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I can’t really speak for the Public Health Service, but I will say that I have met many officers from that service that were serving with other services. The NOAA Corps does not have a medical staff and relies on USPHS to fill the medical professional roles within the fleet and on shore. For more information, you might read up on the history of the USPHS at the link below:History of USPHSAs for the NOAA Corps, I will begin by saying that a majority of my career was spent with the Office of Coast Survey, which is where I feel that the NOAA Corps officers have the clearest role (as opposed to Fisheries or Oceanography vessels). My response is going to be centered on hydrographic (hydro) officers and not touch on Fisheries vessels, Oceanography vessels, or flight.The predecessor of the NOAA Corps was the US Coast and Geodetic Survey Corps; hence the modern NOAA Corps has its history tied to the Coast Survey. For a detailed look at this history, I recommend the book U.S. Coast Survey Vs. Naval Hydrographic Office: A 19Th-Century Rivalry in Science and Politics, which discusses a lot of the political reasons for the formation of the Corps and I consider a pretty interesting read (of course I also am a licensed hydrographer, so take that recommendation with a grain of salt).The (hopefully) short version is this: Coast Survey was formed in 1807 by Thomas Jefferson to survey the coast and created navigation charts for the safety of shipping. They did this for 110-years as a completely civilian organization; they had a Superintendent and then Assistants that were in charge of all the field parties. In 1917 the Coast and Geodetic Survey Corps came into existence after the US entered WWI and Coast Survey personnel were transferred to the Army, Navy, and Marines to bring their survey knowledge to bare in the battle field. The same thing happened during the Civil War, when Coast Survey Assistants worked surveying battlefields as civilians. Civilian Coast Surveyors served in virtually all theaters of the war including the defenses of Washington, on the Peninsula with McClellan, with the Union blockading forces, with Farragut and Porter on the Mississippi and Red Rivers, with Grant at Chattanooga and in Virginia, and with Sherman in Georgia and the Carolinas. They were often in the front lines or in advance of the front lines conducting their mapping or charting and ran the very real risk of being captured and executed as spies (civilian assistants accompanying armed forces).Upon calling on the USC&GS Assistants to again accompany armed forces into battle, it was decided that transferring them as a commissioned corps of uniformed officers would be a good solution to the problem of being potentially shot as spies and would allow for the quick and easy assimilation of USC&GS into the armed forces should their skills be required in the future. Assistants were given ranks commensurate with their seniority and positions within USC&GS and thus the Corps was born. During the war they served as artillery orienteering officers, mine-laying officers in the North Sea, troop transport navigators, intelligence officers, and even on the staff to General "Black Jack" Pershing.That’s the official line on why the USC&GS Corps came into existence, but it also solved a few other problems the USC&GS was having regarding retirement, structure, and vessel staffing. The first was that there was no retirement pension for Assistants and being in a military structure resolved that issue by entitling retiring Corps officers to standard military retirements. Secondly, the Navy and, to a lesser extent, the Army had previously been significant parts of the USC&GS operations. The Army withdrew all their officers after the Civil War, but the Navy still provided masters for the USC&GS vessels through the Spanish American War (1898). Following the withdrawal of the Naval officers, the civilian Assistants were acting as masters on these vessels without clear authority to do so (they had no licenses). By becoming commissioned officers, they could legitimately fill these roles in the same way that Navy deck officers may stand a navigation watch on a government vessel without the need for a merchant mariner credential. Their service was also fraught with the hardships of a lifestyle that was characterized by years in survey field assignments or attached to survey vessels; a lifestyle akin to military deployments and improved by the ability to provide special pay and benefits as a uniformed service.The USC&GS was again called upon to serve in action during WWII. Officers of the Survey served in North Africa, Europe, and throughout the Pacific; many were assigned to Army, Navy, or Marine Corps units, but several of the Survey’s ships were also transferred to the Navy to undertake survey work ahead of the front lines. Admiral Chester Nimitz is quoted as stating, "The road to Tokyo was paved with Pathfinder charts" and made a point of referring to the ship as a C&GS ship, even though it was technically a Navy vessel during the campaign.After a couple reorganizations the USC&GS was eventually rolled into the modern day NOAA along with several other federal science agencies (Bureau of Commercial Fisheries and National Weather Service) in 1970. At that time the USC&GS Corps became the NOAA Corps. Slowly the Corps officers were distributed across all of NOAA’s six main line offices (The National Weather Service; National Marine Fisheries Service; Office of Oceanic and Atmospheric Research; National Environmental Satellite, Data and Information Service; National Ocean Service; and Office of Marine and Aviation Operations). They also have billets with DOD, the U. S. Coast Guard, NASA, and the Department of State. Through the Office of Marine and Aviation Operations, they operate NOAA's fleet of research and survey vessels and aircraft.That’s the history. While it’s true that the modern NOAA Corps officers could be transferred in the same way to the military during time of emergency, I don’t think that it is a very likely scenario. So, what is the justification of the NOAA Corps and why couldn’t they be replaced by civilians? (Wow, it took me that long to get to answering the question…so much for the short version).Again, speaking only from the perspective of a hydro officer, I think there are a few areas where the commissioned officers offer a distinct benefit. To replace a Junior Officer (JO) on one of the hydrographic survey platforms you would need to hire a civilian mate with a USCG license and you would need to hire a survey technician, because the JO fills both roles. I would also argue that the JO does a better job in both roles for the sole reason that experience on the bridge driving the ship and using nautical charts for navigation informs their hydrographic survey work and helps produce a better product, and vice versa. When you have someone making a product, it’s likely to be much better if that person has used that product themselves. Additionally, officers rotate from sea to shore assignments and bring their experiences with them in a way that civilians generally don’t (not that they don’t bring their experience, but they don’t move within the organization as often). NOAA Corps officers are often moved from one side of the country to the other and face prolonged family separations (ultimately the reason I resigned my commission). However, that movement creates movement of ideas, concepts, and knowledge within the organization; bringing field experience to headquarters and political/strategic experience to the field. The Director of the Office of Coast Survey is a NOAA Corps RDML (currently RDML Shep Smith), which means he started out his career as an Ensign managing a survey sheet on a ship and has a direct connection to how the nautical charting data is acquired in the field and how it is used on a chart.That’s my take on why NOAA needs a commissioned corps, and if it is ever done away with I think the National Ocean Service will suffer for it.

HelloThe U.S. health care system is unique among advanced industrialized countries. The U.S. does not have a uniform health system, has no universal health care coverage, and only recently enacted legislation mandating healthcare coverage for almost everyone. Rather than operating a national health service, a single-payer national health insurance system, or a multi-payer universal health insurance fund, the U.S. health care system can best be described as a hybrid system. In 2014, 48 percent of U.S. health care spending came from private funds, with 28 percent coming from households and 20 percent coming from private businesses. The federal government accounted for 28 percent of spending while state and local governments accounted for 17 percent.[1] Most health care, even if publicly financed, is delivered privately.In 2014, 283.2 million people in the U.S., 89.6 percent of the U.S. population had some type of health insurance, with 66 percent of workers covered by a private health insurance plan. Among the insured, 115.4 million people, 36.5 percent of the population, received coverage through the U.S. government in 2014 through Medicare (50.5 million), Medicaid (61.65 million), and/or Veterans Administration or other military care (14.14 million) (people may be covered by more than one government plan). In 2014, nearly 32.9 million people in the U.S. had no health insurance.[2]This fact sheet will compare the U.S. health care system to other advanced industrialized nations, with a focus on the problems of high health care costs and disparities in insurance coverage in the U.S. It will then outline some common methods used in other countries to lower health care costs, examine the German health care system as a model for non-centralized universal care, and put the quality of U.S. health care in an international context.In Comparison to Other OECD CountriesThe Organization for Economic Co-operation and Development (OECD) is an international forum committed to global development that brings together 34 member countries to compare and discuss government policy in order to “promote policies that will improve the economic and social well-being of people around the world.”[3] The OECD countries are generally advanced or emerging economies. Of the member states, the U.S. and Mexican governments play the smallest role in overall financing of health care.[4] However, public (i.e. government) spending on health care per capita in the U.S. is greater than all other OECD countries, except Norway and the Netherlands.[5]This seeming anomaly is attributable, in part, to the high cost of health care in the U.S. Indeed, the U.S. spends considerably more on health care than any other OECD country.The OECD found that in 2013, the U.S. spent $8,713 per person or 16.4 percent of its GDP on health care—far higher than the OECD average of 8.9 percent per person.[6] Following the U.S. were the Netherlands, which allocated 11.1 percent of its GDP, then Switzerland also at 11.1 percent, and Sweden, which allocated 11 percent of its GDP to health care in 2013. In North America, Canada and Mexico spent respectively 10.2 percent and 6.2 percent of their GDP on health care.On a per capita basis, the U.S. spends more than double the $3,453 average of all OECD countries (see chart[7] below).[8]Health Expenditure per capita, 2013 (or nearest year)Drivers of Health Care Spending in the U.S.Prohibitively high cost is the primary reason Americans give for problems accessing health care. Americans with below-average incomes are much more likely than their counterparts in other countries to report not: visiting a physician when sick; getting a recommended test, treatment, or follow-up care; filling a prescription; and seeing a dentist.[9] Fifty-nine percent of physicians in the U.S. acknowledge their patients have difficulty paying for care.[10] In 2013, 31 percent of uninsured adults reported not getting or delaying medical care because of cost, compared to five percent of privately insured adults and 27 percent of those on public insurance, including Medicaid/CHIP and Medicare.[11]While there is no agreement as to the single cause of rising U.S. health care costs, experts have identified three contributing factors. The first is the cost of new technologies and prescription drugs. Some analysts have argued “that the availability of more expensive, state-of-the-art medical technologies and drugs fuels health care spending for development costs and because they generate demand for more intense, costly services even if they are not necessarily cost-effective.”[12]In 2013, the U.S. spent $1,026 per capita on pharmaceuticals and other non-durable medical care, more than double the OECD average of $515.[13]Another explanation for increased costs is the rise of chronic diseases, including obesity. Nationally, health care costs for chronic diseases contribute huge proportions to health care costs, particularly during end of life care. “Patients with chronic illness in their last two years of life account for about 32% of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations.”[14] The National Academy of Sciences found that among other high-income nations the U.S. has a higher rate of chronic illness and a lower overall life expectancy. Their findings suggest that this holds true even when controlling for socio-economic disparity.[15] Experts are focusing more on preventative care in an effort to improve health and reduce the financial burdens associated with chronic disease.[16] One provision of the Patient Protection and Affordable Care Act, commonly referred to as simply the Affordable Care Act (ACA), implemented in 2013, provides additional Medicaid funding for states providing low cost access to preventative care.[17]Finally, high administrative costs are a contributing factor to the inflated costs of U.S. health care. The U.S. leads all other industrialized countries in the share of national health care expenditures devoted to insurance administration. It is difficult to determine the exact differences between public and private administrative costs, in part because the definition of “administrative” varies widely. Further, the government outsources some of its administrative needs to private firms.[18] What is clear is that larger firms spend a smaller percentage of their total expenditures on administration, and nationwide estimates suggest that as much as half of the $361 billion spent annually on administrative costs is wasteful.[19] In January 2013, a national pilot program implemented under the ACA began. The aim is to improve administrative efficiency by allowing doctors and hospitals to bundle billing for an episode of care rather than the current ad hoc method.[20]Health Insurance in the U.S.: Uneven CoverageWhile the majority of U.S. citizens have health insurance, premiums are rising and the quality of the insurance policies is falling. Average annual premiums for family coverage increased 11 percent between 1999 and 2005, but have since leveled off to increase five percent per year between 2005 and 2015.[21] Deductibles are rising even faster. Between 2010 and 2015, single coverage deductibles have risen 67 percent.[22] These figures outpace both inflation and workers’ earnings.The lack of health insurance coverage has a profound impact on the U.S. economy. The Center for American Progress estimated in 2009 that the lack of health insurance in the U.S. cost society between $124 billion and $248 billion per year. While the low end of the estimate represents just the cost of the shorter lifespans of those without insurance, the high end represents both the cost of shortened lifespans and the loss of productivity due to the reduced health of the uninsured.[23]Health insurance coverage is uneven and often minorities and the poor are underserved. Forty million workers, nearly two out of every five, do not have access to paid sick leave. Experts suggest that the economic pressure to go to work even when sick can prolong pandemics, reduce productivity, and drive up health care costs.[24]There were 32 million uninsured Americans in 2014, nine million fewer than the year prior. Experts attribute this sharp decline in the uninsured to the full implementation of the ACA in 2014.[25] Of American adults who had health insurance in 2014, 73 percent had one or more full-time workers in the family and 12 percent had one or more part-time workers in the family.[26] Just 49 percent of American adults reported getting health insurance from an employer in 2014.[27]Coverage by employer-provided insurance varies considerably by wage level. Firms with higher proportions of low-wage workers are less likely to provide access to health insurance than those with low-proportions of low-wage workers.[28]In 2014, 11.2 percent of full-time workers were without health insurance. However, the percentage of part-time workers without insurance was 17.7 percent, a significant decrease from 24 percent in 2013, thanks in part to the Affordable Care Act. The uninsured rate among those who had not worked at least one week also decreased from 22.2 percent in 2013 to 17.3 percent in 2014.[29]Smaller firms are significantly less likely to provide health benefits to full or part-time workers. Among all small firms (3-199 workers) in 2015, only 56 percent offered health coverage, compared to 98 percent of large firms.[30]After the Affordable Care Act allowed for many young adults (19-25) to remain on their parents’ health plans, there was a statistically significant increase in the percentage of insured young people from 68.3 percent in 2009[31] to 82.9 percent in 2014.[32] Over the same period, the percentage of young people aged 26-34 with insurance increased from 70.9 percent to 81.8 percent.[33]Minorities and children are disproportionately uninsured. In 2014, 7.6 percent of non-Hispanic Whites were uninsured, 11.8 percent of Blacks were uninsured, 9.3 percent of Asians, and 19.9 percent of people of Hispanic origin were uninsured.[34] The Kaiser Family Foundation has found that about 80 percent of the uninsured are U.S. citizens.[35] Among children, six percent were uninsured in 2014.[36] These children are 10 times more likely than insured children to have unmet medical needs and are five times as likely as an insured child to go more than two years without seeing a doctor.[37]Women in the individual market often faced higher premiums than men for the same coverage. Beginning in 2014, the Affordable Care Act banned this practice, as well as denying coverage for pre-existing conditions.[38]In 2014, 19.3 percent of the population living below 100 percent of the poverty line ($23,550 a year for a family of four) was uninsured.[39] According to the Kaiser Family Foundation, 90 percent of the uninsured have family incomes within 400 percent of the federal poverty level. This makes them eligible for either subsidized coverage through tax credits or expanded Medicaid eligibility under the Affordable Care Act’s state health exchanges. [40]Rising Healthcare PremiumsHealth insurance premiums in the U.S. are rising fast. From 2005 to 2015, average annual health insurance premiums for family coverage increased 61 percent, while worker contributions to those plans increased 83 percent in the same period. This rate of increase outpaces both inflation and increases in workers’ wages.[41]In 2005, the average annual premiums for employer-sponsored health insurance were $2,713 for single coverage and $8,167 for family coverage. In 2015, premiums more than doubled to $6,251 for employer-sponsored single coverage and $17,545 for employer-sponsored family coverage.[42]A growing number of workers face a deductible of $1,000 or more for individual plans. In 2015, 46 percent (compared to 38 percent in 2013 and 22 percent in 2009) of workers were enrolled in a plan with an annual deductible of $1,000 or more. Employees at small firms are more likely than those at large firms to have a deductible greater than $1,000.[43]The Union Difference: Union workers are more likely than their nonunion counterparts to be covered by health insurance and paid sick leave. In March 2015, 95 percent of union members in the civilian workforce had access to medical care benefits, compared with only 68 percent of nonunion members. In 2015, 85 percent of union members in the civilian workforce had access to paid sick leave compared to 62 percent of nonunion workers.[44] At the median, private-sector unionized workers pay 38 percent less for family coverage than private-sector nonunionized workers, according to a 2009 study.[45]Across states, there are significant disparities in both the availability and the cost of health care coverage.In 2012, Medicare reimbursements per enrollee varied from $6,724 in Anchorage, Alaska to $13,596 in Miami, Florida.[46] Annual premiums are similarly disparate. In 2015, the average family premium in the South was $16,785 while the same coverage averaged $18,096 in the Northeast.[47]Firms in the South were less likely to provide coverage for an employee’s domestic partner than other regions. In the South, 41 percent of firms reported providing benefits for same-sex partners (compared to 51 percent in the Northeast) and 20 percent reported offering benefits to opposite-sex domestic partners (compared to 46 percent in the Northeast).[48]High Costs Drive Americans into BankruptcyUniversal coverage, in countries like the United Kingdom, Switzerland, Japan, and Germany makes the number of bankruptcies related to medical expenses negligible.[49] Conversely, a 2014 survey of bankruptcies filed between 2005 and 2013 found that medical bills are the single largest cause of consumer bankruptcy, with between 18 percent and 25 percent of cases directly prompted by medical debt.[50] Another survey found that in 2013, 56 million Americans under the age of 65 had trouble paying medical bills.[51] Another 10 million will face medical bills they are unable to pay despite having year-round insurance.[52]It has been suggested, based on the experience of Massachusetts, where medical-related bankruptcies declined sharply after the state enacted its health reform law in 2006, that the ACA may help reduce such bankruptcies in the future.[53]The Affordable Care Act: Successes and Remaining ChallengesIn March, 2010, President Obama signed the ACA into law that made hundreds of significant changes to the U.S. healthcare system between 2011 and 2014. Provisions included in the ACA are intended to expand access to healthcare coverage, increase consumer protections, emphasizes prevention and wellness, and promote evidence- based treatment and administrative efficiency in an attempt to curb rising healthcare costs.Beginning in January 2014, almost all Americans are required to have some form of health insurance from either their employer, an individual plan, or through a public program such as Medicaid or Medicare. Since the so-called “individual mandate” took effect, the total number of nonelderly uninsured adults dropped from 41 million in 2013 to 32.3 million in 2014.[54] The largest coverage gains were concentrated among low-income people, people of color, and young adults, all of whom had high uninsured rates prior to 2014.[55]A major provision of the ACA was the creation of health insurance marketplace exchanges where individuals not already covered by an employer-provided plan or a program such as Medicaid or Medicare can shop for health insurance. Individuals with incomes between 100 percent and 400 percent of the federal poverty line would be eligible for advanceable premium tax credits to subsidize the cost of insurance. States have the option to create and administer their own exchanges or allow the federal government to do so. Currently, only 14 states operate their own exchanges.[56]Designed to promote competition among providers and deliver choice transparency to consumers, the state-based exchanges appear to be doing just that. A recent analysis by the Commonwealth Fund found that the number of insurers offering health insurance coverage through the marketplaces increased from 2014 to 2015.[57] Additionally, there was generally no reported increase in average premiums for marketplace plans over that period. The analysis found only a modest increase in average premiums for the lowest cost plans from 2015 to 2016.[58]The ACA also included a major expansion of the Medicaid program, although the Supreme Court ruled in 2012 that this expansion is a state option. As of November 2015, 30 states have chosen to expand Medicaid. As of 2014, adults with incomes at or below 138 percent of the federal poverty line are now eligible for Medicaid in the states that have adopted the expansion.[59]Despite improvements to the U.S healthcare system under the ACA, a number of challenges remain. In 2014, 10.4 percent of Americans were still uninsured[60], and those with insurance still face high deductibles and premium costs. Furthermore, in the 20 states that had not expanded Medicaid, an estimated three million poor adults fall into the “coverage gap” where their incomes are above current Medicaid eligibility limits but below the lower limit of premium credits on the healthcare exchanges. The bulk of people in the coverage gap are concentrated in the South, with Texas (766,000 people), Florida (567,000), Georgia (305,000) and North Carolina (244,000) having among the highest number of uninsured.[61]The ACA included a number of other provisions to improve healthcare access and affordability. The law banned lifetime monetary caps on insurance coverage for all new plans and prohibited plans from excluding children and most adults with preexisting conditions.[62] Insurance plans are also prohibited from cancelling coverage except in the case of fraud, and are required to rebate customers if they spend less than 85 percent (80 percent for individual and small group plans) of premiums on medical services. Additionally, the ACA established the Prevention and Public Health Fund to allocate $7 billion towards preventative care such as disease screenings, immunizations, and pre-natal care for pregnant women and between 2010 and 2015. Furthermore, $11 billion in funding for community health centers and $1.5 billion in additional funding for the National Health Service Corps was included in the law.[63]A number of cost control provisions were included in the ACA in an attempt to curb rising medical costs. Among them is the Independent Payment Advisory Board, which will provide recommendations to Congress and the President for controlling Medicare costs if the costs exceed a target growth rate. The administrative process for billing, transferring funds, and determining eligibility is being simplified by allowing doctors to bundle billing for an episode of care rather than the current ad hoc method. Additionally, changes were made to the Medicare Advantage program that would provide bonuses to high rated plans, incentivizing these privately-operated plans to improve quality and efficiency. Furthermore, hospitals with high readmission rates will see a reduction in Medicare payments while a new Innovation Center within the Centers for Medicare and Medicaid Services was created to test new program expenditure reduction methods.[64]Common Methods to Lower Health Care CostsBy taking an international perspective and looking to other advanced industrialized countries with nearly full coverage, much can be learned. While methods range widely, other OECD countries generally have more effective and equitable health care systems that control health care costs and protect vulnerable segments of the population from falling through the cracks. Among the OECD countries and other advanced industrialized countries, there are three main types of health insurance programs:A national health service, where medical services are delivered via government-salaried physicians, in hospitals and clinics that are publicly owned and operated—financed by the government through tax payments. There are some private doctors but they have specific regulations on their medical practice and collect their fees from the government. The U.K., Spain, and New Zealand employ such a system. [65]A national health insurance system, or single-payer system, in which a single government entity acts as the administrator to collect all health care fees, and pay out all health care costs. Medical services are publicly financed but not publicly provided. Canada, Denmark, Taiwan, and Sweden have single-payer systems.A multi-payer health insurance system, or all-payer system, which provides universal health insurance via “sickness funds,” used to pay physicians and hospitals at uniform rates, thus eliminating the administrative costs for billing. This method is used in Germany, Japan, and France.[66]A universal mandate for health care coverage defines these systems. Such a mandate eliminates the issue of paying the higher costs of the uninsured, especially for emergency services due to lack of preventative care.[67] Other methods for reducing costs may include:Funding health care costs in relation to income rather than risk or people’s medical history.[68]Negotiating the price of prescription drugs and bulk purchasing of prescription medications and durable medical equipment is a method used in other countries for lowering costs. This has been effectively used by the U.S. Department of Veterans Affairs, Medicaid, and Health Management Organizations in the U.S. Yet, it has been prohibited by law from traditional Medicare. Savings of up to five percent of total health care expenditures could result from the full adoption of these practices.[69]An International Case Study: How Germany Pays for Health CareGermany has one of the most successful health care systems in the world in terms of quality and cost. Some 240 insurance providers collectively make up its public option. Together, these non-profit “sickness funds” cover 90 percent of Germans, with the majority of the remaining 10 percent, generally higher income Germans, opting to pay for private health insurance. The average per-capita health care costs for this system are less than half of the cost in the U.S. The details of the system are instructive, as Germany does not rely on a centralized, Medicare-like health insurance plan, but rather relies on private, non-profit, or for-profit insurers that are tightly regulated to work toward socially desired ends—an option that might have more traction in the U.S. political environment.[70]The average insurance contributions to German sickness funds are based on an employee’s gross income, around 15.5 percent with an income cap at $62,781, and employers and employees each pay about half of the premium. Generally, an individual employee’s contribution is 8.2 percent and the employer pays the remaining 7.3 percent.[71] [72]Premiums are not based on risk and are not affected by a person’s marital status, family size, or health. Germans have no deductibles and low co-pays.[73]Doctors are private entrepreneurs and get a fee from insurers for every visit and procedure they perform. However, they are tightly regulated. Groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets. Doctors must remain in these budgets, as they do not receive additional funding if they go over. This helps keep health care costs in check and discourages unnecessarily expensive procedures. The average German doctor also makes about one-third less per year than in the U.S., around $123,000.[74]Government general revenues cover premiums for children, on the premise that the next generation should be the entire nation’s fiscal responsibility, instead of just the responsibility of the parents.[75]Germany reformed its coverage for prescription drugs in 2010 after costs for prescription drugs continued to rise. Prior to reforms, drug companies set the price for new drugs and were not required to show that the new drug was an improvement over previously available prescription drugs. Pursuant to the reforms effective in 2011, manufacturers could set the price for the first 12 months a new drug is on the market. “As soon as the drug enters the market, a new process of benefit assessment begins.” Manufacturers must establish, through comparative effective research that the new drug has an “added benefit to the patient, compared to the previously existing standard treatment.” Drugs without added benefit will be reimbursed according to a government pricing list. New drugs without added benefits are available to patients, but the patient has to pay the price difference. For drugs with added benefit, a price will be negotiated between health insurers and the manufacturer.[76]Quality of U.S. Health Care in an International ContextU.S. health care specialists are among the best in the world. However, treatment in the U.S. is inequitable, overspecialized, and neglects primary and preventative care.[77] The end result of the U.S. approach to health care is poorer health in comparison to other advanced industrialized nations. According to the Commonwealth Fund Commission, in a 2014 comparison with Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the U.K., the U.S. ranked last overall. In terms of quality of care, the U.S. ranked fifth, but came in last place in efficiency, equity, and healthiness of citizens’ lives.[78]Comparing other health care indicators in an international context underscores the dysfunction of the U.S. health care system.Despite the relatively high level of health expenditure, in the U.S. there are fewer physicians per capita than in most other OECD countries. In 2013, the U.S. had 2.6 practicing physicians per 1,000 people—below the OECD average of 3.3.[79]In the U.S., there are only about 1.2 primary care physicians per 1,000 people. Projections indicate that the U.S. will need 52,000 more primary care physicians by 2025 to meet demand.[80] While population growth and aging make up a substantial proportion of this increased need, expanded access to insurance under the Affordable Care Act means more people will seek out treatment. Therefore, there are provisions in the legislation to increase the number of primary care physicians in the U.S.There is a significant spatial mismatch within the United States for physicians as well. While the U.S. averaged 225.6 doctors active in patient care per 100,000 people in 2014, there is a wide variance across states; Massachusetts ranks highest with 349.5 active doctors per 100,000 people, while Mississippi has only 170.3.[81]In 2013, the U.S. infant mortality rate was 5.96 per 1,000 live births[82], while the OECD median was 3.8.[83]The obesity rate among adults in the U.S. was 35.3 percent in 2013, down slightly from 36.5 in 2011. This is the highest rate among OECD countries. The average for the OECD countries was 19.0 percent in 2013.[84]Thanks

Slavery, racism, Civil Rights, Social Justice, Women’s suffrage.Keep in mind as you read this list of facts that the “Big Switch” of conservatives and/or racists from the Democratic Party to the Republican Party never happened, nor did Richard Nixon’s so-called “Southern Strategy.” See items 20, 21, and 23.Number of slaves owned by Republicans in 1860: ZeroNumber of slaves owned by Democrats in 1860: All of themRacists and Non-Racists never switched parties. The “Big Switch” between Republicans and Democrats, and the “Southern Strategy” are lies. See facts 20, 21, and 23 below.Slavery for many centuries needed no defenders because it had no criticsSlavery came under attack in the seventeenth centuryThe American founding, which had no power to end slavery but which established a framework for reducing, corralling, and ultimately placing slavery on a path to extinctionSlavery came under attack again in the nineteenth centuryThe Republican Party was explicitly founded to block and then eliminate slavery, healing the “crisis of the house divided,” and creating a single union of free citizens.Anti-slavery activism, of course, preceded the Republican Party, although it finally found its most effective expression in that party. The earliest opponents of slavery in America were Christians, mostly Quakers and evangelical Christians. They took seriously the biblical idea that we are all equal in the eyes of God, and interpreted it to mean that no person has the right to rule another person without his consent.Remarkably, Christians discovered political equality through a theological interpretation of the Bible. For them, human equality is based not on an equality of human characteristics or achievements but on how we are equally loved by God. Moreover, the argument against slavery and the argument for democracy both rested on the same foundation, a foundation based on human equality and individual consent.The American Anti-Slavery Society was founded in 1833. A few years later, the Liberty Party was founded to pursue emancipation. In 1848, the Liberty Party, anti-slavery Whigs, and Democrats who opposed the extension of slavery merged to form the Free Soil Party. Abolitionism, which sought the immediate end of slavery, had been present since the founding but grew in political strength during the middle part of the nineteenth century.With the passage of the Kansas Nebraska Act— repealing the Missouri Compromise which curtailed the spread of slavery beyond the designated 36-30 latitude— Free Soilers, former Whigs, and abolitionists joined together and created the Republican Party.Democrats in the South AND North defended slaverySouthern Democratic Party invented the “positive good” school that argued slavery was good not only for the master but also for the slaveDemocratic Senator John C. Calhoun.Northern Democrats like Stephen Douglass fought to protect slavery in the South and in the new territories.Northern Democratic Party invented “popular sovereignty,” (aka States Rights) which allowed each state and territory to decide for itself whether it wanted slavery.Democrats on the Supreme Court forged the majority in the 1858 Dred Scott decision that upheld slavery and insisted that blacks have no rights that a white man needs to respect.Democratic Presidents from Polk to Buchanan protected slavery from abolitionist, free soil, and Republican attack.The Charleston Mercury editorialized during the secession debate that the duty of the South was to“rally under the banner of the Democratic Party which has recognized and spported…the rights of the South.”Lincoln was elected on a platform of stopping the advance of slaveryThe south secededIf Lincoln had lost the election of 1860 the South probably would not have secededCivil War was fought between Anti-Slavery Republicans in the north and Pro-Slavery Democrats in the North AND South.Republicans won the Civil War.Democrats assassinated Lincolnconspired to assassinate President Lincoln, Vice President Johnson, and Secretary of State Seward. They succeeded with Lincoln, failed with Johnson, and gravely injured Seward.All the figures who upheld and defended American slavery and, later, racism were DemocratsSenators John C. CalhounSenator Jefferson DavisSenator James Henry HammondGeorgia Governor Joseph BrownSenator Stephen DouglassPresident James BuchananSupreme Court Justice Roger Taney, architect of the Dred Scott decisionPreston Brooks, assaulted Republican Senator Charles Sumner with a cane on the senate floorBen Tillman, South Carolina governor and later Senator“Republicanism means Negro equality, while the Democratic Party means that the white man is superior. That’s why we Southerners are all Democrats.”“Now that Roosevelt has eaten with that nigger [Booker T.] Washington, we shall have to kill a thousand niggers to get them back to their place.”Democrat James Vardaman of Mississippi“I am just as opposed to Booker Washington with all his Anglo-Saxon reinforcements as I am to the coconut-headed, chocolate-colored typical little coon Andy Dotson who blacks my shoes every morning.”All the heroes of black emancipation were RepublicanSojourner TruthFrederick DouglassHarriet Tubman (organized underground railroad)Ida B. WellsSenator Charles SumnerJohn BrownBlanche K. Bruce, former slave first black Senator from Mississippi to serve a full termAbraham LincolnThe First Civil Rights RevolutionThe Thirteenth Amendmentending slaverypassed with 100% Republican support and 23% Democratic support.in 1864 (Senate) and early 1865 (House)The Fourteenth Amendmentoverturning Dred Scott (which said “separate but equal was Constitutional) and granting full citizenship and equal rights under the law to blackspassed with exclusive Republican support and 0% Democratic support.in 1866The Fifteenth Amendmentgranting suffrage – the right to vote – to blacksAll “Yes” votes came from Republicans. A few Republican Senators abstained because they wanted the amendment to go further than it did.All “No” votes came from Democrats.passed in 1868The Civil Rights Act of 1866,guaranteeing to blacks the rights to make contracts and to have the criminal laws apply equally to whites and blacks.Passed by Republicans,Vetoed by Democratic President Johnson.“This is a country for white men and, by God, as long as I am President, it shall be government of white men.” – President Andrew JohnsonRepublicans overrode Johnson’s veto.Reconstruction Act of 1867Passed by RepublicansAimed at rebuilding the South on a new plane of equality of rights between the racesEstablished the Freedman’s Bureau.Opened hundreds of schools for blacksProvided newly freed blacks with food, health services, and legal protectionHelped unite the families of former slavesA reparations billmodeled after General Sherman’s Field Directive 15 which provided blacks with forty acres of land to farm on their own plus a retired army mule.Democratic President Johnson killed it.Appoint military governors with power to override local authority in the south.More than 1500 blacks won federal, state, and local offices.A former slave named Blanche K. Bruce became first black senator from Mississippi to serve a full term.John Langston became first black congressman from VirginiaEvery single one of these blacks was a RepublicanKu Klux Klan Act of 1871, aka the Force BillPassed by RepublicansSigned by Republican President Ulysses GrantRestricted northern Democratic inflows of money and weapons to the KlanEmpowered federal officials to crack down on Klan’s organized violenceImplemented by military governors appointed by GrantThese made possible the Second Civil Rights Revolution, see item 22 below.Democrats introduced White Supremacy: Black Codes, Segregation, Jim Crow laws, and the KKKWhite Supremacy“This is a white man’s country – let the white man rule.” – Official Democratic Party slogan, 1868 presidential election campaign.“The one thing that held the Democratic Party together [after the Civil War] was a commitment to maintaining white supremacy.” – Historian George FredericksonBlack Codes in state legislatures and state constitutional conventionsBlacks permitted to work only in certain professions, thus granting whites a labor monopoly on the remaining ones.White masters could whip young black servantsBlacks could not travel freely; if they did, they ran the risk of being declared “vagrants” I which case they could be arrested and imprisoned.Sheriffs could then assign hard labor or hire them out to whit employers to work off their sentence.Black children could be apprenticed to white employers at willBlacks could not vote or serve on juries.Their testimony in court was only considered relevant in cases involving other blacks.Many crimes – such as rebellion, arson, and assaulting a white woman – carried the death penalty for blacks, but not for whites.Blacks were not allowed to sell alcohol or carry a firearm.Blacks could marry, but “marriage between a white person and a person of color shall be null and void.”SegregationPlessy v. Ferguson, 1896, Supreme Court confirmed constitutionality of segregationSupreme court was largely though not exclusively DemocraticSole dissent came from Justice John HarlanRepublican from Kentucky“Our constitution is color-blind and neither knows nor tolerates classes among citizens.”A Democratic legislature passed the lawA Democratic governor signed the law“Separate but equal”Democratic majority in the Supreme Court declared in the Plessy decision that if blacks feel inferior as a result of segregation it’s because they choose to view it that way, not because of anything in the law itself.Democrats in the south segregated: Hotels, Taverns, Inns, Schools, Public water fountains, Prisons, Public theaters, Public libraries, Public Parks, Hospitals, Jails, Cemeteries, Movie theaters, Opera houses, Professions , Barbers, Plumbers,Jim Crow LawsSigned by Democratic governorsUpheld by Democratic judgesEnforced by Democratic sheriffs and public officialsThe Ku Klux Klan was founded by Democrats; a group of Confederate soldiers.“the domestic terrorist arm of the Democratic Party.The main point of the Klan’s orgy of violence was to keep blacks from votingThe Nineteenth AmendmentRepublicans proposed women’s suffrage as early as 1878, it was voted down by a Democrat-controlled CongressRepublicans re-introduced it the issue each year but for many years Democrats tied it up in committees.It got to the floor in 1887, Democrats defeated it.Frustrated the suffagettes – who were mostly Republican – took the issue to the statesBy 1900 several Republican-dominated states granted women the right to voteIn 1916 Montanna Republican Jeannette Ranking became the first woman elected to CongressCongress took up the issue again in 1914, when it was again rejected by Senate Democrats.Only when the GOP won landslide majorities in both houses in 1918 did the Nineteenth Amendment finally have the necessary two-thirds majority to passThe Democrats took their opposition to the statesEight of the nine “no” votes on the Nineteenth Amendment came from Democrat-controlled state legislatures.“During the Wilson years the composite of racism and progressive liberalism came to dominate the Democratic Party.” – Historian Ira KatznelsonWilson showed “The Birth of a Nation” in the White House“It’s like writing history with lightning, and my only regret is that it is all so terribly true.” – Democratic President Woodrow WilsonProtestors against “The Birth of a Nation” were all Republicans, e.g.,Harvard President Charles EliotFeminist reformer Jane AddamsBooker T. WashingtonDefenders of the film were all Democrats, e.g.,Former Supreme Court Justice Edward WhiteWilson’s progressivism can be seen in the way he championed centralized power in Wachington, D.C., and repudiated the South’s traditional political doctrine of state’s rights.Wilson openly advocated that America’s founding principles be replaced by centralized planning“We are not bound to adhere to the doctrines held by the signers of the Declaration of Independence.” – Woodrow WilsonWilson denounced the founders in the name of progressive centralization of power, which for him were the way of the future; they represented progressFDR’s Racist BargainThe New DealSouthern Democrats made demands in exchange for their support of FDR’s progressive programsFDR must oppose desegregationFDR must block anti-lynching schemes of blacks and RepublicansFDR must not hold it against Democrats if they belonged to white supremacist organizations like the KKKA disproportionate share of New Deal programs must be steered toward the SouthBlacks, who mainly worked as domestic servants and farm laborers, be excluded from those programs.FDR agreedAt the White House, he continued Wilson’s policy of segregation among the household staffBanned black reporters from White House press conferencesContinued Wilson’s segregation of armed forces.The TVA Act, which involved the construction of huge power and navigation dams on the Tennessee River, benefited Missouri, Tennessee, Alabama, Georgia, North Carolina, Kentucky, and Virginia.Ensured that the two main occupations involving blacks, namely domestic and farm labor, were excluded from federal benefitsThe result was that millions of blacks were ineligible to receive Social Security, unemployment, and a host of other benefits that were being offered to workers in every other type of industry.New Deal programs like the National Industrial Recovery Act (NIRA) and the Civilian Conservation Corps (CCC) were segregated and offered the best jobs to whites.The administration denied FHA loans to blacks seeking to move into white neighborhoods, but they did assist blacks in buying homes in black areas.FDR Interned Japanese Americans during WWIIThe ACTUAL “Big Switch” Part 1:Blacks saw that FDR’s programs at least offered employment to tens of thousands of blacksBlack votes during the New Deal era moved steadily toward the Democratic Party, in a sense selling their votes for a mess of pottage.From 1865 to 1933 approximately 90 percent of blacks voted RepublicanBy 1936, 75 percent of blacks became DemocratsThis tend has only continued since then, so that today around 90 percent of blacks vote Democratic and only 10 percent vote RepublicanThe black vote switched from Republican to Democrat mostly during a period of four years during the 1930s.Democrats could scarcely believe their good fortune. They found that they could continue to exclude, exploit, and subjugate blacks, and still get the black vote. Democratic strategists at the time expressed their amazement and delight that blacks votes came so cheap. In subsequent decades, progressive Democrats recognized that they could secure a virtually permanent hold on the black vote by creating plantation-style dependency on the state.The ACTUAL “Big Switch,” Part 2:The south became more Republican over a period of decades during the 1950s and 1960s as it gradually became less racistAs the South became more prosperous economically during the 190s and 1960s, the racist appeal lost its currency and white southern Democrats realized that they had more in common with the Republican Party. The identified with the GOP idea of controlling your own destiny and improving your own life.In a remarkable book, The End of Southern Exceptionalism, Byron Shafer and Richard Johnston make the case that white southerners switched to the Republican Party not because of racism but because they identified the GOP with economic opportunity and upward mobility. As the agrarian South became more industrial and then post-industrial, white southerners switched parties not because of race but because of economic prospects. Interestingly, whites moved to the Republican Party for the same reason blacks moved to the Democratic Party: both groups saw the journey as congruent with their economic self-interest.Shafer and Johnston show how Democrats tried, and failed, to keep southern whites in the fold by appealing to racism. Southern whites, however, migrated to the GOP as the party that better represented their interests and aspirations. Shafer and Johnston supply reams of data to substantiate their claim that the poorest, most racist whites remained Democratic, while more prosperous whites who were not racist were more likely to become Republicans. To the horror of the Democratic Party, the South moved in the Republican direction as white southerners embraced the GOP as the non-racist party of economic opportunity and patriotism. 21LBJ Spoke of civil rights legislation as a tactical measure to keep blacks on the plantationJohnson was himself a member of the racist group of southern Democrats that FDR worked with and cut deals with.Johnson vociferously opposed civil rights early in his career.“These niggers, they’re getting pretty uppity these days and that’s a problem for us since they got something now that they’ve never had before. The political pull to back up their uppityness. Now we’ve got to do something about this, we’ve got to give them a little something, just enough to quiet them down, not enough to make a difference.” Otherwise, blacks may start voting Republican and “it’ll be Reconstruction all over again.” – President Lyndon Johnson, speaking to Democratic Senator Richard Russell of Georgia“I’ll have them niggers voting Democratic for two hundred years.” – President Lyndon Johnson, traveling on Air Force One with two Democratic governors, telling them how important it was to him that they vote for the Civil Rights Act of 1964Other Tactical Aspects of Democratic support for Civil Rights LegislationIf blacks became independent they would have no more reason to vote DemocraticBlack suffering gave Democratic progressivism a continuing claim to “social justice.”As long as blacks were beholden to Democrats anyone who dissented from the progressive program could then be accused of being anti-black.Republicans who opposed progressivism could be charged with being racist.Black conservatives and the party of black emancipation and of civil rights could now be tarred with the charge if bigotry and being against civil rights.The Second Civil Rights RevolutionBrown v Board of EducationEnding school segregationCivil Rights Act of 1964Guaranteed blacks, women and other minorities the right not to be discriminated against in jobs and government contractspassed the House with63 percent of Democrats and80 percent of Republicans voting “yes.”Passed the Senate with69 percent of Democrats and94 percent of Republicans voted “yes.”Fair Housing Bill of 1968Extended the antidiscrimination provisions of the CRA of 1964 to housing.The Voting Rights Act of 1965guaranteed to blacks and other minorities full enfranchisementpassed the House 333-85,No votes: 61 Democrats, 24 RepublicansIt passed the Senate with73 percent of Democrats and, 94 percent of Republicans.Had Republicans voted in the same proportion as Democrats the laws would not have passed.Where did these rights come from?Desegregation and anti-discrimination laws both relied on the notion that blacks weren’t slaves any longer; rather, they were free and could make their own choices. This freedom had been secured for blacks by the Thirteenth Amendment which permanently abolished slavery.The desegregation court rulings and the anti-discrimination provisions of the Civil Rights Act and the Fair Housing Bill were also based on the “equal protection” clause of the Fourteenth AmendmentThe Voting Rights Act attempted to secure for blacks full enfranchisement, the right to vote. The right was specified in the Fifteenth Amendment. This amendment declared that, as citizens, blacks had the same prerogative to cast their ballots as whites and all others. The 1965 Voting Rights Act merely sought to enforce an equality provision that had been constitutionally affirmed much earlier.The Thirteenth, Fourteenth, and Fifteenth amendments were passed in the aftermath of the Civil War. They were passed by the Republican Party.The main opposition to the second Civil Rights Movement came from Democrats (Dixiecrats).Organized protests against desegregation rulings by the Supreme CourtDemocrat governors refused to enforce those rulingsSenate Democrats filibusterd against the Civil Rights Act of 1957 and the Civil Rights Act of 1964.Leading members of the Dixiecrats:James Eastland, Democrat, MississippiJohn Stennis, Democrat, MississippiRussel Long, Democrat, LouisianaStrom Thurmond, Democrat, South CarolinaThe only one to switch to Republican PartyHerman Talmadge, Democrat, GeorgiaJ. William Fulbright, Democrat, ArkansasLestor Maddox, Democrat, Georgia,Al Gore Sr., Democrat, TennesseeRobert Byrd, Democrat, West VirginiaRepublican Barry Goldwater, founding member of NAACP, active in integrating Phoenix public schools, voted against the Civil Rights ActBecause it outlawed private as well as public discriminationGoldwater believed the federal government did not have legitimate authority to restrict the private sector in that way.Democrat Governor Orval Faubus of Arkansas ordered the Arkansas National Guard to stop black students from enrolling in Little Rock Central High SchoolRepublican President Eisenhower sent troops from the 101st Airborne to enforce desegregation.Democrat Governor Faubus shut down all the public high schools in Little Rock for the 1958-59 school year.Democrat Governor George Wallace of Alabama attempted to prevent four black students from enrolling in elementary schools in Huntsville“Segregation now, segregation tomorrow, segregation forever.” – Democrat George WallaceA federal court in Birmingham intervened.Democrat Sheriff Bull Conner unleashed dogs and fire hoses on civil rights protestors.Nixon’s so-called “Southern Strategy” never happened.Progressives who cannot refute this history—facts are stubborn things—nevertheless create the fantasy of a Nixon “Southern strategy” that supposedly explains how Republicans cynically appealed to racism in order to convert southern Democrats into Republicans. In reality Nixon had no such strategy—as we have seen, it was Lyndon Johnson who had a southern strategy to keep blacks from defecting to the Republican Party. Johnson, not Nixon, was the true racist, a fact that progressive historiography has gone to great lengths to disguise.Nixon’s political strategy in the 1968 campaign is laid out in Kevin Phillips’s classic work The Emerging Republican Majority. Phillips writes that the Nixon campaign knew it could never win the presidency through any kind of racist appeal. Such an appeal, even if it won some converts in some parts of the Lower South, would completely ruin Nixon’s prospects in the rest of the country. Nixon’s best bet was to appeal to the rising middle classes of the Upper South on the basis of prosperity and economic opportunity. 22 This is exactly what Nixon did.There are no statements by Nixon that even remotely suggest he appealed to racism in the 1968 or 1972 campaigns. Nixon never displayed the hateful, condescending view of blacks that Johnson did. The racist vote in 1968 didn’t go to Nixon; it went to George Wallace. A longtime Democratic segregationist, Wallace campaigned that year on an independent ticket. Nixon won the election but Wallace carried the Deep South states of Arkansas, Louisiana, Mississippi, Alabama, and Georgia.Nixon supported expanded civil rights for blacks throughout his career while Johnson was—for the cynical reasons given above—a late convert to the cause. Nixon went far beyond Johnson in this area; in fact, Nixon implemented America’s first affirmative action program which involved the government forcing racist unions in Philadelphia to hire blacks.To sum up, starting in the 1930s and continuing to the present, progressive Democrats developed a new solution to the problem of what they saw as useless people. In the antebellum era, useless people from the Democratic point of view were mainly employed as slaves. In the postbellum period, southern Democrats repressed, segregated, and subjugated useless people, seeking to prevent them from challenging white supremacy or voting Republican. Meanwhile, northern progressives like Margaret Sanger sought to prevent useless people from being born. Today’s progressives, building on the legacy of Wilson, FDR, and Johnson, have figured out what to do with useless people: turn them into Democratic voters.The Evidence | "Hillary's America"