Politics

Despite strong opposition, a little progress is being made at informing consumers about medical quality and prices.

Healthcare Blue Book has some info about normal prices for standard procedures.

Healthgrades has some information about which hospitals produce the best outcomes (although more of the site seems devoted to patient ratings of doctors, which probably don’t make much distinction between rudeness and killing the patient).

Insurers are trying to create rating systems, but reports are vague about what they’re rating.

One objection to ratings is that

such measures can be wrong more than 25 percent of the time

A 25 percent error rate sounds like a valuable improvement over the current near-blind guesses that consumers currently make. Does anyone think that info such as years of experience, university attended, or ability to make reassuring rhetoric produces an error rate in as low as 25 percent? Do medical malpractice suits catch the majority of poor doctors without targeting many good ones? (There are some complications due to some insurers wanting to combine quality of outcome ratings with cost ratings – those ought to be available separately). Are there better ways of evaluating which doctors produce healthy results that haven’t been publicized?

More likely, doctors want us to believe that we should just trust them rather than try to evaluate their quality. I might consider that if I could see that the profession was aggressively expelling those who make simple, deadly mistakes such as failing to wash their hands between touching patients.

Book review: Awakening Giants, Feet of Clay: Assessing the Economic Rise of China and India by Pranab Bardhan.

This short book has a few interesting ideas.

The most surprising ones involve favorable claims about China’s collectivist period (but without any claim that that period was better overall).

China under Mao apparently had a fairly decentralized economic system, with reasonable performance-based incentives for local officials, which meant that switching to functioning capitalism required less change than in Russia.

Chinese health apparently improved under Mao (in spite of famine), possibly more than it has since, at least by important measures such as life expectancy. This is reportedly due to more organized and widespread measures against ordinary communicable diseases under collectivism.

Book review: This Time is Different: Eight Centuries of Financial Folly by Carmen M. Reinhart and Kenneth S. Rogoff.

This book documents better than any prior book the history of banking and government debt crises. Most of it is unsurprising to those familiar with the subject. It has more comprehensive data than I’ve seen before.

It is easier reading than the length would suggest (it has many tables of data, and few readers will be tempted to read all the data). It is relatively objective. That makes it less exciting than the more ideological writings on the subject.

The comparisons between well governed and poorly governed countries show that governments can become mature enough that defaults on government debt and hyperinflation are rare or eliminated, but there is little different in banking crises between different types of government / economies.

They claim that international capital mobility has produced banking crises, but don’t convince me that they understand the causality behind the correlation. I’d guess that one causal factor is that the optimism that produces bubbles causes more investors to move money into countries they understand less well than their home country, which means their money is more likely to end up in reckless institutions.

The book ends with tentative guesses about which countries are about to become mature enough to avoid sovereign debt crises. Among the seven candidates is Greece, which is now looking like a poor guess less than a half year after it was published.

Book review: City of Gold: Dubai and the Dream of Capitalism by Jim Krane.

This book describes how a nearly barren piece of land became a prosperous city. Dubai sounds like what you’d expect if Bill Gates had taken over a small desert tribe and turned it into a real estate development company.

Part of its success is due to having the right amount of oil given its population size. Most non-industrialized countries that find enough oil to affect their economy are corrupted by dependence on it and by political fighting over who profits from it. Dubai found enough to finance a good deal of growth, but quickly saw that oil revenues would decline before long. Also, it had few enough people that the ruling family could afford to buy off any potential opposition.

But Dubai’s development started before it had much hope for oil money, and is partly due to the ambitions of a few people who ruled it. There must be a fair amount of luck involved – it seems to be an accident that Dubai is ruled by competent businessmen who are uninterested in politics (one ordered his reluctant brother to become the ruler). British rule over the region early on also helped ensure political stability.

The book’s description of Dubai’s legal system is confusing. How did a tribe with no tradition of private property make investors feel safe? I’ve read elsewhere that importing a British judge and British common law to the financial district is part of the explanation. The rest of Dubai seems to manage with virtually no legal system. I’m still puzzled about how Dubai provides enough predictability to attract large investments.

He describes Dubai’s lack of democracy as “an embarrassment”. But most of the book suggests that Dubai has been doing better than a democracy could. It makes much faster decisions than a democracy, and it forces bureaucrats to compete for performance scores that would be too easily gamed if voters were in charge.

Dubai’s ambitious expansion has made it resemble a financial bubble for much of the past 55 years, but most of its gambles have succeeded. This makes me wonder how to distinguish similar expansions from bubbles in the future (or in China, the present).

Dubai is an important model for how seasteads might develop, and will compete with any seastead.

The author has a modest pro-Dubai bias, but reports some serious problems such as workers being unable to leave because their passports has been confiscated, and wasteful subsidies of energy and water prices.

He claims that until 2008 the region “hadn’t experienced a financial shock for more than three decades”. Was the 1982 Kuwaiti stock market crash in a different region? It’s not obvious where to get enough financial data to say how the shock from that affected Dubai.

Book review: Capitalism with Chinese Characteristics: Entrepreneurship and the State by Yasheng Huang.

This is the most insightful book I’ve read so far on the Chinese economy. Most commentators only look at the most readily available data, but Huang dug through many obscure detailed records that were less likely to be manipulated.

The most important point of the book is to show that the widely held view of China as having gradual, steady improvement since 1978 is wrong. There was a dramatic political change in 1978 that allowed the rural parts of China (which still account for a large part of the economy, and where entrepreneurial culture had not been stamped out by communism) to prosper. Then starting in 1989 urban-focused leaders stifled rural businesses, causing stagnation there until 2002, when leaders more friendly to rural business gained power and allowed fairly healthy growth to resume.

Meanwhile urban areas have been dominated by crony capitalism which produced a good deal of gdp growth through massive state-directed investment in large companies, especially in the 1990s. This growth has produced fewer benefits to the average person than gdp numbers would lead us to expect.

Most of China’s success has been due to private enterprise. Beliefs that state-run businesses have produced growth are partly due to confusing reports about which companies are private.

I’m fairly impressed by the documentation of the changes in the rural political climate, but since the author seems to be the only one reading his sources of data and since it would be very time consuming to check them, it would be easy for errors to go unnoticed. For urban issues, he appears to be overstating the importance of problems that are not unique to China.

He partly clears up the puzzle of China doing better than should be expected for a country whose legal system doesn’t provide much rule of law. He provides evidence that some of the most important successes depend on British law imported via Hong Kong. But he doesn’t provide enough evidence to tell us how important this effect has been.

He leaves unanswered many questions I’d like answered. Why did government policies undergo these changes? Is the surprisingly reported steady gdp growth mostly the result of manipulated statistics? How much of the growth has been an investment bubble, and how much is sustainable? How did entrepreneurial culture survive communism in rural China so much better than in other countries?

How can a hospital-like business operating outside of existing territorial jurisdictions avoid harrassment by governments whose medical lobbies want to spread FUD?

Given that these businesses will initially have no track record to point to and less protection than existing medical tourism providers from whatever government provides a flag of convenience to the business, merely providing comparable quality medical care won’t be enough for such businesses to thrive. So I’m proposing practices which could enable those businesses to argue that current U.S. hospitals are more dangerous. I’m not suggesting this just for marketing purposes – I want safe hospitals to be available, and regulatory costs in the U.S. make it easier to start an innovative hospital offshore than in the U.S. (especially for types of innovation that don’t respect doctors’ prestige).

It has been known since 1847 that doctors kill patients by failing to wash their hands often enough. Yet this threat is still common. An offshore hospital could offer patients documentation showing when medical personel who touch the patient washed their hands (e.g. by providing the patient with video recordings of the procedures sufficient for the patient to verify cleanliness), with a double your money back guarantee. There are many other less common errors that patients could use such videos to check for.

The book Counting Sheep argues that hospitals often impair patients’ health by disturbing their sleep. Paying patients if night-time noise or light levels exceed some pre-specified limits should reduce this problem.

Next, I want the hospital’s fee structure to give it increased incentives to avoid failure. For procedures with objectively measurable results, I want the hospital to charge the patient only if those results are achieved, and to pay the patient some pre-specified amount if results leave the patient measurably worse off. (For hard to measure results such as change in pain, this approach won’t work).

The article You Get What You Pay For: Result-Based Compensation for Health Care has more extensive discussion of incentives and of strategies that hospitals might use to reduce the rate at which they harm patients.

I attended about 2/3 of the recent Seasteading conference. There were plenty of interesting people there. But I became less optimistic that seasteading will be implemented within the next decade.

The most discouraging news was that floating breakwaters probably won’t work with using propulsion to control location. They might work if anchored (which needs shallow water that only provides a little usable area outside territorial waters), and should still work with seasteads that drift were the currents take them (only suitable for people comfortable with being isolated).

The medical tourism ship business idea had last year seemed the most promising stepping stone on the way to seasteading. This year’s talk by Na’ama Moran on that subject provided better talking points that might be used to interest investors, but had nothing resembling a business plan. A year ago there was some hope that moderate changes to SurgiCruise‘s business plan could turn it into something viable. The seasteaders who were involved in that gave up on working with SurgiCruise recently, and no progress appears to have been made yet on creating an alternative.

I was also disappointed that she described no plans for dealing with the U.S. medical establishment’s ability to smear competitors. A company with no track record and weak regulation by, say, Panama can be made to sound dangerous to patients even if it provides care as good as U.S. hospitals. Could a medical cruise company hope to get accreditation early enough? There are large uncertainties about how much that costs and how soon it would be needed. I want a medical tourism company to prepare to demonstrate ways in which it provides higher quality care than U.S. hospitals (more on this in a later post).

Kevin Overman presented a vaguely promising idea for using RepRap and products from algae to build (print) structures at a cost that he hopes will be an order of magnitude less than with the materials currently envisioned to build a seastead. If he’s right, he should be able to make a nice profit building things on land before anyone is ready to build a seastead. The one drawback that I noticed is that it requires thicker structures (2X?) to get the same strength.

I also stopped by Ephemerisle for Saturday afternoon. It shows some promise as a competitor to Burning Man, but it’s unclear whether anything people learned there is related to skills needed to hold a festival in international waters. Possibly the design of the main platform can be adapted to the ocean without radical changes, but virtually all the other activity was done without any apparent regard for whether it could be repeated in the ocean.

Book review: Meltdown: A Free-Market Look at Why the Stock Market Collapsed, the Economy Tanked, and Government Bailouts Will Make Things Worse by Thomas E. Woods Jr.

This book describes the Austrian business cycle theory (ABCT) in a more readable form than it’s usually presented. Its basic idea that malinvestment creates business cycles, and that central bank manipulation of interest rates can cause malinvestment, is correct. But when Woods tries to argue that only errors by a government can cause business cycles, his ideological blinders become obvious. He’s mostly right when he complains about government mistakes, and mostly wrong when he denies the existence of other problems.

He asks why businesses made a “cluster of errors” that added up to a big problem rather than independent errors which mostly canceled each other out. The only answer he can find is misleading signals sent by the Fed’s manipulation of interest rates. He doesn’t explain why businessmen fail to learn from the frequent and widely publicized patterns of those Fed actions. It’s unclear why groupthink needs a strong cause, but one obvious possibility that Woods ignores is that most people saw a persistent trend of rising housing prices, and didn’t remember large drops in housing prices over a region as large as the U.S.

He shows no understanding of the problems associated with sticky wages which are a key part of the better arguments for Keynesian approaches.

He wants to credit ABCT with having predicted this downturn. If you try to figure out when was the last time it didn’t predict a downturn (the early 1920s?), this seems less impressive than, say, Robert Shiller’s track record for predicting when bubbles burst.

His somewhat selective use of historical evidence carefully avoids anything that might present a picture more complex than government being the sole villain. He describes enough U.S. economic expansions to present a clear case that credit expansion contributed to the ensuing bust, and usually points to a government activity which one can imagine caused excessive credit expansion. But he’s unusually vague about the causes of the expansion that led to the panic of 1857. Could that be because he wants to overlook the role that new gold mining in California played in that inflationary cycle?

He mostly denies that free market approaches have been tested for long enough to see whether we would avoid business cycles under a true free market. He points to a few downturns when he says the government followed a wise laissez faire policy, and compares the shortness of those downturns with a few longer downturns where the government made some attempts to solve the downturns. When doing this, he avoids mention of the downturns where massive government actions were followed by mild recessions. Any complete survey comparing the extent of government action with the ensuing economic conditions would provide a much murkier picture of the relative contributions of government and market error than Woods is willing to allow.

The most interesting claim that I hadn’t previously heard is that a large decrease in the money supply in 1839-1843 coincided with healthy GNP growth, which, if true, is hard to explain without assuming Keynesian and monetarist theories explain a relatively small fraction of business cycle problems. My attempts to check this yielded a report at http://www.measuringworth.org/usgdp/ saying GDP in 2005 dollars rose from $31.37 in 1839 to $34.84 in 1843, but GDP per capita in 2005 dollars dropped from $1884 in 1839 to $1869 in 1843. Declining GDP per capita doesn’t sound very prosperous to me (although it’s a mild enough decline to provide little support for Keynesians/monetarists).

He tries to blame the “mistakes” of credit rating agencies on an SEC-created cartel of rating agencies. That “cartel” does have some special privileges, but he doesn’t say what stops bloggers from expressing opinions on bond risks and developing reputations that lead to investors using those opinions in addition to the “cartel”‘s ratings (Freerisk is a project which is planning a sophisticated alternative). I say that anyone who understands markets would expect the yield on the bonds to provide as good an estimate of risk as any alternative. Credit rating agencies must be performing some other function in order to thrive. An obvious function is to mislead bosses and/or regulators who don’t understand markets into thinking that the people making investment decisions are making choices that are safer than they actually are. It appears that the agencies performed that function well, and helped many people avoid being fired for poor choices.

His discussion of whether WWII spending cured the Great Depression points out that mainstream theories falsely predicted a return to depression in 1946. But it’s unclear whether all versions of Keynesianism make that mistake, and it’s unclear how ABCT could predict the U.S. would be much more prosperous in 1946 than at the start of the war.
Here’s an alternative explanation that lies in between those theories: wages were being kept too high for supply and demand to balance through 1941. Inflation and changes in government policy toward wage levels during WW2 eliminated the causes of that imbalance.

Arnold Kling has a good quasi-Austrian alternative here and here.

Book review: The Return of Depression Economics and the Crisis of 2008 by Paul Krugman.

Large parts of this book accurately describe some processes which contribute to financial crises, but he fails to describe enough of what happened in crises such as in 2008 to reach sensible policy advice.

He presents a simple example of a baby-sitting co-op that experienced a recession via a Keynesian liquidity trap, and he is right to believe that is part of what causes recessions, but he doesn’t have much of an argument that other causes are unimportant.

His neglect of malinvestment problems contributes to his delusion that central banks reach limits to their power in crises where interest rates approach zero. The presence or absence of deflation seems to provide a fairly good estimate of whether liquidity trap type problems exist. If you recognize that malinvestments are part of the problem that caused crises such as that of 2008, the natural conclusion is that the Fed solved most of the liquidity trap type problem within a few months of noticing the severity of the downturn. There is ample reason to suspect that the economy is suffering from a misallocation of resources, such as workers who developed skills as construction workers when perfect foresight would have told them to develop skill in careers where demand is expanding (nurses?). Nobody knows how to instantly convert those workers into appropriate careers, so we shouldn’t expect a quick fix to the problems associated with that malinvestment. It appears possible for he Fed to make that malinvestment have been successful investment by dropping enough dollars from helicopters to create an inflation rate that will make home buying attractive again. Krugman’s suggested fiscal stimulus looks almost as poor a solution as that to anyone who sees malinvestment as the main remaining problem.

His claim that central bank policy is ineffective is misleading because he pretends that controlling interest rates is all that central banks do to “stimulate” the economy. If instead you focus on changes in the money supply (which central banks can sometimes cause with little effect on interest rates), you’ll see they have plenty of power to inflate.

He dismisses the problem of sticky wages as if it were minor or inevitable. But if you understand the role that plays in unemployment, and analyze Singapore’s policy of automatically altering payroll taxes to stabilize jobs, you should see that’s more cost-effective than the fiscal stimulus Krugman wants.

I’m not satisfied with his phrasing of lack of “effective demand” being caused by people “trying to accumulate cash”. If we apply standard financial terminology to changes the value of a currency (e.g. saying that there’s a speculative bubble driving up the value of the currency, or that there’s a short squeeze – highly leveraged firms have what amounts to a big short position in dollars), then it seems more natural to use the intuitions we’ve developed for the stock market to fluctuations in currency values.

He doesn’t adequately explain why most economists don’t want a global currency. He says labor mobility within the area that standardizes on a currency is important for it to work well. I’m unconvinced that much mobility is needed for a global currency to work better than the mediocre alternatives, but even if it is, I’d expect economists to advocate a combination of a global currency and reducing the barriers to mobility. How much of economists dislike for a global currency is due to real harm from regional fluctuations and how much is it due to politicians rewarding people like Krugman for biasing their arguments in ways that empower the politicians? Or do they not give it much thought because they’ve decided it’s politically infeasible even if desirable?

His description of the shadow banking system clarifies quite well how regulatory efforts to avoid crises failed. His solution of regulating like a bank anything that acts like a bank would work well if implemented by an altruistic government. But his “simple rule” is too vague for his intent to survive in a system where politicians want to bend the rules to help their friends.