Medicare for America Tweaks

The Medicare for America Act of 2019 is an amazing piece of work. It’s an Australian-type plan, where Americans not covered by conforming private insurance are covered automatically by Medicare.

Subtitle B, Sec. 2203 establishes all the things Medicare for America covers; likewise, as per Part C of Subtitle B, all private plans shall conform to Medicare for America, and are called “Medicare Advantage for America” plans.

There are a few things I’d change, of course.

Premium Formula

Title I, Sec. 104 establishes premiums based on all kinds of bounds and numbers. The premiums are based on regional rates, may be no more than 8% of adjusted gross monthly income, and are reduced based on the household income relative to the poverty line.

The American Citizens Dividend would eliminate all downsides of a flat FICA, providing a more-stable and reasonable system. Instead of paying an 8% premium if you’re enrolled in the plan, every American would pay the Medicare for America FICA—which would be roughly 1.25% by calculations I made in 2017.

Consider a household with $25,000 of income and the high 8% premium. The dividend’s premium is 12.5%, so the household pays 20.5% into these FICA taxes in total. The American Citizens Dividend pays over $6,000 per single adult, so a one-adult household is still net plus $875 after FICA and Dividend, and a two-adult household is net plus $6,875.

At the 1.25% level, it’s $2,500 and $8,500, of course.

All Americans should pay into the healthcare plan, unlike in Subtitle B, Sec. 2204(a)(1), which specifies:

Subject to paragraph (2), each individual enrolled for benefits under this title for a year shall pay monthly community-rated premiums for such year in an amount determined by the Secretary in accordance with subsection (b).

Medicare for America, Subtitle B, Sec. 2204(a)(1)

By having all Americans pay in equally, we greatly reduce the FICA and share our collective responsibility for healthcare. Yes, that means those of us with individual healthcare pay a bit more—I’d be paying $1,000/year into Medicare for America only to use my private plan.

There’s more, though: the plan as-is isn’t sustainable except for the provisions that the fund will receive Federal subsidies. This means it’s a mystery how much of anyone’s money goes to the fund, and arguments about how Medicare affect the deficit are suddenly valid because it’s no longer really a social insurance and not self-funded. My method is totally self-funded, revenue-neutral, and removed from any impact on the deficit.

Employee Opt-In

Under Subtitle C, Sec. 126(c), we find this long paragraph:

Employee Choice.—An employee may opt out of a qualifying employer-sponsored plan as satisfied by subsection (b)(1) in order to enroll in Medicare for America. The employer shall make a contribution equal to the contribution it shall make in order to meet the requirements established by subsection (a)(1) or (a)(2). The Secretary of Health and Human Services shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within Medicare for America by inducing individuals to decline coverage under a qualifying employer-sponsored plan and instead to enroll in Medicare for America. An employer violating such standards shall be treated as not meeting the requirements of subsection (a).

Medicare for America, Subtitle C, Sec. 126(c)

In essence, if an employee opts out, then the employer must pay an 8% payroll tax.

The employer is required to pay 70% of the healthcare plan costs in any case. Instead of 8%, I have suggested the employer and employee both pay as payroll tax what the employer would have paid had the employee taken the employer’s plan. This removes any financial incentive and allows the employee to select whichever option they prefer.

Small Employers

Under Subtitle B, Sec. 2202(b)(3)(B), small and large employers are treated differently regarding enrollments.

My solution is simpler: each employee shall pay no more than some affordable rate (e.g. 8% of income) into their premium, and the employer shall pay a minimum of 70%. If the employer does not provide conforming care (notably, by charging the employee more or by making an employee ineligible), then the employer shall pay twice this affordable rate as a payroll tax.

That means if the employer pays $7,000/year for the employee’s premiums and the employee earns less than $43,750 annually (yes, nigh-impossible with a structural minimum wage, except for part-time employees), the employer is better off simply not offering a healthcare plan.

This offsets some of that 1.25% FICA, and effectively pro-rates and subsidizes employers for the healthcare costs of part-time employees below a certain wage: instead of paying $7,000/year for a half-time employee, the employer only pays $3,500/year.

Under this approach, there is no difference between large and small businesses. The administration is the same, and tax considerations and inflation and whatnot factor out.

Ghent System

I would additionally provide a hybrid Ghent system, such that an employer and labor union gets a 10% subsidy for their share of the premium for any employee covered by a union-provided healthcare plan, so long as the employee is a member of the union.

If the employee’s union has negotiated a conforming Medicare Advantage for America plan, then the employer must pay 70% of the premium cost. The union can collect the remainder through dues. In this case, the employer will receive a subsidy of 7% of the premium cost, and the union will receive a subsidy of 3%.

This encourages union participation, as the employer receives a minor tax break and the employee’s dues are slightly-lower. Note that 70% of the healthcare premium is shifted to the employee and off the union, so the employee doesn’t cover those costs through dues.

Other Notes

There are a lot of excise taxes, notably on tobacco and alcohol, in here. The pipe tobacco excise jumps from about $2 to $50, for all that’s worth.

Illustrations of Electoral Failures

Many people find electoral systems abstract and esoteric. Party primary and plurality seem like obvious, fair systems, yet draw large amounts of attention for their unfair results and damage to our democracy; and the Electoral College gets attention when it disagrees with that same often-maligned popular vote system, ironically creating a call for a national popular vote. People aren’t generally experts in the economics of social decision making, and only recognize that there is absolutely something wrong here.

Fortunately, people are in general intelligent and capable of understanding complex concepts if someone explains them well enough. For complex electoral systems, we can use the United States 2016 Presidential Election as a frame of reference, and propose several different sets of votes. From these votes, we can calculate outcomes and show how each electoral system fails.

We must understand upfront the utmost importance of representation. Our elections must produce a representative result. That representation might not fit with what we as individuals or larger groups want; that’s not the point. The point is for us, as a majority, minority, or whatever portion, to have our say and to influence the election so that every vote counts—that means we must concede some things sometimes.

To emphasize this point, I’ve used a model in which there are more Republicans voting than Democrats in the 2016 election. In general, this means a Republican wins—but which Republican? That’s the key question.

In our first example, we have 24% ranking Rubio, then Trump, then Clinton: we’ve assumed the Republicans will always vote Republican first.

As seen above, Plurality selects only from first-ranked votes. More voters—a full 30%—voted Trump than anyone else, so Trump wins. We can see how flawed a system this is.

Party Primary is actually worse. In the real 2016 Republican primary, Trump won with 44% of the votes thanks to the same vote splitting seen above. The Party Primary system also faces non-mathematical flaws rooted in human economic behavior.

Party-line voters who don’t care who wins the primary are less-inclined to vote. In practice, you might see 75% of the Sanders voters turn out, and only 50% of the Clinton voters. Using our example here, with more Democrats preferring Clinton, Sanders would achieve a victory at 54% to 46% in the primary. Social media propaganda attacks capitalize heavily on this problem.

Our example also shows a top-two system, which just picks Trump and Clinton by plurality vote. Again, Trump wins.

Majority Runoff and its ranked choice voting version, Instant Runoff Voting, show the center squeeze effect: least-voted Bernie Sanders gets booted early, sending votes to Clinton. Clinton and Trump thus squeeze out Rubio, turning this into a Clinton-Trump contest, in which Clinton wins.

The last example is our Condorcet method. The graph on the right holds particular importance: it shows who defeats who, with the arrows pointing toward the losers in one-on-one contests.

Because Rubio defeats Trump, Clinton, and Sanders in the respective two-candidate elections, Rubio is the Condorcet winner. Systems like Tideman’s Alternative elect this winner, representing a consensus of the voters.

So okay, there were more Republicans, and Rubio wins under this system. Does that mean this is a better system, or is it just electing a candidate some of us personally dislike less than the winner?

Those aren’t mutually-exclusive propositions: 70% of voters preferred Rubio to Trump. A lot of us apparently personally disliked Rubio less than Trump, yet Trump got elected. Trump got elected despite a majority of voters not wanting to elect Trump.

Let’s fiddle with the numbers a little.

Hillary Clinton won the popular vote in 2016. A large body of Never-Trump Republicans had no alternative but to vote Clinton, and the above illustration supposes Clinton won the popular vote because of a great many Republicans ranking Rubio, then Clinton, then Trump. The Electoral College essentially stuffed these Republicans into strong Red jurisdictions, covering up their votes just like gerrymandering, so Trump won anyway.

Again, Trump wins Plurality; and again, Rubio remains the Condorcet candidate—so far, the correct winner, given the arguments above. What about the other systems?

Party Primary selects Clinton and Trump. This removes Rubio. The graph shows Rubio defeats Clinton, who defeats Trump; since Rubio has been removed, Clinton wins. Just as with Trump, 54% of the voters preferred Rubio to Clinton.

Top-Two again selects Clinton, and Rubio voters bail out on Trump. Runoff and Instant Runoff Voting also squeeze out Rubio, leading to a Clinton victory.

Even though the majority of the voters clearly prefer Rubio to Trump, Clinton, and Bernie, only the Condorcet system elects Rubio. The rest fail, this time electing Clinton instead of Trump.

A small, unimportant change to the votes has a big change to the outcome. How badly can this fail, anyway? Let’s find out what happens if fewer people vote Trump and more people vote Bernie Sanders.

Sanders is now preferred among Democrats; Rubio voters still prefer Clinton to Trump, which elected Clinton in our second example; and one percent of voters have moved from the Trump camp to the Never-Trump camp.

Plurality still elects Trump, who has the most votes—no surprise there. A Condorcet system still picks Rubio.

Party Primary now selects Bernie Sanders. Sanders can’t beat Trump, so Trump wins. Voting for Bernie instead of Clinton elected Trump.

Top-Two actually gets it right for once. Because more people voted for Rubio, the line-up is Rubio versus Trump, and Rubio beats everybody.

This outcome is precarious: if more than 1% of voters additionally switched from Clinton to Bernie, Top-Two would have selected a Bernie-Trump election, and Trump wins—once again, voting for Bernie Sanders elects Donald Trump. This should never happen, yet it keeps happening.

Runoff and Instant Runoff Voting again center-squeeze. This time it’s Bernie defeating Clinton, instead of Clinton defeating Bernie; and then Rubio goes, leaving a Bernie-Trump election once again. Instant Runoff Voting elects Trump—and once again, changing your vote from Clinton to Sanders elects Trump.

That’s all fine, but what if nobody’s on top?

Enter strategic bloc voting. The Trump voters are trying to eliminate Rubio by burying under Sanders—a known flaw that can manipulate Condorcet systems. Tideman’s Alternative carries a high degree of resistance.

In this example, Plurality elects Trump, Top-Two picks Rubio, and both Party Primary and run-off elect Clinton. Trump voters have identified Sanders as the weakest candidate, and so buried Rubio under Sanders.

The attack works fairly well: Sanders defeats Rubio and Clinton. Rubio defeats Clinton, who defeats Trump, who defeats Sanders; and Rubio defeats Trump, who defeats Sanders.

From any candidate, you can find a path of victories leading back to that candidate. Rubio defeats Clinton, who defeats Trump, who defeats Sanders, who defeats Rubio. Looks like we don’t have a Condorcet candidate, and every candidate except Sanders seems to win under these systems, so how do we decide who wins?

Enter Tideman’s Alternative.

Tideman’s Alternative identifies the top cycle—in this case the Smith Set, which is those candidates who are not defeated by any candidate not in the Smith Set.

To better illustrate, this example includes Gary Johnson, defeated by everybody. The green arrows show the Smith Set path. None of the candidates in the Smith Set are defeated by Johnson. You can trace a path of victories from any candidate in the Smith Set to any candidate in the election.

Tideman’s Alternative eliminates all non-Smith candidates—that being Johnson—and then performs one round of run-off (sometimes called “alternative vote”). This eliminates Sanders, leaving Rubio, Trump, and Clinton.

In round 2, the Smith set is Rubio. This makes Rubio the Condorcet winner, and so Tideman’s Alternative elects Rubio.

As shown here, Tideman’s Alternative can reliably find a consensus winner, and resists tactical manipulation. It does have failure modes, but those failures rely on a large amount of manipulation: Sanders defeated all non-Trump candidates in this example, so even if Rubio voters voted Rubio, then Trump, then Sanders in an attempt to bury Clinton, the outcome wouldn’t change.

The failure modes can also be unpleasant. Consider this attack if 4% more of the voter were Trump voters instead of Rubio voters.

Here we see more Trump voters and fewer Rubio voters. An honest vote, with Trump voters placing Rubio second, elects Rubio; but the Condorcet burying attack changes the outcome.

By attempting to corrupt our elections through tactical manipulation of their voting ranks—by ranking not by the order they favor, but rather in an attempt to mathematically distort the outcome—Trump voters succeed in electing Hillary Clinton.

This happens because a few Rubio voters are honestly opposed to Trump—these are the Never-Trump voters who voted Clinton in 2016. This attack also requires Trump to be the stronger candidate—and Trump won 44% of the Republican Primary, in which the more-moderate independent voters can’t even vote.

To make this clear: if just over 4% of Rubio voters defect to Clinton, Trump has fewer than 50% of the votes. Clinton has around 28%, and Sanders is eliminated. Sanders votes go to Clinton, granting over 50% of the votes, a Clinton victory. That mean this attack elects Clinton even if almost no Rubio voters reject Trump.

Our electoral system matters. Our elections need to find the consensus of voters, not the end result of manipulations and errors. We’re not here to elect a winner, but a representative.

Range Voting: A Complex Version of Plurality

Range voting represents a variety of systems by which a voter may express a partial vote for a candidate, rather than a full vote.  Where ranked voting allows a voter to move their vote onto a second choice in search of an electable, preferred candidate, range voting systems require rating candidates.  In simplest form, the voter rates their top-ranked candidate as 1 and their lower-ranked candidates as less.

Range voting advocates suggest voting is about marginal utility, whereby voters seek to identify the most-useful candidate by rating how “good” they are and then adding up their scores.  This contrasts with Condorcet voting, which seeks consensus on an overall-preferred candidate by rank.

Due to vote splitting, range voting simplifies to plurality:  ratings depend on whether a third candidate appears strong or weak, rather than the marginal utility of a second-choice.

Plurality and the Split Vote

In a plurality system, voters elect by casting the most single votes for a candidate.  When two desirable candidates exist, they may split the vote and elect a third candidate, as shown below.

6 Marshall
5 Carter
8 Dark

In modern American elections, voters avoid casting a vote for a third party or even a weak candidate in a primary because they don’t want to throw their vote away.  Knowing that Marshall is a strong candidate and Carter is the underdog, voters wishing to avoid electing Dark will vote for Marshall because a vote for Carter is a vote for Dark.

9 Marshall
2 Carter
8 Dark

Ranked ballots allow voters to rank candidates in order, and so those five Carter voters may rank #1 Carter and #2 Marshall.  Because all Carter voters also rank Marshall as preferred over Dark, the race between Marshall and Dark would reflect eleven votes for Marshall and eight for Dark.  Marshall gets six votes against Carter’s five.  Marshall thus beats Carter and Dark, and is the Condorcet Winner.

Without ranked ballots, voters must consider whether the popular candidate can clearly and strongly defeat the unpopular candidate, and whether they are for or against the popular candidate.  Generally, the voter must vote for the most-popular candidate they find acceptable or they will weaken their chances.

Range Voting and the Split Vote

Range voting suffers an almost-identical defect.  Consider the above race, where Marshall has a weak advantage over Dark, and Carter acts as a spoiler candidate.

A voter who prefers Carter over Marshall and considers Marshall half as good might rate the three candidates as follows:

0.5 Marshall
1 Carter
0 Dark

Knowing that Marshall might just barely defeat Dark, however, the voter also knows that a half-vote for Marshall is a half-vote for Dark.  Such ballots, with Marshall and Dark voters fully-committed, generate the following election results:

7.5 Marshall
5 Carter
8 Dark

As such, Carter voters will want to increase the rating for Marshall, essentially diminishing their vote.  By contrast, if Marshall and Carter are expected to come close to one another—say 8.5 and 9—and Dark is expected to lose, then Carter voters will want to rate Marshall lower to avoid electing Marshall when their first choice is Carter.

As with simple plurality voting, voters can more-freely vote for a third candidate when the opposition is expected to lose in any case.  In such cases—such as where one party has a strong hold and all opposition parties are expected to receive far less than one-third of the vote—the choice often comes down to two candidates, and functions as a vote-for-one plurality vote:  the voter’s best strategy is to rate their preferred candidate 1.0 and their lesser candidates as close to 0 as they feel confident in the capacity of the popular candidates to beat the unpopular ones regardless of any vote splitting.

Also as with simple plurality voting, voters must essentially sacrifice their third-party vote if they fear vote splitting.  When rating a second-choice candidate, they must provide a high rating to avoid vote-splitting, and so increase the likelihood of electing that candidate.

The Not-So-Obvious Conclusion

Range voting systems behave little different than current plurality systems.  In the most extreme cases, systems like STAR voting behave little different than California jungle primaries with instant run-off voting:  split voting causes strategic voting, and the plurality winner becomes the majority winner.

Ranked voting systems provide voters the confidence in their vote:  supporting a second-choice candidate does not harm their first-choice candidate, as an unranked candidate is only another type of lower-ranked candidate.  Likewise, casting their first choice for a non-incumbent, non-popular candidate does not throw their vote away, as an utter loss simply moves the whole vote down.  Ranked voting systems thus free the voter to seek a consensus vote through Condorcet voting rules, and better reflect the voter’s desires than range voting.

Smith-Set Voting: Protecting Our Democracy

Americans routinely voice concern over our election system, including internal threats such as gerrymandering and voting fraud, external threats from foreign interests, and even the design flaws of plurality voting and the Electoral College.

These threats open us up to more than just fraud and split votes.  Our election process isolates ideological groups for party nomination, and then presents Americans with a choice between these nominees.  This excludes the broad consensus of Americans in the nomination process, encouraging extreme views and giving victory to whichever party activates a slim majority of swing voters.

Polarization of politically-engaged Americans

Such polarization robs the American people of consensus, while creating governmental instability:  extreme candidates win elections, and so the candidates become more-extreme and power shifts back and forth with disastrous consequences.  New administrations tear down the work of old at great cost to our economy and national security, each claiming progress while trampling over the will of half the American people.

A more-representative election system resists this pull, bringing victory to those who represent the electorate.  Many voting rules can even resist gerrymandering and minimize the impact of voter fraud, foreign influence, and other internal and external attacks.

The Legislature and Executive

Before we discuss voting systems, we should create a goal for our elections.  The United States Federal government and most States have a bicameral legislature, as well as an executive such as the President, Governor, or Mayor.  Their purpose and the method of election make an enormous difference in representation.

Most States divide their legislatures between the House of Delegates and the State Senate.  They elect multiple Delegates and one Senator per each legislative district.  By contrast, the States elect single Senators in separate elections at-large, and single Representatives per Congressional district.

City and County governments generally elect one member per district to a unicameral legislative body—City or County Council.

To provide fair representation, we must treat each of these as having different and very particular function:  Houses should represent the diversity of views; while Senates, Councils, and Executives must represent the electorate at large.

Proportional Delegates, Condorcet Senators
Proportional representation (top) and Condorcet representation (bottom)

The House of Delegates

The House of Delegates should represent the varied needs of the electorate.  Each Delegate should represent a block of voters with similar needs to which they more-fully commit than a more-majoritarian representative.

Ideally, the United States Congress would also increase representation and require multi-member districts—at least three Representatives per Congressional district—to enable proportional representation.  That’s a more-ambitious goal, whereas States only need change their voting rules.

Proportional representation strengthens the voice of subgroups of voters, even when mixed into population.  Across the district, those voters impact the election in such a way as to select a candidate for themselves, drawing their needs out from the broad geographical body.

The Senate and the Executive

Both the State legislative bodies and the United States Congress elect fewer Senators.  A body of voters has several representatives in the House, and only one Senator to represent them as a whole.  City and County Councils are effectively a Senate without a House.

City and County Councils, Senators, and the Executive must represent the electorate as a whole, rather than a simple majority.  Whereas each Delegate emphasizes the needs of a subset of the district, a Senator represents all of those needs simultaneously.

Structure of a Bicameral Representative Democracy
Proportional Delegates, with Condorcet Senators and Executives

This contrast between the House and Senate allows negotiation between the varied needs in the House along with the general approval of the outcome in the Senate.  Coalitions of Delegates where a simple majority holds a strong ideological tilt must pass Senator who individually represent a compromise ideology.


Elections must fulfill the above needs by voting rules.  Voting rules control how election boards count ballots:  plurality, majority, run-off, and more-complex systems such as Condorcet and Smith methods.

We must use election methods with ranked ballots to implement what are called Proportional and Condorcet voting rules.  These election methods select by consent of the governed:  Condorcet voting, especially, determines which single candidate has the greatest support overall.

Proportional Elections

Proportional representation requires a system called Single Transferable Vote, or STV.  While actually voting is simple enough, the voting rule—the method of counting—is unfortunately complex.  Those rules most-resistant to attack and most-effective at ensuring fair and correct representation carry the greatest complexity.

Most implementations compromise in some way, such as by simply using the Scottish method or the Meek transfer.  Rather than Schulze STV, one could consider removing the Condorcet Loser instead of the Plurality Loser each round.  The effects are questionable.

In general, any STV method produces satisfactory results.  Unnecessary complexity introduces risk of fraud, and so compromises have merit.  Likewise, strong election verification at the early stages allows independent third parties to count the ballots and challenge the outcome with trivial computer implementations.  The American People can decide their comfort and press for the finer details.

Single Transferable Vote, when electing three or more winners, nearly eliminates the impact of gerrymandering.  It works well for Delegates, and would be an asset to Americans with multi-member Congressional districts.

Single Elections

Single-winner elections, such as Senate and Executive, should use a Condorcet method such as Schulze or Ranked Pairs.  These methods elect from the broadest majority support, essentially selecting a candidate from voter consensus.

Condorcet methods generally elect only from the smallest set of candidates who, in one-on-one elections, would gain a majority vote over every candidate not outside the set—called the Smith Set.  If the Smith Set contains only one candidate, that candidate is the Condorcet candidate.

Each candidate in the Smith Set (top) defeats all of each candidate not in the Smith Set (bottom)
Each candidate in the Smith Set (top) defeats all of each candidate not in the Smith Set (bottom)

When a candidate gains the majority vote, that candidate is the Condorcet candidate.  As such, elections must provide a span of candidates sufficiently representing the voting base.  It makes sense, then, for primary elections to nominate two or three candidates per party via Single Transferable Vote, eliminating the tendency to run two extremes against each other while not exhausting the voter with an enormous number of candidates to research and rank.

Electing through STV primary and a Smith-set restricted general—such as Tideman’s Alternative Smith, which resists all kinds of tactical voting and nomination—ensures the winner represents the voting base as a whole, rather than the result of strategic politics, voter base rallying, and party loyalty.