Dan Munro

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Are State-run Single-Payer Healthcare Systems Viable?

June 1, 2017 By Dan Munro

In a word — no. The latest attempt is Senate Bill 562 in California (the Healthy California Act), but there have been others before it. The first challenge is always the same — overcoming all the big financial obstacles. There have been several recent studies for CA, but raising taxes is both a critical and fundamental requirement. The legislative analysis suggests that the cost for SB-562 would be about $400 billion per year. Here’s a chart from the L.A. Times:

According to a report in the Wall Street Journal, the California State Appropriations Committee is looking at a 15% payroll tax on earned income as one idea — which mirrors recent attempts by Vermont and Colorado.

  • Amendment 69 in Colorado would have increased payroll taxes by 10%
  • Vermont would have increased payroll taxes 11% and income taxes 9%

Colorado is more of a swing state — so it was thought to be a better test for other states. It’s also larger than Vermont by almost 9X. In the end, voters overwhelming rejected the measure (~80%) so it wasn’t just defeated, it was crushed. Vermont’s governor (Peter Shumlin) calculated the fiscal hurdle as too high and simply abandoned the initiative before it got to the ballot.

Recent polling in California by the Public Policy Institute of California summarized their finding this way:

As the state legislature considers Senate Bill 562, which would establish a single-payer state health insurance program, 65 percent of all adults and 56 percent of likely voters say they favor such a plan. But support falls to 42 percent of adults and 43 percent of likely voters if the plan would raise taxes. Overall, strong majorities of Democrats (75%) and independents (64%) favor a single-payer plan, while a strong majority of Republicans (66%) are opposed.

This polling is eerily (but not surprisingly) like some of the early Obamacare polls.

Basically, 11 of the 12 Obamacare provisions polled positively (and 7 of the 11 polled near or above 70%). The 12th provision that polled with a big negative? The individual mandate (66% against).

The larger narrative here has not changed since Obamacare was passed. Everyone likes getting healthcare services, but the vast majority of people don’t want to actually pay for them. It’s juvenile, but that’s the reality and that debate doesn’t magically change by moving it to the state level.

Also, like Colorado, the opposition to a single-payer system by industry stakeholders would be likely and significant.

Amendment 69 [in Colorado] brushed up against a powerful lobbying campaign by major health insurers like Anthem, Kaiser Permanente, and UnitedHealthcare, which raised more than $4 million to defeat it, as the Denver Post reports. Fortune – November 8, 2016

There are additional, ongoing challenges as well. Here are 3 big ones:

  1. Assuming a state managed to cross the fiscal Rubicon with voter support, there’s an even bigger systemic challenge to maintaining the actual system. With higher income (and payroll) taxes, at least some wealthy individuals and businesses would be incentivized to move out — and certainly some citizens of other states who wanted (and needed) healthcare would move in, so the cycle of adverse selection begins — just in a different way.
  2. One of the benefits of a single-payer system is, of course, single-pricing, but in order to support that, states would likely need to cut what doctors and hospitals charge — which would create another exodus — doctors and graduating medical students who could easily relocate to other states for better rates.
  3. Also, unlike the federal government, individual states have to actually balance their state budgets so the spiral generated by opposing forces (tax revenue leaving the state and the sick arriving in need of healthcare) would, over time, create a “death-spiral.” Tax increases would likely be annual so it’s more than just a one-time tax hit.

Given all the variables — especially the fiscal ones — I see no viable path forward for state-based “single-payer” healthcare. The sentiment is there — and that will help drive the national debate — but the size and scope of a single-payer healthcare system is so large and fundamentally different, that running it entirely at the state level quickly devolves into a fiscal non-starter.

Some Democrats felt the bill was rushed and undeveloped. Sen. Ben Hueso (D-San Diego) withheld his vote on the bill on grounds it does not provide enough detail of what a single-payer system would look like. “This is the Senate kicking the can down the road to the Assembly and asking the Assembly to fill in all of the blanks,” Hueso said. “That’s not going to happen this year.” L.A. Times — June 1, 2017


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Filed Under: Single Payer

Trump and the Dunning-Kruger Effect

May 29, 2017 By Dan Munro

President Trump forcing his way past the Prime Minister of Montenegro

By most accounts, President Trump survived his first foreign trip without a major gaffe, but that’s not to say all of his behavior was presidential — and in many ways, it was a “complete disaster” politically.

While the events of Trump’s trip didn’t produce any major fireworks (as some were expecting), they did add considerably to his long and growing list of abnormal, jaw-dropping behavior.

In fact, what’s emerging is a pattern of reckless, juvenile and boorish behavior that demands both assessment and accountability — even for Trump loyalists. The pattern was clearly evident during the campaign, of course, but as POTUS, it’s quickly deteriorating into a global embarrassment with dire, short term consequences.

I’m not a psychiatrist or psychologist, but the best description I’ve seen of his behavior is the cognitive impairment known as the Dunning-Kruger effect.  The definition from Wikipedia certainly seems (even for a layperson) to be a classic, text-book fit.

Dunning-Kruger: In the field of psychology, the Dunning–Kruger effect is a cognitive bias, wherein persons of low ability suffer from illusory superiority when they mistakenly assess their cognitive ability as greater than it is. The cognitive bias of illusory superiority derives from the metacognitive inability of low-ability persons to recognize their own ineptitude; without such self-awareness, they cannot objectively evaluate their actual competence or incompetence.

Basically, it’s the inability to accurately assess one’s own competence (or lack thereof). At 70, Trump may be physically fit to withstand the rigors of the office, but is he capable of judging his own competence? The evidence that he lacks this basic judgment is growing and compelling.

  • “I’m like, wait a minute. I made a speech. I looked out, the field was, it looked like a million, million and a half people.” President Trump (Jan 21)
  • “Trust me. I’m, like, a smart person.” President Trump at CIA Headquarters (Jan 27)
  • “We’re now having dessert — and we had the most beautiful piece of chocolate cake that you’ve ever seen — and President Xi was enjoying it.” President Trump (Apr 12)
  • “My generals are the most respected that we’ve had in many decades I believe. And they lost Ryan.” President Trump (Feb 27)
  • “Nobody knew healthcare could be so complicated.” President Trump (Feb 27)
  • “The plan gets better and better and better, and it’s gotten really, really good. And a lot of people are liking it a lot.” President Trump (on healthcare — Apr 20)
  • “And I don’t watch things that I know are going to be unpleasant.” President Trump (Apr 23)
  • “We have to prime the pump. Have you heard that expression used before? Because I haven’t heard it. I mean, I just … I came up with it a couple of days ago and I thought it was good.” President Trump (May 4)
  • Pushing his way to the front row for a group photo
  • Asking French President Macron for his cell phone number (May 27)
  • His inappropriate and aggressive “tug n’ shake” death grip

It starts off like a normal, unassuming handshake, until the shakee is pulled suddenly toward the president, resulting in a very unprofessional body-lurch. Trump follows this embarrassment up by reassuring the shakee with an even more awkward top-of-the-hand pat.

This partial list is all within the first 4 months of his presidency and reflects, I believe, a painful and visible ignorance of his own incompetence. This isn’t just bizarre or juvenile behavior for a president (any president), it’s strange behavior for any politician — and there will be consequences.

Here’s the deal: once you elect a clown like Trump, you lose trust not just now but for many years to come. A nation that elects a Trump once could easily elect a similar figure again in the future. That becomes priced into national reputation. For the Germans, South Koreans, Japanese etc. this is no joke: they’ve staked their lives on having stable USA foreign policy. Jeet Heer, Senior Editor at the New Republic

The loss of that national reputation among strong allies happens all too quickly.

The president’s failure to endorse Article 5 in a speech at NATO headquarters, his continued lambasting of Germany and other allies on trade, his apparent decision to walk away from the Paris climate agreement — all suggest that the United States is less interested in leading globally than has been the case for the last 70 years. Ivo H. Daalder, Former US Ambassador to NATO

The times in which we can fully count on others are somewhat over, as I have experienced in the past few days. German Chancellor Angela Merkel

No freely elected head of government in our country should allow him — or herself to be humiliated in this way — the way this man [Trump], like an autocratic leader, believed he could inflict humiliation in Brussels. Election campaign or no election campaign, in this situation let me be entirely clear — the [German] chancellor represents all of us at summits like these — and I reject with outrage the way this man takes it upon himself to treat the head of our country’s government. That is unacceptable. Martin Schulz (chief political rival to Angela Merkel)

Given his age and his personal history (multiple failed marriages and businesses), we should not expect a significant change in President Trump’s behavior. The Dunning-Kruger effect clearly isn’t grounds for removal under Article 25 of the Constitution, and there may be better attempts by those around him to control and minimize the public view, but as long as Trump is President, we should brace for more of this total incompetence — and the consequences that result.


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Filed Under: Trump

A Dark Healthcare Truth About Donald Trump

May 1, 2017 By Dan Munro

Ages ago — all the way back in February of this year — President Donald Trump proudly boasted that healthcare was complicated. He even went as far as to suggest that no one knew of this complexity. It quickly became a laughable Trumpism.

Now, I have to tell you, it’s an unbelievably complex subject. Nobody knew that healthcare could be so complicated. 

I actually think this “ignorance” supports the argument that Trump suffers from a cognitive impairment known as the Dunning-Kruger effect, but that’s a separate entry in the Trump folder.

Incompetence aside, I don’t believe President Trump was, in fact, all that ignorant about healthcare. At least not the health insurance component he once leveraged against a family member with a significant health condition. This wasn’t just inhuman behavior, it was one that was leveled against a member of his own family. It came across my radar initially because it’s both noteworthy and specifically relevant to healthcare. The full story was actually covered by the New York Daily News in December of 2000.

Even when it comes to a sick baby in his family, Donald Trump is all business. The megabuilder and his siblings Robert and Maryanne terminated their nephew’s family medical coverage a week after he challenged the will of their father, Fred Trump. “This was so shocking, so disappointing and so vindictive,” said niece Lisa Trump, whose son, William, was born 18 months ago at Mount Sinai Medical Center with a rare neurological disorder that produces violent seizures, brain damage and medical bills topping $300,000. 

On March 30, Donald, Maryanne and Robert Trump retaliated. Fred Trump 3rd (Donald’s nephew) received a certified letter informing him the medical benefits that had always been provided to his family by the Trump organization would end on May 1, 2000. 

So — to retaliate against a sibling feud over the sizable estate of Fred Trump, Sr., the Trump organization (in the form of Donald, Maryanne and Robert) cut off health benefits to their nephew even though there were immediate and long-term needs associated with Fred’s son William (diagnosed with cerebral palsy).

As a chronic developmental disability (DD), the fiscal burden associated with cerebral palsy will easily overwhelm most families. In 2003, the CDC estimated the average lifetime costs of a person with cerebral palsy at $921,ooo. Simple inflation and cost-of-living increases over the last 14 years would easily push that average beyond $1 million today.

Fred Trump, 3rd with his son William (circa 2013)

Of course many will consider this old news because the events unfolded in 2000, but I think anyone who uses health benefits as retaliation in a family dispute over money should be challenged in the court of public opinion — especially when the central figure in terminating those benefits now holds the highest elected office in our country AND has the final authority in signing healthcare reform legislation.

It’s certainly easy to claim ignorance over the complexity of health benefits, but using actual health benefits in a familial dispute over money should be at least unconscionable. I’m still struggling to understand which line of basic human decency was crossed when that same individual publicly mocks people with a development disability.


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Filed Under: Bad Behavior, Trump

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About Dan

Dan Munro is a writer who lives outside of Phoenix, Arizona. He is authored and writes about the intersection of technology and policy for a variety of online and print publications.

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