By Sarah Kliff Vox, September 2, 2014 1) Americans pay way, way, way more for health care than anyone else Health care in the United States is expensive. Worst of all Barbie would have to walk on all fours with her 6 inch ankles and size 3 feet that are unable to support the weight of her spider long legs. Barbie’s body and lifestyle tells us a lot about what society believes a woman should be.
As states prepare their budgets for the coming year, they face the challenge of reinvesting in public higher education systems after years of damaging cuts — the product of both the economic downturn and states’ reluctance to raise additional revenues.
States are spending $2,353 or 28 percent less per student on higher education, nationwide, in the current 2013 fiscal year than they did in 2008, when the recession hit. In many states the cuts over the last five years have been remarkably deep.  Eleven states have cut funding by more than one-third per student, and two states — Arizona and New Hampshire — have cut their higher education spending per student in half.
Increased tuition.  Public colleges and universities across the country have increased tuition to compensate for declining state funding. These sharp increases in tuition have accelerated longer-term trends of reducing college affordability and shifting costs from states to students.
But policymakers will need to make sound tax and budget decisions in the coming years if they are to renew state investment in higher education.  Significant investments in higher education in most states may require raising new revenue, as state revenues have yet to recover from the recession and a wide range of other crucial public services also require reinvestment after years of deep cuts.
Conversely, states that enact deep tax cuts will make it much more difficult to rebuild their higher education systems and jeopardize their ability to compete for the jobs of the future. The cuts have resulted from state and federal responses to the deep recession and continued weak recovery. Thanks to the boost in federal assistance, the College Board calculates that the annual value of  grant aid and higher education tax benefits for students at four year public colleges has increased by an average of $1,410 in real terms since the 2007-08 school year, enough to offset over three quarters of the $1,850 tuition increase paid by the average student nationwide.[19]   But since the sticker price increases have varied so much while federal grant and tax-credit amounts are basically the same across all states, students in states with large tuition increases (such as Arizona or New Hampshire) undoubtedly have borne a much higher share of the increased cost, while students in states with smaller tuition increases may have realized net reductions in cost. The University System of Louisiana furloughed 727 employees, laid off another 210 staff and faculty members, and cut 217 academic programs. The University of North Carolina-Chapel Hill eliminated 493 positions, cut 16,000 course seats, increased class sizes, cut its centrally supported computer labs from seven to three, and eliminated two distance education centers. This trend has meant that students have assumed much greater responsibility for paying for public higher education without those institutions receiving more money to fund quality improvements. Reinvesting in public higher education should be an urgent priority for policymakers who are concerned about the long-term economic success of their state and its residents.  Diminished educational resources and rising tuition at the nation’s public colleges and universities have serious consequences for students, their families, and the broader economy. The reduced college access and reduced graduation rates that research suggests are likely to result from budget cuts affect more than just the students, because college attainment has grown increasingly important to long-term economic outcomes for states and the nation.
This research suggests that states should strive to expand college access and increase college graduation rates to help build a strong middle class and develop the skilled workforce needed to compete in today’s global economy.  It suggests further that the severe higher education funding cuts that states have made since the start of the recession will make it harder to achieve those goals.
States may also wish to consider more funding for higher education as an alternative to new tax cuts.  This may be particularly true in a number of states that have made deep cuts to higher education funding and where policymakers are proposing deep new tax cuts that would lock in — even add to — those higher education cuts. Florida governor Rick Scott, for example, is calling for $135 million in business tax cuts at a time when Florida’s higher education funding stands 41 below pre-recession levels, and tuition at its public four year colleges has increased by 67 percent over the last five years.  Other states that have made deep cuts to higher education funding and yet are now considering tax cuts include Idaho, Indiana, Kansas, Louisiana, Nebraska, New Mexico, North Carolina, Ohio, South Carolina, and Wisconsin. Tax cuts are often sold as a recipe for economic growth.  But to the extent that tax cuts prevent investments in higher education that would increase access to college, improve graduation rates, and reduce student debt, their net effect could be a drag on the economy. Economic growth in and of itself will not be sufficient to propel higher education funding to previous levels any time soon.
Carnevale, Nicole Smith, and Jeff Strohl, “Help Wanted: Projections of Jobs and Education Requirements through 2018,” June 2010. Exploring the Impact of Contingent Faculty on Undergraduate Education.” The Review of Higher Education, Volume 30, Number 2, Winter 2007, pp. Carnevale, Nicole Smith and Jeff Strohl, “Help Wanted: Projections of Jobs and Education Requirements Through 2018,” Georgetown University Center on Education and the Workforce, June 2010, p. The beauty ideal we impose on women, to be thin, blond, long legged, big busted and even, foot binded. Notice that Barbie always walks on her tippy-toes.
Her glamorous beach houses, convertibles and clothing subliminally teach little girls from a very young age that consumerism is what we should aspire to.
Dowd, “The Impact of Undergraduate Debt on the Graduate School Enrollment of STEM Baccalaureates,” The Review of Higher Education, Volume 35, Number 2, Winter 2012, pp.
That works out to about one-sixth of the total economy and more than $8,500 per person — and way more than any other country. But here we are decades after she was first conceived, our kids still playing with her, while millions of girls battle anorexia, slut shaming and wondering if being conventionally beautiful is a better path to success than having a career.
If the health-care system were to break off from the United States and become its own economy, it would be the fifth-largest in the world. The circumference of her head would be 20 inches, while her waist would only be 16 inches. She would only have room for half a liver and a few inches of intestine.
An ideal is merely an abstraction whereas real bodies are concrete, genetic expressions influenced by a number of factors.
Her legs would be dangerously thin and 50% longer than her arms, while the average American woman’s legs are only 20% longer. Her waist would be 56% the circumference of her hips, while the average American woman’s is 80%. America's government spends more, as a percentage of the economy, on public health care than Canada, the United Kingdom, Japan or Australia.
The belief that little kids shouldn’t be playing with anatomically correct toys, is merely asserting that kids should be ashamed of their bodies. The reason that American health care is expensive is all about the price: when we go to the doctor, it costs more than when, say, someone in Canada goes to the doctor. From prescription drugs to imaging scans, nearly everything costs more when it's prescribed in America. Take the heartburn medication Nexium: the exact same medication costs $215 here and $23 in the Netherlands. Most other countries have some form of price controls; the government negotiates with drug companies and device makers for lower prices, and the government has the power to win those negotiations.

Many say that our higher spending creates financial incentives for drug companies to come up with wonderful new drugs.
Harvard University's David Cutler points out that we have much higher administrative costs than most other countries — and those costs get tacked onto the bill when we go to the doctor.
The average American doctor spends All those extra billing specialists' salaries have to get paid somehow — and that gets worked into our prices. Lastly, American hospitals tend to throw more technology at health problems — a heart attack, for example, is treated with more scans and tests in America than elsewhere, and that also drives up the price of going to the doctor in the United States. The net price of a heart attack in the United States, then, is more expensive because of the unit price of each service delivered, the more intense treatment and the additional administrative costs of processing the ultimate insurance claim. 2) We pay doctors when they provide lots of health care, not when they provide good health care The best way for a doctor to make money in the United States right now is simple: prescribe treatments.
The American health-care system by and large runs on what experts describe as a "fee-for-service" system. For every service a doctor provides — whether that's a primary care physician conducting an annual physical or an orthopedic surgeon replacing a knee — they typically get a lump sum of money. Apple gets more money when it sells more iPads and the Ford gets more money when it sells more cars.
When patients buy knee replacements, for example, what they're buying isn't really knee surgery itself.
But here's the thing: most American doctors aren't paid on whether they deliver that improved health.
Their income largely depends on whether or not they performed the surgery, regardless of patient outcomes.
Their patient's knee could be good as new or busted as always at the end — but, in most cases, that doesn't factor into their surgeon's ultimate pay. There are certainly many non-financial incentives for doctors to help their patients get better; it's hopefully a big part of why they got into medicine in the first place.
But those intrinsic motivations are often in tension with most doctors' financial interests.
There is a growing movement in health care to change this and tether payments to patients' outcomes.
There are now penalties, for example, if a patient returns to the hospital after something was screwed up the first time. 3) Half of all healthcare spending goes towards 5 percent of the population Americans are not equal health care spenders.
There's a handful of patients who use lots of medical services — and tens of millions of people who barely go to the doctor at all. The lower-spending half of the population, meanwhile, spent a paltry $236 per person during that same year.
They are older and living with multiple chronic conditions, like diabetes and high blood pressure. These are people who take multiple trips to the hospital per year and many prescription drugs every day.
For health-care experts, this spending pattern suggests that the real space to save money is focusing on these high spenders. It would have nurses check up on patients to make sure they took their medications — and it worked. Whether that type of hands-on, labor-intensive intervention can scale up in a big way remains to be seen.
But the spending patterns of the health-care system suggest that the biggest gains are to be made by focusing on the sickest patients. 4) Our health insurance system is the product of random WWII-era tax provisions If you want to understand why we are the only developed country with an employer-based health insurance — really, the only one — then you had better get familiar with the 1954 Internal Revenue Service Tax Code. The 1954 Internal Revenue Service Tax Code is the document in which the federal government codified into law that companies can provide health insurance benefits to workers tax-free. This affirmed a 1943 IRS Tax Court ruling that had also decreed health benefits to be non-taxable. There were overwhelming taxes meant to stop wartime profiteering and keep unions from shutting down production to extract wage gains. But when health care was protected from these taxes, it immediately became incredibly valuable to workers, and companies were able to keep it tax-free even after the war. The result is that a dollar in health benefits is worth more to a worker than a dollar in wages, because the dollar in health benefits is untaxed and the dollar in wages is taxed.
The majority of non-elderly Americans get their health insurance at work, and with good reason: the tax-free dollar can buy a lot more medical care. As a rule, people who have jobs that offer healthcare benefits are paid more than people who don't have jobs that offer healthcare benefits — or who don't have jobs at all.
In short, we've created a tax system where the people with good jobs are getting their health care subsidized by the people with worse jobs or even no jobs. But partly, it's because employees usually don't know the real prices of their health benefits.
Though ultimately economists believe that the money employers spend on health benefits comes from the money they would have spent on wages, workers don't feel the direct cost of their health-insurance choices, and so they have little reason to try to keep spending low.
Doing away with the tax exclusion might seem like a no-brainer, but it's very politically difficult.
It would mean a huge price increase on employer-sponsored insurance, which is not a popular platform to run on (John McCain got nailed for suggesting capping, not eliminating, this particular tax exclusion). Know as the "Cadillac tax," this fine will hit any insurance plans that cost more than $10,200 for an individual or $27,500 for a family.
That tax is meant to push back against the too-generous plans that the tax exclusion encourages.

What the Cadillac tax does not do is eliminate the tax-exclusion for employer-sponsored coverage. Instead, it puts a dent in a 60-year-old policy — one that was set up with little forethought and is pretty much universally derided by health economists on both ends of the political spectrum. 5) Insurance companies have small profit margins Health insurance companies are an incredibly easy target for any antipathy towards the American health care system. They're the ones that deny claims for the care that we want, but still charge an always rising premium for their coverage. But here's one fact about insurers that often gets lost in the debate over health care: their profit margins tend to be relatively small. Having hundreds of different carriers, for example, means no one insurer has lots of negotiating power — hence those high prices drug and device makers can charge. This suggests that tamping down on insurers' profits won't do much to tamp down on overall healthcare costs.
They're not pocketing a large amount of premiums; instead, they're spending those premiums on a really expensive medical products. So now's as good of a time as any to take a short breather and be thankful for how well the airline industry works. 6) Getting health care in the United States is dangerous We don't know exactly how many Americans are killed in hospitals each year, but we do know that it is a lot. In 1999, the Institute of Medicine published a seminal report titled To Err is Human, which estimated that at least 44,000 patients — and as many as 98,000 — die in hospitals each year as results of medical errors.
Blumenthal remembers, shortly after the landmark IOM report came out, trying to start up a consulting business that would teach hospitals how to reduce errors. It was sobering, and it made clear that abstract data was not going to change the behavior of complicated health care institutions." And on their own, patient deaths are small events that often happen with little notice or fanfare, making them less noticeable than other events.
Even if it couldn't get to each and every case (there are thousands more patient deaths than airplane accidents), it would create some federal oversight that, right now, does not exist.
7) One third of healthcare spending isn't helping The United States spends $765 billion annually (about one third of our overall health care dollars) on things that do not make Americans any healthier.
That requires lots of billing staff: for every three doctors in the United States, there are two administrative staff to handle all the paperwork.
In addition, there's unnecessary care: of the $765 billion wasted each year, the Institute of Medicine estimates that $210 billion is spent on medicine we don't need. Researchers have known for decades this isn't an effective treatment, but nearly three-quarters of doctors do so anyway. Those prescriptions are actively harmful, as overuse of antibiotics can speed up the creation of deadly, antibiotic-resistant superbugs. Wasteful spending doesn't just mean extra dollars put towards health care — in cases like this, it also means worse care.
Unfortunately, most situations of waste aren't as easy to recognize as the overprescribing of antibiotics.
At many appointments, doctors have difficulty knowing when treatment is needed — and when it won't provide help at all. The medical community tries to address these issues with comparative effectiveness research.
As the name suggests, these studies compare the effectiveness of one treatment against another for a given patient population. Many national health insurance programs use comparative effectiveness research, for example, to decide which drugs they will cover, aiming to pick the medication that gives the best results at the most affordable price. Study methods can be faulty and results contradictory; one drug might work great for certain patients but terribly for others. When the government, for example, recommended lowering the frequency of breast cancer screenings — more screenings, decades of research had found, didn't save any more lives — there was public outcry.
And that's one of the really tough issues with cutting down on waste in medicine: there are lots of healthcare treatments that we want, even when it might not actually be health-care treatment that we need. 8) Obamacare is not universal health care The United States does have a very recent, very large expansion of health insurance coverage — that's the program we all call Obamacare. Obamacare doesn't eliminate uninsurance in America; instead, it cuts the number of people lacking coverage about in half. Even after Obamacare is fully implemented, budget forecasters still expect that 31 million Americans will lack insurance coverage — a bigger group than the people buying coverage on the exchanges. This group includes people who are locked out of the insurance expansion and those who do have access but decide not to participate. Among the groups left out of the healthcare law are undocumented workers, who are not eligible to purchase any healthcare plans from the new insurance exchanges, and people who live in states that are not expanding Medicaid. For a sense of how big a population that is, the 10 largest states not expanding Medicaid are leaving out an estimated 3.6 million low-income residents. There will also be millions of people who do have access to health insurance, maybe at work or through the new exchanges, but decide not to enroll. Maybe they think its too expensive — lots of shoppers felt that way during's open enrollment — or maybe they don't think health insurance will help them. This will continue to set the United States apart from most other industrialized nations, in which universal coverage is the standard. And it means there will still, in decades to come, be people who can't afford health insurance.

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