Friday, October 16, 2009

Plutonomy, and the bliss cycle

This morning, Economist Andrew Jackson posted to the Progressive Economic Forum a brief article about the idea of Plutonomy. This is defined as an increase in spending resulting from extreme concentration of wealth.
He writes:
The core of the argument is that countries which have shown an extreme concentration of income and wealth at the very top of the distribution - the US, Canada and the UK are the examples - also have, as a result, very low national savings rates.
The Citigroup report itself argues that it is high spending by the wealthiest that drives this low savings rate, as the wealthiest acquire larger debts to support their lifestyles. But Jackson cites economic studies that seem to contradict this: A Goldman Sachs (why is this the best sauce?) report that the wealthiest actually have an 11% savings rate (while the Average American doesn't have a positive savings rate).

Jackson goes on to argue that it is the Keynesian view (n.b - It isn't really something Keynes thought up but an older idea) that the savings rate increases with wealth, and that the low savings rate of countries with high wealth stratification (US, UK, Canada) "would seem to be at odds" with this. He then asks:
So the question is - what are the implications of hyper income inequality for aggregate consumption and savings?
By way of answering this question, a discussion of measurements and implications is warranted before discussion of broader theoretical questions.

There is no contradiction here between the savings theory and the low rate of savings in stratified economies. A careful assessment of the definitions involved reveals that the entire discussion is one of apples and oranges. The theory of savings is not a relative income theory. It does not argue that those who are at the top save more by virtue of their position, but rather by their income relative to the cost of living. Thus, measuring stratification alone does not provide an argument for some level of savings. Aggregate consumption can increase without reducing savings in aggregate, so long as all the new consumption comes from economic growth. The same holds true for aggregate savings, and for decreases in consumption or savings during recession. The savings rate may change while holding one of the variables fixed.

In particular, this is relevant in the USA, where real wages have been on the decline. If we posit a cost of living in the United States that has gone up moderately over the decades, and then concentrate all the gains in GDP in the hands of the few, it becomes clear how the average savings level can decline. The increased savings of the relatively small class of the wealthy could very easily be eclipsed by the decreased savings of the very large class who are now saving much less due to declining real income.

No modern theory argues that savings habits are uniquely determined by income. There are always a variety of factors. Government inducements to save (such as tax credits or penalties), lending and investment regulations, cultural attitudes, market conditions, etc. all play a part in determining the savings rate of a society. These factors are not uniform either - they can be different for the wealthy than the poor. The U.S. has particular inducements to invest, reinvest, purchase property, etc. written all over in its tax code, so it is logical to see a lower level of savings here. Also, these three nations are toward the more capitalist end of the economic spectrum when compared to other westernized nations, adding another factor of differentiation: savings is also a function of economic security, which is arguably in a long term crisis in these countries (savings is a rate, thus it is more strongly correlated with gains in economic security and vice versa due to fewer social safety nets in more laissez-faire economies).

There is also the question of what constitutes savings - it seems that a proper definition of savings will include long term appreciating assets purchased with loans as savings. A middle class person's house is that person's net worth. (S)he is clearly saving by paying money toward the home loan. But, when measuring consumer debt and savings rates, mortgage debt counts against savings.

So, from an experimental/empirical perspective the problems of measurement make the question difficult to answer given the typical methods of economic measurement. It is not so much that these measurements are inadequate, but that they are conceived from a perspective that is too limited in time, context, and incidental economic conditions. Thus, the methods of measure fail to achieve the universality that is necessary for them to be used for analysis outside of the evidence from which they were conceived. They are objects which only exist "in situ" but depend too much on unexamined assumptions to ever exist as general metrics. This is itself evidence of the limits that our naive doxic modalities place on the development of nondynamic social sciences. We suffer acutely from this in the United States because our idea of tradition in the political sphere is skeptical and static.

The question, of course, can still be answered in a theoretical sense even when the facts are elusive. Unfortunately this theoretical issue requires a critique of the concept of productivity that illustrates the economic trade-offs that technology poses. The final result of the critique will show that productivity gains cannot be expected to drive economic growth beyond a certain threshold. For sake of brevity, I will not include natural resource limitations or negative externalities like pollution or anomie. When general economic growth stops, the owners of the firms will continue to grow their own incomes through the same process of productivity increase, only now the result is no longer positive for the economy as a whole, meaning a period of stratification begins. Eventually the owners will also begin to lose money, and a period of random behavior follows. Hyper-income inequality only occurs during these last two periods, and it is relieved only by programs of wealth redistribution or failures of massive asset classes owned by the wealthy. The consumption and spending behavior of the masses during these two periods depends on the presence and efficacy of various social programs. The implication of hyper-income inequality to aggregate consumption and savings patterns is therefore not causative, but rather a symptomatic relationship.

Since income is a portion of the value of production, with the total income equal to total cost, the principal question of income distribution seems to be the distribution of the income from each unit sold. The individual cannot maintain the same level of income at the same level of productivity if his share of the unit price declines. From a single-firm perspective, the individuals employed may still have increasing incomes so long as the gains from increased productivity are distributed between workers and owners. The lot of the many does not improve when productivity gains are not matched by incremental increases in wages. Prices may fall, but price decreases cannot make up the difference beyond small shifts. A person's bills, rent and car payment will not decrease, nor can services not subject to productivity gains become more affordable. A steady increase of wages in parity with productivity gains is appealing, in part because it satisfies the basic definition of sharing that we learn in Kindergarten.

However, if one analyzes productivity gains from a macroeconomic perspective, this amelioration proves insufficient. Assume a market that perfectly clears. Now, consider that one additional good is produced in that market through a productivity gain. This event must necessarily lead to one of three changes:
  1. The good is sold at listed price and so aggregate savings decrease.
  2. Prices decrease, stimulating demand to sell that one additional good.
  3. The good goes unsold (or is expected to not sell and therefore never produced).
Whenever Case 1 occurs, savings decrease by the simple fact that this money would be all savings were it not spent on the purchase. If a different purchase was preempted in order for this purchase to occur, this contributes only to case 2 or 3 in the market for the other good. Case 3 can happen frequently in the short run, but in the long run it occurs only after the exhaustion of case 2. The price decreases, as described above, do not endlessly benefit the economy, as the increasing relative cost of services that cannot be automated eventually exhausts the balancing effect of these decreases. Furthermore, price decreases and the accumulation of unsold inventories create incentives to disinvest from the industry. Though the argument is not yet complete, for sake of clarity at this point the equilibrium production level for that industry has increased slightly and moved toward a lower price. The proportion of decrease in price will depend on the degree of competition in the industry - the single firm has an incentive to push for price decreases in order to capture a greater portion of the market, but in oligopolistic or monopolistic settings there is little or no incentive to lower prices, respectively. Prices, in any event, are not important for the discussion at hand, being significant only in their changing of consumption habits which all do the same things, relative to my conclusions, anyway.

To a certain degree, we are assuming that the gains in productivity are shared with the workers. This implies that the additional profits from production will produce a demand stimulus. However, this demand stimulus is limited to less than the revenue gain of the firm (because the remainder of increased revenue must go toward the owner). This quantity is also reduced by any decreases in price. The demand stimulus is therefore always insufficient to absorb the higher quantity of goods - therefore savings decrease and/or other parts of the market experience reduced sales.

Through various mechanisms the profits of the owner become investments into industry. The degree to which these new investments become sources of economic growth depends on the existence of new or possible industries which would compete favorably for consumer dollars with the existing industry. For our purposes, these industries pay wages but do not produce any competing goods yet - they are "start ups". In combination with the other sources of stimulus thus far, we have an equation (in dollars):

Increase in wages + reductions in savings + reductions in sales of other goods + wages from new industry = increase in sales of a given good.

Here I will posit a few constraints in the form of bliss points toward which consumers trend. Consumers have a "variety of goods" bliss point which determines the degree to which new industries will eventually succeed. Consumers have a "total goods" bliss point which determines that eventually the equation trends toward "Reductions in sales of other goods = Increase in sales of a given good", i.e. good substitution. When wages increase, increases tend to affect less than the entire workforce, and so create increases in savings that in turn cause a drag on sales increases. So long as the entirety of productivity gains express themselves through wage increases and new industries, these constraints will eventually come into full effect.

The corresponding situation when sales of a given good are not increasing is given by the same equation. We simply set the right side to zero or a negative. In this situation, gains in productivity lead only to decreases in the total labor utilized on a particular good, and possibly increases in other goods production, wages from new industry, or savings.

Eventually, however, the aggregate of all of these markets for particular goods will "zero out" (with balanced levels of increase and decrease typical of any equilibrium situation). Thus, economic growth is culturally limited by the bliss points - the accepted level and variety of consumption within the society. Therefore, the transformation toward a consumer culture is necessary as part of the package of long term economic growth. However, such a culture is not necessarily a more pleasant one to live in; and it is likely that there is a limit to any possible bliss point in terms of quantity and variety. Thus, the first stage of "growth" comes to an end.

The onset of stagnation gives rise to (and is accelerated by) the accumulation of wealth by the richest classes. Wealth becomes concentrated at the stagnation point because from this point forward, productivity gains lead to no further economic growth, and thus there is no sales growth to divide between worker and owner. The entirety of the productivity gain is thus expressed through the cost saving, i.e. the reduction in labor utilization. Thus, the productivity gain leads only to profits. These profits will see limited expression through new goods that have narrow or nonexistent profit windows. This is the second stage, the "stagnation" period.

This can only occur if the tax rates on the wealthiest classes actually permit the unlimited concentration of wealth. Where tax rates are progressive, they can slow this process, but can't really halt it. Only where there is no incentive whatsoever to acquire wealth beyond a certain point (either a 100% threshold on income tax or a wealth tax that creates an effective maximum wealth) will this process not occur.

In any event, the lack of meaningful investment opportunities for the newly accumulated profits leads the wealthy to behave erratically after some time has passed within the stagnation period. All manner of investment schemes will be invented in the vain hope of providing some means of profit. A stiff competition will arise that drives competitors to many tricks in an effort to gain advantages over each other without resorting to the horrors of the price war. This is the "erratic" stage.

In most economic situations (and I am still speaking theoretically here, even though this is virtually a statement of obvious fact), the system of competition is not perfect or "pure". Typically, the producers have a certain degree of agreement between each other on production levels. A complex system of laws always accompanies economies for the purpose of enforcing against unfair trade practices and other abuses. Systems also exist to protect workers and consumers. The economy is therefore managed synthetically or "by design". During the worst of times, blame is passed around like a hot potato and it is no wonder that systems of prediction break down - they were based on what politicians, corporations, and other power players wanted people to believe but they were never the whole truth. Of course, the people involved in these simplifications do not have a total awareness of what they have done, and so are somewhat helpless when real objectivity is needed. Ergo, amok.

At this juncture the various economic stages can be expressed as the growth stage, the stagnation stage, and the erratic stage. The cycle is allowed to repeat as a new generation rises up with a new set of consumerist indoctrinations, allowing the entire system to achieve a higher degree of consumption. It is not a business cycle, but a bliss cycle. The driving factor is the revolution in consumer purchasing patters enabled by the development of higher degrees of dependence on material objects for quality of life. In particular, the ideas that are lost in this material transformation are self-sufficiency, charisma, and spirituality. It is also worth noting that as these things develop, new levels of productivity are realized, creating "better" goods than what was available before. But are they really "better"?

The loss of self-sufficiency is the loss of knowledge and skill in daily crafts, routines, and handiwork, and the dependence on various material objects that cannot be readily produced by the individual or immediate community. The person becomes dependent on distant parts of the economy for his very existence. A person cannot survive in much of America without a car, and this dependence on automobiles ensures a much higher level of total economic output than what we would otherwise have. But the individual cannot produce his own food, clothing, grooming products, bedding, housing, or virtually any other thing in the modern economy. Therefore, these must all be purchased. This is a major source of growth.

The loss of charisma is the loss of the appreciation of other humans in our daily lives. It is the loss of free or inexpensive means of entertainment rooted in the appreciation of the beauty of other humans. Storytelling is replaced by live theater. Live theater is replaced by books, radio, eventually movies and television. Even the idea of beauty is replaced: it is no longer a particular girl or boy in the village, town, or city, but the digitally retouched famous person. Ideas discussed between individuals are instead only read about (and ultimately become politically irrelevant) because now individuals perceive each other as being stupid or ignorant in comparison with the polished and vetted non-fiction media that is marketed to every demographic. A person cannot be free without drugs or alcohol. A person cannot make love without condoms, birth control, batteries of tests, their own apartment, fantasies, etc. And there is no time for (annoying) children in the careers of busy professionals. This includes what one might think of as mass media, but it is not caused by any particular actor or institution.

When speaking of a loss of spirituality, it is easy to step on toes. So I will be brief in this regard: the way that people live today is one in which they are utterly unaware of their own effect on the world and are disinvested from their own feeling of potency. So long as the individual depends on external, market sources for self esteem, he is hopelessly committed to spending.

These transformations are brought about through the collective effect of the marketing efforts of the producers of the various products that become integrated into our material existence. The individual marketing firms use advertising, product placements, promotions, salesmen, etc. to increase sales of their particular products, but the collective effect is the transformation of social values and norms and the increased susceptibility of the general populace to any and all new products or technologies. Utilizing hooks that draw the individual into the belief that the purchase is necessary is the essential means by which the prospect is turned into the sale. In so doing, the marketing force constantly convinces the individual of his or her own insufficiency.

In connection with the thesis proper, the very presence of hyper-stratification is evidence of economic mismanagement. It only occurs through the accumulation of wealth by the richest for which no similar accumulation occurs in other classes. It takes a unique political sphere for this to even come about. Welcome to America.

Tuesday, October 13, 2009


People are judged most severely for what they think when they try to offer solutions to problems. Both the common man and politicians are discouraged from offering solutions because of this. Unfortunately, with a complex problem that requires lots of data sources, it is basically impossible to get it totally right on the first go. The first people to attempt to solve the problem are therefore the sacrificial lambs to the innovators who come after them and steal the glory with a more or less correct solution. Nobody wants to be that first guy, and so problems go unsolved.

In many scientific spheres, there is an attitude of development and documentation that ensure that people receive their due. The system in place is much more encouraging of speculation, and of course because scientists are an elite club, they always give each others' ideas more deference. Hence, natural science has developed splendidly, while social science, dependent on systems where individual expertise is always in doubt, can never build off the theories of those who came before.

Friday, October 9, 2009

The proper role of insurance in healthcare

After reading the two part healthcare articles by L. Randall Wray over at Economic Perspectives from Kansas City, I found that my squishy brains was churning with thoughts regarding his argument that we are utilizing insurance too much in the provision of healthcare. What is the proper role of insurance in healthcare?

1. Healthcare and Insurance

The issue can be elucidated by taking two analytical steps. First, pretend that healthcare services are classical or "typical" services and posit what properties they have that differentiate them from the norm. From these properties comes the justification to treat healthcare services as being different from other services. Of course, the degree of regulation that a person expects to exist for the economy in general can muddle this analysis, and it is likely that many important properties of healthcare services will actually be present in other classes of service. The second step is then to determine how well insurance provide various functions of healthcare.

In the past I have asserted that the healthcare problem is a public contracting problem. This is true because healthcare services are much like services provided by private contractors to the government. Public contract services are paid for by a public agency but provided by private entities. Often, these companies are one of a few firms that can fill the contract, and so the contracting agency may have few options. Similarly with healthcare. For people who actually receive healthcare through the government or paid for by the government, their healthcare really is a public contract. Although healthcare is not always paid for by the government in the United States, the public pays into health insurance pools which are then administered by insurance companies. A person is often limited in his/her healthcare options by where he/she works. Even where healthcare is purchased on the market by private citizens, few have the understanding or sophistication to see how the policy will actually play out for them, and so competitive regulation is absent and the decision is essentially arbitrary. For people who develop medical conditions and are unable to switch providers, these folks are locked into a public contract situation where their insurer can often make arbitrary changes to the contract. In public-private contracting, the government, and therefore the public, is in danger of being harmed by companies that use manipulative business and accounting techniques to undermine the level of service that they provide for their own profit. Similarly, a person or group of people entering an agreement with an insurance company are in danger of being harmed by the fine print of their contract, negotiations made by their employer on their behalf, and "pre-existing conditions". In order to ensure that private entities are providing efficient and quality services, the key questions and the place that most of the work must be done is in the oversight of the private contractors.

But healthcare through an insurance model is really a question of double contracting. First, insurance companies enter into contracts with the general public. Then, these companies turn around and enter into contracts with health service providers. For government provided healthcare, there are services provided through the Veterans Administration or Military, where the government actually provides the service, and there are services like medicaid that contract with healthcare providers, just as insurance companies do.

But healthcare is not really a uniform service. It is often tacitly assumed that people have no real preference beyond "the best quality available" in choosing their healthcare service provider. This, however, isn't true. Some people will prefer a more friendly doctor or one with a more professional demeanor. Some people believe in alternative medicines. One healthcare economist has compared this to people's taste in restaurants, though this may be a stretch. People primarily want consistency and accuracy from their doctors. Data compiled in hospital mortality rates clearly show that some surgical teams are much better than others. The public is not allowed to know which hospital they are more likely to die at, or which doctors are most likely to misdiagnose their condition at the clinic. Faith is placed in the doctors that they are all trying their best, and that is enough for even the most free-market voices in the public debate on the issue.

It is not clear that the public would do the right thing with hospital quality of care information, were it aggregated by a nonprofit or government agency and made available to them, but a good argument can be made that it would. At the very least, it might cause services at better rated hospitals to be bid up in price, and services at not-so-good hospitals to fall in price. Very rarely, this would create a situation where those who couldn't afford to go to the nicer hospital instead go to the alternative hospital and experience a reduced health outcome or even death as a result. This is only a very small harm. Hospitals, however, would experience a much stronger incentive to provide quality care, because the prestige of the institution and its management would be at stake. Here there would actually be a rarity in business: an accepted philosophy for what a quality service actually is combined with public concern sufficient to motivate action. It might happen that hospitals that serve poorer communities would suffer an even greater reduction in health outcomes than what currently exists, but how do we separate our new knowledge from the effect of knowing? There is also a deeper, philosophic argument for why this information should be available. Public disclosure is a necessity in free societies.

Enter the insurance company. The insurance company will not insure patient care. Though it does have the sophistication and means to determine, to some degree, the quality of service provided by each medical provider, even while keeping the general public from knowing. However, they only have a limited interest in preserving patient health, insofar as preserving the health of the patient will maximize the future difference between premiums collected and costs of services paid out. This makes them unlikely to act on such knowledge. The insurance company also has no interest in limiting costs that it can pass directly to patients. As an actuarial institution, the insurer has an incentive to limit payouts on the patient's behalf, passing as many costs to the patient as possible. The insurer that is unable to do this will instead seek to negotiate for lower costs of service from the provider, but the items of negotiation do not necessarily correspond to the profit margin of the service, and hence can lead to strange gamesmanship between providers and insurers that undermines quality of service. In short, it would be difficult, if not impossible, to create a system where insurance companies act on behalf of their patients. The relationship is naturally one of adversarial negotiation. The insurance company is really meant to address the financial aspect of the situation, specifically providing large short term payments that individuals cannot afford.

One can expect the average individual to pay much more to insurance companies than he receives in benefits. Theoretically, this is the only way such companies can exist, as they must pay for their own employees as well as turn a profit for their investors with an income stream that is only premiums. In practice, however, insurers negotiate steep discounts on service costs from health providers. Therefore, insurance can lead to reduced costs for the average consumer. This is at least partially a result of information availability to consumers, specifically the nondisclosure of provider quality. This factor seems to be a source of abuse as well, as insurers do not necessarily act as agents of their policy holders. To complicate matters, these contracts are not subject to uniform standards of disclosure. Even so, the insurer maintains some level of negotiating leverage with health providers by being able to route its policy holders toward less expensive hospitals. It is not quality of care that matters so much as price, but the downward pressure this exerts on healthcare costs is probably significant.

Here it is worth noting that the presence of strategically placed regulations and oversight requirements can be very powerful in forcing insurance companies into the proper negotiations with providers instead of allowing them to gouge consumers. This seems to be a significant part of the current Democrats' healthcare reform strategy. As is usual in politics, the people who proposed a solution were criticized harshly and in ways that had little to do with the facts. Where insurance is providing services it reasonably should, the addition of sensible regulations will lead to a very efficient outcome that can be called a "solution". In cases where insurance really has no business, this change is not really going to solve problems so much as suppress bad outcomes, requiring constant regulatory adjustment and fixes to cover loopholes and tricks, and a high degree of efficiency will not be achieved.

It is also worth asking, if only for theoretical reasons, what criteria a person can use to select an insurance company. Often times a person will pick insurer based on cost alone. In other situations the individual will know that they are more likely to use one or another service, and pick an insurer that has good coverage of that particular health service. Distance also becomes a factor, and sometimes people will ask their friends about quality as well. All of these are valid criteria, and so long as free markets work in general, there is no reason to believe that individuals cannot pick insurance plans that work for them, so long as there is some minimal quality of contract that insurers provide, i.e. so long as the government pursues reasonable regulation of the insurance business practices.

2. Where health insurance works

The types of health service paid for by insurance companies are nicely described by Professor Wray, and I will briefly summarize them, then assess whether they are best provided by insurance companies, the government, or individuals.

Insurance companies cover random, catastrophic health events. These include physical accidents and injuries caused by others, outbreaks of disease, and some other non-chronic conditions. As long as these health events conform to solid actuarial standards, and there are proper government regulations to constitute a "second best equilibrium" where insurers compete for quality of service and financially incentivize people against risky behavior, this type of healthcare is well provided by the insurers. These catastrophic events will, of course, visit individuals more or less frequently and at greater or lesser cost along demographic factors which a person does not have control over - age, gender, geographic location, occupation, specific health conditions, etc. Here, regulations requiring insurers to offer the same rates to all these different demographics would only lead insurers to compete to control the "choicest" demographics. In fact, they will do this anyway, but much less desperately. To a certain degree, risky behavior cannot be separated from the demographics, because insurers are limited in the information that they can obtain. If the question is one of equality, there is no reason that the burden of equalization should fall on the insurance company (For instance, if the cost of being female is just higher in our society than it is for being male, a subsidy could be used to ensure that women are not made poorer than men on average as a result). Health insurance works in this case, and it is very similar to what one sees in car insurance or any other type of insurance.

Insurance companies cover routine care. Here, the individual will express the greatest preference for variety of care. Some individuals are best served through home visits. Others seek alternative medicines. Still others will not be bothered to take any steps toward routine care whatsoever. Though the majority may still come to regular check-ups with traditional doctors, individuals will express a variety of preferences in this regard. In this market, it really doesn't make sense for insurance companies to be involved. What is really needed is consumer advocate groups who can rate care providers along the lines of price, quality of service, sanitary standards, etc. Insurance companies cannot be trusted to do this consistently, as they are not agents of their policy holders and don't really care about quality of service. However, in this situation, insurers who provide catastrophic coverage can look to personal health records and give lower premiums to those who show evidence of actively working to preserve their own health. Because of its low price, routine care is not well provided by insurers, and the price-negotiating effect is less likely to reduce costs for consumers. If the goal is to make it affordable for all people to receive routine care, subsidies should be introduced to make it affordable for everyone, or perhaps the issue of poverty should simply be addressed separately.

Insurance companies cover the cost of chronic conditions. Here, the unlucky insurer ends up trapped in a situation where they are paying large sums of money for a long and indeterminate period. The money is spent on expensive medical techniques, drugs, and hospital stays that would be much more expensive if paid out of pocket. This is probably the porkiest part of the entire system. Here, the power of insurance companies to negotiate prices down is probably the strongest, but also where the greatest tension arises between insured and insurer. Here is where people are denied coverage because of preexisting conditions, where fine print costs families their savings, where secret deals fleece the consumer, and where the vast majority of healthcare costs are incurred. The problem with this is that here there is no actuarial element - a person has a condition and there is no risk against which the person is insured. Here, a person needs a health advocate who gets people together in groups and negotiates with the healthcare provider on their behalf. This really shouldn't be an insurance company.

To summarize: Health Insurance should cover only actuarially appropriate health risks and should not be used to pay for routine checkups or long term care.

3. Solutions

The issues that most critically need to be addressed are the costs associated with chronic conditions, the transition from catastrophic event to chronic payment, workplace-funded healthcare, general regulation, and standards of disclosure. These are really issues in healthcare and not insurance. Where insurance should not be involved, the structure of a system that does not utilize it is sketched out.

A. Chronic conditions

Because of the great disparity in costs associated with the cost of chronic conditions, the way that this aspect of the healthcare problem is managed will essentially determine the success of the entire system. There are really three groups of chronic conditions: those associated with old age, those associated with poor health choices, and those that the individual is not at fault for.

Chronic conditions associated with old age for the most part fall under medicare in our current system, so I won't dwell on these issues much longer, except to say that medicare should probably phase in sooner for most people. The effects of aging become pretty clear by the time someone is 55. From now on, my discussion will focus on chronic conditions caused by poor health choices and events outside of a person's control.

Medicaid and other programs that provide medical services to the poorest of the poor should also be expanded to provide these services in a complete and consistent manner. Unless a person is in such a group, there is no reason to expect their healthcare to be free, and so everyone else will have to pay, even if only a little bit.

In order to control costs and ensure quality of service, people with chronic conditions need a union, not an insurer. A "Health Union" would be an organization that geniunely represents the interests of its members. Those who don't have chronic conditions don't have a reason to pay dues or be members, and they shouldn't. Those who do have chronic conditions would pay to hire a collective bargaining team to lower costs for them. Unions, as fundamentally democratic and not-for-profit entities, have the potential to maximize both the cost savings and the quality of care for their members, and they won't hesitate to fight for their members in court. If conservatives get all pissed off about the term "health union", they could be called "health advocacy associations" or even "HMO"s.

If costs are still too high after bargaining, which they most certainly will be, these costs would need to be subsidized. The best way to structure this subsidy would be to preserve a portion of the individual incentive to shop for lower costs while covering the bulk of the expense from the supply side. Something like 60-99% of the cost of procedures would be paid by the subsidy. Individuals who cannot afford to purchase their medicine even under these conditions would ideally also qualify for medicaid. Where there are cases of individuals not being able to afford care, it is really a case for expanding medicaid, not a case for universal coverage.

Funding for subsidies related to poor health choices would come from taxes on products that contribute to those choices. This is already the standard for cigarettes and lung cancer. This philosophy should be expanded to include all products in the proportional degree of their contribution. For instance, soda contributes to type II diabetes, and therefore it and other sugar sources should be taxed appropriately. Motorcycles and Automobiles lead to traumatic brain injuries, and therefore they should pay a tax to help cover the cost of these injuries. Alcohol, of course, would be taxed heavily. Individuals should pay for their own health choices, but I can think of no other way to bring this about. Making individuals pay for their own chronic care only at the time of providing the health service is impossible. If these taxes are not levied, most people will not be paying the "real cost" of the products they consume. This is the most fair alternative I could think of, and it will reduce costs in the long term as well.

Funding for subsidies stemming from no fault on the part of the individual must come from the government. We have a long and compassionate tradition in this country of providing for people who have disabilities. We believe in a level playing field from which everyone has the same opportunities for success. If this creed is more than words, it must be put into action in a way that allows those with chronic conditions to live without crippling medical debts. This is a general fund issue, just as education, human services, and national defense are. Any one of us could wake up tomorrow and find that something has gone horribly wrong with our body. Just as the government protects us from Al-Quaida, it should protect us from the financial ruin associated with such a situation. If the cost is high, we should accept a higher deficit or raise taxes in whatever way is fair.

B. From catastrophic to chronic

The transition between catastrophic care and chronic care is worth addressing here because I have assigned one function - catastrophic health coverage - to insurers while reserving chronic care price negotiations to health unions and government agencies that set subsidies. Insurers will want to reclassify people as receiving chronic care at an early stage, while the legislatures crafting budgets will want to keep individuals in the catastrophic coverage stage as long as possible so that they can then reroute general fund dollars to their own pet programs.

There is no simple argument for when the transition should occur. Insurers may be able to set this threshold in a reasonable manner, preventing any formal legal definition from stipulating an exact time frame. There are reasonable bounds: post operative care should be covered as part of the definition of covering the cost of an operation; catastrophic coverage that pays for an emergency surgery to battle an invasive tumor should not be required to cover a person's chemotherapy for the rest of their life.

Whenever the transition happens, it will be crucial to prevent any disruption of care. For this reason, a person should receive both advanced notice and expert counseling that informs them of the financial effects of the transition and their options. Because chronic care is directly subsidized, even if disruptions do occur, a person who pays out of pocket rather than through a health union would not usually pay significantly more. When (s)he does pay significantly more, it is an incentive for both the individual to join the health union and the government to improve the transition, because the government would pay more in subsidy as well.

C. Workplace funded healthcare

Workplace funded healthcare is not so much of a horrible mistake as Professor Wray contends. Because workers spend a disproportionate part of their lives at work, and because occupational hazards can lead to many catastrophic events and chronic conditions, it is really a prudent public policy to make businesses financially responsible for the health of their workers. The problem is that businesses must pay for a huge variety of events that they aren't responsible for at all. Many businesses cover the entire family of the worker, even though the worker's family never sets foot on the factory floor.

There is a specific class of care that businesses should be responsible for. Though the majority of businesses these days aren't the dangerous factories of yore, safety hazards still exist at all businesses. When a person is injured on the job, the company should be required to pay for the catastrophic treatment and subsequent chronic care. This does not necessitate an insurance policy unless the business is small, but it is possible that businesses will purchase policies to cover financial costs merely to outsource the administration details. In this situation, the worker is made more remote from the insurer. For this reason, a strict and narrow standard should be used: individuals should purchase their own catastrophic coverage which covers all non-workplace related health calamities; businesses purchase coverage which covers their cost of paying for medical expenses that result from workplace accidents or chronic ailments.

If a business has a practice that results in 20% of its workers developing back injuries due to repetitive strain, the business should pay the cost of this care. Even if this means that the business has to charge more for its products, society isn't paying the real cost of production unless it pays this extra. If this contributes to other countries outcompeting the United States, one must ask if tariffs really don't make sense. After all, these foreign countries dotted with sweat shops aren't making their own businesses pay the real cost of production, and so they don't deserve this competitive advantage. Businesses, of course, will have an incentive to treat their workers well when they have to pay for injuries. When they don't, they won't.

As a final note on this issue, the practice of using temporary employees and independent contractors must be regulated and disincentivized. A company that contracts with a third party to bring workers into its own factory or production process should be required to treat these individuals as its own employees. There are far too many abuses that manifest under the alternatives.

D. General Regulations

Regulations take the form of rules that determine what is acceptable and allowed. They also form the groundwork from which individuals make decisions in the context of market competition. Regulations can improve health outcomes mainly through information sharing requirements and intercompatibility rules.

Healthcare, being a complex process of coordination, negotiation, and expertise-dependent decision making, is prone to the development of proprietary architectures. The role of the government in this situation is to spare the consumer from the horrors of learning a separate system for each different clinic or hospital that (s)he visits. Because of the way that businesses operate, often they will not see an individual incentive to change their system to conform to those of other businesses, but massive improvements in efficiency can be realized through standardizations. The creation of standard forms and intercompatibility rules should have very strong positive impacts on efficiency.

Many things that need to be required or regulated may already be so. A person's health record should be available to be transferred in total from one provider to another. Privacy rules should be uniform and strict.

Insurance must be prevented from worming out of commitments. Customers need a credible belief that they are actually buying something. This is especially true if the government plans to force individuals to purchase catastrophic coverage.

E. Disclosure and Oversight

I return now to the topic of disclosure, as it was mentioned at the beginning of this essay.

Disclosure is the keystone of any effective partnership between public and private. The necessity of disclosure is absolute. Without knowing what all health companies are doing with the money they earn, it is not possible to know if services are being provided efficiently. Similarly, insurance companies can conspire to gouge consumers if their profit margin is not public knowledge. The main obstacle to disclosure requirements are several arguments against them, which I must now turn to.

Some will argue that disclosure requirements harm firms by forcing them to share proprietary information or trade secrets. However, there shouldn't be these kind of things in healthcare. If a company has a way to do something better or more efficiently, it is that company's duty to share it.

Others will argue that there is a high cost associated with creating and maintaining the records needed for disclosure requirements to be met. However, these records should be kept by the company even in the absence of them being required to publicly disclose them. Should a hospital keep track of the success rate of its operations? Probably. If there is any credible argument to be made that businesses strive to provide quality of service, these same businesses should be measuring the quality of the services they provide.

4. In conclusion

So long as healthcare is provided entirely through an insurance system or a centralized "single payer", incentives to select for true quality of service at an affordable price will be muted. Real savings are best realized through a sober dissection of the healthcare question. Insurance has its role in catastrophic care. Markets and consumer choice are key to routine and preventive care. Chronic care must be treated as a different beast entirely. The government's role in Medicare and Medicaid should be expanded.

There are many many details behind each and every generalization I have made here. Much of what can be realized will depend on the work that is done to craft accurate payment schedules, savvy negotiation of prices, and work through the details. These details must equal the whole: I am writing with the expectation that good faith is followed. This is always the case, with any statement of what must be done. Arguments that what I have imagined cannot be done are welcome.

After writing most of this, I noticed that a soda tax has been proposed. This is an excellent idea.

Monday, October 5, 2009

The definition of 'work'

I would like to construct a better definition of work that is broad enough to engage a more general philosophic view.

Work is the object of labor - workers labor only because there is work to do. In the market setting, whenever there is work to do, this implies an expectation of profit. Even in the short term case of unprofitable firms, labor is only contracted under expectations that losses are thereby reduced. Thus, profit as used in this essay is only a relative quantity, a "net gain". In short: labor implies work; work implies profit. Throughout the essay, work and labor will be used almost interchangeably: work IS labor in the sense that there is always much work to be done but we tend to be oblivious to the vast majority of it because we do not perceive anyone actually intending to do it.

If work is to be a well defined aspect of our economic life, then it cannot be defined such that the same action taken by two different people is work for one of them and not work for the other. Although this distinction - the subjective division between work and leisure - underpins much of the early philosophy of economics, it suffers from several flaws. The first is that meaningless service exchanges look better from the perspective of common metrics such as "unemployment". For example, suppose two unemployed people decide to work for each other by buying each others' groceries. In this way, they are each performing a service for someone else and getting paid for it. Thus, one might suppose that this is work, but that buying groceries for oneself is not. Secondly, a person might enjoy doing something that others consider to be work, or a person might not enjoy doing some action that he or she is in some way compelled to do without pay because it is considered to not be work. Therefore, the idea of the desirability of any activity is a hidden, subjective, and informally classified determinant of economic variables - it is a source of error.

Accepting the above gives a very broad definition of work: work becomes virtually all human activity. The distinction between voluntary action and pecuniary actions, which was never well adhered to in economic theory anyway, disappears. Work can be defined as all human activity except those functions that another person literally cannot do for a person. For example, although I may feed you, I may not eat for you; although I may change channels for you I cannot watch TV for you. In certain cases the distinction is subtle - a person may gather information for themselves or have it reported to them, but the act of learning and internalizing is not delegable, and therefore not work. One can make distinctions in work based on telos: Is it work for oneself, for "pleasure", etc. or for an organization or for society in general? The problematic aspect of this type of distinction making is that it is not always clear what constitutes what, nor does the individual always have a clear idea of their own causes of action. The substitute person need not be a real and identified other who will step forth to act - (s)he is a theoretical person who could step into one's role and complete the task. Additionally, work is a separation of action from authorship. Workers do literally sign away their rights to their own creations when they work in a creative capacity for a corporation. More fundamentally, anything that one can conceive of as being an activity someone else could do is an activity of which a person cannot also claim himself author, and so anything truly authentic or unique is not definable as work. Here, the distinction is between general action and details.

If economics is to be a predictive discipline, it must make every effort to maximize the degree to which it predicts future economic activity. Continuing with the assumption that work is any human activity that another person could complete in your stead, the basic premise that work implies profit must either be abandoned or profit must be defined to include nonpecuniary goals. The latter assumption seems to be more straightforward and elegant, and for purposes of descriptive brevity, this is how it will be defined throughout the essay. More precisely, profit is the direct achievement of personal ends or the achievement of ends on which some personal goal is contingent. The theory is not violated when a person's goal in life is to make as much money as possible, nor is it violated when a person's goal in life is to smoke as much weed as possible. Here I note again that in practice individuals act on expectations of profit.

That offers of work are often treated as implying profit on the part of the firm is a particularly troubling assertion. In this, the "firm" is created as a mystical entity, where in fact it is a collection of individuals. Furthermore, the profits of the firm are collectively the property of the investors and creditors. The balance sheet shows this to be true. To say that a firm owns property is to assign total ownership to one group - the investors and creditors - and then to assign some other level of ownership to the firm itself. Therefore, the firm does not own itself, and cannot claim its own profits; it becomes nonsensical then to assume it is interested in achieving profit. A person who takes an offer of work receives money in exchange for some activity. This is labor in the classical sense, and it work in time and effort. A person who spends money in exchange for some goods or services has been offered work as well - it is work in selecting and exchanging. Even a person who is watching television is working by viewing advertisements. An author depends on the work of his or her readers. All of these are work in the broader sense, and all of them are acts of labor. One might object that these are different kinds of transactions, one being a spending of wages for goods and the other being the production of goods for wages. Here, though, one must ask what the significance of this distinction is: limiting work to work for money forces us to treat volunteering as not being work, or the work of a student as not being work.

The appeal to a framework of division between needs and wants does not help the matter. When a teenager goes to the mall to buy designer clothes, we do not treat this as work, even if the teenager feels that he needs these clothes in order to fit in with his peers. When a person takes on a second job simply because he wants to save up money, we do treat this as work, with or without appealing to a theory of necessity. Furthermore, we encounter many difficulties if we attempt to make more formal definitions. Does a person need to be literate? Does a person need adequate nutrition or is malnourishment simply an unpleasant part of life, like boredom? The first instinct is to introduce a rights framework, but then one has effectively abandoned wants and needs. Rights, of course, suffer similarly: to introduce the individual right to be nourished is too weak of a demand to actually ensure nourishment.

Returning now to the idea itself - that work is any human activity that another person could complete in a person's stead - the benefits of this definition are numerous. Many problems are clarified.

1. Ensuring that there is enough work becomes a meaningless endeavor. The real objective becomes to ensure that social goals are achieved.

Economists use measures like "unemployment" to gauge the health of the economic system. This definition and its common use strongly imply work to be a good thing. Although intuitively we often feel that work is a bad thing (just as we might curse when we spill a glass of milk rather than saying "hurray! Some work to do!") we just as often enjoy work: we may enjoy shopping, cooking a meal, or even arguing on the internet. As outlined above, it is silly to distinguish between work and play on the basis of some subjective sense of enjoyment or dread because work is the path to the achievement of personal goals, not the actual goals themselves.

The real problem with people not working is that they may be unable to provide for themselves in the long run. Their quality of life is compromised. This is an ethical judgment, just as any preference for some level of employment is ultimately ethical, whether based on Pareto optimums or some other economic pseudoethics or on a philosophic theory of ethics.

When society decides that it wants to address unemployment, it is a mistake to try to create work. In reality, everyone is always employed, and so the question is whether to change their actions so that they are more profitable. This may require a mix of mandates, training, subsidies, and assistance programs. What the society should do is find work that is not being done and entice people to do it. Here, individual goals are scrutinized on the basis of their importance. Avoiding starvation is relatively more important than buying another toy. In our present society, there is no shortage of work to be done that is very valuable to everyone. Our goal of preventing climate change could motivate us to build more wind power generators. Our goal of preventing homelessness could motivate us to produce low cost housing. Our goal of westernizing the world could motivate us to teach or volunteer in impoverished countries.

When there is no work that is not being done that that society feels is worth doing, the alternative is to either change the division of labor between individuals or to create a class of people who do not work. America has categorically rejected the second option - we do not want to create a dole. The goal, however, is to ensure that everyone has a minimum quality of life, and this means they must have the income to support that quality of life or receive services as a charity.

2. Individuals will tend to minimize work along profit isoquants.

In a more technical sense, work is a collection of activities to the achievement of profit. I have not yet created a metric for measuring quantity of work, but any such definition will feature a balance of criteria such as time, effort, physical hardship, etc. that detract from an individual's profit. There will be situations where optimizations exist, and it is reasonable to expect individuals to take actions to optimize work (i.e. do less work per unit time, but still be considered "working" throughout that time). Nobody wants to be Sisyphus, rolling a boulder up a hill only to have it roll back down over and over again. A person who is working is always accomplishing something in his own mind.

3. People are always working. Consumer behavior is explained in the same way that worker behavior is.

A person who is doing an "enjoyable" activity that is not classically categorized as work is engaged in a profit-seeking process just as a worker or manager is. Take, for instance, the person shopping at the mall for new clothes. The profits come from ideas of achievements of fashion. The person is directly experiencing joy through social pressures that tell them this is how to behave and through the experience of feeling closer to the goals of looking good. Perhaps the person is achieving the direct goal of simply going out and shopping, possibly with friends.

Even a person who is loitering on the street or sitting around bored is working toward goals. The person is "killing time" or "hanging out" or one of many descriptors that indicate that this is the way by which they are looking forward to future profit. Such a person is not choosing against any better thing he or she could be doing, he is valuing these as less valuable than simply waiting. There is no room in this model for people to choose against what they value - a person chooses by valuing.

4. Work is locked into the political world - denying that some work is work is political disempowerment of some workers.

That some functions in our society are prestigious, there is no doubt. That this makes others shameful is a proposition that positive thinkers might decry. Nevertheless, it is true. An unemployed person is not engaged in a prestigious function, and most people are ashamed to be unemployed. In fact, the first question a person asks upon meeting someone else is usually "What do you do for a living?"

Without taking a broad definition of work, the prestige system becomes locked into the economic theory. It is a dangerous politicization to define things along the lines of pecuniary profit. Economies get distorted by economics, particularly when the economic theory ends up arguing that those who participate in certain ways are not merely "more valuable" than others, but not producing value at all! This type of result must be avoided, even if it is an abuse of the economic theory. It is reflected in the treatment of homemakers as not part of the economy and the deligitimization of this profession has had ripple effects - it seems that the basic skills of parenting are no longer passed on and exchanged to the necessary degree. However, when various types of excluded work are compared to included work, it becomes clear that many sources of pecuniary profit have questionable social value. Does the world need car salesmen more than it needs good parents?

Work is connected to the fundamental expression of the human as a social animal. As thinkers and as competitors, we create a variety of illusions by which we attempt to monopolize resources for ourselves. Much of our political activity is a part of this competition. The social sciences are plagued by the problems that this introduces. I have summarized the attitude toward work as "prestige based" but it is probably more complex.

In conclusion, the concept of work can be broadly defined in a way that reduces the complexity and theoretical difficulties of economic work. In so doing, economics comes to a different understanding of the value of work that individuals do rather than the tacit and abused conclusions that are reached through a classical approach.

Economics is wrong to incorporate what are really engineering concerns (limiting data input in order to achieve a result through simplified calculations) into the foundational theory. The nature of the data containment structure must be broad enough to contain all possible data. From there, theories can be tested through the development of engineered applications. This proper course will require a stern reevaluation of much of economic philosophy. This essay is really only the tip of the iceberg.