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“Yes, an individual worker might get a little more or less than market compensation from time to time,” said Steven Pizer, a health economist at the Boston University School of Public Health. “But if employment is fluid, there’s just no way, according to the theory, for that to happen consistently.”

One option under Senator Bernie Sanders’s Medicare for all plan would reduce employer spending on health insurance by $9,000 per employee and raise taxes on the wealthy. Senator Elizabeth Warren’s plan would also raise taxes on the wealthy, but would aim to tax employers an amount intended to match what they would have spent on health care anyway.

Rural America is getting old. The median age is 43, seven years older than city dwellers. Its productivity, defined as output per worker, is lower than urban America’s. Its families have lower incomes. And its share of the population is shrinking: the United States has grown by 75 million people since 1990, but this has mostly occurred in cities and suburbs. Rural areas have lost some 3 million people. Since the 1990s, problems such as crime and opioid abuse, once associated with urban areas, are increasingly rural phenomena.

Rural communities once captured a greater share of the nation’s prosperity. Jobs and wages in small town America played catch-up with big cities until the mid 1980s. During the economic recovery of 1992 to 1996, 135,000 new businesses were started in small counties, a third of the nation’s total. Employment in small counties shot up by 2.5 million, or 16 percent, twice the pace experienced in counties with million-plus populations.

The number of Americans who live in rural areas declined in the last decade, the first time in history that the nation’s rural population dropped between one U.S. census and the next.

A new report from Kenneth Johnson, a demographer at the Carsey School of Public Policy at the University of New Hampshire, finds the number of Americans who live in rural communities dropped by 289,000 over the last decade, or just about 0.6 percentage points, not much more than a rounding error among the 46 million people who live in rural areas.

Economic growth in the United States has slowed in recent decades, but the negative effects have been especially severe in rural America. Although some rural communities continue to prosper, much of rural America has faced stagnant economic conditions. One possible cause of declining economic growth is declining economic “dynamism” manifested through long-running trends such as fewer firm startups and deaths, declining entrepreneurship and innovation that leads to lower productivity growth, sclerotic labor markets, and less product market competition.

When examining key indicators of dynamism, rural America appears to have faced even greater drops dating back to the late 1970s. These include greater relative declines in migration rates, especially rural-to-urban migration that has long been a key source of upward mobility. Rural areas have also seen larger declines in new-firm creation than their urban counterparts, and there has been a greater relative shift away from small to large firms and a relative reduction in the importance of self-employment. The concern is that both small and new firms are disproportionally responsible for net job growth, and localities with greater shares of small firms and self-employment tend to subsequently grow faster in the long run.

This is, of course, not news to the people who live in rural and small-town America, who have been fighting for years to reverse this decline. But now, the nation’s political class is finally noticing. The election of Donald Trump, powered in no small degree by rural voters, has brought the troubles of small-town America to national attention, with an urgent question: What can be done to revive it?

Rural America is getting old. The median age is 43, seven years older than city dwellers. Its productivity, defined as output per worker, is lower than urban America’s. Its families have lower incomes. And its share of the population is shrinking: the United States has grown by 75 million people since 1990, but this has mostly occurred in cities and suburbs. Rural areas have lost some 3 million people. Since the 1990s, problems such as crime and opioid abuse, once associated with urban areas, are increasingly rural phenomena.

US rural hospitals are on the verge of a crisis: 430 rural hospitals — or 21% of all rural hospitals in the US — are at risk of closing unless their financial situations improve, according to a new analysis from management consulting firm Navigant.

The data highlights a likely acceleration in rural hospital closures, a trend that’s already picked up in recent years: While just three rural hospitals shuttered their doors in 2010, there were 16 closures in 2015, and 97 rural hospitals closed between 2010 and 2019 to date, according to the Cecil G. Sheps Center for Health Services Research.

Small businesses were also given a major boost when the findings of economist David Birch submitted that they were responsible for 80% of all new employment opportunities during 1968-1996. Although Birch recanted by admitting that the figure is dubious this statistic is frequently adduced to justify support for small businesses. Luckily, today there are ample studies guiding analysts to properly dissect the efficacy of small businesses.

Based on the data furnished by researchers it is evident that the importance of small businesses has been greatly embellished. For instance, innovation charity NESTA reported that during 2002-2008 in the United Kingdom, six percent of high-growth firms generated half of employment growth. Moreover, in their piece featured in the Harvard Business Review of Tuesday, February 3, 2014, Isenberg and Ross assert: “The literature consistently shows that a very small number, from one percent to six percent, or so, of all ventures in a region account for the lion’s share of net job creation and spill overs from entrepreneurship. However, increasing the number of start-ups has not increased the number of high-growth ventures.”

“Small business is the backbone of our economy.” President Barack Obama, August 17, 2010

“New businesses are the lifeblood of a healthy… economy.” PM David Cameron, November 20, 2013

Senator Whitehouse asked the Congressional Budget Office to gauge the accuracy of its projections of federal health care spending over time. In particular, he would like information about several aspects of the agency’s work: how CBO’s 2010 projections compare with actual spending and the agency’s current baseline; why the 2010 projections overestimated or underestimated actual spending; how health outcomes and spending on health care in the United States compare with those measures in other countries; and how CBO incorporates past errors into its current and future baseline projections and estimates of the costs of legislation. This letter addresses those questions. In brief, these are the agency’s findings:

CBO overestimated mandatory spending for health care in its projections for the 2010–2020 period. Over that period, mandatory outlays for the two broad budget categories covering the major health care programs (mostly Medicare and Medicaid) were 9 percent lower than CBO projected in 2010.

The share of the gross domestic product (GDP) devoted to health care reached 19.7% in 2020, an uptick from prior years as health spending increased and GDP decreased. In 2021, total national health expenditures as a share of GDP fell to 18.3% as the economy recovered and health spending increased moderately. Still, health expenditures represented a larger share of the economy in 2021 compared to pre-pandemic levels.

Health spending growth slowed in recent decades but consistently exceeded GDP growth until 2021

Health spending consumes a higher share of output in the United States than in other countries. In 2013, it accounted for 17% of Gross Domestic Product. The next highest country was France, where health spending accounted for 12% of GDP. Critics of U.S. healthcare claim this shows the system is too expensive and a burden on our economy, demanding even more government intervention. This conclusion is misleading and leads to poor policy recommendations, according to new research published by the National Center for Policy Analysis (U.S. Health Spending is Not A Burden on the Economy, NCPA Policy Report No. 383, April 2016). Discussing health spending in dollars, rather than proportion of GDP, the report notes Americans spent $9,086 per capita on healthcare in 2013, versus only $6,325 in Switzerland, the runner-up. (These dollar figures are adjusted for purchasing power parity, which adjusts the exchange rates of currencies for differences in cost of living). This big difference certainly invites us to question whether we are getting our money’s worth. However, it is not clear that this spending is a burden on Americans, given our very high national income.

After subtracting health spending from U.S. GDP, we still had $44,049 per capita to spend on all other goods and services we value. Only two countries, Norway and Switzerland, beat the United States on this measure. But compared to larger developed countries, Americans have higher income per capita after subtracting healthcare spending. For example, in the United Kingdom, GDP per capita after health spending was only $34,863 in 2013. So, even though Americans spent significantly more on healthcare than the British, the average American enjoyed $9,185 more GDP after health spending than his British peer; and just under $6,000 more than his Canadian neighbor.

Some of America’s productivity growth comes from more investment. But total factor productivity (tfp), which strips out those effects in an attempt to show increases in efficiency and the adoption of new technology, has also increased. According to the Penn World Tables, a database for cross-country comparisons, tfp in America increased by about 20% between 1990 and 2019. The g7 as a whole averaged less than half that.

How to account for this higher productivity? For starters it is useful to identify where America is at its most productive. In 2019 Robert Gordon of Northwestern University, the dean of growth studies in America, and Hassan Sayed of Princeton divided the economy into 27 different industries to pinpoint the stars. They found them in the flourishing information and communications technology industry, and saw that they shone brightest from the mid-1990s to the mid-2000s. But the rapid growth of the bit of the economy making and connecting computers was only part of the story. The rest of the economy busied itself in using the new technology productively. Productivity growth of American businesses doubled to more than 3% annually during that magical decade, whereas their European counterparts managed less than 2%. Since then American productivity growth has fallen back towards its long-run average of about 1.5%. But it is still faster than in most other rich countries, and still driven by the technology sector.

There is just one snag. On a whole range of measures American dominance remains striking. And relative to its rich-world peers its lead is increasing.

It is true that, by one measure, America is no longer the largest economy in the world. Using currency conversions based on purchasing power—that is, on what individuals can buy in their own country—China’s economy has been larger than America’s since 2016. Today China represents 18% of the world economy calculated in terms of purchasing power and America just 16%, whereas in 1990 the shares were 4% and 22% (see chart 1).

The Consumer Financial Protection Bureau (CFPB) released a new report that shows that the number of Americans with medical debt on their credit reports fell by 8.2 million from the first quarter of 2020 to the first quarter of 2022. This report is consistent with a recent report from the Centers for Disease Control and Prevention (CDC) that found that the number of Americans who are part of families having trouble paying their medical bills declined by 5.5 million between 2020 and 2021. One driver of these declines is the significant increase in the number of insured Americans over this period, a result of the President’s strategy of protecting and strengthening the Affordable Care Act (ACA) and lowering health care costs. The decline also reflects continued actions by the CFPB to highlight problems with inaccurate reporting of debt in collections and put the industry on notice to correct their behavior.

The new data also underscore the importance of the Biden-Harris Administration’s government-wide initiative to reduce the burden of medical debt. Following the Vice President’s April 2022 announcement, medical debt was directly relieved for many low-income Americans. And, informed by research showing that medical debt is not a reliable predictor of financial health, federal agencies are working to eliminate the use of medical debt to assess creditworthiness for participation in government lending programs. Specifically:

The proposal is broadly similar to Senator Sanders's proposed single-payer plan introduced during the 2016 Presidential campaign. While the campaign itself estimated that plan would cost the federal government about $14 trillion over a decade, most other estimates that we are aware of are at least twice that high.

At the time, for example, the Committee for a Responsible Federal Budget estimated roughly that the plan would cost $28 trillion through 2026 (we estimated the Sanders plan in particular would also raise $11 trillion of revenue, leading to $17 trillion of net costs). All other estimates come to similar conclusions.

Analysts estimate that a single-payer plan would cost California between $330 and $400 billion per year. If this sounds like a lot, it is. In covering a population of roughly 40 million, this would amount to about $10,000 per person per year. To give you a relative idea of the cost, this would approximately double the entire state budget.

The cost estimate is also understated, because such a plan would draw in new residents from other countries and other states who may have very expensive conditions. This could easily increase costs by 5 percent or more, for an additional $20 billion.

At the heart of the “Medicare for all” proposals championed by Senator Bernie Sanders and many Democrats is a revolutionary idea: Abolish private health insurance.

Proponents want to sweep away our complex, confusing, profit-driven mess of a health care system and start fresh with a single government-run insurer that would cover everyone.

Nor would Medicare for All insulate employers from the yearly rise in costs they've faced as health insurance premiums have marched upward. As envisioned by Senator Sanders, Medicare for All is massively underfunded—despite the historic tax increases he's promising.

Studies from the Urban Institute, the RAND Institute, and the Mercatus Center estimate the ten-year cost of Medicare for All at about $30 trillion to $40 trillion. The revenue from his new taxes, including new taxes on the wealthy and large financial institutions, would amount to only $17 trillion over ten years.

One aspect of the health care debate in the United States that is, unfortunately, riddled with misinformation is the state of Canada’s single-payer health care system. Too often advocates of Canadian-style health care in the U.S. present limited or even misleading information about the true state of Canada’s health care system and worse, often times present the ideal of Canadian health care rather than its reality.

It’s first important to recognize that a single-payer model is not a necessary condition for universal health care. There are ample examples from OECD countries where universal health care is guaranteed without imposing a single-payer model.

The idea of a single-payer health system has been gaining ground among the general U.S. population and among doctors.

However, a new study focused on the long wait times that Canadians face between the time they see a primary care doctor and can get an appointment with a specialist for follow-up. Canada has had a single-payer system since 1984.