Hur ska man bedöma Bernie Sanders? Bernie Sanders är en mycket intressant amerikansk politiker. Hans framgång i kampen mot Hillary Clinton och hans framgångar hittills under årets presidentvalskampanj förtjänar analys. En viktig faktor är att många amerikaner vet att det inte är presidenten som avgör politiken (även om Donald Trump tror så) utan att majoritetsförhållandena i kongressen är det som avgör det politiskt möjliga. Det sannolika är att en president Sanders skulle ha ett starkt republikanskt motstånd i kongressen vilket skulle försvara eller omöjliggöra allt (eller det mesta av allt) han generöst nu utlovar. Just det är det främsta argumentet mot Sanders: många väljare skulle i kongressvalen rösta republikanskt för att säkerställa en maktbalans och en broms på vildsinta reformlöften. En demokrat som kan dra med sig väljare till partiets kandidater i kongressvalen är alltså det politiskt mest attraktiva ur partiets synvinkel och även med tanke på vad man skulle vilja genomföra i politiska beslut. Här kommer några intressanta analyser av Sanders. The Price of a Sanders Nomination David Frum, Staff writer at The Atlantic Supporters of Senator Bernie Sanders insist that their guy can eject Donald Trump from the White House. The more insistent question, though, is whether Sanders will cost Democrats the House of Representatives. Democrats won the House in 2018, riding a surge of anti-Trump voting from a constituency that’s been scared by the Sanders campaign: older, college-educated, conservative-leaning women. Such voters tipped into the Democratic column the congressional seats once held by George H. W. Bush, Newt Gingrich, and Eric Cantor. In 2018, upmarket districts voted to reprimand the president’s language and behavior. A Sanders nomination invites those districts to vote in 2020 to raise their taxes and replace their health insurance. That may be a tougher sell. The Democratic House majority is new, fragile, and dependent on voters who are more conservative than the median Democrat. In 2018, Democrats flipped districts like New Mexico’s Second, which stretches across the bottom tier of the state. Trump carried the district by 10 points in 2016, but Xochitl Torres Small won it by two points in 2018, thanks in part to an ad that showcased her skill with a bird gun. “New Mexicans,” said the ad copy, “don’t care which party gets the credit or the blame. We just want someone to deliver.” Democrats won South Carolina’s First, which stretches from the posh coastal towns of Hilton Head and Beaufort to the Charleston suburbs. The district was formerly held by the very conservative Mark Sanford. Trump won it by 13 points in 2016; freshman Representative Joe Cunningham nabbed it by only one point in 2018. Democrats won New York’s Twenty-Second, which extends from the university city of Binghamton to postindustrial Utica. Trump won there by a staggering 15 points in 2016; Anthony Brindisi defeated by two points a Republican incumbent prone to incendiary comments like—in a radio interview shortly after the Parkland school shooting—“It's interesting that so many of [the] people that commit the mass murders end up being Democrats.” Altogether, 31 of the congressional districts won by Trump in 2016 are now held by Democrats, 21 of them freshman. Only three Hillary-won House districts are represented by Republicans. Democrats succeeded in Trump country because the Democratic Party attracted a broad coalition of moderates and liberals. The Sanders campaign aims first and foremost to reinvent the Democratic coalition as a narrower ideological movement, in much the same way that the once-broad Republican coalition has been transformed. But the difference between the two is that many fewer Americans identify as “progressive” than as “conservative.” Worse for Democrats: Not only does Sanders propose to break the cookie in such a way as to leave his party with the smaller piece, but he also does so in a political context that already disfavors them. Democrats hold virtually every one of the urban and academic districts that will rally to progressive politics. But thanks to enterprising candidates who keep in touch with their districts, they also hold Minnesota’s Seventh, a 90 percent white district running north-south adjacent to the two Dakotas. It’s represented in Congress by Collin Peterson, a pro-life Democrat who chairs the House Agriculture Committee. In 2018, a Democrat won the country’s richest congressional district, the Virginia Tenth, which has a median household income of more than $127,000. Democrats now represent all of the country’s 10 richest districts. Peter Beinart: Regular Democrats just aren’t worried about Bernie Sanders supporters take as an article of faith that Sanders will win votes from working-class voters who swung to Trump in 2016. This idea is based on a single data-point: Some 10 to 12 percent of those who voted for Sanders in the 2016 primary then voted for Trump in the general election. If Sanders could have held all those primary voters in a general election, and also if he had won everybody who voted for Hillary Clinton in the primary, then he would have defeated Trump. But once you state the two ifs, you see the problem. The political scientist Brian Schaffner, who closely studied these Sanders-Trump switchers, finds that they were older white voters with conservative racial views. As compared with other Sanders voters, the Sanders-Trump switchers were much more likely to deny that white people enjoy special advantages in American society. They were also much less positive about President Obama than were Sanders voters who did not switch to Trump. No Democrat, including Sanders, is likely to outbid Trump for these voters in a general election. Meanwhile, it’s very hard to identify congressional districts where the hypothetical return of Sanders-to-Trump voters to the Democratic column would swing the district—and it’s easy to identify many where discomfort with Sanders could swing the district back to the Republican column. In 2018, Democrat Lizzie Fletcher won Texas’s Seventh, a wealthy district in and around Houston. The district had been held continuously by Republicans since 1966, when it was won by George H. W. Bush. In 2016, Republican John Culberson got almost 144,000 votes; Democrat James Cargas, 112,000. In 2018, the Democratic vote improved to 128,000; the Republican vote fell to 116,000. Yet the district remains Republican +7 according to “The Cook Political Report.” What happens to Lizzie Fletcher if Bernie Sanders wins the nomination on a message of higher taxes, no private health insurance, and admiration for Fidel Castro? Do you think a Republican House member cannot recover to 144,000 running against that? Bernie Sanders is sometimes compared to George McGovern, the liberal Democrat who lost every state except Massachusetts and the District of Columbia to Richard Nixon in 1972. Derek Thompson: Bernie Sanders Is George McGovern Defenders of Sanders correctly point out that we live in a more polarized and partisan era, and that anti-Trump feeling will surely put a political floor under Sanders well north of McGovern’s 37.5 percent of the vote. And that’s probably true. It’s hard to see Sanders losing California or New York, as McGovern did. But in an important way, Sanders represents an even greater danger to Democrats than McGovern did. McGovern ran in an age of ticket-splitting. In that same election where McGovern did so disastrously, Democrats lost only 12 seats in the House. They actually gained two in the Senate and also won a governorship. That pattern will not repeat itself in 2020. If Sanders loses badly as moderate voters swing away from Democrats, he will take with him a big clutch of House Democrats and Democratic Senate hopefuls. It will be a loss up and down the ticket, a loss that could not only reelect Trump, but also enable him, by preserving his elected bodyguard in the Senate and restoring his majority in the House. The question to weigh before Super Tuesday is thus not only Sanders versus Biden or Sanders versus Bloomberg. It is whether you prefer Speaker Pelosi or Speaker McCarthy, and Chairman Schiff or Chairman Nunes. The hopes of congressional Democrats hang in the balance in the fateful week ahead.   DAVID FRUM is a staff writer at The Atlantic and the author of Trumpocalypse: Restoring American Democracy (2020). In 2001 and 2002, he was a speechwriter for President George W. Bush. Bernie Sanders looks electable in surveys — but it could be a mirage By David Broockman and Joshua Kalla  Feb 25, 2020, 11:40am EST The most important factor for Democratic voters in the 2020 primary is electability: A majority of Democrats say they would rather nominate a candidate who can beat President Trump than a candidate who agrees with them on the issues. So which candidate is most likely to beat Trump? Decades of evidence from academic studies suggests that more moderate nominees tend to perform better in general elections than more ideologically extreme nominees. For example, Democratic US House candidates who supported Medicare-for-all fared approximately 2.2 percentage points worse in the 2018 midterms than candidates in similar districts who did not. But early polling testing how Democratic nominees would fare against Trump suggests a different conclusion: Bernie Sanders, the most left-wing candidate in the Democratic primary, polls as well against Trump as his more moderate competitors in surveys. Democratic voters have appeared to take these polls to heart, as a recent Washington Post-ABC News poll finds that Democrats believe Sanders has the best chance of beating Trump. Why does Sanders look similarly electable to leading moderates in polls against Trump? We fielded a 40,000-person survey in early 2020 that helps us look into this question with more precision. We asked Americans to choose between Trump and one of the leading Democratic candidates: Sanders, Elizabeth Warren, Pete Buttigieg, Joe Biden, and Mike Bloomberg. So that respondents would not strategically claim to only support their chosen candidate against Trump, we only asked each respondent about one Democratic candidate. The surveys were fielded by Lucid, an online market research company that provides nationally representative samples of Americans. Our data (laid out in an academic working paper here) also found what polls show: that Sanders is similarly electable to more moderate candidates. But, on closer inspection, it shows that this finding relies on some remarkable assumptions about youth turnout that past elections suggest are questionable. We found that nominating Sanders would drive many Americans who would otherwise vote for a moderate Democrat to vote for Trump, especially otherwise Trump-skeptical Republicans. Republicans are more likely to say they would vote for Trump if Sanders is nominated: Approximately 2 percent of Republicans choose Trump over Sanders but desert Trump when we pit him against a more moderate Democrat like Buttigieg, Biden, or Bloomberg. Democrats and independents are also slightly more likely to say they would vote for Trump if Sanders is nominated. Swing voters may be rare — but their choices between candidates often determine elections, and many appear to favor Trump over Sanders but not over other Democrats. Nominating Sanders increases the share of Republicans voting for Trump, but reduces the share of independents and Democrats who say they’ll stay at home. Broockman / Kalla 2020 Despite losing these voters to Trump, Sanders appears in our survey data to be similarly electable to the moderates, at least at first blush. Why? Mainly because 11 percent of left-leaning young people say they are undecided, would support a third-party candidate, or, most often, just would not vote if a moderate were nominated — but say they would turn out and vote for Sanders if he were nominated. The large number of young people who say they will only vote if Sanders is nominated is just enough to offset the voters Sanders loses to Trump in the rest of the electorate. (Warren appears to lose at least as many Republicans as Sanders but does not seem to benefit from any compensating enthusiasm from young voters.) Sanders himself has been clear that his strategy for beating Trump is to massively boost turnout, especially among young people — and young people in our data indeed say they would turn out at much higher rates for him. But for Sanders to do as well as a moderate Democrat against Trump in November by stimulating youth turnout, his nomination would need to boost turnout of young left-leaning voters enormously — according to our data, one in six left-leaning young people who otherwise wouldn’t vote would need to turn out because Sanders was nominated. There are good reasons to doubt that Sanders’s nomination would produce a youth turnout surge this large. The reason Sanders appears equally electable These “Bernie or bust” voters that come off the sidelines for Sanders in our survey are almost entirely limited to one group: Democrats and independents under age 35. These voters are about 11 percentage points more likely to say they would vote for Democrats if Sanders is nominated — and almost all of them say they would not vote at all or vote third party if he’s not on the ballot. However, the “Bernie or bust” phenomenon appears almost entirely limited to left-leaning young people, who are usually a small share of the overall electorate. This stands in contrast to many theories of Sanders’s electoral appeal: For example, whites without a college degree — a demographic some speculate Sanders could win over — are actually more likely to say they will vote for Trump against Sanders than against the other Democrats. The same is true of the rest of the electorate, except left-leaning young people. Young left-leaning voters are the only group whose turnout Sanders increases. Broockman/Kalla 2020 This finding in our data mirrors many other surveys: Morning Consult finds dramatic increases in young Americans’ stated turnout intentions when asked how they would vote in matchups between Sanders and Trump. How huge of a turnout surge does Sanders need to be as electable as a moderate? The case that Bernie Sanders is just as electable as the more moderate candidates thus appears to rest on a leap of faith: that youth voter turnout would surge in the general election by double digits if and only if Bernie Sanders is nominated, compensating for the voters his nomination pushes to Trump among the rest of the electorate. There are reasons to doubt a Sanders-driven youth turnout surge of this size would materialize. First, people who promise in surveys they will vote often don’t, meaning the turnout estimates that Sanders’s electability case rests upon are probably extremely inaccurate. Second, such a turnout surge is large in comparison to other effects on turnout. For example, Sanders would need to stimulate a youth turnout boost much larger than the turnout boost Barack Obama’s presence on the ballot stimulated among black voters in 2008. Third, Sanders’s electability case requires this 11 percentage point turnout increase among young voters in 2020 to occur on top of any turnout increase that would otherwise occur if another Democrat were nominated. If the turnout of all age groups increases from 2016 to 2020 (as happened from 2014 to 2018), then the turnout among young people must increase by 11 percentage points above and beyond this broader trend, and must do so solely due to Sanders’s presence on the ticket. Finally, youth voter turnout doesn’t usually go up or down by nearly as much as 11 percentage points from election to election; the Sanders boost would have to be truly unprecedented. And this enormous 11 percentage point turnout boost is only enough to make Sanders as electable as the more moderate candidates, given the other votes he loses to Trump. For him to be the most electable Democratic candidate based on his ability to inspire youth turnout, Sanders’s nomination would need to increase youth turnout by even more. According to our survey, Sanders would have to boost youth turnout far above historical levels to be as electable as a moderate nominee. Broockman/Kalla 2020 There is no way to be sure whether Sanders’s nomination would produce this historic youth turnout surge — but it seems doubtful. Turnout in the 2020 primaries so far has not exceeded 2008 levels, including among young voters. If anything, research suggests the opposite is more likely to occur: In response to an extreme Democratic nominee, Republicans could be inspired to turn out at higher rates to oppose him. What if Sanders’s nomination doesn’t stimulate youth turnout enough to offset the votes it would lose to Trump? In an academic working paper based on this survey, we consider this possibility. In one analysis, we disregard what voters say about whether they would vote, and use their demographics and party affiliation to infer the shape of the likely electorate. In particular, we base their guesses about who will vote on the demographics of the 2016 voting electorate instead of what people tell us about whether they will vote (and assume people who don’t list a preference will vote for their party). With this approach, Sanders trails all three leading moderate candidates in head-to-head polls against Trump. Would Republican attacks knock the more moderate candidates down to Sanders’s level? One concern about our findings is that Republicans who say they would vote for Biden or Buttigieg might not really do so in November, after the general election campaign has heated up. After months of sustained attacks from Trump and Republicans throughout the general election, would the more moderate candidates still be more electable than Sanders? To examine this possibility, we first conducted an experiment to identify effective attacks against each of the Democratic candidates. For example, Biden’s historical support for freezing Social Security benefits undermined his support, but hearing about Buttigieg’s sexual orientation and the fact that he met his husband online did not decrease his support. Admikebloomberg.com Then, to examine the resiliency of each Democrat’s support in the general election in the face of effective attacks, we showed some of our survey respondents the three attacks that were most effective against each Democrat before asking them who they would vote for in a contest between that Democrat and Trump. After showing three attacks against each candidate, we find that Sanders would still need the same large youth turnout surge to overcome his deficit relative to the more moderate candidates against Trump. When we analyze the data using the same approach described above that disregards what voters say about whether they will vote, we find that, after being shown the attacks, Buttigieg, Bloomberg, and Biden still do better against Trump than Sanders does. (Warren still performs even worse than Sanders against Trump in this test. We did not include Klobuchar in this survey.) Prediction markets have been sounding the alarm, too, as Trump’s probability of winning reelection has steadily risen as Sanders has looked increasingly likely to be the Democratic nominee. Early polls are never a surefire guide to what will happen in an election months later. But Democrats should not be very reassured by early polls that find Sanders faring as well against Trump as the more moderate candidates: These numbers may only look decent for Sanders because they assume he will inspire a youth turnout miracle. Our survey data reveals voters of all parties moving to Trump if Sanders is nominated, a liability papered over by young voters who claim they would be inspired to vote by Sanders alone. The gamble Democrats supporting Sanders based on his early polls against Trump must be ready to make is that, despite the evidence to the contrary, the lowest-participating segment of the electorate will turn out at remarkably high rates because Sanders is nominated. David Broockman is an associate professor of political science at the University of California Berkeley.  Joshua Kalla is an assistant professor of political science and statistics & data science at Yale University. Donation disclosure: Broockman has donated $27 to Bernie Sanders’s 2016 campaign, $5 to Julián Castro’s 2020 campaign, $5 to Amy Klobuchar’s 2020 campaign, and $2 to Pete Buttigieg’s 2020 campaign. Kalla has donated $250 to Buttigieg’s 2020 campaign and $100 to Elizabeth Warren’s 2020 campaign. Even With New Pay-Fors, Bernie’s Agenda Still Has A $25 Trillion Hole Ben Ritz Vermont Sen. Bernie Sanders has made some extraordinary promises in his campaign for president, including free health care, a federal jobs guarantee, universal forgiveness of all student debt, and radical expansions of nearly every government program from Social Security to housing subsidies. When asked at a CNN town hall last night how he would pay for this gargantuan expansion of government, Sen. Sanders presented moderator Chris Cuomo with a new document that Sanders claimed detailed how he would pay for his proposals. But don’t be fooled: these numbers still don’t add up, and Sanders should be pressed to explain his magic math at tonight’s debate. The first problem is that the list of Sanders’ proposed spending increases is incomplete. Sanders has proposed costly plans for K-12 education, expanding disability insurance, paid family leave, and more that were not accounted for in the new document. He also grossly understates the cost of his Medicare for All plan by citing a flawed analysis that neglected to incorporate the costs of specific benefits Sanders proposes, such as universal coverage for long-term services and supports, and failed to account for how offering universal health-care benefits more generous than those offered by any other country on earth would increase utilization of health services. Sanders and his surrogates regularly claim that critics are wrong to focus on how much Medicare for All increases government costs because it would reduce the total cost of health care. But independent analyses from the Urban Institute and Committee for a Responsible Federal Budget have concluded that even with the aggressive price controls he has proposed, Sanders’ Medicare-for-All framework would actually increase national health expenditures by up to $7 trillion. Sanders himself also admitted in a 60 minutes interview this weekend that his Medicare-for-All plan would likely cost around $30 trillion, yet the list of “options” Sanders has offered to pay for them (options which, it should be noted, he has never explicitly endorsed enacting together) would together cover less than 60 percent of that amount by the Sanders campaign’s own accounting. In January, the Progressive Policy Institute published comprehensive cost estimates of the proposals offered by each of the leading candidates for president before the Iowa Caucus. After incorporating new proposals that Sanders has released since the publication of our analysis and minor methodological updates, PPI concludes that Sanders has now proposed over $53 trillion of new spending over the next 10 years – an amount that would roughly double the size of the federal government. Our estimate is, if anything, overly charitable to Sanders, as it accepts most of the Sanders campaign’s cost estimates outside of Medicare for All and assumes significant overlap in the costs of his proposed federal jobs guarantee and other spending proposals. Other analysts have estimated the total costs of Sanders’ proposals could be anywhere between $60 trillion and $100 trillion over 10 years. Sanders’ proposed pay-fors don’t even come close to covering these costs. The document Sanders published last night, along with others released earlier in his campaign, claim to collectively raise less than $43 trillion in new revenue – meaning that he’s at least $10 trillion short. But the revenue projections Sanders uses for his tax proposals are well outside the mainstream of what independent analysts at the Committee for a Responsible Federal Budget, Congressional Budget Office, Tax Policy Center, Penn Wharton Budget Model, and others have estimated. After reconciling Sanders’ latest list of pay-fors with these independent estimates, PPI concludes that even if Congress were to adopt every single revenue option Sanders has offered for consideration, it would fall almost $25 trillion short of his proposed spending increases over the next decade – leaving a gap nearly equal to the total value of all goods and services produced by the U.S. economy in one year. Sanders wants voters to reward him for proposing a left-wing wishlist of spending increases and take him at his word that taxes on billionaires will pay for it, but the math just doesn’t add up. He has already embraced every tax increase on wealthy Americans imaginable and still comes up fourteen figures short. Will the middle class be willing to foot the bill in the form of dramatically higher taxes? Will young Americans accept the burden of financing “the revolution” with a doubling of their government debt? At a time when President Trump has plunged the nation into trillion-dollar deficits as far as the eye can see, the worst thing Democrats could do is let him off the hook by nominating a candidate who is promising them the same kind of voodoo economics on a far greater scale.   Ben Ritz I am the Director of the Progressive Policy Institute’s Center for Funding America’s Future, which works to promote a fiscally responsible public investment agenda that fosters robust and inclusive economic growth. We tackle issues of public finance in the United States and offer innovative proposals to strengthen the foundation of our economy and build shared prosperity. Before joining PPI, I staffed the Bipartisan Policy Center’s Commission on Retirement Security and Personal Savings, where I helped develop the commission’s tax and Social Security reforms. I also covered other budget issues at BPC including the debt limit, sequestration, and budget process reform. I previously served as Legislative Outreach Director for The Concord Coalition, where I coordinated activities with members of Congress and other organizations promoting fiscal responsibility. I earned my Master’s of Public Policy Analysis and a Graduate Certificate of Public Finance from American University, where I previously completed my undergraduate education

Varför är debatten i USA om sjukvårdssystemet så omfattande – och förvirrande?

I den amerikanska presidentvalsdebatten är frågan om hälso- och sjukvårdssystemets utformning en lika viktig fråga som det var för president Barack Obama när han drev sin kampanj 2008. Därefter följde en mycket komplicerad politisk process som ledde till det som brukar kallas Obamacare men som formellt heter Affordable Care Act. När Donald Trump valdes till president 2016 hade han haft ett dubbelt budskap i sin valkampanj: Obamacare skulle avskaffas men allt som var bra med reformen skulle bibehållas. Striden om Obamacare förlorade Trump men den komplexa ACA-lagstiftningen har förändrats – försämrats för många. Jag har i decennier i diskussioner om USA brukat framhålla att detta stora land samtidigt är ett rikt u-land och ett underutvecklat i-land. Det beror helt enkelt bara på vad man fokuserar på. En annan viktig utgångspunkt för varje diskussion om hur USA fungerar är att detta land inte har en lika stark centralmakt som t ex vi i Sverige är vana vid. Delstaterna har omfattande ansvar och möjligheter att reglera vilket t ex innebär både att försäljning av marijuana kan både vara tillåten i en del delstater men förbjuden i den federala lagstiftningen. Detta gör att sjuk- och hälsovårdssystemet är mycket komplicerat och därför mycket svårt att reformera. Till bilden hör också den stora misstänksamhet som många amerikaner har mot den federala makten – träsket i Washington DC (The Swamp som president Trump kallar den federala regeringsmakten). Med dessa utgångspunkter låt mig plocka fram några intressanta texter. Den första är från New York Times-kolumnisten Nicholas Kristof som i en krönika bl a skriver:

What caused the financial crisis? The Big Lie goes viral Democrats’ internecine battle over so-called Medicare for all is largely irrelevant, because the plan won’t get through Congress. What’s imperative is simply achieving universal medical and dental coverage, either by a single-payer system (like Britain’s) or a multipayer system (like Germany’s); both work fine. What matters is the universal part. In some ways, America’s health care is outstanding. Specialized anti-cancer treatments are saving lives. But over all our system has two fundamental flaws. First, outcomes are mediocre and inequitable. Rich Americans live 20 years longer than poor Americans, and low-income American men have approximately the longevity of men living in Sudan. Several American counties have a shorter life expectancy than Cambodia does. We’re bad at simple things, like vaccinating children. Rwanda has a higher share of girls vaccinated to prevent cervical cancer than the United States does. One study found that 21,000 American children’s lives would be saved each year if we only had the same mortality rates as the rest of the rich world. So two American kids die each hour because we have worse child survival rates than our peer countries. In my reporting, I’ve been struck by how much more widespread dental pain is in America than in other countries. Some 74 million Americans don’t have dental coverage, about four times as many as lack medical insurance. When their teeth rot, they suffer constant excruciating, debilitating pain that should be unfathomable in a country as rich as ours. Health care in the United States is “a moral morass,” a question of our “soul,” Uwe Reinhardt, a brilliant health economist at Princeton wrote in “Priced Out,” a book recently published posthumously. The second fundamental problem with our health care system is that it delivers these second-rate outcomes at enormous cost. “Prices for virtually any health care product or service in the United States tend to be at least twice as high as those for comparable products or services in other countries,” Reinhardt wrote. We spend an average of more than $10,000 per person on health care each year, more than twice what France, Canada and Japan each spend (even though the French, Canadians and Japanese all live longer). An excellent forthcoming book by Anne Case and Angus Deaton, “Deaths of Despair and the Future of Capitalism,” argues that this discourages hiring of low-income workers. The average cost of a family health insurance policy is $20,000, which is a reason for a company not to hire a junior employee and assume insurance costs. “Unless costs are somehow reined in, the long-run prospects for less-educated Americans remain bleak,” Deaton warns. Sadly, health professionals are part of the problem. Dentists have fought the licensing of dental therapists, who can perform simple procedures more cheaply. And doctor groups limit medical training and qualified foreign physicians to keep prices high; that’s why there are fewer doctors per capita in the United States than in peer countries. As Case and Deaton write: “The industry that is supposed to improve our health is undermining it.” Det finns alltså mycket starka intressen som av olika skäl inte vill se en reform. De som kommer ihåg Bill och Hillary Clintons försök att reformera systemet vet vad som hände. Annars står Wikipedia till tjänst här: En myt som många odlar är att ”non profit” skulle vara på något sätt överlägset vinstdriven verksamhet. Detsamma gäller givetvis offentligt drivna verksamheter. Vad som skiljer ”non profit” och offentlig verksamhet är att dessa i praktiken är svårare att granska och särskilt offentlig verksamhet skyddas av bl a medier med en ideologisk agenda. NYT publicerade nyligen en intressant artikel om ”icke vinstdrivande sjukhus” i USA. Där avslöjas hyckleriet bakom begreppet men tro inte att detta är ett undantag som bara gäller USA. Varje land som har denna modell kommer ofta att finna snarlika förhållanden. Jag förkortar NYT-artikeln eftersom den delvis är mycket teknisk och specifikt amerikansk:   Why Are Nonprofit Hospitals So Highly Profitable? These institutions receive tax exemptions for community benefits that often don’t really exist. By Danielle Ofri Dr. Ofri is a physician at Bellevue Hospital and a clinical professor of medicine at New York University Grossman School of Medicine. “So, how much money do you guys make if I do that test you’re ordering for me?” This is a question I hear frequently from my patients, and it’s often followed by some variant of, “I thought hospitals were supposed to be nonprofit.” Patients are understandably confused. They see hospitals consolidating and creating vast medical empires with sophisticated marketing campaigns and sleek digs that resemble luxury hotels. And then there was the headline-grabbing nugget from a Health Affairs study that seven of the 10 most profitable hospitals in America are nonprofit hospitals. Hospitals fall into three financial categories. Two are easy to understand: There are fully private hospitals that mostly function like any other business, responsible to shareholders and investors. And there are public hospitals, which are owned by state or local governments and have obligations to care for underserved populations. And then there are “private nonprofit” hospitals, which include more than half of our hospitals. Nearly all of the nation’s most prestigious hospitals are nonprofits. These are the medical meccas that come to mind when we think of the best of American medicine — Mayo Clinic, Cleveland Clinic, Johns Hopkins, Mass General. The nonprofit label comes from the fact that they are exempt from federal and local taxes in exchange for providing a certain amount of “community benefit.” Nonprofit hospitals have their origins in the charity hospitals of the early 1900s, but over the last century they’ve gradually shifted from that model. Now their explosive growth has many questioning how we define “nonprofit” and what sort of responsibility these hospitals have to the communities that provide this financial dispensation. It’s time to rethink the concept of nonprofit hospitals. Tax exemption is a gift provided by the community and should be treated as such. Hospitals’ community benefit should be defined more explicitly in terms of tangible medical benefits for local residents. It actually isn’t much of a surprise that nonprofit hospitals are often more profitable than for-profit hospitals. If a private business doesn’t have to pay taxes, its expenses will be lower. Additionally, because nonprofit hospitals are defined as charitable institutions, they can benefit from tax-free contributions from donors and tax-free bonds for capital projects, things that for-profit hospitals cannot take advantage of. The real question surrounding nonprofit hospitals is whether the benefits to the community equal what taxpayers donate to these hospitals in the form of tax-exempt status. On paper, the average value of community benefits for all nonprofits about equals the value of the tax exemption, but there is tremendous variation among individual hospitals, with many falling short. There is also intense disagreement about how those community benefits are calculated and whether they actually serve the community in question. (- - -) An analysis by Politico found that since the full Affordable Care Act coverage expansion, which brought millions more paying customers into the field, revenue in the top seven nonprofit hospitals (as ranked by U.S. News & World Report) increased by 15 percent, while charity care — the most tangible aspect of community benefit — decreased by 35 percent. (- - -) The average chief executive’s package at nonprofit hospitals is worth $3.5 million annually. (According to I.R.S. regulations, “No part of their net earnings is allowed to inure to the benefit of any private shareholder or individual.”) From 2005 to 2015, average chief executive compensation in nonprofit hospitals increased by 93 percent. Over that same period, pediatricians saw a 15 percent salary increase. Nurses got 3 percent. A number of communities that think nonprofit hospitals take more than they give back have started to sue. The University of Pittsburgh Medical Center fought off one lawsuit from the city’s mayor to revoke its tax-exempt status. Last year it faced another from the Pennsylvania attorney general, alleging that the medical center, valued at $20 billion, did not fulfill “its obligation as a public charity” (the lawsuit was dismissed). (- - -) The most profitable nonprofit hospitals tend to be part of huge health care systems. Consolidations are one of the driving forces behind the towering profits, because monopoly hospitals are known to charge more than nonmonopoly hospitals. Should these highly profitable institutions be exempt from the taxes that pay for local roads, police services, fire protection and 911 services? Should local residents have to pay for the garbage collection for institutions that can afford multimillion-dollar salaries for top executives? Tax exemption needs to be redefined. Low-impact projects such as community health fairs that function more like marketing shouldn’t be allowed as part of the calculation. Nor should things that primarily benefit the institution, like staff training. (- - -) As many policy scholars have noted, tax exemption is a blunt instrument. For struggling hospitals, particularly in communities with a shortage of health care resources, tax exemption can make sense. In medically saturated areas, where profits and executive compensation approach Wall Street levels, tax exemption should raise eyebrows. If society decides that tax exemption is a worthwhile means to improve health — and it certainly can be — then our regulations need to be far stricter and more explicitly tied to community health. As the United States continues to fall behind its international peers in terms of health outcomes in local communities, there is certainly no lack of opportunity.   Danielle Ofri, a physician at Bellevue Hospital and a clinical professor of medicine at New York University Grossman School of Medicine, is the author of “What Patients Say, What Doctors Hear” and the forthcoming “When We Do Harm: A Doctor Confronts Medical Error.” Kommer årets presidentval leda till någon större reform av amerikansk sjuk- och hälsovård? Svaret är med största sannolikhet detsamma som när paret Clinton gjorde sitt försök 1993.

Larsson läser nyhetsbrevet 24 feb

Vad orsakade finanskrisen i USA 2008/2009?

Detta har dykt upp som en debattfråga i den amerikanska presidentvalsdebatten. 2011 publicerade Washington Post denna artikel:

What caused the financial crisis? The Big Lie goes viral By Barry Ritholtz I have a fairly simple approach to investing: Start with data and objective evidence to determine the dominant elements driving the market action right now. Figure out what objective reality is beneath all of the noise. Use that information to try to make intelligent investing decisions. But then, I’m an investor focused on preserving capital and managing risk. I’m not out to win the next election or drive the debate. For those who are, facts and data matter much less than a narrative that supports their interests. One group has been especially vocal about shaping a new narrative of the credit crisis and economic collapse: those whose bad judgment and failed philosophy helped cause the crisis. Rather than admit the error of their ways — Repent! — these people are engaged in an active campaign to rewrite history. They are not, of course, exonerated in doing so. And beyond that, they damage the process of repairing what was broken. They muddy the waters when it comes to holding guilty parties responsible. They prevent measures from being put into place to prevent another crisis. Here is the surprising takeaway: They are winning. Thanks to the endless repetition of the Big Lie. A Big Lie is so colossal that no one would believe that someone could have the impudence to distort the truth so infamously. There are many examples: Claims that Earth is not warming, or that evolution is not the best thesis we have for how humans developed. Those opposed to stimulus spending have gone so far as to claim that the infrastructure of the United States is just fine, Grade A (not D, as the we discussed last month), and needs little repair. Wall Street has its own version: Its Big Lie is that banks and investment houses are merely victims of the crash. You see, the entire boom and bust was caused by misguided government policies. It was not irresponsible lending or derivative or excess leverage or misguided compensation packages, but rather long-standing housing policies that were at fault. Indeed, the arguments these folks make fail to withstand even casual scrutiny. But that has not stopped people who should know better from repeating them. The Big Lie made a surprise appearance Tuesday when New York Mayor Michael Bloomberg, responding to a question about Occupy Wall Street, stunned observers by exonerating Wall Street: “It was not the banks that created the mortgage crisis. It was, plain and simple, Congress who forced everybody to go and give mortgages to people who were on the cusp.” What made his comments so stunning is that he built Bloomberg Data Services on the notion that data are what matter most to investors. The terminals are found on nearly 400,000 trading desks around the world, at a cost of $1,500 a month. (Do the math — that’s over half a billion dollars a month.) Perhaps the fact that Wall Street was the source of his vast wealth biased him. But the key principle of the business that made the mayor a billionaire is that fund managers, economists, researchers and traders should ignore the squishy narrative and, instead, focus on facts. Yet he ignored his own principles to repeat statements he should have known were false. Why are people trying to rewrite the history of the crisis? Some are simply trying to save face. Interest groups who advocate for deregulation of the finance sector would prefer that deregulation not receive any blame for the crisis. Some stand to profit from the status quo: Banks present a systemic risk to the economy, and reducing that risk by lowering their leverage and increasing capital requirements also lowers profitability. Others are hired guns, doing the bidding of bosses on Wall Street. They all suffer cognitive dissonance — the intellectual crisis that occurs when a failed belief system or philosophy is confronted with proof of its implausibility. And what about those facts? To be clear, no single issue was the cause. Our economy is a complex and intricate system. What caused the crisis? Look: ●Fed Chair Alan Greenspan dropped rates to 1 percent — levels not seen for half a century — and kept them there for an unprecedentedly long period. This caused a spiral in anything priced in dollars (i.e., oil, gold) or credit (i.e., housing) or liquidity driven (i.e., stocks). ●Low rates meant asset managers could no longer get decent yields from municipal bonds or Treasurys. Instead, they turned to high-yield mortgage-backed securities. Nearly all of them failed to do adequate due diligence before buying them, did not understand these instruments or the risk involved. They violated one of the most important rules of investing: Know what you own. ●Fund managers made this error because they relied on the credit ratings agencies — Moody’s, S&P and Fitch. They had placed an AAA rating on these junk securities, claiming they were as safe as U.S. Treasurys. • Derivatives had become a uniquely unregulated financial instrument. They are exempt from all oversight, counter-party disclosure, exchange listing requirements, state insurance supervision and, most important, reserve requirements. This allowed AIG to write $3 trillion in derivatives while reserving precisely zero dollars against future claims. • The Securities and Exchange Commission changed the leverage rules for just five Wall Street banks in 2004. The “Bear Stearns exemption” replaced the 1977 net capitalization rule’s 12-to-1 leverage limit. In its place, it allowed unlimited leverage for Goldman Sachs, Morgan Stanley, Merrill Lynch, Lehman Brothers and Bear Stearns. These banks ramped leverage to 20-, 30-, even 40-to-1. Extreme leverage leaves very little room for error. •Wall Street’s compensation system was skewed toward short-term performance. It gives traders lots of upside and none of the downside. This creates incentives to take excessive risks. • The demand for higher-yielding paper led Wall Street to begin bundling mortgages. The highest yielding were subprime mortgages. This market was dominated by non-bank originators exempt from most regulations. The Fed could have supervised them, but Greenspan did not. • These mortgage originators’ lend-to-sell-to-securitizers model had them holding mortgages for a very short period. This allowed them to get creative with underwriting standards, abdicating traditional lending metrics such as income, credit rating, debt-service history and loan-to-value. • “Innovative” mortgage products were developed to reach more subprime borrowers. These include 2/28 adjustable-rate mortgages, interest-only loans, piggy-bank mortgages (simultaneous underlying mortgage and home-equity lines) and the notorious negative amortization loans (borrower’s indebtedness goes up each month). These mortgages defaulted in vastly disproportionate numbers to traditional 30-year fixed mortgages. ●To keep up with these newfangled originators, traditional banks developed automated underwriting systems. The software was gamed by employees paid on loan volume, not quality. ●Glass-Steagall legislation, which kept Wall Street and Main Street banks walled off from each other, was repealed in 1998. This allowed FDIC-insured banks, whose deposits were guaranteed by the government, to engage in highly risky business. It also allowed the banks to bulk up, becoming bigger, more complex and unwieldy. ●Many states had anti-predatory lending laws on their books (along with lower defaults and foreclosure rates). In 2004, the Office of the Comptroller of the Currency federally preempted state laws regulating mortgage credit and national banks. Following this change, national lenders sold increasingly risky loan products in those states. Shortly after, their default and foreclosure rates skyrocketed. Bloomberg was partially correct: Congress did radically deregulate the financial sector, doing away with many of the protections that had worked for decades. Congress allowed Wall Street to self-regulate, and the Fed the turned a blind eye to bank abuses. The previous Big Lie — the discredited belief that free markets require no adult supervision — is the reason people have created a new false narrative. Now it’s time for the Big Truth.   På tisdagen skrev Paul Krugmnan detta i New York Times: Have Zombies Eaten Bloomberg’s and Buttigieg’s Brains? Beware the Democrats of the living dead.       MADRID — I’m in Spain right now, talking about zombie ideas — ideas that should have been killed by evidence, but just keep lurching along. In the modern United States, most important zombie ideas are on the right, kept undead by big money from billionaires who have a financial interest in getting people to believe things that aren’t true. But sometimes zombie ideas also manage to eat centrists’ brains. Sure enough, some of the most destructive zombies of the past dozen years have shambled their way into the Democratic primary fight, where a couple of centrists are repeating ideas that were thoroughly debunked years ago. And as it happens, the experience of Europe, and Spain in particular, provides some of the bullets we should be using to shoot these particular zombies in the head. So let’s start with the origins of the 2008 financial crisis, a topic that remains relevant if we want to avoid repeating past mistakes. Although few saw 2008 coming, in retrospect it was a classic banking panic, the type of thing that happened frequently before the 1930s. First, lenders got caught up in a gigantic housing bubble; then, when the bubble burst, much of the financial system just froze up. What made this panic possible, after two generations of relative financial calm? The answer, clearly, was the erosion of effective financial regulation over the previous few decades. But right-wingers refused to accept the obvious. Instead, they pushed an alternative narrative in which liberals somehow caused the crisis by forcing poor innocent bankers to lend money to people of color (they weren’t usually that explicit, but that was the clear message). This narrative was so nakedly self-serving that it’s hard to believe that anyone took it seriously; but some influential people bought it. And among those people was Michael Bloomberg. At this point the evidence against the liberals-did-it story is overwhelming. The surge in bad loans came neither from government-sponsored agencies nor from regulated banks, but from unregulated mortgage originators. The fallout was so severe because investors believed, wrongly, that fancy financial instruments protected them from risk. And, crucially, the housing bubble was an international phenomenon: Spain had a bigger bubble than we did, followed by a worse slump. Did U.S. liberals force Spanish banks to make bad loans? But zombie ideas can’t be killed by evidence. Perpetrators of the liberals-did-it lie are still out there, still getting space to spread their disinformation in mainstream media. Elizabeth Warren argues that Bloomberg’s embrace of a false right-wing narrative about the financial crisis should disqualify him for the Democratic nomination. But I’d be willing to cut him some slack if he’d admit that he was taken in by right-wing disinformation. If he isn’t willing to make that admission, she’s right. At the same time that Bloomberg is being called out on his housing bubble zombie, Pete Buttigieg is facing justified criticism for buying into another zombie idea — the obsession with government debt. That obsession did much to hobble recovery from the financial crisis. To be fair, deficit panic wasn’t as naked a scam as the claim that do-gooders caused the financial crisis, although some of the loudest voices decrying the evils of deficits were obvious phonies. What happened instead was that many important people imagined that inveighing against the dangers of debt made them sound serious, because that’s what all the other serious people were doing. At this point, however, the debt obsession has been thoroughly debunked by both economic research and experience. We live in a world awash in private savings looking for someplace to go, with investors willing to lend money to governments at incredibly low interest rates. It’s actually irresponsible not to put this money to work investing in the future, both by building physical infrastructure and through programs that help children develop their potential. Now, the Trump administration is doing it wrong — borrowing large sums, but squandering the money on tax cuts for corporations and the wealthy. But even bad deficit spending boosts the economy to some extent, and it is the reason America is still growing reasonably fast while Europe, still in the grip of austerity ideology, is stagnating. Look: It’s easy to make the political case that Democrats should nominate a centrist, rather than someone from the party’s left wing. Candidates who are perceived as ideologically extreme usually pay an electoral penalty; this is especially true if, like Bernie Sanders, they actually pose as more radical than they really are. But a key part of centrism’s appeal is the belief that centrists are realists, who understand how the world works. It’s much harder to make the case for centrists who repeat manifestly false claims, especially if those claims were essentially right-wing propaganda. As I said, you can make a good case for the proposition that Democrats should, in the end, nominate a centrist. But a centrist whose brain has been eaten by zombie ideas? Not so much. På Twitter länkade AEI:s James Pethokoukis till en Federal Reserve-rapport med denna slutsats: Conclusion The CRA provides an incentive structure that could plausibly have motivated banks to originate or purchase loans they would have otherwise considered too risky. However, empirical research indicates that CRA-related loans were a small fraction of the subprime market during the mortgage boom. The literature estimating the effect of the CRA finds small increases in originations--if any at all--and effects on delinquencies that are small or even negative. While we do not have a good estimate of the net costs or benefits of the act, the current best evidence suggests that the CRA was not a significant contributor to the financial crisis.   New York Times publicerade i helgen en krönika med motsatt uppfattning: Bloomberg Is Right About the 2008 Financial Crash