The Real Cost of National Health Care

Around early August 2018, a research paper from the Mercatus Center at George Mason University by Charles Blahous made both the Wall Street Journal and Fox News within two days. It also attracted attention widely in other media. Later, I thought I heard sighs of satisfaction from conservative callers on talk show radio whenever the paper came up.

One figure from the study came and stayed at the surface and was quoted correctly many times (rare occurrence) in the electronic media. The cost of what Senator Sanders proposed with respect to national health care was:

30 trillion US dollars over ten years (actually, 32.6 over thirteen years).

This enormous number elicited pleasure among conservatives because it seemed to underscore the folly of Senator Bernie Sanders’ call for universal healthcare. It meant implicitly, federal, single-payer, government-organized health care. It might be achieved simply by enrolling everyone in Medicare. I thought I could hear snickers of relief among my conservative friends because of the seeming absurdity of the gigantic figure. I believe that’s premature. Large numbers aren’t always all they appear to be.

Let’s divide equally the total estimate over ten years. That’s three trillion dollars per year. It’s also a little more than $10,000 per American man, woman, child, and others, etc.

For the first year of the plan, Sanders’ universal health care amounts to 17.5% of GDP per capita. GDP per capita is a poor but not so bad, really, measure of production. It’s also used to express average gross income. (I think that those who criticize this use of GDP per capita don’t have a substitute to propose that normal human beings understand, or wish to understand.) So it’s 17.5% of GDP/capita. The person who is exactly in the middle of the distribution of American income would have to spend 17.5% of her income on health care, income before taxes and such. That’s a lot of money.

Or, is it?

Let’s imagine economic growth (GDP growth) of 3% per years. It’s optimistic but it’s what conservatives like me think is a realistic target for sustained performance. From 1950 to 1990, GDP per capita growth reached or exceeded 3% for almost all years. It greatly exceeded 3% for several years. I am too lazy to do the arithmetic but I would be bet that the mean annual GDP growth for that forty-year period was well above 3%. So, it’s realistic and probably even modest.

At this 3% growth rate, in the tenth year, the US GDP per capita will be $76.600. At that point, federal universal health care will cost – unless it improves and thus becomes more costly – 13% of GDP per capita. This sounds downright reasonable, especially in view of the rapid aging of the American population.

Now, American conservative enemies of nationalized health care are quick to find instances of dysfunctions of such healthcare delivery systems in other countries. The UK system was the original example and as such, it accumulated mistakes. More recently, we have delighted in Canadian citizens crossing the border for an urgent heart operation their nationalized system could not produce for months: Arrive on Friday evening in a pleasant American resort. Have a good but reasonable dinner. Check in Sat morning. Get the new valve on Monday; back to Canada on Wednesday. At work on the next Monday morning!

The subtext is that many Canadians die because of a shortage of that great free health care: It nice if you can get it, we think. Of course, ragging on the Canadians is both fair and endlessly pleasant. Their unfailing smugness in such matters is like a hunting permit for mental cruelty!

In fact, though, my fellow conservatives don’t seem to make much of an effort to find national health systems that actually work. Sweden has one, Denmark has one; I think Finland has one; I suspect Germany has one. Closer to home, for me, at least, France has one. Now, those who read my blogging know that I am not especially pro-French or pro-France. But I can testify to a fair extent that the French National Healthcare works well. I have used it several times across the past fifty years. I have observed it closely on the occasion of my mother’s slow death.

The French national health system is friendly, almost leisurely, and prompt in giving you appointments including to specialists. It tends to be very thorough to the point of excessive generosity, perhaps. Yes, but you get what you pay for, I can hear you thinking – just like a chronically pessimistic liberal would. Well, actually, Frenchmen live at least three years longer on the average than do American men. And French women live even longer. (About the same as Canadians, incidentally.)

Now, the underlying reasoning is a bit tricky here. I am not stating that French people live longer than Americans because the French national healthcare delivery system is so superior. I am telling you that whatever may be wrong with the French system that escaped my attention is not so bad that it prevents the French from enjoying superior longevity. I don’t want to get here into esoteric considerations of the French lifestyle. And, no, I don’t believe it’s the red wine. The link between drinking red wine daily and cardiac good health is in the same category as Sasquatch: I dearly hope it exists but I am pretty sure it does not. So, I just wish to let you know that I am not crediting French health care out of turn.

The weak side of the French system is that it remunerates doctors rather poorly, from what I hear. I doubt French pediatricians earn $222,000 on the average. (Figure for American pediatricians according to the Wall Street Journal 8/17/18.) But I believe in market processes. France the country has zero trouble finding qualified candidates for its medical schools. (I sure hope none of my current doctors, whom I like without exception, will read this. The wrong pill can so easily happen!)

By the way, I almost forgot to tell you. Total French health care expenditure per person is only about half as high as the American. Rule of thumb: Everything is cheaper in the US than in other developed countries, except health care.

And then, closer to home, there is a government health program that covers (incompletely) about 55 million Americans. It’s not really “universal” even for the age group it targets because one must have contributed to benefit. (Same in France, by the way, at least in principle.) It’s universal in the sense that everyone over 65 who has contributed qualifies. It’s not a charity endeavor. Medicare often slips the minds of critical American conservatives, I suspect, I am guessing, because there are few complaints about it.

That’s unlike the case for another federal health program, for example the Veterans’, which is scandal-ridden and badly run. It’s also unlike Medicaid, which has the reputation of being rife with financial abuse. It’s unlike the federally run Indian Health Service that is on the verge of being closed for systemic incompetence.

I suspect Medicare works well because of a large number of watchful beneficiaries who belong to the age group in which people vote a great deal. My wife and I are both on Medicare. We wish it would cover us 100%, although we are both conservatives, of course! Other than that, we have no complaints at all.

Sorry for the seeming betrayal, fellow conservatives! Is this a call for universal federal health care in America? It’s not, for two reasons. First, every country with a good national health system also has an excellent national civil service, France, in particular. I have no confidence, less than ever in 2018, that the US can achieve the level of civil service quality required. (Less in 2018 because of impressive evidence of corruption in the FBI and in the Justice Department, after the Internal Revenue Service).

Secondly, when small government conservatives (a redundancy, I know) attempt to promote their ideas for good government primarily on the basis of practical considerations, they almost always fail. Ours is a political and a moral posture. We must first present our preferences accordingly rather than appeal to practicality. We should not adopt a system of health delivery that will, in ten years, attribute the management of 13% of our national income to the federal government because it’s not infinitely trustworthy. We cannot encourage the creation of a huge category of new federal serfs (especially of well-paid serfs) who are likely forever to constitute a pro-government party. We cannot, however indirectly, give the government most removed from us, a right of life and death without due process.

That simple. Arguing this position looks like heavy lifting, I know, but look at the alternative.

PS I like George Mason University, a high ranking institution of higher learning that gives a rare home to conservative American scholars, and I like its Mercatus Center that keeps producing high-level research that is also practical.

Electricity in Quebec before Nationalization (1919 to 1939)

A few weeks ago, I mentioned that  I am generally skeptical of “accepted wisdom” on many topics. “Accepted wisdom” is a construction of a stylized fact by a party with intense preferences that is gradually able to remove nuances over time to solidify its preferred narrative. The example I gave a few weeks ago concerned antitrust laws. There are many more. One of those concerns a research agenda that I laid claim to in a recent article in Atlantic Economic Journal (co-authored with my dear friend Germain Belzile): the nationalization of electricity in Quebec.

My home province of Quebec is basically one giant network of rivers well-suited for the production of hydro-electricity – a potential that was noticed in the late 19th century and led to a rapid expansion of the network. Historians (and some economists) have depicted the early electrical industry in Quebec as a “trust” (a cartel) that gouged consumers and could only be resolved, as witnessed by the neighboring province of Ontario, by nationalization (which occurred in two waves – one in 1944 and one in 1962).

In the article I published with Belzile, I argue that this narration is largely incorrect. First, before nationalization prices in Quebec were falling and were low by North American standards (see figures below). Second, production was expanding rapidly. This is in spite of the fact that taxes imposed on the electrical industry grew rapidly over time from less than 10% of total expenditures to close to 30%.  Moreover, we point out that looking at residential prices is bound to yield bad comparisons (if we can call those made above as “bad”) if there is price discrimination. The industry price discriminated and offered incredibly low prices for industrial customers (large power) than in Ontario or anywhere else in Canada  (in spite of the taxes it was operating under and the fact that Ontario subsidized its own).

We also point out that there was a dynamics of interventionism problem. The neighboring province of Ontario (more populous and richer than Quebec) nationalized its industry and set prices well below the market level which is an implicit subsidy. However, at the subsidized rate, Ontario could not supply its own demand and had to buy at the market price in Quebec. Its over-equilibrium quantity of energy demanded was transferred on the freer Quebec market, thus increasing prices on that market.

We also argue that there was wide heterogeneity of rates in Quebec that relate to the structure of municipal regulation (the level at which electricity was regulated pre-1935). The price differences depended on the political games involving rent-seeking firms and politicians (best exemplified by the case of Quebec City). Cities with high prices were places where the electrical market was heavily politicized and franchises (i.e. the contracts fixing rate schedules over long periods of time to recoup capital investment) were short and subject to holdups.

This latter point is meant for us (me and Germain) to stake a claim on future research to document the nationalization and regulation process at the municipal level and see what the effects on prices and outputs were. In a certain way, I am trying to establish a research agenda extending the skepticism of “accepted wisdom” that has emerged with the economic history of antitrust in the United States to the case of electricity trusts in Quebec. This first article is, I believe, a promising start for such an inclusion.

 

Figure2Electricity

Figure4Electricity

 

On demography and living standards in the colonial era

This is a topic that has been bugging me. Very often, historians will (accurately) point out mortality statistics in the United States, Canada (Quebec) and the Latin America during the colonial era were better than in the comparable Old World (comparing French with French, British with British, Spanish with Spanish). However, they will argue that this is evidence that living standards were higher. This is where I wish to make an important nuance.

Settlement colonies (so, here there is a bigger focus on North America, but it applies to smaller extent to Latin America which I am more tempt to label as extractive – see here) are generally frontier economies. This means that they are small economies because of small populations.  This means that labor and capital are scarce relative to land. All outputs that come from the relatively abundant factor will thus tend to be cheaper if there is little international trade for the goods that they are best at producing. The colonial period pretty much fits that bill. The American and Canadian colonies were basically agricultural colonies, but very few of those agricultural outputs actually crossed the Atlantic. As such, agricultural produces were cheap. This is akin to saying that nutrition was cheap.

This, by definition, will give settlement colonies an advantage in terms of biological living standards. As they are not international price takers, wheat is cheaper than in the old world. This is why James Lemon spoke of the New World as the “Best poor man’s country” (I love that expression) : it was easy to earn subsistence. However, beyond that it is very hard to go beyond. For example, in my dissertation (articles still in consideration at Cliometrica and Canadian Journal of Economics) I found that when wages were deflated by a subsistence basket containing very few services and manufactured goods and which relied heavily on untransformed foods, Canada was richer than the richest city of France. Once you shifted to a basket that marginally increased transformed goods and manufactured goods, the advantage was wiped away.

Yet, everything indicates that mortality rates were greater in Paris and France and than in Quebec City and Quebec as a whole (but not by a lot) (see images below).  Similar gaps seem to exist for the United States relative to Britain, but the data is not as rich as for Quebec. However, the data that exists for New England suggests that death rates were lower than in England but the “bare bones” real incomes measured by Lindert and Williamson show that New England may have been poorer than Great Britain (not by much though).

Crude Death Rates

IMR

I am not saying that demographic and biological data is worthless. Quite the contrary (even I wanted to, I could not since I have a paper on the heights of French-Canadians from 1780 to 1830)! The point is that data matters in context.  The world is full of small non-linearities between variables. While “good” demographic outcomes are generally tracking “good” economic outcomes, there are contexts where this may be a weaker relation (curvilinear relations between variables). I think that this is a good example of that point.

Prices in Canada since 1688

A few days ago, I received goods news that the Canadian Journal of Economics had accepted my paper that constructed a consumer price index for Canada between 1688 and 1850 from homogeneous sources (the account books of religious congregations). I have to format the article to the guidelines of the journal and attach all my data and it will be good to go (I am planning on doing this over the weekend). In the meanwhile, I thought I would share the finalized price index so that others can see it.

First, we have the price index that focuses on the period from 1688 to 1850.  Most indexes that exist for pre-1850 Canada (or Quebec since I assume that Quebec is representative of pre-1850 Canadian price trends) are short-term, include mostly agricultural goods and have no expenditures weights to create a basket. Now, my index is the first that uses the same type of sources continuously over such a long period and it is also the first to use a large array of non-agricultural goods. It also has a weights scheme to create a basket.

PriceIndexCanada

The issue of adding non-agricultural goods was especially important because there were important differences in the evolution of different types of goods. Agricultural goods, see next image, saw their nominal prices continually increase between the 17th and 19th centuries. However, most other prices – imported goods, domestically produced manufactured goods etc. – either fall or remain stable. These are very pronounced changes in relative prices. It shows that reliance on agricultural goods price index will overstate the amount of “deflating” needed to arrive at real wages or incomes.  The image below shows the nominal price evolution of groupings of goods as described above.

PriceIndexCanada2

And finally, the pièce de résistance! I link my own index to other existing post-1850 index so as to generate the evolution of prices in Canada since 1688. The figure below shows the evolution of the price index over … 328 years (I ended the series at 2015, but extra years forward can be added). In the years to come, I will probably try to extend this backwards as much as possible at least to 1665 (the first census in Canada) and will probably try to approach Statistics Canada to see if they would like to incorporate this contribution into their wide database of macroeconomic history of Canada.

PriceIndexCanada3

On the popularity of economic history

I recently engaged in a discussion (a twittercussion) with Leah Boustan of Princeton over the “popularity” of economic history within economics (depicted below).  As one can see from the purple section, it is as popular as those hard candies that grandparents give out on Halloween (to be fair, I like those candies just like I do economic history). More importantly, the share seems to be smaller than at the peak of 1980s. It also seems like the Nobel prize going to Fogel and North had literally no effects on the subfield’s popularity. Yet, I keep hearing that “economic history is back”. After all, the Bates Clark medal went to Donaldson of Stanford this year which should confirm that economic history is a big deal.  How can this be reconciled with the figure depicted below?

EconomicHIstoryData

As I explained in my twittercussion with Leah, I think that there is a popularity for using historical data. Economists have realized that if some time is spent in archives to collect historical data, great datasets can be assembled. However, they do not necessarily consider themselves “economic historians” and as such they do not use the JEL code associated with history.  This is an improvement over a field where Arthur Burns (former Fed Chair) supposedly said during the 1970s that we needed to look at history to better shape monetary policy. And by history, he meant the 1950s. However, while there are advantages, there is an important danger which is left aside.

The creation of a good dataset has several advantages. The main one is that it increases time coverage. By increasing the time coverage, you can “tackle” the big questions and go for the “big answers” through the generation of stylized facts. Another advantage (and this is the one that summarizes my whole approach) is that historical episodes can provide neat testing grounds that give us a window to important economic issues. My favorite example of that is the work of Petra Moser at NYU-Stern. Without going into too much details (because her work was my big discovery of 2017), she used a few historical examples which she painstakingly detailed in order to analyze the effect of copyright laws. Her results have important ramifications to debates regarding “science as a public good” and “science as a contribution good” (see the debates between Paul David and Terence Kealey on this in Research Policy for this point).

But these two advantages must be weighted against an important disadvantage which Robert Margo has warned against in a recent piece in Cliometrica.  When one studies economic history, one must keep in mind that two things must be accomplished simultaneously: to explain history through theory and bring theory to life through history (this is not my phrase, but rather that of Douglass North). To do so, one must study a painstaking amount of details to ascertain the quality of the sources used and their reliability.  In considering so many details, one can easily get lost or even fall prey to his own prior (i.e. I expect to see one thing and upon seeing it I ask no question). To avoid this trap, there must be a “northern star” to act as a guide. That star, as I explained in an earlier piece, is a strong and general understanding of theory (or a strong intuition for economics). To create that star and give attention to details is an incredibly hard task and which is why I argued in the past that “great” economic historians (Douglass North, Deirdre McCloskey, Robert Fogel, Nathan Rosenberg, Joel Mokyr, Ronald Coase (because of the lighthouse piece), Stephen Broadberry, Gregory Clark etc.) take a longer time to mature. In other words, good economic historians are projects that have have a long “time to build problem” (sorry, bad economics joke).  However, the downside is that when this is not the case, there are risks of ending up with invalid results that are costly and hard to contest.

Just think about the debate between Daron Acemoglu and David Albouy on the colonial origins of development. It took more than five years to Albouy to get his results that threw doubts on Acemoglu’s 1999 paper. Albouy clearly expended valuable resources to get the “details” behind the variables. There was miscoding of Niger and Nigeria, and misunderstandings of what type of mortalities were used.  This was hard work and it was probably only deemed a valuable undertaking because Acemoglu’s paper was such a big deal (i.e. the net gains were pretty big if they paid off). Yet, to this day, many people are entirely unaware of the Albouy rebuttal.  This can be very well seen in the image below regarding the number of cites of the Acemoglu-Johnson-Robinson paper on an annual basis. There seems to be no effect from the massive rebuttal (disclaimer: Albouy convinced me that he was right) from the Albouy piece.

AcemogluPaperCites

And it really does come down to small details like those underlined by Albouy. Let me give you another example taken from my work. Within Canada, the French minority is significantly poorer than the rest of Canada. From my cliometric work, we now know that there were poorer than the rest of Canada and North America as far as the colonial era. This is a stylized fact underlying a crucial question today (i.e. Why are French-Canadians relatively poor).  That stylized fact requires an explanation. Obviously, institutions are a great place to look. One of the institution that is most interesting is seigneurial tenure which was basically a “lite” version of feudalism in North America that was present only in the French settled colonies. Some historians and economic historians argued that there were no effects of the institutions on variables like farm efficiency.  However, some historians noticed that in censuses the French reported different units that the English settlers within the colony of Quebec. To correct for this metrological problem, historians made county-level corrections. With those corrections, the aforementioned has no statistically significant effect on yields or output per farm. However, as I note in this piece that got a revise and resubmit from Social Science Quarterly (revised version not yet online), county-level corrections mask the fact that the French were more willing to move to predominantly English areas than the English were willing to predominantly French areas. In short, there was a skewed distribution. However, once you correct the data on an ethnic composition basis rather than on the county-level (i.e. the same correction for the whole county), you end with a statistically significant negative effect on both output per farm and yields per acre. In short, we were “measuring away” the effect of institutions. All from a very small detail about distributions. Yet, that small detail has supported a stylized fact that the institution did not matter.

This is the risk that Margo speaks about illustrated in two examples. Economists who use history merely as a tool may end up making dramatic mistakes that will lead to incorrect conclusions. I take this “juicy” quote from Margo (which Pseudoerasmus) highlighted for me:

[EH] could become subsumed entirely into other fields… the demand for specialists in economic history might dry up, to the point where obscure but critical knowledge becomes difficult to access or is even lost. In this case, it becomes harder to ‘get the history right’

Indeed, unfortunately.

In health care, expenditures to GDP may be misleading!

In debates over health care reform in the US, it is frequent for Canada’s name to pop up in order to signal that Canada is spending much less of its GDP to health care and seems to generate relatively comparable outcomes. I disagree.

Its not that the system presently in place in the US is so great, its that the measure of resources expended on each system is really bad. In fact, its a matter of simple economics.  Imagine two areas (1 and 2), the first has single-payer health care, the other has fully-private health care.

In area 2, prices ration access to health care so that people eschew visits to the emergency room as a result of a scraped elbow. In area 1, free access means no rationing through price and more services are consumed. However, to avoid overspending, the government of area 1 has waiting lists or other rationing schemes. In area 2, which I have presented as an ideal free market for the sake of conversation,  whatever people expend can be divided over GDP and we get an accurate portrait of “costs”. However, in area 1, costs are borne differently – through taxes and through waiting times. As such, comparing what is spent in area 1 to what is spent in area 2 is a flawed comparison.

So when we say that Canada spends 10.7% of GDP on health care (2013 numbers) versus 17.1% of GDP in the US, is it a viable comparison? Not really.  In 2008, the Canadian Medical Association produced a study evaluating the cost of waiting times for four key procedures : total joint replacement surgery, cataract surgery, coronary artery bypass
graft (CABG) and MRI scans. These procedures are by no means exhaustive and they concern only “excessive” waiting times (rather than the whole waiting times or at least the difference with the United States). However, the CMA found that, for the 2007 (the year they studied), the cost of waiting was equal to 14.8$ billion (CAD).  Given the size of the economy back in 2007, this represented 1.3% of GDP. Again, I must emphasize that this is not an exhaustive measure of the cost of waiting times. However, it does bring Canada closer to the United States in terms of the “true cost” of health care.  Any estimate that would include other wait times would increase that proportion.

I know that policy experts are aware of that, but it is so frequent to see comparisons based on spending to GDP in order to argue for X and Y policy as being relatively cheap.  I just thought it was necessary to remind some people (those who decide to read me) that prudence is mandatory here.