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Tuesday, April 30, 2013

Wealth Inequality and Political Inequality

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Bruce Bartlett held senior policy roles in the Reagan and George H.W. Bush administrations and served on the staffs of Representatives Jack Kemp and Ron Paul. He is the author of “The Benefit and the Burden: Tax Reform â€" Why We Need It and What It Will Take.”

A crucial question in the debate over income and wealth inequality is whether its growth necessarily leads to a growth in the inequality of political power. If it does, then this is a powerful reason for the federal government to take active measures to reduce income and wealth inequality â€" even if it comes at an economic cost to the nation.

Conservatives and libertarians generally do not believe that increased inequality is a political or economic problem. To a large extent, I think that is because they fear that acknowledging the problem would require the adoption of policies they find distasteful, immoral and economically counterproductive.

That is, income and wealth would have to be redistributed â€" taken via taxation from the wealthy and given to the poor. The higher taxes will reduce the incentive to work, save and invest among the wealthy, conservatives and libertarians believe, which will reduce economic growth and lead to the expatriation of the wealthy from the United States, while fostering a culture of dependency among the poor that will reduce their incentive to better themselves and escape poverty.

Insofar as the political dynamics are concerned, conservatives and libertarians are generally fearful of democracy. That is because, in principle, there is essentially no constraint on the ability of the majority to take from the minority and reward themselves in a pure democracy. The founding fathers very much shared this concern and intentionally enacted numerous restraints on the majority to protect the rights of the minority to their wealth. Among these are the federal system, with relatively strong states and a weak national legislature, as compared to parliamentary systems, and a Senate where small, sparsely populated states, per capita, have more influence than large, populous states; a written constitution with strong protection for property rights; and an Electoral College instead of election of the president by pure popular vote.

One reason that conservatives and libertarians obsess over the large percentage of the population that pays no federal income taxes, often put at 47 percent, is the political concern that the nation is very close to a tipping point where the have-nots can take from the haves almost at will.

The simple solution to this problem, to the extent there is one, would be to extend the tax net to some of those now living free of federal income taxation. But this is practically impossible because Republicans, who mainly complain about the large numbers of nontaxpayers, enacted most of the tax policies that removed them from the tax rolls. These include the earned income tax credit and the refundable child credit.

Secondly, almost all Republican legislators have signed a tax pledge promising never to raise taxes for any reason. Most Republicans are also ideologically opposed to a value-added tax, which would be the simplest way of getting everyone to pay some federal taxes to cover the government’s general operations. The payroll tax, which is more broadly based than the income tax, is earmarked to pay Social Security and Medicare benefits only.

Because the simple and obvious solution to their problem is off the table, conservatives and libertarians have concentrated on cutting benefits for the poor. They believe that programs such as unemployment compensation and food stamps subsidize laziness and undermine the work ethic. If such programs were cut, then those now benefiting would be forced into the labor force, where they would become taxpayers and cease being tempted by politicians promising them something for nothing.

The liberal view, by contrast, is that the poor are relatively powerless. They vote in lower percentages than the well-to-do and often suffer from policies to reduce their political influence, such as onerous voter registration requirements, demands for government identification at the polls and long waiting times to vote on Election Day. There is also evidence of growing pressure by employers to force their employees to vote against their own interest and for the employer’s.

Liberals believe our political system is generally more responsive to the interests of the wealthy. The poor, after all, are not major sources of campaign contributions.

But that is only part of the story. The well-to-do are far more likely to be engaged in the political process and to bring their concerns to bear on their elected representatives through direct contact.

Thus we have seen that while the recent budget sequestration has brought hardship to both the poor and the wealthy, Congress has taken no action to relieve the burden on the poor but acted with amazing speed to relieve a key concern of the wealthy â€" furloughs for Federal Aviation Administration personnel that created airline delays.

A new study by the political scientists Benjamin I. Page, Larry M. Bartels and Jason Seawright presents strong evidence that the wealthy are more aggressive and more successful than the poor at influencing the political system in their favor. This study is based on interviews with 83 wealthy people in Chicago.

The authors contrast the views of those in their survey with those of the general public based on national public opinion polls. They find that the wealthy are much more concerned than the general public about budget deficits, much more in favor of cutting social welfare programs, much less in favor of government jobs programs and much more opposed to government regulation, among other things.

Professors Page, Bartels and Seawright were unwilling to draw firm conclusions about whether the wealthy have disproportionate influence in American politics, owing to the small size of their survey sample. But it is at least obvious that the economic policy preferences of the wealthy strongly overlap with those of the Republican Party.

On the other hand, research by the political scientist Martin Gilens in his book “Affluence and Influence: Economic Inequality and Political Power in America” shows that the wealthy tend to be more liberal than the Republican Party on social issues. By and large, the wealthy are not religious, favor abortion rights and support gay rights.

The best hope for liberals in the future may be to emphasize social issues, which split the Republican Party between the interests of the wealthy and those of religious and social conservatives who dominate primary elections.



Monday, April 29, 2013

The Welfare Queen of Denmark

Nancy Folbre, economist at the University of Massachusetts, Amherst.

Nancy Folbre is an economics professor at the University of Massachusetts, Amherst.

To anyone who lived through Ronald Reagan’s presidency, it’s a familiar story. It begins with a detailed description of a woman living high off the hog on welfare. Then it asserts that runaway social spending poses a threat to economic growth and well-being. The up-close-and-personal touch makes a more memorable case for austerity than an argument based on numbers like debt ratios and growth rates.

The headline on Suzanne Daley’s article about a political kerfuffle in Denmark, recently published in The New York Times, summarizes its main point: “Danes Rethink a Welfare State Ample to a Fault.” The star of this story, dubbed “Carina,” is real, unlike the single mother in Ronald Reagan’s famously fictional anecdote.

But the economic claims made in the debate go far beyond “welfare” (means-tested benefits) to concerns about the effects of excessive assistance to students and pensioners â€" recapitulating the evolution of austerity arguments in the United States from the early 1990s to the present.

Certainly, policy debates in Denmark, as here, reflect partisan dynamics. In 2001, a conservative coalition came to power in Denmark, with the strong support of the anti-immigration Danish People’s Party. The Social Democratic Party regained power by a narrow margin in 2011. Many members of this party see support for mothers like Carina as a means of reducing child poverty; as in the United States, conservatives put a lower priority on this goal.

Most important, however, are the economic arguments that come into play, both within this article and the larger genre. Ms. Daley reports concern that public benefits reduce incentives to work. While Danish labor-force participation rates are higher than those in the United States, average hours worked are lower because of more part-time employment, longer vacations and paid family leaves from work.

Is this a problem? It’s not as though the supply of hours to paid employment is constraining economic growth in Denmark or elsewhere. On the contrary, distressingly high rates of unemployment in both the United States and Europe indicate a shortfall of labor demand. Many Americans would love longer vacations and paid family leaves.

As Ms. Daley points out, surveys rank Denmark as the happiest country in the world and even conservative politicians are not suggesting abandoning the Danish model.

Christian Bjornskov, an economics professor at Aarhus Business School, elaborates: “We probably spend our money differently here. We don’t buy big houses or big cars, we like to spend our money on socializing with others.”

But note that the Danes are neither lazy nor poor. Despite high marginal tax rates (or perhaps because of them) they are about as rich, on average, as Americans are. The World Bank estimates that gross domestic product per capita in Denmark for the 2008-12 period at $59,889, compared with $48,112 for the United States. Adjusted for differences in the cost of living, Danes’ G.D.P. per capita is slightly lower than ours.

The Danes spend far less on health care per capita than we do in the United States, yet achieve better health outcomes in many areas, including life expectancy. Their child poverty rates are far lower: About 6.5 percent of Danish children live in families with disposable incomes under 50 percent of the median, compared with 23.1 percent in the United States.

The Danish banking system, like most, took a hit in the financial crisis. But its banking regulations prevented major losses in mortgage lending. Overall levels of public debt as a percentage of G.D.P. are far lower than ours, and remain well below the European Union average.

In short, the Danish record offers no support for the social-spending-hurts-growth position. That doesn’t mean that some economists can’t figure out a way to make that argument anyway. For instance, Daron Acemoglu, James A. Robinson and Thierry Verdier have devised a theoretical model to show why what they term “cuddly” capitalism of the Danish sort may just be free-riding on the “cutthroat” capitalism of the United States sort.

The model posits that cutthroat levels of inequality, as in the United States, promote high levels of technological innovation. The benefits of these innovations cross national borders to help Danes and other Scandinavians achieve growth. In other words, they may be able to get away with being “cuddly,” but some country (like the United States) just has to be tough enough to reward risk-taking, even if it leads to hurt feelings.

The gendered language deployed in this model echoes a general tendency to view social spending in feminine terms: women like to cuddle and are often described as more risk-averse than men. It’s not uncommon to see the term “nanny state” used as a synonym for the welfare state.

Call the Scandinavians sissies if you like, but plenty of evidence in the latest World Competitiveness Report testifies to high levels of overall innovation there â€" as you might expect in economies even more export-oriented than our own. Danes are world leaders in renewable energy technology, especially wind power.

Danes may do plenty of cuddling, but their form of capitalism is more aptly described as team-based. And international competition remains, to a very large extent, a team sport.

And about welfare queens: According to Ms. Daley, Carina is taking home about $32,400 a year in public assistance. A constitutional monarchy, Denmark spends roughly $52 million to $70 million a year supporting its royal family, headed by Queen Margrethe II.

Yet the Danish royal family is considered the most popular in Europe. Maybe that’s because queens can’t always be judged by their record of paid employment.



Friday, April 26, 2013

Starving the Beast

In the 1950s, government spending fell quickly after the Korean War ended. In the second quarter of 1956, the total government gross domestic product was $91.4 billion, at an annual rate. That was 0.4 percent lower than the $91.8 billion rate three years earlier, in the third quarter of 1953.

It would be almost 60 years before another such decline was recorded.

The G.D.P. report released Friday states the total government part of G.D.P. - federal, state and local - came to $3.0306 trillion in the first quarter of this year. That is 0.01 percent below the $3.0309 trillion recorded four years earlier.

Those are nominal figures, not adjusted for inflation (as are the figures in the chart below). On a real basis, the decline was 6.5 percent.

Source: Bureau of Economic Analysis, via Haver Analytics

Those who complain about big government will point out, correctly, that some government spending does not show up that way in the G.D.P. accounts. Transfer payments like Social Security are recorded when the recipient spends the money, and characterized based on what he or she bought. But the figure does include all the salaries paid by governments, and all the things they buy, from schoolbooks to rifles.

Governments as a group had 648,000 fewer employees in March than they had three years earlier. Some of that decline - 87,000 jobs - reflects temporary employment for the 2010 census, but the rest reflects real cutbacks. Most of that decline has been in local government jobs, and most of the fall in local government jobs has come in schools.

Source: Bureau of Labor Statistics, via Haver Analytics

In the G.D.P. numbers, state and local spending is up a little over the last three years, measured in nominal terms. The decline came from federal spending.

Aides to Ronald Reagan used to talk about “starving the beast.” In the Obama years, it is happening.



Why the Rent Is So High in New York

In a magazine piece this week (and accompanying blog post), I talked about why many of the goods and services that high-income people consume are cheaper in New York â€" because it has such a large concentration of high-income people. I also mentioned that the big, glaring exception to this is housing, which is expensive for rich people as well as poor people.

So why is housing so expensive here, and getting even more so?

There are a few reasons. One is that New York has become a much more attractive place to live and work over the last few decades as crime has fallen and other amenities have improved. So demand for apartments here is up â€" and not just among people who live here full time.

“Manhattan and increasingly parts of Brooklyn are part of the global real estate market, attracting part-time people,” said Richard Florida, director of the Martin Prosperity Institute at the University of Toronto’s Rotman School of Management. “It’s similar to London in that way, where it’s not necessarily Londoners and New Yorkers buying and rent apartments. These are the two places where the global super-rich want to be.”

Joseph Gyourko, an economics professor at Wharton, adds that one incentive for the global super-rich to buy in New York, besides the proximity to world-class restaurants and entertainment, is that it may be a safe investment. “They may be buying to park money in a jurisdiction where they’re pretty sure it wouldn’t be expropriated,” he said. “If I were a Middle Eastern billionaire, you can bet I’d be parking a lot of money in New York.”

I asked N.Y.U.’s Furman Center for Real Estate and Urban Policy to look into whether the share of homes in New York that are not primary residences has risen in the last few years. It has:

Housing Units Used for Seasonal, Recreational, or Occasional Use in New York City, 2000-2011
Source: Furman Center analysis of the U.S. Census (2000) and the American Community Survey (2005-2011)
Seasonal units per 1,000 total units
Place 2000 2005 2006 2007 2008 2009 2010 2011
Bronx County, New York 2.0 3.4 3.3 1.8 2.9 2.2 4.3 5.6
Kings County, New York 2.8 2.0 1.6 3.7 3.5 3.6 6.0 8.5
New York County, New York 24.4 42.8 45.4 48.9 30.3 34.0 40.5 48.1
Queens County, New York 5.6 3.4 6.8 7.7 7.0 8.9 11.1 11.6
Richmond County, New York 3.2 3.9 3.7 5.7 9.8 7.7 7.0 8.1
New York City, New York 8.8 12.9 14.4 16.0 11.4 12.7 15.7 18.8

In New York City over all, about 8.8 of every 1,000 housing units (or 0.88 percent) were for seasonal/recreational/occasional use in 2000, versus 18.8 out of 1,000 homes (1.88 percent) in 2011, the most recent year for which data are available. In Manhattan alone, the share of part-time units has nearly doubled over that same time, from 24.4 out of 1,000 (2.44 percent) in 2000 up to 48.1 out of 1,000 (4.81 percent) in 2011.

Those numbers may affect the high end of the sales market, which could potentially trickle down to everyone else, but the effect seems as if it should be relatively small given how small a share of housing is directly affected.

A second key reason that housing has become so expensive is that as demand for housing from both these occasional visitors and full-time residents has grown, supply has not kept up.

Housing in New York is tightly constrained, because of limited land to build upon plus lots of regulatory, building and zoning restrictions. Construction costs are very high. And the existing supply of housing is pretty inflexible, too. Right now, nearly half of the rental housing stock in New York City over all (as well as in Manhattan specifically) is rent-regulated, meaning the apartments are either rent-controlled or rent-stabilized. Another 17 percent of the rental housing stock across the city is public or subsidized (20 percent in Manhattan specifically).

A third key reason housing is so expensive, related to the first one I mentioned, is that a lot of amenities that wealthy people like are bundled into the price of an apartment in New York, including a high concentration of bars, restaurants and theaters, and a greater variety of high-end goods.  Living in New York gives you access to a lot of perks that you would not have in lower-income places like Detroit, no matter how much you were willing to pay, and you’re paying for the cost of the entire bundle. For high-income people, who value these kinds of amenities, the cost is a bargain. The problem is that low-income people, for whom these perks are less important to the quality of life, cannot unbundle the cost of having a roof over their heads from the cost of being in close proximity to 66 Michelin-starred restaurants and the Metropolitan Opera.

New York offers higher salaries than most other cities, too, for both high-skilled and low-skilled people, which is another reason that housing costs are higher. High salaries and high housing costs are sort of mutually reinforcing: for high-skilled people, access to lucrative jobs nearby is baked into the cost of an apartment, and for low-skilled people, who are pinched by the higher cost of housing (and everything else they spend money on), better wages are required to convince them it’s worth staying and working here.

Given the better pay in New York, housing costs are actually less onerous than they might seem. The Furman Center crunched the numbers for rent burdens, or the share of household income that goes to paying the landlord. It’s about the same in New York as it is in the next four largest American cities.

Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011).

Likewise, the share of households that are moderately rent-burdened (meaning more than 30 percent of household incomes goes to rent) and severely rent-burdened (more than 50 percent to rent) is comparable with other cities.

Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Per definitions from the U.S. Department of Housing and Urban Development, a moderate rent burden is defined as spending more than 30 percent of household income on rent, and a severe burden is defined as spending more than 50 percent of household income on rent. Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Per definitions from the U.S. Department of Housing and Urban Development, a moderate rent burden is defined as spending more than 30 percent of household income on rent, and a severe burden is defined as spending more than 50 percent of household income on rent.
All that said, there are still some New Yorkers who feel strongly that rents are unreasonably high:



Why the Rent Is So High in New York

In a magazine piece this week (and accompanying blog post), I talked about why many of the goods and services that high-income people consume are cheaper in New York â€" because it has such a large concentration of high-income people. I also mentioned that the big, glaring exception to this is housing, which is expensive for rich people as well as poor people.

So why is housing so expensive here, and getting even more so?

There are a few reasons. One is that New York has become a much more attractive place to live and work over the last few decades as crime has fallen and other amenities have improved. So demand for apartments here is up â€" and not just among people who live here full time.

“Manhattan and increasingly parts of Brooklyn are part of the global real estate market, attracting part-time people,” said Richard Florida, director of the Martin Prosperity Institute at the University of Toronto’s Rotman School of Management. “It’s similar to London in that way, where it’s not necessarily Londoners and New Yorkers buying and rent apartments. These are the two places where the global super-rich want to be.”

Joseph Gyourko, an economics professor at Wharton, adds that one incentive for the global super-rich to buy in New York, besides the proximity to world-class restaurants and entertainment, is that it may be a safe investment. “They may be buying to park money in a jurisdiction where they’re pretty sure it wouldn’t be expropriated,” he said. “If I were a Middle Eastern billionaire, you can bet I’d be parking a lot of money in New York.”

I asked N.Y.U.’s Furman Center for Real Estate and Urban Policy to look into whether the share of homes in New York that are not primary residences has risen in the last few years. It has:

Housing Units Used for Seasonal, Recreational, or Occasional Use in New York City, 2000-2011
Source: Furman Center analysis of the U.S. Census (2000) and the American Community Survey (2005-2011)
Seasonal units per 1,000 total units
Place 2000 2005 2006 2007 2008 2009 2010 2011
Bronx County, New York 2.0 3.4 3.3 1.8 2.9 2.2 4.3 5.6
Kings County, New York 2.8 2.0 1.6 3.7 3.5 3.6 6.0 8.5
New York County, New York 24.4 42.8 45.4 48.9 30.3 34.0 40.5 48.1
Queens County, New York 5.6 3.4 6.8 7.7 7.0 8.9 11.1 11.6
Richmond County, New York 3.2 3.9 3.7 5.7 9.8 7.7 7.0 8.1
New York City, New York 8.8 12.9 14.4 16.0 11.4 12.7 15.7 18.8

In New York City over all, about 8.8 of every 1,000 housing units (or 0.88 percent) were for seasonal/recreational/occasional use in 2000, versus 18.8 out of 1,000 homes (1.88 percent) in 2011, the most recent year for which data are available. In Manhattan alone, the share of part-time units has nearly doubled over that same time, from 24.4 out of 1,000 (2.44 percent) in 2000 up to 48.1 out of 1,000 (4.81 percent) in 2011.

Those numbers may affect the high end of the sales market, which could potentially trickle down to everyone else, but the effect seems as if it should be relatively small given how small a share of housing is directly affected.

A second key reason that housing has become so expensive is that as demand for housing from both these occasional visitors and full-time residents has grown, supply has not kept up.

Housing in New York is tightly constrained, because of limited land to build upon plus lots of regulatory, building and zoning restrictions. Construction costs are very high. And the existing supply of housing is pretty inflexible, too. Right now, nearly half of the rental housing stock in New York City over all (as well as in Manhattan specifically) is rent-regulated, meaning the apartments are either rent-controlled or rent-stabilized. Another 17 percent of the rental housing stock across the city is public or subsidized (20 percent in Manhattan specifically).

A third key reason housing is so expensive, related to the first one I mentioned, is that a lot of amenities that wealthy people like are bundled into the price of an apartment in New York, including a high concentration of bars, restaurants and theaters, and a greater variety of high-end goods.  Living in New York gives you access to a lot of perks that you would not have in lower-income places like Detroit, no matter how much you were willing to pay, and you’re paying for the cost of the entire bundle. For high-income people, who value these kinds of amenities, the cost is a bargain. The problem is that low-income people, for whom these perks are less important to the quality of life, cannot unbundle the cost of having a roof over their heads from the cost of being in close proximity to 66 Michelin-starred restaurants and the Metropolitan Opera.

New York offers higher salaries than most other cities, too, for both high-skilled and low-skilled people, which is another reason that housing costs are higher. High salaries and high housing costs are sort of mutually reinforcing: for high-skilled people, access to lucrative jobs nearby is baked into the cost of an apartment, and for low-skilled people, who are pinched by the higher cost of housing (and everything else they spend money on), better wages are required to convince them it’s worth staying and working here.

Given the better pay in New York, housing costs are actually less onerous than they might seem. The Furman Center crunched the numbers for rent burdens, or the share of household income that goes to paying the landlord. It’s about the same in New York as it is in the next four largest American cities.

Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011).

Likewise, the share of households that are moderately rent-burdened (meaning more than 30 percent of household incomes goes to rent) and severely rent-burdened (more than 50 percent to rent) is comparable with other cities.

Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Per definitions from the U.S. Department of Housing and Urban Development, a moderate rent burden is defined as spending more than 30 percent of household income on rent, and a severe burden is defined as spending more than 50 percent of household income on rent. Source: Furman Center for Real Estate and Urban Policy analysis of American Community Survey (2011). Per definitions from the U.S. Department of Housing and Urban Development, a moderate rent burden is defined as spending more than 30 percent of household income on rent, and a severe burden is defined as spending more than 50 percent of household income on rent.
All that said, there are still some New Yorkers who feel strongly that rents are unreasonably high:



Hammurabi’s Code and U.S. Health Care

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Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

Sometime around 1780-70 B.C., the Babylonian King Hammurabi promulgated the now famous Code of Hammurabi, covering both civil and criminal law.

The code is said to have informed both Jewish and Islamic law. Remarkably, it has echoes also in modern health policy in the United States.

Among the 282 laws in Hammurabi’s Code, nine (215 to 223) pertain to medical practice:

215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive 10 shekels in money.
216. If the patient be a freed man, he receives five shekels.
217. If he be the slave of someone, his owner shall give the physician two shekels.
218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.
219. If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.
220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.
221. If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.
222. If he were a freed man he shall pay three shekels.
223. If he were a slave his owner shall pay the physician two shekels.

Not all of these laws have survived the millennia. Relative to Hammurabi’s draconian medical malpractice code, for example, modern medical malpractice penalties represent mere slaps on the wrist.

On the other hand, our modern, differentiated payment system for health care does resemble the Code of Hammurabi in some respects.

To illustrate, for a primary care office visit with a new patient of 30-minute duration (using Current Procedural Terminology, or C.T.P. codes, in this case Code 99203), New Jersey’s Medicaid in 2012 paid a nonspecialist $25 and a board-certified specialist $32.30. The comparable fees paid physicians for commercially insured patients are jealously guarded trade secrets, but it is reasonable to assume them to be $100 to $200. Other fees in the C.P.T. code are similarly low for Medicaid.

I recall addressing a group of New Jersey State legislators on this point a few years ago as follows:

I teach my students that the price a buyer is willing to pay for a thing signals to suppliers of that thing the monetary value the prospective buyer puts on it. It is a basic tenet of economics. Leaning on that tenet, I conclude that the value you in your role as state legislators put upon the professional work of, say, a pediatrician, if applied to a poor child on Medicaid, is less than a quarter of the value you put upon that same professional work it applied to your own commercially insured children.

Physicians clearly understand this relative valuation being signaled to them. According to a recent estimate, almost a third of American physicians are unwilling to accept any new patients covered by Medicaid. In New Jersey in 2011, only 40 percent of physicians accepted new Medicaid patients (see Exhibit 4). Given the insulting valuations many state Medicaid programs put upon the physicians’ work, that’s understandable.

Naturally, New Jersey’s legislators were not well pleased by my comment. To be fair, I doubt they had ever thought of their Medicaid budgets in that way. More probably, they tacitly assume that our health care system will give patients covered by Medicaid the same health care for a given medical condition that would be given a commercially insured patient, regardless how much legislators are willing to pay for that care.

Perhaps these legislators believe that the Hippocratic Oath, sworn to by all physicians at the onset of their careers, compels that egalitarian approach. In fact, neither the ancient nor modern version of the oath imposes on healers an obligation to treat patients at a monetary loss.

Not all states value the work of physicians on Medicaid patients as lowly as does New Jersey and, for that matter, New York, even though both states rank near the top in the United States in terms of per-capita income.

Nationwide, the fee paid physicians for an “office visit, new patient, 30 minutes” (C.P.T. Code 99203) in 2012 ranged from $29 to $165, with an average of $63.36. The minimum of $29 is probably a weighted average of the two fees for New Jersey cited earlier. There is a similarly wide range of Medicaid fees across the nation for other C.P.T. codes.

We do not know whether King Hammurabi expected physicians to give patricians, plebeians (freed men) and slaves the same health care for a given medical problem, in spite of the glaring fee differentials articulated in the code. Chances are that Hammurabi would have expected differential treatment as well; he is said to have been a straight thinker.

Americans today have a more, shall we say, “nuanced” view of the matter. One the one hand, we signal to our health care professionals vastly different valuations of their work. On the other, we expect them to be punctiliously egalitarian on their job.

Woe to physicians who give inferior care to Medicaid patients than they do to their commercially insured patients. And woe to any hospital if it even toyed with the idea of segregating Medicaid patients in separate wings of hospitals with fewer amenities and with, say, six patients to a room. Even the mildest hints at segregating Medicaid patients quickly bring outcries from the public and litigation.

In conclusion, I note that under the Affordable Care Act of 2010, the federal government is willing to pick up the added cost of raising physician fees paid by Medicaid for primary services to equality with the usually higher fees paid by Medicare for those services. That provision, if carried out, would more than double such fees in six states, including New York and New Jersey.

Alas, for the states, the federal government will pick up the bill for this policy only during 2013 and 2014. It is anybody’s guess, therefore, how many states will retain the more generous and to them costly payment policy after 2014.



Hammurabi’s Code and U.S. Health Care

DESCRIPTION

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

Sometime around 1780-70 B.C., the Babylonian King Hammurabi promulgated the now famous Code of Hammurabi, covering both civil and criminal law.

The code is said to have informed both Jewish and Islamic law. Remarkably, it has echoes also in modern health policy in the United States.

Among the 282 laws in Hammurabi’s Code, nine (215 to 223) pertain to medical practice:

215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive 10 shekels in money.
216. If the patient be a freed man, he receives five shekels.
217. If he be the slave of someone, his owner shall give the physician two shekels.
218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.
219. If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.
220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.
221. If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.
222. If he were a freed man he shall pay three shekels.
223. If he were a slave his owner shall pay the physician two shekels.

Not all of these laws have survived the millennia. Relative to Hammurabi’s draconian medical malpractice code, for example, modern medical malpractice penalties represent mere slaps on the wrist.

On the other hand, our modern, differentiated payment system for health care does resemble the Code of Hammurabi in some respects.

To illustrate, for a primary care office visit with a new patient of 30-minute duration (using Current Procedural Terminology, or C.T.P. codes, in this case Code 99203), New Jersey’s Medicaid in 2012 paid a nonspecialist $25 and a board-certified specialist $32.30. The comparable fees paid physicians for commercially insured patients are jealously guarded trade secrets, but it is reasonable to assume them to be $100 to $200. Other fees in the C.P.T. code are similarly low for Medicaid.

I recall addressing a group of New Jersey State legislators on this point a few years ago as follows:

I teach my students that the price a buyer is willing to pay for a thing signals to suppliers of that thing the monetary value the prospective buyer puts on it. It is a basic tenet of economics. Leaning on that tenet, I conclude that the value you in your role as state legislators put upon the professional work of, say, a pediatrician, if applied to a poor child on Medicaid, is less than a quarter of the value you put upon that same professional work it applied to your own commercially insured children.

Physicians clearly understand this relative valuation being signaled to them. According to a recent estimate, almost a third of American physicians are unwilling to accept any new patients covered by Medicaid. In New Jersey in 2011, only 40 percent of physicians accepted new Medicaid patients (see Exhibit 4). Given the insulting valuations many state Medicaid programs put upon the physicians’ work, that’s understandable.

Naturally, New Jersey’s legislators were not well pleased by my comment. To be fair, I doubt they had ever thought of their Medicaid budgets in that way. More probably, they tacitly assume that our health care system will give patients covered by Medicaid the same health care for a given medical condition that would be given a commercially insured patient, regardless how much legislators are willing to pay for that care.

Perhaps these legislators believe that the Hippocratic Oath, sworn to by all physicians at the onset of their careers, compels that egalitarian approach. In fact, neither the ancient nor modern version of the oath imposes on healers an obligation to treat patients at a monetary loss.

Not all states value the work of physicians on Medicaid patients as lowly as does New Jersey and, for that matter, New York, even though both states rank near the top in the United States in terms of per-capita income.

Nationwide, the fee paid physicians for an “office visit, new patient, 30 minutes” (C.P.T. Code 99203) in 2012 ranged from $29 to $165, with an average of $63.36. The minimum of $29 is probably a weighted average of the two fees for New Jersey cited earlier. There is a similarly wide range of Medicaid fees across the nation for other C.P.T. codes.

We do not know whether King Hammurabi expected physicians to give patricians, plebeians (freed men) and slaves the same health care for a given medical problem, in spite of the glaring fee differentials articulated in the code. Chances are that Hammurabi would have expected differential treatment as well; he is said to have been a straight thinker.

Americans today have a more, shall we say, “nuanced” view of the matter. One the one hand, we signal to our health care professionals vastly different valuations of their work. On the other, we expect them to be punctiliously egalitarian on their job.

Woe to physicians who give inferior care to Medicaid patients than they do to their commercially insured patients. And woe to any hospital if it even toyed with the idea of segregating Medicaid patients in separate wings of hospitals with fewer amenities and with, say, six patients to a room. Even the mildest hints at segregating Medicaid patients quickly bring outcries from the public and litigation.

In conclusion, I note that under the Affordable Care Act of 2010, the federal government is willing to pick up the added cost of raising physician fees paid by Medicaid for primary services to equality with the usually higher fees paid by Medicare for those services. That provision, if carried out, would more than double such fees in six states, including New York and New Jersey.

Alas, for the states, the federal government will pick up the bill for this policy only during 2013 and 2014. It is anybody’s guess, therefore, how many states will retain the more generous and to them costly payment policy after 2014.



Hammurabi’s Code and U.S. Health Care

DESCRIPTION

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

Sometime around 1780-70 B.C., the Babylonian King Hammurabi promulgated the now famous Code of Hammurabi, covering both civil and criminal law.

The code is said to have informed both Jewish and Islamic law. Remarkably, it has echoes also in modern health policy in the United States.

Among the 282 laws in Hammurabi’s Code, nine (215 to 223) pertain to medical practice:

215. If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive 10 shekels in money.
216. If the patient be a freed man, he receives five shekels.
217. If he be the slave of someone, his owner shall give the physician two shekels.
218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.
219. If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.
220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.
221. If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.
222. If he were a freed man he shall pay three shekels.
223. If he were a slave his owner shall pay the physician two shekels.

Not all of these laws have survived the millennia. Relative to Hammurabi’s draconian medical malpractice code, for example, modern medical malpractice penalties represent mere slaps on the wrist.

On the other hand, our modern, differentiated payment system for health care does resemble the Code of Hammurabi in some respects.

To illustrate, for a primary care office visit with a new patient of 30-minute duration (using Current Procedural Terminology, or C.T.P. codes, in this case Code 99203), New Jersey’s Medicaid in 2012 paid a nonspecialist $25 and a board-certified specialist $32.30. The comparable fees paid physicians for commercially insured patients are jealously guarded trade secrets, but it is reasonable to assume them to be $100 to $200. Other fees in the C.P.T. code are similarly low for Medicaid.

I recall addressing a group of New Jersey State legislators on this point a few years ago as follows:

I teach my students that the price a buyer is willing to pay for a thing signals to suppliers of that thing the monetary value the prospective buyer puts on it. It is a basic tenet of economics. Leaning on that tenet, I conclude that the value you in your role as state legislators put upon the professional work of, say, a pediatrician, if applied to a poor child on Medicaid, is less than a quarter of the value you put upon that same professional work it applied to your own commercially insured children.

Physicians clearly understand this relative valuation being signaled to them. According to a recent estimate, almost a third of American physicians are unwilling to accept any new patients covered by Medicaid. In New Jersey in 2011, only 40 percent of physicians accepted new Medicaid patients (see Exhibit 4). Given the insulting valuations many state Medicaid programs put upon the physicians’ work, that’s understandable.

Naturally, New Jersey’s legislators were not well pleased by my comment. To be fair, I doubt they had ever thought of their Medicaid budgets in that way. More probably, they tacitly assume that our health care system will give patients covered by Medicaid the same health care for a given medical condition that would be given a commercially insured patient, regardless how much legislators are willing to pay for that care.

Perhaps these legislators believe that the Hippocratic Oath, sworn to by all physicians at the onset of their careers, compels that egalitarian approach. In fact, neither the ancient nor modern version of the oath imposes on healers an obligation to treat patients at a monetary loss.

Not all states value the work of physicians on Medicaid patients as lowly as does New Jersey and, for that matter, New York, even though both states rank near the top in the United States in terms of per-capita income.

Nationwide, the fee paid physicians for an “office visit, new patient, 30 minutes” (C.P.T. Code 99203) in 2012 ranged from $29 to $165, with an average of $63.36. The minimum of $29 is probably a weighted average of the two fees for New Jersey cited earlier. There is a similarly wide range of Medicaid fees across the nation for other C.P.T. codes.

We do not know whether King Hammurabi expected physicians to give patricians, plebeians (freed men) and slaves the same health care for a given medical problem, in spite of the glaring fee differentials articulated in the code. Chances are that Hammurabi would have expected differential treatment as well; he is said to have been a straight thinker.

Americans today have a more, shall we say, “nuanced” view of the matter. One the one hand, we signal to our health care professionals vastly different valuations of their work. On the other, we expect them to be punctiliously egalitarian on their job.

Woe to physicians who give inferior care to Medicaid patients than they do to their commercially insured patients. And woe to any hospital if it even toyed with the idea of segregating Medicaid patients in separate wings of hospitals with fewer amenities and with, say, six patients to a room. Even the mildest hints at segregating Medicaid patients quickly bring outcries from the public and litigation.

In conclusion, I note that under the Affordable Care Act of 2010, the federal government is willing to pick up the added cost of raising physician fees paid by Medicaid for primary services to equality with the usually higher fees paid by Medicare for those services. That provision, if carried out, would more than double such fees in six states, including New York and New Jersey.

Alas, for the states, the federal government will pick up the bill for this policy only during 2013 and 2014. It is anybody’s guess, therefore, how many states will retain the more generous and to them costly payment policy after 2014.



Thursday, April 25, 2013

The Gorilla and the Maginot Line

Janet Yellen likes metaphors. This is a common trait among central bankers, at least the ones who see value in trying to explain their work.

In 2007, she compared problems in the housing market to a 600-pound gorilla lurking in the corner of the Federal Reserve’s meeting room.

In 2010, she described the state of financial regulation before the crisis as “a financial Maginot Line that we believed couldn’t be breached.”

We all know what happened next: The gorilla broke through the Maginot Line.

She is not the most colorful of the current crop of Fed officials. That honor surely belongs to Richard Fisher, president of the Federal Reserve Bank of Dallas, whose most recent speech was titled “Oil and Gas, Blondes and Over-Accessorized Brunettes, and Ruthless, Hard-Drinking Cowboys.”

Nor has she ever produced anything quite as enduringly memorable as former Fed chairman William McChesney Martin’s famous description of central banking. The job, he said, is “to take away the punch bowl just as the party gets going.”

But Ms. Yellen, whom I profiled Thursday as a logical successor to Ben S. Bernanke as Fed chairman, can paint a picture. Consider her description at the September 2007 meeting of the Fed’s policy-making group, the Federal Open Market Committee, of “the earthquake that began roiling financial markets in mid-July.  Our contacts located at the epicenter â€" those, for example, in the private equity and mortgage markets â€" report utter devastation.  Anecdotal reports from those nearby â€" for example, our contacts in banking, housing construction, and housing-related businesses â€" suggest significant damage from the temblor.”

In 1995, concerned that the Fed was keeping interest rates too high, she compared the effects to “a termites in the basement problem,” suggesting that the high rates would gradually weaken and undermine the vitality of the economy.

“A ‘termites in the basement’ problem is a nagging, chronic little problem that can eventually cause a lot of grief if it is not attended to,” Ms. Yellen said at the Fed’s September meeting, according to the Fed’s transcript. “Termites nibble away slowly so the problem just creeps up and there is no great sense of urgency that one absolutely has to deal with it on one day as opposed to the next.”

Other members of the committee then picked up on the metaphor, invoking termites to make their own case for lower interest rates.

And then there is my personal favorite. Earlier in 1995, the Fed was debating whether to endorse Congressional legislation directing the Fed to make price stability its sole objective, replacing the “dual mandate” that instructs the central bank to minimize both unemployment and inflation.

Ms. Yellen was one of the strongest voices in opposition, arguing repeatedly that the people wanted the central bank to mitigate economic downturns in addition to minimizing inflation, and that the central bank had the ability and therefore the responsibility to do so.

Even the German central bank, famous for its commitment to suppress inflation, sought to mitigate economic downturns, she said.

“Who would be prepared to believe that the F.O.M.C. is single-mindedly going to pursue an inflation target regardless of real economic performance, if not even the Bundesbank is prepared to go that far?” she said. “So, that means that the targets are going to be perceived as a hoax.”

And then, to drive the point home, she added, “They are not going to be any more believable than I would be if I told my child that I was going to cut off his hand if he put it in the candy drawer.”



This Week’s Links: _why Edition

DevTools Can Do That?

Since the bad old days of alert messages like “Object Expected,” web debugging has become more sophisticated and powerful. These slides â€" from a Chrome Developer Tools presentation by Ilya Grigorik of Google â€" offer a nice overview of some of the latest goodies in Chrome DevTools. Pro tip: be sure to open chrome://flags and enable “Developer Tools experiments”; that way you can use some of the features, such as snippets, mentioned in the deck. And if you don’t yet know of the wonders of continuous paint mode, you are about to find out.

The Node.js Community Is Quietly Changing the Face of Open Source

Gregg Caines offers some thoughts on how Node.js development and use reflects a sea change in open source development in general. He notes the move from holistic platforms, such as Python’s “batteries included” philosophy, to the “core necessities” approach of Node.js, and the heavy lean on npm to get only what you need, and customize to your heart’s content. In contrast, Node is a monoculture on the back end, built heavily around Github. Caines notes that this makes it much easier to contribute because there’s no communication overhead: everything works the same. Contributed by Trevor Landau

_why

If you read only one of our links this week, make it this one. Why the Lucky Stiff is a pseudonymous hacker from the Ruby community, best known for writing what I consider to be the definitive intro to Ruby, Why’s (Poignant) Guide to Ruby (warning: this is not like any programming guide you’ve ever seen, or will see). Why also wrote numerous code libraries.

Last year Why vanished from, well, everywhere. He took down his website and deleted all his code. He was gone, with almost no comment or explanation. Numerous Ruby fans rushed to create backups of his work, which is why you can visit the links above.

In January of this year, the site came back online, and this month it began displaying printer commands that, when pieced together, create a large document. The document, in true Why form, meanders through the background of what Why is thinking about and what was happening when he decided to erase his digital presence and vanish. And as noted in the linked story, Why’s site is back down again.

Also: chunky bacon.



The Treasury’s Mistaken View on Too Big to Fail

DESCRIPTION
DESCRIPTION

Simon Johnson, former chief economist of the International Monetary Fund, is the Ronald A. Kurtz Professor of Entrepreneurship at the M.I.T. Sloan School of Management.
John E. Parsons is a senior lecturer in the finance group at the Sloan School and co-author of the blog bettingthebusiness.com.

At this point, no one will stick up for too-big-to-fail financial institutions. Even Tim Pawlenty, the newly appointed head of the Financial Services Roundtable, a group that represents big banks, contends that we must end the phenomenon of too big to fail. No financial institution should be so big â€" or so systemically important for any reason â€" that its failure would jeopardize the macroeconomy.

The question of the day has therefore become whether too big to fail is already dead and buried or whether, like some resilient and unsavory zombie, it still stalks within our financial system.

In a speech on April 18, Mary Miller, Treasury under secretary for domestic finance, made the case that the Dodd-Frank reform legislation has substantially ended the problem of too-big-to-fail financial institutions. This is a well-composed speech that everyone should read â€" and then compare with the broadly parallel messages coming from parts of the financial sector (e.g., see the presentation of the Clearing House, an association of banks).

The original written version of Ms. Miller’s speech did not contain footnotes or precise references to the sources on which she drew, but the Treasury Department was kind enough to share this information with us and has now posted a version of the speech with links to sources; this is also most helpful. As a result, we are able to evaluate Ms. Miller’s arguments in some detail.

Ms. Miller’s argument rests on eight main points. On each there is a serious problem with her logic or her reading of the data, or both. Taken together, we find her position to be completely unpersuasive. Unfortunately, the problem of too big to fail still lurks.

First, Ms. Miller makes a great deal (at the top of Page 2) out of legal changes under Dodd-Frank that make it harder to bail out financial institutions. She is right on the formal changes but misses the essence of the issue. The question is not whether the government can swear up and down not to provide bailouts or some other form of support, but rather whether such commitments are credible. If banks are so big or so linked to the rest of the economy that their distress will bring unacceptable costs, then any government or central bank will be tempted to provide support, for example by seeking new legislation that authorizes emergency bailouts.

Ms. Miller stresses the lack of potential future “taxpayer support” â€" and that is an appropriate point for a Treasury official to make. But sophisticated modern central bankers have many ways to provide help to troubled financial institutions (e.g., through various kinds of asset-purchase programs), while complying with the letter of Dodd-Frank. To assert otherwise is to create the wrong impression.

Second, Ms. Miller claims that “some evidence actually suggests the opposite conclusion â€" that larger banks’ funding costs are higher than those of their smaller peers” (see Page 2). The Treasury’s evidence on this point is embarrassingly naïve; it compares funding costs irrespective of the source (see Page 11). A small bank funded mostly with insured deposits will have a lower funding cost than a bank that relies more on wholesale funding. But this difference does not speak to the issue of too-big-to-fail implicit subsidies.

The right comparison is what large banks are paying compared with what they would pay if they did not have implicit government backing.

Banks used to be good at measuring this kind of implicit government support, when it provided an unfair competitive advantage to Fannie Mae and Freddie Mac. Now that they (the private megabanks) are the recipients of this largess, they have become much hazier on methodology â€" asserting that everything anyone tries to measure is awfully complicated.

In a speech at the International Monetary Fund last week, Jeremy Stein, a Federal Reserve governor, acknowledged that too big to fail is not over: “We’re not yet at a point where we should be satisfied,” he said in the third paragraph. The Fed chairman, Ben Bernanke, has recently made the same point. It’s interesting that Treasury should want to confront the Fed on this relatively technical point. This is exactly the kind of issue on which the Fed usually has better information and analysis, and in the current iteration the Fed also seems to have a distinct edge.

Third, Ms. Miller insists that “the evidence on both sides of the argument is mixed and complicated” because of the many factors besides too big to fail that could be the cause of the funding advantage. But isn’t this why we elevate Treasury appointees to such a high position in the pantheon of our officials, because they are supposed to be able to sort out complex issues?

Where is the Office of Financial Research, a unit created within Treasury by Dodd-Frank, on this issue? In her reluctance to take sides or state a clear position, Ms. Miller appears to be ducking (Pages 3-4). This is a disappointing performance by an experienced and well-informed official.

In fact, there is a long list of studies that find various ways to take into account all of the complicating factors and isolate the too-big-to-fail subsidy. None of these are cited by Ms. Miller, but taken together, the conclusion is clear â€" the implicit subsidy is large and still with us.

One example is a study by Profs. Viral Acharya of New York University, Deniz Anginer of Virginia Tech and A. Joseph Warburton of Syracuse (released on Jan. 1) that measures the funding cost advantage provided by implicit government support to large financial institutions, while controlling for other factors. Credit spreads were lower (because of implicit guarantees) by approximately 28 basis points on average over the 1990-2010 period â€" with a peak of more than 120 basis points in 2009 (when having access to this subsidy really mattered). In 2010, the last year of the study, the implicit subsidy this provided to the largest banks was worth nearly $100 billion. The authors conclude, “Passage of Dodd-Frank did not eliminate expectations of government support.”

If Ms. Miller contests the methodology or results of this (or any other) study or regards the numbers as insufficiently current, she should request that the Office of Financial Research, the Fed or any other competent government body devise better methodology on the latest available data (or even use the real-time data available to supervisors). The United States government has many smart people, the best available data and the undoubted ability to conduct sensible econometric work (with full disclosure). Five years after the onset of the worst financial crisis since the Great Depression, we should expect nothing less from the Treasury Department.

Fourth, Ms. Miller is very taken with the fact that credit rating agencies have reduced the “uplift” they determine is due to government support for megabanks â€" i.e., they assign a lower probability of default (and losses for creditors) because there is some form of official backstop. And she makes a great deal of Moody’s saying that it may eliminate uplift altogether. We can debate for a long time about the value of credit-rating-agency opinions, but the striking fact about Ms. Miller’s reference to Moody’s is that it exactly contradicts her on the current situation (see Moody’s report). Moody’s still has a significant too-big-to-fail uplift for big banks.

Fifth, Ms. Miller is adamant that if too big to fail were a problem, we would see low credit-default-swap spreads across the board (for megabanks). But the figure to which she refers (see Page 10) is not persuasive. Look at the pattern of credit-default-swap spreads at the height of the crisis, when the doctrine of too big to fail was undeniably in effect; it is very similar to what we see today. Or hide the date and try to find the magic moment when Dodd-Frank supposedly changed the bailout game.

Sixth, Ms. Miller points out that credit-default-swap spreads have declined since the crisis. That is correct. But all that tells you is that we are not currently in a crisis phase. The real question is what happens the next time large financial institutions mismanage their risks and bring us to the brink of disaster.

Seventh, Ms. Miller asserts that capital requirements have increased “significantly” since the crisis (Page 4). But notice the complete absence of numbers in this part of her speech. How high are minimum capital requirements under Basel III? They are low â€" a bank could fund itself with 97 percent debt and 3 percent equity and still comply with the rules (see Section 4 in this handy Accenture guide to Basel III, Page 32). In this context, global megabank is a fancy name for a high-risk hedge fund, albeit one with access to the government-sponsored safety net.

Eighth, Ms. Miller points out that banks now have more capital on their balance sheets than they did four years ago (meaning they are funded with more equity relative to debt). This is correct, but it is a completely standard reaction among corporate survivors of financial crises. They are more cautious, for a while. But then they start to push up their return on equity, unadjusted for risk; this is the basis for executive and trader compensation, after all. And the best way to do this is to borrow more heavily, increasing leverage and reducing equity funding relative to their balance sheets (an equivalent way of saying that they borrow more and rely less on equity â€" in banking jargon, they reduce their capital levels).

It is alarming that Ms. Miller demonstrates no awareness of this well-established historical pattern â€" or the ingrained incentives in the financial system that make overleveraging hard to avoid.

Over all, Ms. Miller’s speech is completely unconvincing on the substance of the points that she is trying to make. Dodd-Frank alone will not end too big to fail.

It makes sense that senior Treasury officials should want to put Dodd-Frank into effect. But it is disconcerting when they are unable to confront the market and political realities of too-big-to-fail banks. Any such level of denial will not serve us well.



The Treasury’s Mistaken View on Too Big to Fail

DESCRIPTION
DESCRIPTION

Simon Johnson, former chief economist of the International Monetary Fund, is the Ronald A. Kurtz Professor of Entrepreneurship at the M.I.T. Sloan School of Management.
John E. Parsons is a senior lecturer in the finance group at the Sloan School and co-author of the blog bettingthebusiness.com.

At this point, no one will stick up for too-big-to-fail financial institutions. Even Tim Pawlenty, the newly appointed head of the Financial Services Roundtable, a group that represents big banks, contends that we must end the phenomenon of too big to fail. No financial institution should be so big â€" or so systemically important for any reason â€" that its failure would jeopardize the macroeconomy.

The question of the day has therefore become whether too big to fail is already dead and buried or whether, like some resilient and unsavory zombie, it still stalks within our financial system.

In a speech on April 18, Mary Miller, Treasury under secretary for domestic finance, made the case that the Dodd-Frank reform legislation has substantially ended the problem of too-big-to-fail financial institutions. This is a well-composed speech that everyone should read â€" and then compare with the broadly parallel messages coming from parts of the financial sector (e.g., see the presentation of the Clearing House, an association of banks).

The original written version of Ms. Miller’s speech did not contain footnotes or precise references to the sources on which she drew, but the Treasury Department was kind enough to share this information with us and has now posted a version of the speech with links to sources; this is also most helpful. As a result, we are able to evaluate Ms. Miller’s arguments in some detail.

Ms. Miller’s argument rests on eight main points. On each there is a serious problem with her logic or her reading of the data, or both. Taken together, we find her position to be completely unpersuasive. Unfortunately, the problem of too big to fail still lurks.

First, Ms. Miller makes a great deal (at the top of Page 2) out of legal changes under Dodd-Frank that make it harder to bail out financial institutions. She is right on the formal changes but misses the essence of the issue. The question is not whether the government can swear up and down not to provide bailouts or some other form of support, but rather whether such commitments are credible. If banks are so big or so linked to the rest of the economy that their distress will bring unacceptable costs, then any government or central bank will be tempted to provide support, for example by seeking new legislation that authorizes emergency bailouts.

Ms. Miller stresses the lack of potential future “taxpayer support” â€" and that is an appropriate point for a Treasury official to make. But sophisticated modern central bankers have many ways to provide help to troubled financial institutions (e.g., through various kinds of asset-purchase programs), while complying with the letter of Dodd-Frank. To assert otherwise is to create the wrong impression.

Second, Ms. Miller claims that “some evidence actually suggests the opposite conclusion â€" that larger banks’ funding costs are higher than those of their smaller peers” (see Page 2). The Treasury’s evidence on this point is embarrassingly naïve; it compares funding costs irrespective of the source (see Page 11). A small bank funded mostly with insured deposits will have a lower funding cost than a bank that relies more on wholesale funding. But this difference does not speak to the issue of too-big-to-fail implicit subsidies.

The right comparison is what large banks are paying compared with what they would pay if they did not have implicit government backing.

Banks used to be good at measuring this kind of implicit government support, when it provided an unfair competitive advantage to Fannie Mae and Freddie Mac. Now that they (the private megabanks) are the recipients of this largess, they have become much hazier on methodology â€" asserting that everything anyone tries to measure is awfully complicated.

In a speech at the International Monetary Fund last week, Jeremy Stein, a Federal Reserve governor, acknowledged that too big to fail is not over: “We’re not yet at a point where we should be satisfied,” he said in the third paragraph. The Fed chairman, Ben Bernanke, has recently made the same point. It’s interesting that Treasury should want to confront the Fed on this relatively technical point. This is exactly the kind of issue on which the Fed usually has better information and analysis, and in the current iteration the Fed also seems to have a distinct edge.

Third, Ms. Miller insists that “the evidence on both sides of the argument is mixed and complicated” because of the many factors besides too big to fail that could be the cause of the funding advantage. But isn’t this why we elevate Treasury appointees to such a high position in the pantheon of our officials, because they are supposed to be able to sort out complex issues?

Where is the Office of Financial Research, a unit created within Treasury by Dodd-Frank, on this issue? In her reluctance to take sides or state a clear position, Ms. Miller appears to be ducking (Pages 3-4). This is a disappointing performance by an experienced and well-informed official.

In fact, there is a long list of studies that find various ways to take into account all of the complicating factors and isolate the too-big-to-fail subsidy. None of these are cited by Ms. Miller, but taken together, the conclusion is clear â€" the implicit subsidy is large and still with us.

One example is a study by Profs. Viral Acharya of New York University, Deniz Anginer of Virginia Tech and A. Joseph Warburton of Syracuse (released on Jan. 1) that measures the funding cost advantage provided by implicit government support to large financial institutions, while controlling for other factors. Credit spreads were lower (because of implicit guarantees) by approximately 28 basis points on average over the 1990-2010 period â€" with a peak of more than 120 basis points in 2009 (when having access to this subsidy really mattered). In 2010, the last year of the study, the implicit subsidy this provided to the largest banks was worth nearly $100 billion. The authors conclude, “Passage of Dodd-Frank did not eliminate expectations of government support.”

If Ms. Miller contests the methodology or results of this (or any other) study or regards the numbers as insufficiently current, she should request that the Office of Financial Research, the Fed or any other competent government body devise better methodology on the latest available data (or even use the real-time data available to supervisors). The United States government has many smart people, the best available data and the undoubted ability to conduct sensible econometric work (with full disclosure). Five years after the onset of the worst financial crisis since the Great Depression, we should expect nothing less from the Treasury Department.

Fourth, Ms. Miller is very taken with the fact that credit rating agencies have reduced the “uplift” they determine is due to government support for megabanks â€" i.e., they assign a lower probability of default (and losses for creditors) because there is some form of official backstop. And she makes a great deal of Moody’s saying that it may eliminate uplift altogether. We can debate for a long time about the value of credit-rating-agency opinions, but the striking fact about Ms. Miller’s reference to Moody’s is that it exactly contradicts her on the current situation (see Moody’s report). Moody’s still has a significant too-big-to-fail uplift for big banks.

Fifth, Ms. Miller is adamant that if too big to fail were a problem, we would see low credit-default-swap spreads across the board (for megabanks). But the figure to which she refers (see Page 10) is not persuasive. Look at the pattern of credit-default-swap spreads at the height of the crisis, when the doctrine of too big to fail was undeniably in effect; it is very similar to what we see today. Or hide the date and try to find the magic moment when Dodd-Frank supposedly changed the bailout game.

Sixth, Ms. Miller points out that credit-default-swap spreads have declined since the crisis. That is correct. But all that tells you is that we are not currently in a crisis phase. The real question is what happens the next time large financial institutions mismanage their risks and bring us to the brink of disaster.

Seventh, Ms. Miller asserts that capital requirements have increased “significantly” since the crisis (Page 4). But notice the complete absence of numbers in this part of her speech. How high are minimum capital requirements under Basel III? They are low â€" a bank could fund itself with 97 percent debt and 3 percent equity and still comply with the rules (see Section 4 in this handy Accenture guide to Basel III, Page 32). In this context, global megabank is a fancy name for a high-risk hedge fund, albeit one with access to the government-sponsored safety net.

Eighth, Ms. Miller points out that banks now have more capital on their balance sheets than they did four years ago (meaning they are funded with more equity relative to debt). This is correct, but it is a completely standard reaction among corporate survivors of financial crises. They are more cautious, for a while. But then they start to push up their return on equity, unadjusted for risk; this is the basis for executive and trader compensation, after all. And the best way to do this is to borrow more heavily, increasing leverage and reducing equity funding relative to their balance sheets (an equivalent way of saying that they borrow more and rely less on equity â€" in banking jargon, they reduce their capital levels).

It is alarming that Ms. Miller demonstrates no awareness of this well-established historical pattern â€" or the ingrained incentives in the financial system that make overleveraging hard to avoid.

Over all, Ms. Miller’s speech is completely unconvincing on the substance of the points that she is trying to make. Dodd-Frank alone will not end too big to fail.

It makes sense that senior Treasury officials should want to put Dodd-Frank into effect. But it is disconcerting when they are unable to confront the market and political realities of too-big-to-fail banks. Any such level of denial will not serve us well.



Wednesday, April 24, 2013

The Bad Economy Behind the Health Care Slowdown

In today’s paper, I took a look at a major innovation in health care delivery, one that Obama administration officials think might play a big role in holding down health costs in the future. It is called accountable care, and the general idea is to enlist doctors and nurses in the fight to control spending.

But how much have such shifts away from fee-for-service medicine already contributed to the big slowdown in health care costs?

That has been one of the biggest puzzles in health economics â€" indeed, in all of public economics â€" in the last few years. Policy makers broadly consider rising health costs to be the single biggest long-term budget challenge, and those same rising costs are eating away at workers’ wages. Economists figured that Americans would spend less on health care because of the deep recession and sluggish recovery. But health costs have slowed even more than they expected given the size of the downturn, leading many to surmise that other factors were at work.

A new study from the Kaiser Family Foundation helps sort out definitively what is the bad economy and what is not. All in all, Kaiser estimates that 77 percent of the cost slowdown is due to the recession, with the remaining quarter due to “continuing changes in the way health care is delivered, but also to rising levels of patient cost-sharing in private insurance plans that discourage use of services.”

A quarter might not seem like much, but in an interview, Drew Altman, the president of the Kaiser Family Foundation, described it as “the whole ballgame” for holding down costs as time goes on. “It’s more than just the A.C.A. reforms, those are just beginning,” he said, referring to the Affordable Care Act. “But in the long run, those are the most important ones, because they have the force of Medicare and national policy behind them.”

He expects that higher co-payments and deductibles â€" cases in which an insured person needs to pay more for health care out of pocket â€" will have a major, underappreciated role in holding down costs in the future, too. “It’s this quiet revolution in insurance,” he said.

In the last few years, accountable care organizations have represented a little revolution of their own, moving from being a mere idea to covering millions of Medicare and privately insured patients.

The one I profiled works like this: Advocate Health Care, a major health system in the Chicago area, struck a deal with the insurer Blue Cross Blue Shield of Illinois. The two jointly picked about 380,000 people who were insured by Blue Cross and used Advocate’s doctors or hospitals. They then projected their expected health costs. If Advocate can keep costs below that amount, the insurer and the provider split the savings. If it cannot, its revenue is at risk.

That gives Advocate a huge financial incentive to prevent illness, reduce complication rates and cut out unnecessary procedures and tests, all while keeping those 380,000 people coming back to Advocate doctors. And it makes the most expensive patients, often those with multiple chronic conditions, like diabetes and heart disease, centers for cost savings.

Thus far, the experiment seems to be working. Advocate has started initiatives to prevent asthma attacks, end elective inductions of labor before 39 weeks of pregnancy and reduce readmissions to the hospital after a patient is discharged, among others. Those changes have resulted in a cost reduction of about 2 percent over all.

Many other health systems have made more incremental steps toward what health economists like to call value-based care, such as accepting bundled payments for a patient’s course of treatment, rather than charging an insurer per procedure. Medicare and Medicaid have also been pioneers in paying for quality, not quantity. For instance, Medicare recently instituted a policy of penalizing hospitals when patients are readmitted after being discharged. Hospitals might not like it. But there are signs it is squeezing spending out of the system.

Indeed, in a recent interview, Secretary Kathleen Sebelius of the Department of Health and Human Services cited falling readmission rates as one of the strongest early signs that the Affordable Care Act is working to bend the health care cost curve.



Test Your Economic Literacy

The Department of Education Wednesday released its latest report on the economic proficiency of 12th graders, based on the test scores of nearly 11,000 students tested in 2012. It found little change in average economic literacy compared to test scores from 2006, although students in the lower part of the score distribution (at the 10th and 25th percentiles) made gains.

In case you want to know how you would stack up against these students, here are some sample questions from the report, followed by the answers.

1. Suppose that the price of grapes increases by a large amount. What will happen in the short term to the quantity of grapes demanded? Explain why.

2. Which of the following best describes an opportunity cost for a student who chooses to quit a full-time job to go to college?
A) Paying state and federal income tax
B) Having a higher level of education
C) Giving up current wages and benefits
D) Paying for housing and meals

3. Which of the following changes is most likely to cause an increase in employment?
A) An increase in consumer spending
B) An increase in interest rates
C) A decrease in business investment
D) A decrease in income

4. A high rate of unemployment that lasts for several years has economic costs for a nation. What are two of these economic costs?

5. a. Explain why United States steel manufacturers would support a tariff on imported steel.
b. Explain why United States steel workers would support a tariff on imported steel.
c. Explain why United States consumers would be hurt by a tariff on imported steel.
d. Explain why a steel tariff might be adopted even if it hurts United States consumers.

6. Which of the following is one way in which economic growth can help a nation reduce its poverty level and increase its standard of living?
A) Economic growth increases the demand for imports, thereby raising the demand for foreign exchange.
B) Economic growth increases the supply of labor, thereby increasing wages.
C) Economic growth increases disposable income, thereby raising the demand for luxury items.
D) Economic growth increases the demand for labor, thereby raising income levels.

Answers from the report:

    1. Demand will fall. When the prices of goods or services increase, individuals will look for substitute goods to avoid paying the higher price, and therefore, the quantity of goods or services demanded will fall.
    2. C
    3. A
    4. Acceptable answers include: expenses incurred by governments when providing financial support to the unemployed; decrease in aggregate demand in the economy that is caused because of lower consumer incomes; loss of tax revenue to the government; increases in poverty; decreases in the standard of living; and increases in the cost of providing job training programs to the unemployed.
    5. (a) Acceptable answers: The price on imported steel would rise, so people would use more U.S. steel. Domestic manufacturers might also favor tariffs because tariffs would tend to increase revenue and profits for domestic producers and would decrease foreign (import) competition in an industry. (b) If imported steel is more expensive and people buy more U.S. steel, then U.S. companies will need more workers to handle increased demand. The same forces might also increase wages at the U.S. steel companies. (c) The tariff would increase the price of imported steel, so U.S. consumers could be harmed because they might pay higher prices for goods using steel as an input in their production. (d) The tariff would bring in money for the government. Tariffs are also sometimes adopted to protect jobs in a given industry as part of the political process.
    6. D