US Health Care: Profits Over People

The US health care system produces healthy profits while leaving growing numbers of people without access to affordable, quality health care.

The US is one of the only advanced capitalist countries without a system of universal health coverage.  Tens of millions are uninsured, and many millions more pay for insurance that is either too limited in its coverage or too expensive to use.  What we need, and could implement if political realities change, is a “Medicare for all,” single-payer system of national health insurance.

As the organization Physicians for a National Health Program explains:

Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.

The program would be funded by the savings obtained from replacing today’s inefficient, profit-oriented, multiple insurance payers with a single streamlined, nonprofit, public payer, and by modest new taxes based on ability to pay. Premiums would disappear; 95 percent of all households would save money. Patients would no longer face financial barriers to care such as co-pays and deductibles, and would regain free choice of doctor and hospital. Doctors would regain autonomy over patient care.

Bad health care outcomes

Our health care system fails to deliver affordable, accessible, quality health care. Even a writer for Forbes magazine, a publication that proclaims itself to be a “capitalist tool,” acknowledges this:

It’s fairly well accepted that the U.S. is the most expensive healthcare system in the world, but many continue to falsely assume that we pay more for healthcare because we get better health (or better health outcomes). The evidence, however, clearly doesn’t support that view.

For example, take a look at the exhibit below, which comes from a 2014 Commonwealth Fund study on health care in the eleven listed nations.

As you can see, the US ranked last in the overall ranking, thanks to its relative poor performance in the category of access and last place standing in the categories of efficiency, equity, and healthy lives.

The Forbes article summarizes the reasons given by the Commonwealth Fund for the poor US performance:

Access: Not surprisingly — given the absence of universal coverage — people in the U.S. go without needed health care because of cost more often than people do in the other countries.

Efficiency: On indicators of efficiency, the U.S. ranks last among the 11 countries, with the U.K. and Sweden ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing.

Equity: The U.S. ranks a clear last on measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. Overall, France, Sweden, and Switzerland rank highest on healthy lives.

What accounts for this outlier status in health care?  According to the report:

The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes.

A Guardian article on the US health care system provides further confirmation of US outlier status:

Broadly speaking, the World Health Organization (WHO) defines universal health coverage as a system where everyone has access to quality health services and is protected against financial risk incurred while accessing care. . . . Among the 35 OECD member countries, 32 have now introduced universal healthcare legislation that resembles the WHO criteria.

And yet we pay the most

The graphic below, from the Guardian article, provides a stark picture of just how much we pay to get our poor health care outcomes.

Significantly, it was in the early 1980s that our per capita health care spending began to soar compared with all other developed capitalist countries, a period marked by the government’s growing embrace of pro-market, neoliberal policies designed to promote corporate profitability. And as the graphic also makes clear, we have seen limited gains in life expectancy despite dramatically outspending the other listed developed countries.

So what gives?

So, you might ask, where is all the money we spend on health care going if not to improve our health care outcomes?  Well, the answer is simple: higher profits for the health care industry.

The headline of a New York Times article says it all: “Gripes About Obamacare Aside, Health Insurers Are in a Profit Spiral.”  As a result:

Since March 2010, when the Affordable Care Act was signed into law, the [stock prices of] managed care companies within the Standard & Poor’s 500-stock index — UnitedHealth, Aetna, Anthem, Cigna, Humana and Centene — have risen far more than the overall stock index. This is no small matter: The stock market soared during that period.

The numbers are astonishing. The Standard & Poor’s stock index returned 135.6 percent in those seven years through Thursday, a performance that we may not see again in our lifetimes. But the managed care stocks, as a whole, have gained nearly 300 percent including dividends, according to calculations by Bespoke Investment Group.

These and other leading health care corporations oppose a Medicare for all system because its adoption would put an end to their massive profits.  And these companies have many allies in the rest of the corporate community because any policy that strengthens the principle of putting people before profits is a threat to them all.

Hopefully, however, the importance of health care and the obviously poor performance of our health care system as a health care system (as opposed to a profit center) will motivate people to keep pressing for real change.  And, who knows, a health care victory might also encourage a broader public discussion about how best to organize the rest of our economy.

Unions Fight Inequality

The decline in unionization is one of the most important factors promoting the concentration of income at the upper end of the income distribution.  The statement may not surprise you, but the fact that this was the conclusion of an IMF study of the causes of inequality might.

Here is how the authors of Inequality and Labor Market Institutions summarize their main findings:

The results indicate that the rise of inequality in the advanced economies included in this study has been driven by the upper part of the income distribution, owing largely to the increase in income shares of top 10 percent earners. We find evidence that the decline in union density—the fraction of union members in the workforce—is strongly associated with the rise of top income shares. . . . Our empirical results also indicate that unions can affect income redistribution through their influence on public policy. We further find that reductions in the minimum wage relative to the median wage are related to significant increases in inequality.

Of course, the authors of the study were quick to add: “These findings, however, should not be seen as a blanket recommendation for strengthening these labor market institutions.”

While we should never count on the IMF to promote progressive policies, the findings of the study do highlight the importance of a strong trade union movement if we want to build an economy that works for the great majority of working people.  The fact that unionization has been in decline in the great majority of the twenty advanced capitalist countries studied by the IMF researchers strongly suggests that elites know exactly what they want.

Trends in inequality and labor market institutions

Inequality has been on the rise in almost all advanced capitalist economies, with attention increasingly focused on the growing concentration of income at the top of the distribution.  Common explanations for this trend include globalization, skill-based technological change, financial deregulation, and the decline in top marginal personal tax rates.  In their study for the IMF, Florence Jaumotte and Carolina Osorio Buitron investigate whether labor market institutions, in particular the degree of unionization and relative value of minimum wage, might also be responsible.

The authors examine inequality trends in twenty advanced capitalist countries over the period 1980 to 2010 using two main measures of inequality, the income share of the top 10 percent earners and the Gini coefficient (which ranges from 0 to 1 with higher numbers showing greater inequality).  The former is most useful for capturing changes at the top of the income distribution.  The latter, because of data limitations, is better at showing changes at the middle and bottom of the income distribution.  They therefore use Gini coefficients of gross and net income to test whether the strength of labor market institutions affects redistribution.

Figure 2 below illustrates the growth in inequality in the sample of advanced capitalist economies, and the importance of income concentration at the top of the income distribution.  As the authors explain:

Gross earnings differentials between the 9th and 5th deciles of the distribution have increased over four times as much as the differential between the 5th and 1st deciles. Moreover, data from the Luxembourg Income Survey on net income shares indicate that income shares of the top 10 percent earners have increased at the expense of all other income groups.

Figure 3 looks at trends in union density and relative minimum wage values, the authors’ proxies for the strength of labor market institutions.  As we can see, the degree of unionization has fallen steadily over the period, while the decline in the relative value of the minimum wage has been far more modest.  However, national experiences differ greatly.  In the case of union density, some countries actually registered an increase while in others density declined by almost 50 percent. Interestingly, the authors find no evidence of a relationship between changes in union density and changes in the minimum wage.

Union strength reduces inequality

The authors begin their test of the relationship between labor market institutions and inequality by running simple correlations between the two.  They find

a strong negative relation between the top 10 percent income share and union density, both within and across countries. The Gini of gross income is also negatively related with union density, but the relationship is somewhat weaker and mostly present within countries. The correlation coefficients for the minimum wage and the various inequality measures are more mixed. A similar exercise suggests a positive association between union density and redistribution: while the correlation between union density and the Gini coefficient of gross income is weak, its correlation with the Gini of net income is clearly negative.

While these correlation results suggest that greater union density helps workers claw back income from those at the top and improve the overall income distribution, simple correlations are far from conclusive because they do not hold other factors that might influence the variables constant.

Therefore, the authors use sophisticated econometric methods to try and isolate the importance of labor market institutions on inequality.  Among the factors they control for are:

technology (the share of information and communications technology capital in the total capital stock); globalization (the share of China in world exports interacted with the country’s lagged level of income per capita); financial reform (the index constructed by Abiad, Detragiache, and Tressel, 2008, which varies with changes in credit controls and reserve requirements, interest rate controls, entry barriers, state ownership, securities market policies, banking regulations, and capital account restrictions); the top marginal personal income tax rate; and a banking crisis dummy variable.

The authors find, consistent with the literature, that technology, globalization, financial liberalization, and tax reductions all increase inequality, with the latter two variables positively associated with an increase in top income shares.  But they also find a significant negative relationship between union strength and inequality and income concentration:

Our benchmark estimates of gross income inequality indicate that the weakening of unions is related to increases in the top 10 percent income share. A 10 percentage point decline in union density is associated with a 5 percent increase in the top 10 percent income share. The relation between union density and the Gini of gross income is also negative and significant.

At the other end of the income distribution, the minimum wage is closely associated with the Gini coefficient of gross income but not with the top income share. A 10 percentage point decline in the ratio of the minimum wage to the median wage is related to a 5 percent increase in the Gini coefficient of gross income.

The authors then test the robustness of their results by adding additional labor market, economic, and social variables, but with little change in outcome.  Their strong conclusion remains: an increase in union density reduces the share of income going to the top 10 percent and improves the overall distribution of income.

Magnitude of the effects

The authors illustrate the relative importance union density and the minimum wage to the growth in inequality in Figure 7, below. “The height of each bar measures the contribution of a variable to the rise in inequality over the period 1980–2010—calculated as the product of the change in the variable over the period and its coefficient—averaged across countries.”

More specifically, as the authors explain:

On average, the decline in union density explains about 40 percent of the 5 percentage point increase in the top 10 percent income share (top panel). . . . By contrast, the decline in unionization contributes more modestly to the rise of the gross income Gini, reflecting the somewhat weaker relation between these variables. However, about half of the increase in the Gini of net income is explained by the decline in union density, evidencing the additional and statistically significant relation between this institution and redistribution. The decline in union density was a widespread phenomenon which, as our estimation results suggest, could be an important contributing factor to the rise in top income shares (middle panel).

Contributions of changes in the minimum wage to inequality appear close to zero on average. However, averaging its contribution across countries hides the important role the minimum wage has played in driving inequality in some countries, as its evolution has been highly heterogenous. Bottom panel in Figure 7 shows the country-specific impact of changes in the minimum wage on the Gini of gross income. In countries where the minimum wage declined the most, it accounts for about 2 percentage points of the increase in the Gini coefficient. Conversely, where the minimum wage rose substantially, it appears to have contributed to reduce the Gini coefficient by 2 percentage points. Overall, these illustrative calculations suggest that changes in labor market institutions are key drivers of the evolution of inequality, alongside other determinants.

Next steps: Movement building

Living conditions have deteriorated for majorities in most advanced capitalist countries.  The rise in inequality, driven by the ever-increasing concentration of income at the top of the distribution, is one major reason.  The IMF has laid out a clear program of action to improve things: strengthen unions and boost minimum wages.  Of course, our fight against inequality would be greatly enhanced if we also intensified our efforts to stop the advance of capitalist globalization, reverse the financialization of economic activity, and raise taxes on the wealthy.

I am not sure that we needed IMF researchers to clarify our tasks, but thanks anyway IMF!

Race and Ethnicity Discrimination in the US Labor Market

The US labor market, much like US society, is marked by discrimination.  The following charts, taken from two Economic Policy Institute blog posts, highlight some of the labor market consequences of racial and ethnic discrimination.

The following chart makes clear that Blacks suffer far higher rates of unemployment than do Whites, at all levels of educational achievement.  In fact, the Black unemployment rate for those with a BA and higher was identical to the White unemployment rate for those with some college but no degree, both at 3.7 percent in June 2017.  The chart also shows the general rise in unemployment since 2000.

The next chart illustrates how unemployment and underemployment rates differ by age and race/ethnicity.    The underemployment rate, officially known as the U-6 rate by the Bureau of Labor Statistics, “includes not only unemployed workers but also those who are working part time because they can’t find full-time work (i.e., part time for economic reasons) and those who are marginally attached to the labor force.”

As we can see, while all young workers suffer high levels of unemployment and underemployment, the rates for Black youth (more than 1 in 4 underemployed) and Hispanic youth (approximately 1 in 5 underemployed) are significantly higher than for White youth.

These racial/ethnic differences mean that our general push for more and better jobs must be accompanied by policies designed to overcome the discriminatory and segmented nature of the US labor market.

 

The Sorry State Of The US Economy

Although reluctant to say it, a recent IMF report on the state of US economy makes clear that US policy makers have failed to protect majority living conditions.

When a country joins the IMF, it agrees to have its economic and financial policies evaluated, in most cases annually, by an IMF team of economists.  As the IMF explains:

The IMF’s regular monitoring of economies and associated provision of policy advice is intended to identify weaknesses that are causing or could lead to financial or economic instability. . . The consultations are known as “Article IV consultations” because they are required by Article IV of the IMF’s Articles of Agreement.

The IMF recently concluded and published a summary of its Article IV consultations with the United States.  While the IMF generally pulls no punches in criticizing the policies of most member governments if it determines that they threaten to slow capitalist globalization dynamics, it tends to tap dance around disagreements when it comes to the policies of its more powerful member countries, especially the United States.  As Adam Tooze points out in his commentary on the IMF statement:

With respect to the US, the stakes are particularly high. The US has the largest vote on the IMF’s board and Congress controls the largest part of the IMF’s budget.

Not surprisingly, then, the IMF went the extra mile in finding nice ways of talking about the state of the US economy and even more importantly the wisdom of Trump administration policies. Even so, US economic challenges could not be completely hidden.  For example, after noting that the “The U.S. economy is in its third longest expansion since 1850,” the IMF goes on to comment:

However, the outlook is clouded by important medium-term imbalances. The U.S. economic model is not working as well as it could in generating broadly shared income growth. It is burdened by a rising public debt. The U.S. dollar is moderately overvalued (by around 10-20 percent). The external position is moderately weaker than implied by medium term fundamentals and desirable policies. The current account deficit is expected to be around 3 percent of GDP over the medium-term and the net international investment position has deteriorated markedly in the past several years. Most critically, relative to historical performance, post-crisis growth has been too low and too unequal.

To address these shortcomings, the administration intends a wide-ranging overhaul of policies, although a fully articulated policy plan has yet to emerge. The administration’s budget proposes to reduce the fiscal deficit and debt, to reprioritize public spending, and to revamp the tax system. However, during the Article IV consultation it became evident that many details about these plans are still undecided. Given these policy uncertainties, the IMF’s macroeconomic forecast uses a baseline assumption of unchanged policies. Specifically, it neither builds in the effect of tax reform nor the expenditure reductions proposed in the administration’s budget. Under this forecast, growth is expected to rise modestly above 2 percent this year and next, driven by continued solid consumption growth and a cyclical rebound in private investment. Growth is forecast to subsequently converge to the underlying potential growth rate of 1.8 percent.

However, IMF concerns over an uncertain US economic outlook and an unclear Trump administration policy plan pale in importance compared to the decline in US living standards illustrated in the following chart that was also in the report.

In broad brush, the US ranking on most of the selected living standards indicators has declined, which means that the US economy is losing ground relative to the other OECD countries in the sample.  But what really cries out for notice is how low the US is on such key indicators as: life expectancy at birth, overall mortality rate, health coverage, poverty rate, and secondary school graduation.  On these indicators, the US is approaching the bottom of the group of 24.  And of course, Trump administration policies, which aim to reduce spending on Medicare and Medicaid, gut worker-protecting health and safety and labor laws, slash taxes on corporations and the wealthy, and weaken unions will only intensify downward trends.

The IMF could easily have pointed out that, because of competitiveness pressures, US policies harm the well-being of workers in other countries as well as in the US, and pressed the US government to reverse course.  But majority living standards are not the most important thing to the IMF or the US government, and that is not how consultations work.

If we want improved living conditions we are going to have to fight for them.  Perhaps greater awareness of just how bad things are in the United States will help speed the effort.