Posts Tagged ‘profits’

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Provoked, first, by liberal celebrations of the recent decline in the poverty rate in the United States—and, then, by conservative attempts to dismiss the issue of inequality, I decided to run some numbers. Just to see.

As it turns out, the corporate profit share (on the right in the chart above) and the poverty rate (on the left) appear to have moved in tandem since the mid-1990s: when the profit share declines, so does the poverty rate, and vice versa.

This is one of those times when I don’t have a theory or an explanation. But I was reminded of that long-forgotten ruthless critic of political economy:

Accumulation of wealth at one pole is, therefore, at the same time accumulation of misery, agony of toil slavery, ignorance, brutality, mental degradation, at the opposite pole, i.e., on the side of the class that produces its own product in the form of capital.

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The best Steven Kaplan can come up with in attempting to defend Wall Street against Lynn Stout’s withering criticisms is that it has helped the U.S. corporate sector in recent decades.

If those criticisms had been accurate, the U.S. corporate sector today would be ailing. Instead, corporate profits are at historical highs both absolutely and relative to GDP. Private equity and activist investors–both Wall Street creations–have pushed companies to become more efficient. Venture capital funded companies, aided by capital from Wall Street and other investors, include firms like Amazon, Amgen, Apple, Facebook, Gilead Sciences, Google, Intel, Microsoft, and Starbucks that have changed the world as we know it. While it is impossible to prove causality, it seems highly likely that Wall Street has played an important role in these results.

And he’s right: nonfinancial corporate profits (as a share of national income, the blue line in the chart above) have in fact risen since 1985 (from 4.4 percent in 1985 to 8 percent in 2015). And Wall Street has also helped itself: financial profits (the red line above) have also risen (from 1.3 percent of national income in 1985 to 3.2 percent in 2015).

What he fails to mention is that, at the same time, the wage share of national income (the green line in the chart) has fallen: from 55.6 in 1985 (and even higher, 57.2 percent in 1992) to a low of 52.5 percent in 2014 (rebounding slightly to  53.1 percent in 2015).

Yes, indeed, Wall Street has been good for business and for itself—and terrible for everyone else, especially American workers.

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There are, of course, many aspects of the U.S. healthcare system I have not had the opportunity to discuss over the course of this series on Unhealthy Healthcare. I am thinking of the growth of new, profitable medical centers (e.g., for out-patient surgery), plus biotechnology companies, diagnostic clinics, rehabilitation centers, and nursing homes. There are also all the nurses, orderlies, bookkeepers, and administrative staff, primary-care physicians and therapists in rehabilitation services, the hospital volunteers and the underpaid staff who provide care in nursing homes, the dedicated people who set up clinics for underserved populations, and many others who are forced to work under increasingly difficult conditions to provide decent healthcare to the American people.

But no matter how hard those healthcare workers labor, the current system of U.S healthcare is a failure. It provides less healthcare at a higher cost than in other rich countries. And it continues to leave large numbers of Americans, especially workers and the poor, without access to affordable, high-quality healthcare.

The U.S. healthcare system, as it is currently configured, only really works for those who make a profit—selling health insurance, pharmaceuticals, and in-patient and acute-care services in hospitals—and those who have the wherewithal to finance their own healthcare.

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As it turns out, the majority of Americans know this. According to the latest Gallup poll, 54 percent of respondents have a somewhat or very negative view of the healthcare industry. And 60 percent have only some, very little, and no confidence in the current medical system. On top of that, 82 percent worry (either a great deal or a fair amount) about the availability and affordability of healthcare in the United States.

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In fact, the majority of Americans (58 percent) say they would like to see the 2010 health care law, the Affordable Care Act, replaced with care for all—along the lines presented most recently by presidential candidate Bernie Sanders.

Obviously, workers and poor people in the United States need and want a healthier healthcare system. The question then is, what would should a system look like?

Here I’ll admit, I don’t have a detailed plan of what the U.S. healthcare system should be or how exactly it should be transformed. There are plenty of such plans out there (the best known of which is probably the single-payer program developed back in 1989 by the Physicians for a National Health Program). And I’m not about to develop and present a new one.

Instead, I am guided by a lesson I learned from an old friend (a veteran of more than three decades of working in the trade-union movement): formulate and win people over to the general goal and, once they’re committed to it, let policymakers and stakeholders negotiate and work out the details to reach that goal.

In this case, the goal is universal, affordable, high-quality healthcare.

Such a system would provide high-quality healthcare (physical and mental, encompassing prevention, acute-care, substance-abuse, rehabilitation, and late-life) to all Americans (without exception, especially those who at the middle and bottom of the economic ladder) at an affordable price (since, as I see it, Americans are willing to pay for decent healthcare but it should be according to their ability to pay, which it currently is not).

That’s it. We shouldn’t care how they provide it. Just that they do so.* And if the key components of the current healthcare system stand in the way, because they’re making profits on how the system is currently organized and don’t want to see real change, they should be bypassed or nationalized (as the case requires). Then, the other private and public entities, the ones actually committed to the goal, can get on with the task of imagining and implementing the universal, affordable, high-quality healthcare system Americans deserve.

 

*Although, to my view, a healthier healthcare system right now probably involves some combination of single-payer (federal and state) financing and a network of non-profit, community, and cooperative healthcare providers.

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Much of the debate about the U.S. healthcare system is focused on the role of public financing (in terms of subsidies and, for some, the possibility of a public option or even a single-payer program). But no one seems to want to look at the other key part, the actual delivery of healthcare to American workers and others. And that, regardless of the system of financing, remains mostly in profit-oriented private hands (which, as I argued earlier this year, undermines patient-centered healthcare).

There are a few exceptions, such as the Veterans Health Administration and Indian Health Service, whereby the government directly employs nurses, physicians, and others to provide health services to targeted populations. But the rest of healthcare is provided by private  (profit and nominally nonprofit) individuals, groups, and corporations.

As I discussed on Friday, a significant sector of private healthcare is the increasingly concentrated and enormously profitable pharmaceutical industry. Hospitals (which I’ve commented on many times over the years) are, of course, another key sector (at close to $1 trillion in 2014). That’s where Americans receive most of their in-patient care, critical care (including many without health insurance in emergency rooms), and an increasing number of out-patient treatments. And while hospitals appear to be independent from and non-overlapping with physicians (whose services accounted for roughly $600 billion in 2014), that’s an optical illusion. Not only do they compete with one another (in surgery, imaging, and other ambulatory services), each is forced to work closely with the other: hospitals rely on physicians to admit patients to their facilities, refer to their specialists, and to use their lucrative diagnostic services (with, as it turns out, illegal kickbacks), while physicians tend to their own patients within hospitals and are contracted for “in-house” supervision. And, increasingly, hospitals are directly employing physicians (and other healthcare workers) as salaried and piece-rate workers.

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U.S. hospitals are, as it turns out, remarkably profitable. And, according to a recent analysis by Ge Bai and Gerard F. Anderson (unfortunately gated), 7 of the 10 of the most profitable hospitals (each exceeding more than $163 million in total profits from patient care services) are officially non-profit institutions.

According to Anderson,

The system is broken when nonprofit hospitals are raking in such high profits. The most profitable hospitals should either lower their prices or put those profits into other services within the community. We need to develop incentives that allow all hospitals to make a fair profit while at the same time keeping prices reasonable.

It’s true, many other hospitals (56 percent in their sample of acute-care facilities) are not profitable strictly in terms of patient services (the median hospital lost $82 per adjusted patient discharge). However, as the authors explain,

the median overall net income from all activities per adjusted discharge was a profit of $353, because many hospitals earned substantial profits from nonoperating activities—primarily from investments, charitable contributions (in the case of nonprofit hospitals), tuition (in the case of teaching hospitals), parking fees, and space rental. It appears that nonoperating activities allowed many hospitals that were unprofitable on the basis of operating activities to become profitable overall.

The most important factors boosting hospital profitability were markups (especially for uninsured and out-of-network patients and casualty and workers’ compensation insurers who often pay the hospital’s full charge) and the combination of system affiliation and regional power.

In fact, 50 hospitals in the United States are charging uninsured consumers more than 10 times the actual cost of patient care. All but one of the facilities are owned by for-profit entities. Topping the list is North Okaloosa Medical Center, a 110-bed facility in the Florida Panhandle about an hour outside of Pensacola, where uninsured patients are charged 12.6 times the actual cost of patient care. Community Health Systems operates 25 of the hospitals on the list. Hospital Corporation of America operates 14 others.

Again according to Anderson:

They are price-gouging because they can. They are marking up the prices because no one is telling them they can’t. These are the hospitals that have the highest markup of all 5,000 hospitals in the United States. This means when it costs the hospital $100, they are going to charge you, on average, $1,000.

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It should come as no surprise, then, that, while the total number of hospitals has remained relatively constant over time, the number of those hospitals in health systems has continued to increase, thereby increasing regional power, markups, and profitability.

In another recent study, by Richard M. Scheffler et al., the authors found that the hospital markets in two states (California and New York) “were moderately to highly concentrated,” with mean Herfindahl-Hirschman indices of 2,259 and 3,708, respectively.* They also found that more concentrated hospital markets were associated with higher premium growth.

As expected, then, there is a continuing strong movement of hospital mergers and acquisitions—with at least 100 deals covering 178 hospitals, involving the takeover of profit and especially non-profit organizations, in 2014—leading to increased concentration in the hospital sector of the U.S. healthcare industry.

As Martin Gaynor explains,

There has been so much consolidation that most urban areas in the US are now dominated by one to three large hospital systems — examples include Boston (Partners), the Bay Area (Sutter), Pittsburgh (UPMC), and Cleveland (Cleveland Clinic, University Hospital). It is also now more likely that further consolidation will combine close competitors, given how many mergers have already occurred.

Clearly, the provision of healthcare through U.S. hospitals—both profit and, at least officially, non-profit—is generating enormous profits for their owners and top executives. But it’s Americans workers, who are both hospital employees and consumers of hospital services, who are paying the price.

 

*To remind readers, the Herfindahl-Hirschman Index is often used to evaluate the potential antitrust implications of acquisitions and mergers across many industries, including health care. It is calculated by summing the squares of the market shares of individual firms. Markets are then classified in one of three categories: (1) nonconcentrated, with an index below 1,500; (2) moderately concentrated, with an index between 1,500 and 2,500; and (3) highly concentrated, with an index above 2,500.