dollars targeted for services for low-
income nursing home residents and sends it instead to hospitals to use as they please... States pay no more than half the costs, although the federal match varies based on a state’s wealth.
.. All the Medicaid funding for nursing homes should be going to those homes to care for the poor, not shared with hospitals to use as they choose, he said.