Tuesday, January 28, 2020

American Capitalism: improve it or lose it in the 2020s By Guest Blogger John Manzella

In 2019, the U.S. unemployment rate reached record lows while the stock market hit record highs. But not everyone has benefitted. According to a recent report by the Pew Research Center, most Americans believe the economy is helping the rich, while hurting the middle class and poor. What does this mean for the future of U.S. capitalism?

Our system of free-market capitalism has generated the world’s greatest economic growth, lifted millions of people out of poverty, and achieved the highest standards of living. But for many Americans, their economic condition is less than optimal.

For example, 44% of all U.S. workers ages 18 to 64 hold low-wage jobs with median hourly wages of $10.22, says the Brookings Institution. That’s a total of 53 million people struggling to make ends meet. What’s more, 15% to 20% of men ages 25 to 54 are absent from the workforce.

In addition, labor’s share of national income, the amount paid out in wages, salaries and benefits, has been declining since the 1980s, according to the McKinsey Global Institute. This has contributed to income inequality that is now greater in the United States than in other advanced economies, notes the Pew Research Center.

Making matters worse, after decades of increases, American life expectancy has begun to decline in the last few years primarily due to drug overdoses, alcohol abuse, and suicides, reports the American Medical Association. Depression and despair primarily associated with economic hardship is suspected as the principal cause.

The impact of these problems, combined with perceptions that the current American economic system is unfair, is reflected in recent surveys. For example, in a November 2019 Gallup poll, only half of 18 to 39 year-olds viewed capitalism positively, down from 66% in 2010. Since then, young adults' opinion of capitalism has deteriorated to the point where socialism is tied in popularity.

Last October, a survey conducted by the Victims of Communism Memorial Foundation revealed a more urgent concern: that 70% of millennials — who represent the largest generational segment of the U.S. population at 75 million people — were likely to vote for a socialist candidate. And the percentage who said they were extremely likely to do so doubled from 2018 to 2019.

American free-market capitalism is the greatest economic system ever devised. Nevertheless, its flaws need to be fixed. If not, an increasing number of Americans who feel they have been left behind are likely to embrace socialism, which has repeatedly failed.

Some of the biggest beneficiaries of our capitalist system have begun to speak out and recommend solutions to ensure we don’t kill the goose that lays the golden egg.

In his 2019 article, “Why and how capitalism needs to be reformed,” Ray Dalio, founder of Bridgewater Associates, the world’s largest hedge fund with $160 billion in assets, explained that most capitalists don’t know how to divide the economic pie very well and most socialists don’t know how to grow it.

Dalio said capitalism is currently not working for the majority of Americans and warned we are at a critical juncture where people of different ideologies will either work together to re-engineer the system so the pie is both divided and grown well or we’ll have a great conflict that will shrink the pie and hurt most everyone.

Last year, Jamie Dimon, Chairman and CEO of JPMorgan Chase & Co., said the American dream is alive but fraying, explained that our shortcomings have failed many over the past two decades, and called upon other chief executives to help design solutions.

In 2019, while serving as Chairman of Business Roundtable (BRT), an association of America’s leading companies with $7 trillion in annual revenues and 15 million employees, Dimon and the BRT issued a statement that redefined the purpose of a corporation as to promote “an economy that serves all Americans.”

The statement, which goes well beyond the previous corporate focus of maximizing profits and share prices, includes compensating employees fairly, dealing ethically with suppliers, supporting communities, and protecting the environment. It was signed by 181 chief executives of America’s largest corporations.

The best run companies do more than work to generate profits and return value to shareholders, said Tricia Griffith, President and CEO of Progressive Corporation. “They put the customer first and invest in their employees and communities.” Let’s hope all American companies heed her advice which in the long run will benefit all parties — even the companies themselves through improved performance.

Let’s also hope more Americans, especially millennials, comprehend the failures of the former Soviet Union and its Eastern European satellite states. Or, for a current example of socialism not delivering, just look at what’s happening in Venezuela, which has been reduced from one of South America’s wealthiest countries to one of its poorest. Today, shortages of basic supplies such as flour and rice, along with rapidly rising prices, have led to riots and chaos.

To save American free-market capitalism in the 2020s, many business and government leaders have begun to call attention to our system’s flaws. It’s time to work together to improve the system, not abandon it.


*John Manzella, founder of the ManzellaReport.com, is a speaker, author and nationally syndicated columnist on global business and economic trends. Contact him at JohnManzella.com.

This article was nationally syndicated by Tribune News Service and appeared in newspapers across the United States.

Tuesday, January 21, 2020

Extreme Views by Guest Blogger Jack Bates, Psychology, Indiana University

Note from Larry: Jack Bates wrote the below after last week's blog. I was wondering what caused the movement of so many people to the ideological political extremes. I think Jack did a great job of thinking about causes of this schism.
              
Here are some factors to add to your column and what I saw in a quick scan of the comments:

1. The U.S. political primary system rewards extreme politicians over bridge builders, because those who actually vote in primaries tend to hold more extreme views.

2. The amount of money it takes to get elected and re-elected has our officials dialing for dollars rather than trying to understand each other at the Washington DC equivalent of the Latona Pub.

3. And why does it take so much money to get elected? Because special interests (such as Dark Money billionaires) have figured out that relatively small investments (for them) in lobbyists and support for candidates and think tanks makes them much wealthier. These same interests also have learned to control the propaganda flows and are now turning their money toward more and more local politics.

4. There are few common sources for information. When it comes to attitude influencing, psychologists learned a long time ago that even if a person is initially skeptical about a proposed attitude because of who it’s coming from, they soon forget the source, and the new attitude sticks, especially if they hear it enough times. We don’t get our attitudes at the local saloon or union hall anymore. 
     Moderate people are not in church much anymore, either. Don’t get me started on the popular, evangelical churches—such an interesting topic. As one of your commenters mentioned, social media influence us, but this too can be manipulated toward the extremes. Sleep-deprived, generally stressed people sitting at the computer are going to follow the excitement, not the reasoned argument with nuance. Factions are an efficient way to decide what your attitudes are. I’m a member of X faction, therefore, if someone from X says it, then that’s good enough for me. No need to bother to talk to any Y’s.

5. Anxious people secretly like bullies. We’re being made anxious by social/economic/political/ climate change, and the propagandists know how to really goose our anxiety. So, if a political leader seems reasonable and amenable to compromise, we fear that they’re weak. And if a political leader of X faction is firm, categorical, rejecting of nuance, and openly hostile to faction Y, that seems reassuring (not that people necessarily think this way consciously).

6. Younger people especially don’t think of themselves as playing an important role in politics, and many do not even care if we preserve our democracy. In general, one of the major “benefits” of negative advertising is to turn voters off. So, again, the more extreme people dominate.

Have you seen the November (I think) issue of The Atlantic, "How to Avoid a Civil War"? Lots of good ideas for untangling this mess. I can’t say I’m highly optimistic, but in chaotic systems, sometimes there will be a big change. Maybe the climate change issue will become enough of a common cause (to pick up one of your reader’s ideas).

Best,
Jack

Your Mother Wears Combat Boots

Last week's post -- Neighborhood Bars --  got a little more attention than my usual boring analysis of the latest macroeconomic data. To me it was illuminating -- not what I said but how some of you reacted to it. I learned a couple things from the interchange.

First, most of us do agree that we don't like the current hypersensitive situation, and we actually do agree that excessive ideological reactions to one another are not helpful when it comes to solving our myriad, deep, and complicated economic and social problems. Look back at some of the posted comments and you will see what I mean. We are not so far apart. We really would like to see a more rational and objective approach to our challenges.

Second, despite the above, we are locked and loaded and ready to explode if a mouse walks into the room. We are ideological. And that is neither bad nor unusual. Even if we are what one might call a "moderate," some of our views might be less moderate. Maybe the abortion issue is your thing and you believe strongly that no one can dictate a woman's choices. You might be less extreme on taxes or utility regulation but if someone dares to challenge a woman's right to abort, then out come the pistols.

Even moderates hold strong views on some issues. And then there are some people who are not moderates and find that many of their views line up with what we call progressives and conservatives.

This means that despite agreement on many things, most of us are ready to "go off" if some unsuspecting fool says one word that challenges our beliefs. Worse yet, we really believe that person is a fool and possibly a bad enough person that they do not warrant an argument. Why waste time with someone so ignorant and mean? So what's our approach?

We are mad at an offensive thing that person said and since that person is beyond redemption, we start calling them names. "Your mother wears combat boots!" (Women in combat boots can be pretty sexy so I'm not sure why this is a negative thing to say.) And then we are off and running. Once we call them a name -- the easiest and most direct thing to do is to respond in kind and call them an even worse name. Woowee. What fun.

I doubt that this behavior is new to America or anywhere else. As I tried to say in last week's Neighborhood Bars, what's different now is that we have a lot of really big problems -- problems that really bother us. We are frustrated by the persistence of these problems. They are also problems that are not easy to resolve. There is very much wrong with an exclusively progressive solution so that gives the conservatives a lot of firepower. Of course, there is also something wrong with an exclusively conservative approach, so that makes progressives ready to jump on conservative suggestions.

Big problems. Complicated solutions. An opening to criticize the other guys. And then the fight breaks out.

To me the answer is simple. Go find someone of the opposite stripe and hug her/him.

Just kidding. The answer is respect and education. Open your mind to the need for multi-ideological approaches to complicated problems. Think about what you want to say before you open your yap. If you disagree with your crazy progressive son, find a way to disagree that shows respect for his views. Try to understand why people who ordinarily love each other would disagree. Put yourself in their shoes and try to understand why they hold a different view. Hmm, maybe it is possible to learn from each other!

I know what you are saying. Larry is in the JD sauce again. And maybe I am. Maybe today I am more of a dreamer than a realist. Maybe we will never escape all this ugliness. But then maybe it is possible for people to be respectful and try to learn about hard things by being exposed to opposing views. I don't know. You tell me.


Tuesday, January 14, 2020

Neighborhood Bars

One thing I like about neighborhood bars is that you can get into some interesting conversations. It doesn’t happen every night, but recently I had one of those nights. I was just about to waddle home when in came a guy I had met once before on a barstool at Taco Guaymas. He is a neonatal doctor but we didn’t talk about saving babies.

We started talking about what appears to be a very popular topic these days: Why have people clumped up into extreme political groups and why do they spend their time pointing fingers and calling each other names? Why is it that we have almost zero real conversation and instead shout out mantras we learned from the latest cable TV entertainment (I refuse to call them news) show?

We remembered out loud Walter Kronkite and Ralph Renick (Miami) and similar news shows of long ago in which, at some point in the newscast, it became very clear that the next few minutes would be devoted to opinion. If the opinion light was NOT blinking, that meant we were getting some form of news that was not opinion. Then we got off on 24 hour cable news and now there isn’t one iota of news that isn’t colored by ideology. Joe Jones fell and hurt his knee because Republicans don’t fund adequate exercise programs for the elderly. Or Joe Jones fell because he is a lazy parson on welfare. That’s what we get these days. No offense to Joe Jones.

My doctor friend and I didn’t share much ideology, but we were just about hugging it out in agreement that something has changed and that something is for the worse. The extremes are making us all cranky. The press makes it even worse. And don’t get me started on our politicians.

Our sad conclusion is that while this state of affairs seems like fun in a perverse way, it has a devastating effect when it comes to solving real problems. As we are unloading F bombs at each other, we are losing precious time to try to find realistic solutions for income inequality, poverty, healthcare, and so on. The clock is ticking and we are doing nothing. And yet we gleefully elect monsters who perpetuate this sad state of affairs.

I took a big swallow of JD. Then we got to the fun part. Why? Why now? What seems to be causing this exciting yet dangerous mud-wrestling? Why do the extremes seem to rule each party? Why do we not recognize that compromise – a dirty word these days – has always been and will always be the solution in a democracy? Clearly, very few real, durable and deep economic and social problems in the USA today are simple enough to be fixed by either right- or left-wing extreme solutions. The world is full of grey, and there is no simple ideological solution to our problems.

Here is the shoe dropping. How did we get here? I think I know why we no longer trust moderates like Lugar and Hamilton to fashion solutions that most of us would approve. But maybe I am full of crap. I am sure you will tell me what you think.

Today we find ourselves with outcomes we don’t love. Let’s not point the finger of blame but just agree that the data supports outcomes that most of us don’t like. Maybe it is the distribution of income. Maybe it is the share of income earned by the rich. Maybe it has something to do with healthcare. Maybe it is the slow growth of the economy. Okay – you can add to the list.

My point is that we find ourselves in 2020 with a long list of disappointments. What do we do? Do we sit down together and patiently go over all the likely causes and try to compromise on very difficult decisions? Oh hell no. Just blame it all on the other guys. That’s easier and more fun and really – that world out there is so damn complicated we probably can’t figure out how to approach all those problems anyway. Let's get out the dictionary and look up some really hateful names to call each other. Commie! Pinko! Racist! Bigot! Now, that’s fun!

Err, no it isn’t. And that’s about all I have to say right now. We have big problems and instead of them requiring the best of us to solve them, it is much easier to start a revolution. We aren't very smart and all that work will take away from our TV time. 

My friend forecast that it is more likely than ever that after so many years of being the world’s most successful democracy, soon the West Coast states (and a few others) will secede from the USA. Wow – he really caught my attention on that one. Why should people on the West Coast be dragged down by the rest of us? Or vice versa? Just secede. Split up. That will solve everything. Or will it? 

From my vantage point today in Seattle I am wondering what it would be like to be living in a foreign country. Maybe we will introduce our own currency. Let's call it the Mariner. How many Mariners will I be able to exchange for one loaf of bread? That’s all folks. Happy New Year. :-)

Sunday, January 12, 2020

A Decade of Employment

We all know that the economy has grown slowly since the recession ended in 2009. We all know that the US economy is not growing robustly as we enjoy the longest expansion on record. We all suspect a recession is somewhere ahead of us. These are the facts that we often hear because they seem very relevant to us.

Our weight goes up and down and we jump on the scale to see the latest changes. Even if we haven't gained much weight in the last year, it is of interest to know if we gained at all. So it is with the economy and its changes.

That's what today's blog post is about. December's employment might not have grown a lot. In fact, employment in the last 10 years might not have grown as much as in the previous 10 years. But has it grown at all? And if so, by how much?

I used my friend Google to travel to the website of the Bureau of Labor Statistics to look at employment in the USA. This post and the below table might not satisfy some of you because it represents a start in thinking about employment in the USA over the past 11 years. It's a start because many of you are going to look at this and then ask a lot of questions about what is missing in the chart. That's fine. We can handle those as we move forward.

The table contains the December values of three employment series -- all workers, manufacturing workers, and government workers -- for all the years from 2009 through 2019. They are presented in millions of workers.

The USA in 2009 had 130 million employed workers. Of those, around 11 million were in manufacturing and another 22 million worked for governments (federal, state, and local). The rest were found in the many various non-manufacturing sectors.

Each December found total employment rising. The fact that we have not had a recession in all those years since 2009 implies that in none of those years did employment decrease. It has been a decade of steady increase.

With respect to ALL employment, employment went from 130 million in 2009 to 152 million in December of 2019. That 23-million worker increase amounted to a 17.4% increase. The 17.4% is not a record but you have to admit that 23 million jobs is not a small number. There are only two states that have a population of as much as 23 million -- California and Texas. 23 million is about the size of New York plus Connecticut.

It might have taken 10 years but the US employment increase was large enough to give jobs to nearly all the people in New York and Connecticut. Or you could say it was enough to have employed everyone in the third largest USA state.

A quick look around the world suggests that the USA was not alone in the slowdown of employment -- but more relevant for today is that in most cases of most advanced nations -- employment grew about half as fast as it did in the USA. (I am purposely not citing numbers for this comparison because it is not possible right now to find employment data for relevant countries that match exactly those I am quoting for the USA. To base my international comparison, I used the B tables from the IMF World Economic Outlook Report published in October of 2019.)

Most people wring their hands and say prayers for USA manufacturing employment, but the table shows an increase of about 2 million jobs or a 12 percent increase over those years. OK, that might not have set any records but it is an increase.

The government sector was not so successful. Employment did not increase by even 1 million people and the increase was less than 1 percent.

I can hear some of you wondering out loud. What about skilled versus less skilled? What about the average wage? What about employment of low-wage workers? What about those Sea Hawks?

Anyway, I said this was just a start. The fact that employment increased by more than one New York is not too bad. If it is not good enough for you, then maybe we should ask our friendly idiots in DC to do something about that.

Table. December Employment USA 2009 to 2019 (in millions of workers)

Year                     All         MFG          Govt
2009             130             11             22
2010             131             12             22
2011             133             12             22
2012             135             12             22
2013             137             12             22
2014             140             12             22
2015             143             12             22
2016             145             12             22
2017             148             13             22
2018             150             13             22
2019             152             13             23
Chg 2009 to 2019*                                   23                                1                                0
% Chg 2009 to 2019 17.4 12.0 0.7

*The change calculations reflect the actual differences before rounding off. 

Tuesday, January 7, 2020

A Look Back and Forward by Guest Blogger Buck Klemkosky

What a difference a year makes. At the end of 2018, the Fed had just raised interest rates for the fourth time that year and was forecasting three more in 2019. Stocks were plummeting and trade tensions rising. At the end of 2019, things don’t seem nearly as bad, even somewhat normal. The economy in 2019 did revert to the “new normal,” the 2% GDP growth rate of prior years. The year started out with first-quarter annualized GDP growth of 3.1% but it reverted to 2.0% in the second quarter and 2.1% for the third quarter. If GDP growth is close to 2.0% in the fourth quarter, growth for 2019 will be 2.3%, down from 2.9% in 2018.

The economy has faced several crosswinds in 2019. Certainly, the trade tensions have been one of the biggest headwinds in 2019. Even though a “Phase 1” trade agreement with China was reached in December, trade tensions are expected to continue not only with China, but Europe and Latin America. Trade tensions and policy uncertainties are the primary reasons that CEO confidence is at the lowest level in a decade. This corporate gloom has resulted in negative corporate investment in the second and third quarters of 2019. Other CEO concerns are slower synchronized global growth and a manufacturing recession in most developed countries plus China. In the U.S., manufacturing has contracted for six consecutive months. While manufacturing doesn’t play as prominent a role in today’s economy, 11% of GDP and 8.5% of employment, it is still considered an economic bellwether.

There are economic tailwinds. The biggest is probably the state of the consumer. Unlike the CEOs, consumer confidence is close to an all-time high. Unemployment of 3.5% is at a 50-year low, wages are growing at a 3% annual rate and jobs are still plentiful; there are still more job openings than people looking for jobs. Household balance sheets are in good shape and household net worth (assets minus liabilities) is at an all-time high. The consumer has been the pillar for the economy in 2019.

Other tailwinds in 2019 have been monetary and fiscal policy. After raising interest rates four times in 2018, the Fed did an about-face and cut rates three times in 2019. These were “insurance cuts” because of trade tensions, slowing global growth and the manufacturing recession. Even though the unemployment rate is at a historic low, inflation appears moderate as the Fed’s preferred measure of inflation continues to be below its 2% target. Monetary easing and subdued inflation have resulted in the bellwether 10-year Treasury bond yield falling from 2.68% at the beginning of 2019 to 1.92% at year end. This has been good for consumers, homeowners and corporate borrowers but financial repression for savers. The biggest benefactor of lower interest rates has been the U.S. government. As the effects of the 2018 tax cuts waned, the government attempted to stimulate the economy via spending and fiscal deficits; the deficit surpassed $1 trillion for the 12 months ending in October 2019 for the first time since the Great Recession of 2007-2009. These $1 trillion fiscal deficits are projected into the foreseeable future.

The stock and bond markets reacted favorably to the economic crosswinds in 2019. The S&P 500 appreciated 28.9% in 2019, the best year since 2013. To keep this in perspective, some of the 2019 stock market appreciation was in reaction to the dismal performance in the fourth quarter of 2018; the S&P 500 peaked at 2930 in September and fell to 2351 by Christmas Eve day, a decline of 19.7%, excluding dividends. A decline of 20% would have been classified as a bear market, so it was close to being the first since 2007-2009. Since earnings growth was slightly negative in 2019, the stock market’s appreciation was all due to higher valuation metrics. Given the stock market performance, individual investors don’t seem to be enthused about the longest-running bull market in history. In 2019, investors have withdrawn more than $156 billion from equity mutual funds and exchange-traded funds – the largest withdrawals since they began tracking flows in 1992. There were record inflows into money market and bond funds in 2019. Going back 35 years, 2019 was the first time the S&P 500, crude oil and gold all appreciated at least 10%, and the 10-year Treasury yield fell .75%. Gold had its best year since 2010 and the S&P 500 since 2013. As both short-term and long-term interest rates fell in 2019, bond markets also performed well – the longer the maturity, the better the performance. It certainly paid to follow the Wall Street adage – Don’t Fight the Fed – in 2019.

Recessions tend to catch economists unaware, and the ones they do see coming often don’t happen. In 2018, many of the economic pundits were predicting a U.S. economic recession in 2020. But recession fears have been dialed back. One of the red flags of 2019 was an inverted yield curve – short-term interest rates higher than long-term rates; it has since uninverted. The other red flag was manufacturing; while still contracting, it is doing so at a decelerating rate and stabilizing. The outlook for the global economy is improving; the economies of the U.S., China and Japan have improved but not the Eurozone.

2020 economic growth hangs on the consumer; consumption is more than two-thirds of overall GDP. The household sector is in good shape; while debt is at an all-time high of $16.2 trillion at the end of the second quarter of 2019, it represents 76% of GDP versus 100% in 2008. Household net worth was $114.9 trillion at the end of the second quarter of 2019, a record high, and debt payments as a percentage of disposable personal income were 9.7% versus 13.2% in 2007. Shoppers have been the heroes of this record-setting economic expansion, 10.5 years and counting. Consumer spending will continue to be the primary force driving the U.S. economy in 2020 given the strength of the job market, wage increases and moderate inflation. Corporate investment is usually one of the driving forces in the later part of economic expansions and this has been missing in 2019. It would help if this could get back on track in 2020 to alleviate some of the burden on the consumer.

Monetary and fiscal policy will continue to be economic stimulants in 2020. But headwinds still exist; trade tensions with China and the rest of the world will not abate, and election worries will probably trump everything. There are wide differences among potential president candidates, and the primary process and election may affect consumer confidence and already deflated CEO confidence. Less trade and policy uncertainty would certainly help the latter.

One macro factor to watch carefully in 2020 is inflation. Many believe inflation is permanently muted because of globalization, demographics and price transparency at the consumer level. Thus far, the historical relationship between a record-low unemployment rate and inflation has not held up. If wage inflation picks up and the U.S. dollar weakens, overall inflation could perk up. If this happens, the Fed will be slow to counteract it by raising interest rates because it has adopted a symmetrical inflation policy whereby their inflation target will be an average of 2%. Since the inflation rate has consistently been below 2%, the Fed plans to let it run above 2% for some time before tightening monetary policy. Higher inflation would translate quickly into higher interest rates, certainly not good for the bond and stock markets.

Investors should not expect 2019’s stock market performance in 2020. In 2018, S&P 500 earnings increased more than 22% for the year and the S&P 500 fell 6% due to the bad fourth quarter. In 2019, S&P earnings declined and the S&P 500 increased 29% due to price-earnings multiple expansions, leaving valuations above historical levels. This could be justified based upon lower-for-longer interest rates. So interest rates will be a critical factor in how the stock markets perform in 2020. Another factor may be FOMO, fear of missing out. There are record amounts of money in money market and bond funds that could navigate into stocks. With bond yields at extraordinarily low levels, there are few alternatives to stocks. Real yields on bonds – the after-inflation return – is barely above zero and stocks do offer the possibility of capital appreciation and dividend growth. Plus stock buybacks offer some support for stock prices. S&P 500 earnings are expected to increase in 2020 relative to 2019 adding more support for the stock market. The consensus of stock market prognosticators is for market returns of around 5% in 2020 with 1.8% coming from dividends. Historically, election years have been good for the stock market with only two down years since 1948.

The consensus for U.S. economic growth in 2020 is the “new normal” of 2%. GDP is a function of the number of hours worked times output for worker. The number of hours worked has been increasing about 0.8% annually and productivity has also been increasing about 1.3% although it was negative in the third quarter of 2019. Given the low unemployment rate, the growth in the number of hours worked is expected to fall below 0.5% going forward. That leaves the heavy lifting to productivity and that has been trending down for several decades – 2.77% in the 2000s and 1.3% since 2010. It will take a dramatic increase in productivity to get GDP growth out of its 2% rut. This is a global as well as a U.S. problem.

Thursday, January 2, 2020

Part 2. Healthcare 2020 America by Guest blogger Bruce Gingles of Cook Medical

The incessant criticism of America's health cost and outcomes/quality is partly legitimate in that we do spend the most and on certain metrics like infant mortality and life expectancy we rank below the top and in some cases, well below.  A recent and very credible study in JAMA found that America's healthcare utilization across several major disease categories mimics that of other developed nations.  

Two costs distinguished the US from other countries.  The first is that our physicians make a lot more money than physicians in other countries and second, breakthrough drug classes (primarily biologics indicated for cancer) are more expensive than most "small molecule" drugs and the price borne by US patients and payers is higher than other countries (1, 2).  It's not clear whether the US has the political will to reform our medical workforce and the prerequisite undergraduate and graduate medical education system in order to produce less expensive yet highly competent labor units.  The average debt at medical school graduation in the US is just under $200K.  That money has to be paid back somehow and the task falls to wages.  We could reduce/eliminate from the curriculum those classes that do not logically increase technical skills like French, art history, geography, astronomy, poli sci, and perhaps even economics.  Dispensing with these credit hours would not harm a physician's ability to accurately diagnose and skillfully treat any disease.  Also, miracle-working specialists like transplant surgeons, trauma surgeons, oncologists and many others, spend months at a time on "shopping" rotations during med school to help to help narrow their residency selection.  Since they only choose one, all the services on which they served before matching were wasted.  Specialty rotations during med school could be eliminated without compromising physician quality and this would save a lot of money and time. 

To the less expensive but more volatile issue of high drug costs, here are the facts.  Drugs represent about 12-13% of total US health spending.  Devices and diagnostics account for about 5-6%, bringing the total for "stuff" to nearly 19%.  Device and diagnostics costs as a percentage of the total have been stable for decades but drug costs began rising unusually rapidly about 10-12 years ago.   These increases were mostly the result of a) new biologic classes of drugs which are very expensive to manufacture when compared to small molecules and b) the development of drugs for rare or orphan indications.  Virtually all new drugs require the same level of testing and pre-market regulatory validation to earn market approval.  This is expensive and time consuming (3).  With the exception of rare, expedited review "breakthrough"  drugs, most run the full obstacle course.  A market feature enjoyed by the pharmaceutical industry which is not shared by device or diagnostic companies is that by federal law, drug manufacturers set market prices and these prices cannot be negotiated by Medicare or other federal payers.  That artifact allows pharma considerable pricing leeway but its not clear that this policy has been detrimental to America's health or R&D dominance.  The facts of the case are that we struggle to survive high drug prices until patents expire, at which point the market nearly instantly converts to the generic equivalent.  About 80% of all prescriptions in the US are generic (4).  Generic drugs reduce prices by about 85% (5).

American per capita GDP is the highest of all major economies.  We're rich and we spend part of our wealth on healthcare, including drugs.  Gilead Sciences paid $11B for the Sovaldi/Harvoni patents alone.  This drug class cures Hepatitis C in about 12 weeks with no known side effects. For affected patients, it's practically a miracle.  The addressable population is small, only a few million (up from the original estimate of 350,000) so the costs have to be amortized over many fewer patients than Lipitor or Nexium.   Our health system and the world's had a mild episode of sticker shock when Sovaldi launched at $87,000 per patient.  Never mind that there was virtually unanimous opinion among health economists that at $87K it was much less expensive for much better outcomes than the prevailing standard of care comprising frequent hospital admissions and palliative care.  The main point is that Americans pay more than other countries for the same patented drugs because we can.  

People who are smart enough to know better insist on arguing that because Canada, France, Uruguay or Somalia pay less, the true market price should be the lowest amount paid.  In reality, and from the manufacturer's perspective, the amount earned can be calculated by multiplying the total number of doses sold times the average selling price (ASP) of each prescription dispensed.   What matters is not the lowest or highest but the average.  Hypothetically, the US pays $50/dose for 5 million patients and Portugal pays $15/dose for 800,000 patients, and so forth.  It's easy math.  In exchange for our higher ability/willingness to pay, we get earlier access to life saving drugs while many countries must wait years for the generic version to become available.  In this way, we are also the proverbial guinea pig since side effects may not manifest for years.  Thalidomide is one scandalous example.  An obvious truth is that pharma is highly incentivized to sell more, not fewer, drug doses.  Pricing one's product above the market's ability to pay is not a winning business strategy and even dull pharma execs get that.  With only a few years to repay investors before patented drugs go generic, the pressure is on to move as much inventory as possible.  Scaling R&D/clinical trial quantities to global production volumes results in miniscule cost/dose.  

It is instructive that each year Forbes and Fortune publish a list of the 1) largest and 2) the most profitable US companies.  Pharma's greed should be on stark display.  In reality, pharma rarely breaks the top 10 and it's uncommon to find more than one or two in the top 25.  Most of the profligate profit hyperbole is urban myth.  


America is by far the most heterogeneous of the world's societies.  Diverse cultural preferences often dictate care delivery and consumer models.  Try explaining vaccine phobia to an educated person, especially those with kids in crowded public schools.  We are also blessed/burdened with many personal freedoms.  It's our birthright to consume junk food and pizza in excess and if we want to Darwin ourselves out of the gene pool, that's our right.  The government's and private sector's best efforts to the contrary notwithstanding.  Modern medicine performs many miracles but our health quality and life expectancy also require individual compliance.  The harmonious relationship between excess and affluence is a proud and long-established tradition.  So what if we chop less firewood than the Norwegians or walk fewer kilometers each day than the French?  We make and consume better bourbon and we should be proud of that.   If some of our bourbon and legal pot is enjoyed by pregnant teenagers, is that really a healthcare problem?  We are now celebrating the excellent reflexes and marksmanship of Texas worshippers willing to exchange gunfire with nefarious congregants.  That's Constitutional policy, not healthcare.  Healthcare is the number of trauma survivors discharged from the operating room after the event.  In that expertise, we remain the envy of the world.