Blue states are losing people. New York, California, Illinois, and Massachusetts have all seen population decline or stagnation over the last decade, and the trend is accelerating. People are leaving for Florida, Texas, and Tennessee — not because those states have better governments, but because they have cheaper housing.

This is not just an affordability problem. It is a political crisis. Congressional reapportionment is based on population, and if blue states keep hemorrhaging residents through the 2020s, the 2030 census will hand Republicans a structural advantage in the House that Democrats may not be able to overcome for a decade. California already lost a congressional seat after the 2020 census. New York nearly lost two. If current trends continue, the next round will be worse.

The root cause is not hard to identify. Many local governments in blue states have development laws that make it damn near impossible to build anything. State Democrats have the power to fix this. Most blue states have trifectas. They have the governor’s office, the state senate, and the state house. There is no Republican blocking these reforms.

The only thing standing in the way is the political will to take on the powerful interest groups that have benefited from keeping housing scarce. This needs to be done. Here are 7 ways it can be.

1. Legalize Missing Middle Housing Statewide

• Legalize medium-density multifamily housing by right in all residential zones

• Legalize townhomes by right in all residential zones

• Legalize accessory dwelling units by right on any residential lot, with no owner-occupancy requirement

Single-family zoning is the original sin of American housing policy. Across many blue states, it is still illegal to build a townhome, ADU (granny flat), duplex, triplex, or small apartment building on the vast majority of residential land.

Legalizing missing middle housing means allowing medium-density multifamily by right in every residential zone in the state. No special permits. No local vetoes. No discretionary review. If the lot is residential, you can build it.

This is the single most powerful thing a state can do to increase housing supply. Every unit of missing middle housing that gets built is one fewer family priced out of the neighborhood.

2. Legalize Mixed Use Development Statewide

• Convert all retail and office commercial zones to mixed-use residential and commercial zones

• Allow adaptive reuse of office and retail buildings for residential use by right, without requiring a full rezoning

It should be legal to build an apartment above a store anywhere in America. In most blue states, it isn’t, because retail and office commercial zones prohibit residential uses entirely.

Converting all retail and office commercial zones to mixed-use by right opens up enormous amounts of land for housing without touching a single residential neighborhood. Main streets, strip malls, and dead office parks — all of it becomes fair game for the housing that people actually need.

There are many other benefits, too. Mixed-use areas provide easy access to amenities for those who live in them. They also allow people to cut their commute by living within walking distance from where they work, thereby also reducing street traffic.

3. Lower Housing Production Costs

• Reform building codes to allow single-stair construction in multifamily buildings

• Legalize manufactured housing that meets HUD standards in all residential zones

It costs too much to build in America, and a significant chunk of that cost is unnecessary. Two reforms can bring it down fast.

Current building codes in most states require two stairwells in any multifamily building over a certain height. Europe has allowed single-stair construction for decades with a strong safety record. Allowing single-stair design unlocks building configurations that are cheaper to build, more efficient to use, and actually better for residents. It is one of the most impactful and least talked-about housing reforms available.

Modern manufactured homes built to HUD standards are safe, durable, and significantly cheaper to produce than site-built homes. Most residential zones still prohibit them through aesthetic requirements designed to keep out lower-income residents. Requiring all residential zones to permit HUD-standard manufactured housing puts homeownership back within reach for people who have been shut out for a generation.

4. Tear Down Permitting Barriers

• Cap permitting fees at a level that reflects actual administrative costs

• Cap permitting wait times with automatic approval if the government misses the deadline

Even when housing is technically legal to build, local governments can kill it through the permitting process. Fees pile up. Applications sit for months. Approvals get delayed indefinitely with no accountability.

States need to cap permitting fees at a level that reflects actual administrative costs, not a revenue stream for local government. And they need to set hard deadlines for permit approvals, with automatic approval if the government misses the deadline. If a city wants the housing, it will process the permits. If it doesn’t process the permits, the housing gets built anyway.

5. Ban Impact Fees on Housing

• Ban impact fees on all new housing development statewide

Impact fees are charges that local governments impose on new housing developments to fund infrastructure. In theory, developers pay for the roads and schools their projects create demand for. In practice, impact fees have become a tool to price housing out of the market and protect wealthy homeowners from new neighbors.

In many California jurisdictions, impact fees add $50,000 to $100,000 to the cost of a single unit. That cost does not disappear. It gets passed on to renters and buyers. Blue states should ban impact fees on housing entirely and fund infrastructure through broad-based taxation instead.

6. Stop Frivolous Litigation from Blocking Housing

• Reform standing requirements so only parties with direct, genuine harm can challenge housing projects in court

In most states, virtually anyone can sue to block a housing project on environmental or procedural grounds. You do not need to own property near the project. You do not need to demonstrate actual harm. You just need a lawyer and enough money to drag the process out until the developer gives up.

States should reform standing requirements so that only people with a genuine, direct stake in a project can challenge it in court. Projects that comply with state housing law should not spend years in litigation before a single unit gets built.

7. Enforce the Law

• Create a state housing appeals board where developers can challenge local denials that violate state housing law, with real enforcement teeth

None of the above matters if local governments can ignore state housing law without consequence.

Blue states need a state housing appeals board with real teeth. When a local government denies a housing project that complies with state law, developers need a fast, low-cost way to challenge that denial and win. Not a years-long court battle. A state administrative process with clear timelines, binding decisions, and penalties for local governments that repeatedly violate state housing mandates.

California has spent years passing housing laws that cities quietly ignore. The lesson is clear: transparency without enforcement is just paperwork. If blue states are serious about the housing crisis, they have to be serious about making sure their own laws get followed.

The housing crisis is not a mystery. We know why housing is expensive. We built a system of laws designed to make it expensive, and the people who benefit from high home prices have fought to keep that system in place. Democrats have the power in blue states to dismantle it. The only question is whether they will.

Some Democratic Governors have taken the lead on this. Including JB Pritzker recently with his bold new BUILD agenda. We need more Governors, and just as importantly, state legislatures to follow suit.

Our democracy hangs in the balance.

Republicans have spent the last few months telling Virginians that Democrats are turning the Commonwealth into a radical communist dystopia.

Exhibit A:

Exhibit B:

Exhibit C:

Notice something about all these tweets? They never actually cite anything specific that Democrats have actually done. Just vague statements or outright lies, like the 50+ taxes claim. Not a single tax hike has been signed into law.

Here is why. When you look at what Virginia Democrats have done in just a few months of unified government, the right-wing hysteria is shown to be ridiculous pretty quickly.

So let’s look at what actually happened.

Workers finally got a raise.

Virginia’s minimum wage has been stuck in a losing battle with inflation for years. Republicans blocked a $15 floor twice under Youngkin. This session, Democrats passed SB1, raising the wage from $12.77 to $15 an hour by 2028. It’s done.

But that’s only part of the worker story. HB5 guarantees paid sick leave for every Virginia worker, one hour earned for every 30 worked. Not just full-time employees. Everyone. The nurse’s aide, the restaurant worker, the warehouse employee. No more going to work sick because missing a shift means missing rent. No more losing your job because your kid had a fever.

And then there is SB2, which is the one that matters most to me personally. Paid family and medical leave. Up to 12 weeks at 80% of wages when a worker has a baby, loses a parent, or faces a serious illness. Youngkin vetoed this bill twice. Spanberger has committed to signing it. When she does, Virginia will become the 14th state in the country to guarantee this right. The other 13 states haven’t collapsed. Their workers have just had a little more security when life gets hard.

They went after the people skimming your prescriptions.

There are many reasons healthcare is so expensive in this country, and pharmacy benefit managers are one of them. PBMs sit between your insurer and your pharmacy, negotiating discounts and keeping a cut that never makes it to the patient. This is why you hand over a prescription, and the price is somehow higher than last month, with no explanation. SB669 ended that, requiring PBMs to pass their negotiated savings on to patients. It passed unanimously, which tells you something. Even Republicans couldn’t defend the status quo on this one.

SB405 addressed Virginia’s healthcare workforce shortage, which has been quietly driving up wait times and costs for years. More providers mean more access, which means lower prices.

HB60 protected access to preventive care. This matters because a $200 annual checkup that catches something early is dramatically cheaper than the emergency care that follows from catching it late.

Housing got a little less ridiculous.

SB628 expanded the Virginia Eviction Reduction Program, getting evidence-based crisis assistance to people teetering on the edge of losing their homes. The research on eviction prevention is consistent: keeping people housed is cheaper than the cascade of costs that follows an eviction, for individuals and for governments alike.

HB655 and SB346 legalized manufactured homes anywhere single-family homes are permitted statewide. Local zoning had been blocking this for years, keeping one of the most affordable paths to homeownership off the table for people who need it most. That changed.

Spanberger also signed EO-3 on her first day, directing the state government to cut red tape on housing supply. More YIMBY bills are coming before April 13 that advocates, including myself, are very optimistic she will sign.

They invested in the grid and the future.

America’s transmission infrastructure is decades behind where it needs to be, and building more of it is one of the most important things a state government can do right now. HB889 and SB497 streamlined permitting for new high-voltage transmission lines, cutting through the bureaucratic delays that have been slowing this build-out for years. That is a genuinely significant reform.

HB369 encouraged investment in cutting-edge energy technology, including nuclear fusion, passing with bipartisan support.

HB1191 and SB377 ensured that data centers, which consume staggering amounts of power, pay for the infrastructure upgrades their operations require rather than passing those costs to ordinary ratepayers.

HB1225 and SB407 expanded EV charging access across the Commonwealth.

Beyond this, Spanberger is expected to sign Virginia back into RGGI, the Regional Greenhouse Gas Initiative, which caps carbon emissions from power plants and generates revenue for clean energy investment. Youngkin pulled Virginia out in 2023 for reasons that were never particularly coherent. With the federal government having abandoned any serious climate leadership, state coalitions like this one are more important than ever. Virginia is about to go back in.

They did the most common-sense thing imaginable.

HB1180 created a free tax filing program for all Virginians. You should not have to pay a private company to comply with a legal obligation. The fact that Americans have been doing this for decades, while most of the developed world offers it for free, is a policy failure. Virginia just fixed it for its residents. It is honestly baffling that this took so long.

They took school safety seriously.

Mass shootings have become a defining feature of American life in a way that would have been unthinkable a generation ago. Spanberger signed a package of bills that take the threat seriously without waiting for federal action that is never coming. Red flag law training means law enforcement actually knows how to use a tool that research consistently shows reduces gun deaths. Panic alarm systems mean a teacher can summon help in seconds rather than minutes, and in a shooting, those minutes are the difference between life and death. Mental health support for at-risk students and after-school programs address the upstream conditions that lead to violence in the first place. Prevention is cheaper than tragedy, and it works.

The ghost gun ban, SB323, is on her desk. Ghost guns are unserialized firearms specifically designed to pass through metal detectors and evade background checks. They have become the weapon of choice for people who cannot legally buy a gun. Making them a felony to manufacture or possess does not infringe on anyone’s right to own a legal firearm. It just closes a loophole that never should have existed. She is expected to sign it.

They ended a policy that made no sense.

Until now, Virginians could legally possess cannabis but not buy it legally, which mostly meant they bought it illegally, with no testing, no regulation, and no tax revenue. HB642 fixes this, creating a licensed retail market starting in 2027 with testing requirements, public standards, and safety rules. Youngkin vetoed this. Spanberger has pledged to sign it. The black market will have some competition, and the state will have a new revenue stream.

In just a few months, with hundreds of bills still awaiting her signature, Virginia Democrats have delivered more concrete wins for working people than the state has seen in years. Wages up. Paid leave guaranteed. Drug costs down. Housing supply increasing. The grid being built for the future. Tax filing becoming free. School safety strengthened. The government has become a little more functional.

Republicans told you we were getting radical chaos. What we are actually getting is bipartisan competence. As usual, they are wrong.

This is what governing looks like when it works.

This is the Virginia Miracle.

Virginia Democrats just had one of the most productive legislative sessions in years. With a historic trifecta, the largest House majority in nearly four decades, a Senate majority, and Governor Abigail Spanberger in the Executive Mansion, they came to Richmond with a mandate: make Virginia more affordable for working families.

And they made real progress. Spanberger has signed legislation reining in pharmacy benefit managers, the middlemen who inflate prescription drug prices. Manufactured homes can now be built in more places. High energy users like data centers must now pay for their own infrastructure, shielding ratepayers from those costs. And a free state tax filing program, passed unanimously, means working Virginians no longer have to pay a private company just to file their taxes.

That’s a genuine start. But let’s be honest, it’s only a start. The affordability crisis in Virginia runs deep, and what’s been signed so far has only scratched the surface of what’s possible. Here are 20 proven ideas that would do exactly that.

HOUSING

Rising housing costs are the single biggest driver of financial stress for Virginia families. The diagnosis is simple: we don’t have enough homes. Building more housing, in more places, faster, is the most powerful lever Democrats have, and it doesn’t require a massive government spending program. It requires rolling back the local rules that are currently making affordable development impossible.

1. Reduce minimum lot sizes statewide.

Zoning rules that require large minimum lot sizes artificially restrict how much housing can be built on available land. A developer who wants to build three modest homes on a lot zoned for one simply cannot, not because of economic forces, but because of a government rule.

In some localities, the minimum lot size requirements are truly astounding. In Prince William County’s agricultural zone, the minimum lot size is 10 acres, over 400,000 square feet. For reference, the footprint of a typical townhome is often just 1,400 square feet.

That is not a market outcome. It is a government-imposed ban on affordable housing. And we should be honest about why these rules exist. They are not about safety. They are not about infrastructure. In many cases, they exist because existing homeowners and local officials want to keep housing scarce and expensive. They want to protect their property values. They want to keep working-class people out. That is the uncomfortable truth that too many politicians are afraid to say out loud.

Virginia Democrats should say it. And then they should do something about it.

Virginia should make it illegal for any locality to ban townhomes, capping the minimum lot size any locality can impose at 1,400 square feet. If a locality is using land use laws to price working families out of their community, the state has not just the power but the obligation to stop them.

2. Eliminate parking mandates.

Requiring developers to build a minimum number of parking spaces adds tens of thousands of dollars to the cost of every new unit. The cost of structured parking alone can run $30,000 to $50,000 per space, costs that get passed directly to renters and buyers. The mandates local governments are imposing are often completely arbitrary, inflating costs for no reason.

Furthermore, in walkable, transit-accessible areas, these mandates are especially absurd. Businesses already have an incentive to build parking for their customer. Imposing arbitrary parking mandates only raises costs and makes off-lot parking solutions (like pooled parking) illegal. The state should step in to end parking mandates, or, at a minimum, reduce them.

3. Legalize ADUs and multiplexes by right.

Accessory dwelling units, a basement apartment, a garage conversion, a backyard cottage, and small multifamily buildings should be legal to build everywhere in Virginia without requiring special permits, board hearings, or neighborhood approval. This is one of the fastest, least disruptive ways to add housing supply in existing neighborhoods. Homeowners get flexibility. Renters get more options. Everyone wins except the big landlords who benefit from artificial scarcity.

4. Limit standing in lawsuits against zoning changes.

This is the silent veto that almost no one talks about. Even when cities and states legalize more housing on paper, organized interest groups (usually wealthy homeowners) sue to block the changes and/or sue to stop individual projects. This drags out approvals for years and kills development even when the city supports it. Developers price in that legal risk, which raises costs, or they simply don’t build. Raising the standing threshold so plaintiffs must show concrete harm, not just “I don’t want this near me,” shortening the statute of limitations on zoning challenges, and requiring plaintiffs to post a bond would protect legitimate pro-housing reforms supported by local communities from being vetoed by wealthy, organized special interests.

5. Cap building permit fees.

In parts of Northern Virginia, permit fees and local charges add tens of thousands of dollars to the cost of building a single home. These costs get passed directly to buyers and renters. They are effectively a government tax on housing construction, and they fall hardest on the most affordable end of the market, where margins are thinnest, and developers are most price-sensitive. Capping them statewide puts direct downward pressure on the cost of building homes.

TAX REFORM

6. Implement a split-rate property tax.

A split-rate property tax taxes land at a higher rate than the buildings on it. The logic is straightforward: taxing land value discourages speculation and landbanking, i.e., holding underbuilt or vacant property in high-demand areas while waiting for values to rise. Taxing buildings less encourages development and improvement. If you are a wealthy investor who owns a surface parking lot in the middle of a thriving neighborhood, your tax bill goes up, which creates real pressure to build something useful. Regular homeowners who actually use their land come out ahead. Renters and new buyers benefit from lower rents and lower housing prices. It is a pro-development, anti-speculation reform that doesn’t require a single dollar of new spending.

7. Eliminate the car tax in exchange for a higher land tax.

Virginia’s personal property tax on vehicles is one of the most unpopular taxes in the Commonwealth, and one of the most regressive. It hits working and middle-class families who depend on their cars to get to work the hardest, while wealthier Virginians who can afford to live close to transit feel it least. Replacing it with a higher land value tax shifts the burden from working people onto land bankers and wealthier property owners. The working class and middle class will come out way ahead from this trade, and Virginia will no longer have to maintain its complex vehicle property tax assessment scheme.

HEALTHCARE

Healthcare costs are squeezing Virginia families from every direction, at the pharmacy, in the hospital, and on their insurance bills. The common thread in each of the following proposals is the same: more competition, more transparency, more supply.

8. Allow full independent practice rights for nurses.

Virginia requires nurses to practice under physician supervision even when they are fully qualified to treat patients independently. The result is a government-enforced bottleneck that restricts the supply of care, particularly in rural parts of the state where physician shortages are most severe. Removing that restriction expands access, increases competition, and drives down costs. It is one of the clearest examples of occupational regulation that protects incumbents rather than patients.

9. Open accelerated medical school pathways.

The physician shortage is fundamentally a supply problem, and supply problems have supply solutions. Accelerated three-year MD programs, already piloted in states across the country, can increase the number of practicing physicians faster without reducing the quality of care. More doctors mean more competition. More competition means lower prices. This is not complicated.

10. Create a Virginia Centralized Health Insurance Claims Clearinghouse.

Every health insurance claim filed in Virginia is a bureaucratic obstacle course. A doctor submits a claim. The insurer reviews it under its own proprietary system. The claim bounces through multiple clearinghouses. The whole process takes four to six weeks and costs between $12 and $19 per claim. That waste is not free. It gets baked into your premiums, your copays, and your care.

We already solved this problem in banking. It does not matter that your employer banks at Wells Fargo and you bank at a credit union. Your paycheck arrives instantly because all banks use the same standardized clearinghouse. The cost of running that entire system is roughly $300 million annually, for more than $50 trillion in transfers.

Virginia should build the health insurance equivalent. Require every insurer in the Commonwealth to submit, process, and pay claims through one standardized system. Insurers still compete on price and coverage. The government just runs the pipes. McKinsey estimates a centralized claims clearinghouse could cut healthcare administrative spending by 10 to 12 percent. In Virginia, that is billions of dollars that could flow back to patients and lower premiums instead of disappearing into bureaucratic overhead.

11. Eliminate Virginia’s Certificate of Need law.

This may be the single most important healthcare cost reform on this list. Virginia’s Certificate of Need law requires hospitals and healthcare providers to get government approval before adding new services, hospital beds, or medical facilities. It was designed to prevent overbuilding, but in practice, it functions as an incumbent protection racket. Existing hospitals use the CON process to block competitors from entering their markets, suppressing supply and keeping prices artificially high. Eliminating it would open healthcare markets to real competition for the first time in decades. Several states, including some deep red ones, have already done it. Virginia should, too.

CONSUMER PROTECTION

12. Comprehensive junk fee ban and all-in pricing law.

Here is a simple principle that Virginia should put into law: if a fee applies to every single customer, it is part of the price. Period. It must be included in the advertised price, online, in print, at the point of first display, everywhere.

The list of fees this would eliminate is long and familiar. Resort fees and destination fees tacked onto hotel bills. Service fees and order processing fees added at the last step of buying a concert ticket. Apartment admin fees and lease initiation fees charged to every tenant. Telecom regulatory recovery fees buried in the fine print of your phone bill. Healthcare facility fees charged for routine outpatient visits that have nothing to do with the care you received.

These fees exist for one reason: to make the price look lower than it is. They are a form of consumer fraud that has been normalized by the industry. Virginia should follow the lead of other states and make them illegal.

13. Require interchange competition on credit card transactions.

Every time a consumer swipes a card, the merchant pays a fee, typically 2 to 3 percent, to the card network and issuing bank. Those fees are built into the prices of everything you buy, whether you pay with cash, card, or anything else. Small businesses pay them and have no choice but to pass them on.

The problem is not the existence of any fee. It is the lack of competition that allows the fee to be so high. Visa and Mastercard dominate the market and set fee schedules with little competitive pressure. Requiring card networks to offer merchants a choice of at least two unaffiliated routing networks, the model behind the federal Credit Card Competition Act, lets the market drive fees down. It is not a price cap. It is a competition mandate. And it would put real money back in the pockets of consumers and small business owners across Virginia.

14. Allow direct sale of cars.

Virginia law requires automakers to sell vehicles through franchised dealerships. This is not a market outcome; it is a government mandate that protects a middleman industry from competition. Consumers pay for it in the form of higher prices and a worse buying experience. Allowing manufacturers to sell directly to consumers, as Tesla and others have gotten permission to do in select states, introduces genuine competition into the car market and drives prices down. There is no consumer protection rationale for this restriction. It exists because dealers lobbied for it. That is not a good enough reason to keep it.

BUSINESS CLIMATE

15. Eliminate all Virginia corporate welfare, redirect the savings to business courts, and reduce business fees.

Virginia hands out hundreds of millions of dollars in targeted tax breaks, subsidies, and exemptions to specific industries and corporations every year. The data center tax exemption alone costs the Commonwealth nearly two billion dollars in a single fiscal year. Some of these giveaways may have made sense when they were created. Most have never been seriously evaluated. All of them represent a choice to favor politically connected industries over ordinary Virginians and small businesses.

Democrats should end them, every single one, and use the savings to do two things. First, create dedicated Virginia business courts: specialized courts with judges who have commercial expertise, designed to resolve business disputes faster and more predictably. This is a genuine competitive advantage for attracting investment and costs a fraction of what we give away in corporate subsidies. Second, use remaining savings to reduce the fees and taxes that fall on every Virginia business, not just the ones with lobbyists. The way to help Virginia businesses is not to give more special giveaways to megacorporations. It is to reduce the real unnecessary burdens that negatively affect all businesses, large and small alike.

FOOD & EVERYDAY COSTS

16. Reform Virginia’s Cottage Food Laws.

Right now, Virginia law severely restricts what home-based food producers can sell, where they can sell it, and how much they can earn doing it. A home baker who wants to sell bread at a farmers market, a jam maker who wants to supply a local grocery store, or a small food entrepreneur trying to build a business from their kitchen runs into a wall of regulations that have nothing to do with food safety and everything to do with protecting incumbent commercial producers from competition.

Reforming cottage food laws means raising or eliminating the revenue cap on home food businesses, expanding the list of approved products, and allowing direct sales through more channels, including online and at retail locations. It lowers the barrier to entry for small food entrepreneurs, increases the supply of locally produced food, and creates more competition that puts downward pressure on food prices. States like Wyoming have gone nearly fully deregulated on cottage food and seen thriving local food economies as a result.

This is a reform that Democrats should own proudly. It empowers working people to build businesses from their own kitchens, creates economic opportunity with zero public spending, and makes food more affordable and more local at the same time.

EDUCATION & WORKFORCE

17. Universal dual credit — 50% enrollment by 2029.

Dual credit programs allow high school students to earn college credits before they graduate, at little or no cost. Every credit earned in high school is a credit that doesn’t have to be paid for in college. Setting a concrete statewide target, 50 percent of Virginia students enrolled in a meaningful number of dual credit courses by 2029, creates accountability and puts Virginia on a path to dramatically reducing the cost of a college degree for the next generation. States like Tennessee have pursued this aggressively and seen real reductions in student debt and time-to-degree.

18. Expand auto-articulation associate degree pathways.

Virginia’s community colleges charge a fraction of what four-year universities charge. But too often, students who complete an associate degree have to fight course by course to have those credits recognized when they transfer to a four-year institution. Strengthening Virginia’s automatic transfer and articulation agreements, so that community college credits stack seamlessly toward a bachelor’s degree, means a student can complete their first two years at community college rates and finish their degree at a four-year school. That cuts the cost of a bachelor’s degree nearly in half. It is one of the most powerful affordability tools available, and it requires no new spending.

19. Streamline occupational licensing.

Virginia requires licenses for dozens of occupations that other states regulate far less heavily or not at all. Every unnecessary licensing requirement is a barrier that keeps willing workers out of jobs and keeps prices high for consumers. A systematic review with a presumption toward eliminating licenses that don’t serve a genuine public safety purpose would expand workforce participation, reduce costs, and make Virginia more economically dynamic. This is not deregulation for its own sake. It is a recognition that the government should protect people, not protect incumbents.

FISCAL STRUCTURE

20. Create a Virginia Sovereign Wealth Fund and enshrine it in the Constitution.

This one is different from the rest. It is not about lowering a specific cost today. It is about building the long-term fiscal foundation that allows Virginia to lower costs and make pro-affordability investments for decades to come.

Here is the problem. When Virginia runs a budget surplus, that money tends to get fought over and spent on one-time giveaways, a tax rebate here, a line item there, with no lasting impact. It is the fiscal equivalent of spending a windfall instead of investing it. Other countries have done something smarter: they have created sovereign wealth funds that invest surplus revenue in the market, build wealth over time, and use the returns to fund public priorities without raising taxes.

Virginia should do the same. The mechanism is simple. Every surplus dollar goes first to fully topping off Virginia’s rainy day fund, already one of the best-managed in the country. Every dollar beyond that flows automatically into a new Virginia Sovereign Wealth Fund, invested in diversified index funds managed by an independent board modeled on the Virginia Retirement System. The fund never flows backward; it only receives, never pays out during downturns. That is what the rainy day fund is for.

Over time, the profits from this fund can be used to finance tax reductions and pro-affordability investments, without raising taxes or cutting services to pay for them.

Both the waterfall mechanism and the withdrawal restrictions should be enshrined in the Virginia Constitution, protected from any future legislature tempted to raid it for short-term political gain.

For too long, Virginia surpluses have been blown on one-time giveaways rather than long-term investments. It is time to change that, structurally and permanently.

Virginia Democrats came to Richmond this year with the most power they have had in a generation. They have already begun using it. But the mandate voters gave them in November was bigger than one session, bigger than one signing ceremony, bigger than any single bill.

The policies above represent a generational opportunity — to make Virginia the most affordable, most economically dynamic state on the East Coast. Not by accident. Not incrementally. But by design, with intention, and with the courage to go further than anyone has gone before.

The work has started. Now it needs to continue.

68% of American voters say they disliked both choices in the 2024 election. That number shocked no one. For decades, Americans have reported the same frustration. So the real question isn’t whether voters are unhappy. It’s how this keeps happening.

How is it that in a nation of 340 million people, we so rarely end up with candidates that most of us actually like? Why do our elections so often feel like a contest between the lesser of two evils, rather than a competition between the best available options? The answer lies upstream, in partisan primaries.

Under the current system, before the general election that everyone votes in, each party holds its own primary to decide who will represent it. These primaries effectively determine the choices available to voters in November. Yet only 20 to 25% of eligible voters participate in them. That small slice of the electorate is not representative of the public as a whole.

Primary voters tend to hold more extreme, ideological views than the broader population. As a result, the candidate most appealing to primary voters is often the least appealing to the general electorate. The consequences are predictable. Candidates are incentivized to represent not their district, but instead the small share of primary voters. This adverse incentive manifests in multiple ways.

First, partisan primaries tend to elevate hardline candidates who struggle with the general electorate. Recent examples include Kari Lake, Blake Masters, Doug Mastriano, Winsome Earle-Sears, all of whom won their primaries decisively, only to suffer clear losses in the general election. In each case, the race was winnable had the party nominated a more broadly appealing candidate.

Second, partisan primaries warp the behavior of candidates once in office. Elected officials are often forced to toe the party line and take positions that are unpopular with the broader public simply to avoid a primary challenge. Deviation from party orthodoxy is punished, even when it reflects the will of most voters.

A high-profile example is unfolding in Texas, where long-time Republican Senator John Cornyn now faces a serious primary challenge from Ken Paxton, a far more extreme Republican. In 2014, Cornyn opposed Ted Cruz’s move to shut down the government over Obamacare, and in 2022, he played a crucial role in the passage of the Bipartisan Safer Communities Act, a law aimed at preventing school shootings. Both positions were broadly popular with Texas voters. Yet those votes now threaten his political survival.

Cornyn is likely to lose to Paxton resoundingly in the primary, despite the fact that Paxton is far less popular with Texans, boasting only a 29% approval rating statewide. Future examples are likely coming in Indiana, where Republican state legislators who voted against Trump’s unpopular gerrymander push now risk defeat by Trump-endorsed primary challengers.

The pattern is unmistakable. Partisan primaries produce leaders who do not reflect the views of the public. They reward ideological purity over problem-solving and punish bipartisanship, even though bipartisan cooperation is essential in a country with divided government as often as ours. Instead of compromise, politicians are incentivized to engage in hyper-partisan posturing that generates attention but accomplishes little.

This institutional failure has consequences. Government policy swings wildly from administration to administration, rather than tracking public opinion, which makes far subtler, less extreme movements. Polarization only deepens as time goes on. And when neither party has a complete trifecta, policymaking comes to a stop.

Thankfully, the American people demand we cure this illness. Every poll in recent years has shown that most Americans don’t trust the government. In fact, an incredible 75% of Americans think that the government is actively working to favor itself and elites, not the country as a whole. Meanwhile, Americans in both parties actually agree on the government’s role and scope in many key issues. We find ourselves in a moment where the American people desperately want change, often agree on what that change needs to look like, but have no faith in the government as it stands today to enact that change. Radically altering our primary system is the best way to end this intolerable status quo.

So then, what would such a rethink of our primary system look like? The first step is to eliminate partisan primaries altogether and replace them with the all-party “jungle primaries” already employed in Alaska, California, and Washington. Under this system, every candidate for an office appears on the same primary ballot, regardless of party affiliation. Every voter participates in the same election. The top two, three, four, or five candidates then advance to the general election.

This reform directly addresses the core defect of partisan primaries: ideological gatekeeping by a small, unrepresentative electorate. Instead of appealing to the most partisan members of their own party, candidates must appeal to the electorate as a whole from the very beginning. The incentive structure shifts away from extremism and toward broad acceptability. Studies back this up and show reduced polarization, increased competition, and a greater likelihood that advancing candidates reflect the preferences of the median voter rather than party bases.

This sort of widespread reform of our primary system would not be unprecedented; after all, we have made big changes to our primaries before. Prior to the Progressive Era of the early 20th century, candidates were chosen by party elites in the “smoke-filled rooms.” Reformers pushed for an end to this undemocratic practice and began a march towards the present system. Gradually, the mid-20th century saw an expansion of primary elections across the country. It took a 1944 Supreme Court ruling to end white-only primaries in the South, and it was not until the 1970s that primaries existed in every state for presidential elections. So before anyone tries to tell you the primary system, as it stands, is some sacred and inviolable element of American democracy, remember that it’s barely 50 years old.

But all-party primaries alone are insufficient. In plurality voting elections, they suffer from a major flaw. Vote splitting. When multiple candidates appeal to similar constituencies, they can divide support and allow a less representative candidate to advance with only a small but cohesive base.

Consider California. Despite being overwhelmingly Democratic, there are scenarios where two Republicans could advance to the general election, simply because a crowded Democratic field splits the vote. A recent Emerson poll of the ongoing California gubernatorial race suggests this could even happen this year. Strategic withdrawals and tactical voting often prevent this outcome, but a well-designed democratic system should not rely on voter gamesmanship to avoid absurd results. That is why approval voting must accompany all-party primaries.

Under approval voting, voters may vote for as many candidates as they approve of. The top four or five most-approved candidates advance to the general election, and the most broadly approved candidate wins. Under an approval-voting, all-party system, the most popular candidate actually prevails. General elections are transformed from two-person lesser-of-two-evils contests into four or five-person greater-of-many-goods competitions. The political landscape would be fundamentally altered.

Demonizing the other side, currently an effective strategy, would become political suicide. Extreme positions that appeal to only 10 to 15% of voters would be abandoned in favor of policies that command broad agreement. The negative campaigns so popular at the moment would backfire, as attacking an opponent risks alienating voters who also approve of that candidate.

The politically optimal strategy would no longer be to please the primary electorate, but to reflect the actual views of constituents. The benefits go further. Third-party candidates and independents would finally have a viable path to victory if they could sway moderates. Long-entrenched incumbents in gerrymandered safe seats would face real competition. At present, over 85% of Congressional districts are uncompetitive; these reforms would help give voters a genuine choice.

The sickness at the heart of American politics, the polarization, the gridlock, the sense that nothing ever changes, is not an unsolvable cultural problem. It is an institutional one. And it can be fixed.

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We live today under a regime that was unimaginable a year ago. Universal tariffs, on every single country, on nearly all goods, at substantial, sometimes eye-popping rates.

Trade Psychosis

We’ve been made four incompatible pitches on why these tariffs are a good idea:

1. Tariffs will reshore America’s industrial base.

2. Tariffs will eliminate our trade deficit.

3. Tariffs are a bargaining chip to get fair trade deals.

4. Tariffs will raise enormous, consistent revenue that we can use to replace other revenue sources.

These justifications, which are often repeated one after the other in the same sequence, are hopelessly inconsistent—a theme in Trump’s trade policy.

If tariffs reshore America’s industrial base (1), we won’t be importing all that much, which means the revenue tariffs raise will be paltry (contradicting 4).

If tariffs are but a temporary bargaining chip for fairer deals (3), then they won’t lead to the insourcing of all supply chain nor will they raise long-term revenue (contradicting 1 and 4). And so on, and so forth.

Even taken individually, none of these arguments withstands scrutiny. If tariffs are about bringing back manufacturing, why are they also being imposed on imports that we simply cannot practically source in adequate quantities domestically? Think coffee beans, bananas, and many raw materials.

If they’re meant to eliminate our trade deficit, why target countries with which the United States already runs a surplus, such as Australia, the Netherlands, and the United Kingdom?

If they’re a tool to secure fair trade deals, why have so few been negotiated—and why punish allies like Switzerland, which already levies zero tariffs on 99.5% of American goods? And if tariffs are designed to raise revenue, why are they set at ever-changing, arbitrary levels rather than the long-term, revenue-maximizing rate?

Nothing makes sense. And no matter how many times the Administration insists on its own brilliance, there is no reconciling its claims with one another—or with observable reality.

But of all the contradictions, confusions, and petty falsehoods in this administration’s trade policy, none has been more pernicious, more cynical, or more contemptible than the lie that tariffs are not paid by Americans.

Mechanics of Deceit

Customs and Border Protection collects all tariffs from domestic “importers of record”—that is, American businesses registered with CBP to receive imported goods. These companies cannot retrieve their shipments from customs without first paying the tariff. In other words, it’s American firms—not foreign governments—that pay the bill.

Some sophisticated right-wing commentators have tried to skirt this basic reality by claiming that while U.S. companies technically pay tariffs, the costs are ultimately reimbursed by foreign exporters through lower prices or side payments. But the data tells a different story. The Bureau of Labor Statistics’ Import Price Index, which tracks the base price of imported goods, has not fallen to offset the new tariffs. In fact, it has slightly risen. That means foreign exporters aren’t “eating” the cost—Americans are.

While a few firms have contracts requiring exporters to pay duties, these are the exception. Goldman Sachs estimates that only about 15% of recent tariff costs have been absorbed abroad. The rest are paid by U.S. importers and, ultimately, consumers. Studies from Yale, the Peterson Institute, and even the Federal Reserve all reach the same conclusion: tariffs are taxes, and nearly all of them fall on Americans.

And we are paying them dearly. The average effective tariff rate has surged from roughly 2% to over 18%, translating into tens of billions in new taxes on U.S. businesses every quarter. These costs cascade through the supply chain—first to manufacturers, then to retailers, and finally to consumers. Prices rise, competitiveness falls, and entire industries are left grappling with higher input costs that make producing in America less viable, not more.

Economic Malaise

The result of Trump’s tariff regime is an economy, once booming, that now can hardly be described as anything but “meh.” Inflation is up to 3%, continuing its upward trend since Liberation Day. Unemployment is rising. GDP growth’s annual rate has averaged out to 1.6% in Trump’s first two quarters, with nearly all of that growth attributed to the AI boom. The U.S. dollar is down roughly 10%. The national debt just surpassed $38 trillion on an unsustainable $2 trillion annual deficit. The trade deficit is, remarkably, up.

The numbers tell a simple story: America is paying more, investing less, and falling behind.

Unfortunately, it will only get worse. That is, unless the Administration tells the truth and ends this madness.

I won’t hold my breath.

This piece was co-written with . Check out his Substack, .

Below is a brief paper I recently submitted as part of an independent research project at my university. I hope you enjoy.

Introduction:

Liberal democracy is at a crossroads. Falling trust, increasing political polarization, and persistent government dysfunction have left populations around the world increasingly dissatisfied with existing liberal-democratic political institutions (Norris 2011; Levitsky and Ziblatt 2018). This dissatisfaction has provoked a growing interest in alternative democratic institutional arrangements that, according to their advocates, have the capacity to address persistent political problems.

Interest in alternatives has produced an expansive and growing literature on the concept of deliberative democracy—a form of democracy that takes voters through a structured process of reasoned discussion prior to voting. Through various theoretical and empirical inquiries, scholars have developed new models of deliberative democratic decision-making inspired by the ancient idea of sortition (Fishkin 2018). In numerous works, including the popular books Open Democracy and Democracy for Realists, academics have advocated for citizens' assemblies—large, randomly selected groups of citizens tasked with making policy decisions or providing policy recommendations (Landemore 2020; Bartels and Achen 2016). Over the past few decades, countries including Scotland, Canada, Iceland, Italy, Belgium, and France have each implemented official citizens' assemblies for this purpose (Farrell and Suiter 2019; Fournier et al. 2011).

This paper advocates for a novel application of sortition—sometimes referred to as ‘democracy by jury’—in the context of elections. In place of the existing system of popular elections, i.e., elections in which the general public votes to elect political officials, an election by jury system would limit suffrage to a randomly selected sample of the population. Prior to voting, this sampled group would undergo a highly structured process of learning and deliberation, enabling them to make maximally well-informed and well-considered voting decisions. As of this writing, no thorough investigation of this particular application of sortition has been published.

Dysfunction in Popular Elections:

In the United States, as with every other liberal democracy in the world, political offices are filled through popular elections. Voters, consisting of the entire eligible public, are given the opportunity to express their preferences regarding candidates and/or parties. Given the widespread use of this system, it is surprising how little research has been dedicated to rigorously analyzing its effectiveness in selecting quality elected officials. I suspect this lack of inquiry is due to the absence of well-known, plausible alternatives to popular elections and the inherent methodological challenges involved in defining and measuring the quality of electoral outcomes.

Any researcher attempting to assess the quality of popular elections must first confront a challenging foundational methodological question: What constitutes a good decision in this context? There appear to be two ways to approach this question. The first—perhaps more common—approach is to evaluate the quality of the outcomes generated by decisions relative to the outcomes of all the alternative choices that could have been made. This method works when outcomes are clearly understood and when the options available differ in finite, measurable ways. For instance, research examining consumer decision-making in health insurance markets has repeatedly found that consumers are generally poor decision-makers. This is because, in controlled experiments, consumers frequently choose “dominated insurance plans”—plans objectively inferior in terms of cost, coverage, or both, compared to alternatives (Abaluck and Gruber 2011, 1183). Because we know consumers want to minimize cost and maximize coverage, and because cost and coverage are clearly measurable and the only differentiating variables between the plans, labeling the choice of a dominated plan “bad” is both appropriate and uncontroversial.

However, in democratic politics, clear determinations become significantly more challenging. Values in politics vary widely among individuals and are ever-changing. There is no one agreed-upon way to evaluate “good” and “bad” political outcomes. While mass starvation and war may be clearly worse than widespread prosperity and peace, most election decisions voters are faced with are not nearly as black and white. The closest thing to a universal outcomes quality measurement variable is “utility,” as defined in economics as the aggregate of individual preferences expressed through market behavior. However, the domain of politics offers no similarly granular method for us to observe people's preferences. In addition, electoral choices in popular elections are between candidates rather than singular policies. These candidates are far from simple. They vary from one another in an enormous number of ways, displaying diverse experiences, attitudes, and policy positions (Achen and Bartels 2016). This makes a systematic and comprehensive comparison extraordinarily difficult, if not impossible.

Consequently, social scientists have generally adopted a ‘customer is always right’ approach in democratic contexts. Given that no objective measure can reliably be used to externally judge election decisions, voter preferences must be taken at face value. To challenge the fundamental rightness or wrongness of these preferences would be to venture beyond empirical social science and into the more precarious realm of philosophy, which is an entanglement most social scientists would prefer to avoid.

Acknowledging these conundrums, I propose an alternative method for evaluating decision-making quality in elections: assessing the presence of conditions conducive to good decision-making. While objectively identifying a good election outcome might not be possible, objectively determining whether voters met the prerequisite conditions necessary for good decision-making is, in fact, possible. Demonstrating that voters in popular elections consistently lack such conditions would suggest that the outcomes generated by popular elections are likely suboptimal.

To illustrate, consider the following hypothetical. Suppose there is an ice cream parlor where all the traditional flavors (chocolate, vanilla, etc.) have been provided entirely cryptic names, and no visual aids or descriptions of the flavors are made available. In this scenario, could customers reasonably be expected to select flavors that match their preferences? Likely not. An individual who wants rocky road would be left with no choice but to choose arbitrarily amongst the options and hope for the best. Decisions made in ignorance seldom reliably fulfill desired outcomes, as they depend on clearly understanding available options and their consequences (Gigerenzer and Goldstein 1996; Lupia 1994). If familiar names were to be restored, customers could effortlessly select their preferred flavor, significantly improving the quality of decision-making.

Similarly, voters must have an understanding of relevant information to properly select candidates who will best secure their preferred outcomes. This includes an understanding of the office being contested, the candidates and their abilities, the policies they support, and the outcomes those policies would yield if they were enacted. Reaching this high knowledge threshold is no easy feat. The sheer number of elections voters are asked to participate in, combined with the immense time demands of daily life, make it challenging even for the highly motivated to stay consistently well-informed for every election in which they cast their ballot.

More troubling, however, is that research suggests many voters do not make a concerted effort to inform themselves in the first place. Studies show that even when easily accessible political information is made available, many citizens opt not to seek it out (Prior 2007). Political scientists have also found that voters often fail to update their opinions when directly exposed to new information, suggesting low motivation among voters to improve their understanding (Nyhan and Reifler 2010). Its no surprise, then, that an extensive body of research going back decades shows that political ignorance is both widespread and deep. When voters are tested, a startling number lack even the most basic knowledge of civics and current events, let alone knowledge of candidates and policy (Delli Carpini and Keeter 1996; Somin 2013).

Some suggest this ignorance could be mitigated through policies promoting civic education, but this claim conflicts with the robust literature in public choice economics on rational ignorance. Rational ignorance posits that voters have minimal incentives to inform themselves thoroughly, given the negligible probability of their individual vote being decisive (Somin 2013). If one’s vote does not sway the results of an election, then, for all practical purposes, it does not matter. In such a context, the considerable effort required to become an informed voter is not meaningfully rewarded, and thus, the costs of acquiring political knowledge are not outweighed by benefits.

Yet, the presence of rational ignorance alone is not sufficient to prove that popular elections are hopelessly flawed. A popular, theoretical defense known as the "miracle of aggregation" posits that, given that uninformed voters make random errors when voting, these errors cancel one another out. Thus, elections are, in reality, only decided by informed voters. To better understand this argument, consider the following example. Imagine an election with three candidates: A, B, and C. Suppose that 90% of voters are completely uninformed and select a candidate completely at random. Since this occurs, each candidate receives about 30% of the vote from the uninformed. Now, further, suppose the remaining 10% of voters are informed and all, due to being informed, prefer candidate A. In this scenario, candidate A receives an additional 10% more than their opponents, putting them at 40%, while B and C remain at 30%. Therefore, despite the fact that the informed voters are only a tiny minority, they ultimately determine who wins.

Yet despite the popularity of the miracle of aggregation idea, empirical evidence thoroughly discredits the notion that poorly informed voters make random errors and, consequently, cancel each other out. Data consistently demonstrates that uninformed voters exhibit systematic biases affecting their partisan affiliations and candidate preferences (Fording and Schram 2017). Research has also shown that low-information voters hold an array of systematic misperceptions about the issues. Referencing a thorough set of polls that split members of the American public into groups based on their level of political knowledge, George Mason University Professor Bryan Caplan documents that poorly informed Americans display a variety of cognitive biases that seriously distort their perception of reality, with these biases being anti-market bias, anti-foreign bias, make-work bias, and pessimistic bias. (Caplan 2007).

Other cognitive biases are common in both the informed and uninformed alike, with one of the most relevant being confirmation bias. This bias, which appears to be almost universal amongst humans, leads individuals to disproportionately accept information that aligns with their existing beliefs while dismissing or downplaying evidence that challenges their views (Mercier and Sperber 2017). Due to confirmation bias, even when voters attempt to inform themselves, they are still, in large part, tethered to their original beliefs, wrong as they may be.

This brings us to our conclusion. Voters in popular elections, by and large, fail to meet the criteria for high-quality decision-making. They not only lack even the basic information necessary to make election decisions that accurately translate their preferences, but also portray a series of serious and systematic misconceptions. In addition, they suffer from an array of cognitive biases, including confirmation bias, which frustrates their ability to fully and impartially digest new information. These widespread shortcomings in voter competence seriously call into question the value of popular elections as a selection mechanism for political officials, opening consideration to alternatives.

Election by Jury as a Viable Alternative:

Given the well-documented flaws of popular elections, it is worth inquiring whether there are institutional alternatives that could do a better job at selecting capable leaders. One such alternative, novel but well-supported by theory and evidence, is what I term “election by jury.” Under this alternative approach, in place of the general public being granted the ability to vote in every election, suffrage for each election would be limited to a randomly assigned sample of citizens, who then would undergo a sophisticated education and deliberation process before casting their votes.

The case for election by jury is straightforward. Given that the core problem of popular elections is that voters lack both an understanding of the relevant facts and the assistance needed to overcome their cognitive biases, a simple solution is to shift the responsibility of voting from the general public to a smaller microcosm of the public where these issues can be rectified.

The structural processes that would be utilized in such a system are well understood. Both in real-world use cases and through a wide variety of controlled trials, the idea of randomly selected citizens’ juries has been thoroughly studied. Research on these experiments has consistently shown that ​​by decision-making time, participants are far more informed, reflective, and open-minded than members of the general public (Grönlund, Bächtiger, and Setälä 2014).

To look at one illustrative example, consider the Citizens' Assembly on Electoral Reform in British Columbia. In this real-world application of sortition, a randomly selected group of 160 citizens spent nearly a full year studying electoral systems. Their studies included extensive reading and consultation with experts, followed by a structured deliberative phase, where they had the opportunity to engage productively with one another before making their final recommendation. Post-assembly assessments found that the participants were starkly different from members of the general public. They developed intricate and nuanced understandings of electoral design, became aware of the full range of arguments and evidence, including those contradicting their initial views, and many changed their opinions over the course of the process (Fournier et al. 2011). In short, the previously articulated decision-making criteria that are so starkly absent in the context of popular elections were successfully established for these assembly members.

Similar findings have emerged from James Fishkin’s deliberative polling experiments. Conducted in over two dozen countries, these controlled trials demonstrate that participants—when provided with the proper environment—shift their policy views in predictable and rational directions (Fishkin 2018). Findings from both these experiments in deliberative democracy suggest that, while voters may currently struggle with ignorance and bias, these issues are not insurmountable. With the proper context, these issues, large as they may appear, can be overcome.

Many of the characteristics of election by jury would reflect those found in these experiments and other related ones. For larger groups—consisting of 100 or more—simple random sampling could guarantee demographic representativeness. When sample sizes must be small, stratified random sampling could be used to ensure balance across race, class, gender, and other relevant demographic variables. Using processes akin to those for traditional jury duty, jurors would be selected from local voter registries with necessary employer leave protections and government compensation to improve access across income levels.

Those refusing to participate would be replaced by other randomly selected citizens to minimize self-selection bias. Though some drop-off may occur, the use of random sampling as the starting point is a key difference from current electoral processes, which is already greatly distorted by unequal turnout amongst demographic groups (Leighley and Nagler 2014).

The deliberative process would begin with a comprehensive educational phase. Jurors would receive background information on the office in question, including its legal powers, institutional limits, and pertinent recent developments. This would be followed by a candidate phase, during which each candidate would be granted the opportunity to provide factual policy summaries and biographical information to the jury. To be eligible to be submitted, these distributed materials would be required to meet a set of clearly defined standards, which will include, but not be limited to, the requirement that their materials only express information about themselves and not any other candidates. The briefs will also be required to include citations for specific factual claims and to avoid making lofty, unsubstantiated promises or assertions. Additional disclosures, such as those pertaining to their criminal record, tax returns, etc, will be presented along with these materials to the jury.

Candidates would then be allowed to address the jury directly in a strictly regulated format, with identical time allotments, standardized questions submitted by the jury, and separate appearances to avoid cross-debate. Public information submissions and expert commentaries would supplement these presentations. Before hearing from candidates, jurors would be explicitly trained to prioritize substance over charisma in order to minimize the risk of empty rhetoric’s effectiveness.

After the candidate phase, jurors would begin a methodical deliberation process in rotating small groups led by trained moderators, examining the strengths and weaknesses of the candidates. Like judges, these facilitators would be evaluated and trained for rigorous neutrality and undergo stringent impartiality training. Sessions would be videotaped and periodically audited to guarantee impartial moderation.

To protect the process from outside interference, clear rules would prohibit candidates or aligned groups from contacting jurors outside of the formal deliberation setting. Financial incentives would be provided to jurors who present to the government proof of illegal campaign contact, and strict penalties will be imposed on abusers.

For most relatively low-stakes elections, these safeguards should be enough to protect the process. But, in the case that the election by jury concept is applied for a decision of particularly high stakes (like a gubernatorial election), jurors could be housed in specialized facilities that fully isolate them from the outside world. This approach substantially reduces the potential perverse influences of campaign donations, targeted disinformation campaigns, and partisan media spin (Persily and Tucker 2020; Allcott and Gentzkow 2017).

The complexities of an election by jury system should not be minimized or ignored. Proper execution of processes, like those outlined, is essential to the legitimacy and effectiveness of the process. But, for the purposes of comparison between election by jury and popular elections, it is crucial to be clear-eyed about how complex existing popular elections are. Due to the popular electoral model, there exists an enormous, multi-billion-dollar industry of politics. From political media to campaigns to nonprofits to fundraisers, consultants, and election lawyers, the political machine is one that is both very complex and very costly. So, too, is the challenge of administering popular elections. Operating free and fair elections in every zip code in the country is an incredibly intricate process requiring the mass distribution, collection, and counting of ballots under heavily supervised conditions. While election by jury introduces new administrative difficulties, it does so with the benefit of avoiding many of the challenges associated with the existing electoral system.

Conclusion & Discussion:

It is more pressing a time than ever to be considering alternative institutional arrangements to those of the status quo. Many liberal democratic societies have reached a breaking point, leaving the public scrambling and looking for reform. This paper articulates an argument for one unique approach to resolving the systematic issues that are presented in popular elections. A strong body of evidence suggests that citizen juries are capable of making decisions that are more informed and deliberative than those produced by the general public.

Still, significant obstacles face any sort of wide-scale adoption of the election by jury idea. The concept is controversial, clashing with widely held views about government legitimacy and democracy. It also requires more procedural experimentation and a level of institutional capacity and competency that is not currently present. There is no doubt that if governments were to entirely switch to this system instantly, it would be a disaster, both politically and practically.

For these reasons, the testing and adoption of election by jury must occur gradually. Popular elections were not made universal overnight, and neither will election by jury. The most fitting place to first apply the concept is in local, low-turnout elections for relatively unimportant offices. Positions like County Treasurer, County Clerk, and local Judge, without much uproar, could transition to being selected via this method. Over time, the number of positions subject to this process could expand to include more and more positions that the public generally desires to be kept independent and non-partisan. As this process continues, eventually, a question will be asked: How far is too far?

Will the public accept a Congressperson elected by jury? What about a Senator? A President? I believe the best world is the one in which the answer to all those questions is yes.

Annotated Bibliography:

Abaluck, Jason, and Jonathan Gruber. 2011. “Choice Inconsistencies among the Elderly: Evidence from Plan Choice in the Medicare Part D Program.” American Economic Review 101, no. 4: 1180–1210. https://doi.org/10.1257/aer.101.4.1180

In this study, Abaluck and Gruber study consumer decision-making quality amongst Medicare Part D health insurance plans. Using administrative data, the authors show that a large percentage of consumers make objectively poor decisions when choosing between plans.

Achen, Christopher H., and Larry M. Bartels. Democracy for Realists: Why Elections Do Not Produce Responsive Government. Princeton: Princeton University Press, 2016. https://www.jstor.org/stable/j.ctvc7770q

This book challenges the widespread notion that popular democracy is optimal. Drawing on a robust body of social science research, the authors demonstrate that voters in popular elections are almost uniformly irrational decision-makers. Archen and Bartels' research reveals that rather than being guided by nuanced and in-depth policy considerations, voters tend to base their voting decisions chiefly on tribal affiliations and partisan loyalties. The authors further show that partisan alignment frequently shapes public opinion rather than the reverse and that people's views on both policy issues and empirical reality are not fixed but rather shift to satisfy their preexisting partisan preferences. Finally, they find that when electoral outcomes are influenced by real-world conditions, they are typically driven by short-term economic factors around the time of the election, a poor proxy for the actual quality of economic decision-making by incumbents.

Bartels, Larry M. Unequal Democracy: The Political Economy of the New Gilded Age. Princeton: Princeton University Press, 2008. https://www.jstor.org/stable/j.ctt7t9ks

In this book, Bartels shows that voters often support policies counter to their own interests, implying a deep and foundational lack of understanding across broad swaths of the voting population. He also dwells on the corrosive effect of big money in politics, discussing at length the effectiveness of campaign spending on securing additional votes, and how the presence of this phenomenon allows moneyed interests to skew policy-making.

Caplan, Bryan. The Myth of the Rational Voter: Why Democracies Choose Bad Policies. Princeton: Princeton University Press, 2007. https://press.princeton.edu/books/hardcover/9780691129426/the-myth-of-the-rational-voter

In this book, Caplan argues that popular democratic systems frequently produce harmful economic policies because voters are not just poorly informed but also systematically irrational. He splits this irrationality into four distinct cognitive biases–these being anti-market bias, anti-foreign bias, make-work bias, and unjustified pessimism. From these observations, Caplan concludes that popular democracy will consistently lead to public policy choices that are deeply flawed.

Delli Carpini, Michael X., and Scott Keeter. What Americans Know About Politics and Why It Matters. New Haven: Yale University Press, 1996. https://yalebooks.yale.edu/book/9780300072754/what-americans-know-about-politics-and-why-it-matters/

In this book, Delli Carpini and Keener draw on an enormous amount of survey data to investigate what Americans do and don’t know about politics. This investigation leads the authors to conclude that there are two groups within the American public: the informed and the greatly uninformed. The informed are disproportionately white, older, and richer, while the uninformed are the opposite.

Farrell, David M., and Jane Suiter. “Deliberative Mini-Publics: Core Design Features.” Paris: OECD Publishing, 2019. https://www.oecd-ilibrary.org/governance/deliberative-mini-publics_7a6e8f2e-en

This brief by the OECD explains principles of design for deliberative “mini-publics” and proposes an array of empirical research standards for evaluating their performance.

Fishkin, James S. Democracy When the People Are Thinking: Revitalizing Our Politics Through Public Deliberation. Oxford: Oxford University Press, 2018. https://academic.oup.com/book/27472

In a world of fake news, big money in politics, and informational bubbles, Fishkin argues that modern democratic systems are failing. He suggests that the “will of the people” requires a citizenry that grasps the relevant truths, is up to date on the issues, and has considered opinions on policy matters. To achieve these ideals, Fishkin argues we should embrace deliberative democracy. To evidence this view, Fishkin draws on decades of global research on deliberative polling, showing that randomly selected citizens, when given good information and an opportunity to exchange ideas in a controlled setting, can form thoughtful opinions on complex policy issues. To materialize these ambitions, Fishkin argues we need to embrace deliberative democracy.

Fording, Richard C., and Sanford F. Schram. “The Cognitive and Emotional Sources of Trump Support: The Case of Low-Information Voters.” New Political Science 39, no. 4 (2017): 670–686. https://www.researchgate.net/publication/316753944

This article shows, using election data, that Donald Trump drew disproportionate support from low-information voters. It also outlines a causal mechanism for how low political information can make voters more sensitive to populist appeals, especially reactionary populist appeals.

Fournier, Patrick, Henk van der Kolk, R. Kenneth Carty, André Blais, and Jonathan Rose. When Citizens Decide: Lessons from Citizens’ Assemblies on Electoral Reform. Oxford: Oxford University Press, 2011. https://academic.oup.com/book/12775

This book covers three-year-long experiments with Citizens' Assemblies in British Columbia, the Netherlands, and Ontario. From these experiments, the authors derive a variety of important conclusions. One amongst them is that in the case of citizen assemblies, a three-phase structure is most appropriate. These three phases are a learning phase, a public consultation phase, and finally a deliberation and decision-making phase.

Grönlund, Kimmo, André Bächtiger, and Maija Setälä, eds. Deliberative Mini-Publics: Involving Citizens in the Democratic Process. Colchester: ECPR Press, 2014. https://cora.ucc.ie/server/api/core/bitstreams/4e15f66a-18fa-4d81-a62c-ab262539fa55/content

In this book, the authors point to international experience, where citizen juries have been selected historically through stratified random sampling, while citizens' assemblies have been selected through pure random selection. Another point they put forward is the decision-making mechanism used by sortioned entities. The authors discuss multiple options, including majority rule, super majority rule, and perfect consensus.

Hartz-Karp, Janette. "How and Why Deliberative Democracy Enables Co-Intelligence and Brings Wisdom to Governance." Journal of Public Deliberation 3, no. 1 (2007): Article 6. https://delibdemjournal.org/article/324/galley/4743/view/delibdemjournal.org+3delibdemjournal.org+3delibdemjournal.org+3

In this piece, Hartz-Karp criticizes traditional consultation methods in Australia, describing them as “ineffective” and often leading to frustration and disengagement despite intending to do the opposite. She introduces the concept of deliberative democracy as a potentially transformational alternative. By involving citizens directly in policy discussions through structured deliberative processes, she argues, democratic governments can achieve outcomes the public perceives as more legitimate and acceptable.

Landemore, Hélène. Open Democracy: Reinventing Popular Rule for the Twenty-First Century. Princeton: Princeton University Press, 2020. https://www.jstor.org/stable/j.ctv10crczs

In this recent book, Yale Professor Landemore argues that traditional representative democracy is dominated by elected elites and suggests that it should be replaced by a system she calls “open democracy.” Her vision of open democracy includes both sortition and mini-publics, which she discusses at length.

Lupia, Arthur. “Shortcuts Versus Encyclopedias: Information and Voting Behavior in California Insurance Reform Elections.” American Political Science Review 88, no. 1 (1994): 63–76. https://www.jstor.org/stable/2944882

In his paper, Lupia examines whether uninformed voters are capable of making competent decisions in elections if they rely on informational shortcuts. Analyzing California ballot initiatives on insurance reform, he shows that certain generally available heuristics enabled less-informed voters to make choices closely resembling those of well-informed voters. This finding suggests that the quality of public decision-making can be dramatically enhanced if the uninformed are presented with high-quality decision-making cues, like those that could be presented in the context of an election by jury.

Mercier, Hugo, and Dan Sperber.The Enigma of Reason. Cambridge, MA: Harvard University Press, 2017. https://www.hup.harvard.edu/books/9780674237827

In this book, Mercier and Sperber put forward the "Argumentative Theory of Reason," postulating that human reasoning faculties evolved for the primary purpose of social interaction. Specifically, he claims that we should justify our actions to others, persuade others through argument, and critically evaluate others’ justifications. To substantiate this claim, they examine experimental literature highlighting the prevalence of confirmation bias, i.e., the frequent propensity of humans to seek evidence supporting their preexisting views rather than to search for truth impartially. They also reference research on the effectiveness of deliberation. Drawing on studies of problem-solving in both children and adults, they demonstrate that individuals consistently overcome confirmation bias more effectively in social settings where they are confronted with alternative positions and can identify arguments stronger than their own. The authors conclude by emphasizing the profound support this research provides for deliberative democracy.

Nyhan, Brendan, and Jason Reifler. “When Corrections Fail: The Persistence of Political Misperceptions.” Political Behavior 32, no. 2 (2010): 303–330. https://doi.org/10.1007/s11109-010-9112-2

In this paper, Nyhan and Reifler provide empirical data that demonstrates voters often fail to adjust their perception after being presented with corrections for previously consumed misinformation. The authors find that, in some cases, corrections can actually backfire, making misperceptions even worse than they were previously. This work demonstrates that the issue of voter ignorance cannot be easily remedied.

Prior, Markus. Post-Broadcast Democracy: How Media Choice Increases Inequality in Political Involvement and Polarizes Elections. Cambridge University Press, 2007. https://www.cambridge.org/core/books/postbroadcast-democracy/A0D17A3CD156A0D1BB4318EE5DBCC60B

In this book, Prior shows that the expansion of media choices in the digital era allows citizens a new opportunity to avoid political content altogether, making room for increased gaps in political knowledge within the population. His research finds that a large portion of the population actively avoids political information, even when said information is readily available and easy to process. This result affirms the argument that political ignorance is not simply accidental; rather, it is often intentional.

Somin, Ilya. Democracy and Political Ignorance: Why Smaller Government Is Smarter. Stanford: Stanford University Press, 2013. https://masonlec.org/site/rte_uploads/files/Somin_Introduction.pdf

Somin argues that rational ignorance among voters leads to poor democratic decision-making. To support this point, he presents empirical data demonstrating that the general public has a limited understanding of current events, political institutions, and policy issues. Somin contends that this ignorance is rational, as the benefits to an individual from being an informed voter are minimal. Consequently, he suggests that widespread ignorance is unlikely to change, making substantial improvements in government decision-making unrealistic. On this basis, Somin advocates for embracing a narrower scope of government, thereby reducing the areas where poor decisions can undermine the outcomes of a free society.

Van Reybrouck, David. Against Elections: The Case for Democracy. New York: Random House, 2016. https://www.penguinrandomhouse.com/books/645360/against-elections-by-david-van-reybrouck/

In this provocative book, Reybrouck critiques the overreliance on elections and presents what he calls “sortitive democracy” as a favorable alternative. One example he points to in this book is Iceland, where a citizens' assembly was used to draft revisions to the Constitution.

We are increasingly confronted with a startling fact: the truth is not popular, at least not nearly as much as it needs to be.

Day by day, society inches further toward views detached from evidence, fueling policies that harm rather than help.

Protectionism and immigration restrictionism are back with defiance. Corporate welfare is being doled out to well-connected industry groups while the tax code becomes riddled each and every year with yet even more complexities and loopholes. Transformational infrastructure projects are held up in costly stasis around our country by endless proceduralism, red tape, and lawsuits. Government services remain defiantly low quality, often hardly different technologically than they were decades prior. Special interest groups wield government influence not to protect the public but to shield themselves from competition, endlessly piling on anti-consumer regulations that inflate prices dramatically. From housing to healthcare, energy to transportation, their silent burden weighs heavy on the weary pocketbooks of working families. Many of us have fallen prey to mental despair and addiction as we fail to find satisfaction in our daily lives. Car dependency and the poor quality of our food yield unhealthy lifestyles, while the risks of crime, climate change, and inadequate disaster preparedness threaten our safety. This occurs as an ineffective welfare system ensnares the poor people it is supposed to help, the national debt accumulates at an unsustainable pace, a class of billionaire oligarchs (namely Elon Musk) increasingly seizes the edifices of the state for their own purposes, and a cabal of authoritarian powers—Russia, China, Iran, amongst others, set out to conquer their neighbors and destabilize America from within.

The facts are sobering and enraging. We are not as free, secure, prosperous, or happy as we should be. Our lives are filled with unnecessary suffering, and few are offering us a promising break from this perilous status quo.

The MAGA Republican Party consists of an ideologically incoherent fusion of ideas centered around a personality cult for an unstable narcissist. In it, are many causes for concern. Trump promises retribution against his political opponents, damaging the institutions that keep our society stable; he promises to appoint tools of America's enemies like Tulsi Gabbard to high-up positions in government and put anti-vax lunatics like RFK Jr. in charge of our public health. His agenda of tariffs and mass deportations promises only to harm the Americans he has promised to save.

The only glimmer of reprieve from this up-and-coming Trump administration is found in Elon Musk and Vivek Ramaswamy's DOGE project, which pays lip service to regulatory streamlining and deficit reduction. However, thus far, their ideas have inspired more caution than optimism. The examples of government waste they've pointed to as of this writing include funding for clean energy projects, scientific research, and interest payments on the debt we have no choice but to pay. These are not the right places to be focusing on for cuts. The Department of Education, they are hell-bent on abolishing, actually has a good reason to exist, even if it needs dramatic reforms.

The big-budget balancing action we need must come through Congress, which is currently gearing up to make our two trillion dollar deficit even larger by extending Trump's 2017 tax cuts. It appears most likely that the competing Musk-Vivek Libertarian vision for the Republican Party will run up against its Vance-Hawley Conservative Nationalist vision, which will almost surely defeat it in the 2028 primary, spelling a continued dark path for the GOP.

This occurs as the Democratic Party is splintered and seemingly directionless. Biden's industrial policy addressed, to a limited extent, America's over-reliance on China, with costs of its own. His continuation of Trump's combative trade policies with our allies was an unforced error, and in an attempt to appease established Democratic party interest groups, he fell short of weeding out the endemic rent-seeking that infects our federal government.

His moves on infrastructure and climate change were commendable, but much of the money has been caught up in the dysfunction that entangles all large infrastructure projects in America these days, diminishing the distance each dollar goes and stretching project completion times many years into the future. His steadfast commitment to supporting Ukraine is perhaps one of the most important elements of his legacy, as it is in large part responsible for the country's survival, even as his Middle East policy has fallen short with the tear-jerking scenes of Afghanistan, the continued chaos in Syria, and catastrophe in the Israel-Palestine conflict.

Harris's campaign was running largely on continuity with Biden. Her candidacy promised a continued steady hand of American leadership, taking more steps forward than backward and safeguarding our precious institutions, but still falling short of the ambition that the present moment demands.

In a Democratic Party reeling from nationwide rejection, the calls of the left grow louder as they present themselves as the only alternative to the mainstream wing, which has just presided over an electoral disaster. Yet this group outright ignores many of our problems, or worse, attempts to confine them to their inherently reductionist class warfare-based view of the world, where behind every problem, there is an evil business at fault, and every solution can be found in a new tax, a new regulation, or a new subsidy.

Their vision of heavier-handed government intervention clashes with the nearly ubiquitous distrust Americans now have of the government, requiring them to make promises they cannot keep. Amongst them is the absurd claim that a Scandinavian-style welfare state can be funded almost exclusively off the backs of the rich, which is not remotely possible.

In short, at this critical juncture in American politics, the ideological marketplace offers few compelling options. Amongst the alternatives we are faced with are aggressive regression, incremental progress with no shortage of painful missteps, or glorious promises that are impossible to keep. We must aspire for better.

Yet, even in this bleak moment, there is hope. Politics ebbs, and it flows. Political views nationwide are but a few viral messages from looking very different than they are today. Where once revilement for tyrants like Putin and support for federal law enforcement agencies seemed unshakable, we just witnessed America elect a man who praises the former and intends to tear apart the latter. Nothing can be taken for granted.

The advocates for the truth are scattered, but they are numerous. In academia and think tanks, careful researchers continue to point out the true origins of our problems and sketch paths to solutions. In business, the inefficient bureaucratism of the status quo is known well and ideas for reform abound.

Embers of change are heating up in the growing movement for radically reforming our voting system, where advocates have rightly pointed to our corrupted political institutions as the source of many of our woes. The pro-housing YIMBY movement grows more powerful day by day and has already scored transformational wins in cities and states in every corner of our nation.

The initial single-issue efforts have catalyzed an entirely new ecosystem around the abundance agenda and effective governance. You may know some of the organizations already: The Breakthrough Institute, The Abundance Network, The Inclusive Abundance Initiative, Chamber for Progress, The Niskanen Center, and Institute for Progress, amongst so many others.

Friends of mine at Project Liberal and the Center for New Liberalism are working on expanding the ideas of this movement even further into a comprehensive liberal ideological alternative to the mainstream ideas of our time. More people are talking about bold ideas like Georgism (Land Value Tax) than ever before.

The talent is there; the resources are increasingly there. What the truth now lacks is a compelling political story that can break through to normal, everyday Americans.

This growing coalition’s ranks are filled with intellectuals who often struggle to communicate with a public that has little interest in data, complex economic reasoning, or abstract principles. Finding a way to close this communication gap has been the subject of my investigation for nearly the past two years now.

Since beginning it, I've made the following discoveries about how successful political movements work, which I think will be useful in informing our effort to bring truth into the mainstream.

1. Successful political movements: Brand bad things as the status quo.

Winning narratives are as compelling as they are because they frame the things they want to change as part of the status quo. They present a story of politics where what is broken is protected by the establishment, and they position themselves as change agents. This framing is extremely useful. It makes them the natural protagonist and all of their opponent's natural antagonists. More so, it allows them to siphon people's deep-seated frustrations with how things are and their desire for change.

2. Successful political movements: Point fingers at the bad guys.

Bad things incite more anger when they are laced with ill intent. Many times, this framing is used dishonestly. For instance, some MAGA Republicans (including Elon) blame dysfunctional immigration on a Democratic plot to flood the country with Hispanics in order to secure a permanent majority. This narrative is obviously false, but it is no doubt effective. When unpopular policies can be tied to ill will, the outrage they inspire increases dramatically.

3. Successful political movements: Use mostly negative messaging.

Which one of these messages is more resonant with you? "We stand up for Ukraine and Taiwan in their fight for Democracy, or "We stand against Russia and China's plan for world Domination." I'm willing to wager for most people; it's the latter. We see examples of the power of negative messaging all the time. Democrat's most effective pro-choice message is "We stand against getting politics into your bedroom," and Republican's most effective pro-life message is "We stand against baby murder." In fact, looking at the Republican side, almost all of their messaging is negative. They "stand against radical woke ideology brainwashing our kids in schools," not for the things they actually advocate for, which is white-washed ahistorical propaganda in our schools. We might not like that people respond more to negativity than positivity, but it is overwhelmingly clear that they do.

4. Successful political movements: Use slogans that are easy to understand.

Specific policy views don't go viral; slogans that imply a constellation of policy views do. Most people don't understand how the government works, nor could they sketch out the particulars of really any policy topic; what they might be able to tell you is whether they support School Choice or not, the Green New Deal or not, etc etc. The good ideas need slogans of their own that are repeatable, identifiable, and marketable.

5. Successful political movements: Use storytelling and anecdotes.

You will never get someone to be interested in your macroeconomic modeling of the negative impacts of the Jones and Dredge Act or the benefits of Permitting Reform. What you can do is cite interesting anecdotes that help people understand these things better than any regression line ever could. We've seen anecdotes on Joe Rogan spawn entire internet-wide discourses; most recently, the spurious accusation that the Consumer Financial Protection Bureau is closing the bank accounts of people for political reasons has inspired a fury amongst right-wingers, leading to increasingly ample public support for abolishing the agency entirely. If people can be made interested in abolishing an entire agency over a single anecdote on a podcast, the potential to stoke popular support for other specific reforms is truly limitless.

6. Successful political movements: Focus on ends, not means.

Trump did not run a campaign on tightening asylum rules. He didn't run on deregulating oil and gas or putting in place ideological loyalty tests in the federal hiring process. These ideas are nerdy and, more importantly, yawn-inducing. Instead, he ran on SEALING THE BORDER, DRILL BABY DRILLING, and SMASHING THE DEEP STATE. Wonks might scoff at the absurdity of such vague language, but it’s proven to be successful over and over again. The policy discourse of mass movements fixates on the ends, not how they are achieved. The ends are always easier to understand and more agreeable than how they are attained.

7. Successful political movements: Tie it all together.

A coherent ideological alternative to the dominant ideas of our time must be able to unite their many sub-narratives into a broader meta-narrative, an overarching story of politics. Trump's meta-narrative is symbolized in his signature slogan, "Make America Great Again," he promises to return to the greatness we once had by crushing the evil forces that have engineered our decline. Bernie's meta-narrative is overthrowing the corporate oligarchy which has taken over our government. The President of Argentina, Javier Milei’s meta-narrative, is ending the control of political gangsters, which are robbing the people and destroying the country. This recipe is used over and over again because it works.

The preeminent populist political movements of our time often use these strategies dishonestly. They point fingers at scapegoats rather than the true causes of our problems. They misrepresent facts to fuel outrage inducing negative messaging campaigns. Their slogans are simple but represent bad ideas, and many of their anecdotes are not indicative of broader phenomena, if not entirely fictitious. The ends they present themselves as pursuing will not be achieved by their policies, and their simplistic meta-narratives clash with the many nuances of the real world.

This is all the more reason that the advocates for truth must begin using the proven communication strategies—that other actors have so effectively deployed—for good. They must exit their current role as bystanders, talking almost exclusively with those who already agree with them, and work to advance an honest view of the world in a way that can resonate with normal people.

To do this, we must occupy ourselves with telling the true story of American politics. One that sheds light on systematically corrupted political institutions that deliver little more than broken promises generation after generation. We must illustrate with stories the many ways our government has put special interests, in their many forms, above the public interest, over and over again harming the many to help the few. We must build a new movement that crusades against a status quo of stagnation and ineffectiveness, using memorable ends-based slogans to articulate our vision.

When our candidates achieve victory, they must make every evil of the existing system our enemy and relentlessly pursue the change that is required. The politics of edge trimming, tweaks, and measly make-everyone-happy language has come to an end. In a time when Americans demand deep change, confrontation is an ally, and lack of ambition is only self-sabotage.

Therein lies the way we deliver ourselves from the perils of the present.

Today, a central usage of my time is attempting to convert what I’ve learned into action to practice what I preach. Success requires us not only to make the truth resonant and compelling but also to get each true message in front of every ear that will listen and every eye that will see.

In my newly restarted YouTube channel, I'm working to do just that. I know many of you are brilliant yourself, and I eagerly hope you do the same. There are tremendous political fights that await us.

But we have the power and the responsibility to win.

Our federal tax code is a disaster.

It's a bureaucratic nightmare, requiring armies of CPAs and lawyers to navigate. It's a damper on growth, imposing penalties on positive behaviors like research and offering harmful special breaks for bad things like coal extraction. It's a distributional mess, imposing higher rates across the board to make room for an endless litany of lobbyist-extracted carveouts and loopholes. Worst yet, it's not getting better; it's getting worse.

Politicians of all stripes are constantly promising even more complexity on the campaign trail. There is little more fashionable on the Hill than a new tax credit, deductions, exclusion, or exemption. These tax expenditures (as they are collectively called) never cease to fail to solve the problem they are aimed at, yet have been deployed ambitious and bipartisanly for decades.

To point to one timely example, our newly elected President Trump proudly campaigned on creating new exclusions for overtime pay, tips, and even things as marginal and specific as car payments. Needless to say, these changes would add more intricacies to our already endlessly spanning pages of code.

Earlier today, I was pondering this fact as a thought jumped into my mind: "I wonder exactly how many tax expenditures there are and how much they cost in total?" It didn't take long for me to find the answer. Thankfully, the Department of Treasury makes the data on tax expenditures readily available on its website.

From their data, there appear to be 169 tax expenditures in total, costing the United States over $1.5 trillion dollars last year. This is a truly whopping sum—nearly equivalent in size to Social Security. I've listed them here so you can look at each one for yourself.

1. Exclusion of employer contributions for medical insurance premiums and medical care - $215.860 billion

2. Exclusion of net imputed rental income - $147.240 billion

3. Defined contribution employer plans - $133.860 billion.

4. Capital gains (except agriculture, timber, iron ore, and coal) - $115.630 billion

5. Deductibility of charitable contributions other than education and health - $47.410 billion

6. Deductibility of mortgage interest on owner-occupied homes - $31.820 billion

7. Deductibility of nonbusiness State and local taxes other than on owner-occupied homes - $7.030 billion

8. Defined benefit employer plans - $70.100 billion.

9. Capital gains exclusion on home sales - $54.410 billion

10. Self-Employed plans - $43.180 billion

11. Treatment of qualified dividends - $35.880 billion

12. Step-up basis of capital gains at death - $49.240 billion

13. Individual Retirement Accounts - $32.690 billion

14. Reduced tax rate on active income of controlled foreign corporations (normal tax method) - $45.190 billion

15. Deductibility of State and local property tax on owner-occupied homes - $6.910 billion

16. Social Security benefits for retired and disabled workers and spouses, dependents, and survivors - $30.700 billion

17. Credit for increasing research activities - $28.220 billion

18. Exclusion of interest on public purpose State and local bonds - $29.810 billion

19. Energy production credit - $7.450 billion

20. Child credit - $67.520 billion

21. Deductibility of medical expenses - $12.260 billion

22. Exclusion of life insurance death benefits - $15.320 billion

23. Exclusion of benefits and allowances to armed forces personnel - $15.990 billion

24. Medical Savings Accounts / Health Savings Accounts - $12.830 billion

25. Exclusion of veterans death benefits and disability compensation - $11.640 billion

26. Credit for low-income housing investments - $12.800 billion

27. Allow 20-percent deduction to certain pass-through income - $37.240 billion.

28. Energy investment credit - $25.970 billion

29. Self-employed medical insurance premiums - $8.150 billion

30. Deductibility of charitable contributions to health institutions - $9.000 billion

31. Tax credits for post-secondary education expenses - $13.940 billion

32. Refundable Premium Assistance Tax Credit - $15.047 billion

33. Deduction for foreign-derived intangible income derived from trade or business within the United States - $15.240 billion

34. Tax credits for clean vehicles - $10.560 billion

35. Deductibility of charitable contributions to educational institutions - $6.230 billion

36. Exclusion of interest spread of financial institutions - $11.100 billion

37. Qualified tuition programs (includes Education IRA) - $3.020 billion

38. Exclusion of employee meals and lodging (other than military) - $7.530 billion

39. Exclusion of workers' compensation benefits - $8.870 billion

40. Additional deduction for the elderly - $7.540 billion

41. Exclusion of scholarship and fellowship income (normal tax method) - $4.430 billion

42. Carryover basis of capital gains on gifts - $4.590 billion

43. Parental personal exemption for students age 19 or over - $2.210 billion.

44. Exclusion of income earned abroad by U.S. citizens - $5.420 billion

45. Deferral of capital gains from like-kind exchanges - $4.020 billion

46. Credit for residential energy efficient property - $7.090 billion

47. Accelerated depreciation on rental housing (normal tax method) - $2.440 billion

48. Exception from passive loss rules for $25,000 of rental loss - $5.470 billion

49. Earned income tax credit - $2.700 billion

50. Premiums on group term life insurance - $3.440 billion

51. Advanced manufacturing production credit - $0.430 billion

52. Clean hydrogen production credit - $0.340 billion

53. Credit for child and dependent care expenses - $3.480 billion

54. Carbon oxide sequestration credit - $0.330 billion

55. Exemption of credit union income - $2.970 billion

56. Tax credit for orphan drug research - $1.740 billion

57. Low and moderate-income savers credit - $1.860 billion

58. Exclusion of interest on hospital construction bonds - $3.120 billion

59. Deductibility of student-loan interest - $0.560 billion

60. Interest Charge Domestic International Sales Corporations (IC-DISCs) - $1.620 billion

61. Exclusion of reimbursed employee parking expenses - $1.827 billion

62. Capital gains exclusion of small corporation stock - $1.780 billion

63. Exclusion of interest on bonds for private nonprofit educational facilities - $2.280 billion

64. Capital gains treatment of certain agriculture income - $1.550 billion

65. Premiums on accident and disability insurance - $1.720 billion

66. Deferral of income from installment sales - $1.750 billion

67. Credit for certain employer contributions to social security - $1.520 billion

68. Clean fuel production credit - $0.000 billion

69. Income of trusts to finance voluntary employee benefits associations - $1.500 billion

70. Exclusion of GI bill benefits - $1.460 billion.

71. Exclusion of employer-provided educational assistance - $1.660 billion

72. Excess of percentage over cost depletion, oil, and gas - $1.530 billion

73. Exemption or special alternative tax for small property and casualty insurance companies - $1.400 billion

74. Exclusion of interest on rental housing bonds - $1.610 billion

75. Employer-provided child care exclusion - $0.760 billion.

76. Exclusion of parsonage allowances - $0.959 billion

77. Credit for energy efficiency improvements to existing homes - $1.970 billion

78. Assistance for adopted foster children - $0.880 billion

79. Tax credits for refueling property - $0.170 billion

80. Exclusion of interest for airport, dock, and similar bonds - $1.050 billion

81. New markets tax credit - $1.210 billion

82. Adoption credit and exclusion - $0.870 billion

83. Deductibility of casualty losses - $0.000 billion

84. Exclusion of public assistance benefits (normal tax method) - $0.760 billion

85. Exclusion of interest on owner-occupied mortgage subsidy bonds - $0.880 billion

86. Exclusion of certain foster care payments - $0.500 billion

87. Deferral of interest on U.S. savings bonds - $0.820 billion

88. Advanced energy property credit - $0.260 billion

89. Work opportunity tax credit - $2.070 billion

90. Tax incentives for preservation of historic structures - $0.710 billion

91. Allowance of deduction for certain energy-efficient commercial building property - $0.430 billion

92. Distributions from retirement plans for premiums for health and long-term care insurance - $0.470 billion

93. Special Blue Cross/Blue Shield tax benefits - $0.370 billion

94. Exclusion for employer-provided transit passes - $0.369 billion.

95. Tax exemption of insurance income earned by tax-exempt organizations - $0.370 billion

96. Exclusion of certain allowances for Federal employees abroad - $0.280 billion

97. Qualified school construction bonds - $0.490 billion

98. Depreciation of buildings other than rental housing (normal tax method) - $0.920 billion

99. Excess of percentage over cost depletion, nonfuel minerals - $0.310 billion

100. Zero-emission nuclear power production credit - $0.000 billion

101. Expensing of certain multiperiod production costs - $0.250 billion

102. Expensing of multiperiod timber growing costs - $0.260 billion

103. Exclusion of interest on bonds for water, sewage, and hazardous waste facilities - $0.290 billion

104. Exclusion of military disability pensions - $0.200 billion

105. Special Employee Stock Ownership Plan (ESOP) rules - $0.220 billion

106. Discharge of student loan indebtedness - $0.100 billion

107. Small employer pension plan startup credit - $0.000 billion

108. Credit for construction of new energy-efficient homes - $0.280 billion

109. Income averaging for farmers - $0.210 billion

110. Exclusion of railroad retirement (Social Security equivalent) benefits - $0.300 billion

111. Capital gains treatment of certain timber income - $0.150 billion

112. Exclusion of veterans pensions - $0.220 billion

113. Advanced nuclear power production credit - $0.030

114. Expensing of exploration and development costs, oil and gas - $0.700 billion

115. Special deduction for teacher expenses - $0.160 billion

116. Reduced tax rate for nuclear decommissioning funds - $0.120 billion

117. Amortize all geological and geophysical expenditures over 2 years - $0.140 billion.

118. Exclusion of interest on student-loan bonds - $0.150 billion

119. Expensing of certain capital outlays - $0.120 billion.

120. Excess of percentage over cost depletion, coal - $0.090 billion

121. Recovery rebate credits - $3.460 billion

122. Exemption of certain mutuals' and cooperatives' income - $0.100 billion

123. Exclusion of interest on bonds for Highway Projects and rail-truck transfer facilities - $0.140 billion

124. Tonnage tax - $0.100 billion

125. Marginal wells credit - $0.190 billion

126. Ordinary income treatment of loss from small business corporation stock sale - $0.070 billion

127. Expensing of reforestation expenditures - $0.060 billion

128. Exceptions from imputed interest rules - $0.060 billion

129. Exclusion of interest on veterans housing bonds - $0.080 billion

130. Credit for holding clean renewable energy bonds - $0.070 billion

131. Treatment of loans forgiven for solvent farmers - $0.060 billion

132. Exclusion of interest on small issue bonds - $0.060 billion

133. Deduction for endangered species recovery expenditures - $0.030 billion

134. Credit to holders of Gulf and Midwest Tax Credit Bonds - $0.100 billion

135. Additional deduction for the blind - $0.050 billion

136. Income of trusts to finance supplementary unemployment benefits - $0.040 billion

137. Recovery Zone Bonds - $0.090 billion

138. Capital gains treatment of royalties on coal - $0.050 billion

139. Exclusion of interest on savings bonds redeemed to finance educational expenses - $0.040 billion

140. Empowerment zones - $0.090 billion

141. Credit for holders of zone academy bonds - $0.090 billion

142. Discharge of business indebtedness - -$0.010 billion

143. Exclusion of utility conservation subsidies - $0.050 billion

144. Discharge of mortgage indebtedness - $0.220 billion

145. Qualified energy conservation bonds - $0.030 billion

146. Employer-provided child care credit - $0.020 billion

147. Tax credit for certain expenditures for maintaining railroad tracks - $0.130 billion

148. Deferral of gain on sale of farm refiners - $0.015 billion

149. Expensing of exploration and development costs, nonfuel minerals - $0.070 billion

150. Disaster employee retention credit - $0.050 billion

151. Expensing of exploration and development costs, coal - $0.050 billion

152. Exclusion of special benefits for disabled coal miners - $0.020 billion

153. Indian employment credit - $0.030 billion

154. Exception from passive loss limitation for working interests in oil and gas properties - $0.010 billion

155. Deferral of tax on shipping companies - $0.010 billion

156. Tribal Economic Development Bonds - $0.010 billion

157. Credit for disabled access expenditures - $0.010 billion

158. Exclusion of interest on energy facility bonds - $0.000 billion

159. Alcohol fuel credits - $0.020 billion

160. Bio-diesel and small agri-biodiesel producer tax credits - $0.020 billion

161. Credit for employee health insurance expenses of small business - $0.010 billion

162. Enhanced oil recovery credit - $0.000 billion

163. Credit for family and sick leave taken by self-employed individuals - $0.520 billion

164. Other Dependent Tax Credit - $0.000 billion

165. Build America Bonds - $0.000 billion.

166. Special rules for certain film and TV production - $0.100 billion

167. Opportunity Zones - $2.080 billion

168. Accelerated depreciation of machinery and equipment (normal tax method) - $10.430 billion

169. Expensing of research and experimentation expenditures (normal tax method) - -$38.660 billion

Clearly, not all of these can or should be eliminated, but the vast majority should. To point to just three opportunities for consolidation:

• Our fragmented array of complicated healthcare tax breaks, which are far from guaranteeing universal affordable access to care, would be better replaced with a single simple health insurance subsidy, done external to the tax code.

• Our various accelerated depreciation schemes and special investment tax breaks would be best replaced by a blanket deduction for all investment costs of all varieties (full expensing).

• Our litany of tax exclusions for government-provided benefits would be better replaced by a single large tax exclusion for all government-provided entitlement benefits.

Simplicity does not require us to abandon the aspirations of our tax code, nor does it require us to give up progressive tax brackets, as many on the right have claimed. What it requires is taking up a large and politically challenging task, one that will put us at odds with a powerful army of special interest groups.

Difficult as that might be, it's a worthwhile priority and one essential for curbing the unsustainable budget deficit we are currently faced with.

Political movements are built on simple stories.

The ascendant Trumpian Right offers one we know all too well. Mass immigration, they claim, has driven up costs, lowered wages, spiked crime, and eroded our national identity. Our country is being exploited by unfair trade deals and foreign aid schemes. As out-of-touch, left-wing elites at the highest echelons of our government and social institutions are using them to push a radical, harmful agenda. The result is a society in decline—one in desperate need of a savior, specifically a spray-tanned billionaire from New York.

The Left also has a simple story of politics. Corporate greed, they argue, has driven growing inequality, environmental degradation, and worker exploitation, amongst a variety of other social ills. In the face of these injustices, the government has failed, having been co-opted by the wealthy to serve their interests at the expense of the public good. This perversion of state power, they contend, has contributed to everything from police brutality to the failed war on drugs to unnecessary foreign entanglements. Their solution is a mass working-class movement to retake government, raise taxes on the rich, tighten regulations on businesses, expand public ownership of assets and services, strengthen unions, and move incrementally towards a society where power is distributed more equally and democratically.

In the face of these two options, I must admit that I am unsatisfied. The Right is clearly wrong. Their anti-immigration hysteria rests on little other than cherry-picked anecdotes and the factless ramblings of their leader. While they correctly note our immigration system is disorderly and the asylum process is broken, immigrants are simply not responsible for stagnant real wages, crime, cultural discord, or any manner of the other things that Right scapegoats them for. Mass deportations are disastrous, and tariffs are self-sabotaging. Foreign aid, which accounts for less than 2% of the federal budget, is hardly the culprit for our national woes. Although some institutions are indeed controlled by out-of-touch elites, they are not part of some centralized cabal orchestrating absurd plots like controlling birthrates, promoting a "great replacement," or brainwashing children into being LGBTQ.

The leftist perspective, while less egregiously flawed, also has some issues. Its reductivism is problematic. Most societal problems cannot be reduced to greed or some endlessly vague concept of "capitalism." Contrary to their frequent claims, economic conditions have improved for most Americans over recent decades. While the American social safety net could be fruitfully expanded, this should be done thoughtfully. Government subsidies risk distorting economic behavior and come with real fiscal and economic consequences. Wealth and high investment taxes are growth-inhibiting and generate limited revenue. Spending hundreds of billions annually on public housing won't resolve the housing crisis if such projects become entangled in the same red tape and bureaucratic inefficiency already fueling the crisis. Price controls create shortages. Not all unions do exclusively good things; some make it their priority to oppose productivity-enhancing automation—an approach deserving of skepticism.

The government has indeed been hijacked, but not by a monolithic wealthy class. It has fallen prey to a myriad of corrupting influences that redirect policy away from the public good. Industry groups have fought to entrench harmful regulations like the Jones Act, which stifles competition and raises consumer costs. Professional associations have fought to legally limit the number of people who enter their industry with licensing restrictions and labor standards boards. Special lobbies have rid the tax code with a myriad of breaks and loopholes, creating a wasteful, byzantine system that inhibits economic activity. Self-serving politicians have driven the deficit to unsustainable levels. Poorly incentivized administrators and economic incumbents have resisted change in the public sector, reducing the quality of public services.

In countless nuanced ways, our government has been corrupted and rendered ineffective—not merely failing to solve problems but also often exacerbating them.

In light of these realities, I believe it is time for a new political movement to emerge in America. The narratives offered by the Right and even, to some extent, the Left are inaccurate and have a tendency to produce policies that hinder progress rather than advance it. We need to offer Americans an alternative—one that speaks to the issues they face, properly attributes blame to these problems' real causes and produces genuine and realistic solutions to these problems.

I believe the Democratic Party can be at the center of this movement. In the face of a sluggish and special-interest-captured government, we can offer Americans an agenda to fix the sickness at the heart of our political system once and for all. One that promises to weed out corruption, restructure institutions to promote effective problem-solving, end anti-competitive and shortage-inducing red tape, slash wasteful corporate welfare, radically streamline the tax code, modernize and digitalize our public services, and reform a federal welfare system that provides far too little income and struggles with problematic poverty traps.

We can add to our critical and important commitments to democracy, gun safety, reproductive freedom, and civil rights, an agenda aimed at truly making the government into the effective servant of the people it should be. But to do so, we will need to get work and do so quickly.

Movements are not born overnight. Successful narratives are ones that get lifted by many voices and are positively received by many ears. If we wish to guide the public towards the real solutions to their problems, we must get started now.

This shall be my focus.

I eagerly hope it will also be—yours.

The average annual earnings for a doctor in the United States is $350,000. That's 50% more than physicians are making in Germany.

Part of this difference is explicable in terms of differences in wage rates between countries. On average, Americans earn significantly more than Germans. But that explanation is insufficient to cover the full delta.

Another part of this difference is explained by the simple fact that America pays its doctors a pretty remarkably high amount by global standards; a Medscape survey found even more profound differences between the US and other rich nations. While a European doctor might be comfortably in the top 10% of the income distribution, an American doctor, on average, is comfortably in the top 3%.

One might think these uniquely high wages in the United States would lead to a disproportionately high percentage of the American population seeking a career as a doctor. But that understandable assumption would be wrong.

Despite lower relative wages, Germany has 65% more physicians than the United States does per capita. This statistic is one of many that sheds light on an issue at the heart of America’s healthcare woes.

The United States has, by international standards, a uniquely low number of physicians per capita. While some peer nations may be able to get away with this due to exceptionally healthy populations, our population, plagued with chronic illness, certainly does not.

The present supply of physicians is far out of lockstep with the demand for them, and high wages are a symptom of this. When the supply of anything fails to be fully elastic in the long run, its price tends to go up (lest demand, for some reason, fails to grow over time). Similarly, as the supply of doctors has been limited, the price of doctors (their wages) has grown.

Mechanically, this is caused by the competition between insurers. As time with a doctor is increasingly scarce, insurers competing against one another effectively bid up the price. American consumers end up paying higher taxes to fund increasing government spending on healthcare programs and higher premiums for their own insurance.

Another symptom is long wait times. Americans wait far longer to see a physician than people in almost any other advanced nation. When they do, they see their doctor for a shorter time, with visits lasting, on average, only about 20 minutes.

Patients suffer the consequences. The shorter the length of a visit, the higher the likelihood the doctor prescribes an inappropriate treatment for their condition. The human cost of this is borne out in the data. A large 2023 cross-sectional study found that “shorter visits were associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and co-prescribing of opioids and benzodiazepines for patients with painful conditions.”

The good news is that the physician shortage is something that can be fixed, but in order to do so, we need to first understand how it has come about.

Part 1: It’s too hard to become a doctor

Becoming a doctor in the United States is one of the most difficult career paths a person can follow.

Students, starting in high school, need to study hard to get good grades; they also need to get a decent score on their SAT or ACT so they can get into a good college.

Then, they need to complete a four-year undergraduate program and must continue to get excellent grades while also completing pre-medical school requirements.

After that, they must get an excellent score on the MCAT (in the 75 percentile or above), which often requires many months of intensive study.

Following this step, they will enroll in a medical school program, which will take them on a four-year process of intensive training. Over the course of these four years, they will take multiple state licensure exams, which require passage in order to eventually legally practice.

Following graduation from medical school, they will need to apply for a residency. If they are accepted, they will be under years of painstakingly difficult training with low compensation.

At the tail end of this process, prospective doctors will be confronted with a final third licensure test, the hardest of the bunch.

Over the course of this, at a minimum, 11-year process the median student will accrue $215,000 dollars in student debt.

Gap years or longer residencies for specific specializations will stretch it across yet even more years. The numerous points of potential failure will, through attrition, pick off many of the people pursuing this career path, ultimately preventing them from entering the workforce as physicians.

All of this contributes to the doctor shortage. The more barriers, whether they be in difficulty, financial costs, or time dedication put up to becoming a doctor. The fewer people who will be willing to pursue that path, the fewer people who will end up on the other side. Furthermore, the longer the period aspiring doctors are locked up in the education system, the shorter their time as practicing physicians will be.

Other countries that are graced with a far more abundant supply of doctors have a much less strenuous process by comparison, without much, if any, evidence that their medical professionals are of notably lower quality. Let’s look specifically at Germany’s process since I referenced them previously.

As shown in the image above, pulled from an insightful comparison of the German and American approaches to training physicians, the German system is notably less arduous than the American system.

Upon graduating high school, students are permitted to go directly to medical school. High grades are sufficient to secure acceptance, although optional entrance exams are available for those with lower grades who seek to prove their abilities.

The duration of medical school is one to two years longer, but it is tuition-free. The state licensure exams are incorporated into the medical school system and do not include additional exams after one has graduated, and once graduating, a residency is virtually guaranteed by a national matching program, without the requirement for stressful and tedious applications.

Part 2: There aren’t enough medical school seats or residencies

Another part of the cause of this problem is that there aren’t nearly enough medical school seats or residency positions.

To demonstrate this visually, consider the above graph. The blue line represents the total number of new first-time medical school applicants, and the orange line represents the total number of medical school students accepted. As you can see, the two are increasingly out of lockstep, which manifests in falling acceptance rates at medical schools.

Despite the difficulty of becoming a physician in America, there are still a lot of people who want to do so. Attracted by high levels of compensation, tens of thousands of Americans try and fail each year to get into medical school.

Many of these applicants are high quality. They have the talent, knowledge, and work ethic needed to succeed in medical school and have GPAs and test scores that would have gotten them into medical school a decade ago when admissions requirements were lower. However, because of an insufficient supply of seats, their applications get chunked.

For those lucky enough to get into medical school and graduate, one estimate finds that 7% fail to secure a residency spot afterward, leaving them unable to continue their path toward becoming a physician and also flailing in debt.

So, what’s causing this preposterous lack of seats? One would think that in a market, if the demand for medical school seats and residency spots grew, and the applicants for these positions were sufficient in quality to meet state licensure standards, the supply would increase accordingly. This would predict that, in the long run, applicants and training program positions would increase in lockstep.

The issue is that our physician education process isn’t a marketplace. Most medical school seats are at public universities. The remaining are in predominantly nonprofit universities. Regulations exist that limit expanding seats at medical schools, and new schools are required to go through federal accreditation with the Liaison Committee on Medical Education, which can be challenging.

Most residencies are funded through a complex formula by Medicare, and the supply of residency slots is controlled by residency review committees staffed with professionals from the specialty in question.

Expectedly, the system doesn’t act very much like a market because market forces are hard to find. This, of course, leads to problems.

Part 3: Bureaucrats and special interest groups are to blame

Many of the groups involved in these state-controlled processes have an incentive to limit supply. A notable group that has caught substantial flack for this in the past is the American Medical Association, which advocates for the interests of doctors. Current doctors financially benefit from limiting entrance into their profession, as this allows them to extract artificially high wages. This phenomenon gives special interest groups like the American Medical Association an incentive to limit supply, and that is an incentive that has historically acted in accordance with.

In the late 20th century, it was these poorly incentivized interest groups and some poorly informed bureaucrats that produced the widespread myth of an impending “doctor shortage.”

A major catalyst for this alarm began in 1976 when the secretary of the Department of Health, Education, and Welfare commissioned the Graduate Medical Education National Advisory Committee to provide policy recommendations on the healthcare workforce. This report, released in 1981, alleged that the U.S. needed to take immediate action to constrain the supply of doctors.

The American Medical Association and related professional organizations were eager to push this narrative. In 1997, they issued a joint statement asserting that “the United States is on the verge of a serious oversupply of physicians.”

Over the course of these years, serious action was indeed been taken to limit the supply of doctors. Federal funding for scholarships was cut. Residency requirements were intentionally made more stringent to reduce the quantity hospitals provided. The number of Medicare-funded residency slots was frozen.

A moratorium on new schools was declared, leading to almost no new medical schools being opened from 1980 to 2005. Class sizes also shrunk, and planned expansions of existing medical schools were canceled.

Along with the newly created artificial limits on supply, additional laws were crafted to artificially increase the demand for physicians. Scope of practice restrictions were imposed in states across the country to exclude nurses and other trained professionals from providing many forms of care, thereby increasing the need for doctors.

Today, the narrative has shifted. The Association of American Medical Colleges has rung alarm bells regarding a projected shortfall of up to 86,000 physicians by 2036. Even the American Medical Association has come around to recognizing the sorry state of doctor supply. Although, predictably, their “solutions” consist primarily of more subsidies, not supply-side expansions.

However, as the discourse on the topic has changed, many of the policies that caused it have remained in place. Occupational licensing requirements are too strict, and the education process is too arduous and long. Scope of practice laws prevent other medical professionals from doing things they can safely do, unnecessarily reducing competition and increasing the need for physicians.

Government funding for expanding medical school seats has been insufficient. Private nonprofits have also failed to grow their schools at a sufficiently quick rate. Private for-profit schools, which theoretically could fill gaps in the public and nonprofit supply of seats, are heavily regulated.

A challenging federal accreditation process required by state regulatory boards prevents new schools from opening, and expansions of existing programs similarly face challenging government hurdles.

The residency process continues to rely on an incredibly complex federal funding system that supports a number of residency spots that are mostly unchanged from what they were decades prior. Furthermore, their supply is controlled by largely unaccountable entities that lack the incentive to approve an adequate number of positions.

Part 4: Deregulation, restructuring, and supply-side investments can fix it

The solution in the face of the present system, plagued by centralized control and special interest group rent-seeking, is a healthy dose of deregulation, restructuring, and supply-side investments.

That includes policies like:

• Reforming medical school by removing bachelor’s requirements for medical school admissions, increasing the length of medical school programs to cover any necessary learning lost from undergraduate pre-med courses, and investing in research to find the most cost-effective and fastest ways to prepare people to practice.

• Revising the occupational licensure process by eliminating unnecessary requirements and embedding it entirely into the medical school system.

• Lowering the upfront cost of attendance by supporting financial instruments like income share agreements, which allow students to go to school debt-free in exchange for a certain percentage of their income over a number of years.

• Changing the scope of practice laws so that nurse practitioners and other medical professionals can perform the full range of services they can safely provide.

• Making it easier to start new accredited medical schools and expand existing ones, and making public capital available for that purpose.

• Eliminating all caps on residency slots and restructuring Medicare residency funding to provide a fixed subsidy amount for every spot that meets federal standards.

• Establishing a unified residency sorting process that ensures all medical school graduates can easily and quickly secure a residency.

These reforms would allow more people to get jobs in the lucrative medical profession. They would bring down healthcare costs and allow Americans to see their doctors faster and for longer periods of time.

Furthermore, they would make the aspiration of universal, affordable access to care a lot more practicable. Currently, the fact that many people don’t have insurance or have insurance makes the effect of the physician shortage on wait times less extreme than it would be otherwise.

An unfortunate and often under-recognized fact about our current healthcare system is that if universal, affordable access to care were achieved tomorrow, the consequence would not be everyone getting the healthcare they need when they need it. Rather, it would be everyone having the right to wait in line to see a doctor, and a long line at that.

Better than the status quo? Yes.

Ideal? No.

With these reforms, we would make the full aspirations of universal high-quality healthcare for all possible. And make our society wealthier and healthier in the process.

We all agree that the current healthcare system sucks and that some way or another, we should achieve universal healthcare. Thus far, it seems like left of center folks have only either advocated for lame incremental reforms to the current system or, alternatively, a single-payer system. In this article, I would like to present an alternative. I will call this system universal multi-payer healthcare, but it also could be called managed competition or universal healthcare choice.

I think this plan has some unique benefits that allow it to harness the benefits of single-payer while sidestepping its pitfalls.

Part 1: Single-payer has some problems

Ok, let’s start by talking about single-payer.

Single-payer is pretty straightforward. Every man, woman, and child would be enrolled in one federal government-administered insurance plan financed by taxes. This plan would have no premiums and little if any, cost sharing.

Single-payer healthcare has some big advantages over the current healthcare system. For starters, it would give us universal, affordable access to coverage, and that would improve healthcare outcomes, shore up many families’ income security, and cut poverty.

It also would simplify our existing byzantine health insurance system, which burns boatloads of cash on administrative waste. I mean, look at this thing, what a monstrosity! One other big benefit it has, especially over the less ambitious proposals pushed by moderate democrats, is that it would delink insurance from employment, thereby increasing worker mobility. This is actually no small deal because the “job lock” effect, induced by workers not leaving their jobs due to fear of losing their insurance, deprives our economy of billions of dollars of economic output each year.

With those pros mentioned, single-payer systems also face some big and notable issues. Let’s run through them real quick.

Longer Wait Times

You’ve definitely heard this one before. A key line of attack by conservatives against single-payer has been that it would fuel intolerably long wait lines. This criticism isn’t entirely unfounded.

Single-payer systems often aspire to provide low to no-fee comprehensive healthcare to the population. But doing this is extraordinarily expensive. Paying for everyone’s healthcare under the current system, which has cost-sharing, wouldn’t be easy for Uncle Sam. But also, under single-payer, there is often little in the way of deductibles, copays, and coinsurance, meaning that people are more likely to seek out care, even for frivolous reasons.

Because of this immense cost, governments often cut corners to lower the price tag and not require taxes to be quite as high. The result is that the government controls costs by providing a low level of reimbursement to providers for care and imposing rigid price controls on drugs and medical products.

This causes demand and supply to become disjointed, as the quantity of healthcare demanded rises due to being healthcare now being free at the point of service, and the quantity of healthcare supplied falls because the profitability of healthcare providers is depressed by lower reimbursement rates.

This disjointment of the healthcare marketplace inevitably leads to rationing in the form of limits on healthcare utilization and, yes… wait times.

The quintessential examples of a chronic shortage of providers are in Canada and the United Kingdom, where wait times have become increasingly high, caused by particularly frugal spending on their public healthcare systems. Given America’s political institutions and its tremendous aversion to broad-based taxation, it is likely that if it ever were to achieve a single-payer system, it would be similarly poorly funded.

One quick aside is that, as some have noted, the United States has also struggled with excessive wait times for certain kinds of services, but in our case, the cause is not insufficient spending on healthcare (far from it); rather, its awful supply-side policies that severely limit the supply of doctors and healthcare providers.

Less Innovation

Through low levels of payment for services, medical products, and drugs, the government also reduces the profitability of investing in the R&D necessary for medical innovation. This leads to slower advancement of the healthcare sector over time, and this fall in private research is rarely made up for in increased public research.

A recent UChicago working paper estimated that “a 1 percent reduction in revenue” leads to “a 1.5 percent reduction in R&D activity.” They also found that a piece of legislation that would create similar price controls to the ones a single-payer system would effectively impose would lead to “a 29 to 60 percent reduction in R&D from 2021 to 2039,” which would translate to “167 to 342 fewer new drug approvals in that period.”

A similar story remains true regarding medical products and treatments. The effect of reducing the profitability of innovation is getting less of it, and those with ailments will ultimately suffer the consequences as they are deprived of healthcare innovations that would have significantly improved their lives.

Slower Productivity Gains

Single-payer standardizes all reimbursements on a centralized fee schedule, providing the same level of reimbursement to all providers for a service. Proponents tout the simplicity of such a system, but it comes with a major downside: it kills price competition.

Imagine for a moment you were choosing between cereals at the grocery store. Imagine as well that all of the cereals were the exact same price, and ultimately, that price was not paid by you but instead to your parents. Would there be such a thing as price shopping in this context?

No! All prices are the same, and even if they weren’t, they weren’t paid by you, so you wouldn’t really care.

Now, let’s ask a follow-up question. Would then cereal producers have an incentive to find ways to lower costs? In a sense, sure. All companies have the incentive to maximize profit, and lowering production costs can do that. But this market lacks an essential feature. It doesn’t allow the cereal companies that are really good at lowering costs to charge lower prices and force their less efficient competitors to either adapt or perish.

In the long term, that’s a big problem. Our existing healthcare system struggles with this issue already. Healthcare prices aren’t transparent, and for many Americans, price exposure is low. This, in part, explains why healthcare prices have dramatically outpaced inflation over time. Healthcare goods and services, lacking strong price competition, have failed to grow in productivity at the same rate as the rest of the economy, leading to uniquely high-cost growth. This phenomenon is often referred to as Baumol’s cost disease.

Single-payer would not only fail to restore to price competition in our healthcare system. It would make it impossible.

Part 2: What multi-payer would look like

So, if not single-payer, then what? The liberal answer is Universal Multi-Payer Healthcare, sometimes referred to as Managed Competition. Some pretty cool countries in Europe central Europe have this system.

In America, I propose it looks something like the following:

• Every American is provided an array of healthcare insurance options to purchase on the individual insurance marketplace. In making shopping, they are granted a government subsidy that will go towards whatever plan they choose. This subsidy will be sufficient to provide them with a high-quality plan, but they will reserve the right to pay more for an even better one if they so choose.

• Those who fail to enroll in a plan will be auto-enrolled in a default public insurance plan. This plan will be run on a non-profit basis and will try to compete with the private insurance options in the marketplace.

• Insurance plan information will be published on an easy-to-use marketplace website. This website will include each plan’s demographic-adjusted mortality scores (how good they are at keeping their enrollees alive), customer reviews, and any added supplemental coverage or perks the plan provides.

• All insurers will be prohibited from charging different premiums to different people on the basis of their age, race, gender, or preexisting conditions. To level the playing field among insurers so that no insurer does worse or better simply because they have sicker or healthier enrollees on average, the government will use a system of risk adjustment and reinsurance to redistribute funds from insurers with naturally less expensive risk pools to those with naturally more expensive risk pools.

• A basic insurance package of covered services and goods will be mandated by the government, which will include comprehensive coverage for all essential healthcare needs. Insurers will also be required to include bundles in life insurance with their policies and provide long-term contracts. These requirements will strengthen insurers' incentive to prioritize the long-term health of their enrollees over short-term cost-cutting.

• Healthcare claims and payments will be centralized into one unified system, ensuring efficiency, simplicity, and timely compensation.

If these ideas seem familiar, that’s because a weak sauce form of Managed Competition already exists to a limited degree today in the form of the individual state health insurance exchanges and Medicare Advantage. It also might be because I’ve written about healthcare on this blog A LOT.

Part 3: Why multi-payer is preferable

Ultimately, this approach to health insurance would achieve all the pros of a single-payer but without the cons. People who like government insurance could get the same experience they would under a single-payer system by enrolling in the public option. Hell, it actually might be a better experience since the government option will be forced to compete with private insurers.

The risks of underfunding will be less significant as people will always be afforded the option to pay more for better insurance if the government fails to fund the system properly.

The government, no longer having a monopoly position as the payer for healthcare, will reduce the likelihood that stringent and uniform price controls are imposed, preserving the profitability of healthcare innovation.

Private health insurers will be incentivized to experiment with alternative payment systems to cut costs, and if paired with price transparency laws, this could lead to productivity-enhancing price competition returning to healthcare.

I think this is a big win-win-win idea. And that’s all, not to mention the fact that this is probably a much easier lift politically.

What do y’all think? Am I crazy here, or is the best universal healthcare idea one that we seem to never talk about? Let me know!

Part 1: The liberalism haters are all over

I’m sure you’ve seen the headlines.

They say the same thing a thousand different ways:

“How Liberalism Failed.”

“Modern Liberalism Has Become a Defense of Hierarchy and Deference to Elites.”

“The liberal order is already dead.”

The message over and over again? Things suck, and liberalism is to blame.

Part 2: Dumb definitions are to blame

My theory is that this message is so prevalent because of the common yet endless irritating habit of defining the status quo as liberalism (or alternatively “neoliberalism”), and thus, any issue with the status quo as an issue with liberalism.

While this might be satisfying for folks looking to centralize blame for our problems on one specific ideology, it’s an incredibly dumb way to use words. There are many things about the status quo that are not liberal.

Is it liberal to highly restrictive anti-market zoning restrictions, which were created to exclude people on the basis of race and class?

That seems pretty textbook illiberal.

Are trade restrictions and protectionism liberal?

That would definitely be news to Adam Smith.

Are unnecessary state monopolies liberal? What about the incarceration of people on marijuana charges? What about qualified immunity for law enforcement?

Obviously, none of these things are liberal.

What is liberal about our society is freedom of speech, assembly, religion, and thought. What is liberal is a constitutionally constrained government with a division of powers and democratic accountability. What is liberal is private property rights.

None of these things are the cause of our problems.

Part 3: Illiberalism solves nothing

It’s this extraordinarily lazy conflation of liberalism with whatever the status quo is that has fueled the resurgence of history’s old failed ideologies. Resurgent political forces on both the left and right have utilized the smearing of liberalism as justification for moving in an illiberal, authoritarian direction.

Socialists have called for ending private property rights and creating huge state monopolies. National Conservatives have called for government-backed religion, legislated religious morality, and ending immigration as we know it.

Yet all of these dramatic changes answer problems we don’t have. America’s issues are not because of private property rights or lack of government monopolies. They also aren’t because of the separation of church and state and immigration.

Part 4: What actually is to blame

America’s problems are caused by broken political institutions that fail to incentivize politicians to pursue good policy and instead suffer from gridlock, interest group capture, and short-term popularism. They are because we have drowned our market economy with bureaucracy, red tape, and proceduralism and failed to build an adequate social safety net capable of fostering widespread prosperity. They are because the government has become too keen on invading people’s personal lives and not keen enough on guaranteeing basic public safety.

The cold, hard fact is that politics is hard. The world is complicated. Things are nuanced. No one set of ideas is at fault, nor any one group.

Rather, the issue of modern politics is to answer the same questions that have plagued our species since the dawn of human society.

• How do we change our institutions to better align individuals' incentives with that of the common good?

• How can we overcome our ignorance and come to understand the real nature of the world?

• How can we rise above our natural prejudices and selfishness in order to become more open-minded, rational, tolerant, ethical, and compassionate neighbors to our fellow beings?

It’s these questions that we must continually find answers to in order to continue making our society better, and often those answers entail making things more liberal, not less.

I have a lot of specific views. I think, for instance, that we should replace our property tax with a land value tax to promote development. I think we should trim unnecessary occupational licensing requirements, shorten the bachelor’s to three years, and strengthen our workforce development pipeline. I think we badly need to ban gerrymandering nationwide and move towards a system of approval voting and all-party open primaries for all elections.

But these ideas, many of which are wonky and specific, are informed by broader themes and general ideas I have about how the world works and what the role of the government is in it. Here is my attempt to summarize my beliefs into concise bullet points:

• For the government to be functional, it must have strong institutions that limit the abuse of power, incentivize political decision-makers to pursue the public good, ensure sufficient internal state capacity for the creation of well-designed policies, and constrain the power of special interest groups and rent-seekers.

• Markets are extremely good at generating wealth and promoting innovation. Regulatory policy should be oriented toward addressing market failures. Tax policies should be oriented toward pricing externalities and raising revenue in a maximally efficient and minimally economically harmful way.

• Social welfare policies can significantly improve people’s lives by providing them with greater income security, eliminating poverty, and fostering widespread prosperity. It’s best when these policies take the form of universal programs that preserve competition and individual choice.

• It is unsustainable for the national debt to grow at a far faster rate than the overall economy. Rules must be put in place to curb excessive borrowing in times when there is no recession or ongoing war.

• All forms of protectionist measures, including Buy America requirements, tariffs, import quotas, industry subsidies, and the like, are counterproductive; spare those that are necessary for national security reasons. Free trade brings down prices, raises wages, speeds up global growth, and promotes peaceful cooperation between nations.

• Immigration should be orderly, documented, and abundant. Immigrants contribute an immense amount to our society, and in turn, the opportunity we afford them when we allow them to come here does immense good for their quality of life. It is a huge win-win.

• Climate Change is absolutely real and undeniably caused by humans. The United States and other nations must take action to stop it, both by addressing its root causes and excessive emissions and mitigating its effects through greater weatherization and disaster-proofing.

• Liberal Democracies must stand together to fight against authoritarian expansionism and promote the causes of liberty and equality around the world. Still, they should do this in a fashion that is measured, careful, and with the utmost respect for human rights.

• The state should stay out of personal lives and respect personal life choices. It’s not the job of the government to be the morality police or to force people to do what is “best” for themselves. It is the goal of the government to protect people from others' violation of their rights.

• Criminal justice should focus on maximizing public safety and rehabilitating violators. It should not seek to punitively impose suffering for suffering’s sake, and it should always be careful not to provide the state powers that are ripe for abuse.

• Car centricism, achieved through draconian land use regulation and automobile-obsessed infrastructure design, is awful. Urban planning should promote a livable and vibrant built environment that is walkable and multi-modal.

With these stated, I think it’s pretty clear I fall into the New Liberal tradition. New Liberals have historically believed that the purpose of the state is to protect individual rights, promote the public welfare, and address market failures. In pursuit of these goals, they have advocated for a system often referred to as “Democratic Capitalism,” which combines liberal democracy with a robust open market economy, a welfare state, and government action to ensure the proper functioning of markets.

What do y’all think? Where do you think this ideology lands on the political spectrum, and which, if any, points do you differ on? I'm curious to read your thoughts!

I’m not gonna pull any punches, folks; a lot of things in this country suck.

Here is a list of ways from a recent article of mine, The FUNDAMENTAL PROBLEM and how we SOLVE IT:

Economic growth is slow, real wages are being squeezed by a crisis of affordability, and too many are left in a state where they struggle to make ends meet or, even worse, fall prey to poverty and homelessness.

Our healthcare system is failing to provide everyone with affordable and timely access to the care they need.

Our education system is falling short of equipping the next generation with the skills and knowledge they need to be productive members of society in the 21st Century.

Mass incarceration is leading to incredible amounts of suffering while failing to keep our communities safe.

People are punished by the state for doing the things they want, even when those things don’t harm anyone else.

A debt crisis is looming in our future, fueled by endless deficit spending over decades and unfavorable demographic trends.

Car centricism has leveled our cities and put 100s of millions of Americans in cities that, by all accounts, are unwalkable and bad for their physical and emotional health.

Greenhouse gas emissions are driving forward a climate crisis that will have devastating consequences for the human race.

Our authoritarian foes around the world are emboldened and now capitalizing on our weakness to attack their neighbors and expand their power.

Pretty bleak stuff.

In part because things suck so much, folks are increasingly looking for answers. They are shopping on the ideological marketplace, trying to find a political worldview that succinctly explains the source of our problems and also provides convincing solutions to them.

Here is the bad news: the bad ideas are winning right now. Populists on the right and on the left have largely been selling people their recycled basket of super lame non-solutions. On the right, it’s deportations, protectionism, and isolationism; on the left, it’s inefficient tax hikes to pay for highly inefficient social spending with a nice side of inefficient regulations, inefficient labor policies, and also inefficient state ownership.

Suffice it to say these ideas, like most ideas that emerge out of a simplistic US vs THEM, zero-sum view of the world, aren’t great. That’s usually where the liberal analysis stops, but NOT THIS BLOG; hell no!

It’s not enough to show that populist ideas are often bad; liberals need to start putting forward their own positive forward-looking agenda, if they want to have any hope of beating out the bad guys on the ideological marketplace, and also, most importantly, if they want to actually have a chance of solving society’s problems.

So that’s what I’ve done right here in the handy dandy blog post. Here is a taste of BIG policy solutions I’ve come up with to solve some of our economic problems, built on the eleven liberal values I detailed in LIBERAL'S 11 core BELIEFS:

#1 The Abundance Agenda

As has aptly put it, America has become a “Build Nothing Country.” We have strangled our own economy in proceduralism, red tape, and bureaucracy, and we are paying the price, literally. When you make it more costly and sometimes even illegal to engage in productive activity, things become more expensive, and high-paying job opportunities are stripped away from the population. It’s a lose-lose, and it’s happening all over the place.

So here is the first big plank of a bold liberal agenda built on the value of Economic Freedom: let’s have an Abundance Agenda.

• Let’s roll back counterproductive zoning and land use regulations so we can build more housing where people want to live.

• Let’s reform the permitting process and the energy regulatory scheme to speed up the clean energy transition.

• Let’s overhaul occupational licensing laws, expand the scope of practice for nurses, end certificate of need laws, and reform the FDA to bring down healthcare costs and increase the rate of medical innovation.

• Let’s reform the tax code so that less of the tax burden is on socially helpful, economically enhancing activity (like investment) and more of it is on rent-seeking, unhelpful activity (land speculation).

I think you are getting the gist by now; just via a smart, evidence-based overhaul of the regulatory state and pro-growth tax policy, we can make Americans' pocketbooks way better off and help solve issues like climate change and homelessness, all without tax hikes, spending cuts, or more borrowing.

#2 Free Trade

Despite what the America First Protectionists tell you, free trade is, in fact, very good.

It allows countries to specialize in doing what they are best at and never fails to raise real (inflation-adjusted) wages and increase the rate of economic growth. That’s why it’s so surprising that we haven’t struck more free trade deals by now.

0 free trade deal with Europe is ridiculous! The American government is leaving 100s of billions if not trillions of dollars, of economic activity on the table by not lowering these trade barriers.

Furthermore, part of this move should also include quasi-protectionist policies like unfair subsidies to domestic industries via buy America requirements, corporate welfare, and the horrid Jones and Dredge Acts.

Want to “end inflation” like the orange guy, MR. DJT keeps talking about? Do the opposite of what he says and embrace free trade.

#3 More Legal Immigration

Our population is aging, and that means more people are going into Social Security and Medicare, and there are fewer workers to support them. That’s putting our national debt in an extra worrisome spot.

Ignoring the looney toons' ideas of MMTers, we are generally presented with two choices: either cut spending or raise taxes. But there is a secret third option: work-based immigration.

America’s superpower historically has been welcoming the best and brightest from all corners of the globe to come to our country and providing them the liberty and economic opportunity to do really cool shit.

Unfortunately, right now, we are blocking a lot of these incredibly talented and skilled folks from coming into our country because of arbitrary work-based immigration caps and visa caps.

Here is a simple solution: abolish the caps. If someone is able to demonstrate sufficient skill and meets basic criteria like not being a criminal, they should be able to come here. Not only is this demonstrably good for their quality of life, but it’s also incredibly for America.

Out of all policies, this would likely be the most pro-growth, and if done with sufficient ambition, it could seriously ameliorate our deficit issues without requiring a dime of tax hikes or spending cuts.

#4 Streamlined Welfare

Our welfare system is not very good at its job. Depending on how you count welfare programs, we have anywhere from 60 to over 100 federal programs. That’s a lot.

But we still managed to have heaps and heaps of poverty, in part because benefits are not comprehensive, in part because many low-income folks never get the benefits they are eligible for, in part because the system is mired in welfare cliffs and poor incentives, and in part because a solid portion of the money we are spending is burned up in administrative expenses.

So here is an idea: let’s streamline the welfare system. Instead of dozens and dozens of tiny, ineffective programs, let’s do a few big, comprehensive, evidence-based ones.

I’m thinking of something like a big Housing First program to get all homeless people off the streets, a universal child allowance/child tax credit to eliminate childhood poverty, a basic income/negative income tax to eliminate adult poverty, a disability benefit, and boosted unemployment insurance.

With this highly streamlined array of benefits and the new focus on enhancing people’s individual choice and autonomy (liberal values), we should also consider copying Estonia and auto-enrolling people in benefits they are eligible for so no one falls through the cracks.

With just the money we are spending today, we could probably wipe poverty out or at least cut it by a lot.

#5 Medicare for Everyone

Like many other sectors of America, healthcare is in a rough spot. Our insurance system is fragmented and byzantine. Competition is often hardly present. Coverage isn’t universal. Everything is crazy expensive.

The previously mentioned Abundance Agenda will help with some of this stuff, and so will other nerdy ideas like requiring price transparency for healthcare providers, reforming intellectual property laws for drugs and devices, improving data sharing, and so on.

However, there is a big ticket item that I think liberals have a unique opportunity to address in an appealing way: What is the best way to achieve universal health insurance?

Progressives have a clear plan: Medicare for All. What is it? Giving comprehensive government health insurance to all people paid for by taxes, with no premiums, deductibles, or copays.

Interestingly enough, this plan has little in common with its namesake, Medicare. Currently, existing real-world Medicare is not a single-payer system; it is a managed competition system. People in the Medicare system are given a choice: choose between the government's Traditional Medicare plan or an array of private Medicare Advantage plans. Right now, just over half choose the latter.

Far from being a Single-Payer system, the current Medicare model is more akin to the Managed Competition healthcare model used in some of our OECD peers, where coverage is universal, but people have a choice over what plan they prefer.

This is preferable to single-payer because people aren’t trapped in a government plan. That’s actually super important because the government plan has a very high probability of being bad.

Look no further than Canada, where the government-funded healthcare system is plagued with crazy wait times because of underfunding. In the Medicare for Everyone system, I propose in the case that the government Medicare plan sucked, people could always take their subsidies and pay extra out of pocket to move over to a better private plan. If the progressives are right and the government plan absolutely rocks, then people won’t do this! I call it risk minimization.

The transition to this system would look something like the following:

Over time, we would increase Medicare Eligibility to everyone, starting by merging Medicare, CHIP, and TRICARE into Medicare, continuing by auto-enrolling newborns and the uninsured, and then allowing people to buy into the system at a price that is subsidized. If the end goal is tax-financed healthcare for everyone, we can ratchet subsidies up each and every year until, eventually, there are no premiums on basic plans (of course, people could always pay extra for an even better plan). If, for political reasons, we can’t give everyone healthcare and want to resort to lame means-tested subsidies instead, we can also have a premium subsidy that phases out with income.

Regardless of approach, this system would ultimately lead to a far more streamlined and efficient healthcare system, where workers, not their employers, get to choose their health insurance plan, and everyone has affordable access to care.

Once we switched over, we could get to work improving the many problems the Medicare System has, including fixing the broken risk adjustment model, promoting longer-term contracts, improving coverage, cutting out-of-pocket costs/premiums, and using more advanced payment processes.

#6 Emissions Taxes

Climate change is bad, but the solution is not the government nationalizing all industries to greenify them, nor a constant barrage of random and arbitrary bans and regulations, nor throwing endless wads of subsidies at every possible form of clean energy. All these things are economically distortionary and impose government rather than individual market-based control over the economy. They also all cost money.

Here is a better, more liberal idea: tax emissions. It’s pretty simple. If you want polluters to pollute less, charge them for it, and they’ll find the best way to do it less. Not only is it elegantly simple and preserves individual choice to the greatest degree possible, but it also gets the government money that it can use on tax cuts, deficit reduction, or worthwhile spending priorities.

Ok, I’m tired of writing now, but I think you are getting the gist.

LIBERALS HAVE BIG AND HIGHLY MARKETABLE IDEAS. We also have the benefit of having the vast majority of economists on our side.

Now we just need to get to work MESSAGING THEM to appeal to more then just hyper nerdy wonks on the internet. Would love y’all’s help in that incredibly important political project!

Liberalism has gone through many iterations.

In its long process of transformation, one of the biggest additions has been the concept of a “welfare state.”

The welfare state has a joint heritage, sharing its roots with both liberal and social democratic traditions. However, liberals and social democrats have always had different conceptions about exactly what is should look like.

Liberals have supported the welfare state for a wide variety of reasons. Some have viewed it as a pragmatic necessity for social stability. Others have made the case for it on the basis of freedom. Finally, some have accepted a more typical case for it on the basis of human well-being and positive social consequences.

Let me talk about each of these justifications in detail.

Social Stability

The case for the welfare state on the basis of social stability is largely pragmatic. It’s based on the descriptive observation that if people are left exposed to the ups and downs of a dynamic market economy, they are at high risk of abandoning liberalism and seeking solace in some alternative economic and social order. Thus, the welfare state is a concession to create a liberalism that can be sustained.

This is the argument provided by Samuel Hammond in his now well-known paper, THE FREE MARKET WELFARE STATE.

Samuel notes that while, at least in the United States, the debate has often been between people who are pro-market and anti-welfare and people who are anti-market and pro-welfare, in the real world, markets and welfare are actually positively related.

Countries that have higher degrees of income security due to the welfare state are able to have economies that are more innovative, dynamic, and disruptive because people are protected from the creative destruction of the market.

Meanwhile, countries that have less social spending on income security programs still attempt to achieve income security just through anti-market mechanisms, like regulations, protectionism, and draconian immigration controls.

Positive Freedom

Many liberals, especially those of the classical variety, have a view of freedom as fundamental freedom from coercion. In the eyes of these liberals, the sole political aim is the minimization of coercion, and thus, state action is only justified when it helps achieve this end.

Yet some have a different view on what the term means. These people termed social liberals, believe that freedom is not just about freedom of coercion but rather the ability to live the life that you wish.

In their eyes, the welfare state is justified on the basis that it enables more of the population to have control over their own destiny and choose their own fate. Social liberals note that financial resources can enhance people’s freedom by expanding the array of choices made available to oneself and opening doors that would otherwise be closed.

Social liberals view those stuck in a status of poverty as being fundamentally unfree. They note that the impoverished face an array of financial impediments that pose a particularly large barrier to the achievement of their will.

On this basis, social liberals argue that the welfare state is a powerful tool for promoting freedom. While they concede that redistribution necessarily reduces the financial resources of some to the benefit of others, they see the end result as an ultimately positive sum on the basis that economic barriers to the achievement of one's will are greatest for those with lower incomes and lowest for those with higher incomes.

Human Wellbeing

This is the argument that I find most appealing as a consequentialist.

It turns out that well-designed welfare programs can have a really positive impact on people’s lives. They can lift people out of poverty, improve their health and quality of life, and lower their likelihood of engaging in criminal activity. They can lead to a more equal distribution of income, which can strengthen the social fabric and lead to higher levels of utility (due to the falling marginal utility of consumption). They can also provide people extra income security, leading to their income being smoother throughout their lives, and thus, the financial stress that comes with large fluctuations in income being reduced.

Solid welfare programs can also have positive economic impacts. They can help people reach their fullest potential in the workforce by providing them the resources, training, and social security they need to pursue the career they are best suited for. They can encourage entrepreneurial risk-taking by lowering the stakes of failure. They can engage portions of the population that have low levels of employment, like mothers, the disabled, and those in impoverished communities.

I’m probably preaching to the quire here. But it’s important to note that one can be a liberal and value something other than Liberty. Some of the most famous Liberals in history, like John Stuart Mill, explicitly did so.

What differentiates Liberals in the political domain from other groups is the precise systems they support and the values that they are informed by. Liberals value openness, agency, choice, tolerance, cooperation, peace, and pragmatism, and that’s why they support a limited democratic government with a market economy. Modifications to the distribution of income could conflict with liberal values if it was achieved in a fashion that empowers state control over people’s lives. However, it could also be complementary to those liberal values and entirely compatible with liberal institutions.

So, there are the justifications. What do you think?

In a future piece, I’ll go over the difference between the characters of the liberal and social democratic welfare states. It is important to note that while they believe in one, they have pretty different ideas about what it should look like.

Until then, sayanora.

There is a new small-l liberal movement on the rise. In the face of rising populism and authoritarianism, more and more Americans are embracing liberal values and bold liberal solutions to the problems of the status quo.

In these times, it’s increasingly important we develop a refined definition of liberalism. One that is in line with its rich legacy and adequately captures it’s modern academic and small-l use. So here is my best attempt.

I believe you are liberal if you agree with the following 11 propositions:

1. Individual Liberty: The central goal of politics is the maximization of people’s freedom to live their lives as they please, pursue their passions, and achieve their fullest potential. (Related: Freedom of Speech, Assembly, and Thought)

2. Political Egalitarianism: All people are worthy of the same treatment, rights, opportunities, and consideration within the political domain. (Related: Equality before the Law)

3. Limited Government: State power must be constrained and dispersed in order to minimize the threats of government overreach, authoritarianism, and tyranny. (Related: Constitutionalism, Federalism, Separation of Powers)

4. Economic Freedom: An open market economy with robust property rights is one most conducive to abundance, prosperity, and social harmony.

5. Democracy: The government governs best when it is democratic and has its decision-makers incentivized to take actions that are in the people’s interest.

6. Methodological Individualism: Society can best be understood when looked at as fundamentally being composed of independent individual decision-makers, not uniformly acting collectives or groups.

7. Liberal Internationalism: Free trade, open immigration, cooperative security agreements, and international institutions are all strong tools for generating a more free and peaceful world. (Related: Cosmopolitanism, North Atlantic Treaty Organization, Organization for Economic Co-operation and Development)

8. Societal Openness: Society thrives when it is defined by openness to difference and change. (Related: Pluralism, Tolerance, YIMBYism, Open-Mindedness, Technological Positivism)

9. Positive Sum Thinking: The world is not a zero-sum tug-of-war between groups; rather, through addressing issues of poorly aligned incentives and overcoming our ignorance, we can achieve true progress toward a freer society. (Related: Emphasis on a Message of Hope, Cultural Optimism, Concern for Questions of Growth and Efficiency)

10. Reason: Trust exists, and it is made accessible through the use of reason. In the face of a complex world, one must reject dogmatism and fundamentalism in the face of a reasonable assessment of the facts. (Pragmatism, Acceptance of Phenomena like Climate Change, Consequential Mindedness)

These criteria are definitive enough to discern rather comprehensively who is liberal and who is not, but not so restrictive so as to clearly preclude one of the two core strands of liberals, with these being classical liberals and social liberals.

The fundamental disagreement between classical and social liberals is on what freedom entails. Is it merely a question of freedom from coercion, or is it more broadly about maximizing people’s ability to have the life they wish?

This difference in accounts allows both classical liberals and social liberals to agree on the above core values while reaching differing views about the welfare state, with classical liberals viewing it as in violation of people’s freedom, and social liberals viewing it as freedom enhancing.

Now, of course, there are also noncore strands of liberalism worth acknowledging. These strands believe that the pure liberal conception is unsustainable, and thus, certain elements of liberalism must be revised so as to form a liberalism that can last.

One of the most notable examples of this type of stance is conservative liberalism, which takes too much openness to change and social transformation as something that could actually undermine the liberal project by tearing away at society’s social fabric. Another example is progressive liberalism, which views inequality as a threat to liberalism and makes an objective out of limiting it, even if that requires jeopardizing a certain degree of economic freedom.

Then, there are groups that have some other ideology but a more liberal variant, such as liberal socialists and liberal conservatives. Expectedly, because these people are not at their core liberals, they will find themselves with greater degrees of disagreement with these propositions.

What’s your liberalism score _/10? Leave it in the replies below!

Authoritarian movements always start under the guise of populism, and they succeed by taking advantage of two of humans’ most problematic psychological imperfections: our desire for simple silver bullet solutions and our tendency to think in tribalistic (us vs them) terms.

Smart authoritarians know these features well and, moreover, know how to exploit them. They paint the world’s issues as fundamentally the fault of scapegoats and their movement as simply the force standing up for the little guy against the evildoers exploiting them.

To drive home their point, they seek to demonize whatever group they are targeting by attributing to them the most wicked of motives, doing whatever possible to make them seem alien, foreign, and “other,” and finding ways to paint them as ultimately culpable for all faults in society. The examples of this are endless. 

The most extreme of leftists will scarcely find a problem they do not believe is the result of the owning class. They attribute nearly every bad government policy to the owning class’s perverting influence. They attribute them the blame for low wages, lack of affordability, wars, the broken criminal justice system, and even the existence of social conservatism and fascism. 

Similarly, the right is addicted to the demonization of immigrants. They want you to believe that the deficit is an immigration problem. High housing prices are an immigration problem. Societal decline is an immigration problem. And on it goes. 

In the mind of an authoritarian, there is no issue that is not the fault of their enemy, and thus, there is no room for thoughts of positive-sum changes, such as those that improve efficiency or increase economic growth. It is no surprise that authoritarians have such an awful economic track record. 

However, cunning authoritarians do not stop at simply attempting to convince people that all their problems lay at the feet of one group. No, that would be insufficient. In their war to remake society in their own image, they need highly motivated soldiers, and more so, soldiers who are not at risk of defection.

They achieve this by maximizing the contrast between the status quo and their perfect future. Never will you find an authoritarian that says something positive about how things are. To do so would be to commit self-sabotage. Rather, like the false messiahs of religious cults, they paint the present with ultimate pessimism as a state of armageddon, collapse, and hell, and they present the new world they and only they offer as a paradise, infinitely better in all respects and nearly divine in its lack of fault or blemish. 

Unfortunately for authoritarians, their ridiculous and absurdly reductionist view of the world quickly collapses upon critical inspection. And this is where the most important element of a successful authoritarian movement comes in: the discrediting of their critics.

In any authoritarian worldview, there is no such thing as a critic who makes a good point. Critics can only be one of two things: victim to the propaganda of the elite or, more commonly, a knowing tool of the elite. To the authoritarian, discourse is a war of ideas, and the elites who have rigged the game have been strategically winning it through an elaborate network of propaganda for a long, long time. Under this view, the goal of authoritarian movements is not to engage productively with the arguments of their rivals—to do so would give them the legitimacy they do not deserve. Rather, it is to call them for what they are: the problem, the ones responsible for destroying society, the liars, the crooks, and the demons that have allowed this injustice to go on for so long. 

This view runs adjacent to the idea shared by almost all authoritarian movements that the people are fundamentally on their side. In their eyes, only by acts of deception or fraud could their authoritarian movement fail to be victorious, and that is why they will never, ever admit defeat in an election, no matter how overwhelming. 

The way to beat authoritarians is to call them out on their bullshit—to forcefully punch through the stream of lies they feed their victims with an even more powerful stream of inconvenient truths. The inconvenient truth that the world is not actually collapsing in on itself, but is, in many ways, getting better. The inconvenient truth that the scapegoat they attribute blame to for causing a problem is not, in fact, the cause of that problem.  And also, the inconvenient truth that the solutions that authoritarians offer to the issues of the status quo are as shallow as their tolerance for opposing views. In other words, nonexistent.

America has some big problems.

Economic growth is slow, real wages are being squeezed by a crisis of affordability, and too many are left in a state where they struggle to make ends meet or, even worse, fall prey to poverty and homelessness.

Our healthcare system is failing to provide everyone with affordable and timely access to the care they need.

Our education system is falling short of equipping the next generation with the skills and knowledge they need to be productive members of society in the 21st Century.

Mass incarceration is leading to incredible amounts of suffering while failing to keep our communities safe.

People are punished by the state for doing the things they want, even when those things don’t harm anyone else.

A debt crisis is looming in our future, fueled by endless deficit spending over decades and unfavorable demographic trends.

Car centricism has leveled our cities and put 100s of millions of Americans in cities that, by all accounts, are unwalkable and bad for their physical and emotional health.

Greenhouse gas emissions are driving forward a climate crisis that will have devastating consequences for the human race.

Our authoritarian foes around the world are emboldened and now capitalizing on our weakness to attack their neighbors and expand their power.

Meanwhile, extremists are turning Americans against one another and sowing division on the basis of race, sex, sexual orientation, class, immigration status, and religion.

None of these problems are unsolvable, and in fact, many of them are easy to fix. In most cases, simply following the evidence would find one with an abundance of policy solutions that are perfectly compatible with the values of the public. Yet each of these problems persists and, in many cases, gets worse; why?

Because our government is broken.

In the face of the crises of the status quo, our government has found itself utterly incapable of effectively solving problems. In fact, in many cases, it is the government itself that has created these problems.

The political system of today is dominated by gridlock, partisanship, propaganda, and special interest group capture. Our political leaders are not incentivized to find evidence-based solutions to our many problems but rather to do what is necessary to maximize their political power, which is often quite different than what is best for society.

This is not a personal moral failing of any one politician but rather a systemic consequence of institutions that are poorly designed for their purpose. Presently, our political institutions promote polarization, and the taking of extreme positions discourages bipartisanship and compromise, leads to laws being rushed and principally informed by special interest groups and politicos rather than academics and experts, is overwhelmed with veto points that provide rent-seeking opportunities, and relies on an election system that frequently gives more of the power to the side with less public support.

It is no wonder our government doesn’t work. How could it, with all these factors working against it? The good news is all of this can be fixed, and most of these fixes do not face insurmountable political hurdles.

Here are some of my favorites:

• Citizens Led Ballot Initiatives

• Approval Voting

  • Which is better than Ranked Choice Voting and more realistic than the best form of voting, STAR Voting.

• Non Partisan Primaries

• Independent Redistricting

• Citizens Assemblies

• Embracing Unicameralism

• Research to Policy Model

• Nerfing the Speaker

• Abolishing the Electoral College

A while back, I shared a video snippet of some of my policy notes on healthcare.

Quickly, I got many requests from people to share these notes, and so, by popular demand, I am finally getting around to doing so. Feel free to leave your questions and thoughts in the replies below. Warning: these notes are *pretty wonky*.

Giving Medicare to Everyone

(X) Universality

• Auto enroll everyone, including the uninsured, those on the individual marketplace, public employee plans, Medicaid, the Child Health Insurance Program, and the group market into Medicare. Auto enroll Veterans Affairs and Tricare beneficiaries into Medicare as well and convert their existing plans into supplements.

Improving Traditional Medicare

(X) Coverage

• Improve Traditional Medicare by adding coverage for drugs, dental, vision, and hearing. In addition, 0 out its premiums.

(X) Payment System

• Provide capitated monthly payments for primary care services, similar to the direct primary care subscription-based model.

• Embrace reference-based pricing for all shoppable services and products.

  • Example:

    “Denmark has a comprehensive, single-payer health insurance system, financed by general taxation and administered at the regional level through block grants. However, Denmark does not regulate prescription drug prices. Instead, the Danish insurance system reimburses for any drug at the lowest price offered by a market participant for a given active pharmaceutical substance. Price transparency is universal; pharmacy prices are posted every two weeks by the Danish Medicines Agency (Lægemiddelstyrelsen). This encourages use of generic drugs. Consumers are free to pay out-of-pocket to use a costlier drug. However, since pharmaceutical companies would lose market share if their prices were too high, they have an incentive to price their products competitively. The Danish Ministry of Social Affairs and Health also has the latitude to choose not to reimburse for drugs in therapeutic areas with a monopoly supplier, though consumers are free to pay for these drugs out-of-pocket.“

• Incorporate, where possible, value-based payment models for non-shoppable services.

• End the defacto 6% commission for drug prescriptions caused by the A+6 formula.

(X) Cost Sharing

• Eliminate deductibles and impose a $3000 out-of-pocket maximum.

• Make preventative medicine and primary care free at the point of use.

• For standard shoppable services, retain the current 20% coinsurance rate, with reduced coinsurance rates available for expensive procedures and for services/products relating to chronic conditions.

• Utilize copayments for unshoppable services, including substantial copays for emergency room visits and hospital visits.

Improving Medicare Advantage

(X) Competition

• Modify the risk adjustment model to take into account the unique cost implications that come from comorbidities.

• Incorporate drug prescriptions and other services into the risk adjustment model.

• Prohibit providers from charging different prices to different insurers for the same service.

(X) Consumer Help

• Impose regulations on Medicare Advantage advertisements that prohibit unsupported claims and require all claims to be presented with data.

• List all Medicare Advantage plans on healthcare.gov.

Lowering Prices

(X) Price Competition

• Require providers to publish all prices publicly in a machine-readable file.

• Strengthen anti-trust action to combat market consolidation among providers

(X) Price Regulation

• Establish all-payer rate setting and central negotiation for ambulances and emergency care.

• Impose federal price caps on monopoly medications (i.e., medication with no plausible alternatives).

  • Example:

    “Holland has a universal system centered around private health insurance coverage. Prescription drug formularies are managed by the insurers under this competitive system. Coverage of some drugs is mandated by the Ministry of Health, which is advised on coverage decisions by the Netherlands Healthcare Institute (Zorginstituut Nederland). While drug prices float based on insurer-manufacturer negotiations, and insurers can increase or decrease deductibles for drugs based on their value, the government protects against monopoly drug pricing by setting price ceilings. Like Denmark and the U.S., generic drugs enjoy high market share in the Netherlands.”

Reducing Low-Value Care

(X) Bad Incentives

• Ban referral-based compensation schemes for clinics and their employees.

(X) Defensive Medicine

• Reform medical malpractice laws by capping non-economic damages.

  • Study:

    The impact of tort reform on defensive medicine, quality of care, and physician supply: A systematic review

Cutting Administrative Costs

(X) Nationalization

• Establish a unified national all-payer claims database housed in a corporatized entity overseen by the Department of Health.

  • Explanation:

    This creates a tremendous resource that can be used to better inform healthcare policy and private action by insurers and providers. Eliminates the need for private independent data gathering.

  • Study:

    Mckinsey Report

• Create a central automated clearing house for all insurance claims.

  • Explanation:

    Eliminates the complexity and costs associated with having multiple private clearing house intermediaries

(X) Standardization

• Achieve national integration of electronic records by requiring mutual interoperability.

  • Explanation:

    Eliminates the frictions caused by a lack of data sharing between different providers and insurers.

• Make healthcare information more accessible to providers by centralizing all plan details into one easily searchable database.

  • Explanation:

    Presently, it’s often unclear to providers what is covered by insurance and what is not, leading to complex back and forths, denials, and appeals. Strengthening minimum coverage standards and centralizing coverage information in a centrally accessible fashion will help minimize these costly frictions.

Expanding the Medical Workforce

(X) Secondary School

• Support the launch of pre-med magnet and charter high schools.

(X) Medical School

• Transition Medical School standard programs to a five-year program that starts directly after high school, with a four-year accelerated program available for undergraduate degree holders

• Invest in substantial expansions in Medical School seats.

• Make it easier for new Medical Schools to launch.

• Require for-profit Medical Schools to abide by minimum admission standards and conditions and a set share of their payment on their graduates passing their medical licensure exam.

(X) Residency

• Eliminate the legislative cap on Medicare-funded residencies.

(X) Other

• Expand the scope of practice for nurse practitioners and physician assistants.

• Provide an accelerated licensure program for immigrant doctors and nurses.

• Establish a federal minimum licensure standard and require that medical professionals who are above that standard be legally allowed to practice in all states.

Expanding the Supply of Providers

(X) Regulatory

• Eliminate all certificate of need laws.

• Eliminate land use restrictions that constrain the supply of providers

(X) Taxation

• Allow providers to expense all investment costs fully.

Promoting Innovation

(X) IP Reform

• Crackdown on copycat drugs and patent trolls.

• Investigate alternative intellectual property models, including royalty-based systems, a harberger tax on intellectual property, and a market-based patent prize model.

(X) Research

• Invest more in public medical R&D and establish an endowment for the National Institute of Health.

• Fully expense all medical R&D.

(X) FDA Reform

• Have the FDA coordinate with other governmental drug approval agencies to organize the mutual recognition of approved drugs.

• Universalize Operation Warp Speed-like treatment for all drug approvals.

• Allow the formation of additional chartered, non-FDA-operated testing institutions.

• Give patients the right to try all drugs shown to not be life-threatening or seriously sickening.

(X) Global

• Establish a global multilateral agreement to finance research on highly contagious diseases and future pandemic risks.

In all advanced nations other than the United States, the government makes an organized effort to control costs, achieve universal access, and promote quality.

They go about achieving this in different ways. There are broadly four different approaches: [1] Socialized Medicine, [2] Single Payer, [3] Managed Competition, and [4] Two Tier.

[1] Socialized Medicine

DESCRIPTION

• Insurance: Public

• Providers: Public / Mixed

In countries that have socialized medicine, both financing and delivery of healthcare are organized by the government. All citizens are guaranteed access to care at low or no cost, with the system funded by taxes.

Public hospitals receive a pre-determined, fixed annual budget rather than payment by insurance for services provided. This practice is often referred to as “global budgeting.”

In the purest forms of socialized medicine, like Cuba, clinics for primary and specialty care are also publicly run. Yet, in other countries that otherwise should be considered socialized medicine, independent primary care and specialist clinics exist and are incorporated within the public system.

Countries with socialized medicine vary in what level of government predominantly manages the system. In Scandinavia, healthcare provision is organized by municipal and regional governments. Meanwhile, in the United Kingdom, the central government plays a much more pronounced role.

Duplicative insurance, i.e., insurance that provides coverage for the same thing the public system provides coverage for, is often restricted. Private supplemental coverage for things not covered by the public system, on the other hand, is usually permitted.

[2] Single Payer

DESCRIPTION

• Insurance: Public

• Providers: Private / Mixed

Single-payer systems feature insurance provided by the government, with usually a mixture of public and private providers. Funding for the insurance comes from taxes or employer and employee contributions. However, in a select few places, like the Canadian Provinces of Ontario and British Columbia, a small premium is charged.

The level of deductibles, copays, and coinsurance depends on the country. In Taiwan, copays and coinsurance are used liberally to cut down on use. In Hungary, there is little to no cost sharing, and the state opts to use care rationing when demand for care outstrips supply.

Not all countries I have classified as single-payer technically have a *single* payer. In some countries, like Austria, there are technically multiple insurance funds that people are assigned to based on variables like region, industry, and employment status. These funds do not compete with one another and are all managed by the state. They also provide the same coverage and operate based on the same reimbursement scheme. For these reasons, there is no practical reason to classify these systems as anything other than single-payer because they operate exactly the same way.

Similar to socialized medicine, duplicative insurance is often prohibited in countries with single-payer insurance, but supplemental and complementary insurance coverage is permitted and relatively common.

[3] Managed Competition

DESCRIPTION

• Insurance: Private

• Providers: Private / Mixed

The most market-oriented of all approaches to universal healthcare managed competition systems rely on a regulated competitive private insurance marketplace. Plans are required to cover a standard government-mandated package of services. Cost sharing is regulated if not completely standardized across plans.

Discrimination against those with preexisting conditions is strictly prohibited. Insurers are required to charge the same price to everyone (except age price discrimination, which is permitted in some places); this practice is referred to as “community rating.” Guaranteed issuance is enforced, meaning insurance companies are never permitted to reject someone who wishes to enroll in their plan.

Because insurers are no longer allowed to charge riskier patients more, a new problem is introduced. Some insurers have, on average, more expensive patients to cover than others, leading them to perform worse through no fault of their own.

To correct this problem, the government establishes risk rebalancing procedures. The most basic of these that all systems employ is called “risk adjustment.” Under risk adjustment, plans that have on-average, healthier patients are charged, and plans that have on-average, less healthy patients are subsidized.

Determinations of people’s health are made using an algorithm that takes into account people’s age, gender, and comorbidities, amongst other variables.

Shopping for insurance is made easier by all of them being available on a centralized marketplace that makes information on the differences between the plans easy to digest. Plans compete on what additional coverage they provide and, in some countries, their premiums and networks.

Cost sharing is common, and insurance plans are funded either by employer and employee contributions or traditional premiums with subsidies provided to those with lower incomes. Some countries have public options, which compete with private options in the insurance market. This is what happens in present-day Slovakia.

Providers consist of a mixture of public firms, for-profits, and non-profits. In some countries, reimbursement rates for providers are centrally negotiated, a process referred to as all-payer rate setting. In these systems, insurance networks do not exist.

In other countries, reimbursement rates are decentrally negotiated, and insurance networks remain.

[4] Two Tier

DESCRIPTION

• Insurance: Mixed

• Providers: Mixed

Two tier healthcare systems are those that feature both an expansive public system and a separate expansive private system. The public system is most commonly a form of socialized medicine, although occasionally, it can be closer to a single-payer or managed competition model. The private system is lightly regulated, with private insurers and providers mostly determining their own policies as they would in an unobstructed market.

To differing degrees, many countries that have socialized medicine, single payer, or managed competition have some extent of an additional private system. For instance, in Germany, 11% of the population receives their health insurance through one of the independent private insurers rather than a regulated sickness fund.

The delineation between non two tier systems and two tier systems is not always the clearest, but for our purposes, I have come up with two criteria:

1. The private system must be a comprehensive alternative to the public system. A private system that just consists of supplementary services to the public system or offers a replacement for some but not all of the public system's functions is insufficient.

2. The size and scope of the private system must be large enough to constitute a genuine option for the majority of the population.

Australia represents the quintessential example of a two tier system.

All Aussies are entitled to coverage under the national health insurance program Medicare. Medicare guarantees access to public primary, specialty, and hospital care, with very low levels of cost sharing.

But in addition to Medicare, as of 2023, 45% of Australians have non-supplemental private health insurance. This private insurance provides them access to an array of health services and commodities not available in the public system.

Two tier systems are often the result of political compromises. In Australia, the tug of war between the Labor Party and the Liberal Party has kept both the public system and the private system alive, with neither overtaking the other.

Both parties seem to have come to terms with its continued existence but with disagreements about what the proper role of each part is.

Labor thinks the public system should be more robust, and private insurance should remain mostly as a thing that only high-income Aussies feel the need to opt for. Meanwhile, the Liberals would say the public system should be limited to a safety net function, with the private system growing in size.

Two tier systems are also common in developing countries, where the government first established the underlying healthcare infrastructure, but as incomes have risen and urbanization has unfolded new private institutions have sprouted up.

As you can see, there are many ways a functional universal healthcare system can be achieved. Denmark, Taiwan, Switzerland, and Australia all have different systems, yet all of them are able to achieve universal access to quality care at an affordable cost to the public.

Despite this fact, these systems are not interchangeable. Each comes with pros and cons, and the appropriateness of any specific approach depends on the context.

I’ll be releasing a piece soon that explains my thoughts on this debate. For now, what are your thoughts? I’m curious to know! Leave your favorite approach and your case for it in the replies. I truly believe that this very critical part of the healthcare debate needs more attention.

People from all over the political spectrum need to know that there is a model of universal healthcare for them. From the market-oriented to the socialistic, there are many paths to the destination of universal healthcare. The question we should be asking ourselves is not whether we should pursue one of these paths but rather which one of these paths should we pursue.