Month: May 2017

H.R. 1628, American Health Care Act Of 2017: Summary Of Cost Estimate

CBO and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of H.R. 1628, the American Health Care Act of 2017, as passed by the House of Representatives.

CBO and JCT estimate that enacting that version of H.R. 1628 would reduce the cumulative federal deficit over the 2017-2026 period by $119 billion. That amount is $32 billion less than the estimated net savings for the version of H.R. 1628 that was posted on the website of the House Committee on Rules on March 22, 2017, incorporating manager’s amendments 4, 5, 24, and 25. (CBO issued a cost estimate for that earlier version of the legislation on March 23, 2017.)

In comparison with the estimates for the previous version of the act, under the House-passed act, the number of people with health insurance would, by CBO and JCT’s estimates, be slightly higher and average premiums for insurance purchased individually—that is, nongroup insurance—would be lower, in part because the insurance, on average, would pay for a smaller proportion of health care costs. In addition, the agencies expect that some people would use the tax credits authorized by the act to purchase policies that would not cover major medical risks and that are not counted as insurance in this cost estimate.

Effects on the Federal Budget

CBO and JCT estimate that, over the 2017-2026 period, enacting H.R. 1628 would reduce direct spending by $1,111 billion and reduce revenues by $992 billion, for a net reduction of $119 billion in the deficit over that period. The provisions dealing with health insurance coverage would reduce the deficit, on net, by $783 billion; the noncoverage provisions would increase the deficit by $664 billion, mostly by reducing revenues.

The largest savings would come from reductions in outlays for Medicaid and from the replacement of the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance with new tax credits for nongroup health insurance (see figure below). Those savings would be partially offset by other changes in coverage provisions—spending for a new Patient and State Stability Fund, designed to reduce premiums, and a reduction in revenues from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance. The largest increases in the deficit would come from repealing or modifying tax provisions in the ACA that are not directly related to health insurance coverage—such as repealing a surtax on net investment income, repealing annual fees imposed on health insurers, and reducing the income threshold for determining the tax deduction for medical expenses.



Pay-as-you-go procedures apply because enacting H.R. 1628 would affect direct spending and revenues. CBO and JCT estimate that enacting H.R. 1628 would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2027. CBO has not completed an estimate of the potential impact of the legislation on discretionary spending, which would be subject to future appropriation action.

Effects on Health Insurance Coverage

CBO and JCT broadly define private health insurance coverage as consisting of a comprehensive major medical policy that, at a minimum, covers high-cost medical events and various services, including those provided by physicians and hospitals. The agencies ground their coverage estimates on that widely accepted definition, which encompasses most private health insurance plans currently offered in the group and nongroup markets. The definition excludes policies with limited insurance benefits (known as mini-med plans); “dread disease” policies that cover only specific diseases; supplemental plans that pay for medical expenses that another policy does not cover; fixed-dollar indemnity plans that pay a certain amount per day for illness or hospitalization; and single-service plans, such as dental-only or vision-only policies. In this estimate, people who have only such policies are described as uninsured because they do not have financial protection from major medical risks.

CBO and JCT estimate that, in 2018, 14 million more people would be uninsured under H.R. 1628 than under current law. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 23 million in 2026. In 2026, an estimated 51 million people under age 65 would be uninsured, compared with 28 million who would lack insurance that year under current law. Under the legislation, a few million of those people would use tax credits to purchase policies that would not cover major medical risks.

Stability of the Health Insurance Market

Decisions about offering and purchasing health insurance depend on the stability of the health insurance market—that is, on the proportion of people living in areas with participating insurers and on the likelihood of premiums’ not rising in an unsustainable spiral. The market for insurance purchased individually with premiums not based on one’s health status—that is, nongroup coverage without medical underwriting—would be unstable if, for example, the people who wanted to buy coverage at any offered price would have average health care expenditures so high that offering the insurance would be unprofitable.

Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan. The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, some areas of the country have limited participation by insurers in the nongroup market under current law. Several factors could lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.

Under the Legislation. CBO and JCT anticipate that, under H.R. 1628, nongroup insurance markets would continue to be stable in many parts of the country. Although substantial uncertainty about how the new law would be implemented could lead insurers to withdraw from or not enter the nongroup market, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with low health care expenditures, and grants to states from the Patient and State Stability Fund, which would lower premiums by reducing the costs to insurers of people with high health care expenditures.

The agencies expect that the nongroup market in many areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain waivers from market regulations. Even though the new tax credits, which would take effect in 2020, would be structured differently from the current subsidies and would generally be less generous for those receiving subsidies under current law, other changes (including the money available through the Patient and State Stability Fund) would, in the agencies’ view, lower average premiums enough to attract a sufficient number of relatively healthy people to stabilize the market.

However, the agencies estimate that about one-sixth of the population resides in areas in which the nongroup market would start to become unstable beginning in 2020. That instability would result from market responses to decisions by some states to waive two provisions of federal law, as would be permitted under H.R. 1628. One type of waiver would allow states to modify the requirements governing essential health benefits (EHBs), which set minimum standards for the benefits that insurance in the nongroup and small-group markets must cover. A second type of waiver would allow insurers to set premiums on the basis of an individual’s health status if the person had not demonstrated continuous coverage; that is, the waiver would eliminate the requirement for what is termed community rating for premiums charged to such people. CBO and JCT anticipate that most healthy people applying for insurance in the nongroup market in those states would be able to choose between premiums based on their own expected health care costs (medically underwritten premiums) and premiums based on the average health care costs for people who share the same age and smoking status and who reside in the same geographic area (community-rated premiums). By choosing the former, people who are healthier than average would be able to purchase nongroup insurance with relatively low premiums.

CBO and JCT expect that, as a consequence, the waivers in those states would have another effect: Community-rated premiums would rise over time, and people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all—despite the additional funding that would be available under H.R. 1628 to help reduce premiums. As a result, the nongroup markets in those states would become unstable for people with higher-than-average expected health care costs. That instability would cause some people who would have been insured in the nongroup market under current law to be uninsured. Others would obtain coverage through a family member’s employer or through their own employer.

Effects on Premiums and Out-of-Pocket Payments

CBO and JCT projected premiums for single policyholders under H.R. 1628 (before any tax credits were applied) and compared those with the premiums projected under current law for policies purchased in the nongroup market. H.R. 1628, as passed by the House, would tend to increase such premiums before 2020, relative to those under current law—by an average of about 20 percent in 2018 and 5 percent in 2019, as the funding provided by the act to reduce premiums had a larger effect on pricing.

Starting in 2020, however, average premiums would depend in part on any waivers granted to states and on how those waivers were implemented and in part on what share of the funding available from the Patient and State Stability Fund was applied to premium reduction. To facilitate the analysis, CBO and JCT examined three general approaches states could take to implement H.R. 1628. Because a projection of a specific state’s actions would be highly uncertain, the agencies’ estimates reflect an assessment of the probabilities of different outcomes, without any explicit predictions about which states would make which decisions. CBO and JCT estimate the following:

  • About half the population resides in states that would not request waivers regarding the EHBs or community rating, CBO and JCT project. In those states, average premiums in the nongroup market would be about 4 percent lower in 2026 than under current law, mostly because a younger and healthier population would be purchasing the insurance. The changes in premiums would vary for people of different ages. A change in the rules governing how much more insurers can charge older people than younger people, effective in 2019, would directly alter the premiums faced by different age groups, substantially reducing premiums for young adults and raising premiums for older people.
  • About one-third of the population resides in states that would make moderate changes to market regulations. In those states, CBO and JCT expect that, overall, average premiums in the nongroup market would be roughly 20 percent lower in 2026 than under current law, primarily because, on average, insurance policies would provide fewer benefits. Although the changes to regulations affecting community rating would be limited, the extent of the changes in the EHBs would vary widely; the estimated reductions in average premiums range from 10 percent to 30 percent in different areas of the country. The reductions for younger people would be substantially larger and those for older people substantially smaller.
  • Finally, about one-sixth of the population resides in states that would obtain waivers involving both the EHBs and community rating and that would allow premiums to be set on the basis of an individual’s health status in a substantial portion of the nongroup market, CBO and JCT anticipate. As in other states, average premiums would be lower than under current law because a younger and healthier population would be purchasing the insurance and because large changes to the EHB requirements would cause plans to a cover a smaller percentage of expected health care costs. In addition, premiums would vary significantly according to health status and the types of benefits provided, and less healthy people would face extremely high premiums, despite the additional funding that would be available under H.R. 1628 to help reduce premiums. Over time, it would become more difficult for less healthy people (including people with preexisting medical conditions) in those states to purchase insurance because their premiums would continue to increase rapidly. As a result of the narrower scope of covered benefits and the difficulty less healthy people would face purchasing insurance, average premiums for people who did purchase insurance would generally be lower than in other states—but the variation around that average would be very large. CBO and JCT do not have an estimate of how much lower those premiums would be.

Although premiums would decline, on average, in states that chose to narrow the scope of EHBs, some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care. People living in states modifying the EHBs who used services or benefits no longer included in the EHBs would experience substantial increases in out-of-pocket spending on health care or would choose to forgo the services. Services or benefits likely to be excluded from the EHBs in some states include maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits. In particular, out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the nongroup enrollees who would use those services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed. That could happen, for example, to some people who use expensive prescription drugs. Out-of-pocket payments for people who have relatively high health care spending would increase most in the states that obtained waivers from the requirements for both the EHBs and community rating.

Uncertainty Surrounding the Estimates

The ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by the legislation are all difficult to predict, so the estimates discussed in this document are uncertain. In particular, states would have a wide range of options—notably, the optional waivers discussed above that would allow them to modify the minimum set of benefits that must be provided by insurance sold in the nongroup and small-group markets and that would permit medical underwriting for people who did not demonstrate continuous coverage. The array of market regulations that states could implement makes estimating the outcomes especially uncertain. But, throughout, CBO and JCT have endeavored to develop estimates that are in the middle of the distribution of potential outcomes.

Macroeconomic Effects

Because of the magnitude of its budgetary effects, this legislation is “major legislation,” as defined in the rules of the House of Representatives. Hence, it triggers the requirement that the cost estimate, to the greatest extent practicable, include the budgetary impact of its macroeconomic effects. However, because of the limited time available to prepare this cost estimate, quantifying and incorporating those macroeconomic effects have not been practicable.

Intergovernmental and Private-Sector Mandates

JCT and CBO have determined that H.R. 1628, as passed by the House, would impose no intergovernmental mandates as defined in the Unfunded Mandates Reform Act (UMRA). JCT and CBO have determined that the legislation would impose private-sector mandates as defined in UMRA. On the basis of information from JCT, CBO estimates the aggregate cost of the mandates would exceed the annual threshold established in UMRA for private-sector mandates ($156 million in 2017, adjusted annually for inflation).

The Climate Fight Reaches Its Crucial Stage

An IPFW Omnibus Lecture Series video presentation featuring the outstanding writer, educator, scholar, athlete, grassroots organizer and environmental activist Bill McKibben.


Speech At The Global Solutions T20 Summit

On May 20th, 2017, Professor Jeffrey Sachs addressed the Global Solutions T20 Summit in Berlin. In this speech, Sachs puts our current economic, social and environmental crises into historical context and addresses the importance of new ideas and solutions to the most pressing issues facing the world today, specifically those in the 2030 agenda of Sustainable Development Goals that were unanimously decided upon in September 2015 by a group of world leaders.


7 Economic Fundamentals

The need for more wealth to the working class is explained in this video by outlining the seven economic fundamentals that demonstrate the problematic nature of the nation’s current wealth distribution – including policies to help working families and how the wealthy do better in a growing economy. 


Jane Sanders Receives Public Servant Of The Year Award, RFJ 2017

Above Photo: Executive Director of The Sanders Institute Dave Driscoll, Co-founder and Fellow of The Sanders Institute Dr. Jane O’Meara Sanders and Vermont Senator Bernie Sanders at the Consumer Watchdog 2017 Rage for Justice Awards, May 6, 2017.


Consumer Watchdog hosts the Rage for Justice Awards to honor the heroes and heroines of the public interest movement. The awards are named after Congressman Phillip Burton, one of the most productive and driven progressive legislators in American history. His story is told in John Jacobs’ acclaimed book A Rage for Justice. This year’s honorees included Bernie & Jane Sanders, Chris Spagnoli, and Jackson Browne.




Good evening. And thank you for that amazing video! As you can see, Bernie and I have been together for quite some time – 36 years actually – and we’ve grown older and wiser – most obviously older.

I want to start by thanking all of you for coming out tonight and being part of this important organization. It’s more vital than ever to have groups like Consumer Watchdog out there, fighting for ordinary citizens.

When we received your letter inviting us to be honorees tonight, there was a line describing you all.

It said: “We have been called hell raisers, bomb throwers, trouble makers.”

“Wonderful,” I thought. These are our people!

Bernie and I are both so honored to be here tonight to receive an award from Consumer Watchdog, an organization we respect so much.  I especially love that we’re being recognized for public service, as that is what brought us together and it is what has sustained us – along with our family – throughout the years.

Speaking of family, we are very happy that our son, Dave, could be here with us tonight.

You’re all familiar with Bernie’s campaign for President, aren’t you?

During that campaign, we travelled around the country, talking to people and listening to their stories. Hearing about their hardships. Finding out about their dreams.

Bernie might not have won the election, but he definitely made a difference. And because of his strong standing with the people, we have something of a bully pulpit right now – and we are using it. To talk about issues that we feel are not getting enough attention. To talk about issues that people do not always want to talk about – would rather sweep under the rug.

We want to be advocates for the victims of injustice – like you are.  To rage against injustice – like Congressman Phil Burton so famously did.

In your invitation to us, you said: “Our honorees share a singular intensity, an unremitting indignation, a profound refusal to accept unfairness that impels them to the pursuit of justice.”

We share that indignation. That intensity. And I want to talk to you about the profound unfairness that is most on my mind right now.

Because it happened exactly one week ago, tonight. And it happened to a young man named Jordan Edwards.

For those of you who don’t know, Jordan was a fifteen year-old Texas teenager. An honors student. A beloved friend. Kind, studious, optimistic, loving.

Last Saturday night he made the terrible mistake of thinking he could do what every other 15 year-old likes to do on a Saturday night. He went to a house party.

He went with his brothers and a couple friends. When the party got big and rowdy – behaving responsibly – they decided to leave.

Unfortunately, they were driving away just as a couple of police officers were walking up to the house, and for some unknown reason – they were doing nothing wrong, they were driving away from the party – one of the officers decided to shoot into the car.

With a rifle. Repeatedly.

He shot and killed Jordan Edwards.

This story is too familiar. The specifics may change. And this one has an even more tragic element as Jordan’s brothers had to witness it, be kept away from him and be arrested.

Body cam footage made it clear that they did nothing wrong.

But this was a car of young black men.

Wouldn’t it be nice if body cam footage could reveal not just what happened on the street that night, but why?

Wouldn’t it be nice if we knew what role racism played in what happened to this young man?

We can’t know for certain.  But we do know this. The shooting was unjustifiable.

Jordan’s death, like far too many black boys who have been murdered, apparently, just for being black – is unjustifiable.

That mothers and fathers have to warn their kids to stay inside after dark because they’re afraid of the police, is unjustifiable.

Traveling around the country in the past year, my husband and I have come face to face with all kinds of discrimination based on race, ethnicity, religion, sexual orientation or station in life.

Native Americans having inadequate health care and education on their reservations. And having little to no say on matters of criminal justice.

Immigrant families living in constant fear of being detained, deported or split up.

Seniors, people in need, forgotten. Watching their social safety net being slashed first, by their states, and now, by the federal government.

People with pre-existing medical conditions, including mental health illnesses. Fearful of what the health care bill just passed by the US House will mean to their stability, their dignity, their health – even their life expectancy.

Children in low-income areas receiving a very different education in their schools than their peers – and they are their peers – in wealthy communities.

People in poor communities across this nation unable to drink the water that comes out of the tap and, in Flint Michigan, being evicted because they can’t pay the exorbitant water bills.

Working families unable to find decent paying jobs. Unable to afford decent housing or the medication they need to stay alive.

We spent a lot of time with real people on the road. And we learned a lot.

That is why I am so honored by your recognition.  Because it is you, who deserve to be acknowledged. You, who passionately defend the defenseless. You, who dedicate every waking hour to preventing consumers from being exploited.  You, who speak out and seek to address bias.

You, who work toward a world where boys like Jordan Edwards have opportunities instead of eulogies.

I realize this is a big topic for a small speech, but I couldn’t speak out for justice tonight without honoring Jordan. And he is not alone. There are many other boys and girls whose promising future is being withheld from them – and parents who are doing the best they can with less and less opportunity in their communities. Too many have to face the ultimate injustice that Jordan, his brothers and parents endured. Too many have to live without fathers or mothers, as Erika Garner and Cameron Sterling do.

Many, many, many others are enduring a daily, insidious racism or discrimination. This is an issue that needs to be admitted, openly discussed, confronted and finally defeated in this country.

Re-dedicating ourselves to justice is the least we can do for the all-too-many people of color and the most vulnerable among us who live in fear everyday. It’s the least we can do for the working class people who are – often against the odds – struggling to live their lives in dignity.

We can stop this madness – if, and only if – we – together – stand up, fight back, fight for what we know is right.

We need to stand together to help the 43 million Americans who live in poverty, climb their way out of it.

We need to stand together to create new jobs; invest in sustainable economies and renewable energy; and make sure that people earn a living wage.

We need to stand together to protect the Fourth amendment and our right to privacy and to stop what – if you listened to FBI Director Comey’s testimony before Congress this week – appears to be unfettered surveillance.

You, at Consumer Watchdog, are willing to stand up and fight back and You understand what the important issues are for the working men and women of this country.

I am proud to stand with you and I promise to continue to stand up, fight back and to earn this gracious award for public service, from this truly honorable organization.

Thank you so much.

And now, I present to you, my hero, my husband, Bernie Sanders.

California Water Fix Is The Biggest Water Problem State Has Ever Faced

In the midst of a 300-mile trek and prayer journey to bring salmon back to the McCloud River, the Winnemem Wintu Tribe and their allies converge on the State Capitol to demand a change in California’s water policy.

Chief Sisk exposed the folly of Brown’s “legacy project,” the Delta Tunnels, at her speech at the “March for Science” on Earth Day 2017 before a crowd of 15,000 people at the State Capitol in Sacramento.

She pointed out how the tunnels, rather than achieving the co-equal goals of water supply reliability and ecosystem restoration, would instead devastate salmon and other fish populations while doing nothing to supply clean drinking water for people in impoverished rural communities in the San Joaquin Valley.

“The California Water Fix is the biggest water problem, the most devastating project, that Californians have ever faced,” said Chief Sisk. “Just ask the people in the farmworker communities of Seville and Alpaugh, where they can’t drink clean water from the tap.”

“The twin tunnels won’t fix this problem. All this project does is channel Delta water to water brokers at prices the people in the towns can’t afford,” she stated.

Sisk said  the Winnemem Wintu Tribe opposes the Tunnels for two main reasons.

“First, it will disrupt and destroy the sensitive nursery for fish and all aquatic life,” said Sisk.

The San Francisco Bay-Delta is the largest estuary on the West Coast of the Americas. It is not only essential to the health of salmon and steelhead populations, but is a crucial spawning ground, nursery and habitat for Delta and longfin smelt, Sacramento splittail, Pacific anchovies, herring, sardines, California halibut, leopard sharks, sevengill and sixgill sharks, starry flounder, Dungeness crab and a host of other fish species.

Second, the state and federal governments are building the tunnels at such a large capacity —  35 miles long with a full capacity of 9,000 cfs — that “it would mean the death of the salmon,” said Sisk. At times of low flows in the Sacramento River, 9000 cfs would amount to the entire flow of the Sacramento into the Delta.

“Why else would they build the tunnels that big?” asked Sisk. “It seems it would be a waste of money for the water contractors not to provide more water in the project.”

She pointed out how modern science is just beginning to catch up with indigenous science, Traditional Ecological Knowledge (TEK).

“Indigenous people were the first scientists,” Chief Sisk emphasized. “Indigenous knowledge has been here since the beginning of time. It’s not learned in a book or academic setting. It’s learned in real time over time.”

She gave the example of how indigenous people would make a net to scoop up salmon and other fish and move them upriver if the water was too shallow for them to ascend the stream.

“Traditional science goes against the tunnels,” she said. “By the time modern science catches up with the traditional knowledge, the salmon will be destroyed, if the tunnels are built.”

In fact, federal scientists largely agree with Chief Sisk’s assessment that the tunnels will devastate salmon and other fish species — and disagree with Governor Brown’s claim that “best scientific thinking” supports the construction of the tunnels.

The National Marine Fisheries Service (NMFS) has released a draft biological opinion documenting the harm the tunnels would cause to salmon, steelhead, Delta and longfin smelt, other fish and wildlife species, and water quality.

An independent peer review panel found the NMFS findings are backed  by  comprehensive analyses, new data, and modeling. The panel further found NMFS used the “best available science” and produced evidence of “significant adverse impacts” to species and critical habitat, including unacceptable harm to salmon.

“If we follow the salmon, it will be good, the water will be good,” she said. “We have to do a paradigm shift. Science has been here a long time — and indigenous people have had their knowledge for thousands of years, with the smallest footprints in the world.”

The Tribe is currently engaged in an ambitious effort to bring back eggs from the McCloud winter-run Chinook salmon that are now thriving in the Rakaira River in New Zealand to repopulate the McCloud above Lake Shasta.

She pointed out the irony of the Tribe being required by federal officials to do testing of winter-run Chinook salmon that were transplanted from the Livingston Stone Fish Hatchery on the McCloud “so that scientists know that they are our fish.  We already know that they are our fish,” she stated.

She said California should take advantage of the opportunity to bring the salmon back, creating both a better environment and a big boon to the economy when salmon fisheries are robust.

“If we could change California back to a fish state, the waters will be cleaner,” she noted. “I hope that as many people who are marching for science today would one day march for the salmon.”

She encouraged people to attend the Winnemem Run4Salmon from September 9 through September 23. The event will begin at Sogorea Tea, a sacred burial site in Carquinez Strait in Vallejo, and conclude on the Tribe’s ancestral river, the McCloud above Shasta Dam.

During the run last year, Chief Sisk said the Delta Tunnels, if built, will not only cause “more death and destruction” to already endangered salmon populations, but will “encourage and motivate” federal plans to enlarge the giant Shasta Dam that impounds the waters of the Sacramento, McCloud and Pit rivers.

“We consider Shasta Dam a weapon of mass destruction,” explained Chief Sisk. “It has already taken our homes, sacred sites, burial sites, and stopped the salmon from returning to their historical spawning grounds.”

“If these tunnels are built, Governor Brown’s so called ‘California WaterFix,’ they will not only cause more death and destruction to the already endangered salmon, but they will encourage and motivate plans to enlarge Shasta Dam. An enlarged Shasta Dam will flood what remaining sacred sites, and cultural sites that we still use today,” she concluded.

The Delta Tunnels project also threatens imperiled salmon on the Trinity and Klamath rivers, since Trinity River water is diverted from Trinity Lake to the Sacramento River watershed to supply San Joaquin Valley corporate agribusiness interests with subsidized water.

This year’s run of Klamath River fall Chinook salmon is projected to be the smallest in history — 11,000 fish, about 10% of average for the last 3 decades — causing great hardship this year to the Yurok, Hoopa Valley and Karuk Tribes that have fished for salmon on the Klamath and Trinity rivers for thousands of years.


With plans to build new Dams and expand existing ones, and proposing to build two forty-foot Tunnels to divert more water out of the Delta, the stakes could not be higher for all of Californian.  Fish species are on the verge of extinction.  Disadvantaged Communities, subsistence fishermen, and small family farmers could see their water and way of life disappear altogether.  And, the Winnemem Wintu Tribe, who suffered over 90% loss of their traditional homeland, sacred sites, and cultural gathering sites along the Sacramento, McCloud and Pit Rivers when Shasta Dam was built, will again suffer the brunt of this destructive water policy.

The Winnemem Wintu and their allies have embarked on a 300-mile prayer journey from Sogorea Te (Glen Cove, Vallejo) to the historical spawning grounds of the winter-run salmon on the McCloud River.  This journey is a walk/run/boat/bike and horseback ride to bring attention to the plight of all the runs of salmon in California, and the water management practices that have brought some of those runs to the edge of extinction.  It is a prayer to let Californians know that the water they enjoy has come to them at the cost of others and the threat of death and extinction to species necessary for a healthy California.

Chief Caleen Sisk of the Winnemem Wintu Tribe says, “We consider Shasta Dam a weapon of mass destruction.  It has already taken our homes, sacred sites, burial sites, and stopped the salmon from returning to their historical spawning grounds.  If these tunnels are built, Governor Brown’s so called ‘California WaterFix’, they will not only cause more death and destruction to the already endangered salmon, but they will encourage and motivate plans to enlarge Shasta Dam.  An enlarged Shasta Dam will flood what remaining sacred sites, and cultural sites that we still use today.”

Barbara Barrigan-Parrilla, Executive Director for Restore the Delta states, “Restore the Delta stands today with the Winnemem Wintu calling on Governor Brown to abandon a failed water plan for California.  The era of unlimited water resource development is over.  As we revealed last week in the state’s own economic analysis, the only way to make the Delta tunnels pencil out in terms of water delivery is to take even more water from the Delta — which will finish off its fisheries, its entire ecosystem.  And to make matters worse, the government expects you and me to pay for this destruction with our taxes.”

Trent Orr, a lawyer for Earthjustice, which represents the Winnemem Wintu in various legal fights to protect and restore salmon, said:

“The Sacramento River’s salmon runs are an emblem of wild California and its mountain-born rivers.  The Winnemem Wintu Tribe has long fought to save these fish, which are central to their culture, and to restore health to the waters they need to thrive.  But it has been an uphill battle.  Much of the Tribe’s homeland was drowned by Shasta Dam, and the salmon’s access to the cold, clean spawning grounds above the dam, to which they had returned for eons, was blocked.  Plans to raise the dam and to pump even more fresh water out of the Sacramento River via the governor’s proposed giant tunnels could doom the salmon, already perilously close to extinction.  The dam raise would also drown much of what’s left of the Tribe’s homeland.  Earthjustice is proud to have represented the Tribe in many of its legal battles to save and restore the salmon.  On behalf of the Tribe and its allies, we will continue to fight for the day when wild salmon again spawn in the headwaters of the Sacramento.”

In written testimony submitted to the State Water Resources Control Board, for the ongoing hearings regarding the Bureau of Reclamation’s and the Department of Water Resource’s water diversion change petition regarding the California WaterFix, Winnemem Wintu Governmental Liaison Gary Mulcahy asks,

“Drowned cultures, dead and extinct fish, broken promises, stolen lands, environmental destruction, water grabs, and years and years of litigation – is it truly worth it?

Can “Trumponomics” Extend The Recovery?

Donald Trump was elected President of the United States as the U.S. economy headed into its eighth year of expansion following the deepest and most protracted recession of the post WWII era. Since the start of the recovery in June 2009, real GDP growth has averaged a reliable 2.1 percent, and the labor market has clawed back all of the 8.7 million jobs that were lost in the aftermath of the financial crisis. Inflation has remained low, and the official unemployment rate had fallen to just 4.6 percent in November 2016. Goldilocks might have declared the porridge to be just right.

To some observers, this looked like a pretty decent backdrop against which to make the case for a continuation of the Obama-era policies that many credited with finally healing the wounds of the Great Recession. While not blazing hot, the American economy was growing and creating jobs, and many believed that Hillary Clinton could best her opponent by pledging to build on the achievements of the past with a fiscally responsible, steady-as-she-goes agenda. Yuge changes were unnecessary, she insisted. America was already great.

Many voters had other opinions, along with vastly different lived experiences. The tailwinds that were supposed to propel the first woman into the Oval Office met their fiercest resistance in the so-called Rust Belt states, where people who had seen their lives and their communities transformed by decades of disinvestment and disenfranchisement decided to roll the dice on a foul-mouthed reality TV star with no experience in public office.

I’m not going to spend time diagnosing the decades-long forces that gave rise to Donald Trump. For that, I recommend Thomas Frank’s excellent book, Listen, Liberal or Matthew Stoller’s outstanding piece in The Atlantic, “How Democrats Killed Their Populist Soul”. What I am interested in pursuing here is a different question altogether – now that we have President Trump, what will he and his Republican colleagues do? Which constituencies will Trump fight for, and can the GOP hold together to deliver any substantive legislative victories for the new president?

Some argue that Trump’s policies pose major downside risks to the U.S. economy. Others see the potential for an upside surprise, at least in the near term. What will President Trump do, and will his policies work as advertised? No one can say for sure. What we do know is that the voters who delivered the White House to Mr Trump are counting on him to deliver real improvements in their lives. This means that simply extending the recovery may not be enough to hang on to the Obama voter who crossed over to give her vote to Donald Trump. To retain the support of these voters, Trump’s policies must go beyond simply prolonging the recovery. They must promote the kind of growth that raises the living standards of millions of struggling Americans, lessens the share of total income going to profits and reverses the yawning gaps in the distribution of wealth and income. Unfortunately, these are not the stated goals of the Trump administration, so the remainder of this essay will focus on the narrower question: can “Trumponomics” extend the recovery?

Where are we today?

At 93 months of age, the U.S. economy is in the midst of its fourth-longest expansion since 1850. If we can extend the recovery for another two-and-a-half years, we will break the alltime record. For that to happen, the economy’s tailwinds must remain stronger than its headwinds. The broad consensus today is that the economy is very close to its full employment potential. And while few see a downturn in the near future, Goldman Sachs puts the risk of recession at about 1-in-4 through 2018Q3.

Whereas Janet Yellen recently gave the economy “a little more room to run,” she now argues that it is close to its potential, and she is preparing markets for a series of rate hikes beginning in March. Such a tightening cycle is consistent with the belief that the Fed’s dual-mandate has been broadly achieved and that there is little room for an acceleration of growth. Goldman’s Hatzius and Pandl (2016) agree:

“While expansions do not die of old age, history shows that they are at greater risk when spare capacity is exhausted, as it probably is now. So it is especially important to monitor whether growth may be running out of steam.”

Before we move to an analysis of “Trumponomics”, we should pause and ask two important questions. First, are we really near our full employment potential? Second, is there room for “Trumponomics” to extend the recovery?

It is probably safe to say that the consensus opinion among Fed economists and academic economists alike is that the economy has essentially returned to its full employment potential. That belief is consistent with the data reported in Figure 1, which shows that the gap between actual and potential GDP has been nearly eliminated.

But there is a problem here, at least in my view. The data depict an economy that is close to bumping up against its long-run ceiling, a constraint that many believe will frustrate Trump’s effort to get things running much hotter. However, there is something more we should know about the position of this ceiling.



As Larry Summers has shown, the bulk of the progress that was made in closing the output gap came, “not through the economy’s growth but through downward revisions in its potential” (2014, p. 66). In other words, as Figure 2 shows, output is near its full employment ceiling not because the economy rose to its potential but because we lowered the definition of what we believe our nation’s productive capacity to be. It’s a bit like giving up on the idea that your child is capable of achieving straight As, relaxing the goal to a 2.0 GPA, and then celebrating when he presents you with across-the-board Cs. Junior is now a high achiever!



To see what a difference these downward revisions make, consider what it would look like if today’s output gap was measured using the 2007 estimate of potential GDP (shown in Figure 2) rather than the revised estimate shown in Figure 1. Instead of full employment, we would be looking at a GDP gap of roughly 14 percent, or nearly $2 trillion.

Why did potential GDP get revised downward in the first place, and how much of that lost potential could be clawed back? The short answer to the first question is that the failure to bring about a swift recovery from the Great Recession imposed lasting harm on the economy. The answer to the second question may be among the most important of our time. And while I cannot offer a rigorous empirical estimate here, both history and theory suggest that there are ways to reverse at least some of the damage. Investments in infrastructure, education, R&D, etc., should help the U.S. reclaim some of the lost potential by boosting long-run productivity.

Even without the kinds of investments that would help nudge potential GDP northward, it still may be possible to safely accelerate growth. Whereas Goldman and Yellen10 see little slack left in the economy, new research from Dantas and Wray (2017) suggests that the U.S. labor market is still far from full employment. In their view, “we are not even close” to full employment, and “reaching full employment would require, on average, gains in payroll employment of 420,000 jobs per month for the next four years”. Nick Buffie (2016) agrees, arguing that, despite the low official unemployment rate, the labor market remains quite weak. If these assessments are correct, then it should be possible to squeeze more growth out of the economy in the short term. It also means that “Trumponomics” could surprise on the upside.

What is Trumponomics?

Less than three months into the Trump presidency, there is no formal budget and no precise blueprint that describes the full range of policies and programs that the administration intends to pursue. “Trumponomics”, therefore, is still very much a moving target, although we are beginning to see the broad contours of an economic agenda taking shape. Harvard economist and former U.S. Treasury Secretary, Larry Summers, sees “enormous uncertainty” ahead, adding:

“This is probably the largest transition ideologically and in terms of substantive policy in the last three quarters of a century.”

What is the ideological philosophy behind “Trumponomics” and how does it represent a break from the guiding principles of the last 75 years? As a presidential candidate, Donald Trump explained his thinking in this way:

“It’s called priming the pump. Sometimes you have to do that a little bit to get things going. We have no choice – otherwise, we are going to die on the vine…The economy would be crushed under Hillary. But no matter who it is, the debt is going to go up.”

To some economists, Trump’s economic approach sounded downright Keynesian.12 Channeling Bernie Sanders, he called for a trillion-dollar boost to infrastructure spending, along with (the usual Republican call for) deregulation and massive tax cuts. He was unapologetic about running budget deficits and adding to the national debt. But he combined the more Keynesian-inspired fiscal maneuvers with a protectionist trade agenda and a nationalist pledge to seal the borders and deport millions of undocumented people. On Social Security and Medicare, he sounded a more compassionate tone, vowing no cuts, and he even talked about bringing the U.S. into the 20th century by supporting paid family leave. As Figure 3 shows, this blend of policy positions makes it difficult to situate “Trumponomics” within a conventional ideological matrix.



So, what exactly is “Trumponomics”? The short answer is that it is too early to put concrete numbers the full range of proposals that will be coming down the pike. Mick Mulvaney, director of the Office of Management and Budget (OMG) is working on those numbers now, promising that “[a] full budget will contain the entire spectrum of what the president has proposed”. An early look at the numbers could come mid-March, when the Trump administration is expected to release a sneak preview of its plans in the form of a “skinny budget”.

For now, we know that the President’s FY18 Budget will call for a 10 percent increase in defense spending, along with equivalent ($54B) offsetting cuts to other federal agencies. The president has also pledged to make long-overdue investments in our nation’s infrastructure, promising, “we’re going to start spending on infrastructure – big”. Democrats have balked at both proposals, preferring traditional government-funded infrastructure investment to the widely-anticipated public-private schemes that are expected to form the basis of the Trump model. And they oppose the cannibalizing of the non-defense, discretionary budget as a means of allocating more resources to the military. As House Minority Leader Nancy Pelosi (D-CA) put it:

“A $54 billion cut will do far-reaching and long-lasting damage to our ability to meet the needs of the American people and win the jobs of the future. The President is surrendering America’s leadership in innovation, education, science and clean energy.”

Thus, Democrats are bracing for massive cuts that could more than offset any stimulus that might result from higher spending on infrastructure and defense. Just how big could these cuts be?

Some (Bolton, 2017) have suggested that Trump’s budget will closely track the Heritage Foundation’s Blueprint for Balance, which calls for $10.5 trillion in cuts over the next 10 years. The already-tiny amounts spent on the Corporation for Public Broadcasting (CPB), the National Endowment for the Arts (NEA) and the National Endowment for the Humanities (NEH) would be eliminated completely, and the departments of Justice, State, and Transportation would suffer deep cuts.

As all good Keynesians know, one person’s spending is another person’s income. So how is cutting $10.5 trillion in spending supposed to help to extend the recovery?

Ronald Reagan to the rescue?

During their first presidential debate, Hillary Clinton criticized Donald Trump’s approach to growing the economy, labeling it “Trumped up trickle down” economics. It was an obvious jab at the kind of supply-side policies that characterized the Reagan years. Rather than fight the comparison, Trump focused on the bigness of his agenda:

“By the way, my tax cut is the biggest since Ronald Reagan – I’m very proud of it.”

Hillary maintained that she and Trump had different economic philosophies, adding that giving the biggest tax cuts to the top percent “is not how we grow the economy.”

Nobel laureate Paul Krugman also compared Trump’s agenda with Reagan’s, predicting Trump’s policies “won’t actually do much to boost growth because [interest] rates will rise and there will be lots of crowding out. Also a strong dollar and bigger trade deficit, like Reagan’s morning after Morning in America.” And while it is true that interest rates rose sharply and America’s trade deficits ballooned under Reagan, it is also true (as Figure 4 shows) that the economy grew at a good clip during much of the Reagan era. Remember, Reagan was reelected in a landslide.



According to Harvard’s Ken Rogoff (2016), “Trumponomics” has the potential to really juice the American economy. “Even if you oppose Trump’s policies,” he says, “you’ve got to admit they are staunchly pro-business.” For this reason, Rogoff has cautioned against the kind of doomsday scenario described by Krugman, warning, “[b]eware of pundits who believe Trump will bring economic catastrophe”.

What Rogoff doesn’t say, however, is that the benefits of the Reagan expansions went overwhelmingly to those at the top of the income distribution. Tax cuts for the wealthy, attacks on unions, cuts to programs aimed at helping the poor and an obsession with deregulation and “free markets” shifted the balance of power toward owners of capital and ushered in an era of increasing insecurity and growing inequality for the working class. Figure 5 shows the remarkable shift in the distribution of income that began under Reagan.



Prior to the election of Ronald Reagan in 1980, the vast majority of Americans – the bottom 90 percent – received the lion’s share of the income generated in a growing economy. It wasn’t a utopia – there were still periods of high unemployment and maldistribution that left millions impoverished – but the bulk of the income produced during an economic expansion went to the vast majority of the population. After “Reaganomics,” however, things changed. The benefits of a growing economy were no longer broadly shared, as the top 10 percent began hauling in more than the bottom 90 percent. It’s a trend that has not only continued but one that has generally worsened over time.

Donald Trump isn’t promising to reverse these trends, though he is claiming that his policies will substantially boost the economy and improve life for millions of “forgotten” Americans. Specifically, the president has championed an agenda that the he says will deliver 3.5-4.0% growth, something the U.S. hasn’t experienced on any kind of sustained basis since the “Clinton Boom”. Judging from the details we have thus far, “Trumponomics” appears to be just what Hillary Clinton called it, a Trumped-up version of Reagan’s trickle-down recipe, with an added ingredient or two.

What do we know about Trump’s recipe for the economy? First, we know that the Trump administration has embraced the House Republican proposal to reduce the number of tax brackets from seven to three and to lower the marginal tax rate on the highest income earners from 39.6 percent to 33 percent. We also know that the president is proposing to eliminate the estate tax, cut the corporate income tax rate from 35% to 20%, and allow businesses to repatriate offshore profits at 10%. Finally, we know that even his health care plan is really just a massive tax cut for the rich. According the Center on Budget and Policy Priorities (2017), the 400 highest income earners in America would see an average tax cut of about $7 million a year if the Republicans succeed in repealing the Affordable Care Act. And while Trump says that his policies will improve life for the “forgotten Man”, the Tax Policy Foundation (TPF) has shown that the little guy isn’t getting much of anything when it comes to the proposed tax reforms. Indeed, TPF estimates that after-tax incomes for the top 1 percent of earners could surge by as much as 16 percent, while the bottom 80 percent could see an after-tax lift of just 1.9 percent. Meanwhile, the bottom quintile would end up with a paltry 0.8 percent boost in their take-home pay.

And then there’s Trump’s proposal for a regressive Border-Adjustment Tax (BAT).

“Like any tax, the tariff burden does not fall uniformly across goods, but falls more heavily on particular goods and the populations that purchase them” (Furman, et al. 2017).

Hence, the tariff burden is essentially a regressive tax. Furman, et al. estimate the distributional impacts of current US tariffs, which amount to $33 billion per year or around 0.2 percent of GDP. They find that tariffs cost the bottom 10-20 percent of households about $95 per month, while middle-income households pay about double that amount ($190 per month) and the richest 10% pay about $500 per month. While the rich pay more in absolute terms, Figure 6 shows that the tax is substantially regressive when you consider the burden relative to income. Taken together, Trumponomics includes a hefty serving of Reagan-inspired trickledown economics along with a side of protectionism, a dash of military Keynesianism and a social agenda that is anti-worker and anti-immigrant.



While the CEOs of some of America’s retail giants have taken aim at the proposed border tax, Wall Street appears to love where Trump is trying to take the economy. For example, Jamie Dimon, chairman and CEO of JPMorgan Chase & Co., says that Trump’s proposed tax cuts, deregulation and infrastructure investment have reawakened animal spirits. “If he gets it done, even part of it, it will be good for growth, good for jobs, good for Americans.”

Is it possible? Can Trump’s supply-side tax cuts and deregulation unleash a current of tailwinds strong enough to propel the economy forward even as they’re coupled with massive cuts in other programs (not to mention mass deportation and a possible trade war)? Most experts find it unlikely.

Can “Trumponomics” extend the recovery? No consensus among experts

For the most part, what follows is a brief overview of the macroeconomic consequences of “Trumponomics” as analyzed by the research staffs at Moody’s Analytics and Goldman Sachs. Both have produced forecasts for a range of macro variables – including real GDP, unemployment, inflation, interest rates, etc. – using different assumptions about what might ultimately come to pass as “Trumponomics”.

Over at Moody’s, Zandi, et al. (2016), looked at three scenarios. The first hews most closely to the agenda espoused by Donald Trump in speeches, interviews, tweets, etc. This scenario is referred to as the “Full Monty Trump” in Figure 7. A toned-down version is also examined, one in which Trump succeeds in getting his basic agenda adopted, though on a smaller scale. This is the “Trump Lite” scenario below. Finally, the Moody’s team simulates a “Washington Reality” scenario that assumes the kind of budget neutral program that Congress could actually pass.



In all three cases, Trump’s policies produce outcomes that are worse (over the full forecast horizon) than the baseline scenario, which assumes no change in current policy. Even in the best-case scenario (Washington Reality) where a recession is avoided, the economy averages just 1.7 percent annual growth over 10 years, well below the promise land of 3.5-4.0 percent. Under the worst-case scenario, the one that assumes all of Trump’s proposed policies become law, including tariffs and the deportation of millions of undocumented people, the economy enjoys a year or two of improved growth, but “a lengthy recession” follows, with 3.5 million fewer jobs and an unemployment as high as 7% by the end of his first term. The economy also does more poorly under the “Trump Lite” scenario, with Moody’s predicting a deep recession beginning in 2018 as unemployment climbs to 8.9% by 2020.

You might wonder whether Moody’s is uniquely pessimistic about the prospects for growth under a Trump administration. That’s a fair question, so let’s look at the analysis done by Goldman Sachs. Over at Goldman, Haztius and Stehn (2017) ran their own simulations, using the Federal Reserve’s economic forecasting model. Their results are shown in Figure 8.



Like Moody’s, the Goldman team found that Trump’s policies are a net negative for growth relative to the baseline (status quo). To get the extreme case, Goldman ran a “Full” Trump scenario that included $450 billion in fiscal stimulus (a combination of infrastructure investment and tax cuts), some reciprocal tariffs, and immigration restrictions that reduce the size of the labor force by 2.5 million compared with the Fed’s baseline projection. As Figure 9 shows, the Full Trump scenario juices the economy in the near term, but the effects of the stimulus quickly diminish, as the model assumes that limits on labor force growth begin to bind, slowing overall growth. As with Moody’s, Goldman doesn’t expect Trump to get everything he wants, so they also simulated a more realistic agenda (GS Expectation), which extends the economy’s growth rate above 2 percent for about an additional year. “Our simulations suggest that Mr Trump’s policies could boost growth slightly in 2017 and 2018, but are likely to weigh on growth thereafter if trade and immigration restrictions are enacted,” wrote Hatzius and Stehn.

Goldman differs from Moody’s in that “Trumponomics” does manage to extend the recovery through 2020, however growth doesn’t approach anything like the 3.5-4.0%. The bottom line is that, compared with the status quo scenario, both Goldman and Moody’s predict a smaller economy at the end of Trump’s first term.

It’s an astonishingly gloomy outlook that is shared by a number of high-profile academic economists. For example, Joseph Stiglitz, speaking at the ASSA meetings in Chicago, said, “There is a broad consensus that the kind of policies that [President Trump] has proposed are among the policies that will not work.” Harvard Professor and former U.S. Treasury Secretary, Larry Summers, believes financial markets are overly enthusiastic about “Trumponomics”, comparing their zeal to a “sugar high” that will dissipate as reality sets in. That reality includes the harmful effects of Trump’s immigration policies and his protectionist impulses, which many believe could drive up prices (of labor and imports), fueling higher inflation and causing the Fed to hike rates more aggressively. Finally, Paul Krugman notes that “Trumponomics” ultimately relies on a burst of supply-side tailwinds, powered by huge tax cuts, which, in his view, are unlikely to propel the economy through the gale force headwinds that will result from trillions in spending cuts:

“But the tax cuts will go to the wealthy, who won’t spend much of their windfall, while the spending cuts will fall on the poor and struggling workers, who will be forced into sharp cutbacks in spending. The overall effect on demand is therefore likely to be negative, not positive.”

Not everyone shares this glum perspective on “Trumpnomics”. As I noted above, Harvard’s Ken Rogoff remains optimistic. While he believes that “inflation is a near certainty”, he sees the potential for a doubling of growth, at least temporarily, cautioning against “pundits who believe Trump will bring economic catastrophe”.


President Trump has promised to “Make America Great Again”. Part of this pledge involves getting the U.S. economy growing at rates it hasn’t experienced in almost two decades. Many economists are skeptical of “Trumponomics” and doubt that his policies can extend the recovery, much less deliver the 3.5-4.0% growth he has crowed about.

My own view is that economists have probably displayed too much pessimism when it comes to the potential for higher economic growth. But that does not mean that I side with Rogoff entirely. As I see it, both Rogoff outcomes are possible. That is, “Trumponomics” – especially tax cuts and deregulation – could produce windfall gains that energize asset prices (stocks and even real estate), generating a strong – if temporary – wealth effect that leads to a surge in aggregate spending. If there is more slack in the economy than Moody’s or Goldman imagine, it seems reasonable to think that growth could surprise to the upside – 3.5 percent does not strike me as inconceivable.

But, as Figure 6 reminds us, growth alone does not prevent economic catastrophe. In other words, both outcomes – higher growth with catastrophic consequences – are possible. And the just-released “skinny budget” from the Office of Management and Budget (2017) certainly looks like a catastrophe for the sick, the poor, the middle-class and the planet. It includes a Reaganesque beefing up of the defense budget, along with massive cuts in non-defense discretionary spending. Couple this with the yet-to-be-announced cuts to non-discretionary spending (Social Security and Medicare) plus Trump’s proposed tax cuts, and you have Reagan on steroids, a full-throated trickle-up program designed to lock in gains for those already at the top of the income distribution. It may elevate growth, for a time, but it will be a catastrophe nonetheless.

Healthcare Fact Sheet

This healthcare fact sheet presented by The Sanders Institute shows what the healthcare system looks like in the United States, how does the system compare to those in other countries, and where the healthcare system is headed.