This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
In Obamacare, online insurance brokers see potential windfall
By Sarah Kliff
The Washington Post, April 8, 2013
Online insurance brokers see a potential windfall when the federal government doles out billions in subsidies to buy help Americans buy health insurance. And they are asking state governments to help them score it.
The online brokers want millions of new insurance customers to be able to use those subsidies to buy health coverage through their Web sites, rather than shop exclusively on the new exchanges being set up by states and the federal government.
“We have the expertise and already generate a tremendous amount of volume of sales,” says Gary Lauer, CEO of EHealth, the country’s largest online insurance broker. “The exchanges are spending a lot of money to enroll people, which is all fine, but we could do the same thing at no charge to the federal government.”
EHealth CEO Lauer does acknowledge that the site has financial motivations when it sells a health insurance plan. But he also contends that the federal regulations are strong enough to ensure that consumers get the same experience, no matter where they purchase coverage.
“We’re a profit-making company,” he said. “Our revenue source is the commission paid to brokers. It’s not an additional charge, it’s built into the premium, the same premium on the exchange. The only difference is the carrier will pay us a commission.”
As Gary Lauer, CEO of EHealth states, “We’re a profit-making company.” Yes, they are a company that draws dollars (over 150 million of them in 2012) away from our heath care funds, and yet provides absolutely no services or products directly related to actual health care.
It is particularly irritating when he states that his firm can provide health insurance brokerage services for the exchanges being established under the Affordable Care Act “at no charge to the federal government,” because the charges are “built into the premium.”
Who pays those charges? The insurance companies certainly do not deduct these expenses directly from their profits. They weren’t born yesterday. As Lauer states, the charges are built into the premiums. Thus they are paid jointly by plan enrollees and by the federal government in the form of premium subsidies.
The expenses of these brokerages or of the state insurance exchanges wouldn’t even exist if we had one universal program instead of a multitude of private insurers, which in themselves generate tremendous administrative waste while imposing greater administrative burdens and costs on the actual providers of health care.
By insurance industry standards, maybe Gary Lauer’s compensation is modest ($1.67 million in 2012), but if he is providing us nothing of value, then any amount is too much.
Haven’t we had enough? Isn’t it time for an improved Medicare that covers everyone? Then Gary Lauer would have to get a real job.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Health Care Cost Containment Strategies Used In Four Other High-Income Countries Hold Lessons For The United States
By Mark Stabile, Sarah Thomson, Sara Allin, Seán Boyle, Reinhard Busse, Karine Chevreul, Greg Marchildon and Elias Mossialos
Health Affairs, April 2013
The past decade has been one of relative affluence for the countries we reviewed (Canada, England, France, and Germany), particularly when compared to the budget scenarios they face over the next few years. It may not be surprising, therefore, that health care costs grew relatively quickly during 2000–10 and that there is limited evidence of the success of recent cost containment strategies.
That said, the four countries discussed here continue to make use of public budgeting and price-setting mechanisms to contain costs in the health care sector, as they have in previous decades. The greater use of public budgeting and price-setting mechanisms, along with the much higher public shares of health care financing in these countries, remain the greatest contrasts between them and the United States.
Our review also revealed that in 2000–10 the four European countries moved away from strategies that simply shifted costs to households through across-the-board budget cuts, rationing of services, and increases in user charges. We found a growing focus on the cost-benefit ratio through the greater use of health technology assessment, activity-based funding with centrally set prices, and value-based approaches to paying for drugs. Although these policies may not drive down costs, they are likely to produce more efficient use of health care resources in the future.
Our review suggests that the four countries have had some success in using a variety of public policy tools and that the United States may wish to emulate their policies to reduce the growth rate in drug spending. The policies include relatively simple levers such as large-scale negotiations with pharmaceutical manufacturers and sellers as well as budget caps. Our review also suggests that the United States may wish to use more challenging tools, such as cost-effectiveness analysis that sets prices for new technologies based on the technologies’ relative value and value-based user charges.
It seems unlikely, however, that the US system will move toward the types of volume and price controls used in the countries examined here. Thus, although the United States is also moving toward policies aimed at changing the cost-benefit ratio and promoting economic efficiency, it is likely that the large gap in health care spending between the four countries in our study and the United States will remain.
Cost containment strategies in the four nations studied – Canada, England, France, and Germany – depend largely on the government, especially through public budgeting and price setting. The authors point out that it is unlikely that the United States will move toward such policies, thus the large gap between our health care spending and that of these four countries will remain.
Also of note is the fact that other more recent cost containment innovations in these four countries have shown only limited evidence of success. It is still the government engagement that perpetuates their success.
Of great significance for the United States is the fact that these nations have moved away from strategies that simply shifted costs to households. Our emphasis on consumer-directed approaches that increase cost sharing through high deductibles, coinsurance, more restrictive provider networks, and our government efforts to reduce “entitlement” spending, are all moving in the wrong direction. Costs can be controlled without impairing access by erecting financial barriers.
The lesson is simple. We need beneficial public policies, designed to serve patients, to displace private sector policies (enabled by government complicity) that currently prioritize the interests of business stakeholders over those of patients.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Fraud in the Workplace? Evidence from a Dependent Verification Program
By Michael Geruso, Harvey S. Rosen
The National Bureau of Economic Research (NBER), April 2013
Many employers have implemented dependent verification (DV) programs, which aim to reduce employee benefits costs by ensuring that ineligible persons are not enrolled in their health plan as dependents. We evaluate a DV program using a panel of health plan enrollment data from a large, single-site employer. We find that dependents were 2.7 percentage points less likely to be reenrolled in the year that DV was introduced, indicating that this fraction of dependents was ineligibly enrolled prior to the program’s introduction. We show that these dependents were actually ineligible, rather than merely discouraged from re-enrollment by compliance costs.
Help Prevent Health Plan Enrollment Fraud
Blue Cross Blue Shield of Hawaii
Hawaii Medical Service Association
Health plan enrollment fraud occurs when a person or company intentionally misrepresents facts to improperly receive health care products and services. This includes adding a person who is not eligible for health plan coverage as a dependent on a health plan.
It is a criminal offense under state and federal laws to fraudulently enroll someone onto a health plan. Enrolling ineligible dependents can lead to increased health care costs for employers. Penalties include fines, immediate loss of health plan coverage, or imprisonment.
Dependent Eligibility Verification Project
The initial phase of the DEV project includes an amnesty period that runs from now through June 30, 2013. If you have one or more dependents on your health plan, you will receive a letter with further details on the DEV project, including dependent eligibility criteria and an Amnesty Disenrollment Document. During the amnesty period, we encourage you to carefully review the definition on an eligible dependent and identify on the Amnesty Disenrollment Document all ineligible dependents who should be removed from your health plan.
There are many circumstances in which a de facto dependent is not technically a dependent when it comes to enrollment in a health plan. Enrolling such individuals is considered a criminal offense. Many employers have instituted dependent verification programs in order to ferret out this fraud. Is this really what we want to be doing?
It seems ironic that at a time in our history when theoretically we are attempting to enroll as many individuals as possible in health insurance programs, we are pushing a program designed to disenroll individuals currently covered as dependents when they are not technically entitled to such coverage.
We are expanding yet more administrative excesses which are resulting in the opposite of our policy goals. That is, we are increasing the numbers of uninsured through application of these dependent verification programs.
Wouldn’t it be far simpler to have a system that automatically covers everyone, regardless of dependency status or any other criteria? Instead of advancing policies that make health care coverage a crime, shouldn’t we make health care a right for all?
TRICARE Multiyear Surveys Indicate Problems with Access to Care for Nonenrolled Beneficiaries
Government Accountability Office (GAO), April 2013
In fiscal year 2012, the Department of Defense (DOD) offered health care services, including mental health care services, to about 9.7 million eligible beneficiaries in the United States and abroad through TRICARE, DOD’s regionally structured health care program.
The number and type of civilian providers available to serve TRICARE beneficiaries can vary depending on a beneficiary’s location and choice of coverage among TRICARE’s three basic plans—TRICARE Prime, TRICARE Standard, and TRICARE Extra. We use the term “nonenrolled beneficiaries” for beneficiaries who are not enrolled in TRICARE Prime and who use the TRICARE Standard or Extra options, or TRICARE Reserve Select (TRS).
Nearly one in three nonenrolled beneficiaries experienced problems accessing care, and they rated their satisfaction with care generally lower than Medicare fee-for-service beneficiaries.
Nearly one in three nonenrolled beneficiaries experienced problems finding civilian providers who would accept TRICARE. Those in PSAs (Prime Service Areas with TRICARE Provider networks) experience more problems finding primary and specialty care than those in non-PSAs.
Civilian providers’ acceptance of new TRICARE patients has decreased over time. Mental health providers report lower awareness and acceptance than other provider types.
TRICARE is a health care service program for active duty military, their dependents, and military retirees – a program that is particularly important for those who cannot use military health facilities nor the VA system. The results of this survey should make us ashamed of how we treat the military and their dependents.
Straight to the point, if we had a single, comprehensive health care system that served everyone and included all health care professionals and institutions, this report would not have been necessary. We really do need an improved Medicare that includes everyone.
Intermountain Healthcare pays $25.5M to settle violations of federal law
By David Wells
Fox 13 News, Salt Lake City, April 3, 2013
Utah’s largest health system self-disclosed violations of federal health care laws and agreed to pay the United States $25.5 million to settle its claims, according to a statement from the United States Department of Justice.
“These issues were primarily technical in nature and involved things such as lack of proper paperwork involving leases of physician offices and service agreements,” said a statement on Intermountain Healthcare’s website.
The DOJ statement said Intermountain Healthcare admitted to violating the Stark Statute by employment agreements under which the physicians received bonuses that improperly took into account the value of some of their patient referrals; and office leases and compensation arrangements between Intermountain and referring physicians that violated other requirements of the Stark Statute. These issues were disclosed to the government by Intermountain Healthcare.
“People should expect that hospitals and doctors care more for their patients than their bottom line profits,” said Gerald Roy, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services region including Utah. “So I applaud Intermountain for recognizing their liability and coming forward to self-disclose these violations. We will vigilantly protect taxpayer-funded health programs against Stark violations through tight coordination with our partners at the Department of Justice.”
This link includes statements from Intermountain Healthcare and from the United States Department of Justice:
The Settlement Agreement:
Most of us have grown weary of the scandalous behavior of our corporate health care system, and so we are no longer surprised by the by headlines notifying us of multimillion dollar penalties assessed against these nefarious entities. In fact we say, “Good riddance.” However, in this instance involving Intermountain Healthcare, it is almost refreshing to see that the story behind the headlines can renew our faith in our health care system.
Intermountain Healthcare is a large, non-profit, highly ethical, integrated health care system in Utah. It has an excellent reputation for providing efficient, high quality care, and for being innovators in improving the delivery of health care. That is why it was surprising to see their name in the headlines reporting yet another scandal.
But a scandal it isn’t. Intermountain Healthcare violated provisions of the Stark statute designed to prevent referral arrangements that could provide perverse incentives for personal profit in health care. The Intermountain violations were technical, involving a flawed formula for physician compensation, and involving improperly documented rental arrangements for use of medical space.
Intermountain discovered these violations on their own. Instead of trying to cover them up, they reported them to the U.S. Attorney for Utah. Considering the total lack of criminal intent, the technical nature of the violations, the lack of harm done, and the self-disclosure of the errors, it can be argued that the $25.5 million penalty was excessive.
What does this have to do with single payer reform? Simply that there is a world of difference between a health care system structured on a business model with a primary mission to make money, and a health care system structured on a service model designed to take care of patients. Intermountain functions as the latter. It is a non-profit, integrated health care system that would be an ideal component of a single payer national health program.
Technical violations will always be with us, but they are understandable errors when the goal is to take care of patients, but not when the goal is to deliberately siphon off health care dollars for personal gain.
Last chance: If ACA fails, single payer is next
The Salt Lake Tribune, March 30, 2012
The Patient Protection and Affordable Care Act should be seen as what it is: One last opportunity for the private health insurance market to prove that it can offer a service that covers the millions of Americans who were previously left out, at a cost that we — as individuals, employers and taxpayers — can afford.
If that is a goal beyond the grasp of the existing system, then it needs to be finally swept aside in favor of something that will meet those needs.
But this is, or should be, the private health insurance industry’s last chance. If Obamacare fails, a return to the cold-hearted free market is not a realistic or humane choice.
An entity with the chops to bargain down the actual cost of care is necessary. At the very least, a robust public option, an idea President Obama bargained away in the creation of the ACA, must be provided. Better still would be a single-payer plan — Medicare for all.
It is already clear that the structure of the private health insurance market that is perpetuated by the Affordable Care Act will continue to fail us – providing us only care that is too expensive and leaves too many out. Not even a competing “robust public option” can alter that. Now is the time to enact a single payer plan – an improved Medicare for all.
Let’s hope that the editorial board of The Salt Lake Tribune – and all other influential observers of the health care scene – will recognize sooner rather than later that the private insurance industry has failed us once again and has to go.
Registered Nurses to the Rescue
Andrew D. Coates, MD, FACP
WAMC Northeast Public Radio Mid-day Magazine
29 March 2013
In a small news article this week in the New York Times Nina Bernstein reported that a provision of the New York State budget to allow for-profit hospitals was been dropped after opposition from the Assembly leadership, specifically the intervention of Assemblyman Richard Gottfried, chair of the Assembly’s Health Committee.
While hospitals may be run as for profit businesses in many states, all New York state hospitals are presently either not-for-profit or public institutions. Keeping for-profit hospital care out of New York is good news for people in New York who need hospital care and marks a successful defense of the public interest.
According to the Times Stephen Berger, “an investment banker who has long advised the state on health care,” was behind the push. Republican leaders in the New York State Senate proposed to expand the pilot project to allow ten for-profit hospitals.
The New York State Nurses Association vigorously opposed the measure. The nurses organized a grassroots push of over 2,000 phone calls and hundreds of in-person visits to lawmakers, including a last-minute push of busloads of nurses traveling to Albany.
Jill Furillo, executive director of the New York State Nurses Association, was quoted in the Times saying: “For-profit health care does not work. People in the Assembly listened to us, and so did Gov. Andrew Cuomo.”
Proponents of for-profit hospitals in New York, like Mr. Berger, point to the need for capital investment in the healthcare infrastructure. Berger led a state-appointed committee in 2011 that recommended closing all public hospital beds in the borough of Brooklyn.
Investment in healthcare works for the investors, but it doesn’t work for the patients or the caregivers. Public money must ultimately fund the care of the vulnerable and the indigent. Allowing investment companies to take a cut increases costs and robs caregiving.
For-profit hospitals amount to bad public policy. For-profit hospital have also been shown, in peer-reviewed policy science literature, to provide inferior quality when compared with their non-profit counterparts. For-profit hospitals also lead to greater health spending than non-profit ones.
Convincing research includes studies by Dr. P.J. Devereaux and his team of researchers. When it comes to hospitals Devereaux found that charges at for-profit hospitals were 19 percent greater than at their non-profit counterparts. In a previous paper, Devereaux and colleagues showed that mortality — death rates — were 2 percent greater at for-profit hospitals.
A cardiologist, Devereaux practices, teaches, and performs his research at McMaster University in Ontario, a world-renowned center for evidence-based medicine. Devereaux has also researched the question of for-profit dialysis centers and for-profit nursing homes.
When compared with non-profit institutions, for-profit dialysis and for-profit nursing homes, like for-profit hospitals, are more expensive and more deadly than nonprofit ones.
Moving a hospital into the private sector shifts its fundamental purpose. A for-profit institution primarily exists to remunerate investors and shareholders. The public service model — or at the very least non-profit, community-based institutions — still organizes care with a primary responsibility to patients and their caregivers.
During our lifetimes health care has been transformed from its charitable roots into a profit-seeking industry.
For-profits operate over 84 percent of home health care agencies and 85 percent of dialysis clinics. 96 percent of the nation’s outpatient surgery centers are for-profit, a sector that has grown by more than a third in the last decade. Hospice care has evolved into a $14 billion business, run mostly for-profit. For-profit hospice!
Over three-fourths of nursing homes are for-profit nursing homes — and the largest owner of for-profit nursing homes are private equity firms run by investment bankers.
The exception has been hospitals, where nonprofits and publicly-operated facilities had 88 percent of revenues in 2010.
I love our nurse colleagues. Judy Sheridan-Gonzalez, RN at Montefiore Medical Center and elected NYSNA leader, said: “We’ve won this battle, but our fight for New York patients is just beginning. Our opponents can re-introduce these changes as non-budget bills at any time this legislative session. That’s why we’re not letting down our guard.”
For-profit hospitals are bad public policy. But with the trend toward privatization — you might call it the profitization — of health care — the nurses public advocacy will remain as indispensable to the patient’s interests as their bedside care.
Factors Affecting Individual Premium Rates in 2014 for California
By Robert Cosway and Barbara Abbott
Report prepared for Covered California, Milliman, March 28, 2013
Covered California retained Milliman to evaluate the changes in individual health insurance premium rates that might be expected due to the implementation of the Patient Protection and Affordable Care Act (ACA) in 2014.
Summary of Potential Rate Changes for People Currently Insured (includes premium tax credits and cost sharing subsidies)
-83.8% Less than 250% FPL
-46.6% 250% to 400% FPL
+30.1% Greater than 400% FPL
Cost at time of care (cost sharing)
-61.8% Less than 250% FPL
-27.3% 250% to 400% FPL
+ 1.2% Greater than 400% FPL
Total cost of care: Premiums plus cost sharing
-76.2% Less than 250% FPL
-39.9% 250% to 400% FPL
+20.1% Greater than 400% FPL
In general, we expect the average currently insured to experience premium increases because they will be part of a new risk pool with a higher average health status. The federal premium tax credits and cost sharing subsidies will more than offset these increases for many low income individuals.
Cost of the Future Newly Insured under the Affordable Care Act (ACA)
Society of Actuaries, March 2013
Note that the ACA’s affect on premium is not modeled in this research; rather, long-term relative claims cost is modeled.
This analysis will primarily focus on the individual, non-group market.
Finding 3: The non-group cost per member per month will increase 32 percent under ACA, compared to pre-ACA projections.
The post-ACA figures include the impact of a) high risk pool members, b) employers dropping group coverage, and c) increased morbidity from selection by those currently uninsured who now purchase coverage.
These two actuarial reports project the potential financial impact of the Affordable Care Act (ACA) on individuals obtaining coverage in the non-group market. The reports are quite complex. Let’s see if we can separate what these reports really say from what the politicians are saying about them.
The excerpts above do not refer to employer-sponsored coverage nor do they refer to Medicaid. They refer only to the differences in plans offered in the individual market before ACA and those to be offered after the ACA exchanges are established next January.
The Society of Actuaries reports that cost of claims, not premiums, will increase 32 percent, but, again, only in the individual market. This increase is due to the change in the mix of individuals covered by these plans. The plans will include more costly individuals who have been insured by the state high-risk pools; they will include individuals dropped by employers from their group coverage, and they will include the previously uninsured who have increased morbidity (i.e., poorer health status).
So those politicians who are using this report to claim that “health care costs are going up 30 percent under Obamacare” either do not understand the report, or they are being dishonest. It is only the insurance pools in the individual market that add in unhealthy individuals that are projected to have 30 percent increases in the cost per enrollee, when compared to the cost per enrollee of current plans in the individual market that have been successful in keeping out individuals with greater health care needs.
The Milliman analysis looks at the pre-ACA and post-ACA change in the premiums, not the change in the cost of claims, but they also include the changes in what the individual actually pays when the premium tax credits and cost sharing subsidies are included. Those individuals with incomes below 400 percent of the federal poverty level will pay significantly less than they would in the current individual market.
For individuals who do not receive subsidies or tax credits, the premiums will increase about 30 percent – again because of the change in the mix of the insurance pools which will include enrollees with greater needs. But the total premiums plus cost sharing are expected to increase about 20 percent since there will be almost no change in cost sharing for these higher-income individuals.
So are the costs for the individual market insurance pools going up 20 percent or about 30 percent? Considering the differences in higher-income individuals in one study and the entire individual market in the other study, the separate impact on premiums, cost sharing, and claims, and the variations in actuarial assumptions, these numbers are quite close. Let’s say 25 percent.
But the number doesn’t matter. Whatever it is, it merely represents the fact that insurers offering individual plans must now sell them to anyone who wishes to enroll, no matter how expensive their medical problems may be. By segregating individuals into different insurance pools, the premiums will have to be set based on how healthy or sick that pool is, especially since risk adjustment is only capable of correcting for just a minor portion of the inequities. Administrative complexity and inequities are inevitable under ACA.
The lesson is that it would be much simpler and much more equitable to have a single insurance pool that covers everyone, and fund it through progressive tax policies. Fix Medicare, improve the tax structure, and use it for everyone.
HMO Quality Ratings Summary – 2013
Office of the Patient Advocate
State of California
“Health Care Quality is getting the right care at the right time.”
First rating is for “HMO provides recommended care,”
and the second rating is for “Getting care easily”:
*** * Aetna Health of California, Inc.
*** * Anthem Blue Cross – HMO
*** ** Blue Shield of California – HMO
*** * CIGNA HMO
*** * Health Net of California, Inc.
**** ** Kaiser Permanente – Northern California
**** * Kaiser Permanente – Southern California
*** * Sharp Health Plan
*** * UnitedHealthcare of California
*** ** Western Health Advantage
California’s Office of the Patient Advocate defines health care quality as getting “the right care at the right time.” So how well are the HMOs doing?
To assess whether or not the right care is being provided, the HMOs report their compliance with standard Health Plan Employer Data and Information Set (HEDIS) measurements. The HMOs make certain that their health care professionals are aware of the 37 HEDIS measurements that will be made, and that they know that it is important to be certain that compliance is documented.
All ten of the California HMOs were able to document that they were either “good” or “excellent” at providing the right care for these 37 measured clinical recommendations. No measurement was made of the hundreds of thousands of other clinical decision processes that take place. It remains debatable as to whether 37 HEDIS measurements are adequate to determine if the HMO is always good or excellent at providing the right care, but there are those of us who have our doubts (pardon the cautious, restrained language).
So regardless of whether or not it was the right care, was it provided at the right time? Patients were surveyed about “experiences in getting appointments with doctors and other providers when needed and getting tests, treatments and other care without delay.” No HMO was rated excellent; no HMO was rated good. Three were rated fair, and seven were rated poor. At least from the patients’ perspective, care was not being provided at the right time.
Under a single payer system, patients have free choice of their health care professionals and institutions. HMOs take away that choice, subjecting patients to severe financial penalties should they obtain care outside of the HMO. The results of this survey suggest that, once HMOs have captive patients, they limit access by limiting system capacity and by establishing queues that are beyond the tolerance of their patients.
The delegated model of HMOs has no place in a single payer system since they function more as intrusive private insurers rather than as truly integrated health care delivery systems.
HMOs that are fully integrated health care delivery systems, such as Kaiser Permanente, do have a place in a single payer system. Right now, Kaiser is heavily dependent on workers enrolling in Kaiser’s plans through their employment, often choosing Kaiser as their least-worst option.
Once we have a single payer system with patients choosing their health care based on perceived quality, to compete successfully with the rest of the health care delivery system, Kaiser will have to show that they can deliver the right care at the right time. After all, that’s what single payer is all about.
Democracy and the Policy Preferences of Wealthy Americans
By Benjamin I. Page, Larry M. Bartels and Jason Seawright
American Political Science Association, Perspective on Politics, March 2013
It is important to know what wealthy Americans seek from politics and how (if at all) their policy preferences differ from those of other citizens. There can be little doubt that the wealthy exert more political influence than the less affluent do. If they tend to get their way in some areas of public policy, and if they have policy preferences that differ significantly from those of most Americans, the results could be troubling for democratic policy making. Recent evidence indicates that “affluent” Americans in the top fifth of the income distribution are socially more liberal but economically more conservative than others. But until now there has been little systematic evidence about the truly wealthy, such as the top 1 percent. We report the results of a pilot study of the political views and activities of the top 1 percent or so of US wealth-holders. We find that they are extremely active politically and that they are much more conservative than the American public as a whole with respect to important policies concerning taxation, economic regulation, and especially social welfare programs. Variation within this wealthy group suggests that the top one-tenth of 1 percent of wealth-holders (people with $40 million or more in net worth) may tend to hold still more conservative views that are even more distinct from those of the general public. We suggest that these distinctive policy preferences may help account for why certain public policies in the United States appear to deviate from what the majority of US citizens wants the government to do. If this is so, it raises serious issues for democratic theory.
The public has expressed much more support for tax-financed national health insurance (61 percent in favor) than our wealthy respondents did (just 32 percent). This represents a major gap on a central issue of social welfare policy. Similarly, a solid majority of the public (59 percent), but only a minority of the wealthy (41 percent), said they would be “willing to pay more taxes in order to provide health coverage for everyone.”
Our evidence indicates that the wealthy are much more concerned than other Americans about budget deficits. The wealthy are much more favorable toward cutting social welfare programs, especially Social Security and health care. They are considerably less supportive of several jobs and income programs, including an above-poverty-level minimum wage, a “decent” standard of living for the unemployed, increasing the Earned Income Tax Credit, and having the federal government “see to” —or actually provide—jobs for those who cannot find them in the private sector.
Judging by our evidence, wealthy Americans are much less willing than others to provide broad educational opportunities, by “spend[ing] whatever is necessary to ensure that all children have really good public schools they can go to” or “mak[ing] sure that everyone who wants to go to college can do so.” They are less willing to pay more taxes in order to provide health coverage for everyone, and they are much less supportive of tax-financed national health insurance. The wealthy tend to favor lower estate tax rates and to be less eager to increase income taxes on high-income people. They express concern about economic inequality and favor somewhat more egalitarian wages than they perceive as presently existing, but—to a much greater extent than the general public—the wealthy oppose government action to redistribute income or wealth.
On many important issues the preferences of the wealthy appear to differ markedly from those of the general public. Thus, if policy makers do weigh citizens’ policy preferences differentially based on their income or wealth, the result will not only significantly violate democratic ideals of political equality, but will also affect the substantive contours of American public policy.
The wealthy have a very strong political voice. They use it to advance their own interests while opposing social programs, including tax-financed national health insurance. This is class warfare, but look at who is waging it.
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