Beat the Press

Beat the press por Dean Baker

Beat the Press is Dean Baker's commentary on economic reporting. He is a Senior Economist at the Center for Economic and Policy Research (CEPR). To never miss a post, subscribe to a weekly email roundup of Beat the Press. Please also consider supporting the blog on Patreon.

Should We Have Billionaires?

(This post originally appeared on my Patreon page.) The Democratic presidential campaign has taken a strange twist in recent days, with candidates being asked whether we should have billionaires. While there may be some grand philosophical questions at stake here, I will stick to more mundane economic ones. The real question is; how do you want the economy to work? The basic story is that if we have a market economy, some people can get very rich. If we buy the right-wing story, the super-rich got their money from their great contribution to society. If we look at it with clearer eyes, the super-rich got their money because we structured the economy in a way that allowed them to get super-rich. This is a point which seems very obvious, but for some reason is largely ignored in policy debates. Most typically these debates take the market distribution of income as a given, and then ask the extent to which we might want to redistribute to have less inequality. The right of course wants little if any redistribution, while people on the center and left argue for varying degrees of distribution. But it is completely absurd to treat the market distribution of income as given. The market is incredibly flexible and it can literally be structured in an infinite number of different ways. (Yeah, I know I make this point all the time, but I can’t help repeating myself.) My favorite here is patent and copyright monopolies, both because it should be obvious that these features are structured by the government, and there is an enormous amount of money at stake. Patents and related protections raise the price of prescription drugs alone by close to $400 billion a year over the free market price, or 1.8 percent of GDP. If we add in the impact of patents and copyrights on medical equipment, software, movies, fertilizers and pesticides, and other areas, the cost could easily exceed $1 trillion annually or close to 5.0 percent of GDP. Many of the country’s billionaires, starting with Bill Gates, owe their vast fortunes to these government-granted monopolies. As I, and others, have argued these can be extremely inefficient mechanisms for supporting innovation and creative work. Not only are they redistributing income upward, they also slow economic growth, and in the case of prescription drugs and medical equipment, impair people’s ability to get health care. The industry with the largest share of the super-rich is finance. There are many ways this sector can be organized differently in ways that are likely to be both more efficient and produce fewer huge fortunes.
(This post originally appeared on my Patreon page.) The Democratic presidential campaign has taken a strange twist in recent days, with candidates being asked whether we should have billionaires. While there may be some grand philosophical questions at stake here, I will stick to more mundane economic ones. The real question is; how do you want the economy to work? The basic story is that if we have a market economy, some people can get very rich. If we buy the right-wing story, the super-rich got their money from their great contribution to society. If we look at it with clearer eyes, the super-rich got their money because we structured the economy in a way that allowed them to get super-rich. This is a point which seems very obvious, but for some reason is largely ignored in policy debates. Most typically these debates take the market distribution of income as a given, and then ask the extent to which we might want to redistribute to have less inequality. The right of course wants little if any redistribution, while people on the center and left argue for varying degrees of distribution. But it is completely absurd to treat the market distribution of income as given. The market is incredibly flexible and it can literally be structured in an infinite number of different ways. (Yeah, I know I make this point all the time, but I can’t help repeating myself.) My favorite here is patent and copyright monopolies, both because it should be obvious that these features are structured by the government, and there is an enormous amount of money at stake. Patents and related protections raise the price of prescription drugs alone by close to $400 billion a year over the free market price, or 1.8 percent of GDP. If we add in the impact of patents and copyrights on medical equipment, software, movies, fertilizers and pesticides, and other areas, the cost could easily exceed $1 trillion annually or close to 5.0 percent of GDP. Many of the country’s billionaires, starting with Bill Gates, owe their vast fortunes to these government-granted monopolies. As I, and others, have argued these can be extremely inefficient mechanisms for supporting innovation and creative work. Not only are they redistributing income upward, they also slow economic growth, and in the case of prescription drugs and medical equipment, impair people’s ability to get health care. The industry with the largest share of the super-rich is finance. There are many ways this sector can be organized differently in ways that are likely to be both more efficient and produce fewer huge fortunes.

This was in the context of the tariffs he has imposed on imports from China. According to the Washington Post, Trump boasted:

“I like what’s happening right now. We’re taking in billions and billions of dollars.”

Tariffs, of course, are taxes on imports. The evidence is overwhelming that the vast majority of these taxes are being borne either by consumers or retailers in the United States. According to the Bureau of Labor Statistics, the price of imports from China has fallen just 1.6 percent over the last year. This means that people in the United States are paying the overwhelming majority of the tariffs that run as high as 25 percent and apparently Donald Trump is very happy about that. 

This was in the context of the tariffs he has imposed on imports from China. According to the Washington Post, Trump boasted:

“I like what’s happening right now. We’re taking in billions and billions of dollars.”

Tariffs, of course, are taxes on imports. The evidence is overwhelming that the vast majority of these taxes are being borne either by consumers or retailers in the United States. According to the Bureau of Labor Statistics, the price of imports from China has fallen just 1.6 percent over the last year. This means that people in the United States are paying the overwhelming majority of the tariffs that run as high as 25 percent and apparently Donald Trump is very happy about that. 

Donald Trump Brings Ukraine Scandal Home in Texas

Donald Trump went to Texas yesterday to take credit for the opening of an Apple plant that had been open for five years and is not actually an Apple plant. (It is a supplier than produces parts for Apple products.) While there, he indicated that he may exempt Apple products imported from China from the 25 percent tariffs he has imposed on Chinese imports more generally.

While the prospect of a seemingly politically motivated waiver did get some attention, it deserves much more. There are real economic arguments against tariffs. They unambiguously raise the cost of items subject to the tariff. Such costs have to be measured against the potential benefits, both as a weapon in a trade war and potentially as part of an economic development strategy.

However, one unambiguous negative of tariffs is the opportunity to exploit exemptions for political or personal advantage. (Tariffs generally allow exemptions, usually for items that cannot be obtained elsewhere.) It appears that this is exactly what Trump was doing with his trip to Texas.

Obviously Trump valued the photo-op, where he could boast about his economic accomplishments. If this can buy Apple an exemption from China’s tariffs it sends a powerful message to other companies about the benefits of showing support for Trump.

This use of government power to advance his political agenda is exactly what Trump did with respect to aid to Ukraine. This sort of abuse is a hugely important issue. As a practical matter, there are far more companies looking for exemptions from tariffs than there are countries in desperate need of aid from the United States.

Donald Trump went to Texas yesterday to take credit for the opening of an Apple plant that had been open for five years and is not actually an Apple plant. (It is a supplier than produces parts for Apple products.) While there, he indicated that he may exempt Apple products imported from China from the 25 percent tariffs he has imposed on Chinese imports more generally.

While the prospect of a seemingly politically motivated waiver did get some attention, it deserves much more. There are real economic arguments against tariffs. They unambiguously raise the cost of items subject to the tariff. Such costs have to be measured against the potential benefits, both as a weapon in a trade war and potentially as part of an economic development strategy.

However, one unambiguous negative of tariffs is the opportunity to exploit exemptions for political or personal advantage. (Tariffs generally allow exemptions, usually for items that cannot be obtained elsewhere.) It appears that this is exactly what Trump was doing with his trip to Texas.

Obviously Trump valued the photo-op, where he could boast about his economic accomplishments. If this can buy Apple an exemption from China’s tariffs it sends a powerful message to other companies about the benefits of showing support for Trump.

This use of government power to advance his political agenda is exactly what Trump did with respect to aid to Ukraine. This sort of abuse is a hugely important issue. As a practical matter, there are far more companies looking for exemptions from tariffs than there are countries in desperate need of aid from the United States.

I’m not kidding, this is what the piece said. The article was about talks by current prime minister and Conservative Party candidate Boris Johnson and Labour Party leader Jeremy Corbin before the United Kingdom’s biggest business group.

The piece told readers:

“In Mr. Johnson’s speech on Monday, he promised a package of tax cuts designed to entice businesses to support his party but said a further cut to the corporation tax would be postponed. Money designated to finance that tax cut would instead be directed to the National Health Service, he said.

“‘Before you storm the stage and protest,’ Mr. Johnson said, ‘let me remind you this saves 6 million pounds that we can put into the priorities of the British people.'”

Since readers may not be immediately familiar with the importance of this 6 million pounds to people in the UK, it would have been helpful to put in a context that makes it understandable. Since a pound is worth roughly $1.25, this money would be equivalent to $7.5 million. The U.K. has a bit less than 70 million people, which means that Johnson is referring to a sum that comes to a bit more than 10 cents per person in the U.K.

The piece also refers to plans by Corbyn to nationalize the railroads and various utilities. It would have been helpful to point out that most of these businesses had previously been owned by the government. They were privatized under Margaret Thatcher.

I’m not kidding, this is what the piece said. The article was about talks by current prime minister and Conservative Party candidate Boris Johnson and Labour Party leader Jeremy Corbin before the United Kingdom’s biggest business group.

The piece told readers:

“In Mr. Johnson’s speech on Monday, he promised a package of tax cuts designed to entice businesses to support his party but said a further cut to the corporation tax would be postponed. Money designated to finance that tax cut would instead be directed to the National Health Service, he said.

“‘Before you storm the stage and protest,’ Mr. Johnson said, ‘let me remind you this saves 6 million pounds that we can put into the priorities of the British people.'”

Since readers may not be immediately familiar with the importance of this 6 million pounds to people in the UK, it would have been helpful to put in a context that makes it understandable. Since a pound is worth roughly $1.25, this money would be equivalent to $7.5 million. The U.K. has a bit less than 70 million people, which means that Johnson is referring to a sum that comes to a bit more than 10 cents per person in the U.K.

The piece also refers to plans by Corbyn to nationalize the railroads and various utilities. It would have been helpful to point out that most of these businesses had previously been owned by the government. They were privatized under Margaret Thatcher.

The Wall Street Journal had a piece last week that purported to explain why wage growth remains weak. The explanation is that people are more reluctant to switch jobs than they had been in the past.

While this is a concern (I have often noted the surprisingly low quit rate, given an unemployment rate of less than 4.0 percent), real wage growth is roughly where we might expect given the extraordinarily low productivity growth of recent years. The real average hourly wage has risen a bit more than 1.1 percent annually over the last five years. This is a period in which economy-wide productivity growth has been around 0.7 percent annually. (Economy-wide productivity is an unpublished series that the Bureau of Labor Statistics produces annually. It is the appropriate basis for comparison with economy-wide wage growth.)

It would be good to see a somewhat larger gap between wage growth and productivity, given how much ground workers lost in the Great Recession, but this pace of real wage seems pretty reasonable give the slow rate of productivity growth. The extraordinarily weak productivity growth of recent years is striking, but that is another story. It also is completely opposite the concern raised by Andrew Yang, of mass job displacement due to extraordinarily rapid productivity growth.

The Wall Street Journal had a piece last week that purported to explain why wage growth remains weak. The explanation is that people are more reluctant to switch jobs than they had been in the past.

While this is a concern (I have often noted the surprisingly low quit rate, given an unemployment rate of less than 4.0 percent), real wage growth is roughly where we might expect given the extraordinarily low productivity growth of recent years. The real average hourly wage has risen a bit more than 1.1 percent annually over the last five years. This is a period in which economy-wide productivity growth has been around 0.7 percent annually. (Economy-wide productivity is an unpublished series that the Bureau of Labor Statistics produces annually. It is the appropriate basis for comparison with economy-wide wage growth.)

It would be good to see a somewhat larger gap between wage growth and productivity, given how much ground workers lost in the Great Recession, but this pace of real wage seems pretty reasonable give the slow rate of productivity growth. The extraordinarily weak productivity growth of recent years is striking, but that is another story. It also is completely opposite the concern raised by Andrew Yang, of mass job displacement due to extraordinarily rapid productivity growth.

Margot Sanger-Katz has a very useful Upshot piece on Elizabeth Warren’s transition plan for Medicare for All, highlighting steps that the president can take unilaterally. The piece mentioned that one of these proposals is to take advantage of current law, which allows the government to effectively end patent monopolies on drugs that it helped to develop.

This is a really huge deal since the vast majority of drugs do include a government research component. Ending a patent monopoly will typically reduce the price of a drug by 90 percent or more. Drugs are almost invariably cheap to manufacture and distribute. Without government-granted patent monopolies, paying for prescription drugs would no longer be a major problem.

If the government were to go this route on a large scale, it would undoubtedly lead to a drop in research funded by the industry. Warren has proposed some additional public funding to make up a shortfall, although we are likely to need more than she has suggested.

However, a great advantage of publicly funded research is that it could all be fully open so that other researchers and clinicians would be able to benefit from it. Also, we would end the incentive to misrepresent the safety and effectiveness of drugs, substantially reducing the risk of another opioid-type crisis.

 

Margot Sanger-Katz has a very useful Upshot piece on Elizabeth Warren’s transition plan for Medicare for All, highlighting steps that the president can take unilaterally. The piece mentioned that one of these proposals is to take advantage of current law, which allows the government to effectively end patent monopolies on drugs that it helped to develop.

This is a really huge deal since the vast majority of drugs do include a government research component. Ending a patent monopoly will typically reduce the price of a drug by 90 percent or more. Drugs are almost invariably cheap to manufacture and distribute. Without government-granted patent monopolies, paying for prescription drugs would no longer be a major problem.

If the government were to go this route on a large scale, it would undoubtedly lead to a drop in research funded by the industry. Warren has proposed some additional public funding to make up a shortfall, although we are likely to need more than she has suggested.

However, a great advantage of publicly funded research is that it could all be fully open so that other researchers and clinicians would be able to benefit from it. Also, we would end the incentive to misrepresent the safety and effectiveness of drugs, substantially reducing the risk of another opioid-type crisis.

 

Making Andrew Yang Smarter

The New York Times ran a column by Andrew Yang, one of the candidates for the Democratic presidential nomination. Mr. Yang used the piece to repeat his claim that automation is leading to massive job loss.

His one piece of evidence is a study that purports to find that 88 percent of job loss between 2000 and 2010 was due to automation. As I and others have pointed out, it is difficult to take this claim seriously. This was a period in which the trade deficit exploded from 3.0 percent of GDP to almost 6.0 percent of GDP. This would seem to be the more obvious source of job loss.

It is also worth noting that we lost very few manufacturing jobs between 1970 and 2000. Since 2010 we gained a small number of manufacturing jobs. So anyone wanting to push the automation job loss story has to believe that for some reason automation didn’t cause substantial job loss from 1970 and 2000 and then stopped causing job loss in 2010.

I suppose Andrew Yang can believe something like this, but I don’t know too many other people who could consider this story credible.

We do have a measure of the rate at which automation costs jobs, it’s called “productivity growth.” Contrary to what Yang claims, productivity growth has been unusually slow the last fourteen years. (A slowdown began in after 2005.) It actually fell slightly in the last quarter. (The quarterly data are highly erratic, so the decline is most likely a measurement fluke.)

Yang goes on to use his piece to present data showing the bad economic condition of much of the U.S. workforce. He is certainly right that most workers have not been doing well for the last four decades. (Contrary to what Yang seems to believe, wage stagnation is not a new story.) However, there is no evidence to support his claim that automation is the main factor behind stagnating incomes for most workers.

The New York Times ran a column by Andrew Yang, one of the candidates for the Democratic presidential nomination. Mr. Yang used the piece to repeat his claim that automation is leading to massive job loss.

His one piece of evidence is a study that purports to find that 88 percent of job loss between 2000 and 2010 was due to automation. As I and others have pointed out, it is difficult to take this claim seriously. This was a period in which the trade deficit exploded from 3.0 percent of GDP to almost 6.0 percent of GDP. This would seem to be the more obvious source of job loss.

It is also worth noting that we lost very few manufacturing jobs between 1970 and 2000. Since 2010 we gained a small number of manufacturing jobs. So anyone wanting to push the automation job loss story has to believe that for some reason automation didn’t cause substantial job loss from 1970 and 2000 and then stopped causing job loss in 2010.

I suppose Andrew Yang can believe something like this, but I don’t know too many other people who could consider this story credible.

We do have a measure of the rate at which automation costs jobs, it’s called “productivity growth.” Contrary to what Yang claims, productivity growth has been unusually slow the last fourteen years. (A slowdown began in after 2005.) It actually fell slightly in the last quarter. (The quarterly data are highly erratic, so the decline is most likely a measurement fluke.)

Yang goes on to use his piece to present data showing the bad economic condition of much of the U.S. workforce. He is certainly right that most workers have not been doing well for the last four decades. (Contrary to what Yang seems to believe, wage stagnation is not a new story.) However, there is no evidence to support his claim that automation is the main factor behind stagnating incomes for most workers.

Impeachment Is a Kitchen Table Issue

(This post originally appeared on my Patreon page.) As the Democrats have pushed ahead with impeachment proceedings, there have been criticisms from both the right and left that impeachment is a needless distraction from the pocketbook issues that people really care about. The argument is that people will see the Democrats as playing political games rather than focusing on health care, jobs, wages, and other issues that directly affect people’s lives. This sort of argument ignores the world we now live in. First, we have to be clear about the Republican agenda. To put it simply, it is to give all the money to rich people. This means that not only that they don’t want rich people to pay taxes, the rich also get to cheat workers out of their pay, pollute drinking water, destroy the planet, and do anything else to ordinary people and the environment that might boost their income. Republicans and their allies also design patent and copyright monopolies to give even more money to the rich (both here and overseas) and they structure the digital economy in ways that deny ordinary people any privacy. It’s true that some Democrats also seem to share much of this agenda, but that’s beside the point. If the Republicans can control the White House and Congress, this is what they will do. So, is impeachment a distraction from fighting this disastrous agenda? Not at all, impeachment is a necessary step in trying to stop it. In case people somehow have missed it, Republicans do not care at all about democracy or the rule of law. They will do anything and everything they can get away with to keep power. We see this again and again. To take one prominent example, Republicans wanted to include a question on citizenship on the Census to discourage immigrants from answering. The explicit purpose was to reduce political representation in areas with large immigrant populations. The Supreme Court ultimately blocked this effort because the Trump administration could not find a plausible reason to include this question, other than to discriminate against immigrants. Just last week, the Republican leader of Kentucky’s state senate suggested reversing the results of the state’s gubernatorial election (which the Democrat won), based on his assessment that a third party candidate had pulled away enough votes from the Republican to cost him the election. While he seems to have backed away from this position in response to mass public outcry, the fact that he could seriously consider completely ignoring the results of an election shows the lack of respect that Republicans have for democracy and the rule of law. The Ukraine affair has to be understood in this context. Trump is quite openly using the State Department, the Justice Department, and most likely other branches of government to directly advance his personal and political interests.
(This post originally appeared on my Patreon page.) As the Democrats have pushed ahead with impeachment proceedings, there have been criticisms from both the right and left that impeachment is a needless distraction from the pocketbook issues that people really care about. The argument is that people will see the Democrats as playing political games rather than focusing on health care, jobs, wages, and other issues that directly affect people’s lives. This sort of argument ignores the world we now live in. First, we have to be clear about the Republican agenda. To put it simply, it is to give all the money to rich people. This means that not only that they don’t want rich people to pay taxes, the rich also get to cheat workers out of their pay, pollute drinking water, destroy the planet, and do anything else to ordinary people and the environment that might boost their income. Republicans and their allies also design patent and copyright monopolies to give even more money to the rich (both here and overseas) and they structure the digital economy in ways that deny ordinary people any privacy. It’s true that some Democrats also seem to share much of this agenda, but that’s beside the point. If the Republicans can control the White House and Congress, this is what they will do. So, is impeachment a distraction from fighting this disastrous agenda? Not at all, impeachment is a necessary step in trying to stop it. In case people somehow have missed it, Republicans do not care at all about democracy or the rule of law. They will do anything and everything they can get away with to keep power. We see this again and again. To take one prominent example, Republicans wanted to include a question on citizenship on the Census to discourage immigrants from answering. The explicit purpose was to reduce political representation in areas with large immigrant populations. The Supreme Court ultimately blocked this effort because the Trump administration could not find a plausible reason to include this question, other than to discriminate against immigrants. Just last week, the Republican leader of Kentucky’s state senate suggested reversing the results of the state’s gubernatorial election (which the Democrat won), based on his assessment that a third party candidate had pulled away enough votes from the Republican to cost him the election. While he seems to have backed away from this position in response to mass public outcry, the fact that he could seriously consider completely ignoring the results of an election shows the lack of respect that Republicans have for democracy and the rule of law. The Ukraine affair has to be understood in this context. Trump is quite openly using the State Department, the Justice Department, and most likely other branches of government to directly advance his personal and political interests.

It is a popular theme in news reporting that there has been a sharp decline in the labor share of income over the last four decades, and that this is a big part of the story of wage stagnation. The data don’t quite agree.

Part of the confusion is that people often look at the labor share of GDP, a measure which includes depreciation of capital equipment. Since the depreciation share of GDP (the amount of spending needed to replace worn out or obsolete capital) has risen, that would definitionally lead to a fall in the labor share, even if there was no change in the split between labor and capital.

However, even looking at GDP, the loss of labor share would not explain much of the wage stagnation for typical workers over the last four decades. The labor share of GDP fell 2.6 percentage points over this period. This implies that wages would have been 4.8 percent higher in 2019 if the wage share had remained constant over this period. That’s not trivial, it means someone earning $20 an hour today would instead be getting $20.96 in a constant shares world, but it is not most of the story of wage stagnation.

But if we want to be more accurate and pull out the impact of rising depreciation, the labor share has only fallen by 1.6 percentage points over this forty year period. That would imply wages would be 2.5 percent higher in a constant share world. That translates into a wage of $20.50 an hour for the worker now earning $20.00 an hour.

It is also worth noting that all of the fall in the labor share has occurred in this century. In fact, I would say that it is really a Great Recession story, where the loss in shares is overwhelmingly the result of the weak labor market in the years 2008-2012. In the last few years, the labor share has been rising as the labor market tightens.

It is true that the data show a drop in shares prior to the Great Recession, but it is important to remember that these were the housing bubble years. During this period banks and other financial institutions were booking enormous profits on loans that subsequently went bad, leading to hundreds of billions in losses in the years 2008-2010. In other words, much of the profits booked in these years were not real profits. If we corrected for the tidal wave of bad loans, it is not clear that there would be much left of the rise in profit shares in the years 2002-2007.

In any case, it is clear that the vast majority of the upward redistribution was within the wage distribution, with pay that used to go to ordinary workers instead going to CEOs and other top executives, Wall Street financial types, and highly paid professionals (e.g. doctors, dentists, and lawyers). If we want to reverse this upward redistribution, the first step is to be clear on who got the money.

This doesn’t mean that we have not had failures in anti-trust policy, especially in areas like cell phones and Internet and cable service, but this is not the major cause of the upward redistribution of the last four decades.

It is a popular theme in news reporting that there has been a sharp decline in the labor share of income over the last four decades, and that this is a big part of the story of wage stagnation. The data don’t quite agree.

Part of the confusion is that people often look at the labor share of GDP, a measure which includes depreciation of capital equipment. Since the depreciation share of GDP (the amount of spending needed to replace worn out or obsolete capital) has risen, that would definitionally lead to a fall in the labor share, even if there was no change in the split between labor and capital.

However, even looking at GDP, the loss of labor share would not explain much of the wage stagnation for typical workers over the last four decades. The labor share of GDP fell 2.6 percentage points over this period. This implies that wages would have been 4.8 percent higher in 2019 if the wage share had remained constant over this period. That’s not trivial, it means someone earning $20 an hour today would instead be getting $20.96 in a constant shares world, but it is not most of the story of wage stagnation.

But if we want to be more accurate and pull out the impact of rising depreciation, the labor share has only fallen by 1.6 percentage points over this forty year period. That would imply wages would be 2.5 percent higher in a constant share world. That translates into a wage of $20.50 an hour for the worker now earning $20.00 an hour.

It is also worth noting that all of the fall in the labor share has occurred in this century. In fact, I would say that it is really a Great Recession story, where the loss in shares is overwhelmingly the result of the weak labor market in the years 2008-2012. In the last few years, the labor share has been rising as the labor market tightens.

It is true that the data show a drop in shares prior to the Great Recession, but it is important to remember that these were the housing bubble years. During this period banks and other financial institutions were booking enormous profits on loans that subsequently went bad, leading to hundreds of billions in losses in the years 2008-2010. In other words, much of the profits booked in these years were not real profits. If we corrected for the tidal wave of bad loans, it is not clear that there would be much left of the rise in profit shares in the years 2002-2007.

In any case, it is clear that the vast majority of the upward redistribution was within the wage distribution, with pay that used to go to ordinary workers instead going to CEOs and other top executives, Wall Street financial types, and highly paid professionals (e.g. doctors, dentists, and lawyers). If we want to reverse this upward redistribution, the first step is to be clear on who got the money.

This doesn’t mean that we have not had failures in anti-trust policy, especially in areas like cell phones and Internet and cable service, but this is not the major cause of the upward redistribution of the last four decades.

The Logic of Medical Co-Payments

Aaron Carroll had a very useful NYT Upshot piece highlighting research showing that even modest co-payments discourage people from getting necessary medical care. The article is about co-payments for prescription drugs where it highlights research showing that people will often skip taking prescribed drugs to avoid co-payments. There are a couple of points worth making about co-payments in this context and more generally.

First, if a drug has been prescribed for a patient, then it is the judgment of a medical professional that they need this drug for their health. The argument for co-pays, that we want people to think twice before getting the treatment, really should not apply here since a medical professional has determined that they do need the treatment. It doesn’t make sense, in general, to encourage people to substitute their own judgement for that of a medical professional. (That doesn’t mean that medical professionals will always be right, but it would be best if patients made the determination to ignore their judgment based on their own research, not the desire to save a co-pay.)

The other point is that drugs are almost invariably cheap. By this, I mean that they are cheap to manufacture and distribute. The research can be expensive, but this is a sunk cost at the point where the drug is being prescribed for the patient. If all drugs sold as generics, with no patent or related protections, they would rarely cost more than $10 or $20 per prescription. For this reason, there are not much savings to society if we get people to take fewer drugs, we are just risking people’s health with co-pays.

We do need to pay for the research. I suggest doing this upfront, with the government contracting out to private firms. All results and patents are in the public domain. (See Rigged, chapter 5 [it’s free].)

The issue with drugs is qualitatively different than with doctors’ visits. First, a visit to the doctor does require the use of a doctor’s time, as well as the time of their support staff and possibly other health care professionals. This means that there actually are savings from discouraging unnecessary visits.

The second point is that a decision to visit a doctor depends on the patient’s judgment, not that of a medical professional. (This is not the case with repeat treatments, just an initial visit.) People will always weigh several factors in deciding whether to visit a doctor, whether or not there is a co-pay.

For example, if they have a busy schedule or long-planned travel, they may choose not to see a doctor for a particular issue where they might otherwise see a doctor. In this context, it may be very reasonable to have a modest co-payment (e.g. $20 per visit — which would be waved for low-income people) to make people think twice before seeing a doctor.

This sort of co-payment can be seen as analogous to charging people five cents for using a plastic bag when they shop, as many cities now do. If someone really wants the bag, the five-cent fee will not prevent them from getting it, but it does get people to think twice, and therefore has led to a large decline in usage.

It is reasonable to think that a modest co-pay could have a similar effect on doctors’ visits. It should not prevent people with serious health issues from seeing a doctor, but it may discourage some visits for relatively trivial matters, like a cold.

Note, this is not the “skin in the game” story pushed by many economists, which wants patients to be comparative shoppers. There is considerable evidence that patients generally are not good at weighing the relative price of different treatments, and when they do, they often make the wrong choice for their health.

This is simply arguing that it would be good if patients think twice before rushing to see a doctor. We can’t guarantee that this will never mean that a person who needed to see a doctor chose not to, but in the alternative, we can’t guarantee that a person in desperate need to see a doctor won’t have to wait because the person in front of them in line has a cold.

Aaron Carroll had a very useful NYT Upshot piece highlighting research showing that even modest co-payments discourage people from getting necessary medical care. The article is about co-payments for prescription drugs where it highlights research showing that people will often skip taking prescribed drugs to avoid co-payments. There are a couple of points worth making about co-payments in this context and more generally.

First, if a drug has been prescribed for a patient, then it is the judgment of a medical professional that they need this drug for their health. The argument for co-pays, that we want people to think twice before getting the treatment, really should not apply here since a medical professional has determined that they do need the treatment. It doesn’t make sense, in general, to encourage people to substitute their own judgement for that of a medical professional. (That doesn’t mean that medical professionals will always be right, but it would be best if patients made the determination to ignore their judgment based on their own research, not the desire to save a co-pay.)

The other point is that drugs are almost invariably cheap. By this, I mean that they are cheap to manufacture and distribute. The research can be expensive, but this is a sunk cost at the point where the drug is being prescribed for the patient. If all drugs sold as generics, with no patent or related protections, they would rarely cost more than $10 or $20 per prescription. For this reason, there are not much savings to society if we get people to take fewer drugs, we are just risking people’s health with co-pays.

We do need to pay for the research. I suggest doing this upfront, with the government contracting out to private firms. All results and patents are in the public domain. (See Rigged, chapter 5 [it’s free].)

The issue with drugs is qualitatively different than with doctors’ visits. First, a visit to the doctor does require the use of a doctor’s time, as well as the time of their support staff and possibly other health care professionals. This means that there actually are savings from discouraging unnecessary visits.

The second point is that a decision to visit a doctor depends on the patient’s judgment, not that of a medical professional. (This is not the case with repeat treatments, just an initial visit.) People will always weigh several factors in deciding whether to visit a doctor, whether or not there is a co-pay.

For example, if they have a busy schedule or long-planned travel, they may choose not to see a doctor for a particular issue where they might otherwise see a doctor. In this context, it may be very reasonable to have a modest co-payment (e.g. $20 per visit — which would be waved for low-income people) to make people think twice before seeing a doctor.

This sort of co-payment can be seen as analogous to charging people five cents for using a plastic bag when they shop, as many cities now do. If someone really wants the bag, the five-cent fee will not prevent them from getting it, but it does get people to think twice, and therefore has led to a large decline in usage.

It is reasonable to think that a modest co-pay could have a similar effect on doctors’ visits. It should not prevent people with serious health issues from seeing a doctor, but it may discourage some visits for relatively trivial matters, like a cold.

Note, this is not the “skin in the game” story pushed by many economists, which wants patients to be comparative shoppers. There is considerable evidence that patients generally are not good at weighing the relative price of different treatments, and when they do, they often make the wrong choice for their health.

This is simply arguing that it would be good if patients think twice before rushing to see a doctor. We can’t guarantee that this will never mean that a person who needed to see a doctor chose not to, but in the alternative, we can’t guarantee that a person in desperate need to see a doctor won’t have to wait because the person in front of them in line has a cold.

Want to search in the archives?

¿Quieres buscar en los archivos?

Click Here Haga clic aquí