Links for July 20, 2016

The responsibilities of heterodoxy. Arjun Jayadev and I have an ongoing project of interviewing dissenting economists who we think deserve wider recognition. Our first interview was with Axel Leijonhufvud; the second, just now up at the INET site, is with our old professor Jim Crotty. Jim’s ECO 710 was for us, as for hundreds of UMass grad students over the past 30 years, the starting point for systematically thinking about the economy as a whole. (You could think of him as sort of the Earth-II version of Rudi Dornbusch.) You can read more of my thoughts about him at the link.

Here’s an interesting clip that didn’t make it into the INET version:

The radicalism — and coherence — of Keynes larger political-economic program is a topic I’d like to return to in the future, as is the importance of an organic relationship to some broader social movement or political project. For heterodox economists, I think even more than for other academics, it’s impossible to even do good scholarship if your relationship to your object of study is only as a scholar. Science, as Max Weber says, “presupposes that what is yielded by scientific work is important in the sense that it is ‘worth being known.’ … This presupposition cannot be proved by scientific means.”

 

The problem with heterodoxy. The post here about the non-existence of mainstream economics is now up at Evonomics, in a somewhat improved form. While we’re on that topic, I will let loose with a peeve. Joan Robinson is like a god to me — in an anthropological sense she might even literally be a divinity for my tribe. But I hate that often-quoted line that the only reason to study economics is “to avoid being fooled by economists.” It reinforces the worst habit of heterodox people: putting negative critique above positive efforts to understand the world.

 

Articles to read. Three recent articles that really deserve posts of their own:

Thomas Palley on negative interest rates (he’s against them).

Jerry Epstein on the costs of big finance.

Cédric Durand and Maxime Gueuder on the weakening link between profits and corporate investment. I’ve been planning to write something on exactly this; clearly it will have to respond to this paper.

 

Interest rates and trade imbalances. Izabella Kaminska has a very interesting post up at FT Alphaville. (Does she write any other kind?) This one brings out two important points. First, to the extent that low interest rates mainly lead to bringing forward future spending — this is  probably especially true in housing — they are good tools for dealing with temporary downturns but not for secular shortfalls. (Kaminska doesn’t say so, but this is one reason the “natural rate” concept is misleading.) Second, the macroeconomic significance of trade imbalances depends on what happens to the corresponding financial flows — and this isn’t automatic. Continuous British surpluses in the gold standard era were compatible with steady growth of the world economy because they financed investment — in railroads especially — in the peripheral countries, using British capital goods. The general lesson is:

If countries want to carry international surpluses indefinitely the suggestion here is they need also to reinvest those “savings” into capacity expanding investments abroad.

Also in FT Alphaville, here’s a nice post by Matthew Klein on a question that should be obvious, but is seldom asked: If large current account deficits are dangerous, then what exactly is the purpose of allowing free flows of portfolio investment across borders? From the point of view of the receiving country, the only benefit of portfolio inflows is that it lets them finance current account deficits. If that’s not desirable, why allow them? Klein doesn’t give the clear negative answer that I would, but it’s the right question to be asking.

 

Evicted. At Dissent, my Roosevelt colleague Mike Konczal has an excellent review of two new books on eviction and foreclosure. It’s an important topic, and Evicted looks like an important book. I had some debates about it on twitter that clarified a question that doesn’t quite come out in the review itself. Are housing costs so high for more people because of market and regulatory failures that allow landlords to exploit poor tenants? Or is the cost of providing adequate housing simply greater than poor families can pay? The first points toward tenants organizing and better regulation of rental housing, the latter toward direct or indirect subsidies or direct public provision of housing.

Also from Mike, a review of two recent books about the appropriate role of the state.

 

Rising health costs in Europe. Via Adam Gaffney, here’s an interesting article on rising household payments for heatlh care in Europe, even in countries that are notionally single payer. Adam’s summary:

 It supports the hypothesis—put forward by many—that there has been a *partial* retreat from universal health care in Europe (especially if we define universal health care as free care at point of use for all). The main findings are as follows:

-The odds of having any out-of-pocket expenditures on health care in the previous 12 months (among 11 European nations) were 2.6 fold higher in 2013 than in 2006-2007;

-Overall out of pocket payments for health care increased 43.6% (inflation adjusted) between 2006-2007 and 2013;

-The proportion of individuals with catastrophic health care expenditures rose, particularly in Spain and Italy, which have been particularly hard-struck by austerity.

My take: We need to stop thinking about universal health care as an end goal or terminus: its actually a work in progress, and neoliberal health policy ideology has already done a number on it in Europe.

 

The poor stay poor. My old UMass comrade Mike Carr has a new article on income mobility, coauthored with Emily Wiemers. There’s a nice writeup of it in The Atlantic.

 

The right vs the rentiers? I was interested to learn that one of Theresa May’s declared priorities as Prime Minister is reforming corporate governance, including requiring worker representatives on boards. I have no idea if anything will come of it, but it’s interesting to see ideas that would be well to the left of the mainstream here adopted at least rhetorically by a conservative government in the UK. Was also interesting, in the coverage, to see some acknowledgement of the importance of cogovernance and works councils in Germany. Obviously export surpluses should not be taken as the measure of economic success in any broader sense, but it’s still worth pointing out that Europe’s biggest exporter is one of its least liberal economies.

Also in Theresa May news, doesn’t it seem like if Article 50 can’t be invoked without Scotland’s ok, that means Brexit isn’t happening? Which I think was the safe bet all along. Because if what scares you is that the “burghers of middle England” can “with a single vote destroy trillions of dollars of value,” then you can probably relax. The trillions will win the next round.

Ten Questions on Health Care Reform

Hello readers!

Knowing what a brilliant and well-informed bunch you all are, I’m hoping you can help with something. Is there somewhere out there a good critical assessment of the specific provisions of the Affordable Care Act?

I don’t mean an explanation of why single payer would be better. It would be better, much better, I know! But we also need to be able to talk to people about the law that passed. What is our best guess about how, concretely, it will affect access to health care, and the distribution of costs?

For just-the-facts, you can’t do better than the Kaiser Family Foundation — their comprehensive summary of the ACA is here. And of course there’s the Congressional Budget Office‘s reports, which include estimates of the impact on insurance status. But there are lots of more specific issues it would be nice to have an informed opinion on.

Here are some questions I’d like to see answers to:

1. What happens to people who still don’t have insurance? According to the CBO, even when fully implemented the ACA will leave over 20 million people — 8 percent of the population; 5 percent excluding undocumented immigrants — without health insurance. (Universal coverage, it ain’t.) What about these people’s access to health care? What happens when they show up at the emergency room? 

2. How will health insurance costs change? The exchange subsidies cover any premium costs above a certain fraction of income, which ranges from 2 percent for households at the poverty line up to 9.5 percent of income for households at 400% of the poverty line. Above that, no subsidies. There are additional subsidies to reduce out of pocket costs, again phasing out at 400% of poverty. It looks like enough to reduce the costs of insurance for everyone eligible for subsidies, but for people above the 400% FPL line, it all depends on what happens to premiums. There is some language in the law about limits on premium increases, but since that is supposed to happen at the state level, one is entitled to doubts. Anyway, I would like to see numbers — this would seem like a good way to make the public case for the law, though since the biggest benefits go to low-income people, maybe not.

3. How much will safety-net hospitals be hurt by the cuts in their funding? One of the less-discussed provisions of the law is its deep cuts in support for hospitals serving large numbers of uninsured patients, mainly Disproportionate Share Hospital (DSH) Medicaid and Medicare funding and Graduate Medical Education (GME) Medicare funding (which in practice goes mainly to hospitals with lots of poor patients). Medicaid DSH payments fall by about half under the law and Medicare DSH falls by 75 percentit appears that cuts to GME will further reduce total Medicare payments by close to 10 percent for big-city hospitals. In theory, this will be compensated by many of these hospitals’ currently uninsured patients becoming insured, but it’s not clear that this will fully make up for the cuts, especially for hospitals that serve large numbers of undocumented immigrants. Which leads to…
4. How will undocumented immigrants be affected? As far as I can tell, documented immigrants will get the same benefits as citizens. Undocumented immigrants will of course get nothing. Since there will be less funding for health care for the uninsured, and since some employers will reduce health benefits, it seems likely that undocumented people will be worse off as a result of the law. 
5. How will employer-provided health insurance change as a result of the law? Since low- and moderate-income workers will have access to subsidized insurance through the exchanges, and since the penalty for employers who don’t offer coverage are trivial, it seems likely that many employers will reduce or eliminate health benefits as a result of the ACA. On the other hand, there are subsidies for small employers and a temporary reinsurance program to reduce costs for insuring older workers, which push the other way. Of course even if employer coverage does fall as a result of the ACA (the CBO guesses it will, but just slightly; some people think it will, by a lot; in Massachusetts it hasn’t at all), that’s not necessarily a bad thing.

6. Will better insurance mean better access to care? Massachusetts’ 97 percent coverage is one of the more hopeful signs for the future of the ACA. But living there, I often heard stories about people who got subsidized insurance but couldn’t find doctors who accepted it; this is a long-standing problem for people with Medicaid as well. Plans on exchanges are required to have an “adequate provider network,” but what will this mean in practice? Is there any way of quantifying how big the gap could be between the number of people who gain insurance, and the number who gain reliable access to care?

7. Was the individual mandate really needed? Liberal conventional wisom is that without the mandate the whole thing falls apart. I’ve never bought the conventional “adverse selection death spiral” argument, both because when states have implemented community rating (the same price for health insurance for everyone) it has not led to the collapse of their individual health insurance markets, contrary to the death-spiral theory; and because the theory hinges on people who don’t buy insurance having lower expected health costs than people who do, which I doubt. Then there’s the other argument, that it’s not about adverse selection, but about people delaying getting insurance until they have health problems. This is more plausible but I’m skeptical of that one too. Anecdotally, the one time I’ve been to a hospital in recent years (I was hit by a car while biking to work), the first thing the paramedics asked me in the ambulance was whether I had insurance, presumably to decide where to take me; in that situation the right to buy insurance would not have been a good substitute for already having it. And of course may people want insurance to pay for routine care. But maybe I’m wrong about this. I’d love to see a good case for the need for the mandate that doesn’t — as they all seem to — just argue deductively from first principles.


8. How do the limits on medical loss ratios compare with the status quo? I recall people arguing that a big sleeper provision in the ACA was the requirement that medical loss ratios (the share of premiums paid to providers) be at least 85 percent for large-group plans and 80 percent for small-group and individual plans. This is already supposed to be in effect; is it binding?


9. Are state level single payer plans (or public options) feasible? Another sleeper provision is Section 1332, which allows states to devise their own plans for using the total subsidies available under ACA to achieve a higher level of coverage. In principle, this opens the way to pass state-level single-payer plans, as in Vermont. Are there non-obvious obstacles to pursuing this elsewhere?

10. What happens to insurance outcomes if states opt out of the Medicaid expansion? Half the ACA’s reduction in the numbers of uninsured comes from the Medicaid expansion, and presumably a large part of that is in states where opt-out is likely.

I’m sure there are a lot of other important issues I’m missing — this isn’t my area and I haven’t been paying careful attention. What I’d like to see is a good critical assessment of what the ACA is actually likely to achieve, for better or worse. Ideally from a left/progressive viewpoint, skeptical but not implacably hostile. Unfortunately debate on our side has become so polarized that that may be hard to find — all the people one would normally turn to seem to be either denouncing or defending the law in its entirety. Still, there’s got to be something out there, right?