healthcare

pnrj core principles, market failure, public policy , , , , , , , , , , , , , , , , ,

There should be a glut of nurses.

Jan 15 JDN 2459960

It will not be news to most of you that there is a worldwide shortage of healthcare staff, especially nurses and emergency medical technicians (EMTs). I would like you to stop and think about the utterly terrible policy failure this represents. Maybe if enough people do, we can figure out a way to fix it.

It goes without saying—yet bears repeating—that people die when you don’t have enough nurses and EMTs. Indeed, surely a large proportion of the 2.6 million (!) deaths each year from medical errors are attributable to this. It is likely that at least one million lives per year could be saved by fixing this problem worldwide. In the US alone, over 250,000 deaths per year are caused by medical errors; so we’re looking at something like 100,000 lives we could safe each year by removing staffing shortages.

Precisely because these jobs have such high stakes, the mere fact that we would ever see the word “shortage” beside “nurse” or “EMT” was already clear evidence of dramatic policy failure.

This is not like other jobs. A shortage of accountants or baristas or even teachers, while a bad thing, is something that market forces can be expected to correct in time, and it wouldn’t be unreasonable to simply let them do so—meaning, let wages rise on their own until the market is restored to equilibrium. A “shortage” of stockbrokers or corporate lawyers would in fact be a boon to our civilization. But a shortage of nurses or EMTs or firefighters (yes, there are those too!) is a disaster.

Partly this is due to the COVID pandemic, which has been longer and more severe than any but the most pessimistic analysts predicted. But there shortages of nurses before COVID. There should not have been. There should have been a massive glut.

Even if there hadn’t been a shortage of healthcare staff before the pandemic, the fact that there wasn’t a glut was already a problem.

This is what a properly-functioning healthcare policy would look like: Most nurses are bored most of the time. They are widely regarded as overpaid. People go into nursing because it’s a comfortable, easy career with very high pay and usually not very much work. Hospitals spend most of their time with half their beds empty and half of their ambulances parked while the drivers and EMTs sit around drinking coffee and watching football games.

Why? Because healthcare, especially emergency care, involves risk, and the stakes couldn’t be higher. If the number of severely sick people doubles—as in, say, a pandemic—a hospital that usually runs at 98% capacity won’t be able to deal with them. But a hospital that usually runs at 50% capacity will.

COVID exposed to the world what a careful analysis would already have shown: There was not nearly enough redundancy in our healthcare system. We had been optimizing for a narrow-minded, short-sighted notion of “efficiency” over what we really needed, which was resiliency and robustness.

I’d like to compare this to two other types of jobs.

The first is stockbrokers.Set aside for a moment the fact that most of what they do is worthless is not actively detrimental to human society. Suppose that their most adamant boosters are correct and what they do is actually really important and beneficial.

Their experience is almost like what I just said nurses ought to be. They are widely regarded (correctly) as very overpaid. There is never any shortage of them; there are people lining up to be hired. People go into the work not because they care about it or even because they are particularly good at it, but because they know it’s an easy way to make a lot of money.

The one thing that seems to be different from my image may not be as different as it seems. Stockbrokers work long hours, but nobody can really explain why. Frankly most of what they do can be—and has been—successfully automated. Since there simply isn’t that much work for them to do, my guess is that most of the time they spend “working” 60-80 hour weeks is actually not actually working, but sitting around pretending to work. Since most financial forecasters are outperformed by a simple diversified portfolio, the most profitable action for most stock analysts to take most of the time would be nothing.

It may also be that stockbrokers work hard at sales—trying to convince people to buy and sell for bad reasons in order to earn sales commissions. This would at least explain why they work so many hours, though it would make it even harder to believe that what they do benefits society. So if we imagine our “ideal” stockbroker who makes the world a better place, I think they mostly just use a simple algorithm and maybe adjust it every month or two. They make better returns than their peers, but spend 38 hours a week goofing off.

There is a massive glut of stockbrokers. This is what it looks like when a civilization is really optimized to be good at something.

The second is soldiers. Say what you will about them, no one can dispute that their job has stakes of life and death. A lot of people seem to think that the world would be better off without them, but that’s at best only true if everyone got rid of them; if you don’t have soldiers but other countries do, you’re going to be in big trouble. (“We’ll beat our swords into liverwurst / Down by the East Riverside; / But no one wants to be the first!”) So unless and until we can solve that mother of all coordination problems, we need to have soldiers around.

What is life like for a soldier? Well, they don’t seem overpaid; if anything, underpaid. (Maybe some of the officers are overpaid, but clearly not most of the enlisted personnel. Part of the problem there is that “pay grade” is nearly synonymous with “rank”—it’s a primate hierarchy, not a rational wage structure. Then again, so are most industries; the military just makes it more explicit.) But there do seem to be enough of them. Military officials may lament of “shortages” of soldiers, but they never actually seem to want for troops to deploy when they really need them. And if a major war really did start that required all available manpower, the draft could be reinstated and then suddenly they’d have it—the authority to coerce compliance is precisely how you can avoid having a shortage while keeping your workers underpaid. (Russia’s soldier shortage is genuine—something about being utterly outclassed by your enemy’s technological superiority in an obviously pointless imperialistic war seems to hurt your recruiting numbers.)

What is life like for a typical soldier? The answer may surprise you. The overwhelming answer in surveys and interviews (which also fits with the experiences I’ve heard about from friends and family in the military) is that life as a soldier is boring. “All you do is wake up in the morning and push rubbish around camp.” “Bosnia was scary for about 3 months. After that it was boring. That is pretty much day to day life in the military. You are bored.”

This isn’t new, nor even an artifact of not being in any major wars: Union soldiers in the US Civil War had the same complaint. Even in World War I, a typical soldier spent only half the time on the front, and when on the front only saw combat 1/5 of the time. War is boring.

In other words, there is a massive glut of soldiers. Most of them don’t even know what to do with themselves most of the time.

This makes perfect sense. Why? Because an army needs to be resilient. And to be resilient, you must be redundant. If you only had exactly enough soldiers to deploy in a typical engagement, you’d never have enough for a really severe engagement. If on average you had enough, that means you’d spend half the time with too few. And the costs of having too few soldiers are utterly catastrophic.

This is probably an evolutionary outcome, in fact; civilizations may have tried to have “leaner” militaries that didn’t have so much redundancy, and those civilizations were conquered by other civilizations that were more profligate. (This is not to say that we couldn’t afford to cut military spending at all; it’s one thing to have the largest military in the world—I support that, actually—but quite another to have more than the next 10 combined.)

What’s the policy solution here? It’s actually pretty simple.

Pay nurses and EMTs more. A lot more. Whatever it takes to get to the point where we not only have enough, but have so many people lining up to join we don’t even know what to do with them all. If private healthcare firms won’t do it, force them to—or, all the more reason to nationalize healthcare. The stakes are far too high to leave things as they are.

Would this be expensive? Sure.

Removing the shortage of EMTs wouldn’t even be that expensive. There are only about 260,000 EMTs in the US, and they get paid the apallingly low median salary of $36,000. That means we’re currently spending only about $9 billion per year on EMTs. We could double their salaries and double their numbers for only an extra $27 billion—about 0.1% of US GDP.

Nurses would cost more. There are about 5 million nurses in the US, with an average salary of about $78,000, so we’re currently spending about $390 billion a year on nurses. We probably can’t afford to double both salary and staffing. But maybe we could increase both by 20%, costing about an extra $170 billion per year.

Altogether that would cost about $200 billion per year. To save one hundred thousand lives.

That’s $2 million per life saved, or about $40,000 per QALY. The usual estimate for the value of a statistical life is about $10 million, and the usual threshold for a cost-effective medical intervention is $50,000-$100,000 per QALY; so we’re well under both. This isn’t as efficient as buying malaria nets in Africa, but it’s more efficient than plenty of other things we’re spending on. And this isn’t even counting additional benefits of better care that go beyond lives saved.

In fact if we nationalized US healthcare we could get more than these amounts in savings from not wasting our money on profits for insurance and drug companies—simply making the US healthcare system as cost-effective as Canada’s would save $6,000 per American per year, or a whopping $1.9 trillion. At that point we could double the number of nurses and their salaries and still be spending less.

No, it’s not because nurses and doctors are paid much less in Canada than the US. That’s true in some countries, but not Canada. The median salary for nurses in Canada is about $95,500 CAD, which is $71,000 US at current exchange rates. Doctors in Canada can make anywhere from $80,000 to $400,000 CAD, which is $60,000 to $300,000 US. Nor are healthcare outcomes in Canada worse than the US; if anything, they’re better, as Canadians live an average of four years longer than Americans. No, the radical difference in cost—a factor of 2 to 1—between Canada and the US comes from privatization. Privatization is supposed to make things more efficient and lower costs, but it has absolutely not done that in US healthcare.

And if our choice is between spending more money and letting hundreds of thousands or millions of people die every year, that’s no choice at all.

The economic impact of chronic illness

pnrj core principles, ethics, inequality, market failure, personal, public policy , , , , , , , , , ,

Mar 27 JDN 2459666

This topic is quite personal for me, as someone who has suffered from chronic migraines since adolescence. Some days, weeks, and months are better than others. This past month has been the worst I have felt since 2019, when we moved into an apartment that turned out to be full of mold. This time, there is no clear trigger—which also means no easy escape.

The economic impact of chronic illness is enormous. 90% of US healthcare spending is on people with chronic illnesses, including mental illnesses—and the US has the most expensive healthcare system in the world by almost any measure. Over 55% of adult Medicaid beneficiaries have two or more chronic illnesses.

The total annual cost of all chronic illnesses is hard to estimate, but it’s definitely somewhere in the trillions of dollars per year. The World Economic Forum estimated that number at $47 trillion over the next 20 years, which I actually consider conservative. I think this is counting how much we actually spend and some notion of lost productivity, as well as the (fraught) concept of the value of a statistical life—but I don’t think it’s putting a sensible value on the actual suffering. This will effectively undervalue poor people who are suffering severely but can’t get treated—because they spend little and can’t put a large dollar value on their lives. In the US, where the data is the best, the total cost of chronic illness comes to nearly $4 trillion per year—20% of GDP. If other countries are as bad or worse (and I don’t see why they would be better), then we’re looking at something like $17 trillion in real cost every single year; so over the next 20 years that’s not $47 trillion—it’s over $340 trillion.

Over half of US adults have at least one of the following, and over a quarter have two or more: arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, or kidney disease. (Actually the former very nearly implies the latter, unless chronic conditions somehow prevented one another. Two statistically independent events with 50% probability will jointly occur 25% of the time: Flip two coins.)

Unsurprisingly, age is positively correlated with chronic illness. Income is negatively correlated, both because chronic illnesses reduce job opportunities and because poorer people have more trouble getting good treatment. I am the exception that proves the rule, the upper-middle-class professional with both a PhD and a severe chronic illness.

There seems to be a common perception that chronic illness is largely a “First World problem”, but in fact chronic illnesses are more common—and much less poorly treated—in countries with low and moderate levels of development than they are in the most highly-developed countries. Over 75% of all deaths by non-communicable disease are in low- and middle-income countries. The proportion of deaths that is caused by non-communicable diseases is higher in high-income countries—but that’s because other diseases have been basically eradicated from high-income countries. People in rich countries actually suffer less from chronic illness than people in poor countries (on average).

It’s always a good idea to be careful of the distinction between incidence and prevalence, but with chronic illness this is particularly important, because (almost by definition) chronic illnesses last longer and so can have very high prevalence even with low incidence. Indeed, the odds of someone getting their first migraine (incidence) are low precisely because the odds of being someone who gets migraines (prevalence) is so high.

Quite high in fact: About 10% of men and 20% of women get migraines at least occasionally—though only about 8% of these (so 1% of men and 2% of women) get chronic migraines. Indeed, because ti is both common and can be quite severe, migraine is the second-most disabling condition worldwide as measured by years lived with disability (YLD), after low back pain. Neurologists are particularly likely to get migraines; the paper I linked speculates that they are better at realizing they have migraines, but I think we also need to consider the possibility of self-selection bias where people with migraines may be more likely to become neurologists. (I considered it, and it seems at least as good a reason as becoming a dentist because your name is Denise.)

If you order causes by the number of disability-adjusted life years (DALYs) they cost, chronic conditions rank quite high: while cardiovascular disease and cancer rate by far the highest, diabetes and kidney disease, mental disorders, neurological disorders, and musculoskeletal disorders all rate higher than malaria, HIV, or any other infection except respiratory infections (read: tuberculosis, influenza, and, once these charts are updated for the next few years, COVID). Note also that at the very bottom is “conflict and terrorism”—that’s all organized violence in the world—and natural disasters. Mental disorders alone cost the world 20 times as many DALYs as all conflict and terrorism combined.

What if everyone owned their own home?

pnrj current events, public policy , , , , , , , , ,

Mar 14 JDN 2459288

In last week’s post I suggested that if we are to use the term “gentrification”, it should specifically apply to the practice of buying homes for the purpose of renting them out.

But don’t people need to be able to rent homes? Surely we couldn’t have a system where everyone always owned their own home?

Or could we?

The usual argument for why renting is necessary is that people don’t want to commit to living in one spot for 15 or 30 years, the length of a mortgage. And this is quite reasonable; very few careers today offer the kind of stability that lets you commit in advance to 15 or more years of working in the same place. (Tenured professors are one of the few exceptions, and I dare say this has given academic economists some severe blind spots regarding the costs and risks involved in changing jobs.)

But how much does renting really help with this? One does not rent a home for a few days or even few weeks at a time. If you are staying somewhere for an interval that short, you generally room with a friend or pay for a hotel. (Or get an AirBNB, which is sort of intermediate between the two.)

One only rents housing for months at a time—in fact, most leases are 12-month leases. But since the average time to sell a house is 60-90 days, in what sense is renting actually less of a commitment than buying? It feels like less of a commitment to most people—but I’m not sure it really is less of a commitment.

There is a certainty that comes with renting—you know that once your lease is up you’re free to leave, whereas selling your house will on average take two or three months, but could very well be faster or slower than that.

Another potential advantage of renting is that you have a landlord who is responsible for maintaining the property. But this advantage is greatly overstated: First of all, if they don’t do it (and many surely don’t), you actually have very little recourse in practice. Moreover, if you own your own home, you don’t actually have to do all the work yourself; you could pay carpenters and plumbers and electricians to do it for you—which is all that most landlords were going to do anyway.

All of the “additional costs” of owning over renting such as maintenance and property taxes are going to be factored into your rent in the first place. This is a good argument for recognizing that a $1000 mortgage payment is not equivalent to a $1000 rent payment—the rent payment is all-inclusive in a way the mortgage is not. But it isn’t a good argument for renting over buying in general.

Being foreclosed on a mortgage is a terrible experience—but surely no worse than being evicted from a rental. If anything, foreclosure is probably not as bad, because you can essentially only be foreclosed for nonpayment, since the bank only owns the loan; landlords can and do evict people for all sorts of reasons, because they own the home. In particular, you can’t be foreclosed for annoying your neighbors or damaging the property. If you own your home, you can cut a hole in a wall any time you like. (Not saying you should necessarily—just that you can, and nobody can take your home away for doing so.)

I think the primary reason that people rent instead of buying is the cost of a down payment. For some reason, we have decided as a society that you should be expected to pay 10%-20% of the cost of a home up front, or else you never deserve to earn any equity in your home whatsoever. This is one of many ways that being rich makes it easier to get richer—but it is probably the most important one holding back most of the middle class of the First World.

And make no mistake, that’s what this is: It’s a social norm. There is no deep economic reason why a down payment needs to be anything in particular—or even why down payments in general are necessary.

There is some evidence that higher down payments are associated with less risk of default, but it’s not as strong as many people seem to think. The big HUD study on the subject found that one percentage point of down payment reduces default risk by about as much as 5 points of credit rating: So you should prefer to offer a mortgage to someone with an 800 rating and no down payment than someone with a 650 rating and a 20% down payment.

Also, it’s not as if mortgage lenders are unprotected from default (unlike, say, credit card lenders). Above all, they can foreclose on the house. So why is it so important to reduce the risk of default in the first place? Why do you need extra collateral in the form of a down payment, when you’ve already got an entire house of collateral?

It may be that this is actually a good opportunity for financial innovation, a phrase that should in general strike terror in one’s heart. Most of the time “financial innovation” means “clever ways of disguising fraud”. Previous attempts at “innovating” mortgages have resulted in such monstrosities as “interest-only mortgages” (a literal oxymoron, since by definition a mortgage must have a termination date—a date at which the debt “dies”), “balloon payments”, and “adjustable rate mortgages”—all of which increase risk of default while as far as I can tell accomplishing absolutely nothing. “Subprime” lending created many excuses for irresponsible or outright predatory lending—and then, above all, securitization of mortgages allowed banks to offload the risk they had taken on to third parties who typically had no idea what they were getting.

Volcker was too generous when he said that the last great financial innovation was the ATM; no, that was an innovation in electronics (and we’ve had plenty of those). The last great financial innovation I can think of is the joint-stock corporation in the 1550s. But I think a new type of mortgage contract that minimizes default risk without requiring large up-front payments might actually qualify as a useful form of financial innovation.

It would also be useful to have mortgages that make it easier to move, perhaps by putting payments on hold while the home is up for sale. That way people wouldn’t have to make two mortgage payments at once as they move from one place to another, and the bank will see that money eventually—paid for by new buyer and their mortgage.

Indeed, ideally I’d like to eliminate foreclosure as well, so that no one has to be kicked out of their homes. How might we do that?

Well, as a pandemic response measure, we should have simply instituted a freeze on all evictions and foreclosures for the duration of the pandemic. Some states did, in fact—but many didn’t, and the federal moratoria on evictions were limited. This is the kind of emergency power that government should have, to protect people from a disaster. So far it appears that the number of evictions was effectively reduced from tens of millions to tens of thousands by these measures—but evicting anyone during a pandemic is a human rights violation.

But as a long-term policy, simply banning evictions wouldn’t work. No one would want to lend out mortgages, knowing that they had no recourse if the debtor stopped paying. Even buyers with good credit might get excluded from the market, since once they actually received the house they’d have very little incentive to actually make their payments on time.

But if there are no down payments and no foreclosures, that means mortgage lenders have no collateral. How are they supposed to avoid defaults?

One option would be wage garnishment. If you have the money and are simply refusing to pay it, the courts could simply require your employer to send the money directly to your creditors. If you have other assets, those could be garnished as well.

And what if you don’t have the money, perhaps because you’re unemployed? Well, then, this isn’t really a problem of incentives at all. It isn’t that you’re choosing not to pay, it’s that you can’t pay. Taking away such people’s homes would protect banks financially, but at a grave human cost.

One option would be to simply say that the banks should have to bear the risk: That’s part of what their huge profits are supposed to be compensating them for, the willingness to take on risks others won’t. The main downside here is the fact that it would probably make it more difficult to get a mortgage and raise the interest rates that you would need to pay once you do.

Another option would be some sort of government program to make up the difference, by offering grants or guaranteed loans to homeowners who can’t afford to pay their mortgages. Since most such instances are likely to be temporary, the government wouldn’t be on the hook forever—just long enough for people to get back on their feet. Here the downside would be the same as any government spending: higher taxes or larger budget deficits. But honestly it probably wouldn’t take all that much; while the total value of all mortgages is very large, only a small portion are in default at any give time. Typically only about 2-4% of all mortgages in the US are in default. Even 4% of the $10 trillion total value of all US mortgages is about $400 billion, which sounds like a lot—but the government wouldn’t owe that full amount, just whatever portion is actually late. I couldn’t easily find figures on that, but I’d be surprised if it’s more than 10% of the total value of these mortgages that would need to be paid by the government. $40 billion is about 1% of the annual federal budget.

Reforms to our healthcare system would also help tremendously, as medical expenses are a leading cause of foreclosure in the United States (and literally nowhere else—every other country with the medical technology to make medicine this expensive also has a healthcare system that shares the burden). Here there is virtually no downside: Our healthcare system is ludicrously expensive without producing outcomes any better than the much cheaper single-payer systems in Canada, the UK, and France.

All of this sounds difficult and complicated, I suppose. Some may think that it’s not worth it. But I believe that there is a very strong moral argument for universal homeownership and ending eviction: Your home is your own, and no one else’s. No one has a right to take your home away from you.

This is also fundamentally capitalist: It is the private ownership of capital by its users, the acquisition of wealth through ownership of assets. The system of landlords and renters honestly doesn’t seem so much capitalist as it does feudal: We even call them “lords”, for goodness’ sake!

As an added bonus, if everyone owned their own homes, then perhaps we wouldn’t have to worry about “gentrification”, since rising property values would always benefit residents.

The necessitization of American consumption

pnrj inequality, macroeconomics, public policy , , , , , , , ,

Dec6 JDN 2459190

Why do we feel poorer than our parents?

Over the last 20 years, real per-capita GDP has risen from $46,000 to $56,000 (in 2012 dollars):

It’s not just increasing inequality (though it is partly that); real median household income has increased over the same period from $62,500 to $68,700 (in 2019 dollars):

The American Enterprise Institute has utterly the wrong interpretation of what’s going on here, but their graph is actually quite informative if you can read it without their ideological blinders:

Over the past 20 years, some industries have seen dramatic drops in prices, such as televisions, cellphones, toys, and computer software. Other industries have seen roughly constant prices, such as cars, clothing, and furniture. Still other industries have seen modest increases in prices that tracked overall inflation, such as housing and food. And then there are some industries where prices have exploded to staggering heights, such as childcare, college education, and hospital services.

Since wages basically kept up with inflation, this is the relevant comparison: A product or service is more expensive in real terms if its price grew faster than inflation.

It’s not inherently surprising that some prices would rise faster than inflation and some would rise slower; indeed, it would be shocking if that were not the case, since inflation essentially just is an average of all price changes over time. But if you look closely at the kinds of things that got cheaper versus more expensive, you can begin to see why the statistics keep saying we are getting richer but we don’t feel any richer.

The things that increased the most in price are things you basically can’t do without: Education, childcare, and healthcare. Yes, okay, theoretically you could do without these things, but the effects on your life would be catastrophic—indeed, going without healthcare could literally kill you. They are necessities.

The things that decreased the most in price are things that people have done without for most of human history: Cellphones, software, and computer software. They are newfangled high-tech goods that are now ubiquitous, but not at all long ago didn’t even exist. Going without these goods would be inconvenient, but hardly catastrophic. Indeed, they largely only feel as necessary as they are because everyone else already has them. They are luxuries.

This even explains why older generations can be convinced that we are richer than the statistics say: We have all these fancy new high-tech toys that they never had. But what good does that do us when we can’t afford our health insurance?

Housing is also an obvious necessity, and while it has not on average increased in price faster than inflation, this average washes out important geographic variation.

San Francisco has seen housing prices nearly triple in the last 20 years:

Over the same period, Detroit’s housing prices plummeted, then returned to normal, and are now only 30% higher than they were 20 years ago (comparable to inflation):

It’s hardly surprising that the cities where the most people are moving to are the most expensive to live in; that’s basic supply and demand. But the magnitude of the difference is so large that most of us are experiencing rising housing prices, even though on average housing prices aren’t really rising.

Put this all together, and we can see that while by the usual measures our “standard of living” is increasing, our financial situation feels ever more precarious, because more and more of our spending is immediately captured by things we can’t do without. I suggest we call this effect necessitization; our consumption has been necessitized.

Healthcare is the most extreme example: In 1960, healthcare spending was only 5% of US GDP. As recently as 2000, it was 13%. Today, it is 18%. Medical technology has greatly improved over that time period, increasing our life expectancy from 70 years in 1960 to 76 years in 2000 to 78 years today, so perhaps this additional spending is worth it? But if we compare 2000 to 2020, we can see that an additional 5% of GDP in the last 20 years has only bought us two years of life. So we have spent an additional 5% of our income to gain 2.6% more life—that doesn’t sound like such a great deal to me. (Also, if you look closely at the data, most of the gains in life expectancy seem to be from things like antibiotics and vaccines that aren’t a large part of our healthcare spending, while most of the increased spending seems to be on specialists, testing, high-tech equipment, and administrative costs that don’t seem to contribute much to life expectancy.)

Moreover, even if we decide that all this healthcare spending is worth it, it doesn’t make us richer in the usual sense. We have better health, but we don’t have greater wealth or financial security.

AEI sees that the industries with the largest price increases have the most government intervention, and blames the government; this is clearly confusing cause with effect. The reason the government intervenes so much in education and healthcare is because these are necessities and they are getting so expensive. Removing those interventions wouldn’t stop prices from rising; they’d just remove the programs like Medicaid and federal student loans that currently allow most people to (barely) afford them.

But they are right about one thing: Prices have risen much faster in some industries than others, and the services that have gotten the most expensive are generally the services that are most important.

Why have these services gotten so expensive? A major reason seems to be that they are difficult to automate. Manufacturing electronics is very easy to automate—indeed, there’s even a positive feedback loop there: the better you get at automating making electronics, the better you get at automating everything, including making electronics. But automating healthcare and education is considerably more difficult. Yes, there are MOOCs, and automated therapy software, and algorithms will soon be outperforming the average radiologist; but there are a lot of functions that doctors, nurses, and teachers provide that are very difficult to replace with machines or software.

Suppose we do figure out how to automate more functions of education and healthcare; would that solve the problem? Maybe—but only if we really do manage to automate the important parts.

Right now, MOOCs are honestly terrible. The sales pitch is that you can get taught by a world-class professor from anywhere in the world, but the truth is that the things that make someone a world-class professor don’t translate over when you are watching recorded video lectures and doing multiple-choice quizzes. Really good teaching requires direct interaction between teacher and student. Of course, a big lecture hall full of hundreds of students often lacks such interaction—but so much the worse for big lecture halls. If indeed that’s the only way colleges know how to teach, then they deserve to be replaced by MOOCs. But there are better ways of teaching that online courses currently cannot provide, and if college administrators were wise, they would be focusing on pressing that advantage. If this doesn’t happen, and education does become heavily automated, it will be cheaper—but it will also be worse.

Similarly, some aspects of healthcare provision can be automated, but there are clearly major benefits to having actual doctors and nurses physically there to interact with patients. If we want to make healthcare more affordable, we will probably have to find other ways (a single-payer health system comes to mind).

For now, it is at least worth recognizing that there are serious limitations in our usual methods of measuring standard of living; due to effects like necessitization, the statistics can say that we are much richer even as we hardly feel richer at all.

Reasons to like Joe Biden

pnrj current events, public policy , , , , , , , , , , , , , , , , , , , , , ,

Sep 6 JDN 2459099

Maybe it’s because I follow too many radical leftists on social media (this is at least a biased sample, no doubt), but I’ve seen an awful lot of posts basically making this argument: “Joe Biden is terrible, but we have to elect him, because Donald Trump is worse.”

And make no mistake: Whatever else you think about this election, the fact that Donald Trump is a fascist and Joe Biden is not is indeed a fully sufficient reason to vote for Biden. You shouldn’t need any more than that.

But in fact Joe Biden is not terrible. Yes, there are some things worth criticizing about his record and his platform—particularly with regard to civil liberties and war (both of those links are to my own posts making such criticisms of the Obama administration). I don’t want to sweep these significant flaws under the rug.

Yet, there are also a great many things that are good about Biden and his platform, and it’s worthwhile to talk about them. You shouldn’t feel like you are holding your nose and voting for the lesser of two evils; Biden is going to make a very good President.

First and foremost, there is his plan to invest in clean energy and combat climate change. For the first time in decades, we have a Presidential candidate who is explicitly pro-nuclear and has a detailed, realistic plan for achieving net-zero carbon emissions within a generation. We should have done this 30 years ago; but far better to start now than to wait even longer.

Then there is Biden’s plan for affordable housing. He wants to copy California’s Homeowner Bill of Rights at the federal level, fight redlining, expand Section 8, and nationalize the credit rating system. Above all, he wants to create a new First Down Payment Tax Credit that will provide first-time home buyers with $15,000 toward a down payment on a home. That is how you increase homeownership. The primary reason why people rent instead of owning is that they can’t afford the down payment.

Biden is also serious about LGBT rights, and wants to pass the Equality Act, which would finally make all discrimination based on sexual orientation or gender identity illegal at the federal level. He has plans to extend and aggressively enforce federal rules protecting people with disabilities. His plans for advancing racial equality seem to be thoroughly baked into all of his proposals, from small business funding to housing reform—likely part of why he’s so popular among Black voters.

His plan for education reform includes measures to equalize funding between rich and poor districts and between White and non-White districts.

Biden’s healthcare plan isn’t quite Medicare For All, but it’s actually remarkably close to that. He wants to provide a public healthcare option available to everyone, and also lower the Medicare eligibility age to 60 instead of 65. This means that anyone who wants Medicare will be able to buy into it, and also sets a precedent of lowering the eligibility age—remember, all we really need to do to get Medicare For All is lower that age to 18. Moreover, it avoids forcing people off private insurance that they like, which is the main reason why Medicare For All still does not have majority support.

While many on the left have complained that Biden believes in “tough on crime”, his plan for criminal justice reform actually strikes a very good balance between maintaining low crime rates and reducing incarceration and police brutality. The focus is on crime prevention instead of punishment, and it includes the elimination of all federal use of privatized prisons.

Most people would give lip service to being against domestic violence, but Biden has a detailed plan for actually protecting survivors and punishing abusers—including ratifying the Equal Rights Amendment and ending the rape kit backlog. The latter is an utter no-brainer. If we need to, we can pull the money from just about any other form of law enforcement (okay, I guess not homicide); those rape kits need to be tested and those rapists need to be charged.

Biden also has a sensible plan for gun control, which is consistent with the Second Amendment and Supreme Court precedent but still could provide substantial protections by reinstating the ban on assault weapons and high-capacity magazines, requiring universal background checks, and adding other sensible restrictions on who can be licensed to own firearms. It won’t do much about handguns or crimes of passion, but it should at least reduce mass shootings.

Biden doesn’t want to implement free four-year college—then again, neither do I—but he does have a plan for free community college and vocational schooling.

He also has a very ambitious plan for campaign finance reform, including a Constitutional Amendment that would ban all private campaign donations. Honestly if anything the plan sounds too ambitious; I doubt we can really implement all of these things any time soon. But if even half of them get through, our democracy will be in much better shape.

His immigration policy, while far from truly open borders, would reverse Trump’s appalling child-separation policy, expand access to asylum, eliminate long-term detention in favor of a probation system, and streamline the path to citizenship.

Biden’s platform is the first one I’ve seen that gives detailed plans for foreign aid and international development projects; he is particularly focused on Latin America.

I’ve seen many on the left complain that Biden was partly responsible for the current bankruptcy system that makes it nearly impossible to discharge student loans; well, his current platform includes a series of reforms developed by Elizabeth Warren designed to reverse that.

I do think Biden is too hawkish on war and not serious enough about protecting civil liberties—and I said the same thing about Obama years ago. But Biden isn’t just better than Trump (almost anyone would be better than Trump); he’s actually a genuinely good candidate with a strong, progressive platform.

You should already have been voting for Biden anyway. But hopefully now you can actually do it with some enthusiasm.

How beneficial is healthcare?

pnrj public policy , , ,

Mar 22 JDN 2458931

Healthcare has been a contentious issue in the US for generations, but became especially so during the Obama administration with the passage of the Affordable Care Act. To be honest, I never quite understood the opposition to transitioning to a single-payer healthcare system; we already spend as much public funds on healthcare as most other First World countries spend in their entire healthcare system (plus we spend even more than that on private spending!), so not only can we afford it—it would in fact save us trillions of dollars a year. We might not even have to raise taxes, but even if we did, we’d pay so much less out of pocket that most of us would end up with more money. I understand why the corporations that run HMOs don’t want single-payer; but why does anyone else oppose it?

It’s not as if there are no models to follow; we could literally just copy the Canadian system (or the British system, or the French system…). It’s always amusing to me when conservatives respond to the suggestion by: “But that’s socialism! Do you want to end up like Cuba?” First of all, I said copy Canada, not copy Cuba. But even if we did copy Cuba, healthcare is one of the few things that Cuba actually does extremely well. On a QALY-per-dollar basis, it’s probably the most cost-effective healthcare system in the world (and the US is probably the least). So yeah, you know what? I kinda do want to end up like Cuba.

And no, countries with single-payer healthcare systems do not have longer wait times. Even by standard measures, our wait types are in the middle of the pack. But in fact these standard measures are clearly biased in our favor. The main way that we reduce wait times is by excluding people from care entirely. That’s not a wait time of zero; it’s a wait time of the rest of your life. If we measured properly, we would clearly have the longest wait times in the First World, because of all those people who never get care at all.

But today I’m going to ask a different question:

How much harm is done by our awful healthcare system?

Or conversely:

How much benefit would we get from insuring everyone?

The largest randomized controlled experiment on health insurance in the United States was the RAND Health Insurance Experiment, and its results were quite surprising: The marginal benefit of better health insurance for most people was very small, in many cases statistically negligible. People who were very poor or very sick benefited from having health insurance, but everyone else used more medical care without getting much apparent benefit. Since this was a large randomized controlled experiment, it should probably be considered our most credible evidence.

On the other hand, the RAND study was done before I was born, so maybe it’s time for a new study?

More recent studies have used regression discontinuity analysis, looking to see if going on Medicare seems to change the trendline in your mortality rate. It doesn’t.Of course mortality rates go up as you get older, and people become eligible for Medicare by getting older… but still, if Medicare is helping, you’d think there would be some kind of kink in the trend, and as far as we can tell, there isn’t. Perhaps people are simply transitioning from one form of adequate health insurance (e.g. employer-provided insurance) to another.

There is some evidence that healthcare saves lives, if we restrict attention specifically to what is called mortality amenable to healthcare, deaths caused by diseases that we know can be effectively treated by medical intervention. (It’s really a continuum, with malaria at one end, and airstrikes at the other. Both kill thousands of people every year, but malaria can be treated with a few doses of quinine, while there’s nothing anyone can do for you if you were in the blast center of a Hellfire missile. In between we have diseases like cancer, which medicine can sometimes save you from but not always.) By this measure, the United States clearly lags behind other First World countries, and the reason is clearly that we deny a lot of people healthcare.

However, I think mortality is really the wrong measure to use, for the following reason: We already have a universal healthcare system when it’s literally a question of life or death, and that’s the ER system. The Emergency Medical Treatment and Labor Act, signed by Ronald Reagan (yes, Republicans also used to like saving poor people from diseases, not so long ago!), guarantees that anyone who needs emergency care can get it immediately, regardless of their ability to pay. They can still bill you later, which may be a big reason why medical costs are the leading cause of bankruptcy in the United States (and literally nowhere else in the world). But at least you won’t die.

A lot of it actually comes down to how we measure health. Self-reported measures are notoriously unreliable in various ways, yet ultimately I don’t see how we can tell whether someone is sleeping well, feeling energetic, or being in pain without asking them. Correlating self-reported measures with objective measures like records of doctor visits shows pretty good correspondence, albeit by no means perfect.

As healthcare spending has increased and medical technology has advanced, there has been a worldwide trend of reduced disability and mortality, and the US is no exception. Clearly healthcare is doing something.

Yet it remains a fair question whether most people need more healthcare—maybe we’re actually getting enough. Maybe most people’s health insurance is already adequate, and we don’t need to improve it in any substantial way.

On balance, I think the best evidence we have says that people who have no insurance at all, or really awful insurance, would strongly benefit from improved access to healthcare. There’s also evidence that people with severe chronic conditions benefit from having steady healthcare. But for most people most of the time, the benefits of more health insurance would be quite small.

Does this mean we should get rid of health insurance? Of course not. But it does mean that future reforms should be focused on getting it to people who have none, not improving it for people who already have it. We don’t need to lower co-pays or deductibles; we may not even need to raise or remove coverage caps. But we do need to get some kind of health insurance to people who don’t have any at all.
To this end, Obamacare has done fairly well: You can just look at a graph of the number of uninsured people in the US and see that not only did Obamacare reduce that number, the steady attempts to undermine Obamacare are starting to bring it back up.

Then again, a single-payer system would clearly do even better, maybe even get that number to zero… so explain to me again why we’re not doing this?

The cost of illness

pnrj core principles, current events, development economics, inequality, public policy , , , , , , , , , ,

Feb 2 JDN 2458882

As I write this I am suffering from some sort of sinus infection, most likely some strain of rhinovirus. So far it has just been basically a bad cold, so there isn’t much to do aside from resting and waiting it out. But it did get me thinking about healthcare—we’re so focused on the costs of providing it that we often forget the costs of not providing it.

The United States is the only First World country without a universal healthcare system. It is not a coincidence that we also have some of the highest rates of preventable mortality and burden of disease.

We in the United States spend about $3.5 trillion per year on healthcare, the most of any country in the world, even as a proportion of GDP. Yet this is not the cost of disease; this is how much we were willing to pay to avoid the cost of disease. Whatever harm that would have been caused without all that treatment must actually be worth more than $3.5 trillion to us—because we paid that much to avoid it.

Globally, the disease burden is about 30,000 disability-adjusted life-years (DALY) per 100,000 people per year—that is to say, the average person is about 30% disabled by disease. I’ve spoken previously about quality-adjusted life years (QALY); the two measures take slightly different approaches to the same overall goal, and are largely interchangeable for most purposes.

Of course this result relies upon the disability weights; it’s not so obvious how we should be comparing across different conditions. How many years would you be willing to trade of normal life to avoid ten years of Alzheimer’s? But it’s probably not too far off to say that if we could somehow wave a magic wand and cure all disease, we would really increase our GDP by something like 30%. This would be over $6 trillion in the US, and over $26 trillion worldwide.

Of course, we can’t actually do that. But we can ask what kinds of policies are most likely to promote health in a cost-effective way.

Unsurprisingly, the biggest improvements to be made are in the poorest countries, where it can be astonishingly cheap to improve health. Malaria prevention has a cost of around $30 per DALY—by donating to the Against Malaria Foundation you can buy a year of life for less than the price of a new video game. Compare this to the standard threshold in the US of $50,000 per QALY: Targeting healthcare in the poorest countries can increase cost-effectiveness a thousandfold. In humanitarian terms, it would be well worth diverting spending from our own healthcare to provide public health interventions in poor countries. (Fortunately, we have even better options than that, like raising taxes on billionaires or diverting military spending instead.)

We in the United States spend about twice as much (per person per year) on healthcare as other First World countries. Are our health outcomes twice as good? Clearly not. Are they any better at all? That really isn’t clear. We certainly don’t have a particularly high life expectancy. We spend more on administrative costs than we do on preventative care—unlike every other First World country except Australia. Almost all of our drugs and therapies are more expensive here than they are everywhere else in the world.

The obvious answer here is to make our own healthcare system more like those of other First World countries. There are a variety of universal health care systems in the world that we could model ourselves on, ranging from the single-payer government-run system in the UK to the universal mandate system of Switzerland. The amazing thing is that it almost doesn’t matter which one we choose: We could copy basically any other First World country and get better healthcare for less spending. Obamacare was in many ways similar to the Swiss system, but we never fully implemented it and the Republicans have been undermining it every way they can. Under President Trump, they have made significant progress in undermining it, and as a result, there are now 3 million more Americans without health insurance than there were before Trump took office. The Republican Party is intentionally increasing the harm of disease.

Subsidies can’t make things unaffordable

pnrj public policy , , , , ,

May 12 2458616

In last week’s post I talked about a supposed benefit of subsidies that almost never materializes. In this week, I’m going to talk about a supposed harm of subsidies that is literally impossible.

The American Enterprise Institute (a libertarian think-tank) has been sending around a graph of price increases over the last 20 years by sector, showing what everyone already intuitively knows: healthcare and education have gotten wildly more expensive, while high-tech products have gotten extremely cheap. Actually I was a surprised how little they found housing prices had increased (enough to make me wonder what metric they are using for housing prices).

They argue that it is government intervention which has created these rising prices:

Blue lines = prices subject to free market forces. Red lines = prices subject to regulatory capture by government.

Along similar lines, Grey Gordon and Aaron Hedlund published a book chapter presenting evidence that student loans and federal subsidies are responsible for increases in college tuition. They are professional economists, so I feel like I ought to take their argument seriously… but it’s really hard to do, because it’s such a silly concept at the most basic level. I could nitpick their assumptions about elasticity of demand and monopoly power, but the whole argument just doesn’t pass the smell test.

Subsidies always make things more affordable for the person being subsidized.

It’s possible for subsidies to create other distortions, and make things more expensive for those who aren’t subsidized. But it’s literally impossible for subsidies to make something unaffordable to the person being subsidized.

That result is absolutely fundamental, and it comes directly from the Law of Supply and Law of Demand.

Subsidies

On this graph, the blue line is the demand curve. The red line is the supply curve. The thick green line is where they intersect, at the competitive equilibrium price. In this case, that equilibrium means we sell 6 units at a price of $3 each.

The thin green lines show what happen if we introduce a subsidy. Here the subsidy is $3. The sticker price can be read off of the supply curve: It will rise to $4. But the actual price paid by consumers is read off the demand curve: It will fall to $1. Total sales will rise to 8 units. The total cost to the government is then 8($3) = $24.

These exact numbers are of course specific to the example I chose. But the overall direction is not.

We can go ahead and draw this with all sorts of different supply and demand curves, and we’ll keep getting the same result.

Here’s one where I didn’t even make the curves linear:

Subsidies_2

In this case, a subsidy of $5.40 raises the sticker price from $6.10 to $11.20, only reducing the price for consumers to $5.80, while increasing the quantity sold from 3.5 to 4.8. The total cost of the subsidy is $25.92. The price effects are very different in magnitude from the previous example, and yet all the directions are exactly the same—and they will continue to be the same, however you draw the curves.

And here’s yet another example:

Subsidies_3

Here, a subsidy of $2.30 raises the sticker price from $4 to $5.30, lowers the cost to consumers to $3, increases the quantity sold from 4 to 7 units, and costs $16.10.

If you’re still not convinced, try drawing some more of the same diagrams yourself. As long as you make the supply curve slope upward and the demand curve slope downward, you’ll keep getting the same results.
A subsidy will always do four things:

  1. Increase the sticker price, benefiting sellers.
  2. Decrease the price that subsidized consumers actually pay, benefiting those consumers.
  3. Increase the quantity sold.
  4. Cost the government money.

The intuition here is quite simple: If I give you free money every time you buy a thing, you’ll buy more of that thing (3) because it costs you less to do so (2). Because you buy more of the thing, the price will go up (1), but not enough to cancel out the reduced cost to you (or else you’d stop). Since I’m giving you free money, that will cost me money (4). This intuition is fully general: It doesn’t matter what kind of product we are talking about, you’re never going to buy less or have to pay more for each one because I gave you free money.

The size of each effect depends upon elasticity of demand and supply, in basically the same way as tax incidence. The more inelastic side of the market is harmed less by the tax and also benefits less from the subsidy. For any given change in quantity, more inelastic markets raise more tax revenue and cost more subsidy spending.

If we allow elasticities of demand or supply to be zero or infinite (which is almost never the case in real life), then some of these effects might be zero. But they will never go the opposite direction, not as long as the supply curve slopes upward and the demand curve slopes downward.

I suspect that education has relatively inelastic demand and relatively elastic supply, which would mean that the subsidies are actually largely felt by the consumer, not the seller. But that’s actually a legitimate economic question: I might be overestimating the elasticity of supply.

There are other legitimate economic questions here as well, such as how much benefit we get out of a given subsidy versus other ways we might spend that money, and how subsidies may hurt others in the same market who aren’t subsidized.

What is not a legitimate question is the one that these libertarian think-tanks seem to be asking, which is “If you give people money, will they end up with less stuff?” No, they won’t. That’s not how any of this works.

And I’m pretty sure the people in these think-tanks are smart enough to know that. They might be blinded by their anti-government ideology, but I actually suspect it’s more sinister than that: They know that what they are saying isn’t true, but they consider it a “noble lie”: A falsehood told to the common folk in the service of a higher good.

They are clever enough to not simply state the lie outright, but instead imply it through misleading presentation of real facts. Yes, it’s true that subsidies will raise the sticker price—so they can say that this was all they were asserting. But not only is that obvious and trivial: It wouldn’t even support the argument they are obviously trying to make. Nobody cares about the sticker price. They care about what people actually pay. And a subsidy, by construction, as a law of economics, cannot possibly increase the amount paid by the buyer who is subsidized.

What they obviously want you to think is that the reason healthcare and education are so unaffordable is because the government has been subsidizing them. But this is basically the opposite of the truth: These things became unaffordable for various reasons, and the government stepped in to subsidize them in order to stop the bleeding. Is that a permanent solution? No, it’s not. But it does actually help keep them affordable for the time being—and it could not have done otherwise. There’s simply no way to give someone free money and make them poorer. (Of course, fully socialized healthcare and education might be permanent solutions, so if the libertarians aren’t careful what they wish for….)

Green New Deal Part 3: Guaranteeing education and healthcare is easy—why aren’t we doing it?

pnrj current events, ethics, inequality, personal, public policy , , , , , , , , , , , ,

Apr 21 JDN 2458595

Last week was one of the “hard parts” of the Green New Deal. Today it’s back to one of the “easy parts”: Guaranteed education and healthcare.

“Providing all people of the United States with – (i) high-quality health care; […]

“Providing resources, training, and high-quality education, including higher education, to all people of the United States.”

Many Americans seem to think that providing universal healthcare would be prohibitively expensive. In fact, it would have literally negative net cost.
The US currently has the most bloated, expensive, inefficient healthcare system in the entire world. We spend almost $10,000 per person per year on healthcare, and get outcomes no better than France or the UK where they spend less than $5,000.
In fact, our public healthcare expenditures are currently higher than almost every other country. Our private expenditures are therefore pure waste; all they are doing is providing returns for the shareholders of corporations. If we were to simply copy the UK National Health Service and spend money in exactly the same way as they do, we would spend the same amount in public funds and almost nothing in private funds—and the UK has a higher mean lifespan than the US.
This is absolutely a no-brainer. Burn the whole system of private insurance down. Copy a healthcare system that actually works, like they use in every other First World country.
It wouldn’t even be that complicated to implement: We already have a single-payer healthcare system in the US; it’s called Medicare. Currently only old people get it; but old people use the most healthcare anyway. Hence, Medicare for All: Just lower the eligibility age for Medicare to 18 (if not zero). In the short run there would be additional costs for the transition, but in the long run we would save mind-boggling amounts of money, all while improving healthcare outcomes and extending our lifespans. Current estimates say that the net savings of Medicare for All would be about $5 trillion over the next 10 years. We can afford this. Indeed, the question is, as it was for infrastructure: How can we afford not to do this?
Isn’t this socialism? Yeah, I suppose it is. But healthcare is one of the few things that socialist countries consistently do extremely well. Cuba is a socialist country—a real socialist country, not a social democratic welfare state like Norway but a genuinely authoritarian centrally-planned economy. Cuba’s per-capita GDP PPP is a third of ours. Yet their life expectancy is actually higher than ours, because their healthcare system is just that good. Their per-capita healthcare spending is one-fourth of ours, and their health outcomes are better. So yeah, let’s be socialist in our healthcare. Socialists seem really good at healthcare.
And this makes sense, if you think about it. Doctors can do their jobs a lot better when they’re focused on just treating everyone who needs help, rather than arguing with insurance companies over what should and shouldn’t be covered. Preventative medicine is extremely cost-effective, yet it’s usually the first thing that people skimp on when trying to save money on health insurance. A variety of public health measures (such as vaccination and air quality regulation) are extremely cost-effective, but they are public goods that the private sector would not pay for by itself.
It’s not as if healthcare was ever really a competitive market anyway: When you get sick or injured, do you shop around for the best or cheapest hospital? How would you even go about that, when they don’t even post most of their prices and what prices they post are often wildly different than what you’ll actually pay?
The only serious argument I’ve heard against single-payer healthcare is a moral one: “Why should I have to pay for other people’s healthcare?” Well, I guess, because… you’re a human being? You should care about other human beings, and not want them to suffer and die from easily treatable diseases?
I don’t know how to explain to you that you should care about other people.

Single-payer healthcare is not only affordable: It would be cheaper and better than what we are currently doing. (In fact, almost anything would be cheaper and better than what we are currently doing—Obamacare was an improvement over the previous mess, but it’s still a mess.)
What about public education? Well, we already have that up to the high school level, and it works quite well.
Contrary to popular belief, the average public high school has better outcomes in terms of test scores and college placements than the average private high school. There are some elite private schools that do better, but they are extraordinarily expensive and they self-select only the best students. Public schools have to take all students, and they have a limited budget; but they have high quality standards and they require their teachers to be certified.
The flaws in our public school system are largely from it being not public enough, which is to say that schools are funded by their local property taxes instead of having their costs equally shared across whole states. This gives them the same basic problem as private schools: Rich kids get better schools.
If we removed that inequality, our educational outcomes would probably be among the best in the world—indeed, in our most well-funded school districts, they are. The state of Massachusetts which actually funds their public schools equally and well, gets international test scores just as good as the supposedly “superior” educational systems of Asian countries. In fact, this is probably even unfair to Massachusetts, as we know that China specifically selects the regions that have the best students to be the ones to take these international tests. Massachusetts is the best the US has to offer, but Shanghai is also the best China has to offer, so it’s only fair we compare apples to apples.
Public education has benefits for our whole society. We want to have a population of citizens, workers, and consumers who are well-educated. There are enormous benefits of primary and secondary education in terms of reducing poverty, improving public health, and increased economic growth.
So there’s my impassioned argument for why we should continue to support free, universal public education up to high school.
When it comes to college, I can’t be quite so enthusiastic. While there are societal benefits of college education, most of the benefits of college accrue to the individuals who go to college themselves.
The median weekly income of someone with a high school diploma is about $730; with a bachelor’s degree this rises to $1200; and with a doctoral or professional degree it gets over $1800. Higher education also greatly reduces your risk of being unemployed; while about 4% of the general population is unemployed, only 1.5% of people with doctorates or professional degrees are. Add that up over all the weeks of your life, and it’s a lot of money.
The net present value of a college education has been estimated at approximately $1 million. This result is quite sensitive to the choice of discount rate; at a higher discount rate you can get the net present value as “low” as $250,000.
With this in mind, the fact that the median student loan debt for a college graduate is about $30,000 doesn’t sound so terrible, does it? You’re taking out a loan for $30,000 to get something that will earn you between $250,000 and $1 million over the course of your life.
There is some evidence that having student loans delays homeownership; but this is a problem with our mortgage system, not our education system. It’s mainly the inability to finance a down payment that prevents people from buying homes. We should implement a system of block grants for first-time homeowners that gives them a chunk of money to make a down payment, perhaps $50,000. This would cost about as much as the mortgage interest tax deduction which mainly benefits the upper-middle class.
Higher education does have societal benefits as well. Perhaps the starkest I’ve noticed is how categorically higher education decided people’s votes on Donald Trump: Counties with high rates of college education almost all voted for Clinton, and counties with low rates of college education almost all voted for Trump. This was true even controlling for income and a lot of other demographic factors. Only authoritarianism, sexism and racism were better predictors of voting for Trump—and those could very well be mediating variables, if education reduces such attitudes.
If indeed it’s true that higher education makes people less sexist, less racist, less authoritarian, and overall better citizens, then it would be worth every penny to provide universal free college.
But it’s worth noting that even countries like Germany and Sweden which ostensibly do that don’t really do that: While college tuition is free for Swedish citizens and Germany provides free college for all students of any nationality, nevertheless the proportion of people in Sweden and Germany with bachelor’s degrees is actually lower than that of the United States. In Sweden the gap largely disappears if you restrict to younger cohorts—but in Germany it’s still there.
Indeed, from where I’m sitting, “universal free college” looks an awful lot like “the lower-middle class pays for the upper-middle class to go to college”. Social class is still a strong predictor of education level in Sweden. Among OECD countries, education seems to be the best at promoting upward mobility in Australia, and average college tuition in Australia is actually higher than average college tuition in the US (yes, even adjusting for currency exchange: Australian dollars are worth only slightly less than US dollars).
What does Australia do? They have a really good student loan system. You have to reach an annual income of about $40,000 per year before you need to make payments at all, and the loans are subsidized to be interest-free. Once you do owe payments, the debt is repaid at a rate proportional to your income—so effectively it’s not a debt at all but an equity stake.
In the US, students have been taking the desperate (and very cyberpunk) route of selling literal equity stakes in their education to Wall Street banks; this is a terrible idea for a hundred reasons. But having the government have something like an equity stake in students makes a lot of sense.
Because of the subsidies and generous repayment plans, the Australian government loses money on their student loan system, but so what? In order to implement universal free college, they would have spent an awful lot more than they are losing now. This way, the losses are specifically on students who got a lot of education but never managed to raise their income high enough—which means the government is actually incentivized to improve the quality of education or job-matching.
The cost of universal free college is considerable: That $1.3 trillion currently owed as student loans would be additional government debt or tax liability instead. Is this utterly unaffordable? No. But it’s not trivial either. We’re talking about roughly $60 billion per year in additional government spending, a bit less than what we currently spend on food stamps. An expenditure like that should have a large public benefit (as food stamps absolutely, definitely do!); I’m not convinced that free college would have such a benefit.
It would benefit me personally enormously: I currently owe over $100,000 in debt (about half from my undergrad and half from my first master’s). But I’m fairly privileged. Once I finally make it through this PhD, I can expect to make something like $100,000 per year until I retire. I’m not sure that benefiting people like me should be a major goal of public policy.
That said, I don’t think universal free college is a terrible policy. Done well, it could be a good thing. But it isn’t the no-brainer that single-payer healthcare is. We can still make sure that students are not overburdened by debt without making college tuition actually free.

You know what? Let’s repeal Obamacare. Here’s my replacement.

pnrj heuristics and biases, public policy , , , , , , , , , , , ,

Feb 18 JDN 2458168

By all reasonable measures, Obamacare has been a success. Healthcare costs are down but coverage rates are up. It reduced both the federal deficit and after-tax income inequality.

But Republicans have hated it the whole time, and in particular the individual mandate provision has always been unpopular. Under the Trump administration, the individual mandate has now been repealed.

By itself, this can only be disastrous. It threatens to undermine all the successes of the entire Obamacare system. Without the individual mandate, covering pre-existing conditions means that people can simply wait to get insurance until they need it—at which point it’s not insurance anymore. The risks stop being shared and end up concentrated on whoever gets sick, then we go back to people going bankrupt because they were unlucky enough to get cancer. The individual mandate was vital to making Obamacare work.

But I do actually understand why the individual mandate is unpopular: Nobody likes being forced into buying anything.

John Roberts ruled that the individual mandate was Constitutional on the grounds that it is economically equivalent to a tax. This is absolutely correct, and I applaud his sound reasoning.

That said, the individual mandate is not in fact psychologically equivalent to a tax.

Psychologically, being forced to specifically buy something or face punishment feels a lot more coercive than simply owing a certain amount of money that the government will use to buy something. Roberts is right; economically, these two things are equivalent. The same real goods get purchased, at the same people’s expense; the accounts balance in the same way. But it feels different.

And it would feel different to me too, if I were required to actually shop for that particular avionic component on that Apache helicopter my taxes paid for, or if I had to write a check for that particular section of Highway 405 that my taxes helped maintain. Yes, I know that I give the government a certain amount of money that they spent on salaries for US military personnel; but I’d find it pretty weird if they required me to actually hand over the money in cash to some specific Marine. (On the other hand, this sort of thing might actually give people a more visceral feel for the benefits of taxes, much as microfinance agencies like to show you the faces of particular people as you give them loans, whether or not those people are actually the ones getting your money.)

There’s another reason it feels different as well: We have framed the individual mandate as a penalty, as a loss. Human beings are loss averse; losing $10 feels about twice as bad as not getting $10. That makes the mandate more unpleasant, hence more unpopular.

What could we do instead? Well, obviously, we could implement a single-payer healthcare system like we already have in Medicare, like they have in Canada and the UK, or like they have in Scandinavia (#ScandinaviaIsBetter). And that’s really what we should do.

But since that doesn’t seem to be on the table right now, here’s my compromise proposal. Okay, yes, let’s repeal Obamacare. No more individual mandate. No fines for not having health insurance.

Here’s what we would do instead: You get a bonus refundable tax credit for having health insurance.

We top off the income tax rate to adjust so that revenue ends up the same.

Say goodbye to the “individual mandate” and welcome the “health care bonus rebate”.

Most of you reading this are economically savvy enough to realize that’s the same thing. If I tax you $100, then refund $100 if you have health insurance, that’s completely equivalent to charging you a fine of $100 if you don’t have health insurance.

But it doesn’t feel the same to most people. A fine feels like a punishment, like a loss. It hurts more than a mere foregone bonus, and it contains an element of disapproval and public shame.

Whereas, we forgo refundable tax credits all the time. You’ve probably forgone dozens of refundable tax credits you could have gotten, either because you didn’t know about them or because you realized they weren’t worth it to you.

Now instead of the government punishing you for such a petty crime as not having health insurance, the government is rewarding you for the responsible civic choice of having health insurance. We have replaced a mean, vindictive government with a friendly, supportive government.

Positive reinforcement is more reliable anyway. (Any child psychologist will tell you that while punishment is largely ineffective and corporal punishment is outright counterproductive, reward systems absolutely do work.) Uptake of health insurance should be at least as good as before, but the policy will be much more popular.

It’s a very simple change to make. It could be done in a single tax bill. Economically, it makes no difference at all. But psychologically—and politically—it could make all the difference in the world.