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Health Care Reform and the National Debt

Current tax rates are relatively low by historical standards.  Here is a table and plot of the rates going back to 1913: link

They're also relatively low by international standards.  See Table 1 in this article from Forbes: link

The combination of our aging demographics and skyrocketing health care costs means higher taxes are inevitable.  See Figure 1 here regarding the coming debt explosion which will be driven primarily by health care costs: link

If you care about the debt and taxes, then the status quo regarding health care is not an option.  Things like tort reform won't make a significant difference.  The non-partisan CBO has estimated that it would only lower health care spending by 0.5 % (link), and the story is much the same for selling insurance across state lines (link).

More fundamental reform is required, yet even the relatively modest currently-proposed reforms are nearly dead.  This doesn’t look good.

Update 2009-02-19:
Admittedly, federal income tax rates don't tell the full story about the tax burden. However, the international comparison in the Forbes article is total taxes (federal, state, and local). In terms of historical U.S. figures, the data from The Tax Foundation show that local and state taxes as a percentage of income have remained stable for the last 30 years (link). In terms of % of GDP (another metric of the tax burden), this figure shows that state and local taxes rose steadily from 1945 to 1970, but not astronomically (link). None of these data support the view that taxes are currently abnormally high. Given the impending debt explosion driven by demographics and health care costs, I'm betting taxes will rise eventually no matter which party is in power.

Bypassing Conference

The Democratic leadership in Congress is making plans to bypass the conference process for working out a compromise between the health care reform bills that passed the House and Senate.  From Jonathan Cohn (link):

According to a pair of senior Capitol Hill staffers, one from each chamber, House and Senate Democrats are “almost certain” to negotiate informally rather than convene a formal conference committee. Doing so would allow Democrats to avoid a series of procedural steps--not least among them, a series of special motions in the Senate, each requiring a vote with full debate--that Republicans could use to stall deliberations, just as they did in November and December.

In terms of the optics, this is bad.  It confirms the GOP talking-point that reforms the people don’t want are being crafted in secret and rammed through Congress.  For example, in the words of a spokesman for John Boehner (link):

“Something as critical as the Democrats’ health care bill, with its Medicare cuts and tax hikes, shouldn’t be slapped together in a shady backroom deal. Skipping a real, open Conference shuts out the American people and breaks one of President Obama’s signature campaign promises. It would be a disgrace — to the Democratic Leaders if they do it, and to every Democratic Member who lets them.”

On the other hand, when it comes to health care reform the Republicans have only a strategy of saying “No” (Republicans voted against the House version 176 to 1;  Republicans voted against the Senate version 39 to 0).  Contrary to the talking point that the Democrats have ignored Republicans in shaping the bills and are rushing reform, the original timelines were much delayed while the Gang of 6 (link) worked deliberately on a bipartisan bill.  Even the Republican participation in those negotiations was questionable (e.g., Grassley: link and link).  Even after significantly influencing the Senate bill, none of Republican members of the Gang of 6 voted for it.  Even after reform bills had passed both houses of Congress, the GOP Senate leadership was still vowing to keep fighting (link).  Given these realities, it seems like the Republicans have already said “No” to reform.  Why indulge the Republicans’ plans to further obstruct?

Apparently, bypassing conference isn’t especially unusual (link):

Hill aides say it often happens with major or contentious pieces of legislation (though not apparently in this current Congress). "This is what we normally do," said one Hill aide, "it is pretty standard."

But it’s certainly nothing like what Obama promised during the campaign (link):

I'm going to have all the negotiations around a big table. We'll have doctors and nurses and hospital administrators. Insurance companies, drug companies -- they'll get a seat at the table, they just won't be able to buy every chair. But what we will do is, we'll have the negotiations televised on C-SPAN, so that people can see who is making arguments on behalf of their constituents, and who are making arguments on behalf of the drug companies or the insurance companies. And so, that approach, I think is what is going to allow people to stay involved in this process.

As a bonus, here’s a plot (link) of life expectancy vs. health care spending for various countries (with the size of the circle proportional to the number of doctor visits per person):


The argument for the public option (in brief)

...the private health insurance industry is irreversibly compromised by its need to turn a profit. But we don't want people's access to health care to be governed by whether or not they're profitable.

Ezra Klein (link)

The Pope, AIDS, and Condoms

From The Wall Street Journal:

Pope Benedict XVI said on his way to Africa Tuesday that condoms weren't the answer in the continent's fight against HIV, his first explicit statement on an issue that has divided even clergy working with AIDS patients.

Pope Benedict had never directly addressed condom use. He has said that the Roman Catholic Church is in the forefront of the battle against AIDS. The Vatican encourages sexual abstinence to fight the spread of the disease.

"You can't resolve it with the distribution of condoms," the pope told reporters aboard the Alitalia plane headed to Yaounde, Cameroon, where he will begin a seven-day pilgrimage on the continent. "On the contrary, it increases the problem."

Not surprisingly, Benedict's statements elicited much criticism.  It was easy to imagine that the Catholic church's teachings about contraception were dictating his viewpoint rather than a rational assessment of the situation on the ground.  Criticism of his statements acknowledged that condoms aren't foolproof and sometimes fail either due to operator error or loss of integrity (link).

Then the official transcript tweaked his words to make it a little less extreme, indicating that condoms risked increasing the problem (link).

Then Edward Green came to the pope's defense.  I assume Green's views on this subject are controversial, but he does have some credibility (link):

Edward C. Green is one of the world's leading field researchers on the spread of HIV and public health interventions. He's the director of the Harvard AIDS Prevention Research Project, and is a leading advocate for evidence-based interventions.

I understand Green's point, and I think it's a good one.  If condoms are the answer for AIDS in Africa, we should be able to see it in the data.  As he said (link):

We have found no consistent associations between condom use and lower HIV-infection rates, which, 25 years into the pandemic, we should be seeing if this intervention was working.

How could condoms contribute to the problem?

...the best evidence we have supports the pope’s comments. He stresses that “condoms have been proven to not be effective at the ‘level of population.’”

“There is,” Green adds, “a consistent association shown by our best studies, including the U.S.-funded ‘Demographic Health Surveys,’ between greater availability and use of condoms and higher (not lower) HIV-infection rates. This may be due in part to a phenomenon known as risk compensation, meaning that when one uses a risk-reduction ‘technology’ such as condoms, one often loses the benefit (reduction in risk) by ‘compensating’ or taking greater chances than one would take without the risk-reduction technology.”

In an interview with Christianity Today (link), Green commented further on what he thinks is and isn't working:

We are seeing HIV decline in eight or nine African countries. In every case, there's been a decrease in the proportion of men and women reporting multiple sexual partners. Ironically, in the first country where we saw this, Uganda, HIV prevalence decline stopped in about 2004, and infection rates appear to be rising again. This appears to be in part because emphasis on interventions that promote monogamy and fidelity has weakened significantly, and earlier behavior changes have eroded. There has been a steady increase in the very behavior that once accounted for rates declining — namely, having multiple and concurrent sex partners. There is a widespread belief that somehow Uganda had fewer condoms. In fact, foreign donors have persuaded Uganda to put even more emphasis on condoms.

I can buy that it's possible that on the level of populations the focus on condom distribution might counter-intuitively fail to reduce the prevalence of AIDS and that this complexity may be underappreciated.  Complicated issues are often over-simplified into inaccurate or incomplete sound bites. 

On the other hand, I think that the pope's and Green's comments are also an over-simplification because they seem not to acknowledge this fact (as others have pointed out): an African woman for whom monogamous sex with an uninfected spouse is not an option is much safer if her spouse uses a condom.  That's the difference between considering the efficacy of condom availability on the individual versus population level.  We should be concerned about both.

Part of the issue is also probably that passing out condoms makes someone some cash and is much easier than the hard work of significantly changing a culture's views regarding sexual fidelity.  It probably makes sense to start with the easier job...but not just stop there either.

Restrictive laws do not reduce abortion

So says the byline of an article in The Economist from last week.  It makes the case that for those of us who desire to see abortion numbers drop (I think we're pretty much all in that category), legislation is not a tool that anyone should expect to be effective for achieving that outcome:

[According to] the largest global study of abortion ever...Restricting abortions...has little effect on the number of pregnancies terminated. Rather, it drives women to seek illegal, often unsafe backstreet abortions leading to an estimated 67,000 deaths a year. A further 5m women require hospital treatment as a result of botched procedures.

In Africa and Asia, where abortion is generally either illegal or restricted, the abortion rate in 2003 (the latest year for which figures are available) was 29 per 1,000 women aged 15-44. This is almost identical to the rate in Europe—28—where legal abortions are widely available. Latin America, which has some of the world's most restrictive abortion laws, is the region with the highest abortion rate (31), while western Europe, which has some of the most liberal laws, has the lowest (12).

Between 1995 and 2005, 17 nations liberalised abortion legislation, while three tightened restrictions. The number of induced abortions nevertheless declined from nearly 46m in 1995 to 42m in 2003, resulting in a fall in the worldwide abortion rate from 35 to 29. The most dramatic drop—from 90 to 44—was in former communist Eastern Europe, where abortion is generally legal, safe and cheap. This coincided with a big increase in contraceptive use in the region which still has the world's highest abortion rate, with more terminations than live births.


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