Sunday, December 10, 2017

Yet Another Sign of a Stronger Labor Market: Increases in Job Leavers and Reentrants

The headline unemployment level remained unchanged at 4.1 percent in November, but a closer look at the underlying data shows signs of increasing strength of the labor market. One such indication is the continued rise in the number of job leavers and reentrants. For slightly different reasons, workers in both categories can be considered voluntarily unemployed, in contrast to job losers, whose unemployment is unambiguously involuntary.

For full details and chart, see my exclusive post on SeekingAlpha.

Monday, December 4, 2017

In Search of the Elusive Effects of the Regulatory State

The Trump administration is at war with the regulatory state. The fight is most intense at the Environmental Protection Agency (EPA), where Administrator Scott Pruitt is reportedly accompanied by armed guards even within the EPA building, but the Departments of Energy, Transportation, Interior and others are doing their bit. The Consumer Financial Protection Bureau is the latest agency to come under attack. Should we cheer all this on?
Certainly, the quality of the country’s regulatory regime does matter. As the Niskanen Center’s Will Wilkinson, puts it,
Whether a country’s market economy is free—open, competitive, and relatively unmolested by government — is more a question of regulation than a question of taxation and redistribution. . .

If we want to encourage freedom and prosperity, we should pay more attention to easing the grip of the regulatory state.
Still, before we take an axe, Pruitt-style, to anything that looks like it might be a regulation, it would be nice to have some actual evidence to show the degree to which regulation undermines our freedom and prosperity, and some data to help us prioritize the worst regulations for early excision. The popular indexes of economic freedom from the Heritage Foundation and the Fraser Institute, both of which have components that purport to quantify the regulatory burden, would seem like a good place to look. What follows is a summary of what we can learn from those indicators, and some thoughts about how they might be improved. 

Friday, November 24, 2017

The High Cost of Healthcare: Is it Really Just the Prices?

Uwe Reinhardt, the eminent health care economist, who died last week, spent his career diagnosing the ills of the U.S. medical system and suggesting remedies. One of his most famous articles, written with colleagues Gerard F. Anderson, Peter S. Hussey, and Varduhi Petrosyan, bore the trenchant title, “It’s the Prices, Stupid.” In it, Renhardt and his co-authors concluded,
In 2000 the United States spent considerably more on health care than any other country, whether measured per capita or as a percentage of GDP. At the same time, most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. But U.S. policymakers need to reflect on what Americans are getting for their greater health spending. They could conclude: It’s the prices, stupid.
Yes, our health care is plagued by high prices, with the cost of some new cancer treatments approaching a million dollars. However, as an article by Katie Hafner and Griffin Palmer in Tuesday’s New York Times details, it is not always just the prices.

Hafner and Palmer explore the rapid increase in the treatment of older Americans for skin cancer. To some extent, the increase can be explained by demographics—the aging of a generation that grew up with no clue that exposure to the sun’s rays could be anything but beneficial. However, demographics alone cannot explain why the number of biopsies for skin cancer that were billed to traditional Medicare Part B has risen 55 percent over the past decade, despite a small drop in that program’s enrollment.

The article zeros in on the role of private dermatology clinics, the largest of which is Advanced Dermatology and Cosmetic Surgery. The growth of ADCS has been fueled, in part, by an investment of $600 million by Harvest Partners, a private equity firm. ADCS makes heavy use of physician assistants to perform thousands of biopsies and treatments. The authors question the adequacy of supervision of the assistants by qualified MDs (as required by law). They report the opinion of independent specialists who characterize ADCS treatments as far too aggressive, especially for cancers that are unlikely to be fatal, and for patients who are near the end of their lives from other causes.

This examination of a single specialty raises the obvious question: Is it still just the prices, stupid, or are other factors also at work?

Although the New York Times story on dermatology is largely anecdotal, it fits in with another line of evidence that suggests that high U.S. healthcare expenditures are driven by demand, not just by higher prices per quantity supplied. Some of that evidence in question is laid out in a long, data-packed post by the anonymous author of the blog Random Critical Analysis (RCA). (If you don’t want to spend an hour working through RCA’s original post, Tyler Cohen has a brisk summary here.)

RCA maintains that although U.S. healthcare spending seems way out of line with that of its OECD peers when stated relative to GDP, it is not nearly so far out of line when compared to consumption. After all, as RCA points out, health care is a “superior good” with high income elasticity. In plain Englsih, that means Americans, like people all over the world, tend to devote a higher percentage of their total consumption spending to health care as their standard of living rises.

Although there are a few countries that have higher per capita GDP than the United States, there are none that have higher per capita consumption. Part of the reason is that Americans don’t save much. Another reason is that the United States runs a trade deficit, which makes its consumption larger as a share of GDP compared to countries that export a lot, like Germany or Norway. RCA also adjusts consumption data to reflect cross-national differences in the share of goods and services that are paid for by government but consumed by individuals.

As John Cochrane points out in a comment on his own blog, the scandal is not that we spend so much on healthcare, but that we don’t get more for our money. Our high propensity to consume health care should not curb, but rather, should spur our search for reforms that could increase the efficiency of our healthcare system.

Based on notes previously posted at

Wednesday, November 15, 2017

Global Carbon Emissions Will Rise in 2017, but Not All the News is Bad

The Global Carbon Project (GPC) has just released a report on carbon emissions for 2017. The GPC was formed to assist the international science community to establish a common, mutually agreed knowledge base supporting policy debate and action to slow the rate of increase of greenhouse gases in the atmosphere.
The headline number in the GPC report is disconcerting. After staying flat for 2014 through 2016, total carbon emissions are expected to resume their upward trend in 2017.

Not all the news is bad, however. The trend of CO2 output is downward in the three countries with the highest emissions, China, the United States, and the European Union. It is still steadily upward in India, the fourth-largest emitter.

The next chart shows emissions in two ways, one of which attributes emissions to the countries where goods are produced and the other to the countries where they are consumed. Since many goods that are produced in China are consumed elsewhere, its consumption emissions are lower than its production emissions. That pattern is reversed in the US and the EU, which import many goods from China and elsewhere.

The biggest factor behind falling emissions in the top three source countries is a decrease in carbon intensity, that is, in carbon emissions per dollar of GDP. Decreased carbon intensity is in part due to cleaner technologies and in part to steady shift away from goods and toward services.

Wider adoption of carbon pricing, whether in the form of taxes or cap-and-trade, would accelerate the downward trend in carbon emissions per dollar of GDP. As the charts show, it would take only a modest additional push to achieve a global peak in carbon emissions, once and for all. Peak carbon would not mean an end to global warming, but it would be an important milestone.
Reposted from Niskanen Center. View many more great charts here:

Thursday, November 9, 2017

Why Does the US Spend So Much on Healthcare? The Case of Urine Drug Testing

U.S. health care reformers face a daunting task. Our country spends more on healthcare than any of its wealthy peers but lags in terms of health outcomes. Just why do we spend so much and get so little for it?

Not because Americans visit the doctor more or spend more days in the hospital. In both categories, according to a report from the Commonwealth Fund, the U.S. ranks below the OECD median. Instead, the excess spending
is likely driven by greater utilization of medical technology and higher prices, rather than use of routine services, such as more frequent visits to physicians and hospitals.
A new study from Kaiser Health News provides a thought-provoking case study that focuses on the high cost of urine drug testing (UDT). Doctors who prescribe opioids for pain management order UDTs monitor compliance with recommended treatments and check for illegal substances that might interfere with health. Up to a point, such tests improve outcomes, but evidently, some practitioners go far beyond that in pursuit of revenue. According to the study, some practitioners receive more than 80 percent of their income not from treatment, but from testing.
 “We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”
What is more, as the report explains, attempts at cost control have sometimes had perverse results:
Tests to detect drugs in urine can be basic and cheap. Doctors have long used testing cups with strips that change color when drugs are present. The cups cost less than $10 each, and a strip can detect 10 types of drugs or more at once and display the results in minutes.
After noticing that some labs were levying huge charges for these simple urine screens, the Centers for Medicare & Medicaid Services moved in April 2010 to limit these billings. To circumvent the new rules, some doctors scrapped cup testing in favor of specialized — and much costlier — tests performed on machines they installed in their facilities. These machines had one major advantage over the cups: Each test for each drug could be billed individually under Medicare rules.
“It was almost a license to steal. You had such a lucrative possibility, it was very tempting to sell as many [tests] as you can,” said Charles Root, a longtime lab industry consultant whose company, CodeMap, has tracked the rise of testing labs in doctors’ offices.
The Kaiser report focuses on the cost of excess testing to Medicare, which by 2014 reached $8.5 billion per year, more than the entire budget of the Environmental Protection Agency. But private insurers, too, are struggling to cope with the same problem. In a separate discussion, Dr. Anthony Guarino, a clinician and expert witness in pain management cases, offers some common-sense guidelines for distinguishing excess from medically necessary testing. In his view,
Excessive and unnecessary UDTs cost patients, insurance companies and the government hundreds of millions of dollars per year. There are no guidelines from any medical society that justifies this form of testing.  When testing occurs repeatedly for a question that has already been asked and answered (i.e. Is the patient reliable and forthcoming), this testing is unnecessary and not medically justified.
The case of overuse of UDT illustrates one of the most formidable barriers facing would-be healthcare reformers: Every dollar of excess healthcare spending is a dollar of revenue for some healthcare provider—a revenue stream that the providers will fight doggedly to protect.

Previously posted on Niskanen Notes

Note to Tax Reformers: Consider Fixing the Formula for Taxing Social Security Benefits

While public attention is focused on big issues like corporate and inheritance taxes, many smaller but sensible opportunities to improve tax fairness and efficiency are being overlooked. A new Economic Brief from the Richmond Fed discusses one such example—taxation of social security benefits.

Currently, seniors pay income tax on a portion of their social security benefits that rises with increases in their total income, including earned income and other pension income. The formula is complex, but, as the brief explains, its effect is to expose seniors with even modest incomes to surprisingly high effective marginal tax rates—higher than younger workers who earn similar incomes from their jobs alone. For example, a senior with $16,000 in yearly Social Security benefits and $32,000 of income from other sources pays an effective marginal tax rate of 27.5 percent–much higher than the 15 percent marginal rate for a younger worker with wage income of $32,000.

According to the research on which the brief is based, the higher marginal rate discourages seniors from continuing to work. A part-time job that might look attractive at a 15 percent tax rate looks less attractive at 27.5 percent. If the seniors in question worked more, they would contribute more to the Social Security system in payroll taxes.

The brief discusses two possible reforms that would lower marginal tax rates and increase labor force participation of seniors while maintaining revenue neutrality. One would be to tax all Social Security benefits as ordinary income, rather than a portion that rises with income. Doing so would lower effective marginal tax rates and induce more work, thereby generating more revenue both through payroll taxes and taxes on benefits. Payroll tax rates could then be decreased to maintain revenue neutrality. Alternatively, all benefits could be made nontaxable, as they were before 1983.

Surprisingly, this change would result in no lost revenue, since greater payroll tax revenue would roughly equal the loss of revenue from benefit taxes.

Why not give it a try?

Reposted from Niskanen Notes

Thursday, October 26, 2017

Thinking about Tax Cuts (Part 1): Growth and Prosperity

Tax reform season is upon us. The White House and Congressional Republicans promise that their unified framework for tax reform will “fuel unprecedented economic growth.” The President has touted numbers as high as 6 percent. His more cautious advisers suggest 3 percent, a full percentage point or more above recent long-run forecasts. But even if faster growth were a sure thing, we need to ask whether that would bring real prosperity. Just what is real prosperity, and what would it take to achieve it?

Growth and prosperity are not the same thing

Economists use GDP as a measure of a country’s total output of goods and services that compresses output of steel, radishes, and flu shots into a single number. Although they are less widely known, it is also possible to measure the broader concept of prosperity by aggregating the many dimensions of human flourishing, including health, education, personal freedom, and living conditions, into one indicator. We expect GDP and prosperity to be positively related, but how closely? 

Let’s look at some numbers. For this post, I will use the Social Progress Index (SPI) as a measure of prosperity. According to Michael Porter, Professor at the Harvard Business School and a member of the Advisory Board of the Social Progress Initiative, the SPI is “a practical tool for government and business leaders to benchmark country performance and prioritize those areas where social improvement is most needed,” and “a systematic, empirical foundation to guide strategy for inclusive growth.” (The Legatum Prosperity Index, an alternative that I have used elsewhere, would yield similar conclusions.)

The SPI is constructed from some 50 individual indicators, covering things like longevity, school enrollment, homicide rates, environmental quality, protection of property rights, freedom of religion, and many more. Despite the “progress” in its name, there is nothing especially “progressive” about it in the political sense. The great majority of its components measure aspects of human wellbeing that are equally valued by progressives, libertarians, and conservatives. 

Here is a scatter plot of the SPI against GDP per capita.* The solid black trendline shows a reasonably close fit between the two variables, with an R2 of 0.82. The fit is best for a logarithmic trendline, indicating that for any given starting point, a 1 percent gain in income yields a roughly the same gain in SPI score, although a $1 gain in income has a much stronger effect for low-income countries. 

The United States ranks fifth in terms of GDP per capita among the 128 countries covered by the SPI and eighteenth in terms of its social progress score. It lies exactly on the black trendline, which is plotted from data for all countries. However, that trend is pulled down by the poor SPI scores of countries like Saudi Arabia and Kuwait (conspicuous outliers in the lower right of the scatter), which suffer from the curse of riches. Compared to its real peers, the wealthy democratic countries of the OECD, the United States is an underperformer. 

There does not appear to be any one group of indicators that pulls down U.S. performance down relative to global or OECD trends. We can see that by looking at some sub-groupings of the SPI indicators.

The creators of the SPI organize their indicators into three groups. Basic Human Needs includes survival-related indicators like nutrition, clean water, child mortality, and violent crime. Foundations of Wellbeing includes education, access to information, life expectancy, and environmental quality. Opportunity includes political rights, property rights, tolerance, and higher education. Compared with all countries, the United States is below the trend for basic human needs and opportunity, and close to the trend for foundations of wellbeing. Within the OECD, the U.S. is below trend in all three categories.

Instead of the SPI’s own groupings of indicators, which I find a bit quirky, we can instead reorganize them into more straightforward categories of health, education, living conditions, and personal freedoms. Among all countries, U.S. indicators are above the GDP-adjusted trend for education, on the trend for personal freedoms, and below the trend for health and living conditions. Within the OECD, U.S. performance is above trend for education and below trend for all of the other three. (Note that the education indicators in the SPI are mostly quantitative measures, such as primary, secondary, and college enrollments, rather than qualitative measures, like test scores.)

Where do we go from here?

By a variety of measures, then, the United States does not do a good job of converting raw GDP into the elements of true prosperity. Where do we go from here?

One option would be to prioritize more rapid GDP growth, as does the GOP’s unified framework for tax reform. If everything worked out for the best, growth would pick up to about three percent per year. After five years of growth at that rate, assuming no change in the position of the United States relative to the GDP-SPI trend, we would catch up with the point that Ireland occupies today. The next chart, which zooms in on the upper-right-hand corner of the preceding one, shows that outcome as Arrow A, which points to the right, parallel to the OECD trendline.

There is a possible catch, though. Backers insist the unified framework will produce enough growth to pay for promised rate reductions without increasing the deficit, but critics dispute that. The liberal-leaning Tax Policy Center estimates that the plan would reduce federal revenues by $2.4 trillion over ten years. The more conservative Committee for a Responsible Federal Budget estimates the revenue loss at $2.2 trillion.

Suppose the critics are right, and deficits widen. Suppose Congress gives in to pressures to cut support for education, public health, clean water, and environmental quality. If those programs were slashed, then, even if the promised 3 percent growth materialized, Arrow A would swing to a more south-easterly direction, significantly undershooting Ireland.

A second option would be to increase spending on social and environmental programs without fundamental structural reforms. Conservative critics would, no doubt, warn that doing so would put the brakes on growth. For the sake of discussion, suppose they were right, and GDP growth slowed to 1 percent per year. Under such a policy, the U.S. economy would travel along a path like Arrow B, with slower growth but larger gains in social prosperity. After five years, we might end up somewhere near the point representing today’s Switzerland.

Could we do even better?

If the only choices were Ireland or Switzerland, I would be tempted to aim for Switzerland. To choose otherwise, one would have to value GDP itself more highly than the better education, health, environmental quality, and personal freedom that go into the Social Progress Index. But could we do better still?

We could, if we pursued reforms that enhanced the inherent dynamism of the U.S. economy while also strengthening social and environmental protections. That combination could send our economy forward along Arrow C in the chart, aiming to the right of Switzerland and higher than Ireland. In bare outline, such a policy package might usefully include the following elements:

First, it would include genuine tax reform, as opposed to the simple tax cuts that are the likely outcome as the proposed unified framework works its way through Congress. Real tax reform would be revenue neutral. It would fully fund any cuts to top corporate and personal rates with elimination of loopholes, and without pie-in-the-sky dynamic scoring. Adding carbon taxes or consumption taxes to the mix could allow a sharp reduction in payroll tax rates, which, according to the Tax Policy Center, is a bigger burden than the income tax for three-quarters of American households.

Second, the package would include reforms of the social safety net to minimize the egregious disincentives to work that are built into today’s welfare system. I have sometimes suggested a Universal Basic Income as one way to increase work incentives, but there are many other ideas. A universal child benefit, an enhanced Earned Income Tax Credit, or an old-fashioned negative income tax also hold promise.

Third, the package would lift barriers to labor mobility that are built into our healthcare system. One critical step would be to end “job lock” by decoupling health insurance from employment. Reforms that made healthcare more portable from state to state would also help. Such reforms would simultaneously boost GDP and SPI scores. 

Fourth, a comprehensive reform package would include a strong free trade policy combined with reforms that enhanced economic resilience in the face of trade and technology shocks. Healthcare and safety net reforms would contribute to shock-proofing the economy, but other measures would help too, including a rollback of excessive occupational licensing, measures like “Ban the Box” that aim to improve the job market success of ex-offenders, and measures to combat the opioid epidemic.

Tax cuts alone are not enough

The lesson here is that the even if the tax cuts in the GOP’s unified framework performed as promised, growth of GDP alone is not enough to guarantee prosperity. Instead of using growth as the be-all and end-all metric for tax policy, or any other area of policy, our primary goal should be to improve the ability of the U.S. economy to transform raw GDP into real social prosperity as measured by indicators of health, education, environmental quality, and personal freedoms. 

Rather than forcing economic growth for its own sake, we should focus on structural reforms that would enhance economic dynamism through improved labor mobility, reduction of work disincentives in the social safety net, and creation free markets for jobs, goods, and services both within the country and among nations. 

This is not, after all, asking the impossible. Just moving up to an average level of performance, as represented by the social prosperity trendline for other wealthy, democratic countries, would be a great step forward. In fact, why be content to shoot for an Ireland or a Switzerland, which themselves are underperformers? Why not aim for the above-trend standards of a Denmark, a Finland, or a New Zealand? Why not try, at least?
*The SPI data are from the 2017 release of the index, which contains the most recent available value of each variable for each country. The average data year for the 2017 release is 2015. Accordingly, I have used 2015 values of GDP per capita, measured at purchasing power parity, downloaded from the IMF data base.

Reposted with permission from

Wednesday, October 25, 2017

Intra-governmental Dispute on Class Actions Poses Dilemma for Trumpian Populism

In today’s New York Times, Jessica Silver-Greenberg reports on a dispute between two federal agencies that pits Steven Mnuchin’s Treasury Department against the Consumer Financial Regulatory Commission (CFRC), headed by Richard Cordray, an Obama appointee. The controversy centers on a proposed CFRC rule that would prohibit financial institutions from enforcing fine-print clauses that mandate private arbitration and prohibit class-actions in contracts governing credit cards, car loans, and the like.

Class actions play a key role in resolving disputes in which a deep-pocket corporation is alleged to cause small harm to many individuals. Air pollution cases often fit that mold. Similar cases arise in the financial world, for example, when a credit-card issuer unfairly imposes excessive late charges of a few dollars each on thousands of customers.

Libertarians often defend both private arbitration and class actions in principle as desirable features of a free-market system of dispute resolution. For example, in a discussion of air pollution in his 1973 manifesto For a New Liberty, Murray Rothbard wrote,
Obviously, if a factory pollutes the atmosphere of a city where there are tens of thousands of victims, it is impractical for each victim to sue to collect his particular damages from the polluter (although an injunction could be used effectively by one small victim). The common law, therefore, recognizes the validity of "class action" suits, in which one or a few victims can sue the aggressor not only on their own behalf, but on behalf of the entire class of similar victims.
However, in practice, free-market thinkers have sometimes tempered their enthusiasm for class actions with fine-print clauses of their own. In another more technical and detailed article on Law, Property Rights, and Air Pollution, Rothbard piled on procedural limitations, including restrictions on joinder of both plaintiffs and defendants, uniformity of interests, and proof of causation, that would render the actual use of class actions impractical. (See here for more on the role of class actions in pollution cases.)

Evidently, Trumpian populists are caught in the same dilemma Rothbard was when it comes to class actions. In their public rhetoric, they pose as defenders of the little guy, a stance that should, logically, favor broad use of class actions. In behind-the-scenes actions like the Treasury’s attack on the CFRC rule, however, the administration more often comes down firmly on the side of party with the deeper pockets.

Friday, October 20, 2017

The Senate's 'Budget Hoax' is Nothing New (Sad)

The Senate is getting ready to pass a budget resolution, six months behind schedule. On the eve of a final vote, Senator Bob Corker calls the resolution a hoax, but plans to vote for it anyway. As quoted in The Hill, Corker says,
The only thing about this that matters is preparation for the tax reform. Other than that, these amendment votes, everything about this is a hoax. A hoax. It has no impact on anything whatsoever.
He goes on to say,
Unless we create a real budget process, which this is not, our country’s fiscal situation will continue to go down the tube, and we have no mechanism to control real spending, 70 percent of which is mandatory, that’s not even covered by this.
Sadly, this is not a new problem. Decades ago, Herbert Stein, then chairman of President Nixon’s Council of Economic Advisers, wrote, “We have no long-run budget policy—no policy for the size of deficits and for the rate of growth of the public debt over a period of years.” Each year, according to Stein, the president and Congress make short-term budgetary decisions that are wholly inconsistent with their declared long-run goals, hoping “that something will happen or be done before the long-run arises, but not yet.” (Quoted in AEI Economist, Dec. 1984.)

It would be fair to say that our fiscal policy has been “going down the tube,” as Corker puts it, for a long time.

Reposted from Niskanen Notes.

Tuesday, October 17, 2017

Winners and Losers from the Mortgage Deduction in Latest GOP Tax Plans

A few weeks ago, I wrote a post titled “Time to Repeal the Mortgage Deduction.” One of the big arguments against the deduction is that, far from being a break for the middle class, households earning $125,000 a year and higher get 87 percent of the benefits. Now, according to an analysis by Laura Kusisto of the Wall Street Journal, Congress is floating a tax reform plan that would keep the deduction but make it even more lopsidedly favorable to the rich.

The latest proposal would preserve the mortgage deduction, at least on paper, but narrow the appeal of itemizing by doubling the standard deduction. According to data from Zillow, cited by Kusisto, it now pays to itemize, on average, only for homeowners with houses worth more than $305,000, or 30 percent homes. If the standard deduction were doubled, the breakeven point would rise to $801,000, or about 5 percent of homes.

Who would be the winners and losers from these changes? To answer, we need to consider the effect on home prices as well as the effect on taxes. Kusisto cites a study by PricewaterhouseCoopers that says average home prices would fall by 10 percent without the mortgage deduction, with most of the effect felt by lower-priced homes. In that case, the effects would break out as follows:
  • Middle-class homeowners who stay in their current homes would not be greatly affected. What they lost from the mortgage deduction they would gain back from the higher standard deduction.
  • Middle-class first-time home buyers would be winners. They would gain both from the higher standard deduction and from lower prices on starter homes.
  • Middle-class families who sell their homes without buying another (for example, to move to assisted living) would be the biggest losers. Loss of the mortgage deduction would erode gains from the higher standard deduction, while the sales value of their homes would drop.
  • High-earners with expensive homes and enough deductibles to itemize would be little affected one way or the other.
  • Realtors and mortgage lenders who earn a percentage on the price of each new home would be losers.
Reposted from

It's Time to Deregulate Adult Autism Care

The Centers for Disease Control and Prevention has been tracking the prevalence of autism spectrum disorder (ASD) since 2000. As the following chart shows, the identified prevalence of ASD among American children especially boys has been rising steadily. No one seems to know how much of the increase is due to greater prevalence of the disorder itself, or greater awareness and better diagnosis. It probably is a little of both. In any case, the number of people who were diagnosed with ASD in childhood and who now are entering adulthood is rising and will continue to increase.

Unfortunately, too many of those now entering adulthood with ASD are running into regulatory barriers that prevent them from getting the kind of care they need. This post explains the nature of those barriers and outlines changes that would help ensure appropriate care for all adults with ASD. 

Origins: Deinstitutionalization

The widespread deinstitutionalization of people with mental illnesses has been one of the most dramatic changes in social policy in the United States since World War II. According to  Dominic Sisti, Ph.D., an assistant professor of medical ethics and human policy at the University of Pennsylvania, the number of patients in state psychiatric facilities decreased from 560,000 in 1955 to just 45,000 in 2014, a 95 percent decrease in the per-capita institutionalization rate. (The linked article by Sisti and colleagues is behind a paywall, but a summary is available here.)

The deinstitutionalization movement was driven, in part, by new therapies that could be delivered outside an institutional setting and also by well-publicized abuse in mental institutions. There is no doubt that many people benefited, but for others, deinstitutionalization brought unintended consequences. For some, it resulted in “transinstitutionalization” to prisons, homeless shelters, and emergency rooms. For others, it has meant living on the street.

Friday, October 13, 2017

Help Save SlideShare! Bring Back Reupload

I, and several other "Power Users" of SlideShare, have continued to pursue this issue. See the latest exchange on the topic with "Jeff" of the SlideShare customer service team that I have added today (10/2118)  at the end of this thread, just before the comments.

SideShare, the popular slideshow hosting service, has 38 million registered users and gets 70 million unique visitors a month. If you are one of those users or visitors, you can help save SlideShare from itself by bringing back REUPLOAD, an essential feature that has recently been removed.

What is Reupload and Why is It So Important?

Reupload is (or was) a feature that allowed users to repost a revised version of a slideshow without changing its URL. Now that it is gone, the only way to revise a slideshow is to delete the original version and repost a new version with an new URL. Why does that matter?
  1. Short-term error correction: We are all human. (Well, at least I am). We make mistakes. After you have posted your slideshow, you, or one of your readers, notices a typo, a wrong number in a calculation, or a broken link. You want to fix it, but meanwhile, you or your readers have bookmarked the original version, or Tweeted the link, or posted it on Facebook. When anyone follows those links or bookmarks, they will be taken to the original version with the error, not your corrected version. If you deleted the original when you made the correction, they won't find anything.
  2. Long-term revisions: Sometimes I publish a slideshow on a topic of lasting interest, say, the economics of a soda tax. I posted this version of my soda tax slideshow in 2010. Last year, soda taxes were back in the news, so I posted this revised version. At the same time, I added the little yellow box on the front page of the original so that anyone who had the old link could find the new version. This week, I wanted to update it again to include the news of the failure of Chicago's soda tax, but with reupload gone, I can no longer steer anyone who finds one of the old versions to the newest version.
  3. Classroom use: College professors and high school teachers use slideshows in their classrooms all the time. They include links to the slideshows in the printed or on-line curriculum materials they give to their students. What if the creator of the slideshow fixes an error or makes an update? Doesn't the teacher want them to find the latest version, not the old one? Without reupload, this won't happen.
What you can do

When I first contacted SlideShare about reupload, I got this non-responsive response:
Hi Ed,
Thank you for your email and I am sorry for any inconvenience this may have caused. We're always looking for ways to improve the SlideShare experience for our members. This sometimes means removing features that aren’t heavily used to invest in others that offer greater value.  Please know we continuously evaluate how features and products are used, and make adjustments accordingly to focus our resources on providing the most value to our members. As a result, we have removed the ability to re-upload documents to SlideShare.
As a workaround, you can upload a new file to SlideShare and delete the current one. Please be aware that this means we will not be able to transfer any views/likes/URL's to the new presentation.   Again, I apologize for the inconvenience and we greatly appreciate your feedback. We have documented the issue in order to track additional reports of the problem and for consideration to be addressed in a future release.
If there's anything else I can help you with, please don't hesitate to let me know. All the best,
Allison LCS Support Specialist - Mobile
This was a boilerplate response that other users have also gotten. It has been posted and reposted several times on discussion boards. I reopened the case and pointed out to "Allison" that it is nonsense. Reupload is not a feature that is "not heavily used." It is an essential feature that people use all the time. It offers great value.

"Allison" sent back this new reply that gave me a tiny bit of hope:

Thanks for your feedback about removing the re-upload feature and I wish I was personally able to do something myself however, please know I've sent your concern to our product team for consideration. Taking member feedback into account, we're always looking for ways to improve the SlideShare experience. When many of our members ask for the same improvement, we try our best to get it done. Though immediate action may not be possible, your feedback will be incorporated into our ongoing discussions about the direction of our design and development.

Again I apologize for any inconvenience this may have caused. If you need anything else, please let me know and I will gladly assist. 
So, if one of us complains, nothing happens, but if a lot of us complain, something might happen. Let's see if "Allison" is right. Let's send lots of requests to bring back reupload and see if they bring it back.

How to send a request to bring back reupload

SlideShare makes it pretty easy to ask for help. Here is how you do it:
  1.  Go to the SlideShare home page:
  2. Scroll down to the very bottom and click on "Support" 
  3. Type "Reupload" in the search box at the top of the main support page
  4. Next, you will get a page that says, "Sorry, we couldn't find any information about 'Reupload' (unless, by the time you do this, they have added some information).
  5. Go to the bottom of that page and click on the "Contact us" link
  6. That will take you to a page where you can send a message to SlideShare help. Ask them to bring back reupload, and tell them why you care.
Thanks! If we all work together, we can save SlideShare from self-destruction!

Update: Matleena Laasko,a freelance trainer in Finland, is, like myself, a heavy user of SlideShare. She has written an extensive post lamenting the loss of reload and also other features, like the ability to download in ppt and failure of links to work when viewing on line. Her original post is in Finnish, but here is a link to a Google Translate version, which, despite the usual limitations, is good enough to give the general idea.

Further update (10/23): Here are more responses from SlideShare:

With regard to reupload:
"I understand your frustration and we did look at the usage of this feature compared to the usage of other SlideShare features and found that it wasn't as heavily used and we have currently removed the feature due to the support cost.

However, we realize that this is a useful feature for some power users and we are actively working on making foundational improvements to our platform, which will make building and supporting a feature such as re-upload much easier in the near future.

Again I apologize for any inconvenience this may have caused."
So, it looks like a lot of casual users don't bother to update and reupload their posts, but it maybe is sinking in that those of us who are "power users" find it important. So far so good.

With regard to the inability to download ppt versions of the slides:

Thanks for reaching out about not being able to download the original ppt file. What you've encountered is a known issue and I'm very sorry for the inconvenience. Our engineering team is working on it but there's no estimate as to how long that might take. We'll do our best to keep you posted.
Since they used to allow downloads of ppts, it shouldn't take their engineering team all that much effort to put this ability back, you would think.

So, some progress, but I think it is worth keeping the pressure on. Anyone who has not yet sent their comments to SlideShare should still do so, rather than just being satisfied with these answers. We don't want this just to become a stalling tactic.

Further update (10/21/18)

Here is the latest exchange I have had with SlideShare on this issue. It is disappointing, since it still includes several bits of boilerplate from last year's conversations, but I think it is still worthwhile for everyone to write to them again, expressing our continued concern.

My question to SlideShare 10/20/18:

I used to be an enthusiastic user of SlideShare, a "keynote author" with nearly 12k followers. Then it all came crashing down when you took away the "reupload" feature. As I explained in a presentation posted on Slideshare a year ago
(, this feature is essential for my work and that of many other serious users. Nearly 3000 people have viewed that slideshow. 33 of them have commented, and many others have contacted me on Twitter. Please read the presentation and especially the comments to see our concerns. None of us can understand why you made this self-destructive change or why you are reluctant to restore it.
Recently some users have contacted me to indicate there may be some hope of bringing back the reupload feature. Can you give me any updates on this? Can you give me any explanation of why you are reluctant to restore it? Thank you for your attention to this issue.

Response the same day from "Jeff"

Hi Ed,

I understand your frustration, and I sincerely apologize for any inconvenience. Please note that we did look at the usage of this feature compared to the usage of other SlideShare features. Through that investigation, we found that the re-upload feature wasn't as heavily used - this is why the feature was removed.   However, we realize that this is a useful feature for some power users. We are actively working on making foundational improvements to our platform, which will make building and supporting a feature such as re-upload much easier in the near future.   Again I apologize for any inconvenience this may have caused. If you need anything else, please let me know and I will gladly assist.
Best Regards, Jeff Customer Advocacy Representative
My rejoinder:

Dear Jeff: You say, "However, we realize that this is a useful feature for some power users. We are actively working on making foundational improvements to our platform, which will make building and supporting a feature such as re-upload much easier in the near future." That sounds very nice, except that it is exactly word for word the same response that I got from someone named "Allison" a full year ago (10/23/17). I wonder if you could spin this out a little for me.
(1) Can you send me some "proof of life" to let me know that you are a human and not a bot. For example, can you tell me the middle initial of the current president of the United States? 
(2) Assuming you can answer Question 1, can you give me some idea in human time of how far off "the near future" is?
(3) Can you explain why "foundational improvements" are needed to restore the reupload feature, since you offered that feature for years? It seems to me that if you turned it off, you could just turn it back on again.Thank you, and I promise I will share your answers with the community of SlideShare "power users" with which I have corresponded on this matter. 
Jeff, back to me:

Hi Ed, Thanks for getting back to me. I'll let you know that I actually reviewed your previous case with Allison prior to responding to you earlier. I don't see anywhere in that specific case where the response I sent to you was by Allison in that conversation from a year ago. I was trying to make sure to not send you information you had already received in that previous case, so I apologize if you had previously received that information.   I assure you that I am, in fact, a human. In response to your specific questions:   1) The middle initial of the current president of the United States is 'J'.   2) Unfortunately, we don't have any specific timeframe in place at this time. For this reason, I am unable to provide any kind of range or ballpark figure at this time. I'm very sorry for any frustration this may cause.   3) We are unable to disclose any additional details regarding the decision to remove this feature, as that information is proprietary. All we're able to share is what has previously been provided - we looked at the usage of this feature compared to the usage of other SlideShare features. Through that investigation, we found that the re-upload feature wasn't as heavily used, so we have currently removed the feature due to the support cost.   I'm sorry that I can't provide additional details at this time. We sincerely appreciate your patience and understanding. If anything else happens to come up, please let me know.   Wishing you all the best, Ed!   Jeff
Me, back again to Jeff:

Thank you, Jeff, for your reply. I am sorry if my request for proof of life sounded snarky, but I was genuinely concerned, since not only I, myself, but other "power users" (PUs) have received boilerplate in the past. I am sure you know that some companies, happily not yours, do use AI rather than humans in their customer service divisions. I appreciate your "J" response and the fact that you and Allison are talking to each other.
I am evidently in error about getting the cited message from Allison. I found it in an archive of messages exchanged with SS last October, but the header and footer were cut off, so evidently the cited passage is from a message sent to another PU. In any event, the point stands that I (we, I should say -- the community of PUs who are communicating about this) are concerned that there is no real forward motion despite the teasers. You (and Allison) would probably be interested to read the whole thread from last October, including my initial blog post explaining the reasons why reupload is so important to us and the 30 comments. I plan to add this exchange to that thread. You can find it here:
BTW, as an economist, I appreciate your need to balance the cost and benefit of a feature like reupload. I would hope that you would rethink that balance. You should consider that material from your relatively few PUs is widely disseminated on other social media and becomes one of the ways that new users are attracted to your platform. If you treat us like humans, you may find that you are rewarded for the costs and efforts.
Yours truly,  Ed Dolan 

Who are the Biggest Obamacare Losers?

In a post on Kaiser Health News, Julie Rovner discusses the plight of a forgotten slice of the population who are the biggest losers from the ACA. These are people who buy insurance in the individual market but earn too much to qualify for premium subsidies.

And no, these are not all millionaire lawyers in private practice and billionaire day-traders who work from laptops in their beach-side condos. The upper income limit for ACA subsidies is 400 percent of the poverty line, which comes to just $64,000 for a family of two. That hits ordinary working couples who would like to take early retirement, people working part-time who have outside income, and self-employed professionals. Even Uber drivers can make $64,000 a year if they work hard enough.

Rovner’s post highlights the case of a married couple from Raleigh, N.C., both in their late 50s, who work as private consultants to the energy industry. When their premiums reached $1,600 a month, with $7,500 deductible for each of them, they decided to forego insurance altogether.

Rovner calculates that there are about 7.5 million such people. That is less than 3 percent of the population, but they constitute 43 percent of those who buy insurance in the individual market.

These same 43 million who are the big losers from the ACA would be among the big winners from Universal Catastrophic Coverage. UCC, as I have explained elsewhere, has potential appeal to both conservatives and liberals. As premiums rise ever higher for unsubsidized shoppers in the individual market, the constituency for UCC can only grow.

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Wednesday, September 20, 2017

National Flood Insurance: Yet Another Program in Need of Market-Based Reform

Looking for yet another costly federal program in need of market-based reform? Put the National Flood Insurance Program (NFIP) near the top of your list. It is a mess, and time is running out to fix it. As sea levels rise and extreme weather events trigger inland flooding, NFIP offers property owners insurance against flood damage at rates that do not come close to reflecting the true risk of losses. It compounds the problem by insisting that money it pays out in claims can be used only to rebuild in the same flood-prone locations—not for moving to higher ground.

There are lots of ideas for a makeover of NFIP. One obvious one would be to charge property owners full risk-based premiums. However, owners resist that measure because it would crash the value of their properties. Another reform would let owners use claims to rebuild in other, safer, areas. However, local governments where the flood-prone properties are located resist that idea because they would lose part of their tax base. Still another idea is to buy out whole communities at fair, pre-flood prices and rebuild them elsewhere. However, powerful realtor and builder lobbies resist all these reforms.

Congressional committees have been working on promising fixes. Reform proposals have been worked up to the point of being ready for a vote. But—did I mention?—Congress has less than two weeks to do something. NFIP expires at the end of September. The pressure to reauthorize it without substantive changes will be overwhelming. 

Here is some background reading if you want to pursue the cause of building a market-based National Flood Insurance Program:

  • is a coalition that promotes risk-based insurance and risk mitigation efforts. Its website is a trove of information and links.
  • The National Resources Defense Council has a great, short backgrounder on the need for flood insurance reform.
  • An excellent article in The Atlantic by Michelle Cottle outlines the politics of flood insurance reform.
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