Henry J. Aaron - Böcker

Increasingly over the past five years, uncertainty about reimbursement for routine patient care has been suspected as contributing to problems enrolling people in clinical trials. Clinical trial investigators cannot guarantee that Medicare will pay for the care required, and they must disclose this uncertainty to potential participants during the informed consent process. Since Medicare does not routinely "preauthorize" care (as do many commercial insurers) the uncertainty cannot be dispelled in advance. Thus, patients considering whether to enter trials must assume that they may have to pay bills that Medicare rejects simply because they have enrolled in the trial. This report recommends an explicit policy for reimbursement of routine patient care costs in clinical trials. It further recommends that HCFA provide additional support for selected clinical trials, and that the government support the establishment of a national clinical trials registry.These policies (1) should assure that beneficiaries would not be denied coverage merely because they have volunteered to participate in a clinical trial; and (2) would not impose excessive administrative burdens on HCFA, its fiscal intermediaries and carriers, or investigators, providers, or participants in clinical trials. Explicit rules would have the added benefit of increasing the uniformity of reimbursement decisions made by Medicare fiscal intermediaries and carriers in different parts of the country. Greater uniformity would, in turn, decrease the uncertainty about reimbursement when providers and patients embark on a clinical trial.

Why did President Clinton's efforts to reform the financing of American health care fail? For years to come, politicians and scholars of public policy will revisit the debate over Clinton's health care plan. What did planners do right? And what did they do wrong? How can the mistakes of that experience be avoided in the future? What steps can now be taken to achieve some measure of reform in smaller pieces? In The Problem That Won't Go Away, economists, political scientists, sociologists, public opinion experts, and government staff offer answers to these and other crucial questions. They recount the history of the Clinton health care plan, present several alternative strategies the administration might have pursued, and conclude that none was likely to achieve the administration's goals of universal coverage and cost containment. Many support the view that the administration, Congress, and the nation lacked the political consensus and the information to credibly describe the effects of any single bill to reform the U.S. health care system. In that case, was the only option available to the administration to reach for goals far more modest than those it sought? Health care financing as a national political issue will not go away. Pressure to cut public spending to balance the budget means that medicare and medicaid will stay in the legislative spotlight; the retirement of the baby-boom generation in the beginning of the next century promises large increases in the cost of medicare; and a flood of new and costly medical technologies will continue to put financial pressure on everyone responsible for paying for health insurance. But, as this book illustrates, the nature of the debate in the years after the demise of the Clinton plan will be altogether different from that of the past several decades.

In the early 1960s America was in a confident mood and embarked on a series of efforts to solve the problems of poverty, racial discrimination, unemployment, and inequality of educational opportunity. The programs of the Great Society and the War on Poverty were undergirded by a broad consensus about what our problems as a nation were and how we should solve them. But by the early seventies both political and scholarly tides had shifted. Americans were divided and uncertain about what to do abroad, fearful of military inferiority, and pessimistic about the capacity of government to deal affirmatively with domestic problems. A new administration renounced the rhetoric of the Great Society and changed the emphasis of many programs. On the scholarly front, new research called into question the old faiths on which liberal legislation had been based.In this book, the sixteenth volume in the Brookings series in Social Economics, Henry Aaron describes both the initial consensus and its subsequent decline. He examines the evolution of attitude and pronouncements by scholars and popular writers on the role of the federal government and its capacity to bring about beneficial change in three broad areas: poverty and discrimination, education and training, and unemployment and inflation. He argues that the political eclipse of the Great Society depended more on events external to it—war in Vietnam, dissolution of the civil rights coalition, and, finally, the Watergate scandal and all its repercussions—than on its intrinsic failings. Aaron concludes that both the initial commitment to use national polices to solve social and economic problems and the subsequent disillusionment of scholars and laymen alike rest largely on preconceptions and faiths that have little to do with research themselves.

The social security system affects people throughout most of their lives, at work and in retirement. The supposed effects of social security on saving, labor supply, and the distribution of income figure prominently in current debates about whether and how to change the system. Theorists have developed alternative analytical frameworks for studying social security, but all involve extreme assumptions introduced for the sake of analytical tractability. Each study seems to describe the behavior of some, but not all or even most people. The shortcomings of available data have created additional roadblocks. As a result, the effects of social security on saving and labor supply are difficult to measure, and how such a complex system influences behavior is not at all well understood.Yet decisions on social security cannot be avoided. If analysts cannot agree, policymakers are likely to increase the weight they attach to perceptions of equity, adequacy of benefits, fairness of taxes, and similar qualitative considerations. Hence it is desirable for lay observers to understand the framework that analysts use and the reasons why there is so much uncertainty.This book sheds light on social security issues by examining evidence from economic studies about how the system affects saving, labor supply, and income distribution. It shows that these studies provide little evidence to support or refute assertions that social security has reduced saving, but they do indicate that it has contributed to the trend toward early retirement. The author finds that the aged are now about as well off on the average as the general population and that social security has played a considerable role in bringing about this equality.This volume is the sixteenth in the second series of Brookings Studies of Government Finance.

Reform of the United States tax system has become a central political issue. Assessing Tax Reform is a concise, nontechnical book to help general readers and students understand the tax reform issues Congress is now debating. Henry Aaron and Harvey Galper lay out the major alternative proposals and analyze principles of taxation that can be used for judging them. They explore the issues surrounding a move to a comprehensive income tax, a cash-flow tax, and the value-added tax or other consumption-based taxes. They show the conflicts and opportunities resulting from large current government deficits and the move for tax reform.In addition to clarifying the problems that must be solved if large-scale, long-term reform is to be achieved, the authors describe alternative strategies for increasing revenues quickly. They also present their own program for a fair, efficient, and less complex tax structure. They conclude with an examination of the political pitfalls that continue to make any major improvements in the tax system hard to enact.

Many medical authorities predict that average life expectancy could well exceed 100 years by mid century and rise even higher soon thereafter. This astonishing prospect, brought on by the revolution in molecular biology and information technology, confronts policymakers and public health officials with a host of new questions. How will increased longevity affect local and global demographic trends, government taxation and spending, health care, the workplace, Social Security, Medicare, and Medicaid? What ethical and quality-of-life issues are raised by these new breakthroughs? In Coping with Methuselah, a group of practicing scientists and public policy experts come together to address the problems, challenges, and opportunities posed by a longer life span. This book will generate discussion in political, social, and medical circles and help prepare us for the extraordinary possibilities that the future may hold.

The well-documented gap between men's and women's earnings has aroused intense debate over the concept of comparable worth, that is, equal pay for work judged to be of equal value. Government, business, labor unions, and the courts have been forced to consider whether workers in dissimilar jobs of comparable worth—measured by such criteria as working conditions, degree of difficulty, and knowledge and responsibility required—should receive equal wages, and how wage adjustments can be implemented.The issue has provoked inflated rhetoric, litigation, and considerable confusion.In this concise study, Henry J. Aaron and Cameran M. Lougy review the conditions that have sparked the debate and unravel the implications of comparable worth for employers in public and private sectors, for labor union agendas and employer-employee negotiations, and for the administrative and and judicial burdens of the nation's courts. The authors conclude with general guidelines for implementing wage adjustments in ways that would not seriously disrupt society or have a major impact on overall economic efficiency.

Examines the effects of rising social security costs and of measures adopted to deal with them, and discusses possible ways of coping with the shortfall of available money for the aging American population.

Whether the nation would be better served by an income tax or by a consumption tax has been debated by tax experts for decades. In practice, tax systems everywhere are mixed or ""hybrid"" systems. And while legislators have reasons for enacting such systems, the mix results in inequities, inefficiencies, and abuse.For Uneasy Compromise, Brookings brought together some of the nation's most knowledgeable tax experts and analysts to address the question: How should lawmakers grapple with the problems that arise from the side-by-side existence of principles of consumption taxation with principles of income taxation? Rather than propose rules for an ideal system that will never exist, this book addresses the problems created by a hybrid system. In so doing, it offers policymakers a comprehensive and sophisticated analysis of our current tax system and the tools for evaluating proposed refinements.

Setting National Priorities continues the highly acclaimed and influential series of books that examine domestic and foreign policy choices confronting the United States. Members of the Brookings staff join outside experts to evaluate America's course through the next decade.In clear and nontechnical terms the contributors explain and evaluate options for the United States in the 1990s, consider whether the federal government's current pollicies are consistent with long-term objectives, and explain what action could best achieve those goals.Charles L. Schultze shows why it is important to solve the problem of the federal budget deficit and how it can be done: John D. Steinbruner addresses the revolution taking place in American foreign policy and explains how the United States can be more secure with lower defense spending; Lawrence J. Korb evaluates President Bush's defense budget and suggests possible improvements; Robert Z. Lawrence describes how the U.S. government and private industry should respond to the competitive challenge from foreign companies; William D. Nordhaus explains the risks form global warming and presents a policy to meet them; John E. Chubb and Eric A. Hanshek chart new directions of American elementary and secondary education; Henry J. Aaron identifies the major problems with the financing of healthcare and describes how they can be solved; and Thomas E. Mann considers how political institutions and public preferences constrain our ability to enact needed policy changes and what might be done to overcome those obstacles.

The United States spends more on health care than any other nation in the world, yet millions of Americans cannot afford basic care for acute illnesses, few are insured against the costs of long-term care, and many frequently used medical procedures have never been fully evaluated. The goals of controlling spiraling health care costs and extending insurance coverage or even maintaining current insurance coverage seem to be in conflict. But progress can be made on both goals if they are tacked together. Henry Aaron evaluates these critical issues and explores how adequate care can be provided without fueling inflation. Because the current arrangements for financing America's health care cannot endure, Aaron contends that a major national debate on the restructuring of the U.S. system of financing health care is inescapable, and major legislation is likely. Serious and Unstable Condition offers a guide that is crucial to understanding the reform debate. It explains the important economic issues of health care as a background for evaluating both the current system and proposals for change. Aaron compares the U.S. system of health care financing with certain foreign systems and reviews major options for reform. He cautions that unless the health insurance system is radically changed, the number of uninsured will continue to increase and costs will continue to escalate. He then offers his own comprehensive plan to address these problems.

In recent years, workers earnings have hardly grown, violence and crime have plagued the inner cities, homelessness and public begging have become commonplace, and family life has greatly deteriorated. With governments facing large deficits and slowly growing revenues, and public distrust in the efficiency of government and elected officials at all-time highs, the authors ask, ""What can government do for you?""This book brings together a prominent group of experts to answer this critical question. Edited by Henry Aaron and Charles L. Schultze, two of the nation's most noted and experienced economists, the book focuses on the crucial domestic and social issues confronting America today.Seven vital areas are discussed by the following contributors: Henry Aaron on health care; Gordon L Berlin and William McAllister on homelessness; Linda R Cohen and Roger G. Noll on research and development; John J. DiIulio, Jr., on crime; Frank Levy and Richard J. Murnane on education and training; Isabel V. Sawhill on children and families; and Clifford M. Winston and Barry P. Bosworth on infrastructure. In each problem area, the authors use the results of research and analysis to identify existing or proposed governmental interventions that are likely to work, as well as some that are likely to fail and some that need to be reformed. They then present a budget proposal that not only pays for suggested changes in domestic policy, but brings the budget into virtual balance in ten years.

It is not uncommon to hear that poor school performance, welfare dependancy, youth unemployment, and criminal activity result more from shortcomings in the personal makeup of individuals than from societal forces beyond their control. Are American values declining as so many suggest? And are those values at the root of many social problems today? Shaped by experience and public policies, people's values and social norms do change. What role can or should a democratic government play in shaping values? And how do these values conditon the efficacy of public policy? In this book, six distinguished social scientists identify trends in America's values and their consequences, and consider public policy tools with which some of those values might be changed. Daniel Yankelovich begins with a discussion of how American values have shifted in the last half-century, and argues that affluence is the driving force behind these changes in values. James Q. Wilson argues that destructive habits which can lead to social pathologies, like crime and drug use, are set early in life; he examines how public policy might intervene when children are young to promote better values. David Popenoe maintains that America has veered too far towards industrialist values, and explores the resulting decline of families and many attendant social ills. Nathan Glazer describes the history and present status of the dispute over multicultural education. Jane Mansbridge examines the process of building cooperation, consensus, and public spirit. And George Akerlof and Janet L. Yellen discuss the problem of gang criminality. Inthe past, social scientists have often sidestepped questions about values as undefinable, unquantifiable, and somehow unscientific. The essays in this volume address these questions at last. Henry J. Aaron, director of the Economic Studies program at Brookings, is the authorof numerous books, including most recently Serious and Unstable Condition: Financing America's Health Care (1991), and coeditor of Setting Domestic Priorities (1992). Thomas E. Mann is director of the Brookings Governmental Studies program, coeditor of Media Polls in American Politics (1992), and coauthor of the Renewing Congress series (1993). Timothy Taylor is managing editor of the Journal of Economic Perspectives at Stanford University.

The tax system profoundly affects countless aspects of private behavior. It is a powerful policy influence on the distribution of income and it is the one aspect of government that almost every citizen cannot avoid. With tax reform high on the political agenda, this book brings together studies of leading tax economists and lawyers to assess the various reform proposals and examine the effects of tax reform in several distinct areas. Together, these studies and comments on them present a balanced evaluation of professional opinion on the issues that will be critical in the tax reform debate.The book addresses annual and lifetime distributional effects, saving, investment, transitional problems, simplification, home ownership and housing prices, charitable groups, international taxation, financial intermediaries and insurance, labor supply, and health insurance.In addition to Henry Aaron and William Gale, the contributors include Alan Auerbach, University of California, Berkeley; David Bradford, Princeton University; Charles Clotfelter, Duke University; Eric Engen, Federal Reserve; Don Fullerton, University of Texas; Jon Gruber, Massachusetts Institute of Technology; Patric Hendershott, Ohio State; David Ling, University of Florida; Ronald Perlman, Covington & Burling; Diane Lim Rogers, Congressional Budget Office; John Karl Scholz, University of Wisconsin; Joel Slemrod, University of Michigan; and Robert Triest, University of California, Davis.

Deciding when and how to retire are among the most important decisions most people make. Can they be depended on to plan with foresight and make sound decisions? According to standard economic analysis the answer is a qualified ""yes."" But studies by psychologists, sociologists, and economists themselves raise doubts about this comforting appraisal. This volume by analysts trained in economics and other disciplines suggests that retirement planning and decisions fall far short of the rational ideal. Gary Burtless explains what economic research has to say about retirement behavior. Annamaria Lusardi reports that many people in their fifties and older say they have not even thought about retirement. Mathey Rabin and Ted O'Donoghue show that procrastination can cause huge economic losses. Robert Axtell and Joshua Epstein show that herd behavior explains observed patterns of retirement behavior better than does the assumption of rational decisionmaking. George Loewenstein, Drazen Prelec, and Roberto Weber report that many people incorrectly anticipate what retirement will be like and rationalize whatever decision they have made. David Fetherstonhaugh and Lee Ross report experimental evidence that the effect of Social Security provisions may depend on how these policies are ""framed"" as well as on the specific content of those policies. These and other authors also explore the broader implications of these behavioral patterns. Copublished with Russell Sage Foundation

Over the past four decades, the share of income devoted to health care nearly tripled. If policy is unchanged, this trend is likely to continue. Should Americans decide to rein in the growth of health care spending, they will be forced to consider whether to ration care for the well-insured, a prospect that is odious and unthinkable to many. This book argues that sensible health care rationing can not only save money but improve general welfare and public health. It reviews the experience with health care rationing in Great Britain. The choices the British have made point up the nature of the options Americans will face if they wish to keep public health care budgets from driving taxes ever higher and private health care spending from crowding out increases in other forms of worker compensation and consumption. This book explains why serious consideration of health care rationing is inescapable. It also provides the information policymakers and concerned citizens need to think clearly about these difficult issues and engage in an informed debate.

People pay taxes for two reasons. On the positive side, most people recognize, even if grudgingly, that payment of tax is a duty of citizenship. On the negative side, they know that the law requires payment, that evasion is a crime, and that willful failure to pay taxes is punishable by fines or imprisonment. The practical questions for tax administration are how to strengthen each of these motives to comply with the law. How much should be spent on enforcement and how should enforcement be organized to promote these objectives and achieve the best results per dollar spent? Over the last few years, the U.S. Congress has restricted spending on tax administration, forcing the Internal Revenue Service to curtail enforcement activities, at the same time, that the number of individual filers has increased, tax rules have become more complex, and more business have become multinational operations. But if too many cases of tax evasion go undetected and unpunished, those who may have grudgingly paid their taxes may soon find it easier to join the scofflaws. These events in combination have created a genuine crisis in tax administration. The chapters in this volume evaluate the capacity of authorities to enforce the tax laws in a modern, global economy and examine the implications of failing to do so. Specific aspects of tax law, including tax shelters, issues relating to small businesses, tax software, role of tax preparers, and the objectives of tax simplification are examined in detail. The volume also builds a conceptual basis for future scholarship, with regard not only to tax administration, but also to such fundamental questions as whether taxpayers respond mostly to economic incentives or are influenced by their experiences with the filing process and what is the proper framework for evaluating the allocation of resources within the IRS.

Few people realize that one of the nation's largest health programs runs through the tax system. Reformers of all stripes propose to modify current tax rules as part of larger programs to increase coverage and control costs. Is the current system working? Will tax-based reforms achieve their goals? Several of the nation's foremost experts on taxation and health policy address these questions in Using Taxes to Reform Health Insurance, a joint product of the Urban-Brookings Tax Policy Center and the American Tax Policy Institute. Led by respected economists Henry Aaron of the Brookings Institution and Leonard Burman of the Urban Institute, contributors examine the role taxes currently play, the likely effects of recently introduced health savings accounts, the challenges of administering major subsidies for health insurance through the tax system, and options for using the tax system to expand health insurance coverage. No taxpayer or consumer of health care services can afford to ignore these issues.

More powerful and affluent today than ever, the United States has promising opportunities to influence the course of history. Yet these prospects are shadowed by significant perils and burdens. In this visionary book, leading scholars from the Brookings Institution and other prominent research organizations and universities analyze the major domestic and foreign policy problems facing the nation over the next five to ten years. The challenges on the domestic front are formidable: assuring fair but affordable access to health care, shoring up retirement income for an aging population, encouraging long-term economic growth, easing the growing pains of an increasingly diverse society, and reconciling energy policies with environmental concerns. In international affairs the central task is to use America's unprecedented power wisely and to protect a homeland that has been revealed as surprisingly vulnerable. Yet efforts must also focus on improving the economic fortunes of poorer countries, expanding trade, and reforming the rules that regulate the flows of capital across national borders. Is the United States government capable of rising to these vast and varied challenges? The concluding chapters of this book offer cautious optimism. While it is often criticized, the American political system is fundamentally resilient and flexible. Ambitious in scope, Agenda for the Nation provides thoughtful, constructive answers to questions of how the U.S. government can effectively serve its citizens and meet its global responsibilities in a world of opportunity and uncertainty.

Academic medical centers provide cutting edge acute care, train tomorrow's physicians, and carry out research that will expand the range of treatable and curable illnesses. But these centers themselves may need urgent care—experts generally agree that many are suffering acute—even life-threatening—financial distress. Many academic medical centers are suffering for several reasons: in-patient admissions are down, as many procedures that once required a hospital stay are now performed on an out-patient basis or in a physician's office ; managed care plans have negotiated discounted fees that cut hospital operating margins; the Balanced Budget Act of 1997 curtailed Medicare reimbursements, lowered margins and pushed some into the red; the revolution in information technology is imposing large new capital costs; and the character of medical education is receiving its most thorough review in decades. While there is a general consensus that medical centers are under pressure, experts disagree about the depth and pervasiveness of the current financial distress. Are they whining about financial pressures other, less-favored sectors find routine; or is the high quality American teaching hospital becoming an endangered species—that could face extinction if nothing is done. Because academic medical centers perform such important jobs, it is critical to determine the true nature and depth of their current financial problems—and then fashion analytically sound and politically sustainable solutions. This book brings together chief executive officers of major medical centers, university presidents, senior members of Congressional and executive office staffs, and leading analysts. These experts address the key issues and prescribe remedies both regulatory and legislative to ensure that the teaching hospital remains a picture of financial health. Contributors include Nancy Kane (Harvard School of Public Health), Jamie Reuter (Institute for Health Care Research P

As the average age of the population continues to rise in industrialized nations, the fiscal impacts of aging demand ever-closer attention. Closing the Deficit examines one oft-discussed approach to the issue—encouraging people to work longer than they now do.Workers would spend more years paying taxes and fewer years drawing pension and health benefits. But how much difference to spending and revenues would longer working lives make? What steps could be taken to make longer working lives attractive? And what would happen to older Americans not in a position to prolong their work lives? Leading scholars examine these issues in Closing the Deficit, edited by Brookings economists Gary Burtless and Henry Aaron.

Everyone agrees on the need to reform Medicare but not on how to do it. Some argue the program is too comprehensive, others that it is not comprehensive enough. Some suggest it pays too much for health care, others, too little. Meanwhile, the financial stakes continue to mount. Medicare spending exceeded $400 billion in 2007, making it more expensive than the entire health systems of most other nations, as well as the largest national public program other than Social Security and national defense. In R eforming Medicare, Henry J. Aaron and Jeanne M. Lambrew deftly guide readers through this complex debate. They identify and analyze the three leading approaches to reform. Updated social insurance would retain the current system while rationalizing coverage and reducing bureaucracy. Premium support would replace the current system with a capped, per-person payment that beneficiaries could use to buy health insurance. Consumer-directed Medicare would have beneficiaries pay for care up to a high deductible from government- supported savings accounts and offer premium-support coverage above the deductible. In addition to rating each option on its ability to promote access to health care, improve the quality of care, and control costs, the authors evaluate each reform's political strengths and weaknesses. Given the heat generated by the Medicare debate, it is unlikely that any single approach will be implemented in full. Consequently, Aaron and Lambrew describe incremental strategies that blend elements of each plan. Their analysis provides essential insight into the types of hybrid policies that Congress will consider in coming years.