Economics

Alain Enthoven, pioneer of “managed competition” and esteemed authority on health-care economics, has an excellent column on Ryan’s premium support plan (What Paul Ryan’s critics don’t know about health economics). Echoing arguments made by Alice Rivlin and Henry Aaron, he argues that the premium support approach would encourage the spread of accountable care organisations, and that these could make a big contribution to improving efficiency and lowering costs. Ryan’s indexation formula is too severe, Enthoven says, but the basic idea is sound.

At the root of the waste and excess is Medicare’s open-ended fee-for-service system, which pays health-care providers for doing more and more costly services, whether or not they’re in the patients’ best interests. Last year’s health-care reform legislation acknowledged that fundamental change is needed from the traditional fee-for-service model to a system in which doctors and hospitals team up to offer coordinated care and are held accountable for per-capita cost and quality. Hospitals and suppliers may participate in this Shared Savings Program by creating or joining an Accountable Care Organization (ACO).

Unfortunately, the incentives to form ACOs and to dramatically cut costs are far too weak and the regulations far too complicated…

A better way to encourage accountable care is the “premium-support” model proposed by House Budget Committee Chairman Paul Ryan, among others. This is a managed competition model in which government would make a defined contribution and beneficiaries would have a choice from a variety of health plans with no discrimination based on health status. Standard coverage contracts would make comparisons possible for ordinary people. Competition would drive health plans to innovate in ways that cut waste and improve quality. And the use of exchanges would drastically reduce marketing costs, so insurance companies would not be taking 20% off the top, as is currently the norm.

This is not “the end of Medicare,” as some would have you believe.

One thing I don’t understand is why Enthoven, like Ryan, takes such exception to the use of the term “voucher” in describing the premium support approach. Premium support is, to all intents and purposes, a voucher. What’s wrong with calling it that?

 

In Madrid on Monday I moderated a discussion on global finance organized by the Aspen Institute Espana. The speakers were Paul Volcker, Agustin Carstens (head of the central bank of Mexico, and a candidate to succeed Strauss-Kahn at the IMF), and Henrique Meirelles (until recently head of the central bank of Brazil, now in charge of preparations for the Rio Olympics). In due course I might be able to post a link to a recording. Meanwhile, three things struck me as notable.

First, none of the speakers had much time for the idea that Greece’s debt would have to be restructured. Paul Volcker’s impatience with this idea especially surprised me. He is usually willing to be outspoken and has no particular reason (unlike Carstens, for instance, a serving rather than former central bank chief) to avoid controversy and choose his words carefully. He usually says what he means. His point was that a modest restructuring would make no great difference to Greece’s fiscal problem–it has to get to a primary budget surplus regardless–and so was probably not worth the risk. Yes, I suggested, but who said anything about a modest restructuring? An immodest restructuring, together with “internal devaluation” (lower wages) and further fiscal tightening, still seems to me the least bad of the terrible alternatives that Greece and the EU are now contemplating. The central bankers weren’t having it.

The next head of the IMF is expected to be Christine Lagarde. Europe’s leaders are converging on this appointment and if the US goes along the deal will be as good as done. Lagarde is a reasonably well-qualified candidate but this choice, guided by the desire to perpetuate the arrangement under which a European heads the Fund and an American the World Bank, is a mistake.

Moises Naim powerfully makes the case against an outrageous dispensation. He detects the stench of colonialism and I agree.

Even the leaders of the Group of 20, the assembly of nations that accounts for more than 80 percent of the world’s economy and two-thirds of its population, recognize that leadership selection at these institutions must change. When they met in early 2009 in London on the heels of the financial crisis, the G-20 leaders asserted that “the heads and senior leadership of the international financial institutions should be appointed through an open, transparent and merit-based selection process.”

That this is not already the standard is outrageous. No more outrageous, of course, than how European countries are offering countless excuses for why Strauss-Kahn’s replacement must carry a European passport.

I’m hoisting this valuable comment from Roger Algase in response to my column last week on immigration up to the main page.

The last paragraph of this article, about the need for executive action in favor of liberalizing the immigration system is especially apt. However, few people who do not deal with the immigration system on a day to day basis, which I do as an immigration lawyer, realize how much executive action on immigration there has been since Obama took office. The problem is that almost all of it has been in the direction of making the immigration system harsher and more punitive, with regard to both legal and illegal immigration.

Christine Lagarde and Kemal Dervis appear to be front-runners to replace Dominique Strauss-Kahn at the IMF. Good candidates, no doubt, but in my view the best choice (if he could be persuaded to do it) would be Stanley Fischer, ex-MIT, ex-IMF, ex-World Bank and currently governor of the Bank of Israel. His performance in each role has been outstanding. I agree with Greg Mankiw’s assessment:

Stan is a superb economist and international policymaker: smart, sensible, experienced, personable, and open-minded. He would be an ideal person to head the IMF.

Frank Partnoy, a law professor at USD and author of “Infectious Greed“, an excellent book on the underlying causes of the financial collapse, comments on the Galleon case. In “The real insider tip from the Galleon verdict” he argues that insider trading may come back stronger from this setback.

If you do the maths, given the amount of insider trading, the chances of doing prison time are roughly the same as getting bitten by a great white shark while surfing off the coast of my home town, San Diego.

There are rare shark attacks and many people become very afraid after them, just as some traders are now fearful after this high-profile conviction. However, that fear is irrational, based on the salience of an unusual event.

The prospects for legislation before the next election may be minimal, but it’s good that President Obama is making the case for comprehensive immigration reform. One can question his sincerity, of course. Since he knows that nothing is going to happen, he can aim to build support for Democrats among Hispanic voters, an increasingly significant group, without much risk of offending too many others. But his position on immigration reform happens to be right. Mending the immigration system is, as he said, an “economic imperative”, both to meet shortages of skilled labor and to bring the illicit migrant economy on to the books, thus helping to repair the tax base. Republicans richly deserve to be punished for their obduracy on the issue.

A stylised fact of US political polling is that, national security aside, the price of gas drives presidential approval ratings. Could house prices might be even more important? If they were, it would be hard to prove statistically, since there are no previous episodes of nationally falling house prices. Which is worse for confidence: gas at say $5 a gallon, or another five figures wiped off your net worth? Perhaps the White House should be more worried about what happens to house prices between now and November 2012 than about what happens to the price of oil.

No respite from housing recession in the first quarter, says Zillow.

Paul Ryan, chairman of the House Budget Committee, gave a talk and took questions this morning at an event organised by the American Council on Capital Formation. In his opening remarks he restated his basic, familiar position: the recovery is slower than it should be, and the country’s longer-term economic prospects are blighted, because of bad economic policy. Good economic policy, he said, means four things.

First, get government spending and deficits under control, to restore fiscal certainty and allay fears of higher taxes down the road. Second, tame the regulatory state. Third, increase tax revenues through higher growth. (Especially, stop putting US firms at a disadvantage with higher taxes than their international competitors face.) Fourth, ensure sound money. (He said he was worried about the scale of the Fed’s recent interventions and where they might lead. He drew from his wallet his portable collection of worthless hyperinflated currency from Zimbabwe, Weimar Germany, and other bankrupt nations, given to him by voters he has met.)

Then he was asked about the current talks over raising the debt ceiling.

When Barack Obama talks about fiscal control, the idea he emphasises – often the only one he offers with conviction – is raising taxes on the rich. This gets ovations from Democrats, thrilled that the US president has not sold out entirely. Equally constant is the Republican response: accusations of class warfare and economic vandalism. For all Mr Obama’s fine talk, says the Grand Old Party, Democrats fall back on their traditional job-killing cure-all.

Clive Crook’s blog

This blog is no longer updated but it remains open as an archive.

I have been the FT's Washington columnist since April 2007. I moved from Britain to the US in 2005 to write for the Atlantic Monthly and the National Journal after 20 years working at the Economist, most recently as deputy editor. I write mainly about the intersection of politics and economics.

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