Recommended Links

Most Externalities are Solved with Technology, Not Coordination
2025-03-14 Maximum Progress
Strategic Deregulation to Spur Economic Growth
2025-03-13 Law & Liberty
How the Corporation for Public Broadcasting is like the human appendix
2025-03-14 Washington Post
Jail Time for Cheap Rides?
2025-03-04 Reason
Denmark postal service to stop delivering letters
2025-03-06 BBC

Blog

Monday, March 31, 2025

Trade Makes Us Rich Beyond Measure

Trade, whether between neighbors or nations, is one of the most powerful forces for wealth creation in human history. Every day, Americans benefit from it, often without even noticing. Whether it’s a farmer selling corn to his fellow Americans or U.S. consumers importing microchips from Taiwan, the effect is the same, both parties are better off from the exchange, and our standard of living rises as a result.

Yet in today’s policy discussions, the gains we accrue from exchange are being taken for granted. There are renewed calls for America to “make everything itself,” to become entirely self-sufficient. That’s certainly possible. But if we take that path, we’ll sacrifice a tremendous amount of our wealth—wealth we enjoy today without realizing its source.

The Invisible Wealth of Trade

Trade-generated wealth is hard to see. It doesn’t show up in a single paycheck or appear neatly itemized on a grocery receipt. It’s distributed across millions of products, transactions, and time-saving conveniences that we’ve become accustomed to. Because of this, people tend to underestimate it, especially when the subject turns to international trade. But whether at the personal level, the state level, or the national level, trade consistently makes us richer.

Making Everything in America Means Making Less of Everything

It’s true that America could make everything it needs. The nation is the third most populous country in the world and the fourth largest in area. We have the people and the resources to provide for ourselves. We could build our own electronics, grow our own coffee, and sew our own clothes. But if we did that, we would give up much of the value created by trade—value that comes from specialization, comparative advantage, and economies of scale.

These principles are easier to grasp at the individual level. Take bread as an example. Any American with an oven can bake it. It’s not hard. But almost no one does. Why? Time is part of it, but the better explanation is that professional bakers are better at baking. They specialize in it. And bread from a grocery store, or a national brand, is cheap—often cheaper than the ingredients alone—because large-scale producers enjoy economies of scale. How much of your leisure would you need to give up to bake your own bread regularly?

A major contributor to the success of the United States is that states, by law, cannot impose tariffs on each other. It is the largest free trade zone in the world.

The same logic applies not just to individuals, but to political and corporate entities. Florida is great at growing oranges. Idaho potatoes. Illinois dominates pumpkins. These aren’t arbitrary facts—they’re reflections of comparative advantage. Because these states have natural advantages in producing certain goods or just because they focus on them, they are able to produce more of those goods than if every state had to supply its own residents with every good.

Like US States, countries have their own strengths. Germany has world-class engineers. Italy has olives. France has grapes. The U.S. excels at corn, wheat, oil, gas turbines, and a host of other industries. By focusing on what each country (or region) is relatively good at, and trading for the rest, everyone gets more—more food, more fuel, more stuff.

By focusing on what each country (or region) is relatively good at, and trading for the rest, everyone gets more—more food, more fuel, more stuff.

Specialization and Scale at the National Level

The United States is the richest country on the planet because the government lets individuals and corporations choose to produce and sell whichever products they want. Consequently, Americans focus our labor, capital, and infrastructure on industries where we have advantages—natural resources, technology, education, or sheer size. This concentration allows us to become more efficient, drive down costs, and produce far more than we could if every state, or every person, tried to be self-sufficient.

That extra productivity is what we trade. And when we import goods that other countries produce more efficiently, we free up our own resources to focus on our strengths. The result is a bigger pie for everyone, and America gets a huge slice of that pie. Trade doesn’t just shift wealth—it creates it.

The Wealth We Take for Granted

Economists understand this because it's a core component of their training. They don’t argue about whether trade creates wealth; they argue about how much. But most people only notice the costs of trade—job losses in specific sectors, factory closures, or trade deficits—while ignoring the benefits spread out over thousands of cheaper goods, better services, and wider choices.

While it is my opinion that the gains discussed in this post are impossible to estimate accurately, I would be remiss to not point to some attempts. The Peterson Institute for International Economics estimated that trading with other countries boosts the average American's annual income by $7,800.

People should use whatever scale helps them understand. If thinking about international trade is too abstract, start with your own household. Why don’t you make your own clothes or repair your own car? If that makes sense, scale up: Why shouldn’t cities, states, and countries behave the same way?

Trade makes us immeasurably rich. We just need to look a little closer to see it.

Thursday, March 27, 2025

Medicaid Provider Taxes - An Explainer

One branch of the current discussion regarding Medicaid and the Sword of Damocles that is the Republican Budget package that looms over it regards provider taxes, and how they are used by states to boost the federal money that comes into the state to pay for Medicaid without contributing anything themselves. Many people on the right and the left have acknowledged how these taxes are an abuse of the Medicaid funding system.

How Provider Taxes Work

While most taxes are imposed on individuals and corporations broadly, provider taxes are levied against health care providers like hospitals and doctors, specifically, as their name implies.

Step 1: States tax the health care providers and hospitals in the state.

Step 2: The state gives that money to Medicaid.

Step 3: Medicaid pays those same providers for providing care to Medicaid beneficiaries.

Step 4: The federal government matches a portion of that money that was taxed and returned to the providers, leaving no one in the state actually worse off from the tax.

In this process, the state has ostensibly taxed providers, but since it gave the same money back to them by paying them for care on behalf of Medicaid beneficiaries, their net tax is zero. Meanwhile, taxpayers in other states have sent additional matching money under the notion that the state was contributing.

By doing this, states break the state-federal Medicaid funding compact, where the Federal government contributes to Medicaid, which is a state-administered program, matching the contributions that the state makes itself. In this case, the state doesn't contribute anything, but runs a shell game to get the match anyway.

Effectively, this allows the state to increase the federal match rate beyond what it should be, getting a 70% from the federal government, instead of, say, 65%. Some estimate the shift to be as high as 14 percentage points.

Modern Medicaid and MCOs

In the last few decades, Medicaid has transitioned from a largely Fee For Service model (patient gets procedure, state pays hospital for procedure), to a managed care model (patient chooses an insurance company, state pays insurance company a fixed amount of money, and the managed care plan or MCO interacts with the providers.

State taxes on MCOs were subject to the same provider tax limits as those on providers. Most importantly, taxes had to be broadly applied, as in not just to Medicaid MCOs but commercial MCOs as well. In 2023, however, California implemented a tax on MCOs that was higher for Medicaid MCOs than commercial, charging MCOs $182.50 per Medicaid enrollee but only $1.75 for private enrollees.

Because of legacy formulas that CMS uses to determine compliance, CMS was forced to allow this tax, even though it ostensibly violates the broad application requirement. CMS is in the process of modifying its rules so that it can reject this tax, but it will take several years to go through the administrative process. In the mean time, other states are following California's lead.

Hold Harmless and Safe Harbor

The 1991 reforms didn't go all the way. Before 1991, states were free to tax only Medicaid providers, and circulate 100% of the taxed money back to them. The 1991 reforms both (1) prevented a tax on Medicaid-only providers and (2) forbade provisions that would have the effect of returning the money to those providers selectively. These are known as "hold harmless" provisions because they would ensure that the tax was harmless to the Medicaid providers by increasing reimbursement rates for Medicaid procedures, as an example.

The reforms did not entirely prohibit methods states took to return the money to Medicaid providers directly. As long as the overall provider tax was less than 6% of provider revenue, and the state's reimbursement system funneled less than 75% of the provider taxes back to these providers, then the government wouldn't challenge it. These allowances are known as the "safe harbor" because they allow the states and providers to use the tactic to an extent, without scrutiny.

The Congressional Budget Office estimates that eliminating these safe harbors entirely could save $612 billion over 10 years.

Some History

This scenario has long been recognized as abusive. In the 1980s, it became so prevalent, that Congress actually passed a limited fix for it. The law was supposed to ensure that any taxes were applied broadly to different provider categories, to prevent states from selectively taxing Medicaid providers only. It also allowed states to take advantage of the provider tax loophole just so long as the tax rate on the providers didn't exceed 6% of their revenues. While this didn't solve the problem, it did constrain it.

Politicians from both parties have recognized this practice for the abusive, shell game to get around the state contributions while still receiving a federal match. Joe Biden called it a "scam" when he was Vice President. President Obama pushed for reforms. The Washington Post favored reform. Democratic Senate Leader Dick Durbin also called it "a bit of a charade".

Informative Links

Fiscal Policy Institute
Kaiser Family Foundation
Paragon Health Institute
MACPAC

Monday, March 24, 2025

Cutting Medicaid is Possible

In February, Republicans announced their intention to cut $2 trillion in spending over the next 10 years. $880 billion of that is to come from the Committee on Energy and Commerce (See Title II), which oversees Medicare, Medicaid, national energy policy, environmental protection, and several others.

Just doing basic searches on Medicaid cuts, trying to find information, all of the top stories include a warning about how many people are going to be hurt by this, but interestingly, there are no mentions of how much Medicaid has grown in the past ten years, even beyond its ACA expansion, how fast it's projected to grow, or how much waste could be cut. Every story just assumes, without including details, that every penny of Medicaid goes to children, poor adults, or disabled adults, but given the recent expansions, this seems unlikely.

The Recent Run-Up in Medicaid

Since 2000, federal Medicaid spending has been trending upward. In 2000, after 8 years of a Democratic president, federal Medicaid spending was just 1.1% of GDP, and it has nearly doubled since then. Some of that surely is the increasing cost of medical care, but it's also driven by enrollment growth due to expanded eligibility and state incentives to get matching federal funding.

Federal Medicaid Spending as a % of GDP

Source: Author Calculation based on NHE (Actual Federal Medicaid Expenditures), FRED (Actual GDP), CBO (Projected Medicaid and GDP)

In the last twenty-five years, the largest, single-year increase in federal Medicaid spending occurred in 2020, the year of Covid. This, in and of itself, is unsurprising, but what's harder to understand is why it has barely fallen back to its pre-Covid rate, even four years later, while the economy has boomed.

In the last twenty-five years, the largest, single-year increase in federal Medicaid spending occurred in 2020, the year of Covid. This, in and of itself, is unsurprising, but what's harder to understand is why it has barely fallen back to its pre-Covid rate, even four years later, while the economy has boomed.

Waste, Fraud, and Abuse

CMS periodically estimates the total "improper payments" in Medicare and Medicaid. The most recent estimate for Medicaid is that 5.1% of total Medicaid payments are "improper." While that sounds like fraud, in fact, the majority of these improper payments are simply insufficiently documented legitimate payments. They also estimated how much of the improper payments were actually illegitimate and found that 20% of them are truly improper and should not have been paid out.

Applying this rate of illegitimate payments to the CBO's ten-year forecast produces an estimate of $91.2 billion over ten years that can be saved without harming Medicaid recipients.

Applying this rate of illegitimate payments to the CBO's ten-year forecast produces an estimate of $91.2 billion over ten years that can be saved without harming Medicaid recipients.

Locking in Normal Growth

One approach Republicans might consider would be to lock in overall Medicaid growth to match its 2016-2019 rate. This was a time of a stable economy, after the major ACA expansion and before further expansions under Covid-era policies and the Biden administration. It represents a steady-state era for Medicaid.

During this time, Medicaid grew at 3.1% per year. This would represent smaller growth than the CBO estimated (between 4 and 5% per year).

Federal Medicaid Spending Growth by Year 2000-2024

Source: Author Calculation based on NHE (Actual Federal Medicaid Expenditures), CBO (Projected Medicaid)

Holding growth in Medicaid to the 2016-2019 average over the next ten years would save $778 billion. Considering that 2016-2019 was a time without major cuts to Medicaid benefits or eligibility, it would seem possible to lock in that growth rate without harming any beneficiaries.

Federal Medicaid Spending if Growth Held to 2016-2019 Rate

Source: Author Calculation based on NHE (Federal Medicaid Expenditures), CBO (Projected Medicaid)

Locking in Enrollment Levels

Another path Republicans might take is setting an enrollment target for Medicaid, which is supposed to assist the poorest Americans, yet enrolls close to 1 in 4. According to poverty statistics, before accounting for transfers 11.1% of Americans are impoverished. Medicaid, however, covered 27.4% of the US population in 2023.1

From 2000 to 2023, enrollment in Medicaid has grown from 12% of the population to 27% of the population, more than doubling, even though the federal poverty rate has barely moved, going from 11.3 to 12.5%. Some of that, obviously, was intentional, as the ACA expanded Medicaid, but in 2019, before the pandemic hit, and after state expansions had taken place, Medicaid penetration was only 23.0%. Since Covid, it has risen several percentage points, even without expanding Medicaid in large states like Texas and Florida.

% of Total US Population enrolled in Medicaid by Year

Source: Author Calculation based on NHE (Total Medicaid Enrollment), CBO (Projected Medicaid Enrollment). Note: The 2025 CBO projection for Medicaid spending is substantially higher than the 2024 CBO projection, but they have not yet released the breakdown. The dotted line represents a higher level of enrollment which could explain the higher CBO estimates.

Setting a maximum Medicaid enrollment of 23.0%, the highest level it reached before Covid and after the ACA expansion, would save $1.4 trillion over the next ten years.

Capping Medicaid enrollment at its pre-Covid peak would save $1.4 trillion over the next ten years.

Federal Medicaid Spending if Enrollment Held at Pre-Covid Maximum

Source: Author Calculation based on NHE (Total Medicaid Enrollment), CBO (Projected Medicaid Enrollment)

Conclusion

Rolling the Medicaid program back to the pre-Covid norm, when there were no significant criticisms of its inadequacy, would save more than Republicans are pushing for.

Medicaid has expanded in scope and scale over the past twenty-five years and has grown to a point where some pruning can be accomplished without the devastating results that many warn will occur. Simply rolling the program back to its scale from prior to the pandemic would provide more money than Congress is looking for and would return Medicaid to funding and enrollment levels that, at the time, drew little to no criticism.

Notes

For a counterargument, Kaiser Family Foundation claims it's impossible.
For some supportive analysis and a more detailed proposal for Medicaid, Manhattan Institute

Stray Thoughts

One of the explanations CBO gave for increased expected Medicaid spending from 2026-2035 was new spending on GLP-1s, which reduce obesity. Theoretically, though, the reduction in obesity should also lead to improved health and reduced spending. I'm curious if that is included in their estimates.

Footnotes

1This number has fallen in 2024 as the Medicaid expansions from the Covid-era are being unwound. The rate today is between 25 and 26%.

Friday, March 21, 2025

Making Up for DOGE

In light of the Trump administration and DOGE’s antipathy towards foreign aid and NIH, and their significant budget cuts, the most moral and productive thing that can be done, for those who strongly disagree with these decisions and are concerned with the hardships they’ll cause worldwide is to donate money directly to the affected programs.

Below, I’ve identified the entire costs of these programs, but also try to break them out individually. I’ve also calculated how much each person would need to donate to make up for the cuts and, where I could, pointed to some organizations that have a history of addressing the same issues.

I encourage you to share any other organizations you come across that could fill in the gap. Also, if you have any links to news articles that identify some of the most effective programs within these agencies, please leave them in comments, and I’ll see if I can add them in to the estimates.

US Total Expenditures on Foreign Aid and Research

US Aid Budget by Year

Some Background Math

For tax-year 2022, the most recent-available, there were 161,336,659 total tax returns filed. Of these, 55 million were married filing jointly, 4 million were married filing separately, 21 million were heads of household, and 81 million were individuals. Since some of the 55 million married filing jointly were dual earners, I determined the total number of tax-payers by assuming 48.9% of the married couples were dual earners. That comes out to 187,155,980 earners paying federal income taxes, if my math is right. As an alternative number, there were 231,529,762 Americans over the age of 25 in 2023.

Filling the Gap

The table below shows how much each adult or taxpayer would need to contribute to completely replace the programs. For example, if NIH were completely eviscerated, because the federal government spent $47 billion on it, each taxpayer would need to throw in $251.13 to make up for the loss.

Obviously, reality is much more complicated. Perhaps you want to make up for your NIH-skeptical friends and double your contribution. And, at this point, it’s not even clear that NIH spending will be cut, without Congressional approval. Also, maybe you want to focus your charity on the most effective aspects of these programs and not everything.

Individual Components

USAID

On March 10th, Secretary Rubio announced the review of USAID programs was done and they were cancelling “83% of programs at USAID.” Because “programs” could encompass small projects and large, it’s unclear how to translate that to a dollar figure. Fortunately, the Center for Global Development estimates the dollar figure to be around 34% of the annual spending. Of course, the normal caveat remains, that this money, as of now, still must be spent on foreign aid, it’s just Rubio and the new Trump-designated team that will direct it.

In addition, one might suspect that the programs cut would be the least beneficial and they maintained the most effective ones (the ones that would be the most difficult to defend cutting to voters), but nevertheless, 34% of USAID amounts to $15 billion.

The other major USAID program is PEPFAR, the US President’s Emergency Plan for AIDS Relief. Created by George W. Bush, PEPFAR provides relief to people living with AIDS around the world and is credited with saving more than 25 million lives.

The FY 2024 funding was $6.5 billion. Now, while that funding hasn’t been cut, it’s not getting to the people who need it, so the best use of dollars would probably address some of that gap.

Some organizations that overlap with PEPFAR

Notes

Thursday, March 20, 2025

Making Up for DOGE II

While a majority of Americans support government funded scientific research, and many support foreign assistance, people often argue that foreign aid and government-funded research are miniscule parts of the federal budget so don't matter, but when you How much does the typical taxpayer contribute to foreign aid and NIH? The answer will probably surprise you. Lower than you might think.

Firstly, as of 2024, US government revenues were 17.1% of GDP, while expenditures were 23.4% of GDP. This means, in 2024, revenues made up only of government revenues only cover 72.9% of government expenditures, so we can say that only 72.9% is paid for by taxes, the rest is paid for by debt-purchasers.

Of all government revenues, income taxes make up about 49%. The next largest portion, 35%, comes from payroll taxes, but since payroll taxes are meant for Social Security and Medicare, they are not used for foreign aid or NIH. Because Social Security and Medicare make up a significant portion of US spending, and they're paid for, in part, by separate payroll taxes, these programs should probably not be included in these calculations.

As a result, individual taxpayers pay only 56% of the cost of NIH and foreign aid. However, even this doesn't tell the full story. Because the federal income tax is progressive, not everyone who pays federal income tax pays for the same share of government.

Proportion of Income Taxes Paid and Discretionary Spending by Income

Annual Income RangeProportion of Total Income
Taxes Paid
Contribution to Discretionary Spending (%)
$0 - $25,0000.4%0.2%
$25,000 - $50,0003.5%1.9%
$50,000 - $75,0005.4%3.0%
$75,000 - $100,0005.8%3.2%
$100,000 - $200,00019.5%10.9%
$200,000 - $500,00022.2%12.4%
$500,000 - $1,000,00011.5%6.5%
$1,000,000+31.8%17.8%

Note: Percentages are author's calculation based on Table 3.5 (2022 version) from IRS Statistics site - https://www.irs.gov/statistics/soi-tax-stats-individual-statistical-tables-by-tax-rate-and-income-percentile

Proportion of Discretionary Spending Paid by tax filers, based on income

Author's calculation

Accounting for all of this, taxpayers contribute much less to NIH and foreign aid than they might first think. The table below lays out the per tax-filer income tax contribution to these programs based on income level.

Total Contribution to Various Discretionary Programs, based on income

Income RangeTotal Foreign AidUSAIDNIH
$0 - $25,000$3.01$1.85$1.97
$25,000 - $50,000$37.57$23.10$24.56
$50,000 - $75,000$90.60$55.70$59.22
$75,000 - $100,000$153.50$94.37$100.34
$100,000 - $200,000$303.02$186.28$198.08
$200,000 - $500,000$891.78$548.21$582.94
$500,000 - $1,000,000$2,777.15$1,707.23$1,815.38
$1,000,000+$15,938.36$9,797.99$10,418.68

Total program costs can be found at previous post on subject. https://chrisoldman784482.substack.com/p/making-up-for-doge

Recent Posts

Medicaid Provider Taxes - An Explainer
March 27, 2025
Cutting Medicaid is Possible
March 24, 2025
Making Up for DOGE
March 21, 2025
Making Up for DOGE II
March 20, 2025
Social Cost of Carbon
March 12, 2025
The Argument Against Extending ACA Subsidies
January 7, 2025
Administrative Costs Aren't Waste
January 3, 2025
Social Security and the End of the Age of Responsibility
December 30, 2024
Questions for Harris
October 16, 2024
FTC, Break Up the Longshoreman
October 9, 2024

Topics

ACA | Biden | healthcare | Social Cost of Carbon | IRA | Musk | USAID | FTC | climate | insurance | 2024 | Supreme Court | student loan | discretionary spending | policy | Trump | environment | IRS | EPA | Social Security | DOGE | CO2 | taxes | inflation | Harris | foreign aid | deficit | subsidies | MA | Hayek | COLA | covid | Democrats | discretionary | standing | ports | moderation | ehrlich | poverty | Medicaid | SNAP | PEPFAR | law | NIH | waste | Bidenomics | administrative costs | market | Medicare | shortage | median voter | spending | competition | loan forgiveness | Romney | retirement | Citizens United | overpopulation | Vance | CTC | regulation | anti-trust | income taxes | non-compete | governance | exchanges | economy | central planning | Medicare Advantage | AI | 2020 | supply | election | budget | union | loans | social media | sowell | NetChoice | population | charity | discount | Child Tax Credit |

Archive