Red States vs. Blue States: Lower Incomes and Less Growth in Texas

State-Level Real GDP per Capita as Ratio to US, 1997-2012

A.  Introduction

Texas Governor Rick Perry’s speech on March 7 to the annual CPAC (Conservative Political Action Conference) meetings was described by various news web sites as “a barn burner address” that wowed the conservatives, as “a rousing speech that was one of the best-received of the conference so far”, as a “fiery speech that ignites CPAC”, as a speech that brought “the audience to its feet and eliciting loud cheers”, and that “received huge applause throughout his rousing speech”.

Rick Perry has been Governor of Texas for more years than any other governor in Texas history.  He was elected Lieutenant Governor in 1998, and became governor in December 2000 when George W. Bush resigned to become President of the US.  Perry was then elected governor in his own right three times (in 2002, 2006, and 2010), the first Texas governor to be elected to three four-year terms.  He is not now running for a further term, and thus will step down following the election later this year.  It is widely assumed he will once again seek the Republican nomination for the Presidency in 2016, and many interpret his CPAC address as confirming this.  He is well known for the failure of his 2012 campaign seeking the Republican nomination, when he quickly went from front-runner to quitting following a series of goofs.  The best known was in one of the debates with the other Republican contenders, when he said he would close three cabinet level departments in the federal government but could only remember two, in his famous “oops” moment.

Perry’s speech at CPAC set forth what will likely be a major theme of his upcoming presidential campaign:  the contrast between the great performance (in his view) of red states (conservative states that generally vote Republican) and the terrible performance of blue states (liberal states that generally vote Democratic).  As the longest-serving governor of the premier red state of Texas, it is not surprising that Perry would say this.  But what has the performance actually been?

B.  Real GDP per Capita

The graph at the top of this post presents one key measure:  real GDP per capita, presented as a ratio to the US average.  Texas is shown (in red), along with two of the top blue states:  Massachusetts (in blue) and New York (in green).  The figures are calculated from data issued as part of the GDP accounts by the Bureau of Economic Analysis (BEA), which provides such data at the state level GDP on an annual basis (with 2012 the most recent available).  The current series goes back only to 1997, before which the state-level figures were calculated on a different basis, and thus are not directly comparable to the later figures.  But 1997 is also the year before Perry was elected Lieutenant Governor, so it provides a suitable starting point.

As the graph shows, real per capita GDP was substantially higher in Massachusetts and New York than in Texas in all of these years.  Indeed, per capita GDP in Texas actually fell relative to that for the US as a whole from 1998 to 2005 (meaning growth in Texas was slower than in all of the US over this period), after which it started to recover.  The oil boom resulting from the sharp escalation in oil prices from the middle of the last decade was certainly a factor helping Texas in recent years.

And it is not only in terms of real income levels where Texas has lagged.  Texas has also lagged Massachusetts and New York in terms of overall growth since 1997.  Real per capita GDP rose by 30.4% in Massachusetts over 1997 to 2012 and by 28.9% in New York, but only by 21.7% in Texas:

State-Level Growth of GDP per Capita, 1997 - 2012

C.  Personal Income per Capita

GDP per capita is the broadest measure of income generating activities in a state, but not all of GDP goes to households.  Part will go to corporations (and not distributed to households via dividends).  It therefore is also of interest to look at per capita personal income by state, again relative to that for the US  as a whole:

State-Level Personal Income as Ratio to US, 1997-2012

Once again one finds this measure of income to be far higher in the blue states Massachusetts and New York than in the red state of Texas.  But what is different and interesting is that personal income per capita in Texas is seen to be also below personal income per capita for the US as a whole.  A higher share of GDP generated in Texas goes to corporations than is the case for the US as a whole.  GDP per capita in Texas is somewhat above the US average (although not as much above as in Massachusetts or New York), but personal income per capita, once one subtracts the share going to corporations, is lower in Texas than for the US as a whole.

D.  Conclusion, and Re-Nationalizing the Postal Service

Conservatives, including not surprisingly Governor Perry, hold up Texas as the ideal which they want the nation to emulate.  But GDP per capita is lower in Texas than in the blue states of Massachusetts and New York, and has grown by less in Texas than in Massachusetts or New York over at least the last fifteen years.  In addition, personal income per capita is not only lower in Texas than in Massachusetts or New York (and very much lower), it is even lower than the US average.  Corporations account for a disproportionate share of incomes earned in Texas.

Perry closed his speech to CPAC, to cheers and loud rounds of applause, by declaring that the federal government should “Get out of the health care business, get out of the education business”.  Presumably this means Perry wishes to end Medicare, and that federal government assistance to students and schools up to and including universities should also end.  It is not clear, however, he has thought this far ahead on the implications of what he is calling for.  Calling for the end of Medicare, as conservatives have in the past, is not currently a popular position.

But while Perry said the federal government should “get out” of health and education, one area where he appeared to call for expanded federal responsibility was in the running of the postal system.  The proper federal focus, as established in his reading of the constitution, should be on defense, foreign policy, and to “deliver the mail, preferably on time and on Saturdays”.

The constitution does indeed call on the federal government to ensure postal services are made available.  But while this was done through a cabinet level department under the US President for many years, since 1971 the postal service has been run as a government-owned but independent establishment, run like a private corporation with its own board.  It is not fully clear what Perry means by arguing the federal government should return to its original mission vis-a-vis postal services, but the implication appears to a be reversal of its 1971 conversion from a cabinet level department to an independent agency run along private lines.  That would be an odd position for a conservative.  But I suspect he has not really thought this through.

The Obama Bull Market Rally on Its Fifth Anniversary

S&P 500 Index, March 9, 2009, to March 10, 2014

Bull Markets, 1940-2014, updated to March 10, 2014

 
   Bull Market Rallies Since 1940
  Ranked by overall growth in real terms
Start Date End   Date Calendar Days Nominal % Change Real % Change Real Rate of Growth
Dec 4, 1987 Mar 24, 2000 4,494 582% 361% 13%
Jun 13, 1949 Aug 2, 1956 2,607 267% 222% 18%
Aug 12, 1982 Aug 25, 1987 1,839 229% 181% 23%
Mar 9, 2009 Mar 10, 2014 1,827 177% 151% 20%
Apr 28, 1942 May 29, 1946 1,492 158% 124% 22%
Oct 22, 1957 Dec 12, 1961 1,512 86% 76% 15%
Oct 9, 2002 Oct 9, 2007 1,826 101% 75% 12%
Jun 26, 1962 Feb 9, 1966 1,324 80% 69% 16%
May 26, 1970 Jan 11, 1973 961 74% 57% 19%
Oct 6, 1966 Nov 29, 1968 785 48% 37% 16%
Oct 3, 1974 Nov 28, 1980 2,248 126% 34% 5%

Today marks the fifth anniversary of the Obama bull market rally.  The rally began on March 9, 2009, just six weeks after Obama was inaugurated.  A reader of this blog suggested that on this anniversary, an update of previous posts on the strong performance of the stock market during Obama’s tenure (see here and here) might therefore be timely and of interest.

Stock market prices have indeed continued to rise, and as the table above shows, stocks during Obama’s term in office have now posted the fourth highest gains of any stock market rally since 1940.  Market rallies are defined as at least a 25% rise in the S&P 500 Index (in real terms), without a 20% fall.  Equity prices (as measured by the S&P 500) have risen by 177% in nominal terms since March 9, 2009, as of the close today.  The increase in real terms (using the CPI inflation index) has been 151%.  And since this rally is on-going, it could move further up in rank.  In addition, in just twelve more days (assuming the rally does not suddenly collapse) this rally will be the third longest in terms of calendar days of all market rallies since 1940.

It is also interesting to see how steady the upward progression has been, especially since September 2011.  This is shown in the graph at the top of this post.  I do not believe anyone had predicted this.

The rally could also end tomorrow.  All rallies eventually come to an end, and this one will as well.  But the rise in prices already achieved, the fourth largest since 1940, needs to be recognized.

Should Obama be given credit for this historic market rally?  Not fully.  I doubt that equity prices in themselves are a primary objective of what Obama has been trying to achieve.   Rather, the objective has been a stronger economy.  Regulatory as well as policy measures have been taken with the aim of strengthening the system, and this ultimately benefits business (as well as the population) as a whole.  This then helps equity prices.  Unfortunately, and as this blog has discussed in earlier posts, fiscal drag from cuts in government spending has held back the pace of the recovery, and this fiscal drag is continuing.  The economy could be doing better.  Nevertheless, there has been a partial recovery.  But it is not yet complete, nor as rapid as one would have had without the fiscal drag.

But what this strong growth in the stock market does clearly indicate is that the charges by Republican politicians that Obama has been bad for business (indeed a disaster for business many of them have said), has no basis.  If there were any truth to the charge, stock market prices would not be up by 177% in nominal terms (and by 151% in real terms) over the last five years, leading to the fourth biggest rally in stock prices in three-quarters of a century.

The Continued Fall in Government Spending Under Obama

Govt Spending on Goods & Services by Presidential Term, Quarterly

A.  Introduction

Government spending continues to fall under Obama.  As this blog has noted in earlier posts, the fiscal drag from this reduction in demand for the goods and services that unemployed workers could have been producing can fully explain why the recovery from the 2008 has been so slow.  As another blog post noted, if government spending had merely been allowed to grow under Obama at the same pace as it had historically, the economy would by now be back at full employment.  The public debt to GDP ratio would also be lower, as GDP would be higher.  And if government spending had been allowed to grow as it had under Reagan, we would likely have returned to full employment by 2011.

Fiscal drag is therefore important.  Yet it is still not yet commonly recognized that government spending has been falling in real absolute terms for the last several years (and even more so when measured as a share of GDP).  Earlier blog posts have reviewed this.  The trends have unfortunately continued and indeed strengthened over the last year.  Whether this will now change with government spending finally leveling off, and perhaps even start to recover, remains to be seen.  The budget compromise for fiscal years 2014 and 2015 reached by Senator Patty Murray and Congressman Paul Ryan in December, and passed by Congress in January, will reverse part of the impact of the budget sequester.  According to calculations by the Committee for a Responsible Federal Budget (fiscal hawks in favor of budget cuts), the agreement for FY2014 will lead to a small (1.8%) rise in nominal terms in budget authority compared to the FY2013 post-sequester levels.  This would still be flat to negative in real terms, based on inflation of about 2%.  And the FY2014 sum would still represent a 3.7% fall compared to what the FY2013 pre-sequester levels would have been.

Possibly more important would be government spending at the state and local level.  This was cut back as a result of the 2008 collapse and slow recovery, due to lower revenues and the requirement in many states and localities of a balanced budget.  While expenditures were still falling in 2013, revenues have started to grow (due to the positive, though still slow, recovery of GDP) and state and local budgets as a result can now start to recover as well.  But it also remains to be seen if that will happen.

This blog post will update the government spending figures during the Obama term through the fifth year of his administration.  And it will present the figures from a different perspective than before, by tracing the paths during the course of each presidential term (going back to Carter’s) relative to what the spending was at the start of their respective presidencies.

[Note that all the government spending figures used in this post will be in real, inflation-adjusted, terms.]

B.  Government Spending on Consumption and Investment

The graph at the top of this post shows the tracks of real government spending on consumption and investment during each presidential term going back to Carter, as a ratio to what it was at the start of their terms.  The base period is always taken as the last quarter before their inauguration (i.e. in the fourth quarter of the calendar year preceding their January 20 inauguration).  The data is computed from the figures in the standard National Income and Product Accounts (NIPA accounts, also commonly referred to as the GDP accounts) of the Bureau of Economic Analysis (BEA) of the US Department of Commerce, and are seasonally adjusted.  Note that all levels of government are included here – federal, state, and local.  We will examine below spending at the federal level only, as well as spending including transfer payments.

This government spending has fallen by 5 1/2% in real terms by the end of the fifth year (the 20th quarter) of Obama’s term in office.  It rose by 2 1/2% during Obama’s first year, which one might note is similar to the increases seen by that point under Carter, Reagan, and Bush I, and with a significantly greater increase by that point under Bush II.  Spending during Obama’s term has since been falling steadily, leading to the fiscal drag referred to above, to a point where it is now 8% lower in real terms than it was in his first year, or a net 5 1/2% fall from when he took office.

There has been no such fall in government spending under any other presidential term since Carter.  The closest was spending during the Clinton period, but there was still a 3% rise by the end of his fifth year in office.  The increases by the end of the fourth year under Carter and Bush I (single term presidencies) were 8% and 6 1/2% respectively.  And the increases by the end of the fifth year in office were 13% during the term of Bush II, and by a full 21% in real terms under Reagan.  Government spending also continued to grow under Bush II and Reagan, reaching increases of 21% and 33% respectively by the end of their eight years in office.

Yet Reagan and Bush II are seen as small government conservatives, while Obama is deemed by conservatives to be a big spending liberal.  The facts simply do not support this.

C.  Government Spending Including Transfers

Government spending for the direct purchase of goods and services (used for consumption or investment), reviewed above, is a direct component of GDP demand.  When there are substantial unemployed resources (as now), such government spending will have a significant positive impact in spurring economic expansion.  As was discussed in an Econ 101 post on this blog, under such circumstances the fiscal multiplier will be positive and high.  Hence the fiscal drag from the cut-back in government spending during Obama’s term in office has kept the recovery below what it would have been.

But there is also government spending on transfers to households (such as for Social Security, food stamps, or unemployment insurance).  Such transfers are ultimately spent by households for their consumption of goods and services (or will in part be saved, including through the pay-down of debt such as mortgage debt).  It will enter into GDP demand by way of the spending of households for consumption, and the impact on GDP will depend on the behavior of households in deciding what share of those transfers they will spend or save.

Such spending rose more sharply during Obama’s first year in office, as he faced an economy in free fall as he was taking his inaugural oath:

Govt Spending, Total incl Transfers, by Presidential Term, Quarterly

The economy was losing 800,000 jobs per month at that time, pushing the unemployment roles up rapidly and plunging the incomes of many in the population to levels where they qualified for food stamps.  Government spending including transfers therefore rose by almost 9% by the third quarter of 2009, and reached a peak of 9.8% in the third quarter of 2010.  Since then, however, total government spending including transfers has been modestly falling, and is now 7 1/2% above where it was when Obama took office.

[Note all figures are in real terms.  The personal consumption expenditures deflator in the NIPA accounts was used to adjust transfer payments for inflation.]

Only during the Clinton period did one see a modestly smaller increase, of about 6 1/2%.  But there was a 16 1/2% increase in such spending at the same point in the term of Bush II, and an increase of over 22% under Reagan.  It was also higher by the end of their fourth years in office for both Carter and Bush I.

The differences are not small.

D.  Federal Government Spending on Consumption and Investment

What matters to the economy when demand is inadequate and unemployment is high is spending at all levels of government.  Yet while we commonly blame the president in office for the performance of the economy, they at best can only influence the federal budget (and influence it only partially, as Congress decides on the budget).  Hence it may be of interest also to examine the paths of only federal government spending.

Such federal spending on direct consumption and investment at first rose during the Obama term, reaching a peak 8% increase in the third quarter of his second year in office.  It then fell sharply, to a point where it is now 5 1/2% below where it was when Obama took office:

Federal Govt Spending on Goods & Services by Presidential Term, Quarterly

The initial increase in federal spending was in part due to the stimulus package that served to restart the economy (GDP was falling from 2008 through the first half of 2009; it then began to recover).  Note that while federal spending rose by 8% by the third quarter of 2010, overall government spending (including state and local) rose only by 2 1/2% at that point.  State and local government was cutting back, as they were forced to do by the balanced budget requirements of many of them, so federal spending and the stimulus it could provide was partially being offset by their cut-backs.

But after this initial increase in the first two years of the Obama presidency, federal spending has been cut substantially, to the point where it is now 5 1/2% below in real absolute terms where it was when Obama took office.  Federal spending also fell during the Clinton term, by 11% at the same point in his term.  In contrast, federal spending rose sharply under Bush II (by 27% at the same point) and especially under Reagan (by over 31%).

E.  Federal Government Spending Including Transfers

Finally, federal government spending including transfers:

Fed Govt Spending, Total incl Transfers, Quarterly

[Technical Note:  Federal government transfers in the NIPA accounts include transfers to individuals as well as transfers to the states or localities for all purposes, including road construction, for example.  Such intra-government transfers are netted out in the accounts when government as a whole - federal, state, and local - is examined, so that remaining government transfers are then solely transfers to individuals, such as for Social Security.]

Such spending is now lower under Obama than under any of the presidencies examined, including Clinton.  Federal spending including transfers rose to a peak in 2010 of 10% above where it was when Obama took office, but has since declined to just 1% above that level.  It was 4% higher at that point in Clinton’s term, 23% higher at the point in the term of Bush II, and 25 1/2% higher at that point in the term of Reagan.

F.  Conclusion

Republicans in Congress and conservatives generally continue to criticize Obama as being responsible for runaway government spending.  But after an initial modest increase in the first two years of his term, as he sought to stop the economic free fall he inherited on taking office (and succeeded), government spending has come down under any measure one takes.  The resulting fiscal drag has held back the economy, leading to an only slow recovery.  And the fiscal drag during Obama’s term in office is in sharp contrast to the large increases in government spending observed during the terms of George W. Bush and especially Ronald Reagan. Yet they have been viewed as small government conservatives.

Rising Income Inequality: Full Employment Would Have Kept the Bottom 20% From Falling Behind

Real Income Growth of Bottom 20% vs Unemployment Rate, 1968-2012

A.  Introduction

President Obama highlighted in this year’s State of the Union address, as well as in other recent speeches and events, the importance of and concerns about the worsening distribution of income in the US.  As this blog noted in a post two years ago, income distribution has worsened markedly in the US since about 1980, when Reagan was elected.  This deterioration since 1980 is in sharp contrast to the period from the end of World War II until 1980, when incomes of all groups in the US moved upward together.  The paths then diverged sharply after 1980, with large increases in the incomes of the rich (and in particular the extremely rich:  the top 1%, top 0.1%, and especially the top 0.01%), while the real incomes of the bottom 90% were flat or even falling.

An important question, of course, is what to do to achieve more equitable growth, and in particular more rapid growth in the real incomes of those in the lower strata of the population.  Much of the discussion has focussed on measures such as improving our educational and training systems, to prepare workers for better paying jobs.  There is no doubt that such measures are important, and need to be done.  Their impact will, however, only be over the long term – in a generation for measures such as improvements in the educational system.

This blog post will focus on a more immediate action that can be taken:  returning the economy to full employment and keeping it there.  We will find that based on historic patterns, slack in the labor market due to less than full employment has been negatively associated with growth in the real incomes of the bottom 20% of households.  Furthermore, based on statistical regression parameters estimated from the historical data, the greater degree of slack in the US labor market since 1980 compared to that in the thirty years before 1980, largely suffices in itself to account for the relative deterioration of real incomes since 1980 of the bottom 20% of households compared to the top 20%.

This is an important result.  Note that the claim is not that greater slack in the labor market (on average) in the decades since 1980 was the sole cause of the deterioration of relative incomes of the poorest 20% vs. the richest 20%.  There were undoubtedly numerous reasons for this.  But what the finding does indicate is that had the unemployment rate after 1980 matched what it had been in the three decades before 1980, this would have largely sufficed in itself to offset the other factors, and would have led to a rate of growth in the real incomes of the bottom 20% close to what it was for the top 20%.

B.  The Relationship Between Real Income Growth of the Bottom 20% and the Unemployment Rate

The scatter diagram at the top of this post shows the relationship between the annual real income growth of the bottom 20% of households since 1968, and the average rate of unemployment in the same year.  The income data for the bottom 20% comes from the series produced by the US Census Bureau, and measures household cash income before tax and from all cash sources (so it will include Social Security, for example, but not payments under Medicare).  The series starts in 1967 (so 1968 is the first year for which one can compute the growth), and goes to 2012.  The unemployment rate comes from the standard series produced by the US Bureau of Labor Statistics, where the annual rate is the simple average of the monthly rates over the year.

The scatter diagram suggests there is a relationship between slack in the labor market (a higher unemployment rate) and the annual change in the real incomes of the bottom 20% of households, but that it is by no means a tight one.  Other factors matter as well.  But a simple ordinary least squares regression of the annual change in the real incomes of the bottom 20% against the average unemployment rate in that year, does suggest that the unemployment rate is an important and statistically significant factor.

The regression fitted line slopes downward with a coefficient of -0.8228, indicating that on average, a 1% point increase in the unemployment rate in the year will be associated with a 0.8228% point fall in the growth rate that year of the real incomes of the bottom 20%.  The t-statistic on the 0.8228 slope coefficient is 3.3, where any t-statistic greater than about 2.0 is generally seen as statistically significant (with a greater than 95% degree of confidence).  That is, with a greater than 95% degree of confidence, the results suggest that the coefficient is significantly different from zero (where zero would indicate no relationship).

The R-squared of the regression (an indication of correlation) is relatively modest at just 0.1982.  It can vary from zero to one.  This indicates that there is more than just the unemployment rate that accounts for the annual change in the real incomes of the bottom 20%.  But this does not mean that the unemployment rate does not matter.  The t-statistic for it is highly significant.  Rather, the modest R-squared indicates there are other factors as well which have not been identified here.

Similar regressions were run for the changes in the real incomes of the other quintiles of the household income groups.  The estimated coefficients became progressively closer to zero, from -0.82 for the bottom 20%, to -0.62 for the second 20%, to -0.52 for the middle 20%, to -0.47 for the fourth 20%, and then dropping sharply to -0.25 for the top 20%.  This suggests that the link to unemployment as a factor explaining the growth in the real incomes of the group became progressively less important for the richer groups.  And the t-statistic for the coefficient for the top 20% was only 1.0, indicating the estimated coefficient (of -0.25) was statistically not significantly different from zero (and hence that one cannot reject the hypothesis that no relationship is there).  The R-squareds for the regressions similarly fell steadily, from 0.1982 for the bottom 20%, to 0.19 for the second 20%, to 0.16 for the middle 20%, to 0.14 for the fourth 20%, and then dropping sharply to an extremely low 0.02 for the top 20%.

The results suggest that slackness in the labor market, as measured by the unemployment rate, was a significant factor in explaining the annual growth in the real incomes of the bottom 20% (with more unemployment leading to lower or indeed negative growth).  The results also suggest that higher unemployment did not have a statistically significant impact on the growth in real incomes of the top 20%.

C.  The Impact of Less Slack in the Labor Market

From 1950 to 1979, when growth was similar for all income groups (see this earlier blog post), the monthly unemployment rate averaged 5.17% in the US.  But from 1980 to 2012, the monthly rate averaged 6.44%, or 1.27% points higher.  The index of real incomes of the bottom 20% of households (in the US Census data cited above) had risen from 100.0 in 1967 (the earliest year with such data) to an index value of 118.9 in 1980.  But since then it has risen hardly at all, reaching only 119.5 in 2012.  The 1980 to 2012 growth rate was only 0.015% per year (note not 1.5% per year, but rather only one-hundreth of that).

Suppose the labor markets over 1980 to 2012 had been as close to full employment as they had been over the period 1950 to 1979.  Applying the estimated regression coefficient of -0.8228 to the 1.27% point difference in the average unemployment rates, the annual growth rate of the real incomes of the bottom 20% would have been 1.045% points higher (equal to 0.8228 x 1.27% points), and hence would have reached a growth rate of 1.06% a year (equal to 1.045% + 0.015%).  With such a growth rate, the real incomes of the bottom 20% would have reached an index value of 166.5 in 2012  This would have been close to the index value of the real incomes of the top 20% in that year of 169.8 (with 1967 set equal to 100.0).  Relative incomes would have grown similarly since 1967, and inequality (for the bottom 20% compared to the top 20%) would not have grown.

This is an interesting result.  It suggests that the higher unemployment rates we have on average suffered from since 1980 can account both for the stagnation of the real incomes of the bottom 20%, and the increasing inequality when comparing this group to the top 20%.  Note it does not offset all of the increasing inequality seen since Reagan was elected.  The real incomes of the top 1%, top 0.1%, and especially the top 0.01% have grown by far more than the incomes of the top 20%.  But keeping up with the top 20% would still be a major accomplishment.

A return to the economic performance that the US enjoyed in the three decades before Reagan would not be impossible.  To keep the average unemployment rate at the 5.17% rate achieved between 1950 and 1979 would not mean that all recessions need be avoided.  There were a number of recessions in the three decades before 1980.  But the recessions since 1980 (dating from January 1980 at the end of the Carter Administration, from July 1981 at the beginning of Reagan, from July 1990 during Bush I, from March 2001 at the beginning of Bush II and December 2007 at the end of Bush II) have been especially severe.  Avoiding those high peak rates of unemployment would have brought down the average.  Specifically, the average unemployment rate (based on the monthly figures) over 1980 to 2012 would have matched the 1950 to 1979 average if one would have been able to avoid those months since 1980 when the unemployment rate reached 6.4% or more.

D.  Conclusion

There is increasing recognition that the rise in inequality in the decades since 1980, and the stagnation since then in the real incomes of those in the lower strata of the population, cannot go on.  But the solutions commonly proposed, such as better education and training, will take decades to have an impact.

The analysis in this post indicates that the more immediate action of bringing the economy back to full employment and then keeping it close to full employment, would have a major positive impact on the real incomes of those in the bottom 20% of households, and would lead to a more equitable distribution.  The analysis suggests that had the unemployment rate over 1980 to 2012 been at the level achieved over 1950 to 1979, then the rate of income growth of the bottom 20% since 1980 would have been similar to that of the top 20%.  The higher rate of unemployment since 1980, on average, may well explain why growth was broadly equal among income groups in the three decades before 1980, but not in the three decades since.

While there are many factors that underlie income growth and distributional changes, particularly for those at the very top of the income distribution (the top 1% and higher), the results suggest that getting the economy back to full employment should be seen as critically important and valuable.  And there is no mystery in how to do this:  As earlier posts on this blog have noted, the fiscal drag from government cutbacks since 2009 can fully explain why full employment has yet to be achieved in this recovery.  Had government been spending been allowed to grow simply at its historical average rate, the economy would already have returned to full employment by now.  Had government spending been allowed to grow at the higher rate it had under Reagan, the US would likely have been back at full employment in 2011 or early 2012.

Unemployment matters.  Not only is it a direct and personal tragedy for those who have lost a job because of the macro mismanagement of the economy, it is also a waste of resources for the economy.  The evidence reviewed in this post suggests further that the greater degree of slack in the US labor market since 1980 may well explain the stagnation of real incomes of the poorer strata of the population, and the widening degree of inequality of recent decades for those other than in the extreme upper strata.

The Economics of Health Insurance and the Health Care Market: Econ 101

A)  Introduction

The health care market and especially the health care insurance market, need to be understood if we are to come up with a viable health care reform.  Health care services are obtained from, and are paid through, such markets, but these markets have particular characteristics which set them apart from what might be considered an ordinary market.  Because of these characteristics, the health care market does not lead to what economists would call an efficient outcome.  Rather, they lead to limited competition in local markets, high administrative and other costs, where the most efficient providers are not rewarded, and where there is little market pressure to move the system to those who provide the highest value to those in need of health care services.

This Econ 101 post will review these characteristics, structured around an approach based on defining some of the strange terms and language that economists use to describe such markets.  Not all terms will be covered – only those important to an understanding of what is needed in health reform.  And the focus will be on aspects relevant to the US system, not necessarily to systems elsewhere.  The first section below will be on health insurance, and the next section then on the broader market for the provision of health care services and its funding.

Most (although not all) of the discussion will be couched in terms of individuals buying health insurance directly.  It is recognized that most Americans are covered indirectly through their employer (who purchases insurance for them as part of their wage compensation package) or through government programs such as Medicare and Medicaid.  But the primary problems are in the individual health insurance market.  The Obamacare reforms are designed to address some of these, but issues will remain.  And the problems in the individual markets are important not only in themselves, but also as they illustrate issues that arise as well in the markets for insurance through employers or government backed programs.  Hence it is necessary to understand what lies behind the failures of the individual health insurance markets prior to the Obamacare reforms, which have led to the extremely high costs and limited access and coverage that Americans have faced in trying to obtain and pay for health care.

B)  Health Insurance

1)  Insurance:  Insurance is a contractual agreement between two parties:  The insurer providing the insurance, and the insured party (or insuree, or client, or customer, or patient) purchasing the insurance.  The insured party makes a regular payment (often monthly) to the insurer (the payment is called the  premium), and in return the insurer will pay part or all of the costs incurred if some event occurs (a claim, as contractually set out).  The event will be some health related event for health insurance.  The timeline is important (and will be discussed further below):  The premium payments are paid first, and the insurance claims are paid at some later point in time when an insured event occurs.

2)  Risk pool:  An insurance company is a financial institution, with sufficient capital (monitored by regulators) to allow it to pay claims that may come due, and with a high degree of statistical confidence that the capital they have on hand or have access to will indeed suffice.  One does not know for any individual whether they will incur health costs leading to an insurance claim in the next period.  However, with a large enough pool of clients being insured, the insurance company can work out with some degree of statistical confidence what the total claims will be in any given period, and from this what insurance rate (premium rate) they will need to charge to cover such costs.  The group they are insuring is called the risk pool.

3)  Unbiased sample:  To work out what to charge, the insurance company will need to know the characteristics (in terms of expected health claim costs) of those they are insuring.  If they are an unbiased sample taken from the population as a whole, then the health characteristics of the population as a whole (with the characteristics, such as age, of those in the risk pool) can be used to determine the level of claims to expect in any given period, and therefore what to charge.

4)  Biased sample:  A biased sample, in contrast, is one with a heavier share (or weighting) of some sub-group who will have a different likelihood of making a claim.  If that sub-group tends to have higher health care claims than the broader group, then the health care characteristics of that broader group will underestimate the costs that will in fact be incurred by the group being insured.

5)  Asymmetric information:  Markets do not function well when the parties on one side of a transaction have more information on what is being traded than the parties on the other side.  In health insurance, the insured individual will know more about their personal health status than a health insurance company will know.

6)  Adverse selection:   If the insurance is being priced to cover the costs of a risk pool that the insurance company assumes will be an unbiased sample from the general population, and an individual knows he or she has some illness or condition which will likely result in higher insurance claims than for an average person, then that individual will in general be eager to purchase such insurance.  And if an individual knows he or she is relatively more healthy than others, then he or she may decide to forego the purchase of such health insurance despite the risks, as on average their expected costs will be lower.  As a result, the insurer will end up with a risk pool that is biased towards those who will likely have higher insurance claims.  This is adverse selection.  The premium rate that was calculated based on an unbiased sample will not then suffice to cover the costs.

7)  Death spiral:  In a situation where there is asymmetric information and the individual can choose whether or not to purchase health insurance, a premium rate sufficient to cover costs for an unbiased risk pool will lose money for the pool actually enrolled.  The insurance company will respond by raising the premium rates in the next period.  But at the higher premium rates, some individuals who were at the borderline of deciding whether or not to enroll (as they were relatively more healthy than those in the biased risk pool), will decide not to re-enroll.  This will lead to an even more biased risk pool, leading to another round of the insurance company raising premium rates, and to another round of those then at the new borderline deciding not to re-enroll.  There might eventually be a stable equilibrium of relatively high cost enrollees and relatively high premium rates, but it is also possible and indeed likely, depending on the characteristics of the population, that there will be fewer and fewer enrollees in each round until it all collapses.  This is the death spiral.

8)  Free riders:  Individuals may choose not to enroll in a health plan because they believe they will have lower health costs than others.  But it is not that they necessarily believe their health costs will be lower than for others for the rest of their lives, but rather only for a period until they once again have the option of enrolling in a health insurance plan.  If insurance companies are required to enroll anyone who wishes to enroll at any time, then some might try to enroll literally on the day before they are scheduled to go to a hospital for a major operation.  Insurance companies try to address this by limiting open enrollment only to certain periods at some regular time each year, but this will be only partially successful.  Many medical procedures can be planned months ahead (such as whether to have a hip or knee replacement, or whether to try to become pregnant or not).  Free riders are those who try to game the system by paying in premiums for only a short period before they incur what they know will be major medical costs.  And free riders include not only those who seek to postpone coverage just to the next open enrollment period when they know they will incur some major medical expense, but also those who might be relatively young and aim to enroll only decades later when, due to their then advancing age, they know there health care costs will be high.

9)  Biased selection:  It is not only the insured parties who use the asymmetric information they have on their own health needs or who seek to exploit the system as free riders, who can play this game.  Insurance companies have become quite capable at designing health insurance plans to exclude, or at least to discourage, those who could be expected to incur higher health claim costs.  One way has been to exclude those with pre-existing medical conditions.  Those in the population who have some existing medical condition that has required treatment will generally continue to require higher than average treatment.  Insurance companies will deny them coverage if they are legally can.  Until Obamacare, they generally could.

10)  Individual mandate:  These problems of adverse and biased selection will be largely resolved if all in the population are required to secure health insurance coverage.  This is the individual mandate.  Individuals cannot then game the system as free riders, or choose to avoid cover if they expect (based on the information they know about themselves, which the insurers will not know) that their health care costs will likely be relatively low, at least until the next open enrollment period.  And with an individual mandate in place, insurers can then be required to offer coverage at non-discriminatory rates to all, including those with pre-existing conditions.  The death spiral would not then take hold.

11)  Biased selection II:  But issues may still remain.  The individual mandate requirement under Obamacare is not terribly strong, with only modest penalties for those who choose not to obtain insurance coverage (and with campaigns also underway by conservative groups to try to stop or at least discourage Americans from enrolling in any health care plan).  Insurance companies can play more subtle tricks as well.  Even though they will not now be able to block enrollment by someone with a pre-existing condition, they can design plans that will be unappealing to those who might have certain types of medical expenses, that might signal conditions associated with overall higher than average medical expenses.  Their hope is that such individuals will then choose to enroll in a health plan offered by some other insurer.  Or they can design plans that might be especially appealing to those who are more healthy.  The classic example of this is to include the price of gym membership in the insurance plan.  The premium rates will be higher than otherwise to cover the cost of gym membership, and those not interested in gym membership will then not find this to be an advantageous plan.  But it would be attractive to those who are already paying for a gym, or who wish to enroll in one.  The advantage to the health insurer is not so much that their enrollees will now start to go to the gym more often (although that will help), but more that those in the population who do use a gym are generally more healthy than the overall population for many reasons, including diet and other activities.

12)  Time inconsistency:  A further issue in health insurance is the arrow of time.  One enrolls in some health insurance plan, pays the premium for a period of time, and at some later point might have a health insurance claim.  But health insurance plans can be extremely complex (often deliberately so), with details buried in the fine print that may give the insurer an excuse to deny a claim that the patient had thought would be insured.  For a more normal product the customer would then absorb the loss and choose to switch to a different vendor, after receiving what they see as bad service or a broken promise.  But this can be difficult in health insurance.  First, the loss incurred on the medical care obtained could well be huge and not easy to absorb.  A study published in 2009 by Harvard Medical School researchers found that 62% of all personal bankruptcies filed in 2007 in the US were caused by medical problems.  Furthermore, these were not mostly bankruptcies of individuals without health insurance.  The Harvard researchers found that 78% of those filing for bankruptcy had medical insurance at the start of their illness.

But a second reason (and until the Obamacare reforms the more important one), is that a person in need for medical care cannot at that point choose to switch to a different health insurance provider.  At precisely that point when he realizes his existing health insurer is not performing, the person needs major medical care and hence has a pre-existing condition, and no new insurer will willingly take them on.  While denial of cover due to pre-existing conditions will now not be allowed under the Obamacare reforms, the individual will still not be able to switch insurance plans in the middle of the year, but only during an open enrollment period.  Depending on the treatment needed and its urgency, the patient will not be able to switch to another insurer precisely when he or she needs insurance the most.

The Obamacare reforms, with effective access for those with pre-existing conditions as well as minimum standards on other aspects of health insurance plans (such as no annual or lifetime limits, and requirements on what will be covered), will be a major step to resolving the time inconsistency problem.  But it will still not be fully resolved.

13)  Moral hazard:  Another commonly cited issue, in particular in conservative circles, is the concern that when patients do not face the full cost of the health care treatment (as insurance covers a part of the cost, and perhaps almost all of it), they will then “over-consume” health care.  They will obtain treatments that they do not really need, or choose more expensive treatments than necessary.  This is actually an issue that exists in principle for any type of insurance, whether for health or something else.  It is called “moral hazard”.

Whether this is an important issue in practice for health care is not so clear.  First, few of us want to go into surgery or be subject to some other major medical procedure unless it is really necessary, even if free.  Second, it is the doctor and not the patient who will normally decide and recommend whether some medical procedure is warranted.  And third, the recommended response by conservatives to the moral hazard issue is high deductible health insurance plans, as was discussed in a previous posting on this blog.  They argue that patients will then face the full cost of care when within the deductible.  But a high deductible plan is simply not relevant for addressing moral hazard for those who need a major medical procedure or treatment.  At that point, the deductible is no longer relevant as it would have already been paid.  Incentives and expenses will be the same.

Rather, high deductible plans will, at best, lead to lower expenditures for initial doctor visits to determine if there is a problem, as the consumer will face 100% of those costs (when still within the deductible for the year).  But as noted in the blog cited above, such expenditures are not where our medical costs primarily lie.  The bottom 50% of the population only accounts for 3% of all medical expenditures, so even cutting these in half, say, would have an insignificant impact on overall costs.  Indeed it might well lead to higher costs in the end, as visits to doctors are postponed and what would have been minor problems develop into something major.

14)  Race to the bottom:  Most working age Americans obtain their health insurance coverage through either their employer or the employer of their spouse (or parent, if a child).  Most employers, and especially employers with 50 or more employees, offer health insurance coverage to their employees as part of their wage compensation package.  Due to substantial tax advantages (as health insurance payments are not subject to income tax, while regular wages are), it is a good deal less expensive for the employer to offer health insurance coverage instead of not doing so and then paying the worker higher wages sufficient to allow them then to purchase on their own equivalent insurance.  Those higher wages would be subject to income tax.

This system can provide health insurance at reasonable cost for firms with a high number of employees (say a few hundred employees or more).  Such a large number of workers will provide a relatively unbiased sample of workers for the risk pool.  If all of the workers and their families (both young and old, sick and not so sick) are enrolled, then a death spiral will not take hold.  There would be no problem of free riders.  While there are coverage issues for those not employed and for those working in small firms (too small to provide a reasonably diversified risk pool), the system worked well enough in the 1950s and 1960s for those employed at larger firms.

However, issues developed as more and more spouses entered into the work force.  If both spouses worked for employers offering health insurance coverage, then the spouses could choose from which firm they would obtain their health insurance.  Family plans are normally cheaper than two individual plans.  The spouses would of course normally choose that plan which was most advantageous to them.  That would be the plan of the employer offering the best benefits.

The result was that those employers offering the plans with the best benefits, which would also be the more expensive plans, would see families choose them rather than a less generous plan offered by the employer of the other spouse.  The costs of the firms offering the more generous plans would then rise, as spouses switched to the better plans.  The incentive, then, was for employers to offer less and less generous plans, in the hope that employees would choose to enroll in the health plan of the employer of the other spouse.  This was a race to the bottom.  The consequence is that employer sponsored health insurance plans have become less and less adequate in recent decades, compared to what they covered before.

The Obamacare reforms will address this partially by setting minimum standards for what a health insurance plan must cover, for it to be considered an acceptable health insurance plan.  This will set a floor.  However, the standards are not high, and there will remain pressures on firms to go down to that floor.

C.  The Health Care Market

1)  Bilateral Oligopoly:  There are tens of thousands of health care providers in the US, and dozens of significant insurers.  However, medical care markets are overwhelmingly local, so what matters is not the number of providers at the national level but rather at the local level.  And medical care providers are of course divided into specialties.  There may also only be a few hospitals which one can effectively reach, and possibly only one or two.  As a result, when treatment in needed for some medical condition, one may effectively have only limited choices.

Similarly, there may be only a few insurers who offer insurance policies in any locality.  This is in part due to regulatory reasons, as insurance companies are regulated in the US at the state level.  As noted above, regulation of insurance is important to ensure that the companies maintain adequate capital to allow them to pay claims with a high degree of statistical confidence.  But even without regulation at the state level, insurance companies will pick and choose which localities to focus their activities in, depending on their knowledge of that local market and the activities of their competitors.

The primary model of health insurance coverage now in the US is for the insurance company to establish a network of “preferred providers” of health care services in each local market, with strong financial incentives for their insurance customers to choose services from members of that network.  The insurance company will negotiate payment rates with each member of that preferred provider network for the services they provide, with these payment rates well below the list prices (or “chargemaster” rates, when referring to hospitals) of those providers.  Indeed, as noted in an earlier blog in this series on health care, the rate negotiated with the preferred provider can be sometimes be ten times (or even more) lower than the rate that same provider would charge for someone with a different insurer or with no insurer.  There are therefore strong incentives to seek out services from members of the preferred provider network of your insurer.

(Health Maintenance Organizations, or HMOs, are also a common model of health care coverage in the US.  There is an even more restrictive network of health care providers in an HMO, and the HMO will generally not cover any of the costs incurred when an out-of-network provider is used.  In contrast, in a preferred provider network the health insurance will still cover some portion of the costs incurred when on out-of-network provider is used, but what is covered is much less than for an in-network provider.  For the discussion below the distinction is not important, so for brevity it will be couched in terms of preferred provider networks.)

The rates paid for health care treatments are therefore largely determined in the negotiations between health insurers and the local health care providers in their preferred provider network.  If there is only one insurer active in some region, that insurer will then have a good deal of leverage over providers to force them to accept low compensation rates.  If the health care provider does not accept those rates, they will see few patients as the patients will instead seek out those providers who joined the preferred provider network at the compensation rate agreed to with the insurance company.

At the other extreme, if there is effectively only one health care provider in some locality for some medical specialty or service (say one large hospital), but a number of insurers, then those medical providers will have a great deal of leverage over the insurers to force them to accept the compensation rates they demand.  The insurance company cannot offer health care coverage if the local hospitals or medical specialists refuse to work with them.  The insurance company must then agree to compensate those health care providers at the rates they demand.

The result has been an arms race:  Both health insurers on one side, and health care providers on the other side, will seek to merge and consolidate with others offering similar services in each local market across the US, in order to strengthen their bargaining position in these key negotiations.  And that is what one has seen over the last two decades.  Health insurers have merged at the national level or have bought up what were previously local or regional insurers, while doctor groups and especially hospitals have merged into chains.

This has led to what are now highly concentrated local markets.  The American Medical Association (representing doctors) has been publishing a report each year for the last 12 years on concentration in health insurers in US states as well as in each of the metropolitan statistical areas of the US (metropolitan areas as defined by the US Bureau of the Census).  The 2013 edition of the report (released in November 2013, and based on data for 2011) reported that health insurance markets would be deemed “highly concentrated” (based on the 2010 guidelines issued by the US Department of Justice and Federal Trade Commission) in 71% of the 388 metropolitan statistical areas of the US.  They also noted that just two insurers accounted for over 50% (together) of the health insurance market in 45 of the 50 US states, and that just one insurer accounted for over 50% of the market in 15 states.  The 2012 edition of the report noted that at least one insurer accounted for over 30% alone of the health insurance market in 89% of US metropolitan areas, and that just one insurer accounted for over 50% of the market in 38% of the US metropolitan areas.  And concentration has increased further since these reports were prepared.

Health insurers have not surprisingly strongly criticized the AMA reports, and have responded with a commissioned report of their own, criticizing health care providers for high and increasing concentration among hospitals.  This report concluded that hospital ownership is “highly concentrated” (by the guidelines of the US Department of Justice and Federal Trade Commission) in 80% of the US metropolitan statistical areas, and is “moderately concentrated” in a further 13% metro areas.  And there was only one hospital in 11% of the metro areas.

So who is right in this debate?  Actually, both are.  US health insurance markets are highly concentrated by local area, as are the local markets for hospital services.  And each side is racing to consolidate further.  Monopolies are still rare in the local markets, but with only a few players on each side, the markets have developed into what economists term “bilateral oligopolies”, where a small number of suppliers (health care providers) must sell their services to a small number of buyers (health care insurers, acting on behalf of their insured clients).

Without further information, one cannot predict whether health insurers or health care providers will be more profitable in a situation of bilateral oligopoly.  It will depend on their relative strength in each of the local markets, and this will vary from one market to the next depending on the local conditions.  However, the party that will face high prices regardless will be the ultimate consumers.  Suppose one is in a market where there are only a few local health care providers but many insurers.  The few health care providers will have a great deal of negotiating leverage with the insurers, and can demand high prices for their services.  The insurers, all of whom face these high prices, will then have to pass along these high prices to their insured customers in high premium rates.

Alternatively, suppose one is in a market where there are many health care providers (note this would be for each medical specialty as well as for hospital services), but only a few insurers (and maybe even effectively only one).  The health insurers would then have a good deal of leverage to drive down the doctor and hospital rates.  However, since there will then not be much (if any) competition among the health insurers (as there will be only a few and maybe effectively only one), there will be little or no competitive pressure to pass along these low prices to their insured customers.  The insured customers will again face high prices.

There have therefore been strong incentives for the US health care market to evolve over recent decades into a system of local bilateral oligopolies, with health care providers on one side and health insurers on the other.  There has been strong pressure on each to consolidate, and both have done so in an “arms race” like fashion.  The result is now highly concentrated local markets, where your profitability depends on your ability to negotiate favorable prices.  But whether it is the health insurers or the health care providers who win in these negotiations (and this will vary by locality), the consumer loses and ends up paying high prices.  This is the major reason for the extremely high US health care costs, where the high prices in the US (compared to other countries) was discussed in earlier posts in this series on health care (see here and here).

2)  Competing on Risk Pool Selection, and Other Sources of High Insurance Costs:  In addition to high health care costs as a consequence of the largely unregulated bilateral oligopolies in most local markets in the US, health costs are high also due to the high administrative costs of private health insurers.  Administrative costs are high since health insurers compete primarily on their ability to assemble networks of preferred providers of health care services in each locality (with prices negotiated with each provider for each possible service), as discussed immediately above, but also based on their ability to assemble a pool of insurees which excludes those who are of higher risk.  The open individual health insurance exchanges will limit this under the Obamacare reforms (or at least shift it to more subtle games in how health insurance plans are structured, as discussed above), but at least until now, the focus on risk pool selection has led to high administrative expenses, since individual applicants had to be vetted.

Health insurance costs are high also because of the high salaries and other compensation paid to the CEOs and other senior management of the insurance companies, as documented in a previous post in this series on health care, as well as their high profitability.  The result is administrative cost margins (which includes the net profits of the insurers in the data as assembled) of the private health insurers.  As was discussed in the blog post just cited, in 2011 the administrative cost margin (including profits) of private health insurance came to 14.0% of the cost of benefits paid.  The admin costs of private insurance companies were even higher for the programs they managed on behalf of government (such as the Medicare Advantage program of Medicare).  Those costs came to 18.6% of benefits paid.

Since the government does not incur the high costs that private health insurers do as a consequence of seeking to bias the risk pool to those of lower risk and other such actions, nor pay out profits or high salaries to CEOs and other senior managers, the administrative cost margin for direct government administered health insurance programs are far below that of private insurers.  As discussed in the blog post cited above, administrative costs for the Medicare programs the government administers directly was only 2.1% of benefits in 2011, far below the costs private insurers incur.

Total private administrative costs (including profits) of private health insurers came to $157.6 billion in 2011, based on the recently released new estimates of the National Health Expenditures data set of the Center for Medicare and Medicaid Services (CMS).  Of this, $109.9 billion was spent on the administrative costs (including profits) of the private health insurers for their privately provided health insurance plans, and $47.7 billion was spent on the administrative costs (including profits) of the private health insurers for the government health insurance plans (primarily Medicare and Medicaid, but also others) that the private health insurers administer on behalf of the government.

If the costs of administering health insurance plans were at the low cost Medicare incurs (of 2.1%) rather than the 14.0% and 18.6% that the private insurers incur, the nation would have saved $135.7 billion in 2011.  This is proportionately a huge savings in administrative costs, of 86%.  Still, a savings of $135.7 billion should also be compared to the roughly $900 billion in savings one would have needed in 2011 for US health care costs in that year (out of total health care costs of $2.7 trillion in 2011) to fall, as a share of GDP, to what the second most expensive OECD country spends on health care (as discussed in an earlier blog post; note that total health care costs of $3.0 trillion are expected in 2014, so a one-third reduction would now be $1.0 trillion).  The $135.7 billion in savings in 2011 would have been significant, but still only 15% of the overall savings needed.

D.  Conclusion

US health care costs are high and excessive, compared to what any other country in the world spends on health care.  These high costs are a consequence of the structure of the health care market in the US, with its focus on private health insurance plans.  As discussed above, there are a number of reasons (including asymmetric information, adverse selection, free riders, and biased selection, as well as non-competitive local markets of bilateral oligopolies), for why private health insurance markets will act quite differently than what economists would call a “normal” market.  They will not be efficient and low-cost.  Rather, a reliance on a private health insurance focussed system has led to inefficiency and high costs, but also high profits for the insurers.

There therefore needs to be a fundamental change in the structure of these health care markets, and the incentives for how they operate, if one is to reduce US health care costs to what other countries in the world have been able to achieve.  Future blog posts in this series on health reform will discuss what such a system might be.