Enforcing Bans on Forced Labor in Xinjiang 2023

WM Trade: Modernizing Customs Policies to Protect American Workers and Secure Supply Chains, March 25, 2023

Sadly, my comments from 2020 still largely apply regarding both China and the U.S. labor markets. The only real change is that China’s Belt Road, like the rest of its economy, is collapsing. This affects the leverage the developing world has, but may increase ours - although that is also a danger.

WM Trade,  Enforcing the Ban on Imports Produced by Forced Labor in Xinjiang, September 17, 2020 

Boycotting the products of slavery worked in fighting the Confederacy. The mass migration of slaves had more of an impact. A boycott of Xinjiang cotton and tomatoes is problematic during a pandemic, but generally it cannot succeed as a stand-alone action. Even though it may hurt in the short run, we should still do it. 

To make a boycott work, we cannot do it alone. At minimum, Islamic nations must join in as well and start linking the cause of the Uyghurs to the New Silk Road. The ethnic Turkmen range from modern Turkey to Xinjiang, so a little solidarity on their part could go a long way. If we do go this route, the whole effort to interfere in Iran must end. We cannot be with South Asian Muslims on some things and expect solidarity with them on others.

2020 only: I doubt current American foreign policy is nimble enough to adapt to such a change. If it cannot, then we must bow to Realpolitik and accept that Xinjaing is part of the Chinese sphere of influence, just as Ukraine is part of Russia’s. (until the invasion - although there may be a lesson here.)

On the moral front, I am not sure we have room to talk. We hold migrants in stark conditions prior to deportation. If you doubt it, visit Lewisburg Federal Prison. Also stop in the Federal Prison Industries factory while you are there. Visit any food processing plant with large immigrant workforces (send people undercover) and see how many workers were trafficked and how local law enforcement reacts when they decide they want to leave. Examine the plight of sex workers in the United States and see how many of their pimps have arrangements with local police.

Our best weapon is our example. As long as slavery exists in the United States, our moral voice is compromised. Again, I am not saying to ignore this situation. I am saying to All In to really fight slavery. Also, call it slavery. On the same subject, examine the Chinese treatment of peasant workers at their factories. There is a two-level society, and American consumers benefit from this. Our commitment to abolishing slavery cannot live only in the fringes.

Government Overreach and Dysfunction

HBUD: Reigniting American Growth and Prosperity Series: Removing the Burdens of Government Overreach, May 24, 2023

Public Administration scholarship features two paradigms related to this hearing: issue networks (aka Iron Triangles) and regulatory capture.

The first tells us that there is a symbiotic relationship between congressional subcommittees (both authorizing and appropriating), agencies and the corporate/contracting/advocacy sector. In other words, if the government is overreaching or, as is more likely the case, under-reaching or performing badly, it is because the system won’t let it perform well.  The Budget Committees have the misfortune of dealing with OMB and competing with the appropriation, revenue and authorizing committees while serving no particular industry sector except the most partisan political organizations. This is not a recipe for success.

The second is that for any regulatory agency to succeed, it must be captured by the industry it regulates. If it is not captured, it is constantly under attack. This can be a problem for such agencies as the Securities and Exchange Commission and the Commodity Futures Trading Commission because under-funding has led to federal personnel not being able to understand the world of the quants, since the quants are usually attracted to industry, not government. 

In the end, this leads to the inevitable collapses of the financial markets. Cryptocurrency’s rise and fall is the perfect example of this. Of course, sometimes, when arrangements are overly complicated, it is because they are fraudulent. Such was the case with credit default swaps in 2008.

Government is not the problem. It is unrestrained capitalism. The only way out is public finance of political campaigns, but with a twist. Parties should be the sole conduit of money and it should be evenly split during the primary season at a caucus where the candidates bring their supporters, with anyone getting over 15% attendance making it into the funding pool - with both ballot access and equal campaign dollars.

The basic premise of the series is that growth is anemic. My advice is to find someone else to do your stock picks, as growth is not anemic and it won’t be as long as housing prices take a soft landing rather than the kind of price collapse that occurred in the Great Recession. Had what Mr. Paulson had promised to be done - that is, bailing out borrowers rather than lenders, people would have kept their homes and the crisis would not have evolved into a Depression.

A depression is not just a bad recession. It is what occurs when asset prices are below the level at which they are financed. We may be headed there - but I hope not. The pandemic provided bailouts to the housing finance sector, which was full of junk that was about to crash anyway - which would have left Secretaries Mnuchin and Ross in quite the pickle, as they are heavily invested in single family homes, which they borrowed against - creating bonds that are basically of 2008 quality.

The iron triangle strikes again.

The recent oil shocks have been priced out of the market. Prices have begun to decline as inflation is no longer compounding. It still drives inequality, however, as prices chase the median dollar, not the median income family. If this were more widely known, the public would demand higher taxes on the wealthy and equal dollar inflation adjustments, rather than equal percentage cost of living adjustments.

Ultimately, growth is driven by the government. Public sector jobs, contracts and benefits are the first order yeast that drives private sector jobs (second order effects) and investments in plant and equipment (which are third order effects that have nothing to do with the markets. 

Both parties are captured by the rich and reward failure by allowing capital gains losses to offset wage and salary income. They drive inflation, as they pay percentage based wage adjustments. The President’s promise to hold 99% of households harmless in tax policy has concentrated the pain of tax increases to the only class of people with enough funds to fight them. Also, not raising taxes on the next 9% is inadequate to pay interest on the debt and balance the budget. This anemic tax performance builds investment accounts too such an extent that they contain junk that is rated as AAA. This risks another financial crisis.

Finally, let us look at the various items of government that do not overreach:

Aerospace

Roads and bridges (formerly inadequately funded)

Social Security (inadequately funded) 

Space exploration (inadequately funded - which is embarrassing)

Agricultural regulation (which is good at tracing food safety issues but not good enough to prevent them for occurring)

The Federal Reserve System and financial regulation agencies (which are too friendly to junk capital)

Transportation safety and air pollution from cars (which is totally captured by industry)

National Institutes of Health

There is some over-reach that should be identified

United States Postal Service - whose only problem is its pension burden to fully fund in order to force it into defined contribution arrangements which reward the financial sector)

The IRS, which can be eliminated by having the SEC collect an asset value added tax, while states collect credit invoice and net business receipts taxes - which are the Fair Tax without the dysfunctions of financial speculation and the inadequate funding of family support

The Intelligence Committee - which sadly must overreach, given the recent history of organizations such as the Oath Keepers and the Proud Boys - who are fascist revolutionary elements of the MAGA movement

The Drug Enforcement Administration, which fight all efforts at legalizing cannabis

National Science Foundation (which drives academic research toward private profit but at pay rates too low for graduate assistance and post-doctoral fellows to survive comfortably - even when Universities would rather pay them a decent amount)The military industrial complex, which demands higher security for personnel than is needed as well as the kind of bloat, as well as global deployments, which many see as unnecessary in peacetime.

I hope this brief tutorial was helpful. I suggest sending staff to some kind of senior political service training, which should also be available to members of Congress and administrative appointees, who are in desperate need of it.

Let's talk about currency & companies and peas & carrots....

American capitalism is backed by mutual, insurance, pension, retirement savings and deposits in Federal Reserve Banks and their loan portfolios containing Treasury Notes and Bonds. China and Japan also hold bonds so they can trade with the US. Other overseas bonds are held by capitalists in tax havens - lots of whom are American billionaires. The top 1% hold half the mutual and bond holdings and 25% of longer term assets. families making less than $150K per year (this includes retirees, not so much for most workers) hold about a quarter of the bonds and mutual funds and less than half of the long term investments. Those with incomes between $150K and $500K hold the remainder - roughly a quarter of the debt held in any account. Those are the people who will later hold all of the assets retirees hold. 

People who labor have nothing. Not even cash. They are owned by capitalists. They do not own capital. The only thing they do own is their share of the debt held by the Social Security and Medicare Trust funds. These are the funds the GOP wants to force more money into from workers. 

What is my source for this analysis. The Survey of Consumer Finance held every three years by the Federal Reserve. Last reported survey is 2019 (pre pandemic). There was a survey gathered last year that will be reported about a year from now.

The GOP members and staff who are playing with debt default are essentially putting their donor base at extreme risk. They are either bluffing or stupid. My guess is the latter.

Tax Incentives in Inflation Reduction Act/Green Corporate Handouts and CCP

Finance: Tax Incentives in the Inflation Reduction Act: Jobs and Investment in Energy Communities, May 18, 2023

I am repeating my comments to Ways and Means of April 19th on the U.S. Tax Code Subsidizing Handouts and the Chinese Communist Party. The subject matter is the same in many respects, but the irony is thick.

WM: U.S. Tax Code Subsidizing Green Corporate Handouts and the Chinese Communist Party, April 19, 2023 

The Climate Crisis is real. It did not go away because La Nina rain events started again, likely due to the Tongan volcano disrupting the El Nino cycle. The fact that El Nino was stuck is likely due to climate change, however.

Florida is not saved by the new rains. Indeed, these have made coastal flooding caused by rising sea levels worse. That sea levels have risen due to arctic ice melt is definitely an artifact of global warming. If someting is not done, even The Villages will be under water before the century is out.

From comments presented to the Finance in April of 2021, on Climate Challenges On warming in general, there is no doubt that it is man-made. While there was a warm period around the first millennium, we came to it gradually. Industrialization may have ended what is called the Little Ice Age, but that warming is sudden and has dire consequences. We do not know that it will stop the way it did in the Middle Ages, indeed, it is not likely to, which makes these hearings vital.

Starting with the coasts, there will be sea level rise. Indeed, the flooding shown in Vice President Gore’s latest film shows how bad it is getting. The wealthy don’t seem to care, because they have flood insurance. The most basic step to at least get wealthier taxpayers on board (including the upper-middle class) is to cap flood insurance benefits to a level where beach houses properties  can no longer be insured. Even that small step could never be enacted. Too many donors have beach houses.

This is a bigger problem for some than the catch of the day, particularly in the Indo-Pacific region. In comments to the Finance Committee on Strategic Climate Engagement in the Indo-Pacific Region in March 2022 Warming in the United States is merely inconvenient. In the Indo-Pacific region, it will be deadly. Island nations and Bangladesh will simply be eliminated. This constitutes a large share of the global population. Java has 154 million people in the same space that the United States has 53 million in the Boston-Washington urban cluster. Visualize relocating them.

We agree that the current tax benefits for electric cars and renewables are the wrong approach. That does not mean that the oil and gas companies deserve a free pass, as I discuss below. There are alternatives that do not rely on Chinese wind turbines or solar panels. To be clear, the reason China produces these things is because their labor is cheap. It is so cheap that they are likely to have a Marxist revolution where the peasants rise up against the Communist Party.

Of course, such revolutions are stuff of myth. Without determined leadership, there are no peasant uprisings. Middle classes revolt, not workers. The Chinese economic revolution is creating a middle class as peasants in the countryside become peasants in the city, but without urban rights. One must actually own a home to have rights within the cities to health care and other human services. It harkens back to early America, where only White male landholders could vote. 

As the Chinese middle class grows, it has not been added to the Communist Party. This will result in a revolution against it. Corrupt parties find it hard to broaden the base. If they were to do so, Chinese leaders would develop a sense of humor, which is absolutely necessary to go beyond tyranny and into freedom. The Party will either modernize or be overthrown. Its recent rollback on Covid testing shows that it has become sensitive to keeping its middle class happy. Now that there is blood in the water, evolution or revolution is certain.

China makes solar cells and turbines because its labor is cheap - although it will not remain that way. Other nations will be cheaper soon, although hopefully they will be advised by someone other than the International Monetary Fund so that their populations can more eailiy develop into consumer societies with empowered workers.

China has pulled back on the Belt Road initiative. It has its own financial crisis so, instead of extending new credit, it is turned into a debt collector. Were it not for a desire to sell consumer goods (and solar panels) to the United States, it would sell its supply of Treasury Bills.

Let me emphasize this. Goods sold in WalMart and solar and wind energy systems have the same profit flows to the soon-to-be-overthrown Communist Party. To condemn one and not the other DOES NOT EXACTLY DEMONSTRATE CLEAR THINKING BY THE NEW MAJORITY.

The solution to both problems is tax policy. Not repealing the Biden tax policies favoring renewable energy, but our allergy to conforming to tax policy in the rest of the developed world. These policies are a boon to consumers, especially wealthier consumers who are also donors. They are  not so good for workers.

 If the United States had a goods and services tax, the wealthy elite could not avoid taxation by borrowing from their asset portfolios to fund consumption. To end this tax dodge, tax consumption. Taxing asset value gains at sale rather than taxing end of the year results also leaves money on the table, but that is a discussion for another day. Please see our paper on taxes and trade policy in the first attachment for how credit invoice AND subtraction value added taxes will impact both trade policy and workers. The second attachment lays out our entire tax proposal.

The Biden energy provisions are not even a drop in the bucket. They were a (successful) olive branch to Senators Sanders and Markey. Not much more. 

Burning gasoline has taken us over the line on warming, catching up with coal. The burning of coal, especially by China, creates acute pollution - the kind that gave me asthma when I lived downwind from an Ohio Edison Plant in Dayton, Ohio and the kind which your grandchildren will get if we continue to burn it. Coal is also a radiation danger. It turns out that when coal is burnt, more radioactive material is added to the environment than the entire nuclear power system emits.

Increasing nuclear power is an environmentally sustainable path, but it will only occur when the demand for more electricity rises as we move away from using gasoline in our cars. Getting this enacted is as likely, for now, as improving environmental and labor trade enforcement and limiting flood insurance. 

Employee-owners and forward thinking communities can step in where the market will not. In testimony to the Energy and Water Appropriations Subcommittee, I describe an experiment to build an integrated system for providing electric power for cars and trucks, while reinventing the grid, that relied on overhead roof decks to transfer power to vehicles in the same way electric trains and buses work. Please see an excerpt in the attachments. 

We don’t need to drill for or export more oil. We need much less. Electric vehicles run on roof covered overhead power lines (and with control from central computers) end the need to burn gasoline in urban areas WITHOUT the use of questionably resourced lithium ion batteries and without the need to expand our electric grid into the wind or by catching a ray of sunshine. Technology from 100 years ago, combined with the latest in nuclear energy can both clean the air and cool the planet down, and do so much more quickly than the entire Biden energy portfolio.

Attachment: Trade Policy Video

Attachment: Tax Reform Videos included

Attachment: Energy and Water Resources FY 2024

Rural Healthcare/Tax Exempt Hospitals and Community Benefit Standard

Finance Health: Improving Health Care Access in Rural Communities: Obstacles and Opportunities, May 17, 2023

The access to healthcare theme for rural hospitals in the post-Dobbs world seems especially relevant.

The ultimate answer for rural healthcare is to send people from rural areas to medical school and nursing school (and to develop career ladders to both) and have the local hospital systems pay the tuition and living expenses in exchange for a period of service. This solves the human capital problem in healthcare, but not the general loss of rural population which is the story of the last 100 years. 

Employee-ownership of companies who provide healthcare services directly rather than through third party insurance will assure everyone has care, however this may or may not save rural areas if there is nothing to keep people there.

What we should not do (and stop doing) is to force vulnerable low-skilled workers into the healthcare field at low levels just because we have the power to do so. There is a term for that. Slavery.

In prior years, when religious organizations ran hospitals… They were trusted to provide for the poor. In some cases, it was in the name of the religious order, such as The Sisters of Charity or The Sisters of Mercy…

WM Oversight: Tax-Exempt Hospitals and the Community Benefit Standard, April 26, 2023

While there is no reporting data to show whether non-profit hospitals measure up in providing charity care during the pandemic, had they not been doing so, it would have been noticed as the entire sector was under a microscope.

Regardless of whether the IRS has audited these hospitals, they are still required to have internal compliance audits as to their financial stability and integrity, which would include meeting legal requirements.

In prior years, when religious organizations ran hospitals, the need to monitor charity care performance was not required. They were trusted to provide for the poor. In some cases, it was in the name of the religious order, such as The Sisters of Charity or The Sisters of Mercy.

With the decline in vocations, many of these hospitals are under professional management. Certain hospital CEOs at Catholic hospitals have been reported as having CEO level salaries, which many have considered scandalous, especially given how they have been run. Although independent auditing will review legal requirements, the CEO culture is known for hiding inconvenient information.

It is important to add a further check on charitable compliance, as professionalism in business is often synonymous with amoral behavior. This is why our recent CEO president failed so miserably in an office that requires moral authority rather than the seeking of personal gain by the executive class.

This need is all the more reason why the IRS needed, and still needs, a larger enforcement budget. Even with additional budget authority, the agency is short staffed.

As far as community service...

... the recent Dobbs Case reminds us of the exemption granted under law to Catholic Hospitals regarding certain kinds of women’s health care. When only Catholic hospitals are left in some states, due to consolidation, it makes this policy that more acute. In order for such hospitals to fully serve women, the drama of abortion politics must settle into compromise. There are proposals on both sides for a federal solution - either a federal law banning most abortions or permitting it in all cases. At some points, electoral stunts need to recede and real compromise must be sought.

In both scenarios, the need to take the issue away from the states is obvious. Justice Alito ignored the problems of both slavery and Jim Crow as reasons why there should not be abortion states and anti-abortion states. The respondents relied on the question of rights rather than on the question of powers. Had they examined the competencies of federal and state government on the question of who makes the rules on personhood, the answer is obviously that this responsibility must be federal. 

A ruling along those lines would have ended the issue at the status quo - with no regulation of abortion unless Congress recognized the rights of the unborn as reservoirs of positive rights. They are already recognized as having the right to life against government action. It is the same as the right to life for adults - the right to not be executed without due process. It is why we do not execute pregnant women, as well as the right to seek redress for outside injury. 

What they cannot claim is a right against the welfare of its mother - especially if the child is doomed due to a fatal defect. In such cases, termination is the only ethical solution - even in Catholic hospitals. Especially if the Catholic hospital is the only hospital for miles around.

For the larger issue, the right to an abortion in the very early stages should be federally guaranteed. After the embryo becomes a fetus - a little person in Latin - then pregnancies should be ended in a live birth, but with no medical intervention required to save the child (other than baptism or other religious blessing). This form of termination should have no upper limit. No one has a right to NOT be born.

Regardless, the Catholic Health Association should have been asked to present testimony on this issue. Since they were not included, their comments should be specifically invited on the issue of charitable care. Ambushing them with an abortion discussion would be rude.

Finally, in a cooperative economy, where companies are owned by their employees and also provide cooperative (democratically chosen) consumption options - especially healthcare - the need for both outside insurance and charitable care will be eliminated. That day may be sooner than you realize, as capitalism’s flaws are showing. 

A few simple steps will quicken the process, such as allowing insured personal accounts for Social Security holding corporate preferred and voting stock (not shares in the Wall Street Casino) and giving holders of public stock the same capital gains exemption given to private company owners when selling to a qualified broad-based Employee Stock Ownership Plan. While the first option is unlikely to ever pass, the second should attract bipartisan support.

Attachment: Asset Value Added Taxes Video

Health Care Price Transparency/Pharmacy Benefit Managers

WM: Hearing on Health Care Price Transparency: A Patient’s Right to Know, May 16, 2023 

My personal experience is as an uninsured individual during the time when I was married and adding me to my wife’s insurance would have been cost prohibitive. Worker and child policies were much cheaper than family policies.. During that time, I never saw an upfront price, except when I tried to take advantage of the Affordable Care Act’s right to a colonoscopy. Apparently, unless you have insurance, it is not a right. The initial consultation was made before that little detail was ironed out. Needless to say, no procedure was completed.

During that time period, my primary care physician ordered a stress echocardiogram with my cardiologist because there had been a problem with an EKG (mostly due to getting a lead seated). On the initial visit, they ran another EKG with no issues, but did the procedure anyway - but with no pricing provided. Because I previously had my adrenal gland removed and my high blood pressure had resolved and my heart muscle was actually in better shape than a few years before. Then I saw the bill. It went on my tab.

When I was hospitalized at a later date, INOVA waived hospitalization charges. They did not waive added consultations and testing. There had been no disclosure on what was not covered or any opportunity to request that it be added to the free care side of the ledger. That was also added to my tab.

This mythical tab existed in the computer systems of various collection agencies and group practices that had never quoted me a price. When the value of the condominium we purchased at the top of the market in 2006 was half of our debt - and because we both lost jobs when the debt deal led to budget cuts in training for government personnel (leading to job loss), we stopped paying our mortgage and this resulted in Chapter 13 bankruptcy. 

Because the marriage was ending, no further payments were being made during that period - which is not allowed, so we shifted to Chapter 7, turned in the keys and started  divorce proceedings. My “tab” was settled in bankruptcy. Had there been disclosure before service, some pricing would have been changed or free care insisted upon. The unwillingness of doctors to do so simply resulted in the true costs being shifted to other payees. Whether cost shifting or price shifting is a more interesting question. There is a lot of margin built into private healthcare.

Finance: Pharmacy Benefit Managers and the Prescription Drug Supply Chain: Impact on Patients and Taxpayers, March 30, 2023

The next comments rely on my experience as a member of the Cost Management Systems project of what was then called Computer-Aided Manufacturing – International, now the Consortium for Advanced Management – International. The project produced Cost Management for Today’s Advanced Manufacturing. I created a handbook based on the project, the U.S. Air Force Orientation Guide to Advanced Cost Management.

A key concept in cost management, supply chain management and cost accounting is non-value added cost. Pharmacy Benefit Managers are a non-value added cost. While they do have an impact on the price manufacturers can charge, they are the primary, if not the sole, beneficiaries.

As I learned as a proposal manager in the public sector contracting world, price and costs are different things. Healthcare is not a cost problem, it is a pricing problem and the lack of transparency means the problem must be faced by the uninsured or by employers.

The answer to this problem is some form of single payer healthcare, whether it be through Medicare for All, an expanded Public Option (to replace Medicaid) or having employers pay for medications, healthcare workers (and education) and specialist/hospital care either directly or as a part of the organization. Please see our Single Payer Attachment for more on this issue.

The other significant driver of drug prices is the question of funding orphan drugs. The answer is easy. Keep control of orphan drug intellectual property in the hands of the National Institutes of Health. Let them, and other agencies such as the National Science Foundation, fund grants and research contracts to generate breakthroughs, as well as to manage clinical trials for FDA approval (if appropriate for the population that needs the drug). When the drug is approved, NIH can then contract for its manufacture and distribution. 

This methodology will get more done faster, without relying on profiteering to do what is necessary to help our most vulnerable patients.

Attachment: HHS Budget, F Y 2022 Video

House GOP IRS Supplemental and the Fair Tax

Finance: House Republican Supplemental IRS Funding Cuts: Analyzing the Impact on Federal Law Enforcement and the Federal Deficit, May 16, 2023

It seems like we were just talking about this as recently as April 19.  In our comments, we will address what the increased IRS funding really pays for and why it is important and how the Majority could adopt the Fair Tax proposal into several consumption taxes (rather than a single tax) and actually defund the IRS.

Anyone who has ever made a mistake on their taxes (like omitting a child’s Social Security number) or has been in arrears and needed a payment plan knows what it can be like to reach an actual IRS agent. While the agency could certainly leverage its resources by contracting out customer service telecommunications, there are some items, like payment negotiations, that must be handled with agency personnel. 

It is reported that during the pandemic and its recovery period, when people had questions on how to start their enhanced Child Tax Credit payments - or had actual difficulty filing for them - that it was impossible to get an agent on the phone. Both the pandemic and underfunding were equally responsible. The additional money for IRS fixed this. 

Given the number of poor people in the states sending Republicans to Congress, it makes no sense to claw this money back. Even donors want to get the IRS on the phone, so playing politics with customer service makes no sense. Lincoln had something to say about fooling some of the people some of the time. Some of these people may even be less informed members of the Senate minority or their staffs.

The repeal of Roe v. Wade makes returning to the Pandemic era child tax credit essential. Increased funding is included in the President’s Budget and will eventually pass (once Special Counsel Smith has examined what was known by the House Freedom Caucus and when they knew it). The question is, how do we want these funds to be distributed. Should the IRS be a direct social services provider? As we have stated before…

… to end the “stink of welfare” that Senator Manchin so objects to, CTC payments should be included with wages for all employees - not just those with three or more children. They should also be distributed through other federal and state assistance programs - some of which can be reduced to do so.

For middle income taxpayers whose increased credits are less than their annual tax obligation, a simple change in withholding tables is adequate. Procedures are already in place to deliver refundable credits to larger families. For the coming year, they merely need to be expanded to all families with children. 

Employers can work with their bankers to increase funds for payroll throughout the year while requiring less money for their quarterly tax payments (or estimated taxes) to the IRS. The main issue is working out those situations where employers owe less than they pay out. This is especially true for labor intensive industries and even more so for low wage employers. 

A higher minimum wage would make negative quarterly tax bills less likely. Indeed, no one should have to subsist mainly on their child tax payments.

As usual, we have attached the latest version of our tax reform plan, with a separate attachment on how implementation of this plan would affect IRS manpower. The answer is that the change would be drastic. It would also allow the Committee to focus more on how social welfare is being delivered in general, as well as eliminating current roadblocks to promptly filing for Social Security Disability Income.

Let me relate the various provisions to the Fair Tax (and how to modify it):

The closest tax to the Fair Tax we propose is the Invoice Value Added Tax. It would fund discretionary government (and, if a constitutional amendment allowed uneven excise taxes), this could be done on a regional basis. Those regions who want to have a lower rate would fund less government. Those who want more projects and military bases would pass a higher tax. 

This tax would also replace the employer contribution to Social Security, but to make revenue accumulation look more like payment distribution, this revenue would be credited equally to all workers who accumulate the minimum number of credits in a quarter. The employee contribution would remain as it is. The check goes to the Department of the Treasury in either instance and the Social Security Administration will record the proceeds in exactly the same way.

A main objection to the Fair Tax is that it can be gamed by claiming everything you buy is wholesale. This is a big hole, a hole that value added taxes fix. There is already a value added tax on the books, although it is intergovernmental and inadequate. Businesses who collect sales taxes can already deduct them from their business income. This puts the national government in the position of subsidizing state and local sales taxes. The Fair Tax could include this provision for a federal sales tax as well.

The inadequarcy comes from the fact that taxes paid are a dedication rather than a credit. This can, indeed this must be fixed - whether the Fair Tax is enacted or not. Any federal tax paid must be fully credited at the federal level, with state taxes paid credited at the state level. These tax payments should still be used to adjust income. For example, state business income would be reduced by federal Fair Tax or VAT while federal income continues to be adjusted in the current manner.

The other issue with the Fair Tax is that payments to families would be shifted from tax credits to payments forom the Treasury (regardless of whether Social Security or the IRS distributes them). Payments above the “prebate” level would be shifted to state social welfare agencies through either new income stabization programs or by putting most American families on the Food Stamp rolls. 

The amount of these subsidies is uneven. Minor children of disabled or retired parents get various benefit levels and the Earned Income Tax Credit and Child Tax Credit phase in and out at various income levels. A universal child credit added to wages or income support programs (including OASDI, Unemployment Insurance and Pell Grants) would unravel this mess and allow all but the richest families to avoid filing taxes at all (unless they were filing separately as a business owner). For workers, these payments would be distributed with wages as an offset to a second consumption tax - what we call a subtraction VAT, which is essentially a net business receipts tax. 

Health care subsidies would also be added to this tax. Firms who provide insurance coverage would be able to credit a portion of their premiums as a credit against this tax. The proceeds would fund any subsidized public option, which would replace Medicaid for the working poor. Medicaid for nursing homes would be funded by the Invoice VAT. 

States would also use a subtraction VAT as a vehicle for additional income subsidies for high cost states (or urban areas), as well as using the tax to fund other social services (again, with offsets if employers provide these services - such as tuition assistance for workers and their families - as well as any other social welfare spending (for example, mental health care and housing)  that should be funded by employers rather than through property or sales taxes.

If the child tax credit is adequate to meet the needs of most families, prebates for Fair Taxes and Carbon taxes would not be necessary. Instead of limiting child tax credit payments to families based on higher (or lower) incomes, a subtraction VAT surtax would be levied on cash payments to workers or investors in excess of the Social Security Employee Payroll tax cap, with graduated rates for higher incomes. The firm would pay these amounts, not the individual employees, with individual taxation paid on cash salary, dividend or interest income above approximately $400,000 per year - again, with graduated rates of between 6.5% to 26% (more or less).

Subtraction VAT would entirely replace Corporate Income Taxation at all levels. The surtax for cash payments to higher income investors or workers would replace most collections of personal income tax and would assure parity between the tax treatments of labor and capital. There would also be no industry based tax subsidies, save for the deduction of all material costs (possibly including equipment, unless the decision is made to maintain depreciation rules).

Capital gains and estate (or death) taxes would be repealed. Stocks could be considered a consumer good, with a Fair Tax payment for each transaction, or could be levied as an asset value added tax. For those who don’t know economics, and for some who do, investment in secondary markets does not add to Gross Domestic Product. It is savings - or rather - it is gambling. In corporate bankruptcy, stock is worthless. 

Like the rest of the tax system, the capital gains and estate taxes are a maze of rates depending on income and time the asset is held. A single rate would be instituted instead for all short and long term investments. Cash payments in inheritance would not be taxed until they are spent or reinvested. This allows for closing all the loopholes in the system, from life insurance to avoid taxation to borrowing from stock to using business losses to reduce taxes on wages and salaries.

Attachment: Tax Reform Videos included

Attachment: Tax Administration Video

Woke and Bloated Bureaucracy

House Budget: Exposing the Woke, Wasteful, and Bloated Bureaucracy, May 11, 2023 

These comments reflect my experience as a federal employee in finance and budgeting, as a contracted grants office technical representative, a contracted contract specialist, an onsite contractor providing direct services,  a proposal manager and coordinator in the private sector, a legislative intern and a political appointee in state and local government, as well as a Master of Public Administration graduate. Unlike your invited witnesses, I have actually been a bureaucrat.

Our first question is how do we define a bureaucrat? In the populist conservative imagination, in other words, that of your witnesses, the government is full of career employees who binge on writing regulations to choke off freedom. The reality is that civil servants hate doing rulemaking. It is a major time commitment to deal with the Office of Management and Budget, publish draft rules and requests for public comment, coordinate drafts with the Office of the Solicitor and congressional correspondence (not to mention any environmental impacts and cost-benefit analysis).

The main reason rulemaking must occur is because Congress mandates that it be done by statute.

From the Senior Executive Service to new college graduates - as well as an army of on-site contractors who would be civil servants save for A-76 requirements - the purpose of the civil service is to implement policies mandated by law and in accordance with guidance from political appointees who actually have the last say on any regulations enacted, the budget priorities of the agency and major contract awards.

The real bureaucrats that people love to hate are actually political appointees who are often former members of Congress, congressional staff, former local government officials  or members of the policy community associated with the president’s party and the industry or issue related to the work of the agency. 

It takes a few years for these officials to learn their jobs - just in time for them to leave. In some administrations, like the last one, many appointees never learn their jobs or are so ideological that they do them badly - sometimes contrary to both the Administrative Procedures Act and the relevant authorizing legislation for the agency or department. In most administrations, there is not so much hostility to the rule of law - especially among senior appointees who may have served in a prior administration (in either party).

Compared to the last administration, the current one is rather woke, if woke means not actively racist - especially in the area of immigration. The question is, for purposes of government service, what is woke? For most of the permanent government, it means having been trained in the laws and regulations guaranteeing equal employment opportunity. Not every manager takes this training to heart, which is why these rules are necessary.

As far as the caricature of a woke, liberal, bureaucracy, this does not exist. Civil servants, as well as military officers, come from all ideological perspectives. There are a good many Republicans in the government - and not just in the Department of Defense. Most know enough to leave their politics at the office door and do their assigned work. If the Hatch Act is violated, this usually comes from the political appointee side of things.

The next question is whether the government is wasteful and bloated. There are legendary stories of contract officers ordering golf balls to use up budget authority. These are old stories, almost old wives’ tales and, because of them, there are procedures in place to finish most procurements a month before the end of the current fiscal year. 

Sometimes, year M money is spent at the last moment on such items as computer hardware (I have walked such procurements through the system myself in program control), but it was vital to have this hardware, considering we were doing budget analysis. This is back in 1988, when getting hardware was hard to do. IT is now ordered on a regular basis, given adequate budget authority - such as the funding increases for the IRS for badly needed equipment. These would not have been necessary but for incompetence in the political sector which thinks that starving the IRS will help service to taxpayers. It does not.

That being said, the government is bloated, especially on the budget and contracting side, because procurements that should be made throughout the fiscal year can only be begun in February of most years. This also applies to program office activities - because the job of most such offices is to propose work to be contracted out. Program ideas can come from inside government (either from appointees or civil servants), from Congress, from industry and individuals or associations of these - usually accompanied by political action committees whose purpose is to buy access.

The bloat  is due to the fact that the budget process is broken - and has been badly broken for the last 49 years - since the passage of the Budget and Impoundment Control Act of 1974, which created the Budget Committees.

The sad truth is that the more hands are in the kitchen, the more opportunities multiply for members of Congress and the Senate to grandstand and stop the process. Exhibit A is this hearing. Were it not for the budget process, the Appropriations Committee could set its own spending targets for the various Subcommittees to hit, with the House going low and the Senate restoring cuts made by the House. 

Tax and entitlement policy can be made by the revenue committees without help, especially since Reconciliation has been used to bypass normal procedure and cut taxes in a manner that can only be regarded as reckless. Prior to the Pandemic, the Tax Cuts and Jobs Act had reduced revenues and increased speculation on Wall Street, which resulted in a reduction in economic growth by one percent in the fiscal year following the passage of the Act. 

Funds that had been going to households through pay went to the CEO/donor sector and its “financial innovations,” i.e. garbage such as mortgage backed securities for single family home rentals and crypto currency, all conveniently buried in Exchange Traded Funds. Now that the pandemic is over, such flawed paper is coming due and may just lead us into a recession yet. COVID bailouts to the financial sector by the Federal Reserve hid the damage - but it will not stay hidden.

Luckily for the nation,  the TCJA cuts for individuals will expire in 2025. This will take money out of the speculative investment sector and, because of greater consumption, will result in more real investment in plant and equipment. Any tax reform (and I am in favor of reforms such as the Fair Tax - but in the form of a value added tax and a net business receipts tax, as well as an asset value added tax) should be pegged to the 2025 revenue laws, not those of the current year.

Aside from nature taking its course, how do we solve the problem of a dysfunctional budget process which results in a bloated bureaucracy? There are a few options. One is to do another Budget Control Act, which will include spending caps that can also function as a budget resolution should no resolution be enacted on schedule. This time, however, the caps should be realistic rather than punitive. 

Realistic caps will result in lower spending. The recent caps simply forced compromises which drove spending up. The second part of this reform is for either a budget resolution (which should be joint rather than concurrent) or the new budget act levels lead to automatic appropriations derived from the Current Services Budget at the start of the new fiscal year should they not pass by October First. While Congress could still pass supplemental appropriations, it could not withhold money for either pet projects or to grandstand about cutting spending.

Another option is to replace both budget committees with an ex officio joint committee made up of the chairs of Ways and Means, Finance and Appropriations in each house who would agree to budget allocations and any tax and entitlement changes, inviting ranking members only when the chambers are controlled by different parties. In other words, turn back the clock to when the system actually worked. 

The final option is for the Budget Committees to do their jobs, which in this case would be for members and staff from this committee to sit down with their opposite numbers in the Senate to work out a realistic compromise. It is the only way the House Budget Committee can really be relevant and allow the bloat to be taken out of government procurement in all sectors (including government contractors whose workloads are held hostage to the congressional calendar).

Would the Appropriations Committee allow the Budget Committees to actually do this? I am doubtful. It is why Budget Committee leadership is always given to the most partisan members. These committees are expected to fail, which preserves the power of the older committees.

Hyper-partisanship is not a good career move. Members of the House generally run for leadership, seek state office or run for the Senate. It used to be that leadership would compromise. Now, not so much. Serving in the Senate, as Governor or working on K Street require the ability to reach across the aisle.  Grandstanding on wokeness is not a good resume item.

The issue of wokeness is not the winner the party expects it to be. Everyone thinks that Glenn Youngkin, who ran on the issue - especially in regard to Trans Youth - won the governorship because of it. The reality is that Terry MacAuliffe tried to run a base election is a purple state. Glenn did not win - Terry lost (also why Gore lost in 2000 with Terry as his chair).

There is a lot for the Budget Committee to do if it gave up grandstanding. I have already suggested some of these options.

It could remedy inflation in the public sector by awarding COLAs on an equal dollar basis rather than as a percentage of current salary. It could even do so based on a lower average percentage than inflation. This would still make most civil servants better off. Only the overpaid would suffer. This limit should also apply in Congress.

Cut back on federal leave entitlements, but balance this with closing the government between Christmas and New Years, as many other professional offices - especially government contractors, do.

Cut the budget by one percent under the inflation adjustment, rather than one percent over current spending (which is a huge cut).

Cut Defense spending, but increase spending by some lesser amount for NASA, with the Defense Appropriations Subcommittee responsible for the agency. This would keep funds in the same sector (aerospace) rather than having NASA fight with the National Science Foundation, the Department of Commerce and the Department of Justice for funding.

Make the Affordable Care Act actually work using a public option, but ending pre-existing condition reforms and subsidizing the public option with an employer-paid subtraction value added tax (which it could offset partially by providing insurance or direct health services to employees - including those who now function as contractors).

Lead a serious discussion of the Fair Tax (but as a series of consumption taxes as I suggest - including an employer paid subtraction VAT designed to be offset by a generous child tax credit and health insurance coverage of employees. The option of having the IRS distribute the Child Tax Credit as it did under the American Recovery Plan Act or through Social Security as currently proposed turns the federal government into a paymaster for too many people.

There is not much time for the current budget committee to make its mark. It is an open secret that members of the Freedom Caucus were involved with Roger Stone in planning the events of January 6th. Jack Smith has prosecuted the level below Stone and the Willard Hotel crew. Anyone Stone was in communication with will either receive a subpoena - or worse will not because they are targets of the investigation. 

Most Freedom Caucus seats are safe, meaning that if certain members must resign at the behest of the Ethics Committee, they may be replaced by Republicans. Or they may not be. If playing with the debt limit or the collapse of Exchange Traded Funds brings about a recession this year, rather than the next, it could coincide with the necessary special elections.

If this happens, the reforms suggested here may happen anyway, but with Democratic Majorities in both Chambers (especially tax legislation and a new Budget Control Act).

Cross-border Drug Manufacturing /Innovation and Patient Access

Finance: Cross-border Rx: Pharmaceutical Manufacturers and U.S. International Tax Policy, May 11, 2023

WM Health: Examining Policies that Inhibit Innovation and Patient Access, May 10, 2023

WM: Drug pricing puts too much of the research and innovation processes into the hands of companies whose main goal is profit. On top of this, the new Majority seeks to cut spending below the level of inflation, jeopardizing new research. This must be rethought.

Regardless of where drugs are developed or manufactured, their costs do not vary by where they are sold. Indeed, if a drug is manufactured in the United States, it may have a lower price in other markets - although usually manufacture has shifted to Asia. Prices are another matter. They are dictated by what the market will bear, given the regulatory environment of each market. As long as price is less than the cost, the drug will be sold. Sadly, this puts prices out of reach in the developing world.

PhARMA relies, in part, on claims that negotiation will lead to cost shifting. The dirty little secret in this debate is that single-payer solutions in the rest of the OECD have already resulted in price (not cost) shifting, where the rest of the world shifts its cost to the United States to the greatest extent possible (although they might anyway) 

Most people with insurance don’t notice this. Single payer healthcare, either through a public option or Medicare for All, will further bury this. For now, allowing drug price negotiation will give drug companies leverage to renegotiate their deals with the rest of the world. As a side note, how Medicare for All or a Public Option might work is explained in an attachment.

PhARMA also relies on the claims that new cures for pandemics and subsidizing the development of orphan drugs and new therapies requires the right to charge the most the market can bear. This ignores the fact that most basic research comes through government grants and contracts, not drug company profits. The latter fund commercial, not scientific, development. 

An important part of decreasing cost to consumers is to expand funding, such as the President’s ARPA-H proposal. Part of ARPA-H is the funding for research on orphan drugs and the lingering problem of their cost once research leads to product development. In comments to Senate Finance on March 16th of this year, we repeated our proposal in this area for NIH to retain ownership in any such drug and contract out its further development and manufacture. Keeping ownership in public hands ends the need for drug companies to charge extreme prices or increase prices for its existing formulary to fund development. 

PhARMA would still make reasonable profit, but the government would eat the risk and sometimes reap the rewards. NIH/FDA might even break even in the long term, especially if large volume drugs which were developed with government grants must pay back a share of basic research costs and the attached profits, as well as regulatory cost.

Finance Only:

International tax policy is broken. The United States leaves potential revenue on the table by not enacting consumption taxes. This hurts American manufacturers, whose sales must include the cost of government in the United States, which may be an unconstitutional export tax if looked at from a product cost perspective. A second attachment gives background to our consumption tax proposals as context for the third, which discusses how these will impact trade.

We propose repealing corporate profits taxes as part of the creation of a subtraction value added taxes and repeal of capital gains taxes in the United States will lead to their repeal worldwide. If Asset Value Added Taxes are adopted, as described in the fourth attachment, the rate should be negotiated so that investors who are able do not market shop for the lowest rate. The recent OECD compact on minimum rates is an example of how tax cooperation on capital can work for other types of asset taxation.

Ways and Means only

Hospital consolidation and privatization (i.e., the closing of public hospitals - often at the behest of industry) limits access and drives poor patients to emergency rooms because they are uninsured. It is good of the Republican Majority to get on board in objecting to such bad behavior. It is even worse in some regions, where the only hospital system remaining is run by Catholic religious orders, which limits family planning and abortion access (with the blessing of public law). 

When only Catholic hospitals are left in some states, due to consolidation, it makes this policy that more acute. In order for such hospitals to fully serve women, the drama of abortion politics must settle into compromise. There are proposals on both sides for a federal solution - either a federal law banning most abortions or permitting it in all cases. At some points, electoral stunts need to recede and real compromise must be sought.

In both scenarios, the need to take the issue away from the states is obvious. Justice Alito ignored the problems of both slavery and Jim Crow as reasons why there should not be abortion states and anti-abortion states. The respondents relied on the question of rights rather than on the question of powers. Had they examined the competencies of federal and state government on the question of who makes the rules on personhood, the answer is obviously that this responsibility must be federal. 

A ruling along those lines would have ended the issue at the status quo - with no regulation of abortion unless Congress recognized the rights of the unborn as reservoirs of positive rights. They are already recognized as having the right to life against government action. It is the same as the right to life for adults - the right to not be executed without due process. It is why we do not execute pregnant women, as well as the right to seek redress for outside injury. 

What they cannot claim is a right against the welfare of its mother - especially if the child is doomed due to a fatal defect. In such cases, termination is the only ethical solution - even in Catholic hospitals. Especially if the Catholic hospital is the only hospital for miles around.

For the larger issue, the right to an abortion in the very early stages should be federally guaranteed. After the embryo becomes a fetus - a little person in Latin - then pregnancies should be ended in a live birth, but with no medical intervention required to save the child (other than baptism or other religious blessing). This form of termination should have no upper limit. No one has a right to NOT be born.

Attachment: Single Payer Video

Attachment: Consumption Taxes Video1 Video2

Attachment: Trade Policy Video

Attachment: Asset Value Added Taxes Video

Attachment: Consumption (Fair) Taxes

Consumption (Fair) Taxes, March 24, 2023

Corporate income taxes as a whole should be abolished and a two stage Fair Tax enacted in its place.  We propose channeling a Fair Tax style subsidy through two taxes, a (credit) invoice value added tax (turning the deduction for sales taxes paid into a full credit - which is the essential the difference between a VAT and income tax based collections) and a subtraction value added tax to channel subsidies for health care and the child tax credit through employers rather than the Social Security Administration (as proposed for the Fair Tax).

Subtraction Value-Added Tax (S-VAT). Corporate income taxes and collection of business and farm income taxes will be replaced by this tax, which is an employer paid Net Business Receipts Tax. S-VAT is a vehicle for tax benefits, including

• Health insurance or direct care, including veterans' health care for non-battlefield injuries and long term care. 
• Employer paid educational costs in lieu of taxes are provided as either employee-directed contributions to the public or private unionized school of their choice or direct tuition payments for employee children or for workers (including ESL and remedial skills). Wages will be paid to students to meet opportunity costs.  
• Most importantly, a refundable child tax credit at median income levels (with inflation adjustments)  distributed with pay. 

Subsistence level benefits force the poor into servile labor. Wages and benefits must be high enough to provide justice and human dignity. This allows the ending of state administered subsidy programs and discourages abortions, and as such enactment must be scored as a must pass in voting rankings by pro-life organizations (and feminist organizations as well). To assure child subsidies are distributed, S-VAT will not be border adjustable.

Video Three: Subtraction value added taxes (net business receipts)

Credit Invoice Value-Added Tax (CI-VAT). Border adjustable taxes will appear on purchase invoices. The rate varies according to what is being financed. If Medicare for All does not contain offsets for employers who fund their own medical personnel or for personal retirement accounts, both of which would otherwise be funded by an S-VAT, then they would be funded by the I-VAT to take advantage of border adjustability. 

CI-VAT forces everyone, from the working poor to the beneficiaries of inherited wealth, to pay taxes and share in the cost of government. As part of enactment, gross wages will be reduced to take into account the shift to S-VAT and CI-VAT, however net income will be increased by the same percentage as the I-VAT. Inherited assets will be taxed under A-VAT when sold. Any inherited cash, or funds borrowed against the value of shares, will face the CI-VAT when sold or the A-VAT if invested.

CI-VAT will fund domestic discretionary spending, equal dollar employer OASI contributions, and non-nuclear, non-deployed military spending, possibly on a regional basis. Regional I-VAT would both require a constitutional amendment to change the requirement that all excises be national and to discourage unnecessary spending, especially when allocated for electoral reasons rather than program needs. The latter could also be funded by the asset VAT (decreasing the rate by from 19.25% to 13%).

Carbon Added Tax (C-AT). A Carbon tax with receipt visibility, which allows comparison shopping based on carbon content, even if it means a more expensive item with lower carbon is purchased. C-AT would also replace fuel taxes. It will fund transportation costs, including mass transit, and research into alternative fuels. This tax would not be border adjustable unless it is in other nations, however in this case the imposition of this tax at the border will be noted, with the U.S. tax applied to the overseas base. 

Video Four: (Credit) Invoice value added (Goods and Services) taxes and carbon added taxes 

Ghost Networks in Mental Healthcare

Finance: Barriers to Mental Health Care: Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost Networks, May 3, 2023

The problem of ghost networks varies, depending upon one’s health plan. If one enters mental health care through Medicaid, state departments of health generally have up to date listings for programs that provide both psychiatric and social worker services. This was my experience as a patient in the District of Columbia. I did not choose a health plan when I was in the DC system, which made finding a primary care physician interesting. After moving to Maryland, I chose Kaiser for medical care, but could not do so for mental health servcies.

Participants in a Psychiatric Rehabilitation Program include access to a nurse practitioner (which is usually what Medicaid pays for). PRPs have case managers who will do the searching for you when a therapist is needed - although this may take some time, precisely because of the problem of ghost networks. Medicaid patients have access to certified counselors and licensed marriage and family therapists, but not to Licensed Clinical Social Workers. LCSWs were only covered by Medicare, while the other therapists were not. 

Starting in 2024, the counselors available with Medicaid are added to Part B coverage. This makes ghost networks a problem for more people - although wider availability may help individuals find care.

In my case, my relationship with my nurse practitioner in my PRP proved toxic, so I had to find a new provider. In reality, there was not much choice - only one was open - even though more were listed.

Before moving to Medicare after two years of Medicaid after my SSDI began, I could no longer meet the asset test of Medicaid when I received assets from my divorce (although I probably did not have to take this step). At this time, I signed up for the Affordable Care Act Silver Plan. The coverage was too expensive and the copays too high for care when I fell and broke a rib. Luckily, at the two year mark, I moved to  Medicare Parts B/D and a Psychiatrist and LCSW. A year later, I signed up for Part C.  

Shifting from Medicaid to the Affordable Care Act to Medicare was seamless with my Primary Care Physician, unlike my mental health services. Of late, I was offered the ability to go out of the HMO for services due to regulatory changes. None were as convenient as what Kaiser provided.

I had previously been a Kaiser member fifteen years prior to this as a government contract employee. During this time, I noted that the DC Government, where I had been working a few years earlier, had shifted to Kaiser as well for their employees.

The point of my tale of coverage is that, once I chose Kaiser, my relationship with my PCP was unchanged, although details of copayments and prescription coverage did vary, especially regarding the pharmaceuticals.

For those who sign up for managed care, we have achieved fusion in some aspects, but not in others - although this will change in 2024 as far as therapists are concerned. One can work for a company, get an individual policy under the ACA at a later time, get Medicaid when disabled and full Medicare without changing doctors. What is complicated is what is covered and what is not with the same provider network.

The real antidote to ghost networks is the kind of network care that is provided through community healthcare in Medicaid and to managed care participants (regardless of funding). Getting to single payer funding is not an issue as much as is seamless coverage WITHIN THE SAME PROVIDER NETWORK regardless of which government or employer plan one uses.

Professional employees always get good coverage, as do unionized employees. Others need to rely on some sort of governmentally funded care. For those in this situation, the care package should be the same, with providers getting the same level of support in each setting.

If this sounds like an endorsement of Medicare for All, which is essentially Dual Eligibility for all (meaning Medicare reimbursement with Medicaid copays) for all seniors, then you have been listening. 

There are other options, however, like Medicare Part E coverage replacing dual eligibility for seniors in long term care (taking these patients off of state Medicaid rolls) and a public option added to Affordable Care Act coverage (which could replace Medicaid - at least for non-retirees - and be more heavily subsidized than current coverage. The other option is to have employers offer direct care. 

Attachment: Single Payer Video