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The budget in 2060

Brad DeLong asks a good question:

What is the most likely outcome for the U.S. budget come 2060?

1. We will have raised taxes to pay for government health spending.

2. We will have cut doctors' wages and enslaved them by drafting them into a socialist national health service.

3. We will have abandoned our commitment to providing state-of-the-art health care to the sick and not just the wealthy.

4. The health care fairy will have figured out a way for us all to have all the medically-appropriate care we need for a surprisingly low private and public budgetary cost.

5. The federal government as we know it will have collapsed, and those of us still alive will be starring involuntarily in a remake of “Mad Max: Beyond Thunderdome”.

I'll say some combination of 1, 2, 3 and 5. What do you think?

By Ezra Klein  | September 23, 2010; 9:30 AM ET
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Thanks, just the dose of optimism I needed to start my work day.

This is tangentially related, but I am increasingly noticing that the more I read what pundits have to say, the more gloomy and divided the world looks. If I look at the actual news -- even with its tendency to play up the bad -- things don't sound so bad, same as when I talk to actual people, particularly those who might hold other political opinions.

Posted by: lde2c | September 23, 2010 9:43 AM | Report abuse

As I wrote at Brad's, in 50 years, everything in healthcare is going to be fine. Now we finally have the correct mix of tools for medicine, and so the price is going to come down. Medicine has been haphazard for millennia, but not any longer. Now we are combining biotech, nanotech, computation and genomics. Of course, soon we shall have to revisit the extended patent protections in this brew, because continued innovation is going to be held back by the undeserved "economic rents" to the patent holders. But clearly the rate of discovery and innovation in medicine has begun to accelerate at the rate of Moore's Law, i.e. doubling around once every 18 months. If you have followed any science news at all for the past few years, you already know this, and you are optimistic upon the future of treatments and cures. And from all other industries you already know that, where the technology is apt, the prices of goods and services come down. Medicine will continue to be a growth industry and employ lots more people for three or four more decades, but the service and price will be more like fast food. You are going to live forever, with a body reverted to 20 years old. Retire? With boundless energy, whatever for? With biotech to make you smarter than Einstein, you'll be building warp-drive spaceships.

Posted by: Lee_A_Arnold | September 23, 2010 9:55 AM | Report abuse

In what possible ways have we demonstrated "our commitment to providing state-of-the-art health care to the sick and not just the wealthy"? That's sarcasm, right?

Posted by: vorkosigan1 | September 23, 2010 10:10 AM | Report abuse

re: Lee_A_Arnold. Healthcare is different than everything else. I don't necessarily need more technology or faster computers, etc. But, we will all do everything in our power to live longer and more fulfilling lives. New hips, knees, eyes, hearing, etc. I agree with Ezra, I say a combination of 1, 2, 3 and 5. 4 is out of the equation.

Healthcare is broken in this country. The hope is the reform bill puts us on a path to fixing it over the next 50 years.

Posted by: fiorehoffmann | September 23, 2010 10:12 AM | Report abuse

What's the word for trifecta, only for 5 things?

Posted by: bgmma50 | September 23, 2010 10:19 AM | Report abuse

Oops, I misread #4. Yes. 1,2,3, and 5.

Posted by: bgmma50 | September 23, 2010 10:22 AM | Report abuse

If I take number 3 to mean we will deliver health care only those that can afford it. I would think number mainly number 3.

I guess Lee thinks the health care fairy will come - not while monopolistic hospitals/medical providers with powerful government actors work on their behalf.

Posted by: ChicagoIndependant | September 23, 2010 10:25 AM | Report abuse

Have a look at what happened in the USSR (which collapsed due to lack of financial discipline) and then you will find clues on how breakdowns in all "traditional" government services happen....not just in healthcare, but also in roads, infrastructure, etc. It is called the illness of living beyond one's means!

Posted by: ordak100 | September 23, 2010 10:28 AM | Report abuse

if big pharma cant find ways to stop forms of dementia and alzheimers, i really fear that we will have a huge, aging population, held together with pig valves, titanium and an arsenal of medications and pampers, but many, simply not present and in their right minds.
i dont see how there will be money left for anything, but caring for the elderly, in 2060.
i almost cant imagine what the world will be like then.
i hope there will be lots of children, good health, hope and a myriad of beautiful things left in the world, though.

Posted by: jkaren | September 23, 2010 10:29 AM | Report abuse

The collapse of our style of government, described by some as Democracy, will be caused by the failure to provide for the people. The Soviet Union was devastated by this type of failure, not by American policies.
A police state will evolve to maintain order and keep the oligarchy in power. We will continue to increase the percentage of peons and will keep them under control.

Posted by: cperrym | September 23, 2010 10:33 AM | Report abuse

Option 3a -- The federal government will be out of the health care picture entirely, allowing states and charities to tend to the welfare of their citizens and adherents as they see fit.

Everyone likes to skirt the fact that national involvement in welfare is unnecessary and unworkable. The European example is useful in that there is no EuroCare: the nations of Europe -- most substantially smaller than the average US state and many substantially smaller than US cities -- are perfectly capable of organizing and implementing health care plans without the involvement of the EU.

I'd enjoy hearing a clear explanation of what has made the Johnson approach of the 1960's -- national involvement in health care -- so successful: what makes Johnson's national Medicaid and Medicare programs shining examples of republican governance, fiscal prudence, and top-notch service? Was the Massachusetts health care reform a total failure; that is, is there evidence to suggest that a state can, in fact, successfully perform tasks which have until recently been their sole purview?

As we watch Germany cut its health care programs and increase the co-payment each citizen must make (see and watch other EU states take different reform actions, where are all of those who six months ago told us to look to Europe? Why should we not look to Europe now? Why should we not put health care decisions into local hands and eliminate the federal controversy entirely?

At this point, the only goal -- and only outcome -- of the federal health care reform seems to be an electioneering mantra of "ObamaCare is Everywhere."

Posted by: rmgregory | September 23, 2010 10:38 AM | Report abuse

Clearly the answer is none of the above. Adding to the fear mongering about health care is really counterproductive. Over the next fifty years we will continue to refine and adapt health care policy to make it work, and for more people, at better cost. Because just as sure as America creates crises it solves them, in equal measure. Life will go on. And you will be on Medicare by then. (Which, by the way, will still exist). Doctors will still be able to afford boat payments. Chill.

Posted by: JJenkins2 | September 23, 2010 10:43 AM | Report abuse

I'm with Lee on this one.

If technological progress continues, there might yet be something pretty close to a free lunch. Ray Kurzweil had a book on it called The Singularity Is Near. The book suggests potentially utopian conditions within the lifetime of most Americans, and so I'm tempted to file it under wishful thinking. That said, there wasn't a whole lot of individual points Kurzeil makes which I thought completely bogus. If his basic premise is correct - essentially, progress continues in AI, genetics, nanotech, etc - we might have a lot of cheap (relative to per capita income in 2060) and extremely effective health care options available.

Outside of that possibility, I'd expect 1, 2 and not quite but almost 5. The U.S. will be a slow growth country (1%/yr). The population will be shrinking, and it's culture and economy will no longer be impressive or influence the world. China and India will both have larger economies and will continue to be growing much faster. The U.S. probably won't be considered a superpower either - more like France is today (not necessarily a bad thing).

Everyone would have health insurance (and in 2060 that care will probably do some awesome things), but the occasional "the government doesn't want to spend the money" annoyance will occur as it does today in other countries, and we probably won't have much choice over things like diet. We'll be spending 30-40%+ of GDP on health care, probably 25-35% of GDP of it from government.

Unemployment will probably be in the 6%-12% range permanently, like it is in the large countries of continental Europe. American corporations might still be influential, but most of the sales and the action will be abroad. I still hope our politicians won't outright bankrupt the country, but that possibility of course cannot be dismissed.

Posted by: justin84 | September 23, 2010 11:05 AM | Report abuse

I'd love to get a full-bore Ezra analysis of what's going on in Europe at the moment. He spent a lot of time (going back way before his WaPo days) pointing out the various European health care models, and their plusses and minuses. How much of the current adjustments alluded to above is due to inherent problems and how much is a temporary fix due to short term economic crisis?

Posted by: jeirvine | September 23, 2010 11:47 AM | Report abuse

Glad to know I'm not the only one who has been watching Mad Max on AMC these past few nights.

Posted by: green21821 | September 23, 2010 11:48 AM | Report abuse

2060? Seriously? Do you think people in 1960 could have given a remotely accurate answer about today's budget situation? Worrying about what the budget will be decades from now is utterly pointless. Too much can change over the course of decades for any kind of projection to be anything other than science fiction.

Posted by: redwards95 | September 23, 2010 12:12 PM | Report abuse

4. The health care fairy will have figured out a way for us all to have all the medically-appropriate care we need for a surprisingly low private and public budgetary cost.

to paraphrase bill clinton, it depends on what the word "need" means.

Posted by: jwogdn | September 23, 2010 12:37 PM | Report abuse

I would say it will mostly be 3, as we don't actually even have a commitment to state-of-the-art healthcare for the sick and not just the wealthy.

We have a commitment to the old, because they don't work, and therefore vote in large numbers.

Posted by: donhalljobs | September 23, 2010 12:41 PM | Report abuse

I'm hoping that by 2060 we're all living sweet new lives in The Matrix; wearing cool clothes and knowing kung fu.

Or maybe having our brains transplanted into sweet robot bodies that are super strong and only occassionally need repair.

But seriously, as others have mentioned above, there are aspects of modern life that would seem fairly utopian to people 50 years ago (and obviously, some things they would hate, like's all noise!). Even as depressed as I sometimes get about the state of the modern world, it's still pretty exciting to think about what amazing things the future could hold.

Posted by: MosBen | September 23, 2010 12:42 PM | Report abuse

I'd say it depends on how campaign finance rules evolve between now and then.

Under current rules (citizens united, money = speech, corporations = people), I'd go with #5 (the Mad Max option).

Posted by: rat-raceparent | September 23, 2010 12:48 PM | Report abuse

I think we will have also adopted #6: (the Republican plan) - Die Quickly

Posted by: AMviennaVA | September 23, 2010 1:32 PM | Report abuse

I holding out for #4. It seems as good as most of the plans coming out of Washington.

Posted by: Kevin_Willis | September 23, 2010 1:45 PM | Report abuse

I think by 2060 people will not be worrying about health care as we know it, but sea levels that have risen 2 meters, chronic, terrible storms and flooding, famine, migration, extinction of fisheries etc.

I wish people in DC understood more about the most recent developments in climate disruption. They are pretty ignorant about deficits, but really so on climate.

Posted by: Mimikatz | September 23, 2010 3:45 PM | Report abuse

I'd actually lean more heavily on 4 than any of the other ones because I expect that, over the next 50 years or so, the "health fairy" will change us culturally, so that care by medical personnel further down the medical economic ladder becomes better equipped and more widely accepted to deal with problems currently handled solely by those with terminal degrees and super-specialties.

Improved communications and remote diagnostic tools will reduce the necessary patient face time with the super-specialists, allowing the super-specialists to serve more patients at a lower per-patient cost, while the (lower cost) primary care physician has downloaded much of his/her time to physician's assistants and nurse-practitioners, permitting him more time with patients. Further, improvements in payment methodologies (insurance) will further reduce office overhead costs.

The number of health care providers won't drop (it may even increase, increasing patient face time), but the cost curve will shift downward as the greater growth occurs at the less expensive levels.

Further, current estimates based on an ever aging (rising life expectancy) population will prove to be overly pessimistic (on a cost of care basis). At some point in time, will will discover that even the best machines with the best care still have a maximum life, before they disintegrate beyond the point of repair.

These may not stop the rise in costs, but they will dampen it from current projections.

Posted by: mikerose2 | September 23, 2010 10:58 PM | Report abuse

Brad missed:
6. The government will cut medical costs by coercing the citizens into a healthy lifestyle. Tobacco will be banned, alcohol trebled in price, junk food regulated out of existence, and sport for all won´t be a simple aspiration. Obesity will be labelled an addiction with compulsory and unpleasant treatment. A mixture of ¨On yer bike¨ and ¨Kraft durch Freude¨.
The constitutional basis will of course be the Second Amendment: a ¨well-regulated militia¨ bearing modern arms and 70lb packs has to be fit.

Posted by: JamesWimberley | September 24, 2010 1:01 PM | Report abuse

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