584 Vetoes

Howdy folks. Today we’re talking with Lawson Mansell of the Niskanen Center about why we don’t have more physicians in America and answering listener feedback about subsidizing drug innovation.

Lawson is the author of Healthcare Abundance: An Agenda to Strengthen Healthcare Supply, a recent report detailing worthy changes to the often-neglected supply side of America’s healthcare system.

Lawson walks us through Medicare’s Graduate Medical Education (GME) cap, established in 1997, which limits the number of residency positions that Medicare funds at teaching hospitals. Aside from a recent increase in 2021 of 1,000 new slots, the number of Medicare-funded residency slots has been frozen at 1996 levels for decades.

Doctors in America are required to complete an accredited residency program in order to obtain a medical license. A shortage of residency slots means even qualified medical school graduates cannot complete their required residency training without an available position.

We discuss the legislative history of how the system developed, what is keeping it in place, and what kind of reforms might be able to increase the number of physicians in America without breaking the budget.

What’s in the Episode

[0:23] - Introducing our guest Lawson Mansell, health policy analyst at the Niskanen Center and author of Healthcare Abundance: An Agenda to Strengthen Healthcare Supply.

[1:10] - An overview of Lawson’s report on improving the supply of healthcare in America

[3:32] - Why aren’t there more physician-owned hospitals?

[6:37] - What is standing in the way of America creating more physicians?

[8:19] - The importance of residency programs on the limit of new physicians

[10:09] - What it takes to become a doctor in the United States

[11:30] - How the system has changed since the 1970s

[12:19] - How the government determines how much to pay for the residency system

[13:38] - Why did the government believe in the 1980s that we were going to have too many doctors?

[16:20] - A discussion of the cap on the number of residency slots that Medicare pays for

[19:00] - Do we solve the problem by just increasing Medicare funding for residency slots?

[21:00] - The residency payment mechanism, determined by DME and IME payments, should probably be re-evaluated

[23:18] - Details about the policy proposal to change the residency funding into a uniform per-resident amount

[27:33] - Discussing international medical graduates

[34:50] - Overcoming resistance by interest groups

[37:07] - Listener feedback inspired by Episode 1: If negotiating prescription drug prices downward negatively affects innovation, shouldn’t we be paying much more for prescription drugs? Where is the line?

[42:49] - Veto of the week: “An act for the promotion of anatomical sciences and to prevent the desecration of graves.”

[44:38] - Send us your feedback or policy questions by emailing [email protected] or finding me on Twitter @TomVChurch

Relevant Sources and Numbers from the Episode

* Healthcare Abundance: An Agenda to Strengthen Healthcare Supply

* Health Affairs article on the ACA’s effect on the formation, expansion and operation of physician-owned hospitals

* SSRN paper on reconsidering the ban on new physician-owned hospitals

* Senator Lankford bill to reintroduce physician-owned hospitals

* AAMC report projecting shortage of 86,000 physicians by 2036

* CMS pays about $180,000 for one residency slot at a hospital

* 1981 Graduate Medical Education National Advisory Committee (GMENAC) report predicting a surplus of 70,000 physicians by 1990

* Recent increase of 1,000 new residency slots in legislation

* 2020 forecast of the physician workforce shortage in the United States by state

* Robert Orr’s report “Unmatched: Repairing the U.S. Medical Residency Pipeline”

* Migration Policy Institute report on the number of available immigrant doctors and medical professionals

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Howdy folks. Today we’re trying to figure out if Elon can identify $2 trillion to cut from the federal budget plus answering listener feedback about cutting foreign aid and fixing government bureaucracies.

What’s in the Episode

[0:52] - The goals of Elon Musk’s Department of Government Efficiency. Can it cut $2 trillion in the federal budget? Danny breaks down the $7.0 trillion FY2025 federal budget.

[3:51] - What is the Dept of Govt Efficiency unlikely to cut?

[8:18] - Early (gimmick?) programs identified by Elon and the Dept of Govt Efficiency

[10:57] - Where could the Dept of Govt Efficiency look for ideas to cut federal spending?

[14:09] - How much would Trump’s deportation plan save (or cost)?

[19:17] - Are reductions in tax expenditures on the table?

[24:20] - How much waste, fraud, and abuse is there and how much can be cut?

[25:08] - How much of the Inflation Reduction Act can be clawed back?

[27:31] - How much can be cut from health care spending?

[31:13] - A discussion of “easy to do” arithmetically versus politically

[34:13] - Predictions of the bottom-line spending and deficit numbers in Trump’s first presidential budget

[38:06] - Feedback #1: “How much in our spending bills are actually going to other countries outside of America.”

[41:41] - Feedback #2: “American bureaucracy is out of control. What can we do to control it?” Can we follow Milei in Argentina’s lead?

[47:21] - Veto of the Week: Cleveland predicts cost overruns. Plus, Danny explains why we named the show “584 Vetoes” and why we should all hope Trump becomes Cleveland 2.0.

[50:06] - Send us your feedback or policy questions by emailing [email protected] or finding me on Twitter @TomVChurch

Sources Mentioned in the Episode

* CBO’s June 2024 Budget & Economic Outlook. Table 1-1 is a good starting point.

* Skepticism from Matt Yglesias on cutting large parts of the budget.

* America PAC’s $900 billion taxpayer dollars wasted includes the net interest on the debt.

* NIH grants that sound silly

* GAO finds $236 billion in improper payments in 2023

* Veronique de Rugy’s suggestions for cutting $2 trillion in government spending

* A recent list of the largest tax expenditures

* Center for Immigration Studies estimate of the cost of illegal immigrants

* Report that Trump might try to kill the $7,500 EV tax credit

* Paragon Institute plan on Medicaid FMAP financing reform

* Paragon Institute study on Medicaid fraud

* Marc Goldwein’s $2 trillion in spending cuts (over ten years)

* CBO Options to Reduce the Defict

* White House Historical Table 3.2 - International Affairs and Defense - Other are the rows to focus on

* Peterson Foundation article on foreign aid

* USJFCOM, no more

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit church.substack.com

Howdy folks. In this episode Danny and I preview all of the big provisions of the Tax Cuts and Jobs Act (TCJA) that will either be extended or allowed to expire at the end of 2025.

If you’d like a written summary plus all of our sources, I pulled them together here.

Disagree with us? Send us your thoughts in the comments or by email at: [email protected]

What’s in the Episode:

[1:06] - The Parts of the Tax Cuts and Jobs Act (TCJA) Expiring Next Year

[2:13] - The Personal Income Tax Changes

[7:00] - Context on Fiscal Cost of Extending the TCJA for Ten Years

The federal debt is expected to increase by $20 trillion in ten years (which already includes the $4.6 trillion cost of extending the TCJA)

[8:37] - The Standard Deduction and Personal Exemption

One of the better changes in the TCJA, in our opinion.

[14:13] - The Child Tax Credit

[20:18] - Alternative Minimum Tax (AMT)

Think about reforming instead of full extension?

[25:58] - State and Local Tax (SALT) Deduction

Should it change to different amounts based on married or single filers?

[30:04] - Mortgage Interest Deduction

[34:00] - Qualified Business Income (QBI) Deduction

[38:58] - Full Expensing / Accelerated Depreciation for Businesses

[42:07] - Estate and Gift Tax

[45:50] - Discussion of Permanent Corporate Tax Rate

[46:56] - Can Elon Musk Cut $2 Trillion from the $7 Trillion Federal Budget?

[47:56] - Veto of the Week!

[50:36] - Call for Feedback

Send an email to [email protected]

Find me on Twitter @TomVChurch

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit church.substack.com

Howdy folks, today Danny and I attempt to call out one positive aspect from each presidential candidate’s campaign promises.

It was more difficult than we thought.

What’s in the Episode:

[0:02] Opening chit-chat

Danny’s Dodgers make a run in the World Series

Tom recounts his first experience working on a Lemons car

[1:45] Are there any good policies in either of VP Harris or former president Trump’s campaign proposals?

Danny highlights the EITC expansion from Harris and Trump’s proposal to pull back the energy/environment tax credits in the Inflation Reduction Act (that was Tom’s too)

Updated CBO score on cost of energy/environment tax credits here and here, showing CBO off by $437 billion(!) over ten years

Tom tries to spin Harris’ proposal to increase the NIIT/additional Medicare tax on high income earners, but fails the ideological Turing test

We, like everyone else, want to highlight CRFB’s scoring of the Harris and Trump plans

[21:30] New Reports! New Data! Kicking people off of Medicaid

We talk about early results of unwinding Medicaid eligibility following the expiration of Covid rules that prevented people from being kicked off

The Health Affairs piece we discuss is: “Resumption Of Medicaid Eligibility Redeterminations: Little Change In Overall Insurance Coverage”

Key lines: “It appears that for many people, the availability of employer-sponsored insurance and other private coverage offset Medicaid coverage loss. These results suggest that the resumption of redeterminations has had less impact on uninsurance than was initially feared.”

We talk about existing problems with underreporting in surveys due to people not knowing what they’re eligible for or already enrolled

We discuss the results to the Oregon Medicaid Experiment

CBOs Federal Subsidies for Health Insurance report

[33:18] I Read a Thing: Why you should prioritize policies that promote long-term growth

Noah Smith on long-run growth: “In the very long run, economic growth is everything. Global GDP has grown at about 2.68% since 1820. If it had grown at only 1.68% instead — just one percentage point less — the human race would be only 37% as rich as it is now, with a per capita GDP of about $6145 instead of $16,677. As Tyler Cowen writes in his book Stubborn Attachments, this means that if you can find some policy that will increase long-term growth, you should do it.”

Danny recounts his time with the Jeb Bush campaign and its goal of 4% growth

[37:56] Let’s Tell People on Twitter Why They’re Wrong

Why isn’t car insurance like a retirement fund or a savings account?

[40:25] Veto of the Week

The one where Cleveland denies an expansion of benefits for a veteran who shouldn’t have been receiving a pension in the first place.

[43:15] Send Us Feedback to Read on the Show

Have questions for us? Want to test out an argument? Do you want to check if something you heard on the internet is true? Let us know!

Send an email to [email protected]

Find me on Twitter @TomVChurch

Howdy! Thanks for reading and listening. Subscribe for free to receive new episodes and get more information at church.substack.com

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit church.substack.com

Howdy folks - Welcome to the first episode of 584 Vetoes, a new podcast I’m doing with Danny Heil.

This week we’re discussing why price controls and “using the government’s size to drive down prices” aren’t the simple solutions in health care that they appear to be.

It’s our first episode, so we’d appreciate your feedback or questions for future shows. Email us at: [email protected]

Why “584 Vetoes?”

Our favorite president is Grover Cleveland, who vetoed an incredible 584 bills in his two non-consecutive terms as president. (We enthusiastically recommend A Man of Iron: The Turbulent Life and Improbable Presidency of Grover Cleveland by Troy Senik to learn more.) We appreciate his stubborn approach to government spending and his principled stand against those who disagreed with him - even among those in his own party.

We’re trying to get the word out about our new podcast. Please help us out by sharing it with your most politics-obsessed friend.

What’s in the Episode:

* [1:53] Show Topic: “Is It Time to Consider More Regulation in Health Care?”

* We respond to this JAMA article by Sherry Glied and Amitabh Chandra

* I mention NASA’s SLS rocket versus SpaceX’s reusable booster

* Danny cites our earlier public option research with Lanhee Chen: “The Fiscal Effects of the Public Option”

* Danny cites more of our state public option research: “Promises Unmet: The Early Experiences of State Public Option Plans”

* [24:21] New Reports / Data

* We discuss CBO’s “Alternative Approaches to Reducing Prescription Drug Prices”

* Hoover’s recent healthcare conference in its Washington D.C. office

* Here’s H.R. 3 that would have created international reference pricing

* Gilead’s Hepatitis C drug, competition, and authorized generics

* [39:00] Interesting Polls

* Gallup Poll: Majority of Americans Feel Worse Off Than Four Years Ago

* The key detail hidden in the post: 72% of Democrats said they were better off and only 7% of Republicans said they were better off

* Danny gets pedantic and explains what “the second derivative of the price level with respect to time” means.

* [42:52] Veto of the Week

* Grover Cleveland’s first veto: “I hereby return without my approval House bill No. 1391, entitled ‘An act to provide for the erection of a public building at Springfield, Mo.’”

* [45:18] Send Us Feedback!

* Have questions for us? Want to test out an argument? Do you want to check if something you heard on the internet is true? Let us know!

* Send an email to [email protected]

* Find me on Twitter @TomVChurch

Howdy! Thanks for reading and listening. Subscribe for free to receive new episodes.

This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit church.substack.com