Friday, December 13, 2013
Thursday, December 12, 2013
“Somewhere, Milton Friedman is smiling.
Casey Mulligan ... has provided an unalloyed Chicago-style explanation for the U.S. economy’s poor performance during and immediately after the Great Recession.”
Wednesday, December 11, 2013
The supply and demand for health services will experience a variety of changes in the near future, especially those from the Affordable Care Act. But nobody has quantified their net impact on the market for doctors. The new law pushes demand for physicians in both directions, making it is easy for advocates on either side of the law to cherry-pick provisions they support.
The law is beginning to build new markets for individual insurance policies that in some ways can reduce the demand for health care and doctors.
Participating families above 250 percent of the poverty line will, on average, pay 30 percent of their medical expenses out of pocket, as compared with the 17 percent out of pocket that is typical for employer-sponsored health plans. That gives patients almost twice the incentive to avoid using doctors or to seek treatments that are less expensive and likely less physician-intensive.
In some states, patients are being pushed toward less physician-intensive care because the insurance plans offered on the exchanges have narrower networks that exclude some of the more expensive facilities. Some of these excluded providers may be considered among the best in the industry, because state regulators seek to keep insurance premiums low. This is a force that could help limit the demand for doctorss in narrow-network states.
Other states include their top facilities in the networks accessible by residents who buy their insurance on the exchanges and do not have this force limiting physician demand. Moreover, the broad-network states will likely pull dcotorss away from the narrow network states where demand for them is less.
Although the new law pushes the insured to shoulder a larger share of their health expenses, the law also mandates that insurance pay for a wider range of health goods and services. That mandate by itself could increase the demand for doctors.
The Affordable Care Act is supposed to increase the fraction of the population with health insurance, and it will in the long run because of the individual mandate, the large insurance subsidies and Medicaid expansions in a number of states. (In the short run, the act is reducing the number of people with health insurance, as many longstanding policies have been canceled because they do not conform with the new law.)
It is a mistake to assume that every person getting insurance coverage is an additional person demanding health care, because many of the so-called uninsured are actually insured in one way or another. Take Medicaid enrollment, for example. Sixteen million people were not enrolled in Medicaid in June 2010 yet participated in the program at other times during the fiscal year, largely because they don’t bother enrolling (or know that they can) when they are healthy and turn to it only when need arises.
If and when those who are eligible but unenrolled make contact with hospitals and other providers – when they actually need the coverage – they are reminded to enroll. In an economic sense, these 16 million were, in effect, insured all along, despite their absence from the official statistics. The new law’s individual mandate encourages some of these people to be perpetually enrolled, even when they are healthy, which is more a change in their official classification than a change in their use of health care.
The numbers of slots in medical schools and residency positions, and rules that permit nurses to perform a wider range of services, have important effects on the incomes of doctors, because easier entry into the medical profession reduces physician incomes. I’m not sure that the new law does much to change these entry barriers, though.
Proponents of the Affordable Care Act can point to the provisions that reduce physician demand and help prevent a doctor shortage; opponents can say that more insurance means more demand on an already strained profession.
A good economist should be able to examine all the provisions and tell us the net result. But none have done this. The most we have in terms of a comprehensive calculus of health reform and the demand for physicians is the example of Romneycare from Massachusetts, which Scott Gottlieb and Ezekiel Emanuel hold up as proof that there will be no doctor shortage.
But Romneycare is a different law than the Affordable Care Act and covered a different population. Even without those differences, Massachusetts could increase health care in the state in part by pulling in medical professionals from elsewhere in the nation.
The Affordable Care Act cannot do the same, except to pull medical professionals from abroad, where the barriers to moving are much greater.
If only the payments to physicians were free to adjust in response to the law, entry barriers, demographics and other forces, there would be neither a shortage nor a glut in the sense that doctors would be available to whoever would pay the market price and positions would be available for qualified doctors willing to work for that price.
But the new law limits payments to physicians and other medical providers. If patients are lucky, the demand for doctors will be low enough that the limits will not matter. But if the new law results in a significant net increase in physician demand, the payment limits will help remind us of Soviet-era limits on the price of bread, with queues and black markets to follow.
Friday, December 6, 2013
Tuesday, December 3, 2013
nber.org is hosting excel files with those updates and extensions (use the version with "update" in the file name).
As robots begin to move goods and people from place to place, urban land might become more valuable.
Amazon.com has announced that it is testing package delivery by drones — small, unmanned helicopters that would bring a purchase from Amazon’s fulfillment center to the customer’s front porch. Driverless cars are being developed to help move goods and people from place to place.
“Location, location, location” is the saying in real estate: a property’s value is determined primarily by its location. An apartment in central Illinois might be worth 20 times as much in Manhattan, because a Manhattan apartment gives its resident access to many more goods, activities and high-paying jobs.
This is not to say that urban living is always the best, or that all urban properties are created equal. Locations involve trade-offs, and rural areas offer amenities that big cities cannot. But for centuries, real estate markets have shown that people and businesses are willing to pay more for urban properties.
As technology helps with moving goods and people more cheaply, it might seem that urban real estate would give up some of its price premium because distance becomes less of an obstacle to economic transactions. Wouldn’t a driverless car cause some workers to sell their Manhattan apartments and commute to their jobs from more spacious homes in the suburbs or even rural New York State?
But don’t forget that many people and businesses currently avoid urban areas because of the monthly expense of owning or renting urban property. New technologies might allow them to use urban properties on a part-time basis, or use less urban property to accomplish the same tasks, which would make urban property more valuable.
A restaurant may need less refrigeration and storage space because it takes multiple food deliveries per day. Grocery stores may save on shelf space by having a greater fraction of their items delivered directly to customers without being shelved in the store. Households may opt for less storage space or parking, for example — and more room for people — when they can get items and transportation cheaply and on time.
For every Manhattan resident who leaves his apartment for the suburbs, there could be many others for whom technology induces them to use a Manhattan property on a part-time basis.
New technologies are more likely to emerge in urban areas, because that’s where the innovators expect to find the most customers. Amazon said that it planned to start its drone service in urban areas, and I wouldn’t be surprised if the first commercial uses of driverless cars were in big cities like San Francisco or Los Angeles.
Thus, while cities already give their residents access to more goods and services, technology may further shift that advantage and thereby increase urban property values.
Wednesday, November 27, 2013
Even if federal unemployment insurance expires at the end of the year, it will be replaced by an even more generous assistance program for people leaving their jobs.
Unemployment insurance is jointly administered and financed by federal and state governments, offering funds to “covered” people who lost their jobs and have as yet been unable to find and start a new one. The cash assistance comes weekly, with states paying benefits of about $300 a week for 26 weeks or until the person starts a new job, whichever comes first.
Normally, the assistance stops after 26 weeks, even if the beneficiary has yet to find a job. But during recessions the federal government’s temporary “extended” and “emergency” unemployment compensation programs pick up benefits after the state benefits are exhausted.
During the recent recession, the federal government paid benefits for up to 73 additional weeks, making the total benefit duration 99 weeks.
The temporary federal programs have expiration dates, but Congress has routinely extended them, at least through 2012. A couple of the federal programs fully expired that year, so in 2013 the unemployed could get benefits for no longer than 73 weeks.
The last remaining federal program, known as Emergency Unemployment Compensation, is set to fully expire at the end of this year. Congress has extended its final expiration date several times in the past – most recently as part of the fiscal cliff deal – but there is no guarantee that Congress will continue its extensions.
If the emergency program continues while the new health care assistance comes on line, the incentives of workers and employers to create and retain jobs will take a big hit. The solid line in the chart below shows my estimates of the average marginal tax rate on worker’s income, accounting for the fact that earning income on a job results in both additional taxes and withheld federal benefits. The higher the tax rate, the less is the incentive to work.
The dashed line shows the marginal tax rate if the emergency program really does expire at the end of the year. Tax rates will increase in January, but much less than they would without the expiration, because the assistance lost from the emergency program will be offset by the health assistance coming online.
The federal unemployment benefits at risk of expiration are economically more important than the already-expired programs, because it is less common for unemployment to last more than 73 weeks (when the expired programs kicked in) than it is to last 26.
Unemployment benefits from any program help people who desperately need it, but they also keep the labor market depressed by permitting people to remain unemployed longer and making layoffs more common. The remaining emergency program is the most important and thereby does the most to help people and the most to keep the labor market depressed.
Even if the emergency program is allowed to expire on Jan. 1, it will ‘be replaced by an even larger program — the Affordable Care Act — assisting the unemployed and others, including premium subsidies for health insurance.
Most people have jobs that provide health insurance and will be ineligible for premium subsidies for as long as they work. But as soon as they are fired, quit, retire or otherwise leave the payroll, they will be eligible for monthly assistance to pay for their health insurance premiums and out-of-pocket expenses.
For households between 100 and 400 percent of the poverty line – that’s about half of households – the new assistance will average about $110 a week, tax free (unlike unemployment benefits, which are taxable). Moreover, the premium assistance is not limited to 26 weeks; it can last for decades.
Regardless of how you evaluate the relative costs and benefits of the emergency program, now is the time for Emergency Unemployment Compensation to expire to make way for new assistance programs.
Tuesday, November 26, 2013
Thursday, November 21, 2013
Most of those plans will adjust to comply. But many will be canceled because canceling a plan is consistent with the law even while keeping an inadequate plan is not.
Wednesday, November 20, 2013
Fundamental changes in economic performance since the John F. Kennedy presidency help explain why economic policy debates are so polarized these days.
In its 34 months, the Kennedy administration embraced a range of interesting federal economic policies. Kennedy proposed permanently cutting personal and corporate income tax rates to promote economic growth, and his cuts became law. During his administration, the maximum duration of unemployment benefits was temporarily extended only 13 weeks, less than in any other recession since then.
He expanded the federal space program. He wanted a strong peacetime military and was willing to use it to stand up to communism. His Department of Justice, led by his brother Robert F. Kennedy, was tough on labor unions.
President Kennedy pushed for national health reform, although he did not see any legislation passed during his term. As a candidate and then president, Kennedy was initially cautious on civil rights issues, but ultimately worked to put together a civil-rights bill that became the Civil Rights Act of 1964.
From today’s perspective, Kennedy looks like a hybrid of a Democrat and a Republican, and as America remembers his assassination in November 1963, journalists and scholars continue to debate whether Kennedy was a liberal.
In my view, Kennedy was entirely a Democrat, but that’s less visible today because Democrats and Republicans, and their respective economists, were a lot less different than they are now, especially on matters of microeconomics. Kennedy was advised by James Tobin of Yale, a Nobel laureate who advised other Democratic presidents, too.
Both Tobin and Milton Friedman, who subsequently advised several Republican candidates and was an adviser to President Richard M. Nixon, were concerned that antipoverty programs would perpetuate poverty by giving people too little reward for taking care of themselves. Tobin wrote that high marginal tax rates cause “needless waste and demoralization,” adding:
This application of the means test is bad economics as well as bad sociology. It is almost as if our present programs of public assistance had been consciously contrived to perpetuate the conditions they are supposed to alleviate.
Tobin thought public programs had gone seriously awry whenever program participants kept less than a third of what they earned on a job, rather than losing it to extra taxes or withdrawn benefits. Friedman thought that people should keep at least half of their earnings after taking into account taxes or lost benefits. Yet in modern times, Friedman and Tobin appear to be quibbling, because now we have millions of citizens who keep a quarter of what they make, or less, in net earnings beyond the benefits they forgo, yet few Democrats are concerned that federal antipoverty programs might be counterproductive.
In “Roofs or Ceilings?” Milton Friedman and George J. Stigler wrote about the economic damage done by minimum wages, rent controls and other restrictions on market prices. Tobin offered similar explanations, writing:
People who lack the capacity to earn a decent living need to be helped, but they will not be helped by minimum wage laws, trade union wage pressures or other devices which seek to compel employers to pay them more than their work is worth. The more likely outcome of such regulations is that the intended beneficiaries are not employed at all.
(Unlike Friedman, Tobin did subsequently support a minimum-wage increase, because he thought better antipoverty tools would not be used).
These days, Democrats push for higher minimum wages, without any apparent concern that poor people might have more trouble finding work.
My point is not that Democrats are more wrong about economics that they used to be, but that, regardless of who is right or wrong, the gaps between Democrats and Republicans in economic reasoning are greater now than they used to be.
The economy is different now than it was in the 1960s, especially in that the incomes of the poor have not kept up with national incomes. When the poor are prevented from working by minimum wages or high marginal tax rates, a lesser fraction of national income is lost than in Kennedy’s era, when the poor could produce a more significant piece of the national economic pie.
So proponents of big social programs have less reason to be cautious about program expansions.
As long as the American economy produces such a wide range of labor market outcomes, we may never see a president, who, like Kennedy, has such wide-ranging economic policies.