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Grading Trump II, So Far

16 Monday Mar 2026

Posted by Nuetzel in Election, Politics

≈ 1 Comment

Tags

Anthropic, central planning, CLARITY Act, Corporatism, DEI, DOGE, Donald Trump, entitlements, ESG, eVTOL, Fed Independence, GENIUS Act, Golden Share, Government Waste, Great Healthcare Plan, Industrial Policy, Jerome Powell, Jones Act, Kevin Warsh, Most Favored Nation Drug Pricing, Obamacare, One Big Beautiful Bill Act, Open AI, Pete Hegseth, Populism, ROAD To Housing Bill, Robert F. Kennedy Jr, SAVE America Act, Stargate, Tariff Dividend, TrumpRx.gov, Voter ID

I voted for Trump because I considered him to be far preferable to Kamala Harris across a range of issues. I still feel that way, but I’m appalled at a number of actions he’s taken and/or proposed in the 14 months since he took office. As a candidate, I gave Trump a “grade point average” of about 2.68, a solid C+. Here, I’ll grade him on most of the same categories, but I’ve made a few changes to the categories based on developments since his inauguration. My perspective here is generally domestic non-intervention and small government.

Yes, I realize this is tldr; I’m sure I elaborated more than necessary, but you can skip around and scroll to sections in which you might have greater interest. Here’s a list of topics:

  • Role of Government
  • Regulation
  • Border Policy
  • Antitrust
  • Foreign Policy
  • Trade
  • Taxes
  • Inflation
  • Federal Reserve Independence
  • Federal Spending and the Deficit
  • Entitlement Reform
  • Government Waste
  • Health and Health Care
  • Abortion
  • Housing
  • Energy
  • First Amendment Rights
  • Second Amendment Rights
  • DEI and Its Evil Financial Twin, ESG
  • Technology
  • Voting Rights
  • Education

Role of Government: It’s probably unfair to treat this as a separate category because it might double count specifics mentioned later, but Trump has demonstrated an unfortunate proclivity for wielding government power over private affairs when it suits him politically. On this point, “The Conspicuous Fist of Trump’s State Corporatism”, is a good read. Trump’s actions demonstrate the awful ways in which populism is often a close cousin to socialism. An example is Trump’s economic micro-management and abrogation of property rights in attacking share buybacks. Trump boasts of his efforts to strengthen the American economy by committing public resources to investments in private enterprises, and by “doing deals” with foreign governments to invest in the U.S. When it comes to limited government, candidate Trump’s C is now President Trump’s D.

Regulation: Despite the kinds of intrusions cited above, the Trump Administration has, at the same time, aggressively pursued deregulation of private activity. The goal is to achieve a 10-to-1 ratio of rule rollbacks to new regulatory rules. One can and should assess regulatory measures one-by-one, but there are plenty of rules that wouldn’t pass a reasonable cost-benefit test. On the whole the regulatory state has grown unwieldy and imposes significant costs on producers, and ultimately taxpayers and consumers, often with little compensatory benefit. I applaud the effort to untangle the regulatory state. My grade for Trump here remains an A.

Border Policy: Despite my preference for non-intervention, I support strong border enforcement along with expanded legal immigration.

Illegal entry has plummeted under Trump, a welcome development. Uncontrolled immigration entails a loss of sovereignty and is a poor fiscal proposition. Those with deeper criminal records, from either before or after entry, deserve no concessions. Strict vetting is also necessary to prevent incursions by potential terror threats.

While illegal entry is a crime, otherwise innocent illegals should be treated kindly. For example, rewards can be offered for voluntary deportation, an approach used extensively by the Trump Administration. There are difficult issues such as birthright citizenship, the constitutionality of which has been questioned on textual grounds, and the practicality of which can be shaky, even for children of parents who enter the U.S. legally. Either way, it seems clear that the promise of birthright citizenship should not serve as an incentive for illegal entry.

The Administration has certainly fumbled immigration enforcement in some instances, with cases of improperly detained individuals. Furthermore, very little has been done to advance the cause of increased legal immigration. On this topic I give Trump an overall B-.

Antitrust: This is a case of excessive government meddling with a big dose of favoritism thrown in. Early on, the Trump Administration chose to follow in the footsteps of Biden-era antitrust enforcement with a bias toward penalizing successful businesses on the pretext of “protecting” consumers.

Even worse, the Trump Administration has used the threat of antitrust as a cudgel in pursuit of a variety of objectives that are purely political. For example, in a recent executive order (EO), Trump threatened antitrust action against companies who invest in *too many* single-family homes, a counterproductive prohibition with hoped-for appeal to populist instincts. Then, under Trump, there have been missives from the FTC to tech companies about their failure to provide “balanced” news coverage, a prerogative protected by the First Amendment.

Trump has also interfered with Netflix’s now aborted acquisition of Warner Bros., in favor of a rival offer from Paramount. Trump also engineered the coercive extraction of a U.S. government “Golden Share” in approving the merger of U.S. Steel and Nippon Steel, which Trump claims gives him “total control”, in part by controlling the number of board seats. And he basically extorted a 15% cut for the government for approving a deal allowing Nvidea and AMD to sell the older H20 chip to China.

Trump’s approach to antitrust is very much entangled with the Administration’s uninhibited embrace of industrial policy and public control over private activity. He shares a fantasy common to interventionists that he can leverage the coercive power of government to create just the outcomes he would like.

The grade here is a D, which I think is generous.

Foreign Policy: I’ll try to keep this category separate from trade and tariff issues, though they are intertwined. Trump’s approach to foreign policy is nothing if not bold, and it’s been a mixed bag in terms of success. In the western hemisphere we have the so-called “Donroe Doctrine”, Trump’s effort to establish U.S. hemispheric leadership. So far: we gained a more effective partnership with Panama over the canal and diminished China’s control; decapitated the Maduro regime in Venezuela, asserting control over its oil shipments and undercutting the flow of narcotics through the country; brought the Cuban communist regime to near collapse by choking off its oil imports (but at the cost of greater human suffering in Cuba); partnered with Mexico in eliminating the head of a major drug cartel; and developed closer ties with several conservative regimes in Central and South America.

I’m troubled by the deadly force used against vessels said to be transporting drugs. We might have great intelligence on smuggling operations, but there must be less deadly ways to interdict.

For better or worse, Trump has trolled Canadian leadership in an effort to provoke dissent and gain influence there with respect to trade and security issues. His provocative stance on Greenland is primarily motivated by concerns over security in the Arctic.

Trump’s action against the repressive Iranian theocracy, its support of terror, and its nuclear ambitions has been a military success. Unfortunately, it has come at the cost of some American lives, at least a few civilian casualties in Iran, and a considerable economic cost. We can only hope for quick resolution and a transition to a more liberal regime for the people of Iran. However, Trump was patient to a fault with the mullahs, offering them an off-ramp during repeated rounds of negotiations. They refused to take it.

Of course, Trump is also pro-Israel and has rallied a coalition of nations who might contribute to a revitalized Gaza. I give Trump huge props for his support of Israel and his disgust with anti-Semitism in general.

Trump’s involvement in negotiations between Ukraine and Russia have been unsuccessful. It’s fair to wonder whether he’s cutting Putin way too much slack, as Putin has no intention of relenting. China remains a major threat to U.S. interests and our allies, but many of Trump’s foreign policy initiatives have served to undermine CCP interests.

Trump unique approach has alienated some of our traditional European allies, though he has had success in influencing policy abroad. In Venezuela, it’s worrisome that Trump acts as if he’s cultivating a relationship with Maduro’s replacements, who are probably no better than Maduro except for their eagerness to cowtow to Trump. Well, maybe, maybe not! Also troubling is the collateral damage suffered by the people of Cuba. There are signs of a willingness among Cuban leaders to negotiate with Trump, though hopes for a friendly successor regime might be foolish.

On the whole, I’ll give Trump a B on foreign policy. It’s bold, but he’s had some real successes.

Trade: I gave Trump an F on trade policy as a candidate. He’s more than justified that grade as president. He is a complete dolt when it comes to the benefits of foreign trade, the meaning of a trade deficit, the costs inflicted by tariffs, their complete inadequacy as a replacement for the income tax, and their counterproductive effect on foreign investment in the U.S. His “emergency” tariffs constituted a huge tax increase on the American people, but those were ruled unconstitutional by the Supreme Court. His latest ploy is to impose punitive tariffs under the guise of a balance of payments emergency, but the balance of payments is zero! This too will be struck down in the courts.

Some might argue that Trump’s other foreign policy achievements would not have been possible without the threat of tariffs, but the fact is Trump imposed the tariffs anyway. Yup, it’s an F.

Taxes: In terms of budget effects, the increased tariff revenue (which might not last at present levels) is much more than offset by tax provisions in the One Big Beautiful Bill Act (OBBBA) passed into law last summer. It makes permanent many of the reductions in the Tax Cuts and Jobs Act of 2017 that had been ready to expire. The standard deduction is increased and more limits are placed on itemization. The Act also creates targeted (and temporary) deductions for tips, overtime, auto loans, and seniors, which is inefficient because it treats various forms of income differently, leading to incentives for unproductive reallocations. Those changes also smack of political pandering.

The OBBBA makes permanent some tax incentives for business, such as immediate expensing of short-term asset purchases and domestic R&D investment. It also provides a temporary 100 percent deduction for certain structures and phases out tax credits for green energy production (bravo!).

To the extent that the tax package includes some pro-growth elements, I applaud it. Tax reductions generally are a good thing because they reduce distortions, but Trump has managed to introduce several distortionary elements just the same. I won’t dock Trump for deficit effects here because the deficit is fundamentally a spending problem, not a tax problem. I gave him a C+ on taxes as a candidate, but I’ll boost him to a B- for his first year.

Inflation: Trump doesn’t have real control over inflation as economists define it, but he’s managed to aggravate some price increases just the same. Unfortunately, he makes repeated claims that “prices have fallen” under his leadership, which of course is false. Egg prices perhaps, and oil prices (er… not this month). Of course, in general prices are up, including import prices. Inflation measures have been fairly steady over the past year, but remain stubbornly higher than the Federal Reserve’s target. I give Trump a grade on this topic only because he deserves a penalty for his false boasts. It’s a C, the same as candidate Trump.

Federal Reserve Independence: Trump has relentlessly badgered Jerome Powell and the Fed to somehow engineer lower interest rates. Of course, many key interest rates are market driven and outside the Fed’s direct control. Trump has gone so far as to bring lawfare to bear against Powell, accusing him of misleading Congress regarding cost overruns on the renovation of the Fed’s offices in DC. Of course, it’s not unusual for a president to jawbone the Fed, but Trump has been absurdly aggressive at a time when reducing the Fed’s rate targets would quite possibly backfire. At least Trump’s selection of the next Fed Chairman, Kevin Warsh, was more reasonable than another top candidate who would probably have been a mere punching bag. For this, I’ll lift his grade slightly, from an F to a D-.

Federal Spending and the Deficit: I discuss a few components of spending under other headings below. Beyond those points, Trump has taken every opportunity to find creative uses for taxpayer money. He has proposed a “tariff dividend” for all households funded by the revenue from import taxes. (Refunds of tariff revenue to “payers” are still in question.) At this point, the better alternative is to put extra revenue toward paying down the federal debt. The same goes for any revenue earned from the many “deals” Trump is counting on. Pay down the debt and earn an immediate, certain, and lasting return, rather than installing the government as part owner of otherwise private enterprises having uncertain returns.

Apart from that and the folly of establishing a sovereign wealth fund while the public debt is burgeoning, Trump has made no progress whatsoever on deficit reduction. Granted, he can’t count on strong legislative support despite slight majorities in both chambers of Congress.

The tax cuts in the OBBBA obviously don’t help the cause of deficit reduction. In fairness, rebuilding the military is a major priority. However, interests costs on the debt will keep rising as will discretionary non-defense outlays. At least the East-Wing Ballroom, the Arc de Trump (!), and the Kennedy Center renovation all appear to be privately funded.

Trump deserves a D here. Some of his priorities are terrible, and I can’t cut him any slack based on trends in discretionary spending.

Entitlement Reform: Trump has been silent on reforms to Social Security’s “Old Age and Survivors” programs and Medicare, except to promise no cuts in benefits under his watch. Kick the can! However, the administration has considered cuts in other entitlements, such as Social Security Disability Insurance, Medicaid and Supplemental Nutrition Assistance (SNAP). These programs have been riddled with fraud, so I applaud steps to clean them up. Nevertheless, any progress made here will still be dwarfed by the insolvency of the Retirement and Medicare programs, which Trump considers a third rail for potential reformers. I gave him an F as a candidate, but his anti-fraud efforts help him salvage a C-.

Government Waste: DOGE was short-lived as originally constituted, its execution was clumsy, and the blow-up in Trump’s relationship with Elon Musk was an embarrassment. However, DOGE was a force for stanching the flow of taxpayer dollars through politicized NGOs. The budget savings were relatively small, but the defunded programs were often egregious varieties of government waste. Subsequently, DOGE personnel had an outsized influence on downsizing the federal bureaucracy and targeting waste across various agencies. In addition, the efforts of one-time DOGE workers were put to good use in identifying entitlement fraud, which could and should result in budget savings. Trump gets a B+ on this one.

Health and Health Care: I’ll give Trump credit here for pursuing a more consumer-oriented approach to health care reform, though at least one of his initiatives is counterproductive.

His initial steps took the form of EOs reducing subsidies paid on ACA marketplace policies, ending remaining penalties for violating the ACA’s individual mandate, approving short-term coverages free of certain ACA restrictions, cutting Medicaid expansion funding, and granting more flexibility for states in defining “essential” healthcare benefits. All of these are basically good steps.

Trump issued an ill-conceived EO calling for “Most-Favored Nation” (MFN) prescription drug pricing, which should reduce Americans’ prescription costs but will dramatically undercut life-saving drug research. Hate the pharmaceutical companies all you want, but they must earn a reasonable profit to risk the massive development costs of new miracle drugs, of which they’ve brought many to market. Price controls always create more problems than they solve.

In early 2026 Trump introduced his “Great Healthcare Plan” (GHP). It would codify MFN drug pricing, fund cost-sharing reductions for ACA plans, encourage price transparency, and redirect payments to consumers and away from insurers to facilitate choice and competition. Also launched was the TrumpRx.gov platform featuring MFN pricing. Ironically, the goal here is to improve access to prescription drugs. Good luck!

Under Robert F. Kennedy, Jr., Trump’s HHS Secretary, the “Make America Healthy Again” agenda has emphasized a healthy diet and exercise, including noteworthy changes in the famous food triangle hierarchy. I can’t argue with those. However, RFK Jr. has upended research under HHS, and those actions were rash in a number cases. He wants to address chronic diseases but I’m skeptical of some of his causal claims. I also have mixed reactions to his changed guidance on vaccines. There are reports that the White House has not been comfortable with all of RFK’s pronouncements and is eager to inject more oversight.

I have varied reactions to Trump’s efforts in the health care arena. MFN price capping is a good way to destroy the advantages Americans enjoy in terms of access to innovative drugs, even if they come at a steep cost. RFK Jr. is a wild card, to be fair. Otherwise, while the GHP should help to improve healthcare affordability, it neglects other critical reforms such as ending the disparate tax treatment of health care premiums and deregulating providers. Still, Trump’s grade improved here, from a D+ as a candidate to a B- thus far in his term.

Abortion: No change here. Trump has consistently supported the right to life. He gets an A.

Housing: Build Baby Build! But aside from harping on the Fed to lower interest rates, Trump hasn’t done much to encourage housing supply.

His EO banning institutional investors from owning “too many” single-family homes won’t help affordability because so few homes are owned by large investors. But to the extent that they are, the EO will increase rents and discourage new housing supply. This is another misguided foray into central economic planning.

While I think a 50-year mortgage should be legal, it’s something I believe potential homebuyers should avoid unless they want to risk stubbornly low equity in their homes stretching into retirement. Trump shouldn’t talk this up too much.

Trump has supported the “ROAD to Housing” bill, which has garnered bipartisan support. It would codify the restrictions on ownership of single-family housing by institutional investors and restrict construction of “rent-to-own” housing by such investors. One couldn’t invent a less effective way to encourage supply and promote “affordability”. But the bill would also subsidize demand, which will increase pressure on housing prices even as the bill aims to assist particular groups (e.g., tax credits for first-time homebuyers). Despite all those downsides, the bill actually includes a few steps to boost housing supply, such as making some federal lands available for development, regulatory reform, and tax incentives for builders.

Trump has also discussed changes to government sponsored enterprises (GSEs, Fannie Mae and Freddie Mac), which purchase new mortgages from lenders, including possible privatization. He might be licking his chops for the $300 billion the GSEs owe the federal government, which could be put toward various “deals” he might like to cut. If privatization were to end the explicit government guarantee for mortgage-backed securities issued by the GSEs, mortgage interest rates would rise and it could be quite disruptive for banks.

Update: On Friday, March 13, the President issued an EO entitled “Removing Regulatory Barriers To Affordable Home Construction“, which looks sensible at a glance.

Housing policy is another mixed bag for Trump, but I’ll give him a B on the strength of his deregulatory effort.

Energy: Drill baby drill! Despite the current disruption to oil shipments through the straight of Hormuz and the spike in oil prices, I deem Trump’s energy policies a success thus far. Largely through deregulation, Trump has opened up the spigots on domestic oil production. He has also realigned energy priorities, eliminating subsidies and mandates for intermittent renewable energy sources in favor of encouraging fossil fuels, hydroelectric, and especially a new emphasis on nuclear power. Some of these steps represent unabashed central planning, so I can’t give Trump an A on energy policy,. However, the preceding green-energy regime was central planning on steroids with the unintended consequence of instability in the power grid. I would greatly prefer a policy of complete neutrality with respect to energy sources, but at least Trump is not cowed by global warming hysteria.

And Trump is considering a temporary suspension of the Jones Act due to the energy crunch brought on by the war in Iran. That would be great except that the waiver should be permanent. The move would lower energy (and other) costs to U.S. consumers and minimize supply disruptions by allowing energy (and other goods) to flow more freely between U.S. ports.

His grade on energy policy is a B.

First Amendment Rights: Trump has not been the defender of free speech that I had hoped. On this, I gave him an A- as a candidate, but his Administration has been belligerent in attacking speech. He (and his FCC Chairman) threaten media outlets with license revocation, his Attorney General says “we will target you” for anything DOJ attorneys might define as hate speech, and Trump has called certain speech he dislikes “illegal”. I also have qualms about an EO issued last year by Trump targeting “campaigns of … radicalization”, which might, in practice, bring any sort of opposition speech under scrutiny. And there are other potentially troublesome provisions for protected speech. Trump’s pure intent might be to stop violent radicalism, which is fine in spirit but hard to bring off without mass surveillance and violations of rights. I therefore downgrade Trump to a C on free speech.

Second Amendment Rights: Trump has not been quite as consistent on gun rights as he was as a candidate. He took a number of actions to reduce burdens and restrictions on gun rights, but in other cases he let restrictions stand, including arrests for gun possession in Washington DC by federal agents and a possible proposal to restrict the gun rights of transgendered individuals. All-in-all, I’ll reduce Trump’s A on gun rights to a B+.

DEI and Its Evil Financial Twin, ESG: There is no question that Trump has done much to cut through the stranglehold that DEI doctrine had imposed on social and economic life. He issued EOs to end DEI practices in the federal government. He also threatened major universities with funding freezes and anti-discrimation actions, an approach that has met with some success. Trump’s words and actions on DEI have reverberated through the private sector as well. He has encouraged individuals who believe they’ve suffered discrimination based on DEI to file lawsuits. The thrust of the Administration’s agenda on DEI and regulatory changes has served to undermine the use of ESG measures. These are intended to draw investors to companies purporting to foster environmental and social goals, which can be at odds with creating value for shareholders. Trump has earned his A in this category.

Technology: As in other policy domains, the record here is marred by misguided industrial policies. That includes the recent snafu over the Department of Defense’s allegation of “supply chain risk” posed by Anthropic. DoD wants carte blanche access to all aspects of any AI model it adopts, including uses in autonomous weapons systems and mass public surveillance. Anthropic said it would not accept that without guardrails, so an apparently infuriated Pete Hegseth moved to designate the company a supply chain risk, an outright punishment that would obviously damage Anthropic’s economic prospects. Yet almost immediately, DoD agreed to an arrangement with OpenAI with guardrails similar to those desired by Anthropic. Now, Trump, who seems to have Hegseth’s back, is readying an EO on the topic… so we shall see. But it’s a mess. Anthropic has filed suit.

And yet Trump has generally been supportive of AI development, signing an order to prevent states from imposing a patchwork of varying, complex regulations. The White House has issued an ”AI Action Plan” to encourage AI exports, minimizing federal regulatory burdens, and “upholding free speech” on “unbiased” frontier models. Let’s hope “unbiased” has a truly neutral definition in this case. Trump has signed a series of EOs related to AI research and deployment, which are linked here.

Post-inauguration, Trump dove right into another socialist joint venture known as Stargate to build data center infrastructure. The rationale for the government’s direct involvement is national security. Of course, that’s the Administration’s rough and ready excuse for almost any kind of intervention.

Trump has helped promote the crypto industry, supporting legislation (the CLARITY Act and the GENIUS Act) enabling more widespread use of stablecoins. He even supports the payment of returns on stablecoins, a development that is unpopular with banks. Trump has also acted to promote cybersecurity and harden infrastructure against malicious actors. More recently, he initiated a program to test eVTOL technologies (electronic vertical takeoff and landing), which are expected to revolutionize local and regional transportation in coming years.

The best I can give Trump on technology is a B-, given his penchant for government control. The Anthropic controversy is a real black eye.

Voting Rights: The Trump-backed SAVE America Act would require an ID proving citizenship to vote in federal elections. It’s stalled in the Senate, seven votes short of the 60 needed to send it to Trump’s desk. GOP senators are unwilling to force a talking filibuster, let alone to use the so-called “nuclear option” to force a simple-majority vote. There is still a possibility of including a voter ID requirement in a budget reconciliation bill if anyone can convince the Senate Parliamentarian that it would have budget impacts. For his part, Trump says he’ll refuse to sign any other legislation until the SAVE Act crosses his desk, though he’s also threatened to issue an EO mandating voter ID should the Senate fail to pass the bill. The constitutionality of such an order would be challenged, of course, but for his determination on the issue, I’ll give him an A+.

Education: This is a quick addition to the list. After inserting the photo of Trump at the top, I realized that I’d completely forgotten to add education as a performance category. Trump’s effort to dismantle the wasteful and unproductive Department of Education is to be applauded. He’s also been an unwavering supporter of school choice. I’ll give him an A here.

I have to stop! That’s 22 categories and a “grade point average” of 2.55 if the categories are equally weighted. It’s a little worse than Trump’s GPA as a candidate (2.67). He could have improved his grades dramatically without his bent for economic intervention, but I’d have to vote for him again given the alternative.

Beware of Government Health Care Yet To Come

02 Sunday Feb 2025

Posted by Nuetzel in Health Care

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adverse selection, Affordable Care Act, Arnold Kling, Bryan Caplan, Claim Denials, David Chavous, Donald Trump, Employer-Provided Coverage, Essential Benefits, Hospital Readmissions, Joel Zinberg, Liam Sigaud, Make America Healthy Again, Matt Margolis, Michael F. Cannon, Moral Hazard, Noah Smith, Obamacare, Peter Earle, Pharmacy Benefit Managers, Portability, Pre-Authorization Rules, Pre-Existing Conditions, Premium Subsidies, Robert F. Kennedy Jr, Sebastian Caliri, Steven Hayward, Tax-Deductible Premiums, third-party payments, Universal Health Accounts

Ongoing increases in the resources dedicated to health care in the U.S., and their prices, are driven primarily by the abandonment of market forces. We have largely eliminated the incentives that markets create for all buyers and sellers of health care services as well as insurers. Consumers bear little responsibility for the cost of health care decisions when third parties like insurers and government are the payers. A range of government interventions have pushed health care spending upward, including regulation of insurers, consumer subsidies, perverse incentives for consolidation among health care providers, and a mechanism by which pharmaceutical companies negotiate side payments to insurers willing to cover their drugs.

It’s not yet clear whether the Trump Administration and its “Make America Healthy Again” agenda will serve to liberate market forces in any way. Skeptics can be forgiven for worrying that MAHA will be no more than a cover for even more centrally-planned health care, price controls, and regulation of the pharmaceutical and food industries, not to mention consumer choices. Robert F. Kennedy Jr., who is likely to be confirmed by the Senate as Donald Trump’s Secretary of Health and Human Services, has strong and sometimes defensible opinions about nutrition and public health policies. He is, however, an inveterate left-winger and is not an advocate for market solutions. Trump himself has offered only vague assurances on the order of “You won’t lose your coverage”.

Government Control

The updraft in health care inflation coincided with government dominance of the sector. Steven Hayward points out that the cost pressure began at about the same time as Medicare came into existence in 1965. This significantly pre-dates the trend toward aging of the population, which will surely exacerbate cost pressures as greater concentrations of baby boomers approach or exceed life expectancy over the next decade.

Government now controls or impinges on about 84% of health care spending in the U.S., as noted by Michael F. Cannon. The tax deductibility of employer-provided health insurance is a massive example of federal manipulation and one that is highly distortionary. It reinforces the prevalence of third-party payments, which takes decision-making out of consumers’ hands. Equalizing the tax treatment of employer-provided health coverage would obviously promote tax equity. Just as importantly, however, tax-subsidized premiums create demand for inflated coverage levels, which raise prices and quantities. And today, the federal government requires coverages for routine care, going beyond the basic function of insurance and driving the cost of care and insurance upward.

The traditional non-portability of employer-provided coverage causes workers with uninsurable pre-existing conditions to lose coverage when they leave a job. Thus, Cannon states that the tax exclusion for employer coverage penalizes workers who instead might have chosen portable individual coverage in a market setting without tax distortions. Cannon proposes a reform whereby employer coverage would be replaced with deposits into tax-free Universal Health Accounts owned by workers, who could then purchase their own insurance.

In 2024, federal subsidies for health insurance coverage were about $2 trillion, according to the Congressional Budget Office (CBO). Those subsidies are projected to grow to $3.5 trillion by 2034 (8.5% of GDP). Joel Zinberg and Liam Sigaud emphasize the wasteful nature of premium subsidies for exchange plans mandated by the Affordable Care Act (ACA), better known as Obamacare. Subsidies were temporarily expanded in 2021, but only until 2026. They should be allowed to expire. These subsidies increase the demand for health care, but they are costly to taxpayers and are offered to individuals far above the poverty line. Furthermore, as Zinberg and Sigaud discuss, subsidized coverage for the previously uninsured does very little to improve health outcomes. That’s because almost all of the health care needs of the formerly uninsured were met via uncompensated care at emergency rooms, clinics, medical schools, and physician offices.

Proportionate Consumption

Perhaps surprisingly, and contrary to popular narratives, health care spending in the U.S. is not really out-of-line with other developed countries relative to personal income and consumption expenditures (as opposed to GDP). We spend more on health care because we earn and consume more of everything. This shouldn’t allay concern over health care spending because our economic success has not been matched by health outcomes, which have lagged or deteriorated relative to peer nations. Better health might well have allowed us to spend proportionately less on health care, but this has not been the case. There are explanations based on obesity levels and diet, but important parts of the explanation can be found elsewhere.

It should also be noted that a significant share of our decades-long increases in health care spending can be attributed to quantities, not just prices, as explained at the last link above.

Health Consequences

The ACA did nothing to slow the rise in the cost of health care coverage. In fact, if anything, the ACA cemented government dominance in a variety of ways, reinforcing tendencies for cost escalation. Even worse, the ACA had negative consequences for patient care. David Chavous posted a good X thread in December on some of the health consequences of Obamacare:

1) The ACA imposed penalties on certain hospital readmissions, which literally abandoned people at death’s door.

2) It encouraged consolidation among providers in an attempt to streamline care and reduce prices. This reduced competitive pressures, however, which had the “unforeseen” consequence of raising prices and discouraging second opinions. The former goes against all economic logic while the latter goes against sound medical decision-making.

3) The ACA forced insurers to offer fewer options, increasing the cost of insurance by encouraging patients to wait until they had a pre-existing condition to buy coverage. Care was almost certainly deferred as well. Ultimately, that drove up premiums for healthy people and worsened outcomes for those falling ill.

4) It forced drug companies to negotiate with Pharmacy Benefit Managers (PBMs) to get their products into formularies. The PBMs have acted as classic middlemen, accomplishing little more than driving up drug prices and too often forcing patients to skimp on their prescribed dosage, or worse yet, increasing their vulnerability to lower-priced quackery.

The Insurers

So the ACA drastically increased the insured population (including the new burden of covering pre-existing conditions). It also forced insurers to meet draconian cost-control thresholds. Little wonder that claim rejection increased, a phenomenon often at the root of public animosity toward health insurers. Peter Earle cites several reasons for the increase in denial rates while noting that claim rejection has made little difference in insurer profit margins.

Matt Margolis points out that under the ACA, we’ve managed to worsen coverage in exchange for higher premiums and deductibles. All while profits have been capped. Claim denials or delays due to pre-authorization rules (which delay care) have become routine following the implementation of Obamacare.

Perhaps the biggest mistake was forcing insurers to cover pre-existing conditions without allowing them to price for risk. Rather than forcing healthy individuals to pay for risks they don’t face, it would be more economically sensible to directly subsidize coverage for those in high-risk pools.

Noah Smith also defends the health insurers. For example, while UnitedHealth Group has the largest market share in the industry, its net profit margin of 6.1% is only about half of the average for the S&P 500. Other major insurers earn even less by this metric. Profits just don’t explain why American health care spending is so high. Ultimately, the services delivered and charges assessed by providers explain high U.S. health care spending, not insurer profits or administrative costs.

Under the ACA, insurance premiums pay the bulk of the cost of health care delivery, including the cost of services more reasonably categorized as routine health maintenance. The latter is like buying insurance for oil changes. Furthermore, there are no options to decline any of the ten so-called “essential benefits” under the ACA, thus increasing the cost of coverage.

Medical Records

Arnold Kling argues that the ACA’s emphasis on uniform, digitized medical records is not a productive avenue for achieving efficiencies in health care delivery. Moreover, it’s been a key factor driving the increasing concentration in the health care industry. Here is Kling:

“My point is that you cannot do this until you tighten up the health care delivery process, making it more rigid and uniform. And I would not try to do that. Health care does not necessarily lend itself to being commoditized. You risk making health care in America less open to innovation and less responsive to the needs of people.

“So far, all that has been accomplished by the electronic medical records drive has been to put small physician practices out of business. They have not been able to absorb the overhead involved in implementing these systems, so that they have been forced to lose their independence, primarily to hospital-owned conglomerates.”

Separating Health and State

The problem of rising health care costs in the U.S. is capsulized by Bryan Caplan in his call for the separation of health and state. The many policy-driven failures discussed above offer more than adequate rationale for reform. The alternative suggested by Caplan is to “pull the plug” on government involvement in health care, relying instead on the free market.

Caplan debunks a few popular notions regarding the appropriate role for markets in health care and health insurance. In particular, it’s often alleged that moral hazard and adverse selection would encourage unhealthy behaviors and encourage the worst risks to over-insure, causing insurance markets to fail. But these problems arise only when risk is not priced efficiently, precisely what the government has accomplished by attempting to equalizing rates.

Pulling the plug on government interference in health care would also mean deregulating both insurance offerings and pricing, encouraging the adoption of portable coverage, expediting drug approvals based on peer-country approvals, reforming pharmacy benefit management, ending deadly Medicare drug price controls, and encouraging competition among health care providers.

Value Vs. Volume

There are a host of other reforms that could bring more sanity to our health care system. Many of these are covered here by Sebastian Caliri, with some emphasis on the potential role of AI in improving health care. Some of these are at odds with Kling’s skepticism regarding digitized health records.

Perhaps the most fundamental reforms entertained by Caliri have to do with health care payments. One is to make payments dependent on outcomes rather than diagnostic codes established and priced by the American Medical Association. To paraphrase Caliri, it would be far better for Americans to pay for value rather than volume.

Another payment reform discussed by Caliri is expanding direct payments to providers such as capitation fees, whereby patients pay to subscribe to a bundle of services for a fixed fee. Finally, Caliri discusses the importance of achieving “site-neutral payments”, eliminating rules that allow health systems to charge a higher premium relative to independent providers for identical services.

For what it’s worth, Arnold Kling disagrees that changing payment metrics would be of much help because participants will learn to game a new system. Instead, he emphasizes the importance of reducing consumer incentives for costly treatments having little benefit. No dispute there!

Avoid the Single-Payer Calamity

I’ll close this jeremiad with a quote from Caliri’s piece in which he contrasts the knee-jerk, leftist solution to our nation’s health care dilemma with a more rational, market-oriented approach:

“Single payer solutions and government control favored by the left are no solutions at all. Moving to a monopsonist system like Canada is a recipe for strangling innovation and rationing access. Just ask our neighbors to the north who have to wait a year for orthopedic surgery. The UK’s National Health Service (NHS) is teetering on the brink of collapse. We need to sort out some other way forward.

“Other parts of the economy provide inspiration for what may actually work. In the realm of information technology, for example, fifty years has taken us from expensive four operation calculators to ubiquitous, free, artificial intelligence capable of passing the Turing Test. We can argue about the precise details but most of this miracle came from profit-seeking enterprises competing in a free market to deliver the best value for the buyer’s dollar.“

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Passive Income Kickstart

OnlyFinance.net

TLC Cholesterol

Nintil

To estimate, compare, distinguish, discuss, and trace to its principal sources everything

kendunning.net

The Future is Ours to Create

DCWhispers.com

Hoong-Wai in the UK

A Commonwealth immigrant's perspective on the UK's public arena.

Marginal REVOLUTION

Small Steps Toward A Much Better World

Stlouis

Watts Up With That?

The world's most viewed site on global warming and climate change

American Elephants

Defending Life, Liberty and the Pursuit of Happiness

The View from Alexandria

In advanced civilizations the period loosely called Alexandrian is usually associated with flexible morals, perfunctory religion, populist standards and cosmopolitan tastes, feminism, exotic cults, and the rapid turnover of high and low fads---in short, a falling away (which is all that decadence means) from the strictness of traditional rules, embodied in character and inforced from within. -- Jacques Barzun

The Gymnasium

A place for reason, politics, economics, and faith steeped in the classical liberal tradition

A Force for Good

How economics, morality, and markets combine

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Spontaneous thoughts on a humble creed

troymo

SUNDAY BLOG Stephanie Sievers

Escaping the everyday life with photographs from my travels

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Gallery of Life...

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Attempt to solve commonly known problems…

Objectivism In Depth

Exploring Ayn Rand's revolutionary philosophy.

RobotEnomics

(A)n (I)ntelligent Future

Orderstatistic

Economics, chess and anything else on my mind.

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Musings on science, investing, finance, economics, politics, and probably fly fishing.

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