Month: July 2017

Health Care Research Paper Delivered To Congress

The Sanders Institute and National Nurses United delivered a research paper, titled Medicare For All vs All the Healthcare Each Can Afford, to every Senate and House of Representatives office on Capitol Hill. This report analyzes our current fragmented healthcare system and suggests a system of healthcare reflecting the nurses’ values of caring, compassion and community.

Scroll down to read the full report.




Medicare for All vs. All the Healthcare That Each Can Afford

We stand at the crossroads between guaranteeing healthcare to everyone through an improved and expanded Medicare program and leaving increasingly more people at the mercy of the market with legislation such as the American Health Care Act. Now is the time to take on our market-driven system and fight for an improved and expanded Medicare for all.1

In contrast to our current system, a Medicare-for-all health plan would provide comprehensive healthcare benefits for all medically appropriate care without regard to income, employment, or health status. Instead of many insurers, each with a variety of health plans and cost-sharing schemes, funding for healthcare would be administered from a single government fund based on a uniform set of benefits.2 Payments would be negotiated by representatives of the Medicare-for-all plan and representatives of hospitals, physicians, and other providers. Finally, prescription drugs, medical devices, and other related supplies would be negotiated in bulk for the entire U.S. population at reduced prices. There would be a single standard of excellence in care for all – not bronze for some and platinum for others. People would be free to seek care from any participating healthcare provider. We would receive the care our doctors and nurses determine we need – not what a profit-seeking insurer deems it will cover or deny. Finally, care would be provided without deductibles or copayments thereby easing economic inequality and health disparities.

This paper begins by examining our market-driven healthcare system and the failings of our private insurance system. It includes discussions on why adding a government-run public insurance option to the ACA private insurance marketplaces could not remedy the problems the marketplaces face and on the limitations in care under a market-driven system. Finally, it will examine the major features of a Medicare-for-all system and how our country could provide healthcare as a right, not a privilege.

Corporate Healthcare and the Games that Insurers Play

For decades, corporate healthcare has played a major role in defeating attempts to guarantee healthcare for all. The influence of this sector decisively shaped the Affordable Care Act (ACA). In the years leading up to and following the passage of the ACA, 2006 through 2012, the health sector spent $3.4 billion on lobbying – more than any other sector for four out of seven years and second for the other three.3 It also contributed a whopping $709 million in campaign contributions over that same time period. 4 Of this $709 million, $332 million went to Republicans, $304 million went to Democrats ($23 million to candidate Obama in 2008), and the balance went to outside spending groups. The “investment” in lobbying and campaign contributions paid off. By spending these vast sums, corporate healthcare was able to block measures that would have improved our healthcare system, but interfered with the health industry’s ability to reap enormous profits, and win provisions that guaranteed increased healthcare industry profits.

Still, in many ways, the ACA was a step forward. Those with pre-existing conditions can no longer be denied coverage and insurers cannot base premiums on health status. The number of uninsured has dropped considerably, with 20.4 million gaining coverage from 2010 to 2016.5 Unfortunately, the ACA didn’t go far enough. With plans available in the ACA insurance marketplaces requiring cost sharing ranging from 10% to 40%, on top of premiums, cost continues to make it prohibitive for many to access healthcare. Catastrophic plans are even worse. Even though the federal government has been propping up the insurance marketplaces through premium support and cost-sharing subsidies, paid by taxpayers to private insurers, these insurance marketplaces have struggled from the beginning. These struggles have been exacerbated under the current administration.

Some contend that adding a public option to the ACA insurance marketplaces could serve as a corrective to the abuses of the profit-based insurance industry and, perhaps, even be a first step on the road to Medicare for all. The public option plans, as designed by a pair of current congressional bills,6 would be administered by the federal government, funded by premiums, and have their own provider networks. The public option plans would be offered alongside the private insurance plans in the marketplaces and be subject to the same terms and conditions, including the premium tax credits and cost-sharing reductions as the other metal plans – bronze, silver, gold, and platinum. The idea is that a public option would be able to drive down insurance prices by competing against private health plans as a low-cost option that would not need to spend huge amounts on executive compensation packages, turn a profit, or pay dividends to shareholders.7 However, the market for health insurance differs dramatically from markets for most goods and services in such a way that increased competition does not necessarily drive down prices. Though the differences are many, consider just two. First, those buying insurance are unable predict in advance what type of healthcare they may need; even those currently being treated for a health condition may have unanticipated health needs arise. The second and crucial point is that the private insurance business model, which seeks to limit claims paid on policies, conflicts with the very reason most people have for purchasing health insurance, the need for healthcare. Insurers’ biggest costs are what they term medical loss, or the costs of paying for policyholders’ covered healthcare services. Thus, insurers strive to limit how much they pay out in claims for care provided to their enrollees. Health insurers do not focus on maximizing policy sales, but on maximizing sales to individuals who they deem will pay more in premiums than they cost in care. Competition among health insurers amounts to competing to sell policies to healthier individuals (also known as “cherry picking”).

This practice continues under the ACA even with thousands of pages in statutes and related regulations. Studies have documented discriminatory insurance policies on the marketplaces that place key HIV/AIDS, cancer, and multiple sclerosis drugs in the highest cost-sharing tier in a drug formulary.8 Selective provider network design offers another means of excluding costly patients. For example, the network may include a limited number of oncologists and other specialists or exclude academic medical centers and cancer treatment centers.9 Although increased competition generally may lower premiums in some of the ACA insurance marketplaces,10 the question remains whether a public option would have a sufficient competitive edge over private plans to keep premium rates affordable, particularly when the private insurers game the system.11 As the public option would not want to replicate the unscrupulous practices of private insurers, it is likely to end up with a great number of costly enrollees that private insurers want to offload, making it nearly impossible for the public option to maintain competitively priced premiums, discrediting the role of the government, and undermining support for public programs such as Medicare and Medicaid.

Moreover, in many areas where the ACA marketplaces are down to a lone insurer, competition is not the problem.12 Rather, many are losing money as the enrollees are much sicker and costlier.13 Insurers that remain in these areas have raised their premiums by double digits and, in one case, triple digits.14 In the four states which dropped down to one insurer in 2017, the increases ranged from 29% to 69%, while cities and counties with a single insurer saw increases ranging from 26% in Anchorage, Alaska to 145% in Phoenix, AZ – which dropped from eight insurers in 2016 to just one in 2017.15 Recent filings for 2018 indicate further dramatic rate increases.16 The only solution to bringing down premiums is to broaden the risk pool by inducing those who are younger, healthier, and less costly to enroll. Given the cost and quality of many of the insurance plans in the ACA marketplaces, this would be very challenging even without the sabotage of the current administration. It may prove to be impossible to cover costs while maintaining premiums at a level that enrollees can manage. Without federal premium support, the premiums required to cover the cost of care in these markets would surely outstrip many enrollees’ ability to pay and, thus, end in a death spiral. The larger issue here is that even if a public option were the answer to saving the insurance marketplaces, we would still be left with the tiered plan model and 10% to 40% cost sharing or worse, a catastrophic plan.

Finally, not only do private insurers avoid covering the most costly patients, they also attempt to limit care to those they do cover. In a more insidious approach than outright denial, insurers impose clinical practice guidelines and protocols that interfere with physician autonomy by limiting the types of tests and treatments that the insurer will reimburse. Physicians may not be able to order a test because a patient does not meet the criteria in the “guideline” the insurer designates, whether or not the criteria are relevant to a particular patient’s circumstances.17 In cases where an insurer, hospitals, and physicians work together as a health plan, such as a health maintenance organization (HMO) or an accountable care organization (ACO), care is often limited through the electronic health record (EHR). EHRs go beyond an electronic version of a paper chart that merely records information.18 Protocols and guidelines, as well as programs to order tests and treatments, can be embedded in the EHR as clinical decision support. Although these software programs may be called clinical decision “support,” and the embedded clinical practice requirements may be called “guidelines,” they often function as hard-and-fast rules that override physicians’ professional judgment as well as limit the full professional practice of nurses and other practitioners that care for patients. As protocols and clinical practice guidelines are about certain percentages of patient populations as a whole, they may not apply to a particular patient. Practitioners must be free to provide care based on their professional judgment about the tests and treatments appropriate for their patient.

All the blame for high premium costs cannot be laid at the feet of insurers, however. Consolidation in hospital and physician practices has also contributed to the increased cost.19 The rate of increase in hospital consolidation has accelerated in recent years. Since 2009, the number of hospital mergers and acquisitions has doubled and the number of independent community hospitals has dwindled.20 In 2015, the most recent year for which data is available, only one in three hospitals remained independent.21 Price gouging in the hospital industry becomes readily apparent by examining charge-to-cost ratios – that is, the relationship between how much a hospital charges compared to its costs. The latest data show that, on average, hospitals charge 379%, nearly four times, more than an item or service costs. Hospitals that belong to systems have, on average, charge-to-cost ratios that are 53% higher than independent hospitals.22 Hospitals are quick to say that this is what they charge, but it is not necessarily what they receive in payment. Yet, as insurers typically negotiate rates based on a percentage of what hospitals charge, the more they charge, the higher their profit margin.23 Unfortunately, the horrifying irony of our current system is that the uninsured pay the highest rates of all.24

If there is any doubt that our market-driven healthcare system is failing us, two measures, expenditures and health status, make it clear. Although the United States consistently spends more on healthcare than any other country, it typically has poorer results. The most recent data from the Organisation for Economic Co-operation and Development (OECD),25 a widely utilized source for making international comparisons, show that the United States spent 16.9% of GDP, nearly twice the average rate of 9% for the 35 member countries.26 The differences are even greater in the amount we spent per person. At $9,451, we spent nearly two and half times the $3,814 average of OECD countries.27 Yet, despite the amount we spend, the patchwork U.S. “system” leaves 28 million uninsured and millions more underinsured.28 The result is poorer health and shorter lives. A widely cited study by the Commonwealth Fund comparing the United States to ten other countries ranked the U.S. dead last overall as well as in the categories of healthy lives, cost-related problems to access, equity, and efficiency.29 A second study, covering 195 countries regarding deaths that were preventable had the patient received “timely and effective medical care,” ranked the U.S. at number 35 on its Health Access and Quality index – in between Estonia and Montenegro.30 The worst U.S. scores were for lower respiratory infections, ischemic heart disease (coronary heart disease), and chronic kidney disease. Looking strictly at the United States, we find a recent dip in the average life expectancy,31 a gap of 10 to 15 years in life expectancy between the richest and the poorest among us,32 and numerous health disparities related to class, race, and sex.

Medicare for All: How it Works

Corporate control of healthcare and our misguided faith in the market has resulted in an inefficient, fragmented “system” that leaves millions with little or no access to healthcare. Our current approach treats healthcare as a commodity on a par with other commodities rather than a public good. We have accommodated the failure of the private insurance market by cobbling together the most expensive public-private system the world has ever seen. The shift to a Medicare-for-all plan reorients our system to providing healthcare as a right, not a privilege. It would be a tremendous step toward ending health disparities and would mitigate economic inequality. Finally, recent public opinion polls demonstrate that a strong majority of Americans favor Medicare for all. In December 2015, the Kaiser Health Tracking Poll found:

When asked their opinion, nearly 6 in 10 Americans (58 percent) say they favor the idea of Medicare-for-all, including 34 percent who say they strongly favor it. This is compared to 34 percent who say they oppose it, including 25 percent who strongly oppose it. Opinions vary widely by political party identification, with 8 in 10 Democrats (81 percent) and 6 in 10 independents (60 percent) saying they favor the idea, while 63 percent of Republicans say they oppose it.33

A 2017 poll by the Pew Research Center demonstrates that support is growing.

Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.34

So what’s stopping us? Supporters of our market-driven model typically sabotage efforts to provide Medicare for all by focusing on how we would pay for it. This is disingenuous. We are already paying for it; we’re just not receiving it. Approximately two-thirds of U.S. healthcare expenditures already come from taxpayers in the form of federal, state, and local government spending.35 Healthcare in the U.S. costs more both because of administrative complexity and higher prices, rather than increased utilization. The comparisons of U.S. spending and health outcomes to other countries strongly suggest that there is enough money in our current system to provide healthcare for all, if we spend that money fairly and wisely. The key point is to demonstrate that there is enough money currently being spent on healthcare in the U.S. to provide Medicare for all, rather than specifying particular funding mechanisms.36

As mentioned above, we would reap enormous savings by eliminating private insurance company costs such as profits, shareholder dividends, excessive executive compensation, and marketing costs. Additional savings would come from the uniformity in health benefits and in claims and billing processing. Instead of many insurers, each with a variety of health plans and cost-sharing schemes, funding for healthcare would be administered from a single government fund based on a uniform set of benefits.37 Hospitals, physicians, and other providers would no longer need large billing departments to manage payments or to pursue collections from the uninsured and the underinsured. Each of these areas is discussed in more detail below.

Cost sharing – copayments, coinsurance, and deductibles. Eliminating patient cost sharing is a first step to achieving health equity and easing the economic inequality that is rife in our country. The very idea of requiring patient cost sharing, also called “out-of-pocket costs,” derives from a market-based approach to healthcare. Those who take this economistic approach to providing healthcare argue that people need to “have skin in the game,” meaning that they must have a financial stake in accessing healthcare, otherwise they will use their health insurance indiscriminately and not just when they truly need it.38

Research confirms that even minimal cost-sharing requirements reduce healthcare utilization.39 Unfortunately, cost sharing keeps people from seeking both needed and unneeded care.40 This should not come as a surprise; laypersons cannot be expected to know prior to seeing their healthcare provider whether or not they need medical treatment. As the cost of providing care has increased, costs have been shifted to individuals and families. Imposing higher deductibles, copayments, and coinsurance is a double win for insurers; healthcare utilization drops and they pay less when healthcare is used. Today, millions with health insurance delay seeking healthcare or filling a prescription because of high deductibles, but even copayments can be difficult for many to manage.41 Those who are sick or low income fare the worst.42 Thus, eliminating cost sharing reduces both health disparities and economic inequality.43 Finally, while prompt treatment of injury and illness is reason enough to eliminate cost sharing, in some cases it also reduces the overall cost of treatment.44

Administrative savings. Administrative savings would come from two primary sources: insurers and providers such as doctors and hospitals.45 On the insurer side, eliminating private insurance company waste such as profits, shareholder dividends, excessive executive compensation, and marketing costs would produce tremendous savings. Having a single, comprehensive benefits package and a single payer, the federal government, creates uniformity in claims and billing processing. Doctors and hospitals would no longer need large billing departments to manage payments or to pursue collections from the uninsured and the underinsured, nor for preauthorizing tests and treatments or checking drug formularies before prescribing medications. This would produce additional savings that could be redirected to care. Overall, replacing our complex, fragmented health system with its many insurers – each with multiple benefit packages and numerous cost-sharing schemes – would produce savings of 9.3% to 14.7%.46 Based on projected national health expenditures of more than $3.5 trillion dollars in 2017, this would amount to $330 to $520 billion in administrative savings alone.47

Global budgets. Hospitals, nursing homes, and similar facilities, as well as home care agencies, would receive a fixed lump-sum annual budget, called a global budget, rather than getting paid separately for each patient’s hospital stay. A global budget, typically paid out in monthly installments, would reimburse the facilities for all their operating expenses and, under a separate budget, for capital expenses such as new buildings and equipment. The savings would accrue primarily from reduced administrative costs related to billing and insurance. The administrative savings estimated above derive, in part, from global budgeting for hospitals and other healthcare facilities. Multiple studies have documented the savings achieved by using the global budget approach.48 A recent study of hospital administrative costs in eight countries found that Canada and Scotland, which are paid using global budgets, had the lowest administrative costs at 12.4% and 14.3%, respectively.49 In contrast, hospitals in the United States, which must manage a far more complex billing system, had the highest administrative costs at 25.3%.

Capital investment. A Medicare-for-all program would require approval for investment in expanding medical facilities and major equipment purchases to ensure they are allocated fairly and where needed. The approval process would prioritize capital investment in projects that address medically underserved populations and health disparities related to race, ethnicity, income, or geographic region. This approach contrasts sharply with a market-driven approach which seeks to maximize revenue. For years, hospital corporations have shuttered “underperforming” hospitals in communities with high numbers of uninsured, often reopening them a few miles down the road in areas with better insurance coverage and higher incomes. Most public hospitals, which typically care for the uninsured, on the other hand, have been severely underfunded and stand in need of critical infrastructure and equipment upgrades. Thus, relying on the market has resulted in a maldistribution of healthcare resources from what should be the guiding rationale, providing care to those who need it. Finally, our current system often leaves expensive equipment standing idle. For example, in a profit-seeking healthcare system with hospitals in relatively close proximity to one another, if one hospital purchases an MRI machine, the other area hospitals may feel the need to do so in order to claim the same capabilities as they compete against each other. In contrast, a Medicare-for-all plan would direct investment in expensive equipment, new hospitals, and medical offices where it is needed, not where corporate healthcare deems most lucrative.

Bulk purchasing. The pharmaceutical/health products industry has spent more money lobbying than any other industry every year since 1999. The spending topped out at $274 million in 2009, with spending at a still sizeable amount of $246 million in 2016.50 In addition, the industry has contributed millions to federal campaigns. According to the Center for Responsive Politics: “The pharmaceutical and health products industry … is consistently near the top when it comes to federal campaign contributions. … The industry’s political generosity increased in the years leading up to Congress’ passage in 2003 of a Medicare prescription drug benefit.”51 This appears to have been money well spent. As part of the Medicare Modernization Act of 2003, Congress not only created a Medicare prescription drug benefit, but also prohibited the Health and Human Services Secretary from negotiating prices or creating a formulary of approved prescription drugs.52 The Center for Responsive Politics also found that “industry spending levels have fluctuated, though they have usually hovered around the $30 million range … .”53 That is until 2012, when campaign contributions increased to over $50 billion and topped out in 2016 at nearly $60 billion.54

A Medicare-for-all plan would negotiate prices on drugs and medical devices for the entire U.S. population.55 Thus, it would garner far greater bargaining power than our fragmented system of insurers, each competing against each other and seeking to maximize profits. Negotiating with pharmaceutical companies would bring the costs of prescription drugs in this country in line with the rest of the world. A recent study found that this alone would have saved $113 billion in 2017.56

Primary care. Research shows that access to primary care, understood as having a usual place of care, continuity over time, care coordination, and a whole-person focus– rather than focusing on a particular disease or body part as specialty care often does – leads to better health.57 Greater emphasis on primary care lowers overall costs by facilitating earlier intervention in disease processes, staying current with preventive measures, and reducing the use of emergency departments. Eliminating cost sharing is crucial to meeting these goals.58

The U.S. lags behind other countries in both access and health status, and spends far more, partially due to a shortage of primary care physicians.59 Although estimates differ as to the magnitude of the growing shortfall of primary care physicians, all agree that it is significant. The mid-range projected shortfall in primary care physicians is 7,800 to 32,000 by 2025, increasing to 7,300 to 43,100 by 2030.60 In addition to this general shortage, many geographic regions and populations are currently suffering due to a severe shortage of primary care physicians. According to the U.S. Health Resources & Services Administration, there are 6,790 health professional shortage areas61 that need primary care physicians, predominantly in rural and lowincome urban communities and among specific population groups within a geographic area such as the homeless, migrant farmworkers, and other groups.62 Over 69 million people live in a shortage area – more than one in five Americans.63 More than 10,000 primary care physicians are needed now to provide the care they need.64

The market has clearly failed to distribute primary care physicians where they are needed or to fulfill overall demand. A difference in compensation between specialists and primary care providers, coupled with the massive debt many students incur in becoming physicians, has resulted in too few primary care physicians. On average, primary care physicians earn far less than specialists. A recent survey found that average annual full-time physician compensation was $294,000 with specialist compensation 46% higher than primary care physicians at $316,000 and $217,000, respectively.65 Orthopedic surgeons, at the top of recent compensation surveys, make more than twice as much as family medicine physicians, who are at or near the bottom.66 A Medicare-for-all program could address these needs, for example, by increasing the number of primary care residencies, scholarships, and loan-repayment programs; targeting education of primary care physicians through dedicated Graduate Medical Education funding; and increasing the reimbursement of primary care physicians.67 Although none of these ideas is new, a Medicare-for-all program would reorient our healthcare system to put primary care at the center with a focus on preventive care and early intervention and treatment.

Physician compensation. First, to prevent inequity in access and care, physicians who accept payment from the Medicare-for-all plan would be prohibited from also receiving compensation for patient care from private payers, including patients themselves. Second, physicians would be required to accept payment by the Medicare-for-all plan as payment in full. There would still be some physicians who would cater to the wealthy, but there would not be inequity in access or care within the system based on higher reimbursement from private payers or additional fees charged on top of the Medicare-for-all payment rate. Finally, no part of physician compensation would derive from incentives to provide less care such as performance bonuses linked to utilization or profitability.68

Representatives of physicians, and other practitioners, would negotiate compensation with representatives of the Medicare-for-all plan. Physicians and their staff would spend far less time on insurance-related administrative matters such as billing and prior authorization for treatment. This decrease in overhead expenses would factor into overall compensation. Compensation would be on either a fee-for-service basis or by a fixed salary, for those working for an organization paid on a per capita basis or operating under a global budget.

The negotiations would also address the difference in compensation between primary care physicians and specialists. This pay inequity lies in undervaluing the cognitive-based services that primary care physicians provide compared to procedure-based services that specialists tend to provide.69 Unlike surgeons and other specialty physicians who are paid based on the number of procedures they perform and often use complex, expensive equipment, “primary care physicians spend most of their time providing cognitive services, such as acquiring and assimilating information, developing management strategies, coordinating care, and counseling.”70 While some specialists would still be compensated at higher rates than the primary care generalists, the difference between rates would be reduced.


Numerous studies document the many inefficiencies of our “system” and its high financial costs. Likewise, study after study documents our failure to provide healthcare to all those who need it, as well as the vast disparities in health and healthcare in terms of class, race, and sex. Finally, our failure to guarantee healthcare to all exacerbates economic inequality through high out-of-pocket costs for care, medical debt, and bankruptcy.

The reason is clear. As discussed above, a market-driven approach to providing care is based on a business model that fundamentally conflicts with the very reason that people purchase health insurance. Whereas private insurers aim at limiting the amount they “lose” by paying for healthcare, people purchase insurance for the express purpose of accessing healthcare when they need it. A Medicare-for-all program would be accountable to the people, not to shareholders and the bottom line. Rather, it would facilitate the distribution of healthcare resources, such as new facilities and equipment, based on human need, not market share. Compensation for physicians and other healthcare providers would encourage better primary and preventive care. Rural and low-income urban areas would no longer be neglected. Additional resources would be directed to medically underserved areas and populations.

The threat by Congress and the Trump Administration to repeal the ACA makes this a crucial and timely issue. Although the ACA has improved healthcare insurance access, it did so by further entrenching the private insurance industry. Improving our current Medicare system and expanding it to cover everyone is the best solution. If we stand together, we can achieve it.


1 This paper will use the phrase “Medicare for all” to mean an improved and expanded version of the current Medicare system. The improvements would include eliminating copayments and coinsurance. The expansion just means that it includes the entire U.S. population rather than just seniors and the disabled.

2 The use of the term “single payer” comes from the use of a single fund to pay for healthcare for all.

3 Center for Responsive Politics. Influence & Lobbying. (, accessed May 12, 2017). The health sector includes pharmaceuticals/health products, hospitals/nursing homes, health professionals, health services/HMOs and miscellaneous health. Calculations based on data retrieved from online database.

4 Center for Responsive Politics. Interest Groups. (, accessed May 12, 2017). Calculations based on data retrieved from online database

5 Martinez, M E., Zammitti, E. P., & Cohen, R. A. Division of Health Interview Statistics, National Center for Health Statistics. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January–September 2016. (, accessed May 15, 2017).

6 The two bills, S. 194 and H.R. 635, bills are identical. There is a third, HR 1307, that is similar to the other two, but has far fewer co-sponsors. They can be accessed here: S. 194:, H.R. 635:, and H.R. 1307:

7 McArdle, M. (2016, August 19). “Obamacare’s Public Option is No Longer Defensible.” Bloomberg. (, accessed May 12, 2017).

8 Jacobs, D. B, & Sommers, B. D. (2015, January 29). Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace. New England Journal of Medicine, 372:399-402. (, accessed April 17, 2017); Avalere. (2015, February 11). Analysis of Prescription Drug Tier Placement and Cost Sharing in Health Insurance Exchange Plan.

9 Gaffney, A., & McCormick, D. (2017, April 8). The Affordable Care Act: implications for health-care equity. The Lancet, 389:1442-1452 (, accessed April 17, 2017); Bertko, J. March 29, 2016. What Risk Adjustment Does — The Perspective of a Health Insurance Actuary Who Relies on It. Health Affairs Blog. (, accessed April 17, 2017).

10 Dafny, L., Gruber, J., & Ody, C. (2015). More Insurers Lower Premiums: Evidence from Initial Pricing in the Health Insurance Marketplaces. American Journal of Health Economics, 1(1):53–81.

11 Cox, C., Semanskee A., Claxton G., & Levitt, L. (2016, August 17). Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors. Kaiser Family Foundation. (, accessed April 20, 2017).

12 Reinhardt, U. (2016, August 25). Why are Private Health Insurers Losing Money on Obamacare? Journal of the American Medical Association Forum. (, accessed May 12, 2017); McArdle, M. (2016, August 19). “Obamacare’s Public Option is No Longer Defensible.” Bloomberg. (, accessed May 12, 2017). Holahan, J., Blumberg, L. J., & Wengle E. (2017, May). “What Characterizes the Marketplaces with One or Two Insurers?” Urban Institute. The Urban Institute research brief found that markets with larger populations and tended to have more competition, concluding that these areas simply have “less business to compete over.

13 Antos, J., & Capretta, J. (2016, October 11). The Future of the ACA’s Exchanges. Health Affairs Blog. (, accessed April 20, 2017); Levitt, L. (2017, April 17). Is the Affordable Care Act Imploding? Journal of the American Medical Association Forum. (, accessed April 20, 2017).

14 ASPE. (2016, October 24). Health Plan Choice and Premiums in the 2017 Health Insurance Marketplace. (, accessed May 12, 2017); Cox, C., Long M., Semanskee A., Kamal, R., Claxton G., & Levitt, L. (2016, November 1). 2017 Premium Changes and Insurer Participation in the Affordable Care Act’s Health Insurance Marketplaces. Kaiser Family Foundation. The exception to the double digit increase is Wyoming which was already down to one insurer in 2016. The rate there increased 9%.

15 Ibid.

16 Livingston, S. (2017, May 10). Health insurers’ proposed 2018 rate hikes are early ‘warning signs.’ Modern Healthcare. (, accessed May 13, 2017).

17 Tritter, J. Q., Lutfey, K., & McKinlay, J. (2014, February 13). What are tests for? The implications of stuttering steps along the US patient pathway. Social Science & Medicine, 107: 37–43.

18 Office of the National Coordinator for Health Information Technology. Clinical Decision Support. (, accessed May 15, 2017).

19 Morrisey, M. A., Rivlin, A. M., Nathan, R. P., & Hall, M. A. (2017, February). Five-State Study of ACA Marketplace Competition. The Brookings Institute. Hospital Industry Consolidation – Still More to Come? New England Journal of Medicine, 370(3):198-199; (, accessed April 22, 2017); Cutler, D. M. & Scott Morton, F. (2013, November 13). Hospitals, Market Share, and Consolidation. Journal of the American Medical Association, 310(18):1964-1970. doi:10.1001/jama.2013.281675. (, accessed April 22, 2017); Gaynor, M. & Town, R. (2012, June). The Impact of Hospital Consolidation – Update. Robert Wood Johnson Foundation. (, accessed April 22, 2017).

20 Tsai, T. C. & Jha, A. K. (2014, July 2). Hospital Consolidation, Competition, and Quality: Is Bigger Necessarily Better? Journal of the American Medical Association, 312(1):29-30. doi:10.1001/jama.2014.469. (, accessed April 22, 2017).

21 American Hospital Association. (1996-2015). AHA Hospital Statistics. The increase over 20 years was 64 percent, with 40 percent in systems in 1996 and 66 percent in 2015.

22 Centers for Medicare & Medicaid Services. (2016, December 31). Medicare Cost Reports for Fiscal Year 2015- 2016. Calculations based on report data.

23 Institute for Health & Socio-Economic Policy. (2013, May 15). Nurses: Hospital Price Gouging Driving Up Healthcare Costs, Self-Rationing, Medical Bankruptcies. Mystery of the Chargemaster: Examining The Role of Hospital List Prices in What Patients Actually Pay. Health Affairs, 36(4):689-696; doi:10.1377/hlthaff.2016.0986, accessed May 1, 2017).

24 Ibid.

25 Organisation for Economic Co-operation and Development. Members and Partners, accessed May 12, 2017). The OECD describes its members as follows: “… our 35 Member countries span the globe, from North and South America to Europe and Asia-Pacific. They include many of the world’s most advanced countries but also emerging countries like Mexico, Chile and Turkey.” These are the member countries: Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israël, Italy, Japan, Korea, Latvia, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom, and the United States.

26 Organisation for Economic Co-operation and Development. OECD.Stat., accessed April 20, 2017) Data are based on estimates and projections; Centers for Medicare & Medicaid Services. (2017, March 21). NHE Fact Sheet., accessed April 26, 2017). Although we don’t have the actual data for the other OECD countries for 2015, we know that in the U.S. actual costs were even higher than the OECD estimate. The most recent figures on our national health expenditures (NHE) from 2015 the show that NHE grew 5.8% to $3.2 trillion, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP).

27 Ibid.

28 Martinez, M E., Zammitti, E. P., & Cohen, R. A. Division of Health Interview Statistics, National Center for Health Statistics. Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January–September 2016. (, accessed May 15, 2017).

29 Davis, K., Stremikis, K., Schoen, C., & Squires, D. (2014, June 16). Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. (, accessed May 12, 2017). The other countries included in the study are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

30 Barber, R. M., et al. (2017, May 18). Healthcare Access and Quality Index Based on Mortality from Causes Amenable to Personal Health Care in 195 Countries and Territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. The Lancet, accessed May 21, 2017).

31 Xu, J., Murphy, S.L., Kochanek, K.D., & Arias, E. (2016, December). Mortality in the United States, 2015. NCHS, 267, accessed April 21, 2017).

32 Chetty R., Stepner M., Abraham S., Lin S., Scuderi B., Turner N., Bergeron A., & Cutler D. (2016, April 26). The Association between Income and Life Expectancy in the United States, 2001-2014. Journal of the American Medical Association, 315(16):1750-1766. doi:10.1001/jama.2016.4226 (, accessed May 11, 2017).

33 Di Julio, B., Firth, J., & Brodie, M. Kaiser Health Tracking Poll: December 2015. (2015, December 17). Kaiser Family Foundation. (, accessed May 26, 2017.

34 Bialik, K. More Americans Say Government Should Ensure Health Care Coverage. Pew Research Center, accessed May 26, 2017).

35 Himmelstein, D. U. & Woolhandler, Steffie. (2016, March). The Current and Projected Taxpayer Shares of US Health Costs. American Journal of Public Health, 106(3):449-452. (, accessed May 11, 2017). This figure includes the money spent to purchase private health insurance for public sector employees and tax expenditures to subsidize employer-sponsored health insurance in the private sector.

36 Some of the savings discussed below would enable federal dollars to go further in providing care. The balance would need to be allocated through the federal budget and, if needed to expand coverage, captured through progressive taxation

37 To prevent tiered care, insurers, including employers who self-insure, would be prohibited from providing coverage for benefits provided by the Medicare-for-all plan, but could offer supplemental insurance. Typically, temporary assistance for up to five years would be provided to workers displaced by the change.

38 Brook, R. H., Keeler, E. B., Lohr, K. N., Newhouse, J. P., Ware, J. E., Rogers, W. H., Davies, A. R., Sherbourne, C. D., Goldberg, G. A., Camp, P., Kamberg, C., Leibowitz, A., Keesey, J., & Reboussin, D. (2006). The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate. RAND Corporation. (, accessed May 16, 2017); Hoffman, B.A. (2006, Winter). Restraining the Health Care Consumer. Social Science History, 30:4 doi: 10.1215/01455532-2006- 007

39 Hoffman, B.A. (2006, Winter). Restraining the Health Care Consumer. Social Science History, 30:4 doi: 10.1215/01455532-2006-007; Trivedi, A. N., Rakowski, W., & Ayanian, J. Z. (2008, January 24). Effect of Cost Sharing on Screening Mammography in Medicare Health Plans. New England Journal of Medicine, 358:375-383. (, accessed May 16, 2017); Howard, D. H., Guy, G. P. Jr., & Ekwueme, D. (2014, October 9). “Eliminating Cost-Sharing Requirements for Colon Cancer Screening in Medicare.” Cancer. (, accessed May 1, 2017). Some have argued for a sliding scale for cost-sharing based on income and no cost-sharing for certain types of preventive care (the ACA has no cost-sharing for certain preventive care measures). But requiring any type of cost sharing would undermine the uniformity that enables much of the administrative savings discussed above.

40 Brook, R. H., Keeler, E. B., Lohr, K. N., Newhouse, J. P., Ware, J. E., Rogers, W. H., Davies, A. R., Sherbourne, C. D., Goldberg, G. A., Camp, P., Kamberg, C., Leibowitz, A., Keesey, J., & Reboussin, D. (2006). The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate. RAND Corporation. (, accessed May 16, 2017).

41 Ibid.; Collins, S. R., Gunja, M., Doty, M. M., & Beutel, S. (2015, November). How High Is America’s Health Care Cost Burden? Findings from the Commonwealth Fund Health Care Affordability Tracking Survey, July– August 2015. The Commonwealth Fund. Among privately insured adults ages 19-64: 43% of those across all income groups found paying deductibles either “very difficult or impossible” or “somewhat difficult” and 17% of those across all income groups found paying copayments either “very difficult or impossible” or “somewhat difficult.”

42 Osborn, R., Squires, D., Doty, M. M., Sarnak, D. O., & Schneider, E. C. (2010). In New Survey of Eleven Countries, US Adults Still Struggle with Access to and Affordability of Health Care. Health Affairs, 29(5):766-772, accessed May 16, 2017); Brook, R. H., Keeler, E. B., Lohr, K. N., Newhouse, J. P., Ware, J. E., Rogers, W. H., Davies, A. R., Sherbourne, C. D., Goldberg, G. A., Camp, P., Kamberg, C., Leibowitz, A., Keesey, J., & Reboussin, D. (2006). The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Care Reform Debate. RAND Corporation. (, accessed May 16, 2017); Hoffman, B.A. (2006, Winter). Restraining the Health Care Consumer. Social Science History, 30:4 doi:10.1215/01455532-2006-007

43 For deep discussion of these issues see the Lancet series, America: Equity and Equality in Health. (2017, April 8). (, last accessed May 23, 2017.)

44 Goldman, D. P., Joyce, G. F., & Karaca-Mandic, P. (2006). Cutting Drug Co-Payments for Sicker Patients on Cholesterol-Lowering Drugs Could Save a Billion Dollars Every Year. RAND Corporation. (, accessed May 16, 2017); Chandra, A., Gruber, J., & McKnight, R. (2010). Patient Cost-Sharing and Hospitalization Offsets in the Elderly. The American Economic Review, 100(1):193–213. (, accessed May 16, 2017).

45 There would also be insurance-related administrative savings for employers that are not captured here.

46 Berwick, D.M. & Hackbarth. A.D. (2012). Eliminating Waste in US Health Care. Journal of the American Medical Association, 307(14):1513-1516. (, accessed May 16); Jiwani, A., Himmelstein, D., Woolhandler, S., & Kahn, J. G. (2014). Billing and Insurance-Related Administrative Costs in United States’ Health Care: Synthesis of Micro-Costing Evidence. BMC Health Services Research 14(556). Percentages calculated based on data in the articles. These are mid-range savings; the larger number comes from the Jiwani, et al. article.

47 Centers for Medicare & Medicaid Services. (2017, March 21). NHE Fact Sheet, accessed April 26, 2017).

48 Himmelstein, D. U., Jun, M., Busse, R., Chevreul, K., Geissler, A., Jeurissen, P., Thomson, S., Vinet, M. & Woolhandler, S. D. (2014). A Comparison of Hospital Administrative Costs in Eight Nations: US Costs Exceed All Others by Far. Health Affairs 33(9):1586-1594. doi: 10.1377/hlthaff.2013.1327, accessed May 4, 2017); Patel, A., Rajkumar, R., Colmers, J. M.., Kinzer, D., Conway, P. H., & Sharfstein, J. M. (2015, November 12) Maryland’s Global Hospital Budgets — Preliminary Results from an All-Payer Model. New England Journal of Medicine, 373(20):1899-1901. (, accessed May 4, 2017), Hsiao, W. C., Knight, A. G., Kappel, S., & Done, N. (2011). What Other States Can Learn From Vermont’s Bold Experiment: Embracing a Single-Payer Health Care Financing System. Health Affairs, 30(7):1232-1241. doi: 10.1377/hlthaff.2011.0515, accessed May 4, 2017).

49 Himmelstein, D. U., Jun, M., Busse, R., Chevreul, K., Geissler, A., Jeurissen, P., Thomson, S., Vinet, M. & Woolhandler, S. D. (2014). A Comparison of Hospital Administrative Costs in Eight Nations: US Costs Exceed All Others by Far. Health Affairs 33(9):1586-1594. doi: 10.1377/hlthaff.2013.1327 (, accessed May 4, 2017).

50 Center for Responsive Politics. Pharmaceuticals/Health Products Industry Profile. (, accessed May 19, 2017).

51 Center for Responsive Politics. Pharmaceuticals/Health Products Industry: Background. (2015, August). (, accessed May 19, 2017).

52 Cubanski, J. & Neuman, T. (2017, January 23). Searching for Savings in Medicare Drug Price Negotiations. Kaiser Family Foundation, accessed May 19, 2017).

53 Center for Responsive Politics. Pharmaceuticals/Health Products Industry: Background. (2015, August). (, accessed May 19, 2017).

54 Center for Responsive Politics. Pharmaceuticals/Health Products: Long-Term Contribution Trends. (, accessed May 23, 2017.

55 Medicare for all legislation would include repealing the prohibition of negotiating drug prices.

56 Woolhandler, S. & Himmelstein, D. U. (2017, April 18). Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs. Annals of Internal Medicine, 166(8):587- 588. DOI: 10.7326/M17-0302 (, accessed May 19, 2017).

57 Chang, C.-H., Stukel, T. A., Flood, A. B., & Goodman, D. C. (2011). Primary Care Physician Workforce and Medicare Beneficiaries’ Health Outcomes. The Journal of the American Medical Association, 305(20):2096–2104. (, accessed May 17, 2017); Osborn, R., Squires, D., Doty, M. M., Sarnak, D. O., & Schneider, E. C. In New Survey of Eleven Countries, US Adults Still Struggle with Access to and Affordability of Health Care. (2010). Health Affairs, 29(5):766-772, accessed May 16, 2017); Starfield, B., Shi, L., & Macinko, J. (2005, September) Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 83(3):457- 502. (, accessed May 17, 2017).

Long-Term Projections Of Social Security’s And Medicare’s Financing Are Not As Scary As They Seem

With the release of the annual Social Security and Medicare trustees’ report, President Trump’s appointees endorsed sharp improvements in Medicare’s financing that occurred under former President Obama. Medicare had a projected shortfall of 3.54 percent of covered payroll (over a 75-year planning period) during the last year of the Bush administration, now it is down to just 0.64 percent.

This development should give pause to those who wish to fundamentally restructure Social Security and Medicare based on these projections. A lot changed over the eight years of the Obama administration and even more can change over 75 years. This is worth taking into account when looking at Social Security’s 75-year shortfall, which is at 2.83 percent of payroll under the intermediate scenario.

The figure below compares the tax increase that would be required to fully fund Social Security — 2.83 percent — with the projected increase in average wages over the next 30 years. The tax increase is dwarfed by the increase in wages over this period, which would be 49.4 percent by the trustees’ own estimates. Wage increases are over 17 times more important than the tax increase.



The next figure is a simple projection of what would happen to a salary of $50,000 per year in 2016 ($46,900 with the current Social Security taxes taken out) over the same 30-year period. With the current Social Security tax rate, this salary would be $69,018 per year in 2047 based on the average wage increase. With Social Security fully funded, it would be $66,936.



It’s unlikely that these projections will hold over such a long time frame, but this should demonstrate that workers should be much more concerned with making sure they receive their share of productivity gains in wage increases over this period than they should be about tax increases. This is not about Social Security needing to be less generous, it is about making sure that workers receive their fair share.

In fact, this problem cuts the other way as well. Unlike Medicare taxes which apply to entire incomes, Social Security taxes apply only up to a threshold — the payroll tax cap — which was set at $127,200 in 2017. With the upward redistribution of income that has occurred over the last four decades, Social Security has less of a base on which to draw. 90 percent of wage income was subject to the tax in 1983 — it was 82.6 percent in 2015. This decline represents a large share of the program’s shortfall.

For Social Security, as with Medicare, long-term financing problems are not indicative of inherent or intractable problems with social programs. Rather, they are indicative of other problems, like policies that redistribute income upwards, and they are fixable.

Remarks On Nelson Mandela Day 2017

To the Secretary General of the United Nations, the President of the United Nations 71st Session– this Saturday happens to be my 71st birthday so we have something in common here – and to all distinguished ambassadors, guests and those who represent the voices of your respective countries, thank you for having me. It is my honor to address this gathering to commemorate Nelson Mandela’s legacy.

Mandela shines as a beacon of humanity triumphing over inhumanity through the force of his love for all people; what many ethnic groups across southern Africa call “Ubuntu.” As an exemplar of “Ubuntu,” Nelson Mandela called on us all to rethink our relationship to personal fulfilment. When we improve ourselves, we must do so in ways that elevate those around us at all levels. We should remember him first and foremost as a leader, our leader, and follow his example. In our time together, I would like for us to recommit ourselves to Mandela’s example as we face new challenges.

Nelson Rolihlahla Mandela was born in 1918 at the end of World War I and had become a leader within the African National Congress’s youth league by the end of another war, World War II. From birth to leadership. Today, as we are all well aware of, we are facing the worst global refugee crisis since World War II. Furthermore, despite some valiant efforts, climate change and global warming continues to worsen and effects those who are most vulnerable. We must brace ourselves for the potential convergence of these two challenges as we could see an even larger refugee crisis spurred on by environmental calamities. As the industrialized nations of the world continue to amass unprecedented wealth, the onus is on them to rethink their relationship to capital and to all of humanity; to devise ways of lifting others as they lift themselves.

To assist us in channeling Mandela’s spirit, I find it helpful to contextualize his legacy with two very different frames. In his 1967 masterpiece “Where Do We Go From Here: Chaos or Community?”, Dr. Martin Luther King, Jr. encourages us toward unity, hope, and optimism to overcome challenges that can only be solved through peaceful collective action. To form new communities that elevate – rather than segregate – through true democracy. In the early 1990s, political scientist Francis Fukuyama argued that the evolution of human governmental models and history itself ended with liberal democracy and that liberal democracy itself had reached the end of its own evolutionary process. For Fukuyama, the answer to Dr. King’s questions was essentially “chaos” as human events would continue to occur without elevating our capacity to form and maintain new institutions.

We must offer a hopeful rebuttal to the nihilism of Fukuyama’s argument through the Ubuntu Mandela exemplified. Mandela led us on a path of justice, democracy, and equity by transforming his righteous indignation into an activist movement with a pragmatic agenda. In the process, he showed the world that nonviolent resistance, when combined with sustained activism, is the key to transforming a potential dead end into a new beginning.

The UN has proclaimed this the International Decade of People of African Descent. As we honor Nelson Mandela’s legacy today, we must also honor the legacy of African philosophy; of Ubuntu – the love of humanity itself – as a transformational model of political philosophy. Through Ubuntu, Nelson Mandela did the impossible; transforming his former jailers into friends and legitimizing the Truth & Reconciliation process. Mandela demonstrated that Ubuntu can save democracy and inspire the kinds of communities that can protect us from chaos.

Contemplating the current political moment requires contemplation of the human spirit. We must look toward Mandela’s legacy not merely as admirers, but has inspired practitioners of his art form. Ultimately, it is not so much the personal spirit of Nelson Mandela that we commemorate today, but rather the excellence with which he embodied the spirit of Ubuntu. Thank you.

Tribes Commit To Uphold Paris Climate Agreement

The Swinomish Indian Tribal Community started planning for climate change a decade ago. Located on the southeastern peninsula of Fidalgo Island on Puget Sound in Washington, the reservation is surrounded by water and at high risk for sea-level rise. A destructive 100-year storm event in 2006 led tribal leaders to research and fund climate programs, and the Swinomish became the first tribal nation to adopt a climate adaptation plan.

So when President Donald Trump announced his decision to withdraw the U.S. from the United Nations’ Paris climate agreement, the Swinomish reacted swiftly and, together with other tribes, publicly committed to uphold the accord in the West, where many tribal communities and reservations are on the frontlines of climate change, tribal leaders are determined to move forward on climate action as sovereign nations despite budget cuts, climate denial, and inaction. “We came together with one another to raise the level of environmental awareness,” said Debra Lekanoff, governmental affairs director for the Swinomish. “We can’t just pick up and move the places where we live.”

Though Indigenous communities have a small carbon footprint, they are often the most severely impacted by climate change. There are 567 federally recognized tribes in the U.S. — 40 percent of them in Alaska — and climate change threatens many of them. In California and the Pacific Northwest, tribal nations are at increased risk of sea-level rise. Coastal communities like the Quinault Indian Nation in western Washington and at least 31 Alaska Native villages, including the Shishmaref village near the Bering Strait, face the danger of coastal erosion. Already, several have been forced to relocate.

Around the Southwest, heat and drought are baking streams and shifting sand dunes, leaving the Navajo Nation and other tribes and pueblos with fewer resources, while wildfires endanger tribal nations from eastern California to the Rocky Mountains. Primary food sources, like salmon and other endangered fish, are dying from acidifying and warming oceans.

On June 3, just two days after Trump made his announcement on the Paris Agreement, the Swinomish Indian Tribal Community joined the Standing Rock Sioux Tribe, the Quinault Indian Nation, and the Central Council of the Tlingit and Haida Indian Tribes of Alaska in committing to support the agreement. The National Congress of American Indians and the Native American Rights Fund did so as well.

Their decision to publicly announce their support is more than symbolic, experts and leaders say: It tells the United Nations that tribal nations are climate leaders and intend to remain part of the global conversation about climate change.

“Tribes have already taken a lot of leadership in planning for the negative impacts of climate change,” said Kyle Powys Whyte, a member of the Citizen Potawatomi Nation and professor of philosophy and Indigenous studies at Michigan State University. “It’s really important that some tribes begin to take the lead on what it means to have the biggest possible energy-saving impact in the area they live, and to exercise self-governance.”

Though tribes and states are sovereign entities within the U.S., they are not allowed to enter treaties or negotiate with foreign nations. Under United Nations policy, Indigenous people are treated as self-determining when it comes to cultural issues, but lack the political self-determination of member nations.

The 2008 United Nations Declaration on the Rights of Indigenous Peoples allows tribal communities to participate in U.N. matters. Signing an agreement like the 2015 Paris climate accord, however, would require changing policies at the U.N. and in the U.S. Tribal leaders say it’s possible. “Just to have them recognize us was a step in the right direction,” said Brian Cladoosby, president of the National Congress of American Indians.

But changing the law is an arduous process, so tribes in the U.S. are taking a short cut: working more closely with Indigenous populations from around the world through programs like the United League of Indigenous Nations, which has its own climate program, or the International Indigenous Peoples Forum on Climate Change.

“Tribes are really trying to get out there and represent themselves, and become stronger partners in agreements where U.S. representation isn’t necessarily good for them, like the Paris Agreement,” Whyte said. According to Whyte’s research, more than 50 U.S. tribes have engaged in formal climate change planning, and many have had climate adaptation plans approved by their councils.

In addition to assessing larger climate goals, tribes are working on the ground to address the impacts. The Swinomish have partnered with the Skagit Climate Consortium to protect the region’s salmon from pollution and warming waters. In Southeast Alaska, the Tlingit and Haida Indian Tribes are monitoring ocean acidification levels and harmful algae blooms while adapting buildings and infrastructure to cope with rising sea levels along rivers and the coasts.

Since 2008, the Pueblo of Jemez in New Mexico has been working on small and utility-scale solar projects, as well as biomass and geothermal energy projects. Last September, the Samish Indian Nation in Washington landed a grant from the Bureau of Indian Affairs for climate adaptation planning and education. But funding is increasingly uncertain: Another Department of Energy grant that arrived this summer was five months later than expected.

“What happens in the future is anyone’s guess at this point,” said Todd Woodard, director of natural resources for the Samish. “Tribal country funding has never been so murky as it is now.”

Trump’s federal budget proposal would cut tribal climate resilience award money by $9.9 million, and in June, the Bureau of Indian Affairs scrubbed all references to “climate change” from the agency’s website about the Tribal Climate Resilience Program. Whyte noted that many tribes may not be able to start renewable energy projects alone; usually, an investment from the federal government is needed.

“It behooves tribes to find ways for their climate change plans to be part of discussion,” Whyte said. “By publicizing them as much as they can and getting interactions with as many parties as possible, we can see if that begins to build traction, so parties at the U.N. begin to see them as what they are: sovereign entities that should be able to self-determine.”

What Would Thoreau Think Of Climate Change?

The hawk sat on a limb three feet above my head and did not stir as I walked under—that was the first sign.

I’d been off hiking for about a week, a long solo backpack through my home mountains, the Adirondacks of upstate New York. The first few days out I might as well have been back in my room—I strode purposefully along the trail, eyes fixed on that focusless middle-distance that you stare at when you drive. My mind chattered happily away—my own little CNN delivering an around-the-clock broadcast of ideas, plans, opinions: What was I going to work on next? Who would win the presidential election? What were some neat things I could buy? My mind was buzzing, following all its usual tracks though I was deep in the woods.

The days wore on. The imposed input lessened—no radio, no paper, no conversation. I could feel the chatter in my head begin to subside. Either the peace of the forest was beginning to penetrate, or the stocks of mental junk food were starting to dwindle; whatever the cause, the buzz turned to hum, and once in a while to quiet.

And so I was not completely surprised when the hawk kept his perch, or a few minutes later when I passed a pair of grazing deer and they merely looked up a moment, didn’t spook. I was still wearing the rustling fluorescent uniform of the modern hiker, but I’d begun, perhaps, to give off fewer, calmer vibrations.

I’d been walking through rain for days; it had long since penetrated my Gore-Tex hide, and so that afternoon when the sun finally came out I made an early camp by the lake. I hung out my clothes in the branches to warm; held my white and wrinkled feet up to the sky to toast; unfolded in the lovely heat like a snake on a stone. Soon a band of merganser chicks, trailing their mother, circled the small cove by which I lay, paying no attention to me. My aura of invisibility lasted all day, soothing one creature after another, until I was feeling part creature myself. Naked, hidden by the fringe of birch leaves, I watched canoeists paddle chattily by, and they seemed nearly to belong to another race. That night I was aware of every second of the endless sunset: the first long rays of the sun as the afternoon turned late, the long twilight, the turn of the sky from blue to blue to blue to—just as it turned black, a heron came stalking through my tiny cove, standing silently and then spearing with a sudden spasm; I couldn’t see her, not really, but I knew where she was. The sky darkened, the stars in this dark place spread across the sky bright and insistent. We were unimaginably small, this heron and I, and extremely right.

I tell this memory—one of my happiest—as a way of plunging into that great sea called Walden. Understanding the whole of this book is a hopeless task. Its writing resembles nothing so much as Scripture; ideas are condensed to epigrams, four or five to a paragraph. Its magic density yields dozens of different readings—psychological, spiritual, literary, political, cultural. To my mind, though, at the beginning of the twenty-first century, it is most crucial to read Walden as a practical environmentalist’s volume, and to search for Thoreau’s heirs among those trying to change our relation to the planet. We need to understand that when Thoreau sat in the dooryard of his cabin “from sunrise till noon, rapt in a revery, amidst the pines and hickories and sumachs, in undisturbed solitude and stillness, while the birds sang around or flitted noiseless through the house,” he was offering counsel and example exactly suited for our perilous moment in time.

He had, of course, no idea that he was doing so.

Although he wrote often about the natural world, Thoreau lived at the very onset of the industrial age, and so knew nothing about parts-per-million, or carcinogenesis, or chlorofluorocarbons. One reads him in vain for descriptions of smog. Mass extinction seems unthinkable—instead, he is gratified and reassured by the profligacy of the living world: “I love to see that Nature is so rife with life that myriads can afford to be sacrificed and suffered to prey on one another, that tender organizations can be so serenely squashed out of existence like pulp—tadpoles which herons gobble up, and tortoises and toads run over in the road.” His world was not used up, suffering—he was in the sixth party of white people to climb Maine’s Mt. Katahdin, on an expedition that took him through the heart of that then-mighty wilderness. And though he could perhaps foresee the ruination that greed might cause (the East would soon be logged so bare that “every man would have to grow whiskers to hide its nakedness”), he had no inkling that we could damage the ozone or change the very climate with our great consumer flatulence. “Thank God the sky is safe,” he wrote.

Furthermore, even if Thoreau had realized the challenges facing the modern environment, there’s no good reason to think he would have pitched in to help. Reformers, he writes, “are the greatest bores of all,” and I doubt a few hundred fundraising appeals from the Audubon Society would have changed his estimation that he’d received but one or two letters “that were worth the postage.” More crucially, he was aggressively uninterested in the prospect of community that sage environmentalists now hold out as our great chance for salvation. The prospect of, say, abiding more closely with his fellows so that they could pool resources, live more efficiently, take pleasure in rubbing shoulders would not have appealed to a man who thought “the old have no very important advice to give to the young,” who considered that two people ought not to travel together, who found it “wholesome to be alone the greater part of the time.” Were Thoreau a modern third-grader, his report card would doubtless note his lack of social skills; it is no accident that he never married, and to imagine him with a child is a joke. There is a great deal he can’t teach us.

You could even lay at his door, I think, some particular environmental problems. In his day, much to his disgust, people clustered together in Concord town and ventured out to Walden to cut ice; partly under his intoxicating influence, many many more of us have come to make our homes on the lake and ocean shores, in the scenic spots, far from the places where we work. There’s hardly an unprotected shoreline in the lower forty-eight not lined with cottages and cabins; wilderness is now a selling point for the enterprising realtor. Even the suburb owes something to him; though clearly a corruption of his vision, in its splendid isolation the subdivision colonial retains a bit of his rude cabin.

So to call him an environmental prophet—in many ways the environmental prophet, a writer of the highest value to the twenty-first century—requires that we think more deeply about what it might mean to live an environmentally sane life. It means recognizing the precise nature of the problems that we face. If those questions are technical, then he is of no help. If our largest environmental problems are the result of something going wrong, some pollutant spewing unchecked from smokestack or exhaust pipe, then he’s simply an interesting historical curiosity. Confronted with a smoggy city, I’d choose a catalytic converter over a pocket copy of Walden. And indeed we’ve nearly solved smog no thanks to Henry David. New equipment scrubs carbon monoxide from the exhaust stream of your car, which is why Los Angeles is cleaner now than a generation ago. New filters on factory pipes clean up rivers and lakes—that’s why fish again swim in Lake Erie.

But what if those are not the largest environmental problems we face? What if we’re really in trouble because things are going right, just at much too high a level? Consider the tailpipe of the car once more. It’s not just carbon monoxide that comes spewing out, it’s also carbon dioxide, carbon with two oxygen atoms. And this time there’s no filter you can stick on the car to cut that CO2; it’s the inevitable byproduct any time you burn fossil fuels. It also turns out that carbon dioxide represents an even greater threat than smog: its molecular structure traps heat near the planet, triggering climate change. The sky’s not safe after all; the sky is heating up. And the answer has defied the technologists. They’ve managed to double the fuel efficiency of our cars in the last forty-five years, but we’ve doubled the number of cars, and the miles they drive, spewing out ever larger clouds of CO2. Scientists tell us they can see the extra heat, watch it melt glaciers and raise sea levels. To prevent it getting worse won’t require some technical change; it will require doing with less, living more lightly. Our other biggest problems—overpopulation, habitat destruction, and so on—present the same challenge: they’re inevitable if we keep living the way we do, thinking our same thoughts.

And it is here that Thoreau comes to the rescue. He posed the two intensely practical questions that must come to dominate this age if we’re to make those changes: How much is enough? and How do I know what I want? For him, I repeat, those were not environmental questions; they were not even practical questions, exactly. If you could answer them you might improve your own life, but that was the extent of his concern. He could not guess about the greenhouse effect. Instead, he was the American avatar in a long line that stretches back at least to Buddha, the line that runs straight through Jesus and St. Francis and a hundred other cranks and gurus. Simplicity, calmness, quiet—these were the preconditions for a moral life, a true life, a philosophic life. “In proportion as he simplifies his life . . . he will live with the license of a higher order of beings.” Thoreau believed in the same intense self-examination as any cross-legged wispy-bearded Nepalese ascetic.

Happily, though, he went about it in very American ways—he was Buddha with a receipt from the hardware store. And it is that prosaic streak that makes him indispensable now.

In the advanced consumer society in which we live, How much is enough? is the first of Thoreau’s questions that we must take up, the most deeply subversive question you can currently pose. We’ve been carefully trained to know that the answer is always: More. Once, researching a book, I taped everything that came across the world’s largest cable TV system for a single day. I took my 2,400 hours of videotape home and spent a year watching it, bathed in the constant message that I needed so much. How much? Here’s a commercial for Rubbermaid. “From the day I was born,” a lady is saying, “I collected so much stuff.” (The picture shows a sad family, hemmed in by their possessions.) “So we stowed our stuff in stuff from Rubbermaid.” (Now the house is bare, save for big plastic boxes full of gear.) “Then we were so unstuffed—Hey! We need more stuff!” (Family charges happily out the door, waving hands in air.)

Thoreau begins at the beginning. He starts with Food, Shelter, Clothing, and Fuel. At the latitude of Concord, anyway, these have become “from long use . . . so important to human life that few, if any, whether from savageness, or poverty, or philosophy ever attempt to do without.” But of course each of these can be either simply or expensively obtained. He considers the possibility, for instance, of living in one of the tool crates that the railroads erect at regular intervals along the track. With a few auger holes bored for air, this did not seem “by any means a despicable alternative.” As we know, however, he opts for something a little larger—the one-room cabin that he built from timbers recycled from the shanty of James Collins. He dug a cellar in two hours’ time (Walter Harding, in his exhaustive edition of Walden, cites a study indicating that he moved 194.25 cubic feet of sand in this span, weighing 9.7 tons), then built a chimney, cut some shingles, bought secondhand windows, and eventually completed his home for twenty-eight dollars and twelve and a half cents. This was a useful exercise. Building a house involves remembering that it’s designed to fulfill a function—to shield you from the rain and snow, to enclose a volume of air that can be heated to keep you warm, to give you room for those possessions you actually need.

In Thoreau’s case, that list included a table, which doubled as a desk, a chair, and a bed. It didn’t include a closet, because the object of clothing is “first, to retain the vital heat, and secondly, in this state of society, to cover nakedness,” and furthermore “every day our garments become more assimilated to ourselves, receiving the impress of the wearer’s character, until we hesitate to lay them aside.” In other words, he wore pretty much the same clothes all the time. There was no pantry to speak of; he subsisted largely on his beloved Indian meal, his rice and rye, his beans, his occasional visits to the homes of his friends, and a woodchuck which was eating his garden. In material terms, he was on a par with many of the poorest people around the world today. And he was like them in being a good, if unconscious, environmentalist. If you are worried about the largest problems, such as global warming, then to consume only a bit is the best remedy; according to one recent calculation, by Charles Hall of Syracuse University, a dollar or its equivalent spent anywhere around the world results on average in half a liter of petroleum being burned—to manufacture the item, and carry it to you, and advertise it, and dispose of it later.

Thoreau chose his deprivation—embraced it, in fact, in the name of simplicity, philosophy, truth, so that it was not deprivation at all. And his heirs, I think, even more than the nature essayists who usually win the title, are that growing band of simplifiers whose books and seminars attract a small but significant portion of a population that has begun to feel materially satiated and desire something else. The best of these books is probably still Your Money or Your Life, by Joe Dominguez and Vicki Robin, which has sold half a million copies even though the authors recommend checking it out of the library. They are unlike Thoreau in many ways; they seem to enjoy working with other people, for instance, and they write with a prosaic clarity that would make him wince. But their books take much from his example.

Thoreau did not have contempt for money—it intrigued him, as his endless careful accounts suggest. But he realized instinctively the lesson that few of us ever learn, which is that there are two ways to get by in the world. The first is to increase income; the second is to reduce expenses. He went further than most of us will ever be willing to go, especially in his nonchalance about future security (“what danger is there if you don’t think of any?”), but there are now millions of Americans pursuing some kind of “voluntary simplicity”; they retain much of his radicalism, only in a more palatable form. And they play to an interested audience. Just as Thoreau reports constant visits from “doctors, lawyers, uneasy housekeepers who pried into my cupboard and bed when I was out,” so the pollsters report that even today many of us remain attracted to some simpler alternative. When the Merck Family Fund sponsored a survey of attitudes on consumerism in 1995 (the last year it conducted the survey), 82 percent of Americans agreed that most of us buy and consume far more than we need, and 86 percent said our children were “too focused on buying and consuming things.” Since shortly after World War II, the Gallup pollsters have inquired each year about whether or not Americans are satisfied with their lives. In 1955 the number who were very satisfied hit 35 percent. Despite the vast gains in material status in the subsequent four decades (only a tiny percentage of Americans owned a dishwasher in 1955; the microwave hadn’t been invented), the number of people who identified themselves as “very satisfied” slipped to 30 percent by 2000. It’s as if the twentieth century served as a large-scale experiment to confirm Thoreau’s hypothesis.

But if that is so—if the mass of us are at least dimly aware of our lives of quiet desperation—then why do we do so little to change? Some of the reasons are structural. The Economy exerts powerful gravity; for many people, it’s hard to escape its demands, be they medical insurance, rent, food on the table. A low-wage job and a child constrain your choices, as do student loans.

This remains an affluent nation, however, by any historical or geographical standard, a place where most people possess real options. So why do we not, by and large, take more advantage of them? I think because of the second question that Thoreau raises, this one equally well timed for the end of this century. If “How much is enough?” is the subversive question for the consumer society, “How can I hear my own heart?” is the key assault on the Information Age. How do I know what I want? What is my true desire?

To understand Thoreau’s genius, remember that he raised this question in a time and place that would seem to us almost unbelievably silent. The communications revolution had barely begun. Advertising had not yet been invented, but the few shop signs in Concord, which we would preserve as quaint markers of a vanished age, appeared already to Thoreau as billboards “hung out on all sides to allure him; some to catch him by the appetite, as the tavern and victualling cellar; some by the fancy, as the dry goods store and the jeweller’s; and others by the hair or the feet or the skirts, as the barber, the shoemaker, or the tailor.” No Internet, no television, no radio, no telephone, no phonograph; and yet somehow he sensed all that this would mean to us. He did not need to see someone babbling into a cell phone as he walked down the street to sense that we’d gone too far; he was such a hypersensitive, such an alert antenna, that he was worried before Alexander Graham Bell was born. “We are in great haste to construct a magnetic telegraph from Maine to Texas,” he writes. “But Maine and Texas, it may be, have nothing important to communicate. Either is in such a predicament as the man who was earnest to be introduced to a distinguished deaf woman, but when he was presented, and one end of her ear trumpet was put into his hand, had nothing to say.” Emerson rushed back from a summer in the Adirondack woods when he heard the great news that the trans-Atlantic telegraph cable had at last been laid; Thoreau wrote “perchance the first news that will leak through into the broad, flapping American ear will be that the Princess Adelaide has the whooping cough.”

Most of us still believe—with yellow-eyed ferocity—in the goddess Information. We want data, we want connections; we want email. We are all the Emperor in his finery, and Thoreau is nearly alone in his calm assurance that he could do without the post office, that “if we read of one man robbed, or murdered, or killed by accident, or one house burned, or one vessel wrecked, or one steamboat blown up, or one cow run over on the Western Railroad, or one mad dog killed, or one lot of grasshoppers in the winter—we never need read of another. One is enough.” Even in his day, “hardly a man takes a half hour’s nap after dinner, but when he wakes he holds up his head and asks, ‘What’s the news?’ ” He would not be shocked by MSNBC.

It’s not that he’s in favor of ignorance or self-absorption. He was well read, politically committed enough to have engaged in Civil Disobedience, and obviously steeped in the minutest changes in the world around him (the precise quality of the ice, the texture of the mud). But he understood the danger of the big Hum—both the constant barrage of chatter from the world (two, three, four hours of television a day) and its lingering echoes. Even when you turn the set off, even when you hike deep into the Adirondack woods, your mind keeps up a constant vibration, playing and replaying words and images and ideas so that you hardly notice your surroundings. So that you rarely notice your thoughts.

Try disconnecting for a while and see what the hum has done to you, see what it’s made of you. Thoreau liked his small library of books, but he recognized the danger even there: “while we are confined to books . . . we are in danger of forgetting the language which all things and events speak without metaphor.” Often, he says, he laid aside his books and even his gardening. “There were times when I could not afford to sacrifice the bloom of the present moment to any work, whether of head or hands.” He would merely sit in his door and the hours would somehow pass. Try this—see if you’re still made for musing. How long can you watch a sunset before you get bored? How long can you look at the night sky before you seek some entertainment?

The idea that we know what we want is palpably false. We’ve been suckled since birth on an endless elaboration of consumer fantasies, so that it is nearly hopeless for us to figure out what is our and what is the enchanter’s suggestion. And we keep that spell alive every time we turn on the radio or the television or the net. Because when someone is whispering something in your ear, there’s no way to think your own thoughts or feel your own responses. The signals that your heart sends you are constant, perhaps, but they’re also low and rumbling and easily jammed by the noise and static of the civilization we’ve lately built. That’s why Thoreau had to run away for a while, and it’s why another small but growing number of people are beginning to question some of the premises of our Information Age. For example, a group called TV-Free America has been organizing nationwide “Screen-Free Weeks” throughout schools since 1995; since then, millions of youngsters have turned off the tube for a week, and perhaps some few of them glimpsed the huge pleasure that comes from hearing your own true voice.

This is an environmental problem not only because the main function of the Information Revolution is to sell us stuff we don’t need, stuff that gives off carbon dioxide or gathers in dumps. It’s a problem most of all because it confuses us as to our place in the scheme of things. Without silence, solitude, darkness, how can we come to any sense of our true size, our actual relationship with the rest of the world? Some years ago I took a group of kids from the local high school for a camping trip. We live in a remote wilderness town, where no city lights blur the view of the sky. And it was the night of the new moon, so the heavens were an absolute velvet black, studded with stars. But as we were looking up and talking, it became clear that two-thirds of the kids had never been shown the Milky Way, that most potent symbol of our own true dimension. They’d been inside watching the other stars on television, the ones that insist that each of us is so central that the world orbits around us.

What nature provides is scale and context, ways to figure out who and how big we are and what we want. It provides silence, solitude, darkness: the rarest commodities we know. It provides reality, in place of the endless electronic mirages and illusions that we consider the miracle of our moment. “There is a solid bottom every where,” Thoreau insists—and it is this insistence that gets him in trouble with so many academics, committed to the postmodern notion that all is idea, stance, mutable. You cannot believe that if you have spent enough time out of doors.

“Let us spend one day as deliberately as Nature, and not be thrown off the track by every nutshell and mosquito’s wing that falls on the rails,” writes Thoreau. “Let us settle ourselves, and work and wedge our feet downward through the mud and slush of opinion, and prejudice, and tradition, and delusion, and appearance . . . till we come to a hard bottom and rocks in place, which we can call reality, and say, This is, and no mistake.” Only when we have some of that granite to stand on, that firm identity rooted in the reality of the world, only then can we distinguish between the things we’re supposed to want and the things we actually do want—only then can we begin the process of satisfying “non-material needs in non-material ways,” which environmentalist Donella Meadows has identified as our chief hope. Only then can we say “How much is enough?” and have some hope of really knowing.

In the 160 years since Walden, Thoreau has become ever more celebrated in theory, and ever more ignored in practice. “Men think that it is essential that the Nation have commerce, and export ice, and talk through a telegraph, and ride thirty miles an hour,” he writes. How sleepy that protest sounds to an age that thinks we must travel supersonically, communicate instantaneously, trade globally. Each week in our world, as many as two billion people—twice as many people as lived on the planet in Thoreau’s time—can watch the TV program Big Brother. Literally, consumption has become national policy—in the days after 9/11, the president’s main (and obscure) advice was that all good patriots should get out there and shop.

And yet the battle could still swing; we live at a pivot in history when, quite suddenly, ideas like Thoreau’s might suddenly flourish. To understand why, remember something I said earlier. He is the American incarnation in a line of crackpots and gurus from Buddha on. Jesus, St. Francis, Gandhi, and the holy men and women of every branch of the ethical religious tradition share an outlook: Simplicity is good for the soul, for the right relation with God. In the Christian formulation: Do not lay up treasure here on earth; you can’t serve both God and money; give away all that you have and follow me. Except, occasionally, for clerics and monks and saints, these are not injunctions we’ve tried very hard to put into practice.

We’ve adopted the competing religious worldview, the one that worships an ever-growing Economy. But such spiritual notions have not disappeared, either; they’ve flowed like a small but steady river through world history, never completely drying up. Thoreau helped add a new tributary to that stream. His nature writing is raw, wild, and haunting. He comes to the marsh at night to hear the hooting owls: “All day the sun has shone on the surface of some savage swamp, where the single spruce stands hung with usnea lichens, and small hawks circulate above, and the chicadee lisps amid the evergreens, and the partridge and the rabbit skulk beneath; but now a more dismal and fitting day dawns, and a different race of creatures awakes to express the meaning of Nature there.” In his wildness he harks back to the ancient pantheistic traditions, older by far than the Buddha and still alive in remnant form among some native peoples, traditions that might have understood his eagerness to eat a woodchuck raw. And he presaged the twentieth-century, American-led boom in his affection for nature. When he wrote, most of the civilized world still regarded the forest and the mountain with distaste; but in his wake came Whitman, Burroughs, Muir, and a thousand other writers, and right behind them came a million people toting backpacks. If the lakeshore cottage colony and the backcountry subdivision can be numbered among his legacies, so can the national parks and wildernesses. This stream grew larger; the concern for right relation with God joined with love of the physical world. It was still not large enough to jump its banks and flood the city where Economy sat enthroned, but more and more people could hear the roar of its rapids.

Now, quite suddenly, at the beginning of the twenty-first century, a whole new tributary of thought swells that countercultural river. The saints in their robes and the nature lovers in their Gore-Tex jackets are suddenly joined by men and women in lab coats, clutching computer printouts. The students of the largest environmental changes taking place around us come with a message eerily similar to those we’ve heard before. When the International Panel on Climate Change reported recently that humans were likely to raise the earth’s temperature 3.5 degrees this century, that they had begun to alter the most basic forces of the planet’s surface, the implication of their graphs and charts and data sets was, Simplify, simplify. Not because it’s good for your relationship with God, but because if you don’t, the temperature of the planet will be higher by 2100 than it’s been for hundreds of millions of years, which means crop- withering heat waves, daunting hurricanes, rising seas, dying forests. They were calling for community, not because it’s good for the soul but because without it there’s little chance we’ll become efficient enough in our use of energy or materials. The math is hard to argue with; business as usual and growth as usual spell an end to the world as usual. This is the one overwhelming fact of our lifetimes.

And so this river rises, gathers new freshets, drains ever more valleys. Perhaps it is nearly ready to flood our joint consciousness, to submerge our current idols, to cut a new channel for us in some as-yet-unseen direction.

But if—to paddle a little further along this metaphor—this new Concord or Merrimack really is swelling with runoff from every direction, we must take care that it is not polluted by fear. Though we need to understand and feel the depth of our dilemma, panic will only make it harder for us to simplify, to retreat from our fortresses of wealth, to back off. Thoreau understood this; his overpowering confidence, in himself and in the world, rings through every page of Walden. One day, feeling an uncustomary melancholy, he sat in his house during a rain. “I was suddenly sensible of such sweet and beneficent society in Nature, in the very pattering of the drops, and in every sound and sight around my house, an infinite and unaccountable friendliness all at once like an atmosphere sustaining me.” That’s the secret Thoreau has to offer, that promise that the world is sweet. That’s the rain which must feed this new river. “I learned this, at least, by my experiment; that if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours.” We must trust that he is right—for ourselves and, though he couldn’t have guessed it, for the planet.

SDG Index Overview And Dashboards Report 2017

The SDGs are a universal agenda of sustainable development, calling on all nations to pursue a holistic strategy that combines economic development, social inclusion, and environmental sustainability. We are gratified that throughout the world, local and national governments are rallying around the goals, seeking ways to incorporate them into planning processes. Businesses, universities, and civil society are also recognizing that the SDGs and the Paris Climate Agreement (incorporated into the sustainable development agenda as SDG 13) require a new orientation of strategy and national planning.

The SDGs rightly emphasize a universal agenda that requires all countries – both rich and poor alike – to take decisive actions to support sustainable development. In this year’s report we note that development patterns of the rich countries may generate adverse “spillovers” that may hinder the ability of poorer countries’ to achieve the SDGs. For example, the high consumption levels, banking secrecy and tax havens, and weapons exports, by the rich countries may severely inhibit sustainable development in poorer and more vulnerable countries. On the other hand, international development finance by high-income donor nations also directly supports the SDGs.

The 2017 SDG Index and Dashboards report generates “tough grading” for all countries, including the richest ones. We choose this approach not to be punitive or pessimistic about the prospects for dramatic improvements, but to draw attention to the most urgent SDG-related challenges facing each country for each SDG.


Agenda 2030 and the Sustainable Development Goals (SDGs, Figure 1), which were adopted by all member states of the United Nations in 2015, describe a universal agenda that applies to and must be implemented by all countries, both developed and developing.




To help fill a major gap in last year’s report and in SDG discussions more generally, we focus this year’s report on countries’ global responsibilities and international spillover effects in achieving the SDGs. Such spillovers must be understood and measured since countries cannot achieve the goals if others do not do their part. For example, rising sea levels will submerge Small Island Developing States (SIDS) unless all countries curb greenhouse gas emissions, and African elephants and rhinos face extinction unless demand for ivory and horns is curbed outside of Africa. Poor countries require increased Official Development Assistance to co-finance the investments needed to achieve the Goals, and all countries must avoid a race to the bottom on taxation and transparency to protect the public revenues required to finance the goals. Only if such positive and negative spillovers across countries are managed carefully can the promise of Agenda 2030 be fulfilled, particularly since negative effects tend to flow from rich to poor countries. It is therefore critical to understand spillover effects and to measure them as part of SDG monitoring, as done for example by the OECD.

Our effort is motivated by the realization that traditional SDG metrics mostly ignore such spillover effects and therefore favor the high-income countries that tend to generate significant negative spillover effects and that have the greatest capacity to misappropriate the resources of the global commons.

In this report we consider three groups of international spillover effects:

Environmental spillovers, include anthropogenic climate change; transboundary pollution and pollution embedded in trade; biodiversity loss embedded in trade; and the misuse of the global commons, such as overfishing in the high seas. Unfortunately, data are limited or unavailable for some of these spillovers.

Spillovers related to the economy, finance, and governance include official development finance and policies related to international investments; trade rules; inefficient tax competition; international tax evasion; banking secrecy; and cross-border corruption.

Security spillovers, include trade in arms, particularly in small arms; international crimes; and investment in conflict prevention (positive spillover).

Overall, the nine spillover indicators affect six goals: SDG 6 on water, SDG 12 on sustainable consumption and production, SDG 13 on climate change, SDG 15 on terrestrial biodiversity, SDG 16 on peace and justice, and SDG 17 on the global partnership. Since high-income countries tend to generate negative spillover effects vis-à-vis the poorer countries, the inclusion of spillover indicators changes the scores and rankings attributable mainly to the high-income countries.


The SDG Index

The SDG Index score signifies a country’s position between the worst (0) and best (100) outcomes. So Sweden’s overall index score of 85.6 suggests that the country is on average 85.6% of the way to the best possible outcome across the 17 SDGs.

Three Scandinavian countries (Sweden, Denmark, and Finland) top this year’s SDG Index, but they score significantly below the maximum score of 100. Each of these countries scores “red” on at least one SDG (Figure 3), particularly on climate change and other environmental SDGs. The addition of the spillover indicators discussed in the next chapter has lowered the SDG Index score for many rich countries, particularly Switzerland, the United States, and several Gulf States. However, additional spillover indicators represent only a subset of SDG Indicators, so they do not profoundly change the overall rankings in the SDG Index.

Poorer countries tend to be closer to the bottom of the rankings. This result is not surprising, since SDGs 1 to 8 focus on ending extreme poverty in all its forms. Moreover, poorer countries tend to lack adequate infrastructure and the mechanisms needed to manage key environmental issues that are the focus of other SDGs. For this reason, the commitments to provide adequate development assistance and climate finance made by rich countries at the 2015 Financing for Development Summit in Addis Ababa and the Paris Climate Agreement are a critical part of the SDGs.


Table 5 Country rank 1


Table 5 Country Rank 2


Contribution of International Spillovers

The data on each spillover indicator (Annex 1) show that high-income countries tend to generate negative SDG spillover effects for poorer developing countries. Figure 2 illustrates this point further. It plots countries’ average performance on the spillover indicators (note that the vertical axis is inverted so that worst performers on spillover indicators are at the top) against per capita GDP PPP (horizontal axis). Negative spillover effects are most common among wealthier countries, but there’s high variation in spillover effects. Some high-income countries generate large negative spillovers (e.g. Belgium Israel, Luxemburg, Netherlands, Switzerland, Singapore, United Arab Emirates, UK, USA) while others score above 70 on spillovers (e.g. Australia, Canada, Denmark). This suggests that good SDG outcomes are often associated with negative spillover effects, but this effect can be tempered through policies.

These results underscore that rich countries in particular need to address negative spillover effects in their SDG implementation strategies and reporting.


Figure 2 spillover


SDG Dashboards

The SDG Dashboards for OECD countries show that every rich country faces major challenges in meeting several SDGs, as indicated by a red rating. The greatest challenges exist on sustainable consumption and production (SDG 12), climate change (SDG 13), clean energy (SDG 7), and ecosystem conservation (SDGs 14 and 15). Here the international spillover effects that are included in the 2017 SDG Index report show up strongly. Several OECD countries are rated “red” on SDG 2 because their agricultural systems are unsustainable, and some countries are rated low because of very high rates of obesity, which we interpret to be a measure of malnutrition. A large number of OECD countries face major challenges in achieving SDG 17 because of their insufficient financial contributions towards international development cooperation, banking secrecy, or unfair tax competition. Some experience low growth and high unemployment (SDG 8) as well as major shortfalls on gender equality (SDG 5). Notably, several OECD countries score “red” on income inequality (SDG 10) and SDG 16 (peace and sound institutions). We recommend that OECD countries carefully study their performance against individual indicators to identify the areas where greater progress is required.


OECD Countries


The dashboards for East and South Asia outperform many other developing regions on the SDGs, but several challenges do remain. While tremendous progress has been made on reducing extreme income poverty (SDG 1), the dashboard shows that the region faces major SDG challenges in health (SDG 3) and education (SDG 4). SDG 2 (improved nutrition and sustainable agriculture) comes up as red across the region since countries either face high levels of malnutrition and stunting or unsustainable agricultural practices. There are still significant shortfalls on ensuring access to basic infrastructure services and innovation (SDGs 6, 7, 9) across the region. Many countries face major challenges on ensuring gender inequality (SDG 5) and promoting environmental sustainability (SDGs 11, 12, 13, 14, 15, as well as SDG 2 on sustainable agriculture). Overall, the dashboard shows that the region needs to better balance its economic performance with environmental sustainability. The expanded data used for the 2017 SDG Index also suggest that SDG 16 (peaceful and inclusive societies) represents major challenges in countries across the region.


East and Southeast Asia Countries


Countries in Eastern Europe and Central Asia have met some of the most pressing challenges in providing social services and access to basic infrastructure, though greater progress is needed to achieve these SDGs. The region has largely ended extreme income poverty (SDG 1). The greatest challenges remain in promoting health (SDG 3), achieving gender equality (SDG 5), addressing renewable energy and climate change (SDGs 7, 13), sustainable consumption and production (SDG 12), and protecting ecosystems (SDGs 14, 15). Available data for SDG 2 show that many countries also need to shift towards more environmentally sustainable agricultural practices and improve nutrition outcomes. Under SDG 9 (infrastructure) countries will need to prioritize greater access to information and communication technologies and promote innovation. A few countries in the region exhibit very high rates of income inequality (SDG 10), and insecurity remains widespread (SDG 16).


Eastern Europe and Central Asia


Extremely high levels of inequality (SDG 10) are a critical challenge across Latin America and the Caribbean. The same applies to the promotion of peaceful societies (SDG 16) with many countries scoring poorly on measures of insecurity and violence. Given the relatively higher levels of per capita incomes in the region it is notable that some countries continue to face major challenges in health (SDG 3), education (SDG 4), as well as poor nutrition (SDG 2). The expanded indicators for the 2017 SDG Index show that countries in the region need to promote innovation (SDG 9) and improve employment outcomes (SDG 8). The SDGs’ stronger focus on environmental sustainability brings out major challenges across the region in meeting SDGs 12 (sustainable consumption and production), 13 (climate change), 14 (oceans), and 15 (terrestrial ecosystems). As the poorest country in the region, Haiti faces particular challenges across the full breadth of the SDGs.


Latin America and the Caribbean


In the dryland Middle East and North Africa food security and sustainable agriculture (SDG 2) and sustainable water management (SDG 6) are high-priority challenges in most countries. Several countries face major challenges in achieving gender equality (SDG 5). Our expanded indicators now underscore the importance of promoting innovation and investments in communication technologies across the region. The data on SDG 8 show that many countries are not growing fast enough and experience high rates of unemployment. These countries also face major challenges in decarbonizing their energy systems to fight climate change (SDG 13), and in conserving marine (SDG 14) and terrestrial (SDG 15) ecosystems. Several countries perform poorly across the full range of SDGs owing to instability and conflict, which also show up in SDG 16. The high-income countries in the region generate substantial negative spillover effects on other countries.


Middle East and North Africa


As the world’s poorest region, albeit one that is now experiencing important advances, Sub-Saharan Africa  faces nearly across-the-board challenges in meeting the SDGs. In particular, major challenges remain in ending extreme poverty (SDG 1) and hunger (SDG 2), health (SDG 3), education (SDG 4), and access to basic infrastructure (SDGs 6 – 9), while noting the tremendous progress that was made in many of these areas under the Millennium Development Goals. The broader SDGs bring out additional challenges for Sub-Saharan Africa that require urgent action. These include sustainable urban development (SDG 11) and reducing high inequality (SDG 10). Similarly, significant challenges remain on SDGs 16, including peace, security, and institutions. Countries in the region fare much better on sustainable consumption and production (SDG 12), climate change (SDG 13), and terrestrial ecosystems (SDG 15), underscoring that richer countries are responsible for a disproportionate share of environmental pressure relating to these goals. The remaining red scores on Goal 17 highlight that Sub-Saharan Africa has significant potential in mobilizing domestic revenue collection.


Sub Saharan Africa


We propose five major findings from this year’s SDG Index report:

1. Every country faces major challenges in achieving the SDGs: The SDG Dashboards highlights some “red” priority SDGs for every country. Even “yellow” and “orange” of course signify important room for improvement and should be interpreted as a major challenge, particularly in wealthier countries. Poor countries face significant challenges in ending extreme poverty in all its forms, social inclusion, access to essential infrastructure, and many forms of environmental degradation. Richer countries face more specific but nonetheless major challenges in areas such as climate change mitigation, inequality, sustaining the global partnership, and targeted challenges in areas such as nutrition, gender equality, or education.

2. Poor countries need help to achieve the SDGs: The SDGs are undoubtedly a very bold agenda. It is clear from this analysis, that the poorest countries will face major challenges in achieving the SDGs. They will need considerable global assistance to supplement national leadership. This assistance should come in many forms: foreign direct investment, global tax reform to enable the poor countries to fight tax evasion by international investors, technology sharing, capacity development, and of course, more Official Development Assistance.

3. The universal SDG agenda contains important spillover effects: Actions by rich countries in particular affect other countries’ ability to achieve the SDGs. Examples include environmental spillovers, such as pollution embedded in international trade, transboundary effects of resource use, or the use of global commons, such as oceans and the high seas. There are also important spillovers related to the economy, finance, and governance, including unfair tax competition by a few tax havens, deliberately opaque financial systems that foster money laundering, corruption, tax evasion, as well as insufficient financing for global public goods. And finally, trade in weapons and insufficient support for peacekeeping generate important security spillovers. Rich countries in particular should spell out in their SDG strategies how they plan to tackle these spillover effects so that every country can achieve the SDGs.

4. Countries should usefully benchmark themselves against their peers as well as against the goal thresholds: The SDG Index and Dashboards highlight substantial variation across countries in a region or income group. In combination, the SDG Index and Dashboards can help countries benchmark their progress against that of their peers and against the top performers to understand reasons for differential performance and to devise better strategies to achieve the SDGs by 2030.

5. Countries and international agencies need to make substantial investments in statistical capacity to track the SDGs: Despite our best efforts to include as many indicators as possible, a number of important data gaps remain. Addressing these gaps will require increased investments in statistical capacity and other forms of data collection especially but not only in low-income developing countries. Table 6 summarizes some of the most important indicator and data gaps.


SDGs Table 6


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2017 SDGs Report Top 10 Countries

As part of the 2017 SDGs report, the UN gave each country a score per SDG as well as a total ranking. Below is the total ranking for each country. This article then includes the breakdowns for the top 10 countries, compared to the United States (which ranks 42nd).


Table 5 Country rank 1


Table 5 Country Rank 2



Rank 1: Sweden


Sweden 1


Sweden 2


Rank 2: Denmark


Denmark 1


Denmark 2


Rank 3: Finland


Finland 1


Finland 2


Rank 4: Norway


Norway 1


Norway 2


Rank 5: Czech Republic


Czech Republic


Czech Republic 2


Rank 5: Germany


Germany 1


Germany 2


Rank 6: Austria


Austria 1



Austria 2


Rank 8: Switzerland


Switzerland 1


Switzerland 2


Rank 9: Slovenia




Slovenia 2


Rank 10: France


France 1


France 2


Those top 10 countries according to the 2017 SDG report have not fully achieved the SDG goals, however they are closer to many other countries.  The United States is ranked 42nd and its chart is below.


United States 1


United States 2


Finally, below are tables that gives the individiual SDG scores for each country:


Country Scores by SDG 1


Country Scores by SDG 2


Country Scores by SDG 3


Country Scores by SDG 4