Monday, December 10, 2018

US Health and Healthcare Spending in the Last 25 Years: Gains and Costs

As an overall pattern over the decades, spending in the US health care has been rising, both on a per person basis and as a share of GDP, and a number of health outcomes have improved. Are the benefits worth the costs?

Jeffrey Selberg, Bradley Sawyer, Cynthia Cox, Marco Ramirez, Gary Claxton and Larry Levitt tackle the question "A generation of healthcare in the United States: Has value improved in the last 25 years?" in a short essay published by the Peterson Center on Healthcare and the Kaiser Family Foundation (December 6, 2018).

In terms of health care costs: "In 1991, the GDP attributable to healthcare was 12.8% or $788 billion. In 2016, healthcare consumed 17.9% of GDP or $3.3 Trillion."

In terms of health care status: " Between 1991 and 2016, life expectancy increased by 3.1 years to 78.6, representing a 4% improvement. In the same time, disease burden (as measured by the total number of disability adjusted life years, or DALYs) improved by 12%.

Disease burden is comprised of two factors: years of life lost to premature death, which improved by 22%, and years living with disability, which worsened by 2%. The improvement in overall years of life lost was driven by a remarkable 36% reduction in years lost due to premature death from diseases of the circulatory system. At the same time, the worsening of years living in disability was led largely by an increase in substance use disorders. Moreover, substance use is one of the primary contributors to the slight decline in life expectancy in 2015 and 2016, the first time life expectancy has dropped two years in a row in several decades. Another critical outlier where outcomes have worsened in the U.S. (and not other comparable countries) is maternal mortality, which has gone up significantly from 14 deaths per 100,000 live births in 1991 to nearly 31 in 2016."

Again, are the benefits worth the costs of health care spending? There are at least three ways to tackle this question, none of them fully satisfactory.

1) One approach is to put a monetary value on the extending life expectancy by a healthy year (mid-range estimate run about $100,000) and on the value of a human life (about $9 million, for reasons given here). These authors decide not to take this approach. They write: "Much more analysis and discussion, beyond the scope of this paper, would be necessary to make such a judgement."  In a way, that's fair enough. As if the problems of putting monetary values on health outcomes were not enough, a deeper issue with this approach is that many factors affect health outcomes other than health care spending, so a basic comparison of changes in health spending with changes in overall health outcomes wouldn't make sense. The economist in me would like to see the results of such an analysis, even just a back-of-the-envelope calculation. But I readily confess that, for example, thinking about how to measure the benefits of US has health care spending against a changing health issues like the opioid epidemic or the rise in maternal mortality mentioned above raises some difficult issues.

2) An alternative approach is to do an international comparison. How do the changes in US health care spending and US health outcomes compare with other high-income countries? The overall pattern is that in the last 25 years, other countries have seen about the same rise in per capita  health care spending as in the US (although at a lower overall levels), while achieving higher gains in health. The authors write: " Over the past 25 years, similarly sizable and wealthy nations generated an average increase in life expectancy of 5.2 years, or 7%, compared to the U.S.’s 3.1 years, or 4% improvement. In these countries, disease burden improved by 22%, compared to the U.S.’s 12%.  ... On average, comparable countries spend under two thirds (60%) of what the U.S. spends on healthcare relative to GDP, while the per capita spending growth has been similar over the last three decades."

3) However, international comparisons also raise raise the question: Are health care problems in the US in some ways worse than in other countries, so that US health care spending is higher in part because it is facing bigger challenges? In the comparison with other high-income countries, the authors write: "The disease burden in the U.S. is appreciably higher at 24,235 versus 18,605 disability adjusted life years per 100,000 population—a difference of 30%. ... The 2016 U.S. rate of obesity is over twice that of other high-income countries (40% versus 17%).":

4) There are two possible goals for society to consider: improving health, and making sure that people have health insurance so that they are not overly exposed to high health care costs. These goals overlap, but they aren't the same. If the goal is to improve health outcomes, it might make sense for the US to spend less on health care, and instead to spend more on the social determinants of health like better housing. In their international comparisons, the authors note:
"According to the OECD’s 2016 measure of poverty (which can be applied across countries more easily than the U.S. federal poverty level), 18% of people in the US are living below poverty, versus 10% in comparable OECD countries. When combined, public and private spending on social services and healthcare is fairly similar across these countries (30.5%) and the U.S. (32.6%), but the distribution is very different in the U.S., where we spent much more than average on health (16.3% vs 10.5% of GDP) and less than average on public social services (16.3% vs 20.0% of GDP) in 2013, the most recent year of available data on social services spending internationally."
In general, I'm a supporter of programs that expand health insurance coverage, like Medicaid and the changes in the 2010 Patient Protection and Affordable Care Act. But it's worth remembering that when we commit substantial resources to making health insurance available, the main effect may be to reduce financial stress rather than to improve physical health outcomes. Medicaid costs thousands of dollars per person. The 2010 Patient Protection and Affordable Care Act expanded health insurance coverage to about 22 million more people at an annual cost to the federal government of about $110 billion--so about $5,000 per person. If the goal is to improve people's physical health, then alternative ways of spending that money might well have a larger effect: say, steps focused on reducing the opioid epidemic, or reducing maternal mortality, or broader improvements in the living conditions of the poor and near-poor.

Tuesday, December 4, 2018

US Not the Source of China's Growth, China Not the Source of America's Problems

A sizeable portion of the US discussions about economic policy toward China seem to me based on two conceptual mistakes. One mistake is that China's rapid economic growth fundamentally depends on trade with the US. The other mistake is that the bulk of US economic problems depend in some fundamental way on trade with China.  

The inexhaustibly interesting Larry Summers puts the point this way in his Financial Times column yesterday ("Washington may bluster but cannot stifle the Chinese economy,' December 3, 2018, soon to be available at his website). Summers writes: 
At the heart of the problem in defining an economic strategy toward China is the following awkward fact: Suppose China had been fully compliant with every trade and investment rule and had been as open to the world as the most open countries at its income level. China might have grown faster because it reformed more rapidly, or it might have grown more slowly because of reduced subsidies or more foreign competition. But it is highly unlikely that its growth rate would have been altered by as much as 1 percent.
Equally, while some U.S. companies might earn more profits operating in China, and some job displacement in American manufacturing because of Chinese state subsidies may have occurred, it cannot be argued seriously that unfair Chinese trade practices have affected U.S. growth by even 0.1 percent a year.
This is not to say that China is not a threat to the international order. It is a seismic event for the United States to be overtaken after a century as the world’s largest economy.
It's worth spelling out the underlying logic here a bit. The formula for economic growth is to invest in human capital, physical capital, and technology, in an economic environment that provides incentives for hard work, efficiency, and innovation. China has made dramatic changes in all of these areas, and they are the main drivers behind China's extraordinary economic growth in the last four decades, and its expectation of above-global-average growth heading into the future.

Looking specifically at trade, China's exports of goods and services were 19.7% of GDP in 2017, and its imports of goods and services were 18% of GDP. China's economy has been growing at 6-7% per year, so the overwhelming majority of that growth has been economic production in China for domestic consumption. No matter your views of China's trade surplus, there's no sensible economic theory which suggests that China's trade surplus, which as a share of GDP is relatively small, is a major driver of China's growth.

Yes, there was a "China shock" after China entered the World Trade Organization in 2001, when China's exports suddenly soared from 20.3% of GDP in 2000 to 36% of GDP in 2006. The size of this shock was not predicted by China or others, and it's fair to argue that neither the US nor others in the world economy did a good job of reacting to that shock at the time. But again, China's exports are now down to 19.7% of GDP in 2017--a lower proportion of China's economy than in 2000. To put it differently, China's exports have been growing more slowly than the rest of its economy since 2006.

Conversely, the US economy has not done a great job of investing in the fundamentals of economic growth. The US once led the world in share of workers with higher education, but now it's middle-of-the-pack. The US is a low-saving economy, with low rates of investment in both private and public capital. US spending on research and development has been stagnant for years, while other countries have been expanding. Rates of business start-ups have been declining.  Mobility of US workers is downEconomic mobility between generations in the US is not high. Further, the US has made little progress--and little effort--to address ongoing issues like the projections of large and growing budget deficits, or rising health care costs, or a much higher level of income inequality than a few decades ago.

These US economic issues and others are in any substantial part not the result of trade with China, or the result of international trade at all. Lasting solutions will not be found in trade squabbles, either. 

The world economy is indeed shifting in a dramatic way. As I've noted in the past, it used to be true that the national economies of the largest size were also the national economies with quite high levels of per capita GDP. However, we are headed toward a world economy where the largest national economies are countries with large populations and only medium levels of per capita GDP. 

This isn't just an issue about China. Some common projections (like these) suggest that by 205, the seven largest economies in the world, in order, will be China, India, the US, Indonesia, Brazil, Russia, and Mexico--then followed in size by Japan, Germany, and the UK.

I lack the geopolitical imagination to see how this shift will play out. But at a small scale, you can see it at the movies, when you see a rising number of roles for Chinese actors and settings in China. It tells you that the international market for movies is becoming ever-more important. At a larger scale, The rest of the world used to complain that it was always having to hear about US products like Coca Cola, Levi's. big American cars, and the like. But US domestic car production is now about 7% of the global totalUS companies are producing around the world: for example, General Motors makes more cars in China than in the US, and US producers make and sell twice as much inside China as they export to China. 

But in 21st century, when it comes a wide array of decisions--international trade talks, decisions of the the International Monetary Fund and the World Bank, who leads the way during global financial crises, who dominates the flows of international investment capital and foreign aid, who has the power to impose trade or financial sanctions, and what kind of military threats are most credible--the shifts in the global economy suggest that the high-income countries of the world will not dominate as they did during most of the 20th century. Instead, countries with the world's largest economies, but much lower standard of living for their populations, will play a central role in setting the rules. 

Monday, December 3, 2018

Excavating Layers of the Tax Cuts and Jobs Act of 2017

"The 2017 Tax Act, sometimes called the Tax Cuts & Jobs Act, has been heralded by some as historic reform and by others as Armageddon. This Collection analyzes the Act, exploring the process by which it was passed, the values that undergird its policies, and how specific provisions will affect the structure of the U.S. and global economy moving forward." Thus begins a five-paper "Forum: Reflections on the 2017 Tax Act" from the Yale Law Journal (dated October 25, 2018)

Michael J. Graetz writes the "Foreword—The 2017 Tax Cuts: How Polarized Politics Produced Precarious Policy." He touches on a number of the themes mentioned in the two papers by Joel Slemrod and Alan Auerbach in the"Symposium on the Tax Cuts and Jobs Act" that appeared in the Fall 2018 issue of the Journal of Economic Perspectives: yes, the US corporate taxation needed both lower rates and more sensible treatment of multinational companies, but in many ways the new tax bill created a muddle--and a muddle that will lead to substantially higher budget deficits. Here's a flavor of Graetz (footnotes omitted throughout): 

"The Democrats’ complaints about the law’s reduction in the corporate tax rate from 35% to 21% ring hollow. Democrats themselves had long realized that the U.S.’s exceptionally high corporate tax rate in today’s global economy—with highly mobile capital and intellectual property income—invited both U.S. and foreign multinational companies to locate their deductions, especially for interest and royalties, in the United States, and to locate their income in low- or zero-tax countries. This is obviously not a recipe for economic success. Both before and after the legislation, Democrats urged a corporate tax rate of 25% to 28%; meanwhile, Donald Trump asked for a 15% rate.So, even if Democrats had been involved in the legislative process, the 21% rate that we ended up with would be in the realm of a reasonable compromise. ... [A] significantly lower corporate rate has been long overdue, and raising it would be a mistake. If Democrats are unhappy with the distributional consequence that a corporate tax cut will benefit high-income shareholders, the appropriate remedy––given the mobility of business capital, businesses’ ability to shift mobile intellectual property and financial income to low-tax jurisdictions, and the challenges of intercompany transfer pricing––is to increase taxes at the shareholder level, not to increase corporate tax rates. ...
Congress’s greatest challenge in crafting this tax legislation was figuring out what to do about the international tax rules. ... Congress confronted daunting challenges when deciding what rules would replace our failed foreign-tax-credit-with-deferral regime. There were essentially two options: (1) strengthen the source-base taxation of U.S. business activities and allow foreign business earnings of U.S. multinationals to go untaxed; or (2) tax the worldwide business income of U.S. multinationals on a current basis when earned with a credit for all or part of the foreign income taxes imposed on that income. Faced with the choice between these two very different regimes for taxing the foreign income of the U.S. multinationals, Congress chose both. ...
No doubt analysts can find provisions to praise and others to lament in this expansive legislation, but we should not overlook its most important shortcoming: its effect on federal deficits and debt.  ...
Under the 2017 tax law, the federal debt held by the public is estimated to rise to more than 96% of GDP by 2028, and this does not count the omnibus spending bill signed in 2018 by President Trump. ... If the current policy levels of taxes and spending are maintained, total deficits over the next decade will approach $16 trillion, with deficits greater than 5% of GDP beginning in 2020. By 2028, current fiscal policy will produce deficits of more than 7% of GDP annually. This is unsustainable. ... The budget legislation of the 1990s, along with the economic growth unleashed by the information technology revolution of the late 1990s, completely eliminated the projected deficits by the year 2000 and produced a federal surplus for the first time since 1969. Indeed, the budget surpluses projected by the Congressional Budget Office at the beginning of this century were so large that, in March 2001, Chairman of the Federal Reserve Alan Greenspan told Congress that the federal government would soon pay off all of the national debt and would have to begin investing its surplus revenues in corporate stocks, a prospect he abhorred. The good news is that this problem has been solved. 

I was also struck by the essay by Linda Sugin, "The Social Meaning of the Tax Cuts and Jobs Act." Sugin describes the social values that seem to underlie the provisions of the TCJA. She writes:
This Essay discusses five American priorities and values revealed by the TCJA:

1. The traditional family is best;
2. Individuals have greater entitlement to their capital than to their labor;
3. People are autonomous individuals;
4. Charity is for the rich; and
5. Physical things are important.
The TCJA’s distributional effects dovetail with these values. ... First, traditional families with a single working spouse and a stay-at-home spouse are disproportionately prosperous, so subsidizing that family model reduces progressivity. Second, access to capital increases with affluence, so a greater entitlement to investment income favors taxpayers who enjoy that affluence. Third, valuing individual autonomy is consistent with robust individual property rights, and less consistent with high levels of taxation for shared community purposes. Fourth, favoring the charitable giving of the rich allows them tax reductions not available to others, and sends the message that philanthropy substitutes for tax paid. Fifth, prioritizing physical assets favors individuals are able to invest in such assets and underrates the important value that workers contribute to prosperity. Critics of the legislation concerned about the law’s reallocation of tax burdens down the income scale and its projected budgetary deficits must focus more on these embedded priorities.

Of the other three papers, two papers dig into details of the changes in the international corporate tax regime, while the other argues that the Tax Cuts and Jobs Act will push firms away from the use of debt financing--and thus toward alternative types of financing--with implications that are not yet clear.

Rebecca M. Kysar discusses "Critiquing (and Repairing) the New International Tax Regime."
"In this Essay, I address three serious problems created—or left unaddressed—by the new U.S. international tax regime. First, the new international rules aimed at intangible income incentivize offshoring and do not sufficiently deter profit shifting. Second, the new patent box regime is unlikely to increase innovation, can be easily gamed, and will create difficulties for the United States at the World Trade Organization. Third, the new inbound regime has too generous of thresholds and can be readily circumvented. There are ways, however, to improve upon many of these shortcomings through modest and achievable legislative changes, eventually paving the way for more ambitious reform. These recommendations, which I explore in detail below, include moving to a per-country minimum tax, eliminating the patent box, and strengthening the new inbound regime. Even if Congress were to enact these possible legislative fixes, however, it would be a grave mistake for the United States to become complacent in the international tax area. In addition to the issues mentioned above, the challenges of the modern global economy will continue to demand dramatic revisions to the tax system."
Susan C. Morse raises implications about International Cooperation and the 2017 Tax Act.
"Some have criticized the 2017 Tax Act for lowering the corporate tax rate. This Essay argues instead that Congress deserves credit for bringing the U.S. rate in line with other OECD countries, potentially saving the corporate tax by establishing a minimum global rate. ... There is a silver lining for the corporate income tax in the Tax Cuts and Jobs Act of 2017. This is because the Act’s international provisions contain not only competitive but also cooperative elements. The Act adopts a lower, dual-rate structure that pursues a competitiveness strategy and taxes regular corporate income at 21% and foreign-derived intangible income at 13.125%. But the Act also supports the continued existence of the corporate income tax globally, thus favoring cooperation among members of the Organisation for Economic Cooperation and Development (OECD). Its cooperative provisions feature the minimum tax on global intangible low-taxed income, or GILTI, earned by non-U.S. subsidiaries. Another cooperative provision is the base erosion and anti-abuse tax, or BEAT. The impact of the Act on global corporate income tax policy will depend on how the U.S. implements the law and on how other nations respond to it."
Robert E. Holo, Jasmine N. Hay and William J. Smolinski discuss issues of corporate leverage in "Not So Fast: 163(j), 245A, and Leverage in the Post-TCJA World."
"The Tax Cuts and Jobs Act will require large multinational corporations to reevaluate the use of debt in their acquisition and corporate structures. Changes to the Tax Code brought about by the Act have reduced incentives to use debt in these contexts. These changes may require practitioners to identify new approaches to financing acquisitions and will necessitate reevaluation of current capital structures used by large multinational entities. ...
"In other words, is it a good idea to dampen the worldwide preference for debt in capital structures? Is there a problematic preference for debt that needs fixing in the first place? It is likely too early to make that call given the potential number of unintended consequences that my result under the new law. ... By changing the rules of the game, the IRS has effectively changed the inputs to that modeling exercise. It remains a complicated question whether, holistically, business entities carry excess debt relative to equity; but it is certainly the case that a new set of rules which, on their face, appear to favor equity over debt, may very well cause those modeling exercises to produce an output that suggests a shift in debt-equity preferences is in order."