Month: January 2016

Why Does Iowa Vote First, Anyway?

Since 1972, Iowa has held the first presidential nominating contests in the country. Over the years, the Iowa caucuses have grown in size, scope and importance, sometimes launching underdogs to the presidency or upsetting established political juggernauts.

It’s easy to accept Iowa’s role in presidential elections for what it is. But in some ways, Iowa should be questioned. The first-in-the-nation caucus state is whiter and more rural than the rest of the country; it doesn’t really represent America in some fundamental ways. Knowing that, why is Iowa first? And is that fair? But first:

1. What’s a caucus?

“A caucus — it’s a neighborhood meeting,” said David Yepsen, former political writer at the Des Moines Register and an Iowa politico of note. “In fact, the term caucus is thought to be a Native American term — an Algonquin term for meeting of tribal leaders.”

A caucus is more than just a vote; like Yepsen said, it’s a meeting. On caucus night, people gather at hundreds of sites across the state and talk about why they’re supporting a candidate. Speeches are made on candidates’ behalf, and there’s jockeying to persuade other people to support their candidate. The process can sometimes take hours. For Democrats in Iowa, caucusgoers publicly show support for their candidates after the speeches by moving to designated spaces in the space they’ve gathered. If a candidate does not get at least 15 percent of the room backing him or her, those supporters must go support another, viable candidate. For Republicans, after the speeches, there’s a secret ballot, no head counts.

2. Why is Iowa first?

“The really important thing to remember about Iowa is not that it’s first because it’s important. Iowa is important because it’s first,” said Kathy O’Bradovich, political columnist for the Des Moines Register. She acknowledges that Iowa didn’t really happen on purpose.

“It happened after the 1968 Democratic National Convention,” she said, which was marred by violence over the Vietnam War and racial tension. “The Democratic Party nationally and in Iowa decided they wanted to change their process to make it more inclusive.”

Part of that meant spreading the presidential nominating schedule out in each state. Because Iowa has one of the more complex processes — precinct caucuses, county conventions, district conventions, followed by a state convention — it had to start really early. (The Democratic Party held Iowa caucuses first in the nation in 1972; the GOP followed suit in 1976.)

And once a peanut farmer named Jimmy Carter rode an Iowa caucus win all the way to the White House, Iowa suddenly became a thing.

3. Is it fair?

Just a warning, there’s probably no consensus for this.

But here’s how Jim Jacobson, a voter from Iowa City, rationalized it:

“Is it fair that Iowa goes first? What’s fair in politics? I mean, seriously. Yeah, OK, we’re like 97 percent white, and we’re really rural, and we don’t look like a microcosm of America. But so what?”

Let’s take that first thing he points out, Iowa’s whiteness.

Officially, non-Hispanic whites make up 87.1 percent of Iowa’s population according to the most recent census data.

But J. Ann Selzer, the top pollster in the state, says that’s actually kind of OK.

“The idea that because Iowans are white and older, they’re going to vote for older white people is not borne out,” she said. “In both parties, candidates of color have often done quite well in Iowa. Look at Barack Obama. Jesse Jackson did well. Alan Keyes did well on the Republican side.”

Even Jeff Kaufmann, the head of the Iowa Republican Party, kind of says the same thing.

“This is going to be awfully odd, to have a Republican chair suggest you look at what Barack Obama has to say about Iowa,” he said. “But I’m guessing Barack Obama has no problem with the diversity that we reflect. And I’m guessing if you talk to Marco Rubio and Ted Cruz and Ben Carson, my guess is that they’re not going to have a problem.”

But there’s another issue of race — not just who Iowans are voting for, but which Iowans are voting. Both parties say they’re reaching out more to Latinos, Iowa’s fastest-growing racial group. But in West Liberty, Iowa, a town that is majority Latino, NPR spoke with several residents who had no idea what a caucus is, had no intention to vote, and said no one had ever talked to them about any of it. One man thought we were asking him about a cactus.

“Nobody says anything, and nobody talks about it,” West Liberty resident Maria Luna said. “And we see nothing, then we’re not going to be nothing — and do nothing.” found that Latinos make up about 3 percent of Iowa’s electorate. The state doesn’t track the race of caucusgoers, but in the last general election, Latino turnout was quote low: 25 percent. Several advocacy groups say they plan to change that, however, particularly the League of United Latin American Citizens, or LULAC.

But the Iowa Caucus Project points out that in general, caucus participation, regardless of race, is usually relatively low. “With the exception, then, of the extraordinary Democratic caucus year in 2008,” wrote Dennis J. Goldford, “we can see from these numbers that in the last two Iowa caucus cycles, not unlike earlier cycles, only roughly 20 percent of eligible caucus-goers actually turn out to participate on caucus night.”

So, low turnout in an already small state; Iowa has a population of about 3 million people. And Iowa is very rural, at a time when an increasing amount of American voters these days live in or around big, urban areas.

“When we get to the general election next November, about 45 percent of the vote is going to come from places that I call big cities or urban suburbs,” said Dante Chinni, director of the American Communities Project at American University. “That’s a lot of the vote. There are none of those [major cities] in Iowa.”

Given those numbers, he says, a state like Georgia might be more ideal. “First of all, you have diversity, a much more diverse state [in Georgia]. The other thing that Georgia has is — it has Atlanta.”

When you look at states that have that mix — more racial diversity and a mix of rural and urban, there are actually a few options.

“Pennsylvania is a very good option. Colorado is an interesting state. My home state of Michigan; Ohio’s a really good one,” Chinni says.

NPR’s Asma Khalid analyzed and indexed the demographics of each of the 50 states compared with the national averages and found that Illinois might be more appropriate based on factors like race and income.

But if you look to bigger states for more diversity, you could end up with a caucus state that’s actually too big. Iowa is small enough for every candidate to make his or her way all across the state and advertise on the cheap. Small candidates can compete with the big dogs in Iowa from Day 1. It would have been much harder for Carter to win a California caucus than one in Iowa.

4. Are Iowans better at this?

Over time, one of the reasons people have come to support Iowa being first has come to be the people of Iowa themselves.

“The real reason we’re first in the nation now is because of what we do. We take this real seriously,” says Andy McGuire, head of the Iowa state Democratic Party. She says Iowans contest a candidate like no one else and that they’ve had literally decades of experience in figuring out how to grill candidates one on one.

“You know, we ask really good questions. We ask follow-up questions,” she said. “We look them in the eye like I am you right now. It’s real. It’s one-on-one vetting of candidates. Are you for real? Not a TV spot, not money — what’s in your heart?”

Whether you believe that Iowa voters are better at this or that they deserve the privilege more, it probably doesn’t even matter. Yepsen says we’re stuck with Iowa.

“Iowa’s first because of inertia,” he said, laughing. “Most people in the country don’t like this process.” But he says no one can agree on what else to do. Should the first nominating contest move to another state, the same questions raised about Iowa would just be shifted there. And when you’re trying to find the state that’s the most representative, you could fall down a rabbit hole: Which state has the most diversity of industry? Which state has education levels that most mirror the country? Which state has the most reflective ratio of things like union membership, or church attendance? You could go on …

Others have proposed alternative primary systems (which Danielle Kurtzleben broke down here).

And say both parties agree on a viable alternative to Iowa, or even a different system altogether (one-day national primary?), Iowa might fight like hell to keep its favored spot. Being first gives Iowa lots of attention to issues Iowans care about, and it’s a really, really big boost to the economy to have hordes of campaign reporters and campaign staffers staying in your hotels, eating at your restaurants, and buying ads on your television stations.

5. Putting Iowa in perspective

With all of this, though, it’s important to put Iowa in perspective. Iowa is first, and in some ways, yes — you could see that as problematic. But as several experts pointed out to NPR, Iowa doesn’t actually pick the president. And it’s not supposed to on its own. They all said that Iowa’s role is that of a winnower; it’s there to start narrowing the field of presidential candidates. And if you look at it that way, maybe it all seems a little more fair. Iowa is not the be all, end all. Iowa alone is not a kingmaker. Iowa is only the start of a long journey. Iowa is just first.

No Way To Pick A President? Here Are 6 Other Ways To Do It

Every four years, Iowans are deluged with the talking points, the stump speeches, the polls and, of course, the ads. They also hear that they shouldn’t be first. Iowans are too white, too old and too few to merit first-in-the-nation status, say the critics. But if Iowa shouldn’t be first, who should be? For more than a century, reformers have been proposing ideas for how to change the primary system. And they’ve been failing. And they’ll probably continue to fail.

No one is going to persuade state and party machinery to change the current primary system anytime soon. However, these ideas can at least help show what works (and what doesn’t) about the way things are now. Here are just a few of the ideas people have proposed over the years:

1. Pick A New State

The gist

Just what it sounds like: let someone else go before Iowa and New Hampshire.

Who has promoted it

Someone new every cycle. Time and the Washington Post’s The Fix blog (twice!) have weighed in in the past year, as has this thread of redditors. (NPR’s own Asma Khalid will have her own best-first-state analysis coming out soon.)


People generally have two big criticisms of Iowa’s first-in-the-nation status (and New Hampshire’s, as well): (1) that the states are not representative of the rest of the country, and (2) that they’re too tiny. Were a state like California or Texas or Florida or New York first, a much bigger share of the U.S. population would get a shot at shaping the presidential race early. And with any of those states (and plenty of others) you get more diversity; Iowa and New Hampshire are two of the whitest states in the country, as well as two of the most rural.


Iowa’s smallness is in some ways a feature, not a bug, in that it allows less well funded candidates a fair shot (see: Rick Santorum, 2012, and Mike Huckabee, 2008). The state’s caucus “ensures that there is at least one place where a candidate with a compelling message has a shot at winning, regardless of money or national fame,” as the Des Moines Register’s Kathy O’Bradovich argued in October.

There’s also more to being representative than race and ethnicity. A 2009 paper by the University of Iowa’s Michael Lewis-Beck and Missouri’s Peverill Squire found that Iowa was the most representative state economically at the time, as well as relatively representative (12th out of 50 states) when a broad range of social, demographic and economic factors were included.

In addition, simply picking a new state wouldn’t solve all of the problems with the current system. In 2008, the scramble to hold early caucuses and primaries led to a massively front-loaded calendar. Scrambling the states into a new order wouldn’t have stopped that struggle from happening.

2. National Primary

The gist

Let people nationwide cast their primary ballots all at once.

Who has promoted it

Rep. Richard Hobson in 1911 and a lot more people since then. Well over 100 bills and resolutions have been introduced in Congress since then to try to create a national primary.


A national primary would eliminate worries about one or two states having outsize sway by virtue of voting super early. Not only that, but it would make a complicated calendar way less complex and stop the constant shifting of dates.

And by eliminating a bunch of confusion, it might make primaries “more accessible to the average voter,” which could in turn make for “more moderate candidates who are more representative of their constituents,” as Pacific Standard’s Shanna Pearson-Merkowitz wrote in 2014.


It would make money and name recognition even more important than they already are. Instead of having to focus early on buying ads in Iowa (or whichever state might otherwise go first), a candidate would have a whole nation of media markets to try to hit. That means a less well funded candidate who currently can stand a chance in the small early states right now would be at a huge disadvantage.

It could also disadvantage a grass-roots-fueled candidate like Bernie Sanders. The Vermont independent leads or is closely matched with former Secretary of State Hillary Clinton in the two early states of Iowa and New Hampshire this year, but he trails by double digits in most national polls.

In addition, this kind of plan could mean that candidates would focus only on the highest-population states, leaving smaller and largely rural states without many cities — and therefore fewer delegates — all but abandoned. That’s what Alabama’s then-Secretary of State Beth Chapman wrote at U.S. News in 2012.

3. Rotating Regional Primary

The gist

Don’t want to give a couple of states all the early-voting power, every single election? A rotating regional primary would break up the U.S. into a few segments and let each take a turn going first. Under perhaps the best-known rotating primary plan, put forward by the National Association of Secretaries of State in 2008, there would be four regions (East, Midwest, South and West), with each taking one primary slot (in March, April, May or June). The order of regions would then rotate in each election cycle.

Who has promoted it

RNC Chairman Reince Priebus, the National Association of Secretaries of State, the National Lieutenant Governors Association and plenty of others.


A scheduled system like this would get rid of the date-wrangling that led to a superearly nominating season in 2008. This is the first reason that the secretaries of state association gave in its 2008 proposal, pointing out that 37 states voted before Feb. 29 that year, while only nine did so in 2000.

It also could give voters more time to get to know the candidates and give more informed votes, not to mention potentially giving more voters a say in who eventually gets nominated, the group argued.

Finally, it could make campaigning more efficient — no longer would candidates have to hop from Iowa to New Hampshire to South Carolina for a few months. And as the University of Arizona’s Barbara Norrander has argued, it would make campaign ads more efficient. (Consider the border-residing Minnesotans and Illinoisans currently being subjected to Iowa’s campaign ads).


Here’s one weird twist: The secretaries of state proposal still puts Iowa and New Hampshire first, “based upon their tradition of promoting retail politics.” That defeats the purpose of reforming the system to some degree, keeping those two demographically unrepresentative states at the front of the calendar.

But leaving that aside, there are other potential problems with rotating regional primaries. While the plan seeks to equalize states’ participation in primaries, whichever region goes last in any given cycle runs the risk of being meaningless; it’s possible the winners will already be apparent by the time the final contest rolls around.

Certain candidates would also probably benefit more in any given election based on which region goes first, as political scientists Steven Smith and Melanie Springer wrote in 2009. Texas Sen. Ted Cruz, for example, could potentially benefit far more if this primary season started with South, and Vermont Sen. Bernie Sanders could get a big initial boost from a Northeastern primary. Not only that, but knowing that her or his region would be first in the next election, a strong candidate in one region could “block out a strong candidate from another region,” as former Ohio GOP Chairman Bob Bennett argued.

And maybe taking things a few states at a time isn’t such a bad idea, argues Norrander.

“Most would agree that face-to-face meetings between the candidates and real voters are a good component of the current system,” she writes. “Because of the large size of each region, candidate strategy will consist of television advertising and tarmac campaigning.”

4. The Delaware Plan

The gist

Let the little states go first. The Delaware Plan separates states into four groups, each with 12 or 13 states, as explained by voting-reform advocacy group FairVote. Group 1, consisting of the smallest-population states and territories, votes first, followed by Group 2 one month later, and so on.

Who has promoted it

Most notably, the RNC considered the Delaware Plan in 2000.


The point of the Delaware Plan was to keep the nomination season from growing shorter and shorter, as states fought to go earlier and earlier, as USA Today reported in 2000. That year, the season was so short that two-thirds of the states ended up “without a voice,” the paper reported.

The Delaware Plan tries to equalize states: Smaller states naturally have a smaller voice, but they’d get amplified by being earlier. Meanwhile, the powerful larger states’ voices would be turned down a bit by being later. And because a candidate couldn’t win the nomination very early, it would prolong the primary season, giving people longer to learn about the candidate and make their decisions.

In addition, it could equalize candidates to some degree — candidates with lots of grass-roots support could likewise gain ground in the small states and potentially then be able to compete in the bigger states, as FairVote argues.


Smaller states tend to be less urban than the rest of the country, not to mention whiter, as Smith and Springer wrote — meaning this plan wouldn’t exactly solve the issue of early states not being representative.

They also add that starting with 12 states that aren’t geographically grouped would create some super-inefficient campaigns, as opposed to the way that a regional plan might make campaigning easier.

In addition, starting off with so many states at once could still favor better-funded candidates, Norrander points out.

5. The Ohio Plan

The gist

This is a sort of compromise between the Delaware Plan and the rotating regional plan. The Ohio Plan would have let four current early states (Iowa, New Hampshire, South Carolina, Nevada) go first, followed by a group of 15 small states and territories.

After that, three bigger groups of states would take turns holding their primaries. Each of those groups would have had at least one high-population “anchor state,” as Brookings’ Elaine Kamarck explains.

Who has promoted it

The Ohio Plan was proposed by Bob Bennett, the then-chairman of the Ohio GOP, before the 2008 election.


Bennett argued that his plan would be more acceptable to big states than the Delaware Plan while maintaining the kind of retail politics influence that small states — and the current early states — allow. In addition, keeping South Carolina and Nevada early would add more diversity early in the process than the Delaware Plan.


The plan would still maintain some of the cons of the secretaries of states’ and Delaware plans — despite the early participation of South Carolina and Nevada, there are still a lot of very white states with early influence. In addition, candidates would have to hit a lot of geographically far-flung states at once.

6. Graduated Random Presidential Primaries (Aka ‘The California Plan,’ Aka ‘The American Plan’)

The gist

It’s a little like the Delaware Plan in the sense that smaller states would go first. However, it’s way more complicated.

So here goes: There would be 10 caucus periods, each lasting two weeks. States with fewer congressional districts would go first, followed by states with a few more in the next period and so on.

This would be according to a particular formula: States with a total of eight districts would go first, with the states being randomly selected. So, for example, Kansas and Mississippi, which each have four districts, might be in the first round. The next round, the number of districts would total 16. The next, 24.

But after that, the numbers get less straightforward. To keep the biggest states like New York and California from always going nearly last, the plan allows for some bigger district totals to go earlier. The order for all 10 caucus rounds would be eight, 16, 24, 56, 32, 64, 40, 72, 48 and then 80 districts, according to FairVote.

Who has promoted it

The Democratic National Committee considered it in 2005, and FairVote has advocated for it as well.


It maintains many of the benefits of the Delaware Plan, potentially making the primary season longer (and therefore, potentially more informative) and giving more states the opportunity to have a say — all without leaving all the biggest states for last.


Once again, there’s the potential for some really inefficient campaigning. Imagine candidates having to hop from Alaska to Idaho to West Virginia to Rhode Island for the first round of caucuses. That could give better-financed candidates a leg up.

Also, it’s complicated — but compared with what? As Smith and Springer wrote, the American Plan “surely would be no more complicated than the current schedule.”

National Health Expenditures 2015 Highlights

In 2015, U.S. health care spending increased 5.8 percent to reach $3.2 trillion, or $9,990 per person. The coverage expansion that began in 2014 as a result of in the Affordable Care Act continued to have an impact on the growth of health care spending in 2015. Additionally, faster growth in total health care spending in 2015 was driven by stronger growth in spending for private health insurance, hospital care, physician and clinical services, and the continued strong growth in Medicaid and retail prescription drug spending. Lastly, the overall share of the U.S. economy devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014.

Health Spending by Type of Service or Product:

Hospital Care (32 percent share): Spending for hospital care increased 5.6 percent to $1.0 trillion in 2015 compared to 4.6 percent growth in 2014. The faster growth in 2015 was driven by continued growth in non-price factors such as the use and intensity of services. However, hospital price growth was just 0.9 percent in 2015, which was the lowest rate of growth since 1998. Hospital services, from a payer perspective, experienced faster growth in Medicaid and private health insurance spending; however this strong growth was slightly offset by slower growth in Medicare hospital spending.

Physician and Clinical Services (20 percent share): Spending on physician and clinical services increased 6.3 percent in 2015 to $634.9 billion. This was an acceleration from growth of 4.8 percent in 2014 and was the first time since 2005 that the growth rate exceeded 6.0 percent. As with hospitals, the faster growth in overall physician and clinical services spending was driven by continued growth in non-price factors. Price growth for physician and clinical services, however, declined 1.1 percent in 2015, driven by the expiration of temporary increases in Medicaid payments to primary care physicians.

Other Professional Services (3 percent share): Spending for other professional services reached $87.7 billion in 2015, an increase of 5.9 percent and an acceleration from growth of 5.1 percent in 2014. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or chiropractic medicine.

Dental Services (4 percent share): Spending for dental services increased 4.2 percent in 2015 to $117.5 billion, which was an acceleration from 2.4 percent growth in 2014. Out-of-pocket spending for dental services (which accounted for 40 percent of dental spending) increased 1.8 percent in 2015 after increasing 0.8 percent in 2014. Private health insurance (which accounted for 47 percent of dental spending) increased 3.0 percent in 2015 following 2.1 percent growth in 2014.

Other Health, Residential, and Personal Care Services (5 percent share): Spending associated with other health, residential, and personal care services grew 7.8 percent in 2015 to $163.3 billion after increasing 5.0 percent in 2014. The robust growth was driven by 10.0 percent growth in Medicaid spending, which represented nearly 57 percent of all spending in this category. This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities.

Home Health Care (3 percent share): Spending growth for freestanding home health care agencies accelerated in 2015, increasing 6.3 percent to $88.8 billion following growth of 4.5 percent in 2014. Stronger growth in both Medicare (2.6 percent) and Medicaid (6.0 percent) spending — the two largest payers which accounted for 76 percent of home health spending — along with faster growth in private health insurance and out-of-pocket spending drove the overall acceleration in 2015.

Nursing Care Facilities and Continuing Care Retirement Communities (5 percent share): Spending for freestanding nursing care facilities and continuing care retirement communities increased 2.7 percent in 2015 to $156.8 billion. The slightly faster growth in 2015 (from 2.3 percent growth in 2014) was mainly due to the faster growth in Medicare spending of 5.6 percent versus 2.5 percent in 2014.

Prescription Drugs (10 percent share): Retail prescription drug spending decelerated in 2015, increasing 9.0 percent to $324.6 billion. Although growth in 2015 was slower than the 12.4 percent growth in 2014, spending on prescription drugs outpaced all other services in 2015. The strong spending growth for prescription drugs is attributed to the increased spending on new medicines, price growth for existing brand name drugs, increased spending on generics, and fewer expensive blockbuster drugs going off-patent.

Durable Medical Equipment (2 percent share): Retail spending for durable medical equipment, which includes items such as contact lenses, eyeglasses and hearing aids, reached $48.5 billion in 2015, and increased 3.9 percent, slightly faster than the 3.5 percent growth in 2014.

Other Non-durable Medical Products (2 percent share): Retail spending for other nondurable medical products, such as over-the-counter medicines, medical instruments, and surgical dressings, grew 3.7 percent to $59.0 billion in 2015.

Health Spending by Major Sources of Funds:

Medicare (20 percent share): Medicare spending grew 4.5 percent to $646.2 billion in 2015, which was a slight deceleration from the 4.8 growth percent in 2014. The slightly slower growth in 2015 was largely attributable to slower growth in Medicare enrollment, which increased 2.7 percent to 54.3 million beneficiaries following 3.1 percent growth in 2014.

Medicaid (17 percent share): Total Medicaid spending slowed slightly in 2015 to 9.7 percent, but continued the strong growth that began in 2014 (11.6 percent) State and local Medicaid expenditures grew 4.9 percent while Federal Medicaid expenditures increased 12.6 percent in 2015. The increased spending by the federal government was largely driven by newly eligible enrollees under the ACA, which were fully financed by the federal government.

Private Health Insurance (33 percent share): Total private health insurance expenditures increased 7.2 percent to $1.1 trillion in 2015, faster than the 5.8 percent growth in 2014. The acceleration in 2015 was driven by increased enrollment and strong growth in benefit spending.

Out-of-Pocket (11 percent share): Out-of-pocket spending grew 2.6 percent in 2015 to $338.1 billion, slightly faster than the growth of 1.4 percent in 2014. The increase in 2015 was influenced by the expansion of insurance coverage and the corresponding drop in the number of individuals without health insurance.

Health Spending by Type of Sponsor:

In 2015, the federal government accounted for the largest share of health care spending (29 percent), followed by households (28 percent), private businesses (20 percent), and state and local governments (17 percent).

Federal government spending on health increased 8.9 percent in 2015 after growing 11.0 percent in 2014, and outpaced all other sponsors of health care in both years. In 2015, the federal government was the largest sponsor of health care at 29 percent, up from 28 percent in 2014 and 26 percent in 2013. The main driver for the increased federal share of health care was the continued enrollment of newly eligible adults into Medicaid, who were fully financed by the federal government.

Health spending by households grew at a rate of 4.7 percent, which was an acceleration from 2.6 percent in 2014. Household spending accounted for 28 percent of health care spending in 2015, unchanged from the year before. The faster growth in spending by households was driven largely by households’ contributions to employer-sponsored private insurance premiums.

State and local government spending increased 4.6 percent in 2015 compared to 3.2 percent growth in 2014. The acceleration was largely driven by faster growth in state and local Medicaid spending which resulted from increased reimbursement rates and an increased effort to expand care in the home and community setting. Overall, state and local government health care spending represented 17 percent of total health care spending in both 2014 and 2015.

Health care spending financed by private businesses accelerated slightly, increasing 5.3 percent in 2015 compared to 4.7 percent growth in 2014. The private business share of overall health spending has remained fairly steady since 2010, at about 20 percent.

Note: Type of sponsor is defined as the entity that is ultimately responsible for financing the health care bill, such as private businesses, households, and governments. These sponsors pay health insurance premiums and out-of-pocket costs, or finance health care through dedicated taxes and/or general revenues.

The Israel-Palestine Conflict: A Brief, Simple History

In this video, Vox outlines the key points of the Israel Palestine conflict. It begins with the fall of the Ottoman Empire after World War I, the rise of Palestinian nationalism and Zionism – the belief that Judaism is a nationality and that Jewish people deserve a nation of their own. 

This history of the conflict then looks at the migration of Jewish people during and after WWII, the tension in the area, international support for a state of Israel and the UN proposal in 1947 to divide the area into two states with Jerusalem as an international zone. It tracks the conflict through: the Arab-Israeli war 1948-1949, the 1967 Six Days War; the Camp David Accords in 1978 that resulted in Israel giving Sinai back to Egypt; the rise of the Palestinian Liberation Organization; Jewish settlements in Gaza and the West Bank, the first and second Intifada; the Oslo Accords, and the assassination the Prime Minister of Israel Yitzhak Rabin.

The video ends with the description that much of the history of the conflict “shows how extremists on both sides can use violence to derail peace and keep a permanent conflict going.” Vox is uncertain about where the situation will lead but they do not see an end in sight.


National Health Expenditures Fact Sheet

NHE grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP).

Medicare spending grew 4.5% to $646.2 billion in 2015, or 20 percent of total NHE.

Medicaid spending grew 9.7% to $545.1 billion in 2015, or 17 percent of total NHE.

Private health insurance spending grew 7.2% to $1,072.1 billion in 2015, or 33 percent of total NHE.

Out of pocket spending grew 2.6% to $338.1 billion in 2015, or 11 percent of total NHE.

Hospital expenditures grew 5.6% to $1,036.1 billion in 2015, faster than the 4.6% growth in 2014.

Physician and clinical services expenditures grew 6.3% to $634.9 billion in 2015, a faster growth than the 4.8% in 2014.

Prescription drug spending increased 9.0% to $324.6 billion in 2015, slower than the 12.4% growth in 2014.

The largest shares of total health spending were sponsored by the federal government (28.7 percent) and the households (27.7 percent).   The private business share of health spending accounted for 19.9 percent of total health care spending, state and local governments accounted for 17.1 percent, and other private revenues accounted for 6.7 percent.

Projected NHE, 2016-2025:

National health spending is projected to grow at an average rate of 5.6 percent per year for 2016-25, and 4.7 percent per year on a per capita basis.

Health spending is projected to grow 1.2 percentage points faster than Gross Domestic Product (GDP) per year over the 2016-25 period; as a result, the health share of GDP is expected to rise from 17.8 percent in 2015 to 19.9 percent by 2025.

Throughout the 2016-25 projection period, growth in national health expenditures is driven by projected faster growth in medical prices (from historically low growth in 2015 of 0.8 percent to nearly 3 percent by 2025). This faster expected growth in prices is partially offset by projected slowing growth in the use and intensity of medical goods and services.

Although the largest health insurance coverage impacts from the Affordable Care Act’s expansions have already been observed in 2014-15, the insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent in 2025.Health spending growth by federal and state & local governments is projected to outpace growth by private businesses, households, and other private payers over the projection period (5.9 percent compared to 5.4 percent, respectively) in part due to ongoing strong enrollment growth in Medicare by the baby boomer generation coupled with continued government funding dedicated to subsidizing premiums for lower income Marketplace enrollees.

This expectation is mainly a result of continued anticipated growth in private health insurance enrollment, in particular for employer-sponsored insurance, during the first half of the decade in response to faster projected economic growth.

National health spending growth is projected to have decelerated from 5.8 percent in 2015 to 4.8 percent in 2016 as the initial impacts associated with the Affordable Care Act’s major coverage expansions fade. Medicaid spending growth is projected to have decelerated sharply from 9.7 percent in 2015 to 3.7 percent in 2016 as enrollment growth in the program slowed significantly. Similarly, private health insurance spending growth is projected to have slowed from 7.2 percent in 2015 to 5.9 percent in 2016 (also largely attributable to slowing expected growth in enrollment).

Health spending is projected to grow 5.4 percent in 2017 related to faster growth in Medicare and private health insurance spending.

Health expenditures are projected to grow at an average rate of 5.9 percent for 2018-19, the fastest of the sub-periods examined, as projected spending growth in Medicare and Medicaid accelerates.

Through the second half of the projection (2020-25), increasing medical prices are offset by projected decelerations in growth in the use and intensity of medical goods and services, leading to average growth of 5.8 percent per year for national health expenditures.

NHE by Age Group and Gender, Selected Years 2002, 2004, 2006, 2008, 2010, and 2012:

Per person personal health care spending for the 65 and older population was $18,988 in 2012, over 5 times higher than spending per child ($3,552) and approximately 3 times the spending per working-age person ($6,632).

In 2012, children accounted for approximately 25 percent of the population and slightly less than 12 percent of all PHC spending.

The working-age group comprised the majority of spending and population in 2012, almost 54 percent and over 61 percent respectively.

The elderly were the smallest population group, nearly 14 percent of the population, and accounted for approximately 34 percent of all spending in 2012.

Per person spending for females ($8,315) was 22 percent more than males ($6,788) in 2012.

In 2012, per person spending for male children (0-18) was 9 percent more than females.  However, for the working age and elderly groups, per person spending for females was 28 and 7 percent more than for males.

NHE by State of Residence, 1991-2014:

In 2014, per capita personal health care spending ranged from $5,982 in Utah to $11,064 in Alaska.   Per capita spending in Alaska was 38 percent higher than the national average ($8,045) while spending in Utah was about 26 percent lower; they have been the lowest and highest, respectively, since 2012.

Health care spending by region continued to exhibit considerable variation. In 2014, the New England and Mideast regions had the highest levels of total per capita personal health care spending ($10,119 and $9,370, respectively), or 26 and 16 percent higher than the national average.   In contrast, the Rocky Mountain and Southwest regions had the lowest levels of total personal health care spending per capita ($6,814 and $6,978, respectively) with average spending roughly 15 percent lower than the national average.

For 2010-14, average growth in per capita personal health care spending was highest in Alaska at 4.8 percent per year and lowest in Arizona at 1.9 percent per year (compared with average growth of 3.1 percent nationally).

The spread between the highest and the lowest per capita personal health spending across the states has remained relatively stable over 2009-14. Accordingly, the highest per capita spending levels were 80 to 90 percent higher per year than the lowest per capita spending levels during the period.

Medicare expenditures per beneficiary were highest in New Jersey ($12,614) and lowest in Montana ($8,238) in 2014.

Medicaid expenditures per enrollee were highest in North Dakota ($12,413) and lowest in Illinois ($4,959) in 2014.

NHE by State of Provider, 1980-2014:

Between 2009 and 2014, U.S. personal health care spending grew, on average, 3.9 percent per year, with spending in North Dakota growing the fastest (6.7 percent) and spending in Rhode Island growing the slowest (2.5 percent).

In 2014, California’s personal health care spending was highest in the nation ($295.0 billion), representing 11.5 percent of total U.S. personal health care spending. Comparing historical state rankings through 2014, California consistently had the highest level of total personal health care spending, together with the highest total population in the nation. Other large states, New York, Texas, Florida, and Pennsylvania, also were among the states with the highest total personal health care spending.

Wyoming’s personal health care spending was lowest in the nation (as has been the case historically), representing just 0.2 percent of total U.S. personal health care spending in 2014. Vermont, Alaska, North Dakota, and South Dakota were also among the states with the lowest personal health care spending in both 2014 and historically. All these states have smaller populations.

Gross Domestic Product (GDP) by state measures the value of goods and services produced in each state. Health spending as a share of a state’s GDP shows the importance of the health care sector in a state’s economy. As a share of GDP, Maine ranked the highest (22.3 percent) and Wyoming ranked the lowest (9.3 percent) in 2014.