The Great Risk Shift, updated

The Times' front page story today about the enormous growth in student loan debt loads is long on personal narrative, but also tells a succinct story in numbers:

From 2001 to 2011, state and local financing per student declined by 24 percent nationally. Over the same period, tuition and fees at state schools increased 72 percent, compared with 29 percent for nonprofit private institutions, according to the College Board. Many of the cuts were the result of a sluggish economy that reduced tax revenue, but the sharp drop in per-student spending also reflects a change: an increasing number of lawmakers voted to transfer more of the financial burden of college from taxpayers to students and their families. (Local funding is a small percentage of the total, and mostly goes to community colleges.)

Minorities set us free

Via Andrew Sullivan, Nate Silver's take on the ethnic underpinnnings of the Democratic resurgence:

Consider this remarkable statistic. In 1980, 32 percent of the electorate consisted of white Democrats (or at least white Carter voters) -- likewise, in 2008, 32 percent of the electorate consisted of white Obama voters. But whereas, in 1980, just 9 percent of the electorate were nonwhite Carter voters, 21 percent of the electorate were nonwhite Obama voters last year. Thus, Carter went down to a landslide defeat, whereas Obama defeated John McCain by a healthy margin.

I am struck by the economic implications of this shift in the electorate. The average Democratic voter is probably not poorer relative to the average Republican than in 1980, since Democrats have lost poor white voters and probably gained richer white ones. Nonetheless, the ethnic shift in the U.S. population does give the less well-off more of a voice-- at least if you assume that Democrats can represent the economic interests of the less well-off more effectively than Republicans.

At the height of the Bush era, as income inequality soared, lobbyists and Republicans flaunted their symbiosis, Rovian smear campaigning reached its apotheosis and the Republicans increased their majorities in Congress, it was possible to think that American democracy was being hollowed out by an oligarchy that was cementing its economic gains with a lock on the political process. But it turned out that the country's hardening democratic arteries still ran clear enough --defibrillated by an unpopular and mismanaged war started until false pretenses -- to give the Democrats a fresh shot at rolling back the great wealth shift and the great risk shift of the last 30 years.

As in 1980, democracy performed its core function: give failure its due reward, throw the bums out, and let a fresh crew at least try to do better. Today that means mending the safety net, rebuilding the educational system, and creating more opportunity for those not born into privelege.

Deflation nation?

Most Americans lucky enough to own any assets have lost - and are still in process of losing - a significant portion of their wealth in the current crisis. Home values will probably have dropped at least 30-40% before bottoming out. People with half their savings in stock funds have lost in the neighborhood of 20% since the fall 2007 peak-- often more, since most bond funds lost too, and most managed funds have outpaced the broad indexes in the downward dive. Those lucky enough not to have lost jobs or gotten seriously ill probably have lost/will lose about quarter of their nominal net worth.

At the same time, wealth is a fluid and relative thing. What we've lost -- if it doesn't reach the level of something that massively impacts current life, like a home or health -- won't be clear for a long time, and may even turn to gain, if we build on more sustainable foundations. That is, if our collective wealth is more equitably and efficiently shared, if we succeed in reforming education and rebuilding effective public safety nets and fostering innovation in sustainable industries. . Life is long, as Salman Rushdie characters bent on revenge like to say -- and so are our economic biographies.

One large set of variables in assessing economic losses is the potential upside of deflation, broadly understood. Deflation, as officially defined by economists, is both a very bad thing -- perhaps the main precondition of a true Depression -- and relatively modest in percentage terms. Like headline inflation over the last two decades, any official deflation we undergo is likely to register in low single digits.

But headline inflation has not captured a far more rapid inflation in the "Three H's" of economic well-being -- homes, higher education, and healthcare. Add to those high costs the increase of major risk in middle class American life -- job loss, loss of health insurance (or loss of adequate health insurance), loss of defined benefit pensions -- and we've clearly suffered a major "inflation" in the sense that solvency and security are more difficult to obtain than they were a generation ago. The convergence and bursting of our several debt bubbles has made it clear that much of our national wealth was illusory.

If real inflation has outstripped officially measured inflation, perhaps a more broadly understood deflation, enabled in part by good policy, will not only far outstrip any official cost-of-living deflation (or co-exist with official inflation), but actually make prosperity and security more attainable. The linchpins of economic well-being should become relatively easier to obtain:

• Housing: In my New Jersey suburb, 20 miles from New York City, small starter homes scraped $600,000 in 2005. How could even affluent young couples afford, say, a $550,000 mortgage? Probably by taking on some exotic interest-only loan, with the rate escalating in 2-3 years - taken on the assumption that the couple could then either refinance or trade up, financing a more expensive home with profits from the first one. In a year or two or five, that same starter home may cost $400,000 or less, with a mortgage -- if the couple can obtain one -- at a fixed rate under 5%.
• Higher education: I've never really understood the massive runup in college costs, topping out today at over $50,000 per year at prestigious private colleges. Today it's hard to imagine schools, themselves slammed by the fiscal crisis, lowering costs. What should improve fast, though, is the disgustingly exploitive privatization of the student loan business, whereby schools have steered students into loans with opaque terms and usurious rates, sometimes scraping 20% for students in trade schools training for relatively low-wage professions. Expanded opportunities to trade tuition aid for service commitments should also help to bring college within reach for many. At the same time, a swift, massive cultural shift away from all kinds of spending, stemming from economic hardship, should at least slow tuition inflation.
• Healthcare: Effective health insurance reform that provides affordable coverage for the uninsured and mandates adequate coverage of catastrophic costs will halt an enormous source of wealth destruction for Americans. If we can't get this done, and at least bring our healthcare costs and outcomes to the levels enjoyed by most advanced democracies, there's simply no hope for continued American prosperity. Can we afford it in the midst of the economic meltdown? As Obama asked in a Dec. 11 press conference: How can we afford not to?
  
• Debt and consumption: Harsher bankruptcy laws were supposed to discipline borrowers. Now, a massive wave of bankruptcies is disciplining lenders. In hard times, people will take on less discretionary debt and save more. That's bad for the economy short-term, but it will mean less money spent on debt service for many Americans. Debt servicing aside, spending less money on what you don't need makes you wealthier. And while vast numbers of Americans have been driven deep into debt and bankruptcy by circumstances beyond their control, such as uninsured or underinsured illness, there's no doubt that we've all been culturally inclined to spend more than we need to on nonessentials.
  

I've always daydreamed occasionally about being offered fairy tale choices, such as Achilles' choice between a long and happy or short and glorious life. One such imagined supernatural game show question that I posed to myself at various points in the election cycle: would you give up, say, a quarter of your worldly wealth to see Obama elected? That is, to have a shot at this country rolling back the shredding of our civil liberties, belligerent adventurism abroad, growing economic inequality at home, accelerated global warming, etc. etc.? Framed as a purely economic choice: would you stand for a drastic downward revaluation of your assets this year, as part of a national and indeed worldwide revaluing and rebalancing, forcing national and international efforts to restructure on a more sustainable footing? To get even deeper into the realm of nonsensical cosmic planning, this time from a future vantage: was it worth eight years of Bush to get us to Obama?

What's the point of framing up supernatural pseudo-choices? Only to get somehow at this: democracy's saving grace is the capacity to self-correct. In the past, the country has recovered from horrendous mistakes to move on toward renewed prosperity, and, as Obama likes to say, progress toward a more perfect union. The election suggests that American democracy has retained that capacity for self-correction. Will we be able to dig ourselves out the hole we've dug. Obama says "yes we can." For this long lovely moment, the country seems disposed to agree.

Hacker urges Obama to shift risk back

Jacob S. Hacker, the economist who best described the erosion of economic security for the middle class over the past thirty years in The Great Risk Shift, makes a tightly argued case that an all-out push toward universal health insurance is at once the best short-term stimulus and the best long-term investment Obama can make right now.

First, the short-term argument: Hacker lays out the extent to which out-of-pocket healthcare costs are eating into the income of the middle class as well as the poor, the underinsured as well as the uninsured:

Today, however, the health care deduction is big and getting bigger. Despite widespread complaints about "overinsurance," the amount people pay for health care out of their own pocket has risen substantially as a share of personal income over the last generation, and especially in the last decade. The Commonwealth Fund recently completed two massive surveys showing that the proportion of adults younger than 65 with health insurance who spent more than 10 percent of their income on health care out of pocket (5 percent for low-income adults) skyrocketed from 13.8 million in 2003 to 21.8 million in 2007, as health plans hiked deductibles and co-payments, denied claims more aggressively, jacked up costs for out-of-network care, and so on. What's more, almost all of the increase occurred among families with higher incomes--meaning that high health care costs have become a standard deduction for the middle class.

The problem is, of course, far worse for those who lack health insurance. Indeed, if you add the ranks of the uninsured to those without adequate coverage, you have more than 40 percent of the working-age population in an immediate economic bind because of medical costs. About half these people--slightly more of the uninsured than the underinsured, but not much more--report severe problems paying their medical bills. These are the families accounting for the 40 percent to 50 percent of people in bankruptcy or foreclosure who say health care is the number one reason for their plight.

So fixing health care isn't just a recipe for better access to medical care. It's an immediate economic lifeline for working families, giving them back part of their income to use on other things. It's also a rescue package for state and local governments burdened by Medicaid and S-CHIP, for doctors and hospitals who treat the uninsured and inadequately insured, for community institutions that help people in distress--in short, for all the rapidly fraying threads of our health care safety net. Put simply, most of the money we spend upgrading coverage and spreading it to the uninsured is going to go directly into the pockets of people who need help now.

And then, the long-term: controlling healthcare costs is the most important known variable in the nation's long-term fiscal prospects:

The faster everyone is in the system, the faster money flows into people's pockets, and the sooner reformers start reaping the political rewards.

And the faster all that happens, the better situated we are to start the difficult but essential task of controlling long-term health spending. Without runaway health spending, as Henry Aaron of the Brookings Institution has shown, the future fiscal picture of the federal government looks surprisingly rosy, even if taxes stay right where they are as a share of the economy. With runaway health spending, it looks catastrophic. Plus, as bad as the federal picture looks, it's prettier than what businesses and workers are facing. According to Sarah Axeen and Elizabeth Carpenter of the New America Foundation, if employer-sponsored insurance premiums and family income rise at the same rate they have for the past decade, an average family health plan will cost more than 45 percent of a typical family's income by 2016.

Will Obama risk his huge store of political capital -- and the nation's long-term fiscal health -- on trying to effect an immediate major investment in healthcare? No question. As he put it in his Dec. 11 press conference introducing his healthcare team: “Some may ask how at this moment of economic challenge we can afford to invest in reforming our health care system. And I ask a different question. I ask, how can we afford not to?”

Indeed, Obama's long campaign was in large part an extended argument for a sustained national investment in rolling back the shift of risk from institutions to individuals that Hacker so thoroughly documented -- through higher taxes on the wealthy that would enable new investments in healthcare, alternative energy and education. To shift risk to the public sector is not to eliminate it. Obama's writings show that he is aware of the dangers -- of large deficits, of taxes raised to the point of crimping economic growth, of bloated and unaccountable government offering ineffective services.

In The Audacity of Hope, he acknowledges those underpinnnings of the Reagan revolution. His argument in the campaign was not that there is no legitimacy to conservative concerns about big government, but that the pendulum has swung too far the other way -- that tax cuts for wealthy have hollowed out programs that sustain opportunity and social insurance. As he put it in Janeville, Wisconsin last February:

when opportunity is uneven or unequal - it is our responsibility to restore balance, and fairness, and keep that promise alive for the next generation. That is the responsibility we face right now, and that is the responsibility I intend to meet as President of the United States.

The genius of his campaign was a bid to move the center back to the left - to cast new social investment as a restoration of balance, fairness, commitment to commonwealth. Now, he cannot afford not to.

Clive Crook hazards a false moral on healthcare

Scouting the Obama healthcare plan for leaving employer based health insurance intact, Clive Crook succumbs to a Republican "ownership society" shibboleth. He'd have us believe that the runup in healthcare costs is driven mainly by consumers:

The real problem is slowing the remorseless trend of future growth. Until healthcare consumers are made to think about costs, that may be impossible. Consumers resist constraint because they think employers are paying for their health insurance; in fact, of course, workers are paying through lower wages.

In fact, the runup in healthcare costs is mainly driven by the incentive structure for doctors, who are paid by the procedure and have financial incentives to order costly tests and treatments (and the negative incentive of defensive medicine, thanks to our litigiousness); by drug companies, which deploy multiple means of bribing doctors to prescribe expensive (and often unproven) new medications, and who have lobbied their way to nearly unchecked pricing power; by insurers, who waste half of doctors' time with insanely arcane claims procedures and cherry-pick the healthiest patients; by the legions of uninsured, whose uncompensated care adds nearly a thousand dollars to the average family healthcare premium; and by the massive failure of our swiss cheese system to deliver preventive care.

It is counterproductive and immoral to induce people to access less healthcare by creating strong financial incentives to eschew treatment. In fact that's just what we do: there are tens of millions of people in this country halving their medication doses, going years without dental care, and avoiding visits to specialists they can ill-afford. You can't have adequate preventive care when every visit demands a consequential financial outlay.

Far from overconsuming healthcare, even Americans with insurance are increasingly underinsured. As reported by Jacob S. Hacker in The Great Risk Shift (2006):

Among insured Americans, 51 million spend more than 10 percent of their income on medical care. One out of six working-age adults are carrying medical debt,and 70 percent had insurance when they incurred it...nearly six in ten of the underinsured postponed needed medical care because of the cost, nearly four in ten had to put off home or car maintenance or repairs due to medical expenses, a third had to dig deep into their savings to pay for medical care, and more than one in five made job-related decisions based mainly on their health care needs. Strikingly, the median family income of the underinsured was $58,000--almost exactly the same as the median income of those with adequate coverage.

Crook has fallen victim to the Republican fallacy that adequate, affordable care creates "moral hazard" -- that patients will gorge themselves on on an open medical buffet if every item is not a la carte. In our healthcare system, the players morally at hazard are doctors who earn more if they prescribe more services, insurers who earn more by cherry-picking customers, and drug companies that earn more by turning doctors into shills. In the U.S., patients' hazard is physical and financial, not moral.

Belief among healthcare economists and policymakers that freedom from paying substantial fee-for-service sums leads patients to inefficiently overuse healthcare services rests largely on the famous RAND Health Insurance Experiment (HIE), a study of consumers provided with varying forms of health insurance over an extended period of time. The RAND HIE, begun in 1974 with results published in 1987 and 1993, purported to find that those in plans where they paid no fees for individual services used more healthcare than those in fee-for-service plans but did not enjoy any measurable health benefits as a result. In other words, the additional care accessed by those for whom services were "free" was effectively wasted.

This conclusion was effectively debunked in an analysis by John A. Nyman, published in October 2007 in the Journal of Health Policy, Politics and Law. Noting that all participants in HIE had the option of dropping out at will and returning to the health plan they held prior to the experiment, Nyman reported that sixteen times as many participants dropped out of the fee-for-service plans as out of the free plans. Since participants were given a financial incentive to remain in the experiment, the inescapable conclusion is that those who dropped out of the fee-for-service plans did so because they became seriously ill or were injured badly enough to need expensive care. In Nyman's analysis, "moral hazard" is exposed as essentially another word for "risk sharing." Those who need expensive healthcare access it if it is not financially prohibitive; those who don't need expensive procedures subsidize those who do. That's what insurance is for.