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Five years ago, my mother needed an orthopedic surgeon for a knee replacement. Unable to find any data, we went with an academic doctor that was recommended to us (she suffered surgical complications). Last month, we were again looking for an orthopedic surgeon- this time hoping that a steroid injection in her spine might allay the need for invasive back surgery. This time, thanks to a recent data dump from CMS, I was able to analyze some information about Medicare providers in her area and determine the most experienced doctor for the job.  Of 453 orthopedic surgeons in Maryland, only a handful had been paid by Medicare for the procedure more than 10 times.  The leading surgeon had done 263- as many as the next 10 combined. We figured he might be the best person to go to, and we were right- the procedure went like clockwork.

Had it been a month prior to the CMS data release, I wouldn’t have had the data at my fingertips. And I certainly wouldn’t have found the most experienced hand in less than 10 minutes.

It’s been a couple of month since the release of Medicare data by the Centers for Medicare and Medicaid (CMS) on the volume and cost of services billed by healthcare providers, and despite the whiff of scandal surrounding the highest paid providers (including the now-famous Florida ophthalmologist that received $21 million) the analyses so far have been somewhat unsurprising. This week, coinciding with the fifth Health DataPalooza, is a good time to take stock of the utility of this data, its limitations, and what the future may hold.

The millions of lines of data was exactly as advertised: charges and paid services under traditional Medicare “fee-for-service,” including the billing provider’s ID and the costs to Medicare. The initial headlines touting “Medicare Millionaires” relied on some basic arithmetic and some sorting.  And the cautions piled up: the data could reflect multiple providers billing under a single ID; payments are not the same as a provider’s actual take home income; it’s not complete information as it doesn’t contain information about other insurers, or even Medicare Advantage, and so on.

But perhaps most damning was how little insight the data seemed to provide on the quality or value of care provided, as opposed to volume of services.  As Lisa Rosenbaum wrote in the New Yorker, “So much of that good isn’t captured by these numbers. You don’t bill for talking to a patient about how he wants to die. There’s no code for providing reassurance rather than ordering a test.”

Where is the value in the data?

Data bear witness to the fundamental flaw of the payment system that generates them. The absence of information on quality, safety, appropriateness, or outcomes appears to have been a genuine revelation to many, but it is in fact exactly the type of output that we should expect from this volume-based system that we have built. This is not a critique of the data release. It is an indictment of our payment system.

Data is revealing important trends in how we pay doctors differently. Not all physician payments are created equal, and the data certainly shows the disparities across specialties, primary care, and others. For example, the average total annual Medicare payment to geriatricians was less than $100,000, while dermatologists and radiation oncologists (who presumably also see non-elderly patients) received on average $200,000 and $360,000 respectively. The important question will be why and should it continue?

Figure 1: Distribution of Total Medicare Pay by Provider Type, 2012 

Source: Author's calculations based on Medicare data released in April 2014

Data is revealing important indicators of cost and pricing – a major contributor to rising health care costs. Why is it that a brief visit with a geriatrician is worth $13; a 45-minute visit with a geriatrician sorting through medications, educating family members, and developing a quality of life plan with a terminal cancer patient is worth $79; and a dermatologist treating suspected skin cancer can earn upwards of $600 for a procedure that takes them minutes?

Data sheds light on practice patterns. The data is also revealing important variances in utilization of drugs and treatments. For example, a block apart on Park Avenue, two ophalmologists differ significantly in their use of treatments for macular degeneration. One uses expensive injectable drugs and gets paid over $10,000 per injection, while the other receives less than $500 for the lower-cost equivalent.

A CBS News report looked at spinal fusion surgeries—a procedure where there is almost no evidence demonstrating a net benefit to patients compared to other conservative therapies. They observed that “while the average spine surgeon performed them on 7 percent of patients they saw, some did so on 35 percent.”

At the extremes, outlier “practice pattern” begins to raise questions of potential improper billing or outright fraud and abuse. For example, simply looking at the frequency and volume of services provided to individual beneficiaries can identify concerning outliers. This laboratory company billed for 28,954 blood glucose reagent strips in 2012- for 88 patients. And yes, that’s highly unusual.

Figure 2: "Outlier" Medicare Billing for Blood Glucose Reagent Strips, 2012

Source: Author's calculations based on Medicare data released in April 2014

One clinical social worker billed for 1,697 separate days of service on 28 patients (the size of the bubble is proportional to the total amount of reimbursement by Medicare in 2012).

Figure 3: "Outlier" Medicare Billing for Days of Service, 2012

Source: Author's calculations based on Medicare data released in April 2014

The most extreme outlier, Dr. Gary Ordog, was named by NPR and ProPublica in their examination of providers who are outliers on their pattern of coding for the highest intensity office. Ordog had previously lost the right to bill California’s state Medicaid program, and yet continued to charge Medicare for over $500,000 in billing in 2012. It’s important to caution however, that even in these extreme outliers, statistics alone cannot provide definitive evidence of abuse. There is a need for formal investigation.

Medicare and law enforcement officials will need to create new processes for dealing with a potential flood of outlier reports from amateur sleuths like me.

What's Next for Medicare Data?

Data can be trended. Updates of data releases can begin to show us not just snapshots, but moving pictures of our healthcare system as it undergoes rapid changes. The New York Times reported on the increase in charges for certain frequent causes of hospitalization between 2011 and 2012. It will be interesting to see whether the data release itself, and the Steven Brill landmark Time article on hospital charges, have an impact on reversing these trends.  

Data can be “mashed up”.  The value of open data is hugely greater than the sum of its parts. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have.  ProPublica linked together cobbled together data on state actions and sanctions on physicians with the Medicare data release to ask why these physicians are still being paid by Medicare.

What does the future hold? Correlations with drug prescribing data, meaningful use, and referral patterns are possible today, Sunshine Act disclosures and quality reporting, and much more is soon to come.

As we get comfortable with the data, analysts can move past the basics of arithmetic and sorting, we have an opportunity to make more ‘meaningful use’ of this data. We can begin to identify practice patterns, overuse, variations in geography or demographics, and potentially even fraud and abuse. As more and more data becomes available, the files can be cross-linked and “mashed up” to be able to answer questions no one database could have addressed. What will determine the value of the Medicare data release will be the creativity of those data scientists, epidemiologists, and health services researchers (amateur as well as professional) who can ask the challenging questions that must be answered.

La fuite des informations du cabinet juridique Mossack Fonseca dans l’affaire des « Panama Papers » a fait et fera la une des journaux pendant des semaines à fur et à mesure de la révélation de nouveaux noms des personnes impliquées. Le scandale a placé le Panama sur le devant de la scène et a donné un aperçu inédit du monde de l’argent caché et de l’évasion fiscale. Afin de mieux saisir le contexte général, il est important de faire la distinction entre la corruption légale, révélée par l’affaire des « Panama Papers » et la corruption illégale, exposée par le scandale Unaoil. Le moment est venu pour les gouvernements de prendre des mesures radicales contre l’une et l’autre.  

Les États-Unis, le Royaume-Uni et plusieurs autres pays annonceront leurs engagements pour lutter contre la corruption lors du sommet anticorruption le 12 mai, dont le Premier ministre David Cameron affirme qu’il changera la donne. La question est de savoir si ces engagements se traduiront par des mesures concrètes à l’égard des types de corruption les plus coûteux qui, aujourd’hui, se prolifèrent à l’échelle mondiale.  

Malheureusement, le monde s’engage souvent dans des  sommets, riches en communiqués, en appels à la coordination et à l’échange d’informations. Parfois, ces sommets mettent en place une initiative inefficace supplémentaire : donnant l’opportunité de créer et promouvoir des articles et photos qui servent les objectifs politiques précis de certains leaders politiques. Voyons si ce sommet sera diffèrent.

Au-delà du Panama

Le cabinet juridique Mossack Fonseca et son pays respectif, le Panama, ne sont que deux éléments dans le vaste et complexe ensemble de « facilitateurs » de la corruption et de l’évasion fiscale à l’échelle mondiale.     

Pour ceux qui sont à la recherche de refuges discrets et de sociétés-écrans, la puissante nation des États-Unis (qui sans surprise n’apparaît pas beaucoup dans les Panama Papers) est une des destinations les plus attrayantes du monde : par example, dans l’état du Delaware la loi requiert  moins de documents pour établir une société-écran que pour obtenir un permis de conduire. Comme on le voit dans l’illustration ci-dessous, c’est cette opacité, conjuguée à la taille du refuge qu’offrent les États-Unis, qui met le pays à la troisième place des juridictions les plus secrètes parmi une centaine évaluée par l’indice d’opacité financière (FSI). Le Panama est à la treizième place.

Illustration 1 : Indice d’opacité financière 2015 (Juridictions sélectionnées, d’après le réseau pour la justice fiscale)

Source : Indice d’opacité financière du Réseau pour la justice fiscalehttp://www.financialsecrecyindex.com/introduction/fsi-2015-results

Ce graphique présente les 40 juridictions les moins performantes ainsi que quatre juridictions choisies pour leurs meilleurs résultats (à droite des pointillés). L’indice présente un score de secret qualitatif basé sur une quinzaine d’indicateurs et une mesure quantitative de l’importance d’une juridiction dans les exportations de services financiers à l’échelle mondiale. 

Le Royaume-Uni est un important facilitateur de corruption : il n’a engagé aucune action contre ses juridictions et protectorats d’outre-mer qui servent de refuge aux richesses illicites, comme le démontrent clairement les  « Panama Papers ». Les Iles Vierges britanniques, par exemple, est le lieu préféré  de milliers de sociétés-écrans établies par Mossack Fonseca.  

Au-delà des refuges fiscaux 

L’affaire des « Panama Papers » ne concerne qu’indirectement les aspects essentiels de la question de la corruption mondiale, qui ne sont liés ni au Panama ni à la fiscalité. Nous devons envisager les scandales suscités sous un angle plus large et reconnaître les immenses et complexes réseaux de la corruption, qui lient de plus en plus les élites économiques et politiques mondiales.

La grande corruption

Les puissants individus qui s’engage dans la corruption à haut niveau, c’est-à-dire la corruption à large échelle ne sont pas inquiétés par l’affaire des « Panama Papers ». On trouve parmi ces individus des dirigeants kleptocrates ainsi que des oligarques qui exercent une influence majeure sur les affaires gouvernementales. Souvent, ces acteurs interagissent et s’associent, en formant des réseaux public-privé très puissants qui font passer pour un jeu d’enfant la définition traditionnelle de la corruption comme étant une transaction illégale entre deux parties.

Dans ces réseaux élitistes, la corruption excède largement le comportement immoral du fraudeur type, puisqu’elle utilise l’abus de pouvoir pour accumuler biens et pouvoir, souvent par le pillage direct des ressources publiques, la confiscation d’actifs ou la corruption à grande échelle. Le scandale à plusieurs milliards de dollars qui touche le géant pétrolier Petrobas au Brésil illustre la complexité de ces réseaux d’entente, et les moyens avec lesquels, la corruption à large échelle  peut provoquer des dégâts politiques et économiques d’ampleur historique dans un pays. 

Le secteur pétrolier offre de nombreux example de corruption à large échelle. Les dirigeants de la société Unaoil, dont un scandale similaire a récemment fait surface,  ont sans doute été soulagés par l’affaire des « Panama Papers » Unaoil est une société monégasque  « facilitatrice » de droit qui a versé des pots-de-vin et influencé des responsables gouvernementaux dans différents pays pour le compte de compagnies multinationales se disputant de juteux contrats d’approvisionnement. Bien qu’éclipsé par l’affaire du Panama, le cas d’Unaoil est aussi emblématique les enjeux inhérents à la lutte contre la corruption mondiale. Il illustre par exemple la pratique fortement enracinée des responsables gouvernementaux irakiens qui demandent des dessous de table en échange de l’attribution de contrats, ainsi que l’empressement des entreprises à verser ces pot-de-vin.

Les élites corrompues, notamment celles qui sont impliquées dans le scandale Unaoil, utilisent souvent des structures telles que les sociétés-écrans et les paradis fiscaux (et les investissements immobiliers ou autres) pour dissimuler leur biens mal-acquis. Toutefois, si l’affaire des Panama Papers incite à plus de vigilance sur les flux financiers illicites et engendre la réforme de ces structures financières opaques, la corruption à large échelle se poursuivra dans nombreux endroits.  Il est à noter que les retombées politiques se sont concentrées dans des pays relativement bien gouvernés, qui ont instauré des systèmes anticorruptions et de responsabilisation, comme en témoignent les démissions du Premier ministre islandais, du ministre de l’industrie espagnol et du dirigeant de la section chilienne de Transparency International. 

En revanche, le président Vladimir Poutine a balayé d’un revers de la main les fuites d’information sur la Russie, les considérant comme une conspiration occidentale contre sa personne. En Chine, le débat et la diffusion de ces informations ont été étouffés par la censure des médias ; en Azerbaïdjan, la révélation des détails concernant les intérêts miniers de la famille du président Aliyev ne menace guère sa mainmise sur le pouvoir. Il est à espérer que les réformes découlant de l’affaire du Panama dissuaderont les fraudeurs ainsi que les entreprises et les particuliers aux pratiques immorales de dissimuler leur argent bien mal acquis. Toutefois, les dirigeants corrompus continueront à bénéficier de l’impunité.

Corruption légale et captation de l’État   

Les Panama Papers ont mis en lumière le type de corruption qui est sans doute le plus dévastateur et le plus dure à contrecarrer : la corruption légale et la captation de l’État.  Partout dans le monde, de puissantes élites économiques et commerciales influencent indûment les lois et les politiques, en redessinant les règles du jeu pour leur propre bénéfice, un phénomène aussi connu sous le nom de « privatisation de la politique publique et des lois ». Une pratique qui génère des revenus exorbitants pour les élites, renforce leur pouvoir et exacerbe les disparités politiques et économiques d’un pays.

Les pays riches en ressources naturelles fournissent de nombreux exemples. En Angola, en République démocratique du Congo, au Nigéria et au Venezuela, par exemple, les élites politiques ont utilisé des sociétés publiques exploitant les ressources naturelles pour servir leur népotisme, souvent - mais pas uniquement - par des moyens légaux.

Dans beaucoup de pays industrialisés, le système fiscal est en lui-même un exemple de captation de l’État. Il est dans l’intérêt des élites de conserver un réseau mondial de sociétés offshore et de paradis fiscaux secrets pour pouvoir dissimuler leur patrimoine - qu’il ait été acquis légitimement ou non. Les preuves d’évasion fiscale aux États-Unis sont révélatrices : selon Zucman, depuis les années 1950, le taux réel de l’impôt sur les sociétés a été réduit de 45 à 15 pour cent, alors que le taux nominal est seulement passé de 50 à 35 pour cent. Et les sociétés américaines font un usage optimal des paradis fiscaux à l’étranger : d’après un nouveau rapport d’Oxfam, les 50 plus grandes multinationales américaines ont rapporté en 2008 que 43 pour cent de leurs revenus réalisés à l’étranger provenaient de cinq paradis fiscaux, représentant seulement 4 pour cent des effectifs étrangers de ces sociétés. En outre, Bourguignon rappelle que les taux d’imposition fédéraux des Américains les plus riches ont diminué de 15 pour cent entre 1970 et 2004.

Le risque de corruption légale aux États-Unis est important, l’argent privé pouvant très facilement influencer les affaires publiques. Suite à l’arrêt Citizen United rendu par la Cour suprême en 2010 [qui permet la participation financière des entreprises aux campagnes politiques], les fonds privés issus de poches bien garnies dirigent de plus en plus les campagnes électorales. Les moyens par lesquels l’argent privé influence les représentants publics pourraient encore se multiplier, si les formes de corruption traditionnellement considérées comme illégales devenaient légales. Selon une décision en instance de la Cour Suprême, il pourrait désormais être légal pour les responsables publics d’accepter les dons en nature des particuliers (ce qui pourrait annuler la condamnation d’un ancien gouverneur de l’État de Virginie accusé précisément de ce délit).  

Quelles mesures prendre ?     

En Bref, Il n’y a pas de solutions simple  et directe, d’autant plus que les décideurs tirent profit de ce statu quo.  Mais l’opportunité de réforme et la pression publique sont actuellement présentes. Comme nous l’avons évoqué, la question de la lutte contre la corruption entraîne souvent des mesures symboliques et l’annonce par David Cameron d’une nouvelle agence mondiale anticorruption pourrait très bien tomber dans cette catégorie. Les pays comme les États-Unis et le Royaume-Uni devraient plutôt prendre des mesures concrètes pour réformer leurs propres pratiques et pousser leurs partenaires à faire de même, qu’il s’agisse des dépendances de la Couronne et des territoires britanniques d’outre-mer, de l’Union européenne et des membres du G20 ou des bénéficiaires d’une aide internationale.

Premièrement, il faudrait prendre la corruption légale et la captation de l’État au sérieux 

La transparence peut changer les règles du jeu, particulièrement si elle s’attaque aux réseaux d’influence par lesquels la politique se « privatise ». La divulgation des contributions financières aux campagnes électorales, des conflits d’intérêts, des avoirs détenus par les hommes politiques et les responsables publics (et de leurs avis d’impôts), des délibérations et votes parlementaires sont autant de moyens d’éviter les abus et de révéler les réseaux cachés qui sont à l’œuvre. La publication récente de la première salve de l’Organisation de Coopération et de Développement Economiques (OCDE) est encourageante : son rapport « Le financement de la démocratie », s’attache à quelques études de cas. La suite logique serait d’habiliter l’organisation à développer des normes et mener des évaluations sur le financement politique de tous les pays de l’OCDE.

La transparence ne sera utile que si les citoyens peuvent mener un examen attentif de leurs gouvernements et dialoguer avec eux.  L’espace civique est en danger dans de nombreuses juridictions où les activistes et les journalistes sont la cible d’intimidations, de poursuites, voire pire. Garantir la liberté d’expression et de réunion devrait être l’affaire de tout acteur international concerné par la lutte contre la corruption ou la gouvernance économique. Par exemple, lors de l’examen des demandes de financement de gouvernements ayant un piètre bilan en matière de protection de la société civile - comme c’est le cas de l’Angola et de l’Azerbaïdjan - la Banque Mondiale et le Fonds Monétaire International, ainsi que les donateurs comme les États-Unis, devraient privilégier la responsabilisation citoyenne et des réformes de transparence plus ambitieuses.

En outre, la corruption à large échelle ne s’évincera pas en l’absence de poursuites ou d’autres sanctions efficaces contre ceux qui se laissent corrompre ou contre les facilitateurs et les intermédiaires de la corruption qu’ils soient avocats, comptables ou entremetteurs comme Unaoil. Bien sûr, les autorités chargées d’appliquer la loi doivent aussi rester vigilantes vis-à-vis des sociétés qui versent les pots-de-vin et à cet égard, les gouvernements - notamment les membres de l’OCDE instaurant, à des degrés divers, la Convention de l’OCDE sur la lutte contre la corruption - feraient bien d’imiter la mise en œuvre effective de la loi américaine sur la corruption dans les transactions à l’étranger (FCPA). Mais les individus corrompus et les facilitateurs n’ont pas été suffisamment surveillés et sanctionnés.

Deuxièmement, il faudrait se débarrasser des zones d’ombre.

Les leçons tirées des événements récents, de la crise financière de 2008 à l’affaire des Panama Papers, indiquent que les principaux acteurs internationaux ne devraient pas permettre que de vastes fractions de l’économie mondiale échappent à un examen attentif. Les États-Unis et le Royaume-Uni (et ses territoires d’outre-mer) devraient répondre aux appels à mettre fin à l’opacité et aux paradis fiscaux.  Quelques premières tentatives  émergent, telle que la décision du gouvernement américain demandant aux banques de révéler l’identité des individus se cachant derrière les sociétés-écrans. Des mesures plus ambitieuses seront toutefois nécessaires, ceci comprend des dispositions législatives.  

La transparence sur la propriété réelle doit devenir une procédure opérationnelle standard, avec des États qui suivent l’exemple du Royaume-Uni, des Pays-Bas et d’autres pays qui ont établi des registres publics et soutiennent le projet d’un registre mondial. Quant aux pays riches en ressources naturelles, un bon point de départ serait d’établir des registres spécifiques au secteur. Cette pratique est maintenant imposée par l’Initiative pour la Transparence dans les Industries Extractives.

Au sein du secteur extractif, les gouvernements des pays d’accueil devraient soumettre les négociants de matières premières à des exigences de divulgation des paiements lorsqu’ils font affaire avec les gouvernements et les entreprises publiques. Les gouvernements de pays comme la Suisse, le Royaume-Uni et Singapour, qui abritent des acteurs du monde de l’entreprise, ont une lourde responsabilité, particulièrement dans le contexte actuel de faible prix des matières premières, où les négociants concluent de nouveaux contrats profitables avec des pays producteurs de ressources à court d’argent. Eclaircir telles zones d’ombre les rendra moins vulnérables aux abus.

Troisièmement, il faudrait donner la priorité à la transparence et au contrôle lors de l’allocation de ressources publiques.

Lorsqu’un gouvernement attribue des ressources pour l’exploitation, il doit le faire de façon tout à fait transparente. L’initiative Open Contracting Partnership a fait de grandes avancées dans la définition d’une norme de référence pour de telles informations, notamment en matière d’orientation sur les questions de l’ouverture des données, des identificateurs des sociétés et de la propriété réelle.

Les recherches sur la corruption dans les secteurs pétrolier et minier menées par le Natural Resource Governance Institute montrent que de multiples allocations à forte valeur nécessitent un examen attentif et une divulgation du contrat. Elles comprennent l’attribution des permis d’exploration et de production, mais aussi des droits d’exportation, d’importation ou de transport, qui ont été associés à la corruption dans des pays comme l’Indonésie, la République du Congo et l’Ukraine. La plupart des affaires liées au secteur pétrolier et portées devant les tribunaux dans le cadre de la FPCA aux États-Unis ont surgi à l’occasion de l’attribution de marchés de service, un segment de l’industrie pétrolière qui concernait également les scandales Unaoil et Petrobras. La transparence devrait être le « paramètre par défaut » de toute transaction allouant des ressources publiques. Il est nécessaire d’exercer un contrôle supplémentaire des régimes de taux de change mis en œuvre et abusifs, qui génèrent des revenus pour quelques-uns et engendrent des disparités économiques majeures, comme c’est le cas actuellement au Nigeria, au Venezuela et en Égypte.

Pour espérer un impact réel, il faudra aussi s’attaquer frontalement au principe d’impunité, puisque la transparence et la liberté d’expression sont certes nécessaires, mais insuffisantes.  Et les Etats, y compris les États-Unis et le Royaume-Uni, devront adopter des réformes pour lutter contre la corruption légale et l’opacité sous toutes ses formes, que ce soit en s’attaquant à la mainmise de l’argent en politique ou aux « zones d’ombre » entourant les négociants pétroliers installés à Genève et Londres. 

Un engagement ambitieux à lutter contre la corruption et l’impunité n’est pas seulement une nécessité actuelle, mais aussi une revendication de nos sociétés, comme l’ont montré les événements au Brésil et ailleurs. Ce pourrait être le moment décisif de faire de réelles avancées à l’échelle mondiale.  

This piece is also available in English and Spanish. 

In partnership with the ESADE Business School and the City of Barcelona, the Metropolitan Policy Program planned and participated in three intensive days of learning in Barcelona in June 2011.  The focus of the session was to look at examples of strategies Barcelona, Spain and its greater metropolitan region is embracing to rebuild and re-invent their economies.  The goal is to share innovative ideas with U.S. metros engaged in similar initiatives as they face the challenge of moving to a new economic growth model.

This paper features brief synopses of the tours and meetings held with the City of Barcelona and the Catalonia Region on their economic development strategies.

Specific strategies include:

Barcelona Activa »

Click on any image below for a larger version

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Editor’s Note: During the Global Cities Initiative’s international forum in São Paulo, Bruce Katz delivered remarks on metropolitan areas and their potential to power national economies worldwide. The remarks were written by Katz and Julie Wagner.

The Metropolitan Future of Brazil and the United States
(This presentation is also available in Portuguese)

Good morning everyone.  It is a pleasure to be back in Sao Paulo with JP Morgan Chase, our partner in the Global Cities Initiative.  I am grateful for their support and leadership.

I first want to thank Governor Alckmin and Mayor-elect Haddad for their participation today and we fully welcome the opportunity to work with both of them and the city and state in the coming months and years.

This has been an extraordinary week for our delegation of mayors and business, civic, and university leaders from 10 major American cities and metropolitan areas.

We have seen firsthand the proud history and infectious energy and vibrancy of this great city and macro-metropolis.  We are grateful to Luiz Felipe D’Avila and the Centre for Public Leadership for co-sponsoring this forum today. We also owe a debt to others who have hosted and guided us this week—the State of Sao Paulo, particularly the State Secretariat for Metropolitan Development, Insper, the Commercial Association of Santos and the Port of Santos and the Brazil-U.S. Business Council, and the U.S. Embassy and Ambassador Shannon.

As Aod said at the outset, São Paulo is the first stop outside the United States in our five year Global Cities Initiative.  That is a deliberate choice.   The relationship between the United States and Brazil is a critical one.  Despite barriers, the economic and social ties between our two countries are strong and growing stronger.  Trade is booming.  Investment is up.  Tourism and business travel have never been higher.  And the recent state visits by presidents Obama and Rousseff send a clear signal that this is a partnership of the highest order. 

Yet there is hard work to do in both our countries. The U.S. and Brazil are undergoing major economic transitions. By global standards, both of us under-perform on exports, far trailing other countries.  The U.S. is shifting slowly back towards a more productive, sustainable economy after our worst downturn in 80 years; Brazil is moving forward towards a more open, outward looking economy.

Against this complex backdrop, our delegation comes bearing a simple proposition. The answers to national challenges lie, in great part, below the national level.

We live in a century where cities and metropolitan areas are driving national economies and the global economy. The U.S. and Brazil have 84 and 85 percent of our respective populations living in our cities and metropolitan areas … and these communities generate 91 percent of the GDP in the U.S. and 88 percent of the GDP in Brazil.  There is, in essence, no American or Brazilian—or German or Chinese—economy; rather our national economies represent networks of powerful city and metropolitan economies.

 Today, I will make three main points.

As the world urbanizes, cities and metropolitan areas have emerged as the engines of national economies.

As our economies globalize, cities and metropolitan areas act as the centers of international trade and investment.

To prosper today, cities and metropolitan areas need to drive their economic destiny.  In our federal republic, where power is shared across national, state and local governments, that requires new thinking about who does what. 

But, first things first; we cannot put forward a metropolitan playbook without first understanding what a metropolis is.  And the best way to do that is from the ground up.

On the right side of the screen you see the São Paulo metropolis, 20 million strong, 10^th most populous in the world.

On the left side of the screen you see Chicago, Mayor Daley’s hometown, with a population of 9.5 million, 26^th largest in the world.

Both of these metro areas cluster around core cities but cover large land masses and encompass multiple jurisdictions.

The São Paulo metro is more than 8,000 square kilometers in size, with more than half of your population living in the city proper and the remainder residing in 38 other municipalities.  

Chicago is close to 19,000 square kilometers in size with one third of the population living in the central city and the remainder spread across, incredibly, three states, 14 counties encompassing hundreds of separate municipalities and townships.

The assets São Paulo and Chicago need to compete nationally and globally are spread across their regions:

Clusters of workers;

Key colleges and universities;

Major hospitals and health care facilities;

A network of urban green space; and

The infrastructure—roads, rail and transit and airports—needed to move people, and freight

In other words, metro areas are the natural, organic geographies of the economy, clustered around central cities for sure, but also benefitting from the assets offered by satellite cities and suburban, exurban and rural areas.   

With that background, let me start with an irrefutable observation: cities and metropolitan areas are the 21^st century engines of national economies.

Since 1950, the world’s urban population has more than quadrupled in size.  Now sized at 3.6 billion people, it is expected to surpass 5 billion by 2030.

In 1950, 29 percent of the world’s population lived in cities and their metropolitan areas.  By 2009, the share surpassed 50 percent. By 2030, urban settlements will harbor more than 60 percent of the world’s population.

In many respects, the world is becoming more like us.  The United States and Brazil are two of the most highly urbanized countries with city and metro concentrations surpassing those of both mature economies in Germany, Britain, and Spain and emerging economies like China, India, and South Africa.  

Cities and metros do not just house people; they power economies.  Today Brookings released our annual Global Metro Monitor that tracks the economic performance of the world’s top 300 largest metropolitan economies.

Incredibly, we find that these metropolitan areas house a little under one fifth of global population but generate nearly half its total output.  Put simply: Metros around the world punch way above their weight.

Why are they so powerful? 

Because they cluster and connect firms, large and small, with ports and airports, transport and energy infrastructure, and a broad range of supportive institutions that supply skilled labor, advanced research and customized capital.    And when that happens, productivity improves, entrepreneurship rises, employment and wages increase.   

The dominance of metros holds true for both our countries, which house 13 and 76 of the top 300 global metros, respectively.

Your thirteen top metropolitan areas are home to one third of Brazil’s population, concentrate half of Brazil’s manufacturing output and your population with college education and account for 56 percent of national GDP and 63 percent of financial services output.

These metros range from Sao Paulo, 11^th largest economy in the world, to Baixada Santista, 295^th largest.    

Eleven of your metro areas are state or national capitals; this state is home to three of the 13 large metro areas.

Metro São Paulo takes its place among the world’s most populous and economically powerful metros.

You are home to one tenth of Brazil’s population, account for one-fifth of Brazil’s GDP and generate 57 percent of the GDP of this state.

For America’s part, our top 76 metros form the real heart of the U.S. economy. 

Housing 61 percent of our population, they concentrate a majority of our manufacturing output, gather our most educated people, and generate more than 68 percent of our national GDP.

They also make an outsized contribution on financial services and the production of patents. 

In the U.S., the top 76 metros range from New York, L.A., and Chicago to less well known communities like Allentown, Little Rock, and Harrisburg.

This leads to my second point: as economies globalize, cities and metropolitan areas act as the centers of international trade and investment.

Metros and trade are inextricably linked, and have been for millennia.   The Silk Road that connected Asia, Europe, the Middle East, and Northern Africa.   The Hanseatic League that grew from Hamburg and Lubeck to include 170 cities that monopolized trade in Northern Europe between the 13^th and 15^th centuries.  The great Italian city-states of Venice, Pisa, Genoa, and Amalfi.   

These historic networks offer essential lessons:

As a recent Brookings report concluded:

“Trade is essential to metros—it is how they grow their economies. And metros are essential to trade—they provide the specialization and market access that facilitates exchange among producers and consumers.” 

The top Brazilian and U.S. metros are our nations’ logistical hubs, concentrating the movement of goods and people by sea and by air.  In Brazil, 61 percent of foreign waterborne trade, measured by tonnage, passes through the seaports of the top metros; in the United States the equivalent share is over 66 percent. Passenger travel is even more concentrated; in both countries, close to 82 percent of international air travel passes through the airports of the top metropolitan areas.

Significantly, the top cities and metros in both our countries are magnets for foreign direct investment, particularly “greenfield FDI” where foreign entities invest in new facilities or expansions of existing facilities rather than just purchase domestic companies. 

From 2003 through September 2012, Brazil’s 13 accounted for 77 percent of greenfield FDI projects in Brazil and 59 percent of the jobs created through this key growth vehicle.  The top 76 U.S. metros also accounted for 77 percent of Greenfield FDI projects and 70 percent of the jobs created.

Brazil’s 13 are responsible for a third of all national goods exports; the share is substantially higher for the top U.S. metros.  Brookings research on U.S. exports shows that our top U.S. metros dominate the trade in manufacturing and services … and, given their edge in sectors like chemicals, consulting and computers, are on the front lines of commerce with China, Brazil, and India. 

In sum, our research has shown the collective centrality of our top cities and metros to the trading position of our nations. 

Yet metro economies do not exist in the aggregate; they have distinctive starting points and vary considerably in their trading prowess and intensity.  What makes São Paulo special on the global stage—your distinctive offer, your special investment potential—is different from what defines and drives Rio or Curitiba or Salvador.

São Paulo is Brazil’s premier global metropolis and the numbers reflect that.  Your metro houses 10 percent of Brazil’s population but:

• Your airports handle 26 percent of all passenger traffic in Brazil and 33 percent of all air cargo.
• Your macro metro neighbor, Santos, which we visited yesterday, is the busiest container port in South America and 43rd in the world.
• You are Brazil’s largest metropolitan exporter, producing 27 percent of all metropolitan exports of goods

• And from 2003-2011 you received 19 percent of all greenfield FDI in Brazil … in fact, more FDI than New York, LA, Chicago, Houston and San Francisco combined.

You trade with the world’s most prosperous cities, in the United States and elsewhere, but in particular ways given your distinctive industry clusters and sectors.

Given your substantial concentration in financial services (with 19 of the 25 top international banks present and the world’s third largest financial exchange), you interact naturally with New York and Miami in the U.S., London, Madrid, and Frankfurt in Europe and Shanghai, Tokyo and Hong Kong in Asia.

Despite the outward movement of industry, you still serve as Brazil’s main global platform for advanced manufacturing sectors like automotive, linking you closely with Detroit in the U.S., Milan and Stuttgart in Europe, and Nagoya in Japan.

The shape and structure of your economy puts São Paulo in an exclusive club of “global cities,” a definition drawn in the 1990s when the process of trade, investment, and globalization was seen as empowering a few command and control finance metros of the world.

But today, our notions of “globalizing cities” are more expansive, recognizing that all cities are fueled, to different degrees, by global investment and connected, in distinctive ways, via global commerce and exchange, global product and labor supply chains. 

The energy cluster in Rio finds common interest with the energy cluster in Houston through investments by Exxon Mobil, Chevron and Petrobras … and then further with energy firms in Amsterdam, Dar es Salaam, and Bogota.

Campinas’ hi-tech sector naturally links with the hi-tech cluster in San Jose’s Silicon Valley via elite universities, advanced R&D institutions, and global tech giants like IBM, Hewlett-Packard and Dell … and then further with tech clusters in Tokyo, Bangalore and Dublin.

As headquarters of Embraer, São Jose  dos Campos links via supply chains to Palm Bay, Florida, Harbin, China and Lisbon, Portugal.

In short, a new global map is being drawn in the world, not of nation to nation trade but of metro to metro exchange.

That leads to my final point: To prosper in the global economy today, metros need to drive their global economic destiny.

We have a three part playbook:

The playbook starts at home, with cities innovating locally to exploit their distinctive competitive advantages in the global economy.

In the U.S., cities and metropolitan areas are acting with intentionality in the aftermath of the Great Recession to devise and implement what we call “metropolitan business plans.”  The purpose: build on their distinctive competitive advantages in the traded sectors of the economy, given the crippling effect on housing and consumption.

The elements of business planning are fairly simple and straightforward

Each metropolis does a market assessment of their unique economic profile and potential … what goods and services they trade, which nations they trade with, where trade trends are likely to head given market dynamics here and abroad. 

Armed with this information, metros then set goals and objectives that build on their distinct advantages, devise strategies to meet those goals and establish metrics to gauge progress.

All these efforts are undertaken by a consortium of corporate, government, university and civic institutions that cut across jurisdictions, sectors, and disciplines and “collaborate to compete” globally.

Let me give you an example of how these business plans are helping cities and their metros grow jobs and restructure their economies.

Los Angeles, represented here by Mayor Antonio Villaragoisa, has devised an ambitious plan to grow exports by identifying and proactively supporting export ready firms in leading trade sectors like aerospace, computers, professional services, and film and television.  The L.A. system of trade is moving from a story of fragmentation, where no clear institution defines or drives decision-making, to a reality of coordination and collaboration, responsiveness and flexibility under one Los Angeles Regional Export Council.  The result: More firms will export more goods and services to more places producing more and better jobs.

We believe business planning holds great potential for São Paulo and other Brazilian metros.   Obviously, fixing the basics is a critical first step for economic growth: safe streets, quality schools, efficient transport and sound governance.  But a business plan might focus on increasing foreign direct investment in infrastructure necessary to reduce congestion, improve mobility, and enhance accessibility to jobs. 

The key is not what you focus on … but to decide your focus based on evidence and in a collaborative manner and then to hold yourself accountable through continuous assessment and measurement. 

Having innovated locally, cities must network globally—creating and stewarding close relationships with trading partners in both mature economies and rising nations.

The new global reality is leading to intricate networks of trading cities which grow together by linking together and learning together.

These networks obviously start with firms and ports that do business with each other.  

But, over time, networks extend to supporting institutions—governments, universities, business associations—that provide support for companies at the leading edge of metropolitan economies.

The city of Houston and the city of São Paulo, for example, executed a formal agreement earlier this year that commits each city to increase commercial relations, intensify scientific and technological connections, and facilitate information to tackle shared challenges.

Enterprise Florida, the principal export and investment organization in that state, opened an office in São Paulo in 2011 to help Florida companies expand trade.  APEX-Brasil, Enterprise Florida’s Brazilian counterpart, has its only U.S. location in Miami’s free trade zone.  There it executes projects like providing clean and renewable fuels to IndyCar, the American based auto racing body. 

The Ohio State University and the University of São Paulo have partnered to support the exchange of students and collaborative research.  Areas of recent focus: natural and mathematical sciences, medicine, and teacher training.  In 2014 Ohio State anticipates opening its third “Global Gateways” office in the world in São Paulo to further capitalize on these linkages.

Here is the simple message: We can see a network of trading cities emerging right here in São Paulo and it is a future characterized by multi-layered relationships across multiple dimensions and disciplines, interests and institutions. 

Finally, having innovated at home and networked globally, cities and metros must advocate nationally for federal and state policies and practices that will support metro growth.

Metros are engines, but they do NOT act alone.

Only national governments can set the rules of the road: enhancing access to foreign markets, enforcing trade agreements, opening up borders to immigrants and protecting intellectual property.  They can also help match domestic firms with potential global customers, provide export promotion support, and commit resources to modernizing logistics hubs.

As the world evolves as a network of trading cities, it is only natural that cities become more articulate and aggressive about the support they need from higher levels of government. 

In the United States, cities have found a receptive partner in the Obama Administration.  Key federal agencies—the International Trade Administration, the Ex-Im Bank, the Small Business Administration—have been central partners in guiding business plans with a particular focus on boosting exports.

Similar alliances could be built here.  As part of the Global Cities Initiative, the ESADE Business School mapped the trading system in São Paulo.  Their research clearly shows the central role of your federal and state governments in advancing the internationalization of your economy.  True success will come when these higher level entities align closely with your distinct assets and advantages.

Going forward, the advocacy of cities must extend beyond accessing the export promotion and finance programs of federal and state governments.  They must get to the heart of the matter.

The United States has had a North American Free Trade Agreement in place for 20 years with our partners, Mexico and Canada.

We have recently concluded important Free Trade Agreements with Colombia, Panama, and Korea.

President Obama was in Southeast Asia this month discussing the possibilities of a Trans-Pacific Partnership.

The 2011 Agreement on Trade and Economic Cooperation signed by President Obama and President Rousseff provides a platform to build on.

As they have expressed, we need a new vision for our Hemisphere … and for our two countries.

We are both growing with healthy demographics.

We both have an enormous pool of natural assets.

We both have a shared imperative to reorient our economies.

Empowered with the right policies, enabled with the right frameworks, we have the potential to grow together this century, powered by our major population and economic centers.

So that’s our playbook:

Innovate locally.  Network globally. Advocate nationally.

Let me end where I began. 

From the beginning of time, cities have been centers of commerce, formed along the roads and routes of trade. 

And so it is today.

The cities of our nations are powering our nations.

They are giving physical shape to the globalizing economy, seamlessly integrating the exchange of people, goods, services, energy, capital, ideas, and culture.

The promise of the Global Cities Initiative broadly is to capture and channel this energy into lasting, sustained networks and partnerships.

Our pledge as we leave here today is to work with you, partner with you, and ensure that the United States and Brazil bind together not just as two nations but as living, vibrant, powerful networks of trading cities and metropolitan areas.

Editor’s note: The following remarks were prepared and delivered by Gary Burtless at a roundtable sponsored by the American Tax Policy Institute on January 7, 2016. Video of Burtless’ remarks are also available on the Institute’s website. Download the related slides at the right. 

To eliminate suspense from the start: Nothing I am about to say undermines the popular narrative about recent inequality trends.  For the past 35 years, U.S. inequality has increased.  Inequality has increased noticeably, no matter what income definition you care to use.  A couple of things you read in the newspaper are untrue under some income definitions. For example, under a comprehensive income definition it is false to claim that all the income gains of the past 2 or 3 decades have gone to the top 1 percent, or the top 5 percent, or the top 10 percent of income recipients.  Middle- and low-income Americans have managed to achieve income gains, too, as we shall see.

Tax policy certainly affects overall inequality, but I shall leave it for Scott, David, and Tracy to take that up. Let me turn to my main job, which is to distinguish between different reasonable income measures.

The crucial thing to know is that contradictory statements can be made about some income trends because of differences in the definition of income.  In general, the most pessimistic statements about trends rely on an income definition that is restrictive in some way.  The definition may exclude important income items, items, for example, that tend to equalize or boost family incomes.  The definition may leave out adjustments to income … adjustments that tend to boost the rate of income gain for low- or middle-income recipients, but not for top-income recipients.

The narrowest income definition commonly used to evaluate income trends is Definition #1 in my slide, “pretax private, cash income.”  Columnists and news reporters are unknowingly using this income definition when they make pronouncements about the income share of the “top 1 percent.”  The data about income under this definition are almost always based on IRS income tax returns, supplemented with a bit of information from the Commerce Department’s National Income and Product Account (NIPA) data file.

The single most common income definition used to assess income trends and inequality is the Census Bureau’s “money income” definition, Definition #2 on the slide.  It is just the same as the first definition I mentioned, except this income concept also includes government cash transfer payments – Social Security, unemployment insurance, cash public assistance, Veterans’ benefits, etc.

A slightly more expansive definition (#3) also adds food stamp (or SNAP) benefits plus other government benefits that are straightforward to evaluate. Items of this kind include the implicit rent subsidy low-income families receive in publicly-subsidized housing, school lunch subsides, and means-tested home heating subsidies.

Now we come to subtractions from income. These typically reflect families’ tax obligations.  The Census Bureau makes estimates of state and federal income tax liabilities as well as payroll taxes owed by workers (though not by their employers).  Since income and payroll taxes subtract from the income available to pay for other stuff families want to buy, it seems logical to also subtract them from countable income. This is done under income Definition #4.  Some tax obligations – notably the Earned Income Credit (EIC) – are in fact subtractions from taxes owed, which would not be a problem in the case of families that still owe positive taxes to the government.  However, the EIC is refundable to taxpayers, meaning that some families have negative tax liabilities:  The government owes them money.  In this case, if you do not take taxes into account you understate low-income families’ incomes, even as you’re overstating the net incomes available to middle- and high-income families.

Now let’s get a bit more complicated.  Forget what I said about taxes, because our next income definition (#5) also ignores them.  It is an even-more-comprehensive definition of gross or pretax income.  In addition to all those cash and near-cash items I mentioned in Definition #3, Definition #5 includes imputed income items, such as: 

• The value of your employer’s premium contribution to your employee health plan;
• The value of the government’s subsidy to your public health plan – Medicare, Medicaid, state CHIP plans, etc.
• Realized taxable gains from the sale of assets; and
• Corporate income that is earned by companies in which you own a share even though it is not income that is paid directly to you.

This is the most comprehensive income definition of which I am aware that refers to gross or pre-tax income.

Finally we have Definition #6, which subtracts your direct and indirect tax payments.  The only agency that uses this income definition is principally interested in the Federal budget, so the subtractions are limited to Federal income and payroll taxes, Federal corporate income taxes, and excise taxes.

Before we go into why you should care about any of these definitions, let me mention a somewhat less important issue, namely, how we define the income-sharing group over which we estimate inequality.  The most common assessment unit for income included under Definition #1 (“Pre-tax private cash income”) is the Federal income tax filing unit.  Sometimes this unit has one person; sometimes 2 (a married couple); and sometimes more than 2, including dependents.

The Census Bureau (and, consequently, most users of Census-published statistics) mainly uses “households” as reference units, without any adjustment for variations in the size of different households.  The Bureau’s median income estimate, for example, is estimated using the annual “money income” of households, some of which contain 1 person, some contain 2, some contain 3, and so on.

Many economists and sociologists find this unsatisfactory because they think a $20,000 annual income goes a lot farther if it is supporting just one person rather than 12.  Therefore, a number of organizations—notably, the Luxembourg Income Study (LIS), the Organisation of Economic Cooperation and Development (OECD), and the Congressional Budget Office (CBO)—assume household income is equally shared within each household, but that household “needs” increase with the square root of the number of people in the household.  That is, a household containing 9 members is assumed to require 1½ times as much income to enjoy the same standard of living as a family containing 4 members.  After an adjustment is made to account for the impact of household size, these organizations then calculate inequality among persons rather than among households.

How are these alternative income definitions estimated?  Who uses them?  What do the estimates show?  I’ll only consider a two or three basic cases.

First, pretax, private, cash income. By far the most famous users of this definition are Professors Thomas Piketty and Emmanuel Saez.  Their most celebrated product is an annual estimate of the share of total U.S. income (under this restricted definition) that is received by the top 1 percent of tax filing units.

Here is their most famous chart, showing the income share of the top 1 percent going back to 1913. (I use the Piketty-Saez estimates that exclude realized capital gains in the calculation of taxpayers’ incomes.) The notable feature of the chart is the huge rise in the top income share between 1970—when it was 8 percent of all pretax private cash income—and last year—when the comparable share was 18 percent.  

I have circled one part of the line—between 1986 and 1988—to show you how sensitive their income definition is to changes in the income tax code.  In 1986 Congress passed the Tax Reform Act of 1986 (TRA86). By 1988 the reform was fully implemented.  Wealthy taxpayers noticed that TRA86 sharply reduced the payoff to holding corporate earnings inside a separately taxed corporate entity. Rich business owners or shareholders could increase their after-tax income by arranging things so their business income was taxed only once, at the individual level.  The result was that a lot of income, once earned by and held within corporations, was now passed through to the tax returns of rich individual taxpayers. These taxpayers appeared to enjoy a sudden surge in their taxable incomes between 1986 and 1988.  No one seriously believes rich people failed to get the benefits of this income before 1987.  Before 1987 the same income simply showed up on corporate rather than on individual income tax returns.

A final point:  The chart displayed in SLIDE #6 is the source of the widely believed claim that U.S. inequality is nowadays about the same as it was at the end of the Roaring 1920s, before the Great Depression.  That is close to being true – under this income definition.

Census “money income”: This income definition is very similar to the one just discussed, except that it includes cash government transfer payments.  The producer of the series is the Census Bureau, and its most famous uses are to measure trends in real median household income and the official U.S. poverty rate. Furthermore, the Census Bureau uses the income definition to compile estimates of the Gini coefficient of household income inequality and the income shares received by each one-fifth of households, ranked from lowest to highest income, and received by the top 5 percent of households.

Here is a famous graph based on the Bureau’s “median household income” series.  I have normalized the historical series using the 1999 real median income level (1999 and 2000 were the peak income years according to Census data).  Since 1999 and 2000, median income has fallen about 10 percent.  If we accept this estimate without qualification, it certainly represents bad news for living standards of the nation’s middle class. The conclusion is contradicted by other government income statistics that use a broader, more inclusive income definition, however.

And here is the Bureau’s most widely cited distributional statistic (after its “official poverty rate” estimate).  Since 1979, the Gini coefficient has increased 17 percent under this income definition. (It is worth noting, however, that the portion of the increase that occurred between 1992 and 1993 is mainly the result of methodological changes in the way the Census Bureau ascertained incomes in its 1994 income survey.)

When you hear U.S. inequality compared with that in other rich countries, the numbers are most likely based on calculations of the LIS or OECD.  Their income definition is basically “Cash and Near-cash Public and Private income minus Income and Payroll taxes owed by households.”  Under this income definition, the U.S. looks relatively very unequal and America appears to have an exceptionally high poverty rate.  U.S. inequality has been rising under this income definition, as indeed has also been the case in most other rich countries. The increase in the United States has been above average, however, helping us to retain our leadership position, both in income inequality and in relative poverty.

We turn last to the most expansive income definition:  CBO’s measure of net after-tax income.  I will use CBO’s tabulations using this income definition to shed light on some of the inequality and living standard trends implied by the narrower income definitions discussed above.

Let’s consider some potential limitations of a couple of those definitions.  The limitations do not necessarily make them flawed or uninteresting.  They do mean the narrower income measures cannot tell us some of the things that users claim they tell us.

An obvious shortcoming of the “cash pretax private income” definition is that it excludes virtually everything the government does to equalize Americans’ incomes.  Believe it or not, the Federal tax system is mildly progressive.  It claims a bigger percentage of the (declared) incomes of the rich than it does of middle-income families’ and especially the poor.  Any pretax income measure will miss that redistribution.

More seriously, it excludes all government transfer payments.  You may think the rich get a bigger percentage of their income from government handouts compared with middle class and poorer households.  That is simply wrong.  The rich get a lot less.  And the percentage of total personal income that Americans derive from government transfer payments has gone way up over the years.  In the Roaring 1920s, Americans received almost nothing in the form of government transfers. Less than 1 percent of Americans’ incomes were received as transfer payments.  By 1970—near the low point of inequality according to the Piketty-Saez measure—8.3 percent of Americans’ personal income was derived from government transfers.  Last year, the share was 17 percent. None of the increase in government transfers is reflected in Piketty and Saez’s estimates of the trend in inequality.  Inequality is nowadays lower than it was in the late 1920s, mainly because the government does more redistribution through taxes and transfers.

Both the Piketty-Saez and the Census “money income” statistics are affected by the exclusion of government- and employer-provided health benefits from the income definition. This slide contains numbers, starting in 1960, that show the share of total U.S. personal consumption consisting of personal health care consumption.  I have divided the total into two parts. The first is the share that is paid for out of our own cash incomes (the blue part at the bottom).  This includes our out-of-pocket spending for doctors’ charges, hospital fees, pharmaceutical purchases, and other provider charges as well as our out-of-pocket spending on health insurance premiums. The second is the share of our personal health consumption that is paid out of government subsidies to Medicare, Medicaid, CHIP, etc., or out of employer subsidies to employee health plans (the red part). 

As everyone knows, the share of total consumption that consists of health consumption has gone way up.  What few people recognize is that the share that is directly paid by consumers—through payments to doctors, hospitals, and household health insurance premium payments—has remained unchanged.  All of the increase in the health consumption share since 1960 has been financed through government and employer subsidies to health insurance plans. None of those government or employer contributions is counted as “income” under the Piketty-Saez and Census “money income” definitions.  You would have to be quite a cynic to claim the subsidies have brought households no living standard improvements since 1960, yet that is how they are counted under the Piketty-Saez and Census “money income” definitions.

Final slide: How much has inequality gone up under income definitions that count all income sources and subtract the Federal income, payroll, corporation, and excise taxes we pay?  CBO gives us the numbers, though unfortunately its numbers end in 2011.

Here are CBO’s estimates of real income gains between 1979 and 2011.  These numbers show that real net incomes increased in every income category, from the very bottom to the very top.  They also show that real incomes per person have increased much faster at the top—over on the right—than in the middle or at the bottom—over on the left.  Still, contrary to a common complaint that all the income gains in recent years have been received by folks at the top, the CBO numbers suggest net income gains have been nontrivial among the poor and middle class as well as among top income recipients.

Suppose we look at trends in the more recent past, say, between 2000 and 2011.  That lower panel in this slide presents a very different picture from the one implied by the Census Bureau’s “money income” statistics.  Unlike the “money income numbers” [SLIDE #9], these show that inequality has declined since 2000.  Unlike the “money income numbers” [SLIDE #8], these show that incomes of middle-income families have improved since 2000.  There are a variety of explanations for the marked contrast between the Census Bureau and CBO numbers.  But a big one is the differing income definitions the two conclusions are based on.  The more inclusive measure of income shows faster real income gains among middle-income and poorer households, and it suggests a somewhat different trend in inequality.