William Baumol and some co-authors recently published a new book on what is widely known as “Baumol’s cost disease.” This is something that Simon wanted to include in White House Burning, but I couldn’t find a good way to fit it in (and it would have gone in one of the chapter’s I was writing), so I it isn’t in there. (Baumol is cited for something else.) But in retrospect, I should have put it in.
Baumol’s argument, somewhat simplified, goes like this: Over time, average productivity in the economy rises. In some industries, automation and technology make productivity rise rapidly, producing higher real wages (because a single person can make a lot more stuff). But by definition, there most be some industries where productivity rises more slowly than the average. The classic example has been live classical music: it takes exactly as many person-hours to play a Mozart quartet today as it did two hundred years ago. You might be able to make a counterargument about the impact of recorded music, but the general point still holds. One widely cited example is education, where class sizes have stayed roughly constant for decades (and many educators think they should be smaller, not larger). Another is health care, where technology has vastly increased the number of possible treatments, but there is no getting around the need for in-person doctors and nurses.
The problem is that in those industries with slow productivity growth, real wages also have to rise; otherwise you couldn’t attract people to become classical musicians, teachers, or nurses. Since costs are rising faster than productivity, prices have to rise in real terms. Note that university tuition and health care costs are both going up much faster than overall inflation. As a consequence, since GDP is measured in terms of prices paid, these sectors take up a growing share of GDP, just as health care is doing throughout the developed world.
But in Baumol’s formulation, that’s just fine. To see why, consider this figure from the Economist’s review of the book:
Look at the right-hand panel. The point is that if you extrapolate from current trends, health care will be a ridiculous proportion of the economy a century from now, even if we do nothing to slow its rate of growth; but because of productivity increases, the non-health care sector will still be much bigger than it is today, so we will still be much better off than today in aggregate.*
But that doesn’t mean that everything is fine and dandy. Unlike a lot of things in the light blue portion of that chart, health care is a necessity. If 60 percent of the economy is health care, health care will be a much larger share of the average family’s budget than it is today; and if it’s a huge share of the average family’s budget, then many families with below-average incomes won’t be able to afford it.
This is the basic problem with market-based approaches to our health care problem: in a free market, poor people won’t get any, and middle-class people won’t get very much. Baumol is right that in the aggregate our society will be able to pay for all the health care we need, and plenty of other stuff besides; but with our current level of inequality, many actual families won’t be able to get the care they need.
Now, Baumol himself realizes this. One corollary of Baumol’s cost disease is that as low-productivity sectors get relatively more expensive, it gets harder and harder to make a profit, so they tend to get taken over by the government. Again, consider health care and education. (Classical music, which cannot make a profit but is not a necessity—much as I love it—has instead been taken over by private charity.) And this is just the way it should be: Everyone needs health care, but the law of productivity increases dictates that it gets more and more expensive, so the only sane solution is to keep prices at an affordable level and let the government bear the losses. And by “bear the losses,” I mean distribute them to taxpayers (since there is no entity called “the government” that exists in isolation from the people) through a progressive tax system.
Guess what? That’s what Medicare does today. (The Medicare payroll tax isn’t progressive, but most of Parts B and D are funded through general revenues, which mainly come from the individual income tax.) By contrast, Romney-Ryan Vouchercare, by capping the growth rate of benefits at an artificially low level, shifts the growing stack of health care costs (dark blue in the chart) directly onto families, many of whom won’t be able to afford it. Vouchercare is an attempt to rein in health care costs through sheer force of will. It won’t work. It can’t work.
This was, in essence, one of the key arguments of White House Burning: health care costs are going to be what they are going to be, and we can pay for them. Yes we can. We can pay for them because we have plenty of room to raise taxes in all sorts of non-distorting or distortion-reducing ways. We can pay for them because productivity increases mean that, in aggregate, our after-tax real income is still going up. This means that tax revenues will grow as a share of the economy, but as Baumol’s cost disease implies, they should rise as a share of the economy. Comparing tax revenues today to tax revenues in a distant past when health care costs were much lower is just not relevant.
* That chart isn’t per capita, but eyeballing it it looks like a fourfold increase in non-health care GDP; with U.S. population growing at a little less than 1 percent, that’s still a big increase in per capita non-health care GDP.
This post was originally published at Baseline Scenario and is reproduced here with permission.
2 Responses to “Why Taxes Should Pay for Health Care”
Of course, there is a logic to Baumol's idea that there are barriers to productivity growth in some personal service sectors, but let's not carry it too far. Many service sectors have increased productivity rapidly. Retail trade is a big example. Check-in at airline counters is a smaller one. Tax preparation services are still another.
Is it inevitable that health care and education cannot make the same kinds of gains? Not really. A lot has to do with the market structures and incentives. Health care is full of perverse incentives linked to the fee-for-service system, which, as far as I know, no other countries follow. Education also has perverse incentives, for example, a system of national ranks that treats measures of quantities of inputs–teacher student ratios, investment in plant, faculty salaries–as if they were measures of outputs.
We should not despair and say these things are just the way the are going to be. We can fix them. Why do we have more efficient retail trade than Japan or Italy but they have more efficient health care systems? It's because we have healthy competition in retail and dysfunctional cartels in health care, whereas they have the opposite configuration. Just as they should, and can, reform their retail services, we should, and can, reform our healthcare to make it more efficient.
I don't mean to exclude the possibility of using tax dollars or a single payer system to do that. I see the logic of it. But let's not move to tax-financed healthcare in a defeatist way that just accepts inefficiencies–too many tests, too many unnecessary Cesarians, etc–that are institutional in nature.
Australia has a minimum wage of $18 an hour with stiff jail-time penalties for abusers, and their median net-worth per adult is much higher than the U.S. and much closer to their mean average adult net worth. The EITC in the US could be doubled from $60 billion to $120 billion or more, or a citizen's wage or minimum annual income could be implemented. But the argument here is not so much high productivity and lower, it's a standard of life quality especially to people who work but receive poverty level incomes. The median income for 75 million workers, half the U.S., was $26,363 in 2010 according to the Social Security Administration. The poverty level for a 4 person family was about $22,400 that year. The average annual wage income for those low-earning 75 million was less than $11,000 in 2010. The average household income is $78,000 something according to the 2012 Survey of Consumer Finances. The average is not clear for single workers, I calculate it at $54,800 per worker, dividing total household income by total workers. But the issue is what basic floor does society extend for the least productive? Lousy education, lousy medical care, lousy job prospects with lousy wages, lousy mobility? It's not all lousy, but some facts are very difficult to refute. Our inequality is the highest. Childhood poverty is about double OECD countries, health care outcomes rank around 38th in world, and wage income really is $11,000 on average for the lower-earning 50%, and so forth. I looked at the wage income data from SSA, the lower-earning 75% of workers (112 million wage earners all with annual incomes below $50,000) have combined total wage income below the combined personal income of the top-earning 1%. And look at the wealth data, the lower-saving 50% of households own 1.1% of all wealth, or about $11,000 per household, while the average household net worth (for 100% of households) is $498,000, again using the Survey of Consumer Finances figures. I wonder why this extreme imbalance is not an issue of public discourse. http://benL8.blogspot.com — essays on inequality.