Just a quick note to repeat something I said a few days ago: don't pay any more attention to President Trump's budget than you do to his tweets. It's not meant as a serious proposal. It's just a way for him to send a message to his fans that he hates the EPA and the State Department and loves vets and the Pentagon.

The real action is in Congress. They won't pay any attention to Trump's budget, and he knows it.

I got into a conversation today about my contention from last night that national health care systems are better at controlling costs than the private sector. We all know that US health care costs are the highest in the world, but are they growing faster than the rest of the world? And how about different health care sectors in the US?

I haven't looked at this in years, so I decided to dig up the data and see. First off, here is growth in health care spending among a representative group of rich countries during recent decades:

This data is a little tricky because some countries changed the way they calculated health care spending in the past few years. I didn't use any of them, and it's possible that one or two might have grown faster than us. But the US is certainly in the top two or three, if not at the very top.

One problem with international comparisons of health care spending is that some countries are aging faster than others, and it stands to reason that countries with older populations will spend more than those with younger populations.  Here's a look at spending growth during the period 1970-2002 that controls for aging:

During these earlier decades there are several countries with higher growth rates than the US. I'm a little surprised there weren't more, given that postwar European countries were still catching up to the US during the first half of this period.

Finally, here's a comparison of growth rates just within the US:

The data here tells a pretty consistent story. Despite starting at a higher base, the US is in the top two or three in the world—maybe at the very top—for health care spending growth over the past half century or so. Within the US, private health care spending growth has outpaced both Medicare and Medicaid. Both internationally and in the US, government-run health care programs appear to be better at controlling costs than the private sector.

Of course, there are other sources of data and other ways of doing comparisons, so don't take this as the last word. If I come across any other studies that seem to have interesting ways of slicing the data, I'll follow up.

Over at The Corner, Alexandra DeSanctis is unhappy that Dawn Laguens, Planned Parenthood’s executive vice president, refuses to say whether she considers a fetus to be a human being:

She avoided the questions because the abortion industry is built on the lie that the unborn child isn’t a living human, and if they acknowledge that this claim is fiction, their entire system will collapse.

....People on either side of the abortion debate can disagree on what rights that human being has. We can argue over the relevance of fetal viability, and we can differ on whether a woman’s right to “bodily autonomy” is more important than her child’s right to life. But these two fundamentally contradictory positions about the child’s humanity cannot both be correct; either each unborn child is a living human being, or it isn’t.....Until pro-abortion leaders such as Laguens are willing to admit to this humanity, it will remain impossible to have an honest disagreement about the competing rights at stake in this debate.

Well, I'm not on TV and nobody cares what I think, so I can say what Laguens wouldn't: a fetus is not a living human in any sensible way. I can't prove this. It's like asking whether a beanbag is a chair. It's an opinion, not a fact.

As for why Laguens wouldn't answer, it's not because she's dishonest. Certainly no more so than pro-lifers who refuse to say whether women who get abortions should be thrown in jail for murder. In both cases there are arguments to be made either way, but none of them really matter. The real reason for reticence is that neither side wants to make scary-sounding statements that might drive moderates away from their side.

In any case, it's not as if this is a bewildering mystery. "Life," in anything other than a technical biological sense, is a matter of human judgment.1 We decide when it starts and when it ends. Both of these are gray areas, but they're gray areas where we set up semi-arbitrary rules: 20 weeks or viability or third trimester or EEG flatline or lack of retinal response or something similar. What other choice do we have? If you're going to have the government involved, you have to create a reasonably bright-line rule for people to follow.

Speaking personally, I offer up this hypothetical. On your left you have a baby. On your right you have a vial with an embryo in it. At the end of 60 seconds, one of them will be randomly crushed unless you make a choice of which to save. So which is it?

I don't think anyone, pro-life or otherwise, would hesitate. You'd save the baby even if the vial had two embryos in it. Or a hundred. Or a thousand. There's simply no visceral sense in which we genuinely feel that a fertilized egg is a human being. You can make an intellectual argument for it, but not one that will survive contact with the real world.

1Needless to say, none of this applies to religious arguments. Dogma is not open to debate with nonbelievers.

Lunchtime Photo

Here's a long exposure of a freeway at night. (It's the, I say the, 405 taken from the Yale overpass.) This picture is practically a cliche, and for various reasons I couldn't even produce a very good one. But I was eager to try it anyway just because I'm so thrilled to once again have a camera that provides enough manual control to do something like this. Technically, my old Canon had most of the manual controls I needed—though not all—but in practice they were all but impossible to use.

One feature the Lumix has is built-in neutral density filters. I had never heard of such a thing before, but it's surprisingly handy. This picture, for example, was taken with the lowest ISO setting and a 64x neutral density setting. It was the only way to get the long shutter time that I needed.

I've been warning for a while that the Republican health care bill could end up destroying the individual market completely. It turns out, however, that the Congressional Budget Office isn't all that concerned. Jordan Weissmann explains:

There are basically two reasons why: First, the Republican plan would nudge a lot of old, costly customers off insurers' rolls. Second, it would fork over a lot of government money to make sure carriers don't lose too much on the extremely sick.

Trumpcare is designed to lower the cost of insurance for young adults while increasing it for older Americans....As a result, the CBO essentially thinks a lot of 60-year-olds will get priced out and replaced by younger customers lured by cheap coverage. The result is a smaller, healthier, more profitable customer base. The Republican proposal would also give states billions of dollars each year for “stabilization funds”—which they could use to compensate insurers for the cost of covering particularly ill customers.

....It's not an absurd theory of the case. But it is a depressing one. Congress's official forecaster thinks that Trumpcare would create a steady market where insurers are happy to sell coverage by making it unaffordable for the older Americans who need help most, while supplementing the system with government cash.

Well...maybe. But Obamacare had stabilization funds too, so that's not really a difference. The big differences boil down to:

  • On the plus side: old people get priced out of the market.
  • On the negative side: old sick people will do whatever they have to in order to remain insured. Basically, this means they'll end up with a lot of financial stress, while old healthy people will skip health insurance and end up with a lot of medical stress. That's quite the win-win for Republicans, isn't it?

So I'm still skeptical. The Republican plan creates a health care market that forces insurers to cover everyone at the same price—even the very sick—but doesn't provide much incentive for healthy people to get coverage. Lowering premiums by a few hundred dollars for young people won't prod them to buy insurance if an $800 penalty didn't do the job.

It's really hard to see how this stays stable. CBO may think that a lot of us oldsters will get priced out of the market, but speaking as an oldster with a $100,000 annual medical bill, there's literally nothing that would stop me from buying insurance. If I were in the individual market and my premium skyrocketed from $5,000 to $15,000, I'd still find a way to stay covered. Even at the higher price it's $85,000 cheaper than going without, and the other alternative is to die. That's a pretty big incentive.

Obviously there are folks at the margins for whom the incentives are different. But if I were a health insurance company, I'd be very, very skeptical about the continued viability of the individual market under the Republican plan.

The latest joke around the Drum household is a question: "Is there any evidence yet?" Marian asks whenever she comes home from an errand. She's waiting diligently for someone to produce evidence that Trump Tower was bugged by President Obama. It looks like she's going to have to wait a long time:

“I don’t think there was an actual tap of Trump Tower,” Rep. Devin Nunes (R., Calif.) told reporters on Capitol Hill Wednesday. “You have to decide, Are you going to take the tweets literally, and if you are, then clearly the president is wrong.”

....By Monday, the White House had walked back Mr. Trump’s allegation. White House spokesman Sean Spicer said that Mr. Trump didn’t believe that Mr. Obama had personally tapped his phone, but instead was talking broadly about surveillance.

“They’ve been all over the map,” said Rep. Adam Schiff of California, the ranking Democrat on the panel. “The reality is, I don’t think they have the foggiest idea of what was behind the president’s claim except maybe something he watched on TV. And I think the rest is designed to downplay, minimize or obfuscate the fact that the president said something that was patently untrue.

Schiff is obviously right. Trump just swatted out something he saw at Breitbart as a way of grabbing a news cycle, and after that he sat back to watch the chaos unfold. On his other Twitter account (the one just for close friends that you and I never get to see) he was probably tweeting something like this:

This is annoying enough even for liberal types, but I wonder how long it's going to be until Republicans start to rebel at this idiocy? Democrats get to just sit back and throw brickbats, after all. It's Republicans who have to waste their time pretending to investigate all this nonsense.

Charles Cooke was not impressed with Rachel Maddow's presentation last night of President Trump's 2005 tax return:

For a moment, it seemed that Rachel Maddow was in possession of a genuine scoop. And then, all of a sudden, it didn’t....Thanks to MSNBC, the suggestion that Trump has “paid no taxes in 18 years” has now been definitively proven to be false. Moreover, Trump seems to have paid a higher tax rate in 2005 than did most political figures, and to have enjoyed a sizeable income to boot. Whether the report was cherry-picked we cannot possibly know. But on the basis of what was presented last night, the president looks both pretty accomplished and perfectly law-abiding. What, one wonders, did Maddow think she was achieving?

David Cay Johnston says he received the tax return in the mail, and he was surprisingly aggressive about suggesting that it might well have come from Donald Trump himself. "It's just a possibility," he said, but it was the very first thing he mentioned on the show.

At first I dismissed it. But then I started to wonder. Maybe 2005 was a year when Trump had both high income and high taxes. If so, anonymously releasing just one page from just that year could be an outrageous but savvy PR move—the kind of thing that Trump is very good at. Besides, there are very few people with access to Trump's taxes, and who would have an incentive to release just this single page? Not someone who's trying to blow a whistle on the guy. It almost had to come from somebody working in Trump's interests.

I dunno. We're all wearing tinfoil hats these days, aren't we?

California has made a lot of noise about being the front line of resistance to President Trump, but mostly it's just blather. This week, however, it's finally getting very real:

President Trump will direct the Environmental Protection Agency on Wednesday to shelve aggressive vehicle fuel economy targets that are a pillar of climate action and anti-pollution efforts in California and nationwide, according to a senior administration official.

...Targeting them puts the White House on a path of direct and costly confrontation with California....Under the Clean Air Act, the state has the authority to impose emissions standards stronger than those set by the federal government, and a dozen other states have embraced the California rules, as the act allows. About 40% of the vehicles sold in America are subject to the rules California sets. Automakers have said repeatedly that it is untenable to manufacture separate fleets of vehicles to meet different standards.

The state had refrained from charting its own course on mileage goals as part of a compromise with auto companies and the EPA early in the Obama administration. That agreement will start to unravel Wednesday with Trump’s action, which will direct the EPA to re-open the rule-making for the mileage standards. If, as environmental and auto lobbyists anticipate, the administration ultimately decides to weaken the rules, California will almost certainly move to invoke its federal waiver.

There are other disputes on the horizon between California and the Trump administration, but this is the first big one. From the very beginning, California has had an exemption under the Clean Air Act to set its own standards, and these standards have often led the nation. The state is pretty jealous of this prerogative, and it will fight to prevent any change to the law that weakens it. However, unless the Trump administration succeeds in doing that, it's likely that California will adopt the current EPA standards and car companies will follow along even if Trump trashes the federal rules. It's either that or build two separate fleets of cars, one for California and its fellow green states, and one for everyone else.

David Frum is a conservative, but he grew up in Canada and lacks an American conservative's instinctive revulsion toward national health care. Today he writes that maybe American conservatives should put aside their revulsion too. After all, the debacle over the Republican health care plan suggests that the public is unwilling to see health coverage withdrawn from millions of people. Democrats seem to have finally won the battle over ensuring health coverage for all, and that means Republicans can't control costs by simply denying health care to anyone who can't afford it. They have to figure out other ways to bring down costs:

Republicans have had too many competing goals in health-care reform. They have wanted to lower costs (to free fiscal room for tax cuts and military spending), but also to avoid tangling with entrenched health-care interests....What that money has bought is a huge and costly health sector....“Patient-centered medicine” sought to transform the user of health-care services as the system’s decisive cost-controller. Confronted with the full cost of medicine, the patient would consume care more prudently—or forgo it altogether.

That hope is listing badly. When and if it finally sinks, Republicans may notice something else. The other advanced countries with universal coverage manage to buy significantly better outcomes at the expense of 11 or 12 percent of GDP instead of America’s 16 percent. That extra increment of GDP could pay for a lot of military spending and a lot of tax cuts. Once politics has eliminated coverage reduction as a means of forcing economy, other possibilities open before a center-right party—and indeed have opened for center-right parties across the rest of the English-speaking world. Perversely, the effort to keep government out of health care has empowered health care to consume more and more government dollars. Where government has been deployed more effectively than in the United States, health care has consumed less.

I dissent in part and agree in part. For starters, it's true that the United States has by far the biggest health care bill of any country in the world:

However, our costs are high because we pay more for everything: doctors, nurses, pharmaceuticals, hospital stays, etc. Politically, it's impossible to adopt a system that would suddenly cut everyone's pay by a third. If America were to adopt national health care, our per capita costs would almost certainly start out right where they are now: far higher than any other country in the world.

In the long run, however, Frum is right. It's ironic, but it turns out that central governments are a lot better at keeping a lid on health care costs than the private sector. The reason is taxes. National health care is paid for out of tax revenue, and the public pressure to keep taxes low is so strong that it universally translates into strong government pressure to keep health care costs low. By contrast, the private sector is so splintered that no corporation has the leverage to demand significantly lower costs. Besides, if health care costs go up, corporations can make up for it by keeping cash salaries low. This is part of the reason that median incomes have grown so slowly over the past 15 years. Corporations simply don't care enough about high health care costs to really do anything about it.

Over the course of a few decades, then, our costs would probably converge on the rest of the world if we adopted universal health care. Contra Frum, this wouldn't open any headroom for lower taxes or higher military spending—government spending would still go up even if overall health care spending slowed down—but it would make the country a better, safer, more efficient place. What's not to like?

Tonight's exciting news: David Cay Johnston somehow got hold of the first page of Donald Trump's 2005 federal tax return. He released it on the Rachel Maddow show tonight:

Here are Trump's major sources of income:

  • Interest income: $9 million
  • Business income: $42 million
  • Capital gains: $32 million
  • Rental income: $67 million
  • Miscellaneous: $2 million
  • Total: $152 million

After a writeoff of $103 million, his adjusted gross income clocked in at $49 million. His taxable income came in at $31 million and his tax bill for this was $5 million. That's a tax rate of about 3 percent. Ka-ching!

Sadly for Trump, the Alternative Minimum Tax kicked in, which meant he had to pay $38 million in taxes. I guess it's no wonder that Trump doesn't think very highly of the Alternative Minimum Tax.

Without more pages from his tax return, there's a limit to what we can learn from this. Trump's income of $150 million fits fairly well with the estimates I've seen. But I will add one thing.

Trump's total investment income was $108 million, and Trump claims to be worth $5 billion or so, depending on what day you ask him. That means he earned a return on his assets of about 2 percent. In 2005! During the housing bubble! I'm no tax expert, and maybe he had hundreds of millions in capital gains that he didn't realize that year. Who needs more than $150 million in income, after all? It still seems pretty low, though, and if Trump really did earn a return of only 2 percent he is, by long odds, the most incompetent billionaire in the country.

Alternatively, of course, Trump is actually worth about $1-2 billion and he earned something like a 5-10 percent return. Take your pick.