Doctors in America

Aaron Carroll thinks that retail health clinics fill a useful niche. "There are times when you need to see a health care professional early in the morning, or later at night," he says. "Have you tried to get an appointment lately when you’re sick? It’s hard!" The chart on the right, which has made an appearance before on this blog, tells the story. Upwards of 20% of people who are sick have to wait a week to get an appointment to see a doctor. Matt Yglesias comments:

A lot of health care professionals in the United States seem to me to be slightly in denial about the level of service they're providing. Somehow we have the most expensive health care system in the world, with the highest paid doctors, and yet it's strangely difficult to actually get an appointment to see one.

My guess is that they're not in denial at all. The reason it takes a long time to see a doctor is because they're booked solid with appointments. They see 20 or 30 patients a day, every day, so most of them really have no particular incentive to make it any easier to make an appointment. Why would they when they're already working at capacity?

And why are they working at capacity? Part of the reason is that we just don't have all that many doctors in America:

These two charts are surprisingly uncorrelated, which presumably has something to do with how healthcare is run in various countries and something to do with cultural mores about how often we like to see doctors. Still, the overall picture is clear: we have relatively few doctors, they're all really busy, and they get paid a lot more than in other countries. That may not be so hot from a patient's point of view, but from a doctor's standpoint, what's not to like?

Liberals and Fraud

The Obama administration has announced plans to crack down on food stamp fraud among both retailers and users. Atrios comments:

Cracking down on thieving retailers is of course a good idea, but, really? Going after SNAP beneficiaries who try to convert their meager benefits to an even more meager amount of cash? I imagine some people who do this are using the money for Things We Officially Frown Upon, but some are probably trying to pay their damn bills.

My guess is that this crackdown is hardly a huge program, so it's not as if loads of resources are being diverted to make life more difficult for the poor. Beyond that, though, Obama seems to instinctively get something that the rest of us lefties probably ought to appreciate more: like it or not, if you want the public to support government programs, you need to make sure they're administered effectively. That's doubly or triply true of social welfare programs, which are easily demagogued even in the best of times. If anything, liberals who support these programs ought to be more concerned about rooting out fraud and improving efficiency than conservatives, who'd be just as happy to see them simply go away.

This is fundamentally a Charlie Peters-ish neoliberal insight, and neoliberalism has obviously taken a lot of lumps over the past decade. Some of them were deserved, some weren't. Either way, this particular insight is one worth holding onto.

The Mystery of Darrell Issa's Low Profile

When Darrell Issa took over the Oversight and Government Reform Committee, everyone expected a tsunami of scandal investigations. But it hasn't really happened. Why? Jonathan Bernstein says it might be because Obama just runs a really clean shop, but he doesn't find that convincing. Or maybe Issa is just incompetent. But that's not very convincing either. That leaves this:

Totally, totally, speculative, but here goes. Perhaps the reason that the House isn't manufacturing scandals is because the changed media environment has changed the incentives. In the old days, opposite-party Congresses had to work hard to manufacture scandals good enough to get the neutral press to notice. Now, why bother? Most partisans, and especially the primary voters that Members of Congress are increasingly most worried about, get most of their news from the partisan press, and they don't need any Congressional stamp of authority to consider something a legitimate scandal worthy of devoting hours of programming to.

Maybe! But there's another possible explanation: maybe Dave Weigel was right all along. It's true that Issa promised lots and lots of investigations ("I want seven hearings a week, times 40 weeks"), but there was also this:

“As Clint Eastwood says, a man needs to know his limitations,” Issa said....While he promises an ambitious — and some say confrontational — agenda, Issa is making overtures to the Obama administration: He already has a meeting scheduled with Vice President Joe Biden to discuss stimulus oversight.

....Issa is also pointedly looking to avoid probing what he seems to view as peripheral issues — like Waxman and former Chairman Tom Davis’s foray into hearings on steroids in baseball. “This is important, in contrast to hearings on steroids in baseball, where I felt that it was inherently wrong to get Roger Clemens to lie to Congress,” Issa said. “The American people really want us to shrink government.”

Issa also wants to avoid the sometimes petty controversies that enmeshed Rep. Dan Burton (R-Ind.) as committee chairman during the Clinton presidency and sometimes made him the issue.

It pains me to say anything nice about Issa, the man who bequeathed us Arnold Schwarzenegger, but maybe he takes this stuff more seriously than his critics ever gave him credit for. Obviously he's going to focus his attention on conservative causes and he's going to focus his oversight on the Obama administration — both perfectly reasonable things to do — but perhaps he was sincere about avoiding petty nonsense. Stranger things have happened.

In the LA Times today, Spike Dolomite Ward lays out Barack Obama's essential political problem for all the world to see. The recession hit her family hard, she lost her health insurance, and then she got cancer:

Fortunately for me, I've been saved by the federal government's Pre-existing Condition Insurance Plan, something I had never heard of before needing it. It's part of President Obama's healthcare plan, one of the things that has already kicked in, and it guarantees access to insurance for U.S. citizens with preexisting conditions who have been uninsured for at least six months.

…Which brings me to my apology. I was pretty mad at Obama before I learned about this new insurance plan. I had changed my registration from Democrat to Independent, and I had blacked out the top of the "h" on my Obama bumper sticker, so that it read, "Got nope" instead of "got hope." I felt like he had let down the struggling middle class. My son and I had campaigned for him, but since he took office, we felt he had let us down.

So this is my public apology. I'm sorry I didn't do enough of my own research to find out what promises the president has made good on. I'm sorry I didn't realize that he really has stood up for me and my family, and for so many others like us. I'm getting a new bumper sticker to cover the one that says "Got nope." It will say "ObamaCares."

And there you have it: Obama's core problem with his supporters from 2008, the ones who listened to his soaring rhetoric and believed he really was going to transform Washington—and have since been bitterly disappointed. This has always been something I could understand only intellectually, since I never for a second paid any attention to his stump speeches. Of course they soared! Of course they promised a new era! That's what politicians always promise. Why on earth would anyone take this seriously, when every single other piece of evidence showed him to be a cautious, pragmatic, mainsteam, center-left Democratic candidate?

Beats me. But lots of people did take it seriously, and now Obama is stuck trying to convince them in very practical, non-soaring terms that he really has done a lot for them. That list is pretty long and includes a big stimulus bill, a landmark healthcare reform bill, student loan reform, an end to the Bush torture regime, the Lily Ledbetter Fair Pay Act, a hate crimes bill, a successful rescue of the American car industry, resuscitation of the NLRB, passage of New START, the death of Osama bin Laden, withdrawal from Iraq, a decent start on rationalizing Pentagon procurement, repeal of DADT, credit card reforms, unprecedented gas mileage improvements, a second stimulus in 2010, and passage of financial reform legislation.

Were there disappointments too? Sure. Obama badly mishandled cap-and-trade, has a weak record on civil liberties, escalated the war in Afghanistan, has been unaccountably sluggish on appointments, treated the financial industry too gingerly, and failed to seriously address underwater mortgages, among other things.

But that's to be expected. This is the real world, not utopia, and Obama is a cautious, pragmatic, mainsteam, center-left Democratic president. So how do you win back the people who believed the soaring rhetoric and either don't know or don't care about Obama's impressively long list of concrete achievements? It's his essential dilemma. Maybe Spike Dolomite Ward can give him some suggestions.

Mitt Romney Winning the Race for the 1 Percent

The Washington Post reports today that Barack Obama has received donations from 30 billionaires while Mitt Romney has received donations from 42 billionaires. Ho hum. But there's this fascinating little tidbit halfway through the story:

Romney has attracted the support of Redskins owner Dan Snyder and other billionaires, including California real estate developer Donald Bren, who is worth $12 billion, and developer and publisher Sam Zell, who is worth $5 billion.

As a lifelong reader of the Los Angeles Times, I'd say that the support of Sam Zell ought to be reason enough to disqualify anyone from the presidency. I suppose there's a good chance that he's not actually much more of an asshole than hundreds of other billionaires, but he sure went out of his way to make it more obvious than usual. He's just lucky that LA also has Frank McCourt around, which means there's at least one zillionaire here that we all hate even more.

Who's Responsible For the Euromess?

A few days ago Tyler Cowen kicked off a discussion of whether or not Germany (and the core European countries in general) have acted more virtuously than Greece (and the periphery countries in general) during the decade since the euro was introduced. It was unclear how much he was simply presenting a debating case vs. how much he actually believed his own arguments, and in that spirit I want to present a different case. This one is about how Europe got where it is today and who deserves a bigger share of the blame for its current mess. I'm not suggesting this is the only way to look at things, or even necessarily the best way, but I do think it's an instructive way. So here it is in seven easy steps.

1. The introduction of the euro made cross-border capital flows far more frictionless. As a result, money began flowing from the sluggish economies of the core countries (mostly Germany, but also France, Benelux, and others) to the more capital-starved economies of the periphery. You can tell two basic stories about why this happened:

a) A "push" story: Investors chasing higher yields actively pushed money into the more vibrant economies of the periphery.

b) A "pull" story: Profligate national governments, addicted to living beyond their means, pulled money into the periphery via heavy borrowing, which crowded out private borrowing.

Most likely, both of these were part of what happened and both reinforced each other. But generally speaking, if the pull story were true you'd expect to see increases in nominal interest rates in the periphery. As the table above shows, that's not what happened, which means the push story is more likely to be the primary explanation. The primal sin here is that for years supposedly sophisticated investors in the core shoveled money into the periphery with abandon, ignoring the obvious risks of doing so.

2. Normally, capital flows would eventually be moderated by changes in exchange rates, but this was impossible for the periphery since they no longer had their own currencies. The result was persistent hot money flows into a fixed exchange rate area and steadily higher inflation in the periphery compared to the core. This state of affairs is widely known to be unsustainable and eventually disastrous, but it was something Germany happily ignored since it provided German savers with a place to invest their money and provided the periphery with enough cheap capital to act as a thriving market for German exports.

3. High inflation in the periphery would normally be moderated by tighter monetary policy. Again, though, this was impossible for the periphery because they didn't control their own monetary policy. The chart on the right shows actual ECB monetary policy during the aughts (red line): it was kept loose in order to keep Germany's sluggish economy growing, but this meant that monetary policy was way too loose for the periphery. The overheated economies of the periphery thus overheated even more. This was largely the fault of the core, which controlled monetary policy, not the periphery. It was Germany that needed loose monetary policy, not Greece.

4. Capital inflows produce a capital account surplus, and the flip side of a capital account surplus is a current account deficit. This is an accounting identity, not a matter of morality or recklessness. And current account deficits always produce either matching government debt (i.e., budget deficits) or matching private debt (i.e., low private savings). This is also an accounting identity, not a matter of morality or recklessness.

So all the current account deficit countries inevitably got one or the other or both. In the event, Ireland and Spain got a property bubble; Greece and Portugal ran up sizeable budget deficits. We know from painful experience that capital flows like this are unsustainable in the long run, but they can go on for quite a while until something happens to scare everyone into calling a halt and producing a sudden crisis. The 2008 financial crisis was "something."

5. There's another side to this too: banks intermediate current account deficits. This is inevitable, hydraulic. A banking system in a current account deficit country always features a high loan-to-deposit ratio, which means that banks in the periphery became dependent on skittish wholesale funding instead of more durable retail deposits. As with capital inflows, when investors suddenly decide to stop the music, wholesale funding dries up and the banking system goes into cardiac arrest.

6. This creates a vicious cycle: The financial crisis produced a recession that cratered both periphery country finances and the periphery's banking system. Budget deficits in the periphery blew out, debt levels became unsustainable, and at the same time investors began a run on their banking systems. As Hyun Song Shin puts it, "The European crisis carries the hallmarks of a classic 'twin crisis' that combines a banking crisis with an asset market decline that amplifies banking distress…In the European crisis of 2011, the twin crisis combines a banking crisis with a sovereign debt crisis, where the mark-to-market amplification of financial distress interacts to worsen the banking crisis."

In other words, as sovereign debt woes got worse, bank woes got worse too. And as bank woes got worse, sovereign debt woes got worse.

7. The damage wasn't limited to the periphery. All those capital inflows came from the core, and when the music stopped and the periphery was left in shambles, banks that had loaned out all the money were suddenly in trouble too. As an example, the chart on the right shows bank exposure to debt from Spain. German and French banks alone have over $300 billion in exposure to Spanish debt, so if Spain goes kablooey, so do they. And that brings us to the present day.


If you've read this far, let me make it clear that nothing here is meant to absolve the periphery countries from their part in this. Ireland fed the fire of its property bubble irresponsibly, Greece lied about its finances, and throughout southern Europe there was a persistent refusal to reform their labor practices, improve productivity, and live within their means. The core countries have every right to hold the periphery accountable for this.

At the same time, this is fundamentally a story of economics, not morality, and it's only in Step 1 above that the periphery countries bear even a share of the blame for what happened. The rest was either caused by deliberate core policies or else the inevitable result of those policies. Whether Germany likes to hear it or not, it's simply a fact that both sides allowed—even encouraged—capital flows to remain imbalanced for far too long. The periphery enjoyed access to cheap money and the core liked having a thriving market for its exports. The core and the periphery both rode this wave up, and now they're both going to have to ride it down.

It's also an unfortunate fact that no one handles hot money flows well, something that's doubly true in a fixed exchange rate area. Germany was no better at identifying this and doing something about it than Greece was, and they're no happier about giving up their export-driven economy than Greece is about giving up its import-driven economy.

What does all this mean going forward? I guess I'd say a few things:

  • Germany is justified in demanding reforms from the periphery as the price of a bailout. Partly this is just because creditors generally have that right. But it's also for practical reasons. Even if you feel that reckless lenders are morally equivalent to reckless borrowers, it's still the case that if Germany simply bails out the periphery without anything changing, they're essentially committing themselves to subsidizing the periphery forever. That's not something any country will (or should) feel obliged to do.
  • At the same time, forced austerity for its own sake is foolish. Demanding reforms that promote long-term growth is fine. Demanding austerity that will make periphery economies even worse off in the short term is counterproductive for everyone, including Germany.
  • It's probably also wrongheaded to focus so heavily on budget deficits, no matter how virtuous it seems to insist on balanced budgets. That's not what caused the eurozone's problems: Spain and Ireland ran budget surpluses during the aughts and only went into deficit after the financial crisis cratered their economies. Europe's fundamental problem wasn't budget deficits, it was capital flows within the eurozone—or, put a different way, the problem was persistent current account imbalances in a fixed exchange rate area. It was the countries with current account deficits that consistently ran into trouble, and any reforms worth doing need to address that directly. That requires changes from both the core and periphery. After all, every country can't run a budget surplus at the same time, just as capital can't flow into every country at once.
  • A non-eurozone country that ended up in the trouble the European periphery is in would most likely declare bankruptcy: They'd "restructure" their debt, meaning that banks and others who held their bonds would lose all or some of their money. The EU's leaders, however, appear to consider this unacceptable for a member of the eurozone. Unfortunately, as Felix Salmon says today, this is probably a mistake. Even if you feel that reckless borrowers are more blameworthy than reckless lenders when a crisis hits, surely lenders should retain some incentive to make sure their loans are properly vetted. A promise from the EU to always keep sovereign bondholders whole sends a message to banks that reckless lending carries no penalty at all. That's a recipe for a repeat of 2008.

As a side note, it's worth pointing out that Italy is sort of a special case here. (That's why I didn't include them in the charts above.) Their economy has been in the doldrums for over a decade, and that's something they need to address. At the same time, they were a middle-of-the-pack country on a wide variety of economic measures all through the aughts: they ran only modest current account deficits and modest budget deficits; their inflation rate was only a bit higher than Germany's; and their debt-to-GDP ratio actually declined. Their problem isn't so much that their fundamental economic position is disastrous, it's that (a) their economic position was weak and the recession made it weaker, and (b) they're much larger than any of the other periphery countries. They're ground zero of the crisis right now simply because investors have lost confidence in them, but they don't really belong in the same basket as the four other periphery countries.

Our Bloated Financial Industry

I've wondered for a long time why the finance industry has gotten so immensely profitable in an era of computerization, globalization, and intense competition. After all, those are things that you'd expect to reduce sector-wide profits, not increase them. The answer remains a bit mysterious, so I'm glad to see an actual economist asking something similar: namely, has the cost of financial intermediation gone up or down in recent decades? Here is NYU finance professor Thomas Philippon:

The cost of intermediation in the US is between 1.3% and 2.3% over 130 years. However, the finance cost index has been trending upward, especially since the 1970s. This is counter-intuitive. If anything, the technological development of the past 40 years — in IT in particular — should have disproportionately increased efficiency in the finance industry. How is it possible for today's finance industry not to be significantly more efficient than the finance industry of John Pierpont Morgan?

If Philippon is correct, the financial industry charges more for its basic task of matching borrowers and lenders than it used to:

What happened? Why did we get the bloated finance industry of today instead of the lean and efficient Wal-Mart?....One simple answer is that technological improvements in finance have mostly been used to increase secondary market activities, i.e., trading.

....The finance industry of 1900 was just as able as the finance industry of 2000 to produce bonds and stocks, and it was certainly doing it more cheaply. But the recent levels of trading activities are at least three times larger than at any time in previous history....I conclude that the most important questions in finance today are:

1. A positive question: Why do people (fund mangers, households, etc.) trade so much?
2. A normative question: Has increased trading led to either better prices or better risk sharing?

I would like to believe that the answer to (ii) is yes, but I am still waiting for the evidence. If the answer turns out to be no, then we would have to conclude that the finance industry's share of GDP is about 2 percentage points higher than it needs to be and this would represent an annual misallocation of resources of about $280 billion for the US alone.

Hmmm. I'm pretty sure that nearly all of the recent increase in trading volume is due to automated trading, and in particular to high-frequency trading. This is almost certainly a socially useless activity, but does it account for $280 billion in resource misallocation? Maybe. That's a big number, but not so big that it seems obviously ridiculous. What's more, if this number is correct, you should probably figure that resource misallocation in fixed-income trading is at least two or three times as big. The total could be a trillion dollars or more. That's a helluva lot of waste.

Where Have All the GOP Donors Gone?

Paul Waldman summarizes a Washington Post piece today that I didn't link to when it first came out. But I should have:

Everyone knows that campaigns get more expensive every cycle; that is, we knew it until this year. As The Washington Post detailed last week, this has been the cheapest primary campaign in over a decade. Four years ago, the Republican candidates spent a total of $132 million through the September before voting began; this year they spent a mere $53 million. That combined total is less than one candidate, Mitt Romney, spent during that period four years ago. This year he spent a mere $18 million through September, compared with the nearly $54 million he spent through September 2007. Political observers swooned over Rick Perry's dramatic fundraising during the 12 minutes or so he spent at the front of the pack. But even if Perry sank $100 million into Iowa, it wouldn't help him now. Meanwhile, Newt Gingrich became the front-runner without his campaign having two nickels to rub together. That isn't to say the ads won't fill the airwaves in Iowa and New Hampshire soon enough, but to this point things have been awfully quiet.

I've been mulling this over ever since I first saw it, but I'm no closer to figuring out what's going on. In theory, this should be a big money year for Republicans since President Obama looks genuinely vulnerable and the conservative base is practically in a frenzy of anti-Obama venom. But it hasn't been so far. I can think of a few reasons why this might be:

  • Despite the happy talk, GOP donors don't actually believe that Obama is that vulnerable. They don't want to waste their money on a lost cause, so they're reluctant to open their pocketbooks.
  • The media landscape has changed more than we think, especially for conservatives. Over the past few years, they've discovered that they can run very effective campaigns by using free media (Fox News, talk radio, etc.) rather than paid ad buys on mainstream media. This is especially true in primary campaigns, where their sole audience is the conservative base.
  • Big money donors don't have much of a dog in the race this year. This is because either (a) they like all the candidates and don't have a strong preference for any of them, (b) they dislike all the candidates and don't want to be associated with any of them, or (c) they just don't think it matters much because they're all pretty much saying the same things.
  • These days, all the right-wing money is going into super PACs, which seem like a more effective force for promoting conservative goals than individual campaigns do.

All of these are partly true, but I'm not sure I believe that even taken together they add up to the real answer. It's especially perplexing because Obama, who has problems with his liberal base that most of the GOP candidates don't, is nonetheless having no trouble raising enormous sums of money. So it's not because donors in general are sick of politics or because the recession has depleted everyone's bank accounts. But what is it?

Chart of the Day: The Death of AAA Assets

Alphaville's Cardiff Garcia calls this the most important chart in the world, and maybe it is. (Though there are lots of competitors for that title these days.) It shows the precipitous drop in the stock of safe, AAA-rated assets from its 2007 peak of about $20 trillion to roughly $12 trillion this year. In one sense, you could say this is a good thing: at least we're no longer pretending that risky assets aren't, in fact, risky assets. Unfortunately, the availability of safe assets is pretty important to the smooth functioning of modern finance because they're necessary as collateral in the repo market:

When you hear concerns that the ECB has lost some control over monetary policy because of a liquidity-starved credit channel — or indeed when you hear Draghi himself say that he’s cognizant of the “scarcity of eligible collateral” — this is why.

....A somewhat obvious and related point here, but the loss of “safe” status for so much debt contributes to the deleveraging burden of European banks and their American subsidiaries; by definition it means higher risk weightings for these assets.

Declining asset quality is surely also one reason that European banks had trouble funding themselves in US repo markets, and the resulting stress in the currency basis swap markets as banks sought dollars elsewhere led to last week’s intervention.

This is bad for Europe, of course, and as we discussed a couple of weeks ago, there's reason to think that deleveraging among European banks could have a pretty serious impact on American credit markets too. We may or may not like much of what the shadow banking system does, but there's no question that it plays a key role in sustaining bank lending, and the repo market is its backbone.

In other words, just another thing to worry about. I wouldn't want this morning's semi-optimistic post about Europe to get you too excited or anything.

Quote of the Day: "Ads are Agitprop"

A couple of weeks ago Mitt Romney ran an ad in which Barack Obama was heard telling an audience, "If we keep talking about the economy, we’re going to lose." The obvious implication was that Obama was desperate to avoid talking about his own dismal handling of the economy. But that was untrue. It was actually a clip from the 2008 campaign in which Obama said "Senator McCain's campaign actually said, and I quote, 'If we keep talking about the economy, we’re going to lose.' "

Today, Thomas Edsall gets the following defense of this lie from a "top operative" in the Romney campaign:

First of all, ads are propaganda by definition. We are in the persuasion business, the propaganda business....Ads are agitprop....Ads are about hyperbole, they are about editing. It’s ludicrous for them to say that an ad is taking something out of context....All ads do that. They are manipulative pieces of persuasive art.

I wonder if this guy actually believes what he's saying? He didn't have to talk to Edsall in the first place if he didn't want to, so I assume he does. He's genuinely aggrieved that anyone holds this against Team Romney.

Edsall's conclusion is that this spot is "the latest step in the transgression by political operatives of formerly agreed-upon ethical boundaries. What was once considered sleazy becomes the norm." The rest of his column is a history of such transgressions, and it's interesting reading. But this sort of thing strikes me as different from the changes in campaign financing and lobbying that he devotes his piece to, and it would have been even more interesting to read a column about the history of changing norms in how baldly you can lie on the campaign trail.

(My guess is that a real history of this would be U-shaped. Flat-out lies were quite common throughout the entire history of the nation but started to decline after World War II in favor of more subtle distortions. Then, over the last few decades, they've risen again as candidates began to learn that they could manipulate — or ignore — the mainstream media in ever more brazen ways without penalty.)

In any case, it would be nice to think that this episode has wakened the media a bit from its nonjudgmental stupor. It's true that campaigns engage in artful distortion and simplifications all the time. So do bloggers. I don't pretend to be writing austerely evenhanded and neutral posts here, and I'm certainly guilty of cherry picking my topics and my evidence on occasion. At the same time, I'm well aware of some boundaries here. It's one thing to present evidence in a way that helps me make my point, but it's quite another thing to flatly lie about what the evidence says or to flatly ignore evidence that I know perfectly well undermines my point entirely. Likewise, I might highlight a damaging quote from someone I dislike, but there's a bright line there: the quote has to be accurate and it has to be offered in its proper context. If it's still damaging, great! That's legitimate blog fodder. If it's not, then it's not.

The same is surely true of political campaigns, even if the stakes are massively higher than the integrity of someone's blog. If Romney and his people genuinely don't get that, or if they get it but they don't care, they shouldn't be allowed to pretend that this is just part of some normal evolution of political norms. It's not.