Sunday, September 28, 2014

WHY MOST EVERYONE DISLIKES ECONOMISTS



If economists could manage to get themselves thought of as humble, competent people on a level with dentists, that would be splendid.  ~ John Maynard Keynes



Over the past several decades economists have established a larger presence in the world of policy formulation. The sun never sets on economic experts making pronouncements that are reported 24/7; everything from inadequate GDP growth to the price of kale[1] and quinoa. Despite this prominence, economists are far from cherished. We lament, "Why aren't we loved?"
We're disliked because, mostly for the best of reasons, we often espouse and support policies that raise the prices of products that people actually purchase. Many economists argue that goods like petroleum products, food, water and sugary drinks are priced too low and should be raised. When offered a choice, most everyone wants lower, not higher prices.[2] Hence the negative feelings folks have with economists (and politicians) who endorse higher prices. 
The rationale for raising prices sometimes focuses on how we can be saved from ourselves – or can save "other people" from themselves (this is more popular than policies that raise prices on goods or services we ourselves buy) – because our consumption of some goods creates negative public externalities like air and water pollution (perhaps remedied by a carbon tax that raises fuel prices). Consuming other goods creates detrimental personal consequences like lung cancer or obesity (resolved in part by implementing a cigarette tax or soda tax that raises these goods' prices, so consumers buy less of them).
Speaking of soda taxes, a growing list of localities have attempted, so far uniformly unsuccessful, to implement various types of soda taxes. This list now includes San Francisco and Berkeley, CA that have each placed differing tax propositions on sugared drinks on their November ballots. The debate about the tax is already bubbling over in both cities.
The advocates of Berkeley's intricate Prop D state it's a 1-cent per fluid ounce tax on distributors of some sugared-drinks (called "Big Soda" by proponents). the Berkeley city attorney states that "The tax would be payable by the distributor, not the customer," which seems to hope that voters will forget such taxes almost always get passed along to final consumers in the form of higher prices. Pro-D'ers say the tax will reduce the incidence of obesity and diabetes. That may be possible in the longer term, but there are many other (known and unknown) factors that contribute to obesity and diabetes. Unfortunately, available information about using soda taxes as a fiscal means of reducing America’s growing obesity epidemic is fairly dispiriting. We'll see if a notably progressive city's citizens will vote to raise the price of many of the sugared drinks they consume in the name of public health.
Does anyone really want to pay higher prices if they have a choice not to? Nope.[3] Witness the popularity and permanence of a myriad of sizeable government subsidies that artificially lower prices for consumers and/or producers. These subsidies include those to industrial agriculture that ultimately reduce commodity food prices (e.g., wheat, corn, milk, cotton) and tax subsidies provided to oil and natural gas exploration and to home mortgage interest payments. Subsidies to agriculture have been estimated to be from $10 billion to over $20B per year. The home mortgage interest payment tax deduction (subsidy) was estimated to cost $80B in foregone revenues in 2010.
The Australian carbon tax "experiment" offers an unusual case study in the fecklessness of politicians raising prices, in this case energy prices. A carbon tax is a tax on the production and/or consumption of fossil fuel based on the fuel's carbon content. Most economists and virtually all environmentalists strongly support such a tax as a means of improving air and water quality, even though many politicians remain extremely wary of imposing one. Their well-founded fear is connected with creating an unpopular policy that raises energy prices.
Australia initiated a national carbon tax in July 2012 under Labor Party Prime Minister Julia Gillard, principally on large industrial and electricity-generation firms' emissions. The tax on carbon that companies paid was about A$25/metric ton in mid-2014. CO2 emissions went down. The price of electricity and other goods increased. And Australians were not at all happy about these price increases. So unhappy that voters threw out the Labor government in the next election. The tax was then repealed in July 2014, under the new leadership of Liberal Party (conservative) PM Tony Abbott, who said the tax was a “9 percent impost on power prices, [and] a A$9 billion handbrake on our economy.” Mr. Abbott probably doesn't spend much time chumming around with economists who advocated for the ex-carbon tax. Australia is thus the only country that has both implemented and annulled a carbon tax.
Closer to home, let's consider the price of water – perhaps the most precious resource that sustains our lives, next to oxygen in the atmosphere. I believe that California's current, devastating drought is caused in large part by the price of water being too low for way too long – ever since the first dams were built in the early 20th century principally to supply water to Central Valley agribusinesses and Southern California consumers. It's true that residential, commercial and industrial users also have benefited from paying low prices for their water. But the biggest beneficiaries have long been agricultural (ag) irrigation users, who all by themselves consume close to 80% of California's fresh water. And who have paid downright benthic-level prices for decades.
For more than half a century, federal and state water policy has been established in California and other Western states to keep irrigators' water prices very, very low via significant government subsidies. As Marc Reisner states in his classic book Cadillac Desert about water policies in the mostly arid West, ''What federal water development has amounted to, in the end, is a uniquely productive, creative vandalism."
Here's a prime example of preposterously low ag water prices, taken from Reisner's book. Through the 1980s the Westlands Water District, one of the largest in California and therefore in the US[4], charged its ag customers between $7.50 and $11.80 per acre-foot. Economists estimated the actual cost of delivering this water was $97 per acre-foot. Thus, these customers were paying only 8% to 12% of the cost of providing this resource. This degree of public financial support is at the very deep end of the subsidy pool. Who paid (and continues to pay) the remaining 90% of the cost? Us taxpayers. Adding more water to this vandalism fire caused by low prices, the dominant planted crop at the time in Westlands was cotton – a very water-thirsty, "surplus crop" whose price is itself heavily subsidized by the federal government. Talk about going from worse to terrible.
With its slight cost, California ag irrigators have had no economic incentive to conserve or efficiently use water. They continued to greedily guzzle until the rivers, reservoirs and wells have almost dried up during this latest drought. This unsustainable water gluttony itself has also created significant environmental damage in the Central Valley.
 Water prices have finally started to increase for ag irrigators; some of Westlands' customers are now paying over $1,000 per acre-foot – nearly 10 times more for water than right before the drought. Irrigators' allotments of water also have been cut– making the price of that water infinite.
However, few if any residential consumers are now paying more for their water. In fact, over 250,000 water users in California do not even have meters to determine their actual water usage. These unmetered customers are charged a flat fee, sometimes as low as $20/mo. Cities and areas where unmetered water usage is significant include South Lake Tahoe (62% unmetered), Merced (52%) and Sacramento (47%).
Thus, it's no surprise that we haven't reduced our water consumption much, in spite of Gov. Jerry Brown's January declaration to cut water use by 20%. In July 2014, statewide water usage was cut 7.5%, compared to a year ago. Southern California consumers reduced their usage a trifling 1.7%. Is it time also to raise non-irrigator water prices? Probably so, but it's also time to further incentivize water conservation by giving credits to customers who have reduced their usage more than 15% to 20% and/or installed water-saving methods.
Are water policy economists popular when they support such needed price increases? Not at all; everyone is completely comfortable with their long-time, subsidized, rock-bottom water prices. But water pricing policy must change from a subsidy-based system, if existing water resources can ever sustainably accommodate both the arid West's significant population growth and increasing agriculture needs. Appropriately set market-based prices can make every user recognize that water is indeed a precious and limited resource that must be used wisely.
But economists and other folks who advocate for such higher prices aren't praised, they are usually disparaged. As always, it's very hard to be loved when you're reducing people's disposable income by increasing prices with higher taxes or reduced subsidies in the name of efficient allocation of resources. Very few people care about efficiency once there's less money in their wallets. So, maybe we'll never be thought of as well as dentists. Still, it's strange that we struggle to be liked as much as folks who grind down worn-out molars. So it goes for those of us affiliated with the dismal science.  L





[1] By the way, October 1st is apparently National Kale Day. Who'd of guessed. 


[2] Recall from your Econ101 course the Law of Demand, which states that ceteris paribus as a product's price increases, the quantity demanded will fall. Rarely-seen examples that dispel the Law of Demand include Giffen and Veblen goods –where as price increases the quantity demanded of the good also increases.


[3] There is a thin sliver of conspicuous consumers who might choose to buy certain goods because they're more expensive. We call such consumers the 1%. As mentioned above, economists call such goods Veblen Goods – think of the Rolls Royce Wraith.


[4] Reisner states that in the 1980s, just 1/4th of Westlands Water District's annual available water would completely accommodate New York City's total annual water needs.




Monday, September 15, 2014

LIVING LONGER WITH CHOCOLATE, BROCCOLI AND ZINFANDEL. IF ONLY.

Beware of false knowledge; it is more dangerous than ignorance. ~George Bernard Shaw 

The media regularly provides tantalizing information from health studies that allege people who eat dark chocolate, for example, have lower blood pressure and can be protected from cancer. Eating dark chocolate, many readers conclude, will thus make you healthier and live longer.
Other published studies relate better health to drinking red wine and eating fruit and veges – come on George, eat your broccoli! The august New York Times published a blog in July that reported a study avowing that people who ran at least 5 minutes a day lived 3 more years than folks who didn't run. Chocolate-, wine- and sneaker-makers hop on the bandwagon promoting sales that supposedly provide greater health and longer life.
Don't count on it.
The vast multitude of these studies only calculate a correlation between some outcome measure of good health (say, lower blood pressure) and differences in a single treatment variable (say, eating dark chocolate or running). Such studies measured blood pressure levels in a (usually small) group of people that show a relationship between blood pressure and eating tasty dark chocolate.
These studies dominate health care and public health assessments and rely on statistical correlation between the treatment variable and the outcome variable to make pronouncements. They are termed "observational" in that they may draw inferences about the possible effect of a treatment on the participants, but the assignment of participants into a treated group versus a control group (the group that does not receive the treatment – like chocolate) is outside the power of the investigator(s). In other words, the investigators do not first pick certain people to be the chocolate-eaters and others to not eat the dark stuff as part of the study's a priori design; instead, they separate the chocolate-eaters and non-eaters after they have the data.
So who'd of guessed that just eating chocolate or drinking red wine could really provide better health? Not someone who actually understands the important difference between correlation and causation. Correlation is a statistical measure that indicates the extent to which two or more variables fluctuate together. A correlation between variables, nevertheless, does not necessarily mean that the change in one variable is the cause of the change in the values of the other variable. Causation, however, indicates that the value of one variable is the result of the other variable(s); i.e. there is a causal relationship between the two variables.
Folks who rush to eat Scharffen Burger chocolate after learning about observational studies' results have perpetrated the all too prevalent post-hoc fallacy. This fallacy involves believing the mistaken notion that just because one thing happens (lower blood pressure) after another (eating dark chocolate), the first event is a cause of the second event. Post hoc reasoning is the basis for many erroneous, but firmly-held beliefs that are espoused and acted upon all too often by all too many people.
Observational health studies – like those mentioned above – at best offer correlations between variables, not a confirmed causal relationship. Such studies cannot control for other important variables that also probably influence one's overall health outcome. Eating chocolate is but one quite narrow, singular slice of a person's daily life. Other slices include, your sex, how old you are, all of what you drink and eat (beyond chocolate), how much you sleep, how much you exercise, where you live and work, what your family's health history is, what medicines you take and whether you smoke. Observational studies rarely account for these other factors. Thus, you should take the results of any observational health study with several grains of salt (good thing you're on that low-salt diet, right?). Correlation is not causality.
A recent Slate article illustrates – in spades – the blunder of following the post-hoc fallacy. The authors offer a table that provides specific calculations for how many daily minutes of your life are subtracted by eating a single hamburger, smoking 15-24 cigarettes per day, being a couch-potato and/or residing in Sweden vs. Russia (huh?) among other actions. They call these time units "microlives per day" (that I first interpreted as a type of small olive, silly me). This table also distinguishes these alleged forever-lost daily microlives' effects between whether you're a male or a female over 35 years old. FYI, being male rather than female costs you 4 microlives/day according to the authors. Ready for that trans surgery now?
To be complete, the table also cites possible factors that increase your microlives per day – like exercising, taking statins, and/or eating fruits and veges. Eating 5 servings of fruits and veges each day apparently can gain you 5 microlives. I don't believe it.
This table of misplaced over-quantifications is almost-certainly based on observational studies.[1] You shouldn't assume any factor or number in this table is causally-connected with your health or lifespan. The authors cannot say with any validity, as they do, that a "single dose of ionizing radiation" (from taking one transatlantic flight) will lessen your life expectancy by 30 minutes (that's 1 microlife per day). They believe their work offers a means of "calculating the exact impact of daily choices on every precious minute of your life." I beg to differ since each and every one of their listed microlives' effects is discredited by their subscription to the post-hoc fallacy.
Such observational studies are not randomized, controlled trials which can provide more statistically-precise information about causality if properly designed but are more costly to conduct. Randomized, controlled trails account for about 80% of biomedical experiments (often called "clinical trials" like those undertaken through the FDA) involving drug or medical device appraisals.
So by all means continue jogging, eating dark chocolate and fruit and vegetables with a glass of Zinfandel, but don't think such activity, by itself, will cause your health to improve or make you live even 1 microlife longer. Right now we have no idea about those specific causal linkages, despite what people say.



[1] The table in the Slate article contains no references identifying where any of the numbers (e.g., microlives) come from. Apparently you have to buy the authors' book to get that source information. 

Monday, September 8, 2014

LOOPHOLE WORLD, THE FISCAL SHENANIGANS OF US CORPORATE TAXES


A tax loophole is something that benefits the other guy. If it benefits you, it's tax reform. ~ Sen. Russell Long
Fiscal shenanigans continue with the latest proposed "inversion" merger – Burger King and Tim Hortons (a donut and restaurant chain in Canada). This merger brought out the crowd of nay- and yea-sayers one more time with feelings, including President Obama. The President said inversion mergers are an "unpatriotic tax loophole."

Inversion describes a merger between 2 companies – one based in the US the other in a foreign locale that has lower corporate tax rates – whose objective is to reduce the US firm's corporate taxes by adopting the foreign location as its headquarters. The US is one of the few countries that applies a second layer of tax on foreign income for companies. US companies can avoid this second layer by becoming foreign firms. If this burger-donut merger happens, the answer for Burger King to "Where's the beef?" will be British Columbia, the likely headquarters of the newly-merged firm. British Columbia's top corporate tax rate is 26%. In the US, the statutory corporate tax rate for corporations is 35%, which large and not-so-large companies loudly complain is too high. Their complaints are outright bunk.

Over 40 US multinationals have reincorporated in foreign countries since 1982. The US Treasury Department may forego $19.5 billion in tax revenues over the next decade because of such inversion mergers. Apple made this maneuver famous by "re-locating" its intellectual property in Ireland, the land of green (that's corporate green because of its very low corporate tax rate[1] and its use of territorial taxation.

Based on a detailed study of 288 firms in the Fortune 500 – who earned more than $2.3 trillion in pretax profits in the US – these large firms' actual average effective tax rate from 2008 to 2012 was only 19.4%; a little over half the statutory 35% rate. For the electric utility companies the rate was 2.8%; for the industrial machinery sector it was 4.3%; the telecommunications industry it was 9.8%; for the aerospace and military industry, it was 19.7%. Dozens of corporations including Verizon, Boeing and Corning paid the government absolutely no taxes. Over the 5-year period the tax subsidy provided by the government to large corporations (to reduce their taxes) was an astonishing $364 billion, $70B in 2012 alone. All by itself, Wells Fargo Bank received a tax subsidy of $21.6B over the 5-year period. Did the Wells Fargo CFO give solid gold medals to his tax CPA's and advisors, who are Olympians in the corporate tax loophole and subsidy slalom? Perhaps I should check Wells Fargo's 10-K form.

It thus should be no surprise that as a percentage of total federal spending, corporations have
contributed less and less over time as shown in the figure and now it's 7%. Yup, a mere 7%. And they're complaining? What about those of us who file 1040 forms to calculate our individual income taxes without the help of Olympic CPAs? Individuals pay nearly 7 times as high a percentage of federal spending as corporations: 47% of federal spending now comes from individual income tax receipts. These corporate wolves are crying Canis lupus.

Not usually mentioned in the media stories about mergers like Burger King's, but lurking in the background with broad smiles and fat wallets, are the financiers and mergers and acquisitions (M&A) specialists who really benefit from these corporate efforts, no matter what their outcome. It's interesting to note that Burger King has been bought and sold 7 times in the last 20 years; Tim Hortons twice. The M&A clan has been busy with burgers, donuts and much more. Global M&A activity has steadily risen, increasing market concentration and tightening market control in a multitude of industries. So far in 2014, M&A deal volumes are at a 7 year high.

As usual, the tribe of Midas (both rich corporations and wealthy individuals) wants it both ways, lower tax rates and preserve every tax loophole and subsidy that shrinks their effective tax rates far below the published ones. In large part this is why Senator Carl Levin's dogged but needed efforts to thread the fiscal needle and reform our tax system (both for personal and corporate income taxes) are going nowhere. Why? Because "Every loophole has a lover."

If corporations want their federal income tax rate reduced, we should consider it, but only if we also eliminate Loophole World – all the loopholes and subsidies that produce their low actual, realized rates.



[1] According to the Tax Foundation, Ireland has the lowest statutory corporate tax rate (12.5%) of any industrialized nation, the US has the highest (35%, which does not include a 4% rate representing the average rate that states levy on corporate income).

 







 
 

 

Saturday, May 31, 2014

WHEN YOU REQUIRE LIFE-SAVING DRUGS AND CAN'T SAY "NO," IT'S GOING TO BE EXPENSIVE


The art of medicine consists in amusing the patient while nature cures the disease. ~ Voltaire

Laughter is the best medicine – unless you're a diabetic, then insulin is pretty high on the list. ~ Jasper Carrott


The continuing debate about the efficacy of the 2010 Affordable Care Act (ACA) places inordinate and misplaced focus on the role of government in US health care. No matter what its role, we continue to spend more on health care than any other developed nation. The most recent information indicates that US health care expenditures in 2012 were about $2.7 trillion or 17.2% of our GDP. This expense is expected to grow to 20% within 7 years. I discuss 3 reasons why health costs will keep rising. One is demographics; second is the cost consequences of utilizing ever-more sophisticated medical technologies to fight nasty diseases. And finally, most federal government health care policy decisions cannot take costs into consideration when assessing new drugs and medical procedures, whose pricing is controlled by powerful, giant companies.

Some of the significant macroeconomic consequences of this health-care cost growth have been much discussed – and not at all resolved because solutions will require agreeing to thorny inter-generational decisions involving very large amounts of money. Namely, will our children (and probably grandkids) be willing to pay for our ever more-expensive health-care during our retirement? Time will tell. As it stands, no politician wants to make those decisions.

Departing from this crucial macroeconomic perspective, I offer here a very micro viewpoint about health-care and its costs, based on my personal circumstances.

I was diagnosed with juvenile diabetes (now known as Type 1) more than 5 decades ago. At this point I don't remember not being diabetic. Because we don't produce any, Type 1 diabetics (T1Ds) require daily dosages of insulin – the hormone that allows the body to metabolize carbohydrates and fats. Before insulin was first synthesized in 1921 by two Canadian doctors – Fredrick Banting and Charles Best – early death was a certainty for every T1D, very soon after prognosis. Without receiving insulin, T1Ds' blood glucose inexorably rises and within a relatively short time causes death from diabetic ketoacidosis. Drs Banting and Best sold their insulin patent for $1 to extend and improve the lives of now countless T1Ds, including me.

Successfully living as a T1D requires conscious and continuous "balance" on a 24/7/365 basis. For me, balance means matching my food intake, my insulin dosage and my activity level (both mental and physical) so my blood glucose is well managed and daily glucose variability is reasonably low. In effect, living as a T1D is akin to forever walking on a tightrope. Most of the time I remain balanced on the rope (maintaining decent blood glucose levels); but like many diabetics, on occasion I fall out of balance and off the line.

Possible longer-term consequences of not well-controlled blood glucose include a litany of medical horrors: blindness, circulatory problems that can lead to amputations, kidney and liver failure and elevated risk of heart attacks, to mention a few. Evidentiary data strongly demonstrate that the better a diabetic controls and manages his/her blood glucose, the less likely such complications become. The life expectancy of any diabetic is shorter than most non-diabetics, as the quotes I once got for a life insurance policy attest. Fortunately, I have avoided these nasty consequences due in large part to being a disciplined, conscientious diabetic and having impressive support in this quest.

I have gained much from the support and assistance of my family and friends. Ever since I was diagnosed, my parents and brother, school classmates and then my spouse, children, friends and co-workers, have selflessly assisted me in times of medical need –during atypical bouts of hypoglycemia (low blood sugar). Thank you all. And, during the past 30+ years I have also greatly benefited from expert and systematic care provided by my Kaiser Permanente doctors and staff. Thank you as well.

Mercifully, long-gone are the days when I gave myself insulin injections using a glass syringe that I sterilized each time I used it, hand-sharpened the syringe's needles with a whetstone and tested my urine sugar in a test tube. In the beginning there were no “diet” or sugar-free foods available, none. The introduction of Diet Rite cola in 1958 by RC Cola Co. and Coca-Cola's 1963 introduction of TAB diet cola were game-changers. Times have indeed changed for the better for me and other diabetics.

As a T1D, my continued good health requires more effort, support and expense than a non-diabetic. A recent New York Times article mentions that annual costs associated with being an uninsured T1D can exceed $25,000, depending on the type and level of treatment and insurance coverage. No matter what the level of treatment, all T1Ds require daily insulin via injection or a pump. Economists characterize our demand for insulin as highly price-inelastic. That is, a change in insulin's price has next to no change in the quantity demanded and bought because it's a necessity. For T1Ds, purchasing insulin is ultimately a buy-or-die decision.

A bottle of insulin now can cost $200 with no insurance coverage. In 1975 a bottle of insulin cost $3 (or $13 in 2013 dollars). What changed? The technology of producing insulin changed. In 1982 it was one of the first biosynthetically-made drugs to be sold. The purer, more stable, recombinant, analog insulins now produced are covered under a variety of patents. There is no generic insulin sold in the US, although Walmart sells less expensive, off-patent insulin. 


New medical advances, including those that involve new technologies, are improving the lives of many people, including me. Microeconomics textbooks describe the introduction of new technology as a means of reducing costs. Think about automated manufacturing using robots that has improved such processes' efficiency and effectiveness. But health care isn't like car manufacturing. Medical technologies' introductions have usually increased the cost of medical care. This has been the case for improved treatment of T1D.
 

When the insulin pump was first introduced in the US in the early 1980s, it revolutionized the administration of insulin in a T1D's body by more closely mimicking the pancreas's real-time provision of insulin. For over a decade, I have used an insulin pump to administer my insulin dosages, providing insulin 24 hours a day, as well as whenever I consume calories from food. Using an insulin pump has improved my blood glucose management dramatically. For decades I have used home-test devices to measure my blood glucose. Blood glucose test strips can cost $2,000/year depending on how many are used per day. I also utilized an integrated continuous glucose monitor (CGM) – that measures blood sugar every 5 minutes – for quite a while but stopped because the monitor did not compute accurately enough my actual blood glucose. More precise CGMs are now becoming available.

"Retail" insulin pump prices can exceed $5,000; pump supplies can cost $20 every 3-4 days. A CGM system can cost $500; CGM supplies can cost over $40 per week. My pump has a 4-year warrantee; after that service and support stop being "free" and many pumpers (diabetics who use insulin pumps) get a new one. Many, but not all, insurance plans provide co-payment for insulin pumps and supplies. Fewer plans offer co-payment for CGM systems and supplies.

Would I pay $200 for a bottle of insulin? Absolutely. Would I pay $500 a bottle? If I had to, yes because my life depends on it. I can hardly say, "No, that's too expensive," if I want to keep living. My buy-or-die need for insulin fundamentally changes the market dynamic for insulin and every other life-essential drug. Such drugs aren't options, they're necessities. For these drugs and many others, pharmaceuticals companies can charge what the market will bear. Without insurance (or even with it) it's going to be expensive, sometimes very expensive. Why?

In part because the US Food and Drug Administration (FDA) only considers whether a new medical drug, test or device is "safe and effective," not whether it's cost-effective. Other nations – like Britain – consider drug pricing and drug cost-effectiveness as factors when making public decisions about health-care options. Not the US.

Defying common sense (and cents), the federal government cannot purchase drugs and pharmaceuticals via Medicare and negotiate on drug prices. As a consequence, the market price for drugs in the US can be very high. Health-care providers can negotiate, but not Medicare. Dr Elisabeth Rosenthal, a New York Times journalist and medical doctor, is writing a series of articles under the title "Paying 'Til It Hurts," about US health care costs. As she states, "How much is it [the drug] going to cost? It’s a simple question that goes unuttered throughout the American health care system. It’s a taboo subject. Our failure to ask costs us dearly, experts say. We approve drugs and devices without considering cost-effectiveness, or even having a clue about price. We don’t ask for estimates and then are surprised when the nation is stuck with a $2.7 trillion annual health care bill." And whose interests are not considered by keeping cost a "taboo subject?" Yours and mine.

This legislative and regulatory inability to assess, let alone manage, drug costs and cost-effectiveness is a basis for much apprehension regarding whether we can "turn the health cost curve" so that the growth in these expenses might be reduced. Medical research and technology have been producing noteworthy improvements in health care therapies, and the cost of some new health care treatments is beyond breathtaking – like the $86,000 expense to cure someone of hepatitis C (for a 6-week treatment using a drug called Sovaldi – about $1,000 per pill). Further confirming it's a sellers' market where pharmaceuticals companies exercise dominant control, especially for unique, life-saving remedies, the revenues for the first 3 months of sales for Sovaldi are a record-breaking $2.3 billion.

Despite the impressive political feat of passing the ACA, I'm not sanguine about the Administration trimming future health-care costs. First, the government's plan for reducing health care costs seems to be based on a general hope, "Don't worry, we'll figure it out" by launching a series of pilot programs designed to reduce costs. Perhaps they will, but it smacks of kicking the health-care-cost can down the road for someone else to deal with – when such costs are even higher. Giant pharmas rule the US drug market and giant hospital networks rule that market. Both enjoy plenty of pricing power – and have significant influence on the FDA and HHS as well. When strong market power and new technology are prescribed for essentials, higher drug prices and medical techniques often result.

Second, as ever-more baby boomers[1] become covered under taxpayer-supported Medicare, the public expense of health care will continue to rise due to straightforward demographics. In 2011, Medicare accounted for 47% ($182.7 billion) of total aggregate inpatient hospital costs in the US. This percentage will grow as boomers age.

According to the US Census Bureau, there are more than 77 million boomers. Last year, 14% of Americans were 65 years or older; by 2030, 65+ year-old boomers will represent an estimated 20% of the population. This means that for the next 19 years every day more than 10,000 baby boomers will turn 65. At the same time, the ACA has rightfully encouraged millions of previously-uninsured people and families to gain health insurance. A RAND study calculates that the ACA so far has lowered the percentage of people without health insurance from 20.5% to 15.8%. This is an important and needed change in health care policy, with direct consequences on future health costs. The hope is that by having access to health insurance, these people's health-care costs can be reduced over the longer-term. There's a lot riding on that hope being realized somehow.

Because my visits to the hospital emergency room have decreased and no serious complications from being diabetic have emerged – due to my conscientious blood glucose control and care regimen – I believe my longer-term health-care costs have been reduced by using new drugs and medical technologies even though it's more expensive in the shorter-term. Ultimately, improving our national health and managing health-care costs will depend on disciplined, responsible personal behavior as much as policies that promote appropriate and cost-effective new therapies. Here's hoping we're privately and publicly responsible enough to reduce the future fiscal burden.

 




[1] Baby boomers are the generation born between 1946 and 1964. See my Nov 2010 blog: http://pathfinderbruce.blogspot.com/2010/11/its-all-about-distribution-big-d.html . The beginnings of a key generational shift in the US have been noted by the Census Bureau; there are now more young adults than boomers.