Editor's note: On March 16, Paul B. Ginsburg testified before the California Senate Committee on Health on fostering competition in consolidated markets. Download the full testimony here.

Mr. Chairman, Madame Vice Chairman and Members of the Committee, I am honored to be invited to testify before this committee on this very important topic. I am a professor of health policy at the University of Southern California and director of public policy at the USC Schaeffer Center for Health Policy and Economics. I am also a Senior Fellow and the Leonard D. Schaeffer Chair in Health Policy Studies at The Brookings Institution, where I direct the Center for Health Policy. Much of my time is now devoted to leading the new Schaeffer Initiative for Innovation in Health Policy, which is a partnership between USC and the Brookings Institution. I am best known in California for the numerous community site visits over many years that I led in the state while I was president of the Center for Studying Health System Change; most of those studies were funded by the California HealthCare Foundation.

The key points in my testimony today are:

• Health care markets are becoming more consolidated, causing price increases for purchasers of health services, and this trend will continue for the foreseeable future despite anti-trust enforcement; 
• Government can still play an effective role in addressing higher prices that come from consolidation by pursuing policies that foster increased competition in health care markets. Many of these policies can be effective even in markets with high degrees of concentration, such as in Northern California.

[1] Gaynor, M., and R. Town, The Impact of Hospital Consolidation – Update, Robert Wood Johnson Foundation Synthesis Report (June 2012).

[2] Baker, L. C., M.K Bundorf and D.P. Kessler, “Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending,” Health Affairs, Vol. 35, No 5 (May 2014).

[3] Chapin White and Megan Egouchi, Reference Pricing: A Small Piece of the Health Care Pricing and Quality Puzzle. National Institute for Health Care Reform, Research Brief No. 18, October 2014.

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Inequality remained a prominent theme in public debate during 2015, likely helped by the unexpected rise and resilience of democratic socialist Bernie Sanders' run for the Democratic presidential nomination. Although the labor market continued its slow recovery, wage growth remained fairly weak—especially for middle and low earners. The upper middle class continues to pull away from the middle, not least in terms of income and wealth.

But it has also become much clearer that inequality is a geographical issue, as much as a social and economic one. Whether the focus is on the more immediate matter of income inequality or the slower-burning issue of intergenerational mobility, there is huge variation between different places in the United States.

National income trends are important, of course. But they can often disguise deep differences by place. The income required to be ‘rich,’ at least by comparison to those around you, varies significantly between different cities, for example. A household income of $100,000 puts you on almost on the top rung (around the 95^th percentile) of the income ladder in Detroit. But to reach the same heights in San Jose, California, you’d need an income three times as great, according to calculations by my colleague Alan Berube.

There are also very large differences in the extent of income inequality in different metropolitan areas. Using the inequality measure used in another recent paper by Berube, the ratio between incomes at the 20^th percentile and the 95^th percentile, shows that while some cities have large gaps between rich and poor, others look almost Scandinavian in their egalitarian distributions. Here are the 20/95 ratios for the three most equal and unequal cities in the U.S.:

In a groundbreaking research paper in 2014, Raj Chetty and his team at the Equality of Opportunity Project at Harvard showed that rates of intergenerational income mobility also vary considerably between different cities. It was always a stretch to compare the U.S. to Denmark on this front, given the colossal differences between the countries. But such comparisons became virtually unconscionable once the variations within the U.S. become apparent.

This year, Chetty and his co-author Nathaniel Hendren went a step further and a big step closer to showing a causal impact of place on the prospects for children raised in different locations. Again relying on large administrative datasets, the two scholars were able to show the variation in earnings for the folk hailing from, say, Baltimore versus Baton Rouge.

Professor Chetty presented his new research at a Brookings event in June (which you can view here), just weeks after the eruption of protest and violence in Baltimore following the death of Freddie Gray. One striking finding was that the worst place in America to grow up, in terms of subsequent earnings, is Baltimore City. Critically, Chetty’s research design allows him to show that these differences do not reflect the characteristics of the people of Baltimore; but the characteristics of Baltimore itself. This downward effect on earnings is particularly bad for boys, as we highlighted in an earlier blog:

In related work, Chetty and his colleagues also show that children who move to a better place see an improvement in their own earnings—and that the younger they are when they move, the bigger the impact. The children of families who move as a result of the U.S. Department of Housing and Urban Development’s Moving to Opportunity program showed sizable improvements in their own outcomes, as Jonathan Rothwell highlighted in his blog, 'Sociology’s revenge: Moving to Opportunity (MTO) revisited.'

Race, place and opportunity

One of the findings from Chetty’s earlier work is that race, place, and opportunity intersect in important ways. Cities with more segregation, and those with larger black populations, tend to show weaker upward mobility patterns. In order to understand the obstacles to upward mobility, policymakers have to adopt both a place-conscious (Margery Turner) and a race-conscious perspective. This policy was the subject of another Brookings event in November, with contributions from the Deputy Prime Minister of Singapore, the Governor of Delaware, and the Mayor of Newton, Mass. (The event can still be viewed here; for my highlights see this piece.) Being poor and black is generally not the same as being poor and white. Being poor in Cleveland is not the same as being poor in Charlotte.

Many states and cities are upping their game on issues of equality and opportunity, for both bad and good reasons. The bad reason is the relative inertia of the federal government. The good reason is a growing recognition that many of the levers for improving opportunity lie in the hands of institutions and agents at the state and metro level. Colorado has adopted a life-cycle opportunity framework and is pioneering efforts to integrate health and social policy. Charlotte has a high-profile taskforce (which I advise) on improving opportunity. Cincinnati has pledged to lift 10,000 children out of poverty within five years. Louisville is leading a push on school desegregation. Kalamazoo is adding greater student supports to its existing promise of free college. Baltimore’s program to reduce infant mortality has shown remarkable success. Durham, N.C. has rolled out a universal home visiting program.

Many of these efforts are building on the emerging ideas around 'collective impact,' harnessing local resources of many kinds around a clearly-articulated, shared goal. Given the scholarship showing just how much particular places influences individual and broader outcomes, this is likely to be where much of the most important policy development will take place in coming years. In terms of equality—and especially equality of opportunity—we need to think local, and act local, too.

Amid anger and protests in Baltimore following the death of 25-year-old Freddie Gray from a spinal injury sustained after being arrested by police, much of the discussion has focused on the poverty-ridden neighborhood in which Gray grew up (Sandtown-Winchester, on the city’s west side). Conversation has centered around the economic disadvantages that Gray, his peers, and so many young adults are facing in certain neighborhoods throughout Baltimore and in other U.S. metro areas.

Metropolitan Policy Program Fellow Jennifer Vey spoke yesterday with CNN’s Maggie Lake on the poverty and economic inequality prevalent in Baltimore—particularly in impoverished neighborhoods like that of Gray’s and throughout the country.

In the interview, Vey says that, “it’s important to look at the events of the last few days in Baltimore against a backdrop of poverty, of entrenched joblessness, of social disconnectedness that’s prevalent in many Baltimore neighborhoods…but that isn’t unique to Baltimore, and I think that’s a really important point here, that we really need to put these issues in a much broader national context.

“I think what this really indicates is we’ve been operating under an economic model for quite some time that clearly isn’t working for large numbers of people in this country.”

Vey also discusses how we can work to break the cycle:

“What we’re really focused on at Brookings is trying to understand how cities and metropolitan areas can really be trying to grow the types of advanced industries that create good jobs, that create more jobs, and also focusing on how then, people can connect back to that economy. What can we do to make sure that more people are participating in that economic growth as it happens?”

She goes on to say that investment in education, workforce programs, and infrastructure are all key in incorporating everyone into a prosperous economy.

To learn more about poverty in Baltimore, read this piece by Karl Alexander.

Inequality remained a prominent theme in public debate during 2015, likely helped by the unexpected rise and resilience of democratic socialist Bernie Sanders' run for the Democratic presidential nomination. Although the labor market continued its slow recovery, wage growth remained fairly weak—especially for middle and low earners. The upper middle class continues to pull away from the middle, not least in terms of income and wealth.

But it has also become much clearer that inequality is a geographical issue, as much as a social and economic one. Whether the focus is on the more immediate matter of income inequality or the slower-burning issue of intergenerational mobility, there is huge variation between different places in the United States.

National income trends are important, of course. But they can often disguise deep differences by place. The income required to be ‘rich,’ at least by comparison to those around you, varies significantly between different cities, for example. A household income of $100,000 puts you on almost on the top rung (around the 95^th percentile) of the income ladder in Detroit. But to reach the same heights in San Jose, California, you’d need an income three times as great, according to calculations by my colleague Alan Berube.

There are also very large differences in the extent of income inequality in different metropolitan areas. Using the inequality measure used in another recent paper by Berube, the ratio between incomes at the 20^th percentile and the 95^th percentile, shows that while some cities have large gaps between rich and poor, others look almost Scandinavian in their egalitarian distributions. Here are the 20/95 ratios for the three most equal and unequal cities in the U.S.:

In a groundbreaking research paper in 2014, Raj Chetty and his team at the Equality of Opportunity Project at Harvard showed that rates of intergenerational income mobility also vary considerably between different cities. It was always a stretch to compare the U.S. to Denmark on this front, given the colossal differences between the countries. But such comparisons became virtually unconscionable once the variations within the U.S. become apparent.

This year, Chetty and his co-author Nathaniel Hendren went a step further and a big step closer to showing a causal impact of place on the prospects for children raised in different locations. Again relying on large administrative datasets, the two scholars were able to show the variation in earnings for the folk hailing from, say, Baltimore versus Baton Rouge.

Professor Chetty presented his new research at a Brookings event in June (which you can view here), just weeks after the eruption of protest and violence in Baltimore following the death of Freddie Gray. One striking finding was that the worst place in America to grow up, in terms of subsequent earnings, is Baltimore City. Critically, Chetty’s research design allows him to show that these differences do not reflect the characteristics of the people of Baltimore; but the characteristics of Baltimore itself. This downward effect on earnings is particularly bad for boys, as we highlighted in an earlier blog:

In related work, Chetty and his colleagues also show that children who move to a better place see an improvement in their own earnings—and that the younger they are when they move, the bigger the impact. The children of families who move as a result of the U.S. Department of Housing and Urban Development’s Moving to Opportunity program showed sizable improvements in their own outcomes, as Jonathan Rothwell highlighted in his blog, 'Sociology’s revenge: Moving to Opportunity (MTO) revisited.'

Race, place and opportunity

One of the findings from Chetty’s earlier work is that race, place, and opportunity intersect in important ways. Cities with more segregation, and those with larger black populations, tend to show weaker upward mobility patterns. In order to understand the obstacles to upward mobility, policymakers have to adopt both a place-conscious (Margery Turner) and a race-conscious perspective. This policy was the subject of another Brookings event in November, with contributions from the Deputy Prime Minister of Singapore, the Governor of Delaware, and the Mayor of Newton, Mass. (The event can still be viewed here; for my highlights see this piece.) Being poor and black is generally not the same as being poor and white. Being poor in Cleveland is not the same as being poor in Charlotte.

Many states and cities are upping their game on issues of equality and opportunity, for both bad and good reasons. The bad reason is the relative inertia of the federal government. The good reason is a growing recognition that many of the levers for improving opportunity lie in the hands of institutions and agents at the state and metro level. Colorado has adopted a life-cycle opportunity framework and is pioneering efforts to integrate health and social policy. Charlotte has a high-profile taskforce (which I advise) on improving opportunity. Cincinnati has pledged to lift 10,000 children out of poverty within five years. Louisville is leading a push on school desegregation. Kalamazoo is adding greater student supports to its existing promise of free college. Baltimore’s program to reduce infant mortality has shown remarkable success. Durham, N.C. has rolled out a universal home visiting program.

Many of these efforts are building on the emerging ideas around 'collective impact,' harnessing local resources of many kinds around a clearly-articulated, shared goal. Given the scholarship showing just how much particular places influences individual and broader outcomes, this is likely to be where much of the most important policy development will take place in coming years. In terms of equality—and especially equality of opportunity—we need to think local, and act local, too.

MEDIA RELEASE

Low-Income Boys in Higher Inequality Areas Drop Out of School More Often than Low-Income Boys in Lower Inequality Areas, Limiting Social Mobility, New Brookings Paper Finds
“Economic despair” may contribute if those at the bottom do not believe they have the ability to achieve middle class status

Greater income gaps between those at the bottom and middle of the income distribution lead low-income boys to drop out of high school more often than their counterparts in lower inequality areas, suggesting that there is an important link between income inequality and reduced rates of upward mobility, according to a new paper presented today at the Brookings Panel on Activity. The finding has implications for social policy, implying a need for interventions that focus on bolstering low-income adolescents' perceptions of what they could achieve in life.

In “Income Inequality, Social Mobility, and the Decision to Drop Out Of High School,” Brookings Nonresident Senior Fellow and University of Maryland economics professor Melissa S. Kearney and Wellesley economics professor Phillip B. Levine propose a channel through which income inequality might lead to less upward mobility—often assumed to be the case but not yet fully proven. The conventional thinking among economists is that income inequality provides incentives for individuals to invest more in order to achieve the higher income position in society, but Kearney and Levine observe that if low-income youth view middle-class life as out of reach, they might decide to invest less in their own economic future.

See an interactive map of inequality by state, plus more findings »

The authors focus on income inequality in the lower half of the income distribution, as measured by income gaps between the 10th and 50th percentiles of the income distribution rather than income gaps between the the top and bottom of the income distribution, which has been more of a focus in popular culture. They show this "lower-tail" inequality is more relevant to the lives of poor youth because the middle is a more realistic ambition. Furthermore, their research could reconcile a puzzle: social mobility does not appear to be falling, despite the rise in income inequality. But, as Kearney and Levine point out, U.S. income inequality has been rising because the top of the distribution has been pulling away from the middle, not because the bottom is falling farther behind the middle.

The authors look specifically at high school drop-out rates through a geographic lens, noting the link between highly variable rates of high school completion and income inequality across the country. One-quarter or more of those who start high school in the higher inequality states of Louisiana, Mississippi, Georgia, and the District Columbia fail to graduate in a four-year period, as compared to only around 10 percent in Vermont, Wisconsin, North Dakota, and Nebraska—lower inequality states. Their econometric analysis goes on to show that low-income youth—boys in particular—are 4.1 percentage points more likely to drop out of high school by age 20 if they live in a high-inequality location relative to those who live in a low-inequality location.

Kearney and Levine examine a number of potential explanations for this link, including differences in educational inputs, poverty rates, demographic composition, and other factors. Ultimately, the evidence suggests that there is something specific about areas with greater income gaps that lead low-income boys there to drop out of school at higher rates than low-income boys elsewhere. The authors' research suggests that adolescents make educational decisions based on their perceived returns to investing in their educational development: a greater distance to climb to get to the middle of the income distribution could lead to a sense that economic success is unlikely—what they term “economic despair.”

"Income inequality can negatively affect the perceived returns to investment in education from the perspective of an economically disadvantaged adolescent,” they write. “Perceptions beget perceptions."

Digging into reasons students themselves give for dropping out, they find that low-income students from more unequal places are more likely to give up on their educational pursuits. Surprisingly, survey evidence shows that academic performance does not have as large an impact on low-income students in high inequality states: 51 percent of dropouts in the least unequal states reported that they dropped out because they were performing poorly, as compared to only 21 percent of students who dropped out in the most unequal states.

The finding suggests that economic despair could play an important role: if a student perceives a lower benefit to remaining in school, then he or she will choose to drop out at a lower threshold of academic difficulty. They also note that while the wage premium of completing high school should reduce the dropout rate, household income inequality has an offsetting negative effect.

The choice between staying in school and dropping out may reflect actual or perceived differences from the benefits of graduating. For instance, the authors note their past research showing that youth from low-income households who grow up in high lower-tail inequality states face lifetime incomes that are over 30 percent lower than similar children in lower inequality states. They also highlight other research showing that the overwhelming majority of 9th graders aspire to go to college, but by 11th grade, low-SES students are substantially less likely to expect they will enroll in college, even among those students with high test scores.

"There are important policy implications for what types of programs are needed to improve the economic trajectory of children from low-SES backgrounds," they write. "Successful interventions would focus on giving low income youth reasons to believe they have the opportunity to succeed. Such interventions could focus on expanded opportunities that would improve the actual return to staying in school, but they could also focus on improving perceptions by giving low-income students a reason to believe they can be the "college-going type." For example, interventions might take the form of mentoring programs that connect youth with successful adult mentors and school and community programs that focus on establishing high expectations and providing pathways to graduation. They could also take the form of early-childhood parenting programs that work with parents to create more nurturing home environments to build self-esteem and engender positive behaviors."

Read the full paper from Kearney and Levine here »

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Video

• How “economic despair” affects high school graduation rates for America’s poorest students

Income and wealth inequality in the U.S. is a stark reality.  Research from a variety of fields demonstrates that children born into poor families tend to end up less educated, less healthy, more prone to contact with the police, and less likely to accumulate wealth over a lifetime.  In contrast, children born into well-off families tend to exhibit better outcomes on all of these dimensions.

How should social scientists and policymakers understand and address intergenerational mobility in the U.S.? This question is difficult to answer—and highly politicized.  To start with, there are several possible mechanisms driving high intergenerational persistence of economic outcomes.  These are often characterized as factors related either to “nurture” or “nature.” 

The “nurture” hypothesis asserts that poor parents lack critical resources such as wealth or information.  Such parents may therefore find it difficult to make the education and time investments that would promote better economic outcomes for their children.  If this is true, then children born into poor families never reach their full potential because of a lack of household resources. 

A second possible mechanism is often referred to as the “nature” hypothesis.  Economically successful parents might be more likely to have successful children.  Such an account hinges on the idea that there are heritable biological traits or abilities that more successful parents “pass on” to their children.

To complicate the matter further, the mechanisms of nature and nurture almost certainly operate at the same time.  Moreover, it is likely that abilities and investments interact in complicated ways. For example, a particular investment might do more to improve the outcomes of a lower-ability child than a higher-ability child, or vice versa.  Understanding this process, and how it affects intergenerational mobility, is notoriously difficult.  However, greater clarity is precisely what is needed to guide effective policy. 

If a lack of investment is the dominant mechanism explaining intergenerational persistence in economic outcomes, then we as a society may be wasting human potential.  Policies correcting under-investments in human capital could therefore be justified as economically efficient. In contrast, if the intergenerational transmission of ability plays a role, then investments in poor children’s human capital may not be enough.  To clarify, it is critical to state that the distinction we make here between “high-ability” and “low-ability” individuals should not be interpreted as a claim that some people are naturally or biologically superior to others.  We use “ability” as shorthand to describe those traits that are rewarded in the existing labor market.  Even if these abilities are linked to heritable biological factors, this does not mean that their impact on life outcomes is immutable or fixed.  Modifying environments could substantially affect genetic disparities. The case of vision and eyeglasses offer one classic example.  There may well be biological factors that explain variation in eyesight “ability,” but these biological differences will matter more or less for life outcomes depending on the availability of glasses and other medical interventions.  In short, it is very possible that the consequences of biological differences can be moderated by appropriate changes in the environment.     

Until now, researchers have typically used variables such as cognitive test scores to measure ability endowments related to human capital.  Yet, these traditional measures are subject to the critique that they are the products of earlier investments in human capital. This makes it difficult to distinguish between the “nature” and “nurture” hypotheses using such data.  Two individuals with similar ability endowments but different levels of household resources are likely to exhibit different cognitive test scores, for example. 

Using genetic information to measure ability endowments can help us better understand the intergenerational transmission of human capital.  As a measure, genetic information has a clear advantage over cognitive test scores because it is fixed at conception. Advances in measuring differences in DNA across individuals, together with very recent advances in behavioral genetics research, now make it possible to link genetic differences across people to behavioral traits.  These new discoveries have even extended to educational attainment, which was once thought to be too complicated and removed from direct biological processes for genetic analysis.

In a recent research paper, we use genetic information to better understand the nature of intergenerational mobility.  We follow the cutting edge in behavioral genetics research, which guides us in computing a type of genetic “score” for any individual.  We compute this so-called “polygenic score” for each person in a sample of over 8,000 individuals from the Health and Retirement Study (HRS). The score, which appears to be related to cognition, personality, and facility with learning, has some predictive power for educational attainment. In particular, it explains between 3.2 percent and 6.6 percent of the variation across individuals (depending on the specification). Thus, knowing the exact value of an individual’s score will tell you very little about that person (over 90 percent of the variation is explained by other factors).  However, the average relationship in the population between the score and human capital outcomes can offer some important lessons.  

Using the polygenic score, we believe we can gain new insights into how ability endowments interact with an individual’s environment to generate economic outcomes.  There is a long-standing debate in the economics literature about how ability and investments interact.  One idea is that both ability and investments are needed for success, i.e., that they complement one another. Though our findings show evidence of this type of interaction, the story that emerges from our analysis is somewhat more nuanced.  We show that ability and the environment (measured by parents’ socioeconomic status or SES) complement one another for generating higher degrees, such as college completion, but substitute for one another in generating lower levels of educational attainment such as a high school degree.  In other words, our findings suggest that ability or being born into a well-off family are enough to get an individual through high school.  For college, however, ability and a well-off family are important predictors of success.

"In other words, our findings suggest that ability or being born into a well-off family are enough to get an individual through high school. For college, however, ability and a well-off family are important predictors of success."

Another set of results concerns the wages of high-ability individuals.  We show that individuals who completed college earned substantial returns on their ability starting in the early 2000s.  Individuals without a college degree did not. The post-2000 rise in returns may be driven in part by “skill-biased technological change.”   As new technologies are adopted in the workplace, the people who benefit most are those with the skills required to adapt to and master new ways of working.  It is not difficult to imagine that people with genetic variants associated with higher education may have found it easier to adapt to computers and other new technologies.  However, we also find that a higher polygenic score was not helpful for individuals who did not complete college, likely because the lack of a college degree shut them out of careers that would have allowed them to creatively use new technologies.  This is a troubling finding given the role of childhood SES in predicting college completion.  It means that poor children with high abilities are less likely to attend college and, subsequently, are less likely to benefit from their ability.  Again, these findings suggest wasted human potential.

Using genetic data to compare individuals from different socioeconomic backgrounds, we also find that children from lower SES backgrounds systematically acquire less education when compared to similarly capable individuals from high SES backgrounds.  Among other things, this suggests that access to education may be an important obstacle, even for the highest ability children.  Our analysis offers some suggestive evidence regarding which environments are especially harmful. For example, acute negative events like physical abuse in childhood can lead to a dramatic loss of economic potential—reducing financial wealth in late adulthood for the highest ability individuals by over 50 percent.

Of course, one must be very cautious when interpreting any genetic association.  In particular, it is important to think carefully about correlation versus causality.  The same parents that pass along genetic material predicting educational attainment may also be more likely to have the resources to invest in their children.  Still, since we base our comparisons on individuals from different socioeconomic backgrounds, but with similar polygenic scores, we offer evidence that economic disparities are not solely due to nature.

In summary, recent advances in behavioral genetics have identified specific genetic variants that predict educational attainment.  The fact that such genes exist confirms previous work (largely using data on twins) showing that “nature” matters for economic outcomes.  Our research demonstrates that “nurture” matters, too.  Perhaps more importantly, our research demonstrates that the roles of “nature” and “nurture” are intertwined and that understanding the role of “nurture” (in the form of human capital investments over the life-cycle) is key to understanding how “nature” (in the form of ability endowments) operates.  In particular, we show that similarly apt individuals with different childhood SES see very different returns to their ability.  This means that policies helping children born into disadvantaged circumstances may be justified not solely for ethical reasons rooted in social justice, but perhaps also as an economically efficient way to mitigate wasted human potential.

Finally, we believe that continued progress in understanding the mechanisms underlying how “nature” affects economic outcomes will eventually lead to policies that help people who are born with different abilities.  For example, our findings suggest that some individuals had more difficulty than others in adapting to new workplace technologies, such as computers. With a fuller understanding of this process, policymakers may be able to devise better training programs or improved school curricula that help individuals of all levels of ability to better respond to a changing technological environment.  In other words we believe that our research shows that learning more about the specifics of “nature” may help us to better “nurture” all individuals in society to help them to reach their full potential.      

Editor’s note: The authors contributed equally to this posting and to the research upon which the posting is based. They are listed alphabetically by last name.

On Thursday, July 7, the International Monetary Fund (IMF) revised its economic outlook for South Africa. Despite “considerable economic and social progress” since 1994, the IMF report cited high income inequality, among other factors, in its projection of slow growth and increased unemployment in the medium term. Earlier this year, in the Brookings Africa Growth Initiative’s Foresight Africa 2016, we explored this pressing problem—high income inequality—across the continent. The initial takeaway was that sub-Saharan Africa has greater in-country income inequality than other developing countries around the world. However, after separating seven outlier economies—Angola, the Central African Republic, Botswana, Zambia, Namibia, Comoros, and South Africa—we noted that income inequality, measured by the Gini coefficient, in the rest of the region actually mirrors the rest of the developing world, which currently stands at 0.39. All seven outlier economies have Gini coefficients above 0.55, a level reached by only four other countries worldwide: Suriname, Haiti, Colombia, and Honduras. 

It is important to explore precisely why this disparity exists. Notably, sub-Saharan Africa is not only an outlier in income inequality, but also in the relationship between economic growth and poverty reduction. Generally, in the developing world, every 1 percent of growth reduces poverty 4 percent. In sub-Saharan Africa, however, every 1 percent of growth only reduces poverty by 3 percent. In Foresight Africa 2016, Brookings Nonresident Senior Fellow Haroon Bhorat suggests that this disparity may be because of the commodity booms that have sustained growth periods in African economies, which bring extraordinary returns to capital but limited job growth. Alternatively, these commodity booms may have accompanied a fall in manufacturing output; growth is thus concentrated in the low-productivity services sector. In any case, this graph forces us to consider exactly what type of structural transformation is necessary for continued economic growth and acknowledge that inequality in sub-Saharan Africa might require different solutions in different countries.

For a more in-depth discussion on this issue, see Foresight Africa 2016 and Bhorat’s discussion of African inequality in relation to the Sustainable Development Goals.

Omid Abrishamchian contributed to this post.

INTRODUCTION

In recent years, there has been a resurgence of interest in the issue of inequality. Part of this resurgence can be traced to new evidence of persistent and widening wealth gaps. Average incomes may be converging globally as a result of high growth in emerging markets, stronger growth in many poor countries, and slow growth in rich countries. However, the evidence also shows that within countries a parallel process of income divergence, marginalization and rising inequality is also taking place. Put differently, the rising tide of global prosperity is not lifting all boats.

Much of the international debate on inequality focuses on the distribution of income across and within countries. Other dimensions of inequality have received less attention. This is unfortunate. Amartya Sen has described development as “a process of expanding the real freedoms that people enjoy” by building human capabilities or their capacity to lead the kind of life they value. Income is a means to that end but it is a limited indicator of well-being. Moreover, a person’s income reflects not just personal choice but also their opportunities for improving health, literacy, political participation and other areas. Education is one of the most basic building blocks for the “real freedoms” that Sen describes. People denied the chance to develop their potential through education face diminished prospects and more limited opportunities in areas ranging from health and nutrition, to employment, and participation in political processes. In other words, disparities in education are powerfully connected to wider disparities, including international and intra-country income inequalities. This is why education has been identified as one of the most critical factors in breaking down the disadvantages and social inequalities that are limiting progress toward the United Nations’ Millennium Development Goals (MDGs)—development targets adopted by the international community for 2015.

Understanding patterns of educational inequality is critical at many levels. Ethical considerations are of paramount importance. Most people would accept that children’s educational achievements should not be dictated by the wealth of their parents, their gender, their race or their ethnicity. Disparities in educational opportunities are not just inequalities in a technical sense, they are also fundamental in equities—they are unjust and unfair. In an influential paper, John Roemer differentiated between inequalities that reflect factors such as luck, effort and reasonable reward, and those attributable to circumstances that limit opportunity (Roemer 1988).1 While the dividing line may often be blurred, that distinction has an intuitive appeal. Most people have a high level of aversion to the restrictions on what people—especially children—are able to achieve as a result of disparities and inherited disadvantages that limit access to education, nutrition or health care (Wagstaff, 2002). There is a wide body of opinion across political science, philosophy and economics that equal opportunity—as distinct from equality of outcomes—is a benchmark of egalitarian social justice. The theories of distributive justice associated with thinkers such as Amartya Sen, John Rawls, Ronald Dworkin and John Roemer argue, admittedly from very different perspectives, that public policy should aim at equalizing opportunity to counteract disadvantages associated with exogenous circumstances over which individuals or social groups have no control. Given the role of education as a potential leveler of opportunity, it is a national focal point for redistributive social justice.

Considerations of economic efficiency reinforce the ethical case for equalizing educational opportunities. Education is a powerful driver of productivity, economic growth, and innovation. Econometric modeling for both rich and poor countries suggests that an increase in learning achievement (as measured by test score data) of one standard deviation is associated on average with an increase in the long-run growth rate of around 2 percent per capita annually (Hanushek and Wößmann, 2010; Hanushek, 2009; Hanushek and Wößmann, 2008). Such evidence points to the critical role of education and learning in developing a skilled workforce. Countries in which large sections of the population are denied a quality education because of factors linked to potential wealth, gender, ethnicity, language and other markers for disadvantage are not just limiting a fundamental human right. They are also wasting a productive resource and undermining or weakening the human capital of the economy.

International development commitments provide another rationale for equalizing educational opportunities. This is for two reasons. First, the commitments envisage education for all and achievement of universal primary education by 2015. Second, there is mounting evidence that inequality is acting as a brake on progress toward the 2015 goals. Since around 2005, the rate of decline in the out-of-school population has slowed dramatically. Based on current trends, there may be more children out of school in 2015 than there were in 2009. Caution has to be exercised in interpreting short-run trends, especially given the weakness of data. However, the past three editions of the UNESCO Education for All Global Monitoring Report (GMR) have highlighted the role of inequality in contributing to the slowdown with governments struggling to reach populations that face deeply entrenched disadvantages (UNESCO, 2008, 2010, 2011). Therefore, picking up the pace toward the 2015 goals requires a strengthened focus on equity and strategies that target the most marginalized groups and regions of the world (Sumner and Tiwari, 2010; UN-DESA, 2009; UNESCO, 2010). It should be added that disparities in education relate not just to access, but also to learning achievement levels.

Accelerated progress in education would generate wider benefits for the MDGs. Most of the world’s poorest countries are off-track for the 2015 MDG target of halving income poverty and a long way from reaching the targets on child survival, maternal health and nutrition. Changing this picture will require policy interventions at many levels. However, there is overwhelming evidence showing that education—especially of young girls and women—can act as a potent catalyst for change. On one estimate, if all of sub-Saharan Africa’s mothers attained at least some secondary education, there would be 1.8 million fewer child deaths in the region each year. Thus while education may lack the “quick fix” appeal of vaccinations, it can powerfully reinforce health policy interventions.

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The Centers for Medicare and Medicaid Services (CMS) recently reported more optimistic news about the Medicare Accountable Care (ACO) Program, which began in 2012.  CMS released final first year financial and quality results for the Medicare Shared Savings Program (MSSP) ACOs and preliminary year two financial and quality results for the Pioneer ACO Model (Pioneer ACOs).

Financial Results: To date, the two programs have generated savings of $817 million—$372 million of which has been saved by Medicare and another $445 that has been returned to the ACOs through shared savings. While these savings are not final calculations, they suggest that both programs have produced modest savings in the first two years with some variability across ACOs.

Pioneer ACOs: Pioneers, generally considered more advanced ACOs, were able to generate more total program savings in year two than in year one ($96 million vs. $87 million), while also qualifying for shared savings payments of $68 million. The Medicare Trust Fund saved approximately $41 million in year two of the Pioneer program. In total, Pioneer ACOs were able to achieve an approximately 1% lower spending trend overall for the Medicare population than fee-for-service (1.4 vs. 0.45 percent lower per capita growth). Seventeen of the 23 Pioneer ACOs had positive or neutral financial performance, eleven of which were able to slow health spending enough to share in savings. On average, those ACOs saved $4.2 million in 2013, up from $2.7 million in 2012; shared savings grew from $1.2 million to $13 million. Six Pioneers generated losses, three of which were significant enough to require those Pioneer ACOs to share in the losses. While remaining Pioneers have been able to attain bigger savings in year two of the program, almost a third of original participants have left the program—some have moved to the lower risk MSSP, while others have focused on commercial ACO contracts or higher levels of risk in MA programs.

MSSP ACOs: MSSP ACOs were likewise able to reduce overall cost trend by slightly less than 1 percent. Of the 220 MSSP ACOs that started in 2012 or 2013, roughly one-quarter (53) were able to reduce spending enough to qualify for total shared savings of over $300 million. An additional 52 ACOs reduced spending compared to their benchmarks, but not enough to qualify for shared savings. One ACO that opted for track two (two-sided financial risk) overspent its benchmark by $10 million and owed shared savings of $4 million. MSSP ACOs as a whole were able to reduce spending by $652 million below their financial benchmarks and saved the Medicare Trust Fund $345 million, including repayment for the track 2 ACO losses.

Quality Results
Medicare ACOs continue to improve significantly on overall quality scores.  Both Pioneer ACOs and MSSPs have been able to attain higher average performance than quality benchmarks and better performance than Medicare fee-for-service on measures with data, such as colorectal screening, tobacco cessation, and depression screening.

Pioneer ACOs: All 23 Pioneer ACOs that remain in the program out of the initial 32 successfully reported their quality measures in their first two years.  The mean quality scores for Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2% in 2013. Pioneer ACOs increased average improvement by 14.8 percent across all quality measures and overall improvement on 28 of 33 quality measures. Patients also report a positive experience receiving care from Pioneer ACOs—the ACOs improved average performance scores for patient and caregiver experience across 6 out of 7 measures.

MSSP ACOs: MSSP ACOs, as a group, posted even more improvement in quality scores than the Pioneer ACOs. MSSP ACOs starting in 2012 and 2013 were able to improve 30 of 33 quality measures, including measures such as patients’ rating of clinicians’ communication, beneficiaries rating of doctors, health promotion and education, screening for tobacco use and cessation, and screening for high blood pressure. In total, MSSP ACOs are experiencing higher CAHPS patient experience survey scores than Medicare fee-for-service, suggesting that patients are engaged and satisfied with being a part of an ACO. Additionally, MSSP ACOs achieved higher average performance rates on 17 of 22 Group Practice Reporting Option (GPRO) Web Interface measures reported by other large physician group fee-for-service providers.  Over 125,000 eligible providers or supplier members of ACOs qualified for incentive payments through PQRS (Physician Quality Reporting System) in 2013. Unfortunately, nine MSSP ACOs failed to successfully report their quality scores, four of which would have otherwise qualified for shared savings.

Digging Deeper into the Results
While program level analysis of financial performance is meaningful, a deeper analysis of the data and organizational characteristics of those MSSP ACOs that earned shared savings reveals some interesting trends. A little over half of those earning shared savings were physician-led ACOs (26/49) and more than a third of these physician led ACOs operate in Florida (10/26). The continued success of physician-led ACOs is consistent with previous findings that these ACOs may be better positioned than institutionally-based ACO to reduce overall costs. In addition, analysis by The Center for Medicare and Medicaid Innovation (CMMI) found that there is no relationship between savings/loss performances and whether the ACO included a hospital. Hospital-led ACOs were overall less likely to share in savings than physician-led ACOs. These two findings together suggest that ACOs can experience success even without an official hospital affiliation, paving the way for more physician practices to join and excel at accountable care.

Interesting regional trends are beginning to emerge from the data. Florida and Texas had the highest concentration of ACOs sharing in savings. Of the 30 Florida-based MSSP ACOs, more than a third (11) were able to share in savings, while almost half (7/15) Texas-based MSSP ACOs qualified for shared savings. Furthermore, the top two earning MSSP ACOs were from Texas (Memorial Herman with $28.34 million) and Florida (Palm Beach ACO with $19.34 million), respectively. The concentration of shared savings in these two states raises important questions about what is driving the high level performance. Are these MSSPs more likely to succeed because of a higher financial benchmark based on disproportionately greater regional Medicare spending? Do these ACOs have a leg up from the start because of their patient population and historical spending trend? Are physician ACOs more likely to form and succeed in these higher-cost areas? The success of these programs should not be understated, but further analysis may be needed to better understand performance drivers so appropriate program adjustments may be considered to level the playing field among MSSP ACOs across all regions.

Next Steps
While these latest Medicare ACO results are encouraging, more work needs to be done. The Pioneer Program recently lost its tenth program participant, Sharp Healthcare, bringing the total number of Pioneers down to 22. Like some other Pioneers that have exited the program, Sharp was dissatisfied with the benchmark and payment methodology and was no longer willing to assume financial risk that they felt was too great. This is just one among many policy and implementation issues with which Medicare ACOs are struggling. In June, we published a set of recommendations to ensure the long-term sustainability of the Medicare ACO program by addressing eight major ACO challenges. These results seem to reinforce the need for several of these recommendations for change in the Medicare ACO Program.

CMMI, which administers the Pioneer ACO Program, has recognized some of these challenges and has begun giving ACOs some greater flexibility in operating within the program. These changes include allowing them to move to population-based payments, waiving the 3-day hospitalization rule to allow ACOs to directly admit qualified patients to skilled nursing facilities, and experimenting with “voluntary alignment” to allow beneficiaries to attest to a primary care physician to offset some of the limitations of the existing attribution process. These are moves in the right direction; however CMS must continue to engage providers across the country to make sure the program remains viable.

Meanwhile, the MSSP will add another round of participants in January 2015 and CMS is expected to release a notice of proposed rulemaking that will amend the current operating requirements for the MSSP program later this year. The scope and nature of changes could dramatically impact the interest of new organization, as well as the continued participation of current MSSP and Pioneer ACOs.  Medicare ACOs will likely be encouraged to continue innovating to improve quality and reduce costs in the Medicare program, but the Medicare ACO program must continue to evolve to meet provider and beneficiary needs to ensure continued success.

Note: This blog has been corrected since its original posting on September 22 to reflect more accurate data.

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• Changes to Medicare ACO Program

In her February 25 Brookings report, Dr. Dale Farran questions the scientific case for endorsing widespread policy in preschool education. Indeed, she argues that enthusiasm for public preschool and its promise is “premature.” Her argument is founded on three points—that the data on impact is mixed, that we do not have scientific direction with respect to the key quality constructs, and that our measurement of these constructs lack empirical validity. There is a grain of truth in each of these statements. Yet, a closer look reveals that when the data are focused on high quality preschools, the weight of the evidence for effectiveness is compelling. The early childhood science is at least evidence informed on the skill sets that will promote later school and life success and valid measures exist for many of the important outcomes. While there is always more to be learned, the bulk of the scientific community contends that high quality preschool programs will play a role in preparing young children for success in school and beyond.

There is no doubt that the literature looking for relationships between preschool access and school readiness outcomes in literacy, mathematics, and other domains are mixed.  Both the Head Start Impact Study and recent findings from Farran’s own Tennessee pre-k study (Lipsey et al., 2015) indicate that preschool of less than high quality produce only modest short-term gains. 

The data do not look bleak, however, when we look across preschool outcomes in the aggregate. And when high quality programs are investigated, whether in well-controlled studies of intensive models (e.g., Perry and Abecedarian) or in studies of strong public programs in Boston (Weiland & Yoshikawa, 2013), Cincinnati (Karoly & Auger, 2016), New Jersey (Barnett et al., 2013), North Carolina (Peisner-Feinberg et al., 2015), and Tulsa (Hill et al., 2015), the results are downright promising  (Yoshikawa et al., 2013; Minervino. 2014). Society reaps benefits from fostering early skill development, as children participating in high quality preschool programs had lower rates of grade retention, less need for special education, decreased antisocial behavior, and greater productivity as adults (Reynolds & Temple, 2015; Cunha & Heckman, 2006). In 2014, over 1,200 scientists who work in the area of early education signed the ECE Consensus Letter for Researchers, attesting to the mountains of data in support of the role of preschool education in improving child outcomes in social development, language, pre-literacy, and mathematics.

Though Farran’s brief reviews only data from the United States, a growing literature suggests that preschool education has long and lasting and causal effects on outcomes around the globe (Atinc & Gustafsson-Wright, 2013). For example, an impact evaluation of a preschool program in Mozambique found that the program increased on-time enrollment into primary school among beneficiaries by 22 percent relative to the children in the control group. Enrolled children also experienced a 6 percent increase in fine motor development, and an 87 percent increase in cognitive development. More importantly, this is not just a story of “everything is bleak in the developing world so the program is bound to have an impact.”

With compelling data in the United States and across the globe, one might ask why there is such a great divide between Farran’s interpretation and that of the wider academic community? One reason appears to be that Farran discounts any data that did not emerge from random assignment longitudinal studies. While correlational studies are not the gold standard, they are informative. Surely practitioners and policymakers would not dismiss data on parenting practices because children were not randomly assigned to parents. Further, in the area of preschool education, there is no difference in findings between randomized trials and other methodologies with respect to targeted cognitive, achievement-related outcomes when other study and program features are taken into account (Duncan & Magnuson, 2013; Camilli et al., 2010). 

Farran also discounts many of the randomized trials because she says they do not tell us enough about cause and effect. She writes of the famous Abecedarian and Perry Preschool studies:

The primary difficulty with this approach as a basis for designing interventions is that there is no way to identify what specifically changed about children’s abilities that enabled them to perform better in school or to link those changes to any particular set of active ingredients in the treatment. Neither Perry nor Abecedarian explicitly describes beyond the broadest level the “treatment” that brought about their positive effects.

But the children did improve, and at some level—while it would be wonderful to isolate the exact recipe for preschool success—we need not deny children the benefits of preschool while scientists probe for the precise combinations of active ingredients that yield the best results. Consider an analogy: the impact of storybook reading on children. While numerous studies document that reading storybooks with children in a joint way improves vocabulary and early literacy, we have yet to isolate the exact causal factors that matter in book reading. Perhaps it is the cuddling that occurs between child and parent; perhaps this crucial unstudied variable is the key that has not yet been turned. But no one would argue that we should stop book reading as a way to foster young children’s interest in reading. So it is with preschool. A quality preschool can heighten young children’s desire to attend school and prepare them for learning—even if all the ingredients in the magic sauce have not yet been identified.

In short, the evidence does provide models of high quality preschool that effectively prepare children for entrée into school and that change a child’s trajectory toward success. Not knowing the exact mechanisms by which preschool exerts its impact is secondary to the fact that poor children need good preschools now and we know how to provide them.

Farran raises the very important point that a narrow focus on only reading and math outcomes would be misplaced in our quest to build high quality preschool curricula. We could not agree more. She goes on to write, however, that “premature as well is the presumption that solid research exists to guide the content and structure of pre-K programs.”

Here we beg to differ. There are thousands of studies that speak to the skill sets children need to achieve success in the changing world. Reading and math are among these skills—collectively bundled under what Golinkoff and Hirsh-Pasek (2016) call “content skills.” But there is overwhelming evidence that children need to master skills that move beyond just reading and math. Content knowledge has, at its base, language and executive function skills. Language is the medium of instruction and executive function skills empower children with the ability to control their impulses and attend. Flexibility and working memory (Galinsky, 2010; Blair, 2016), also part of executive function, enable children to shift gears and remember what they have been told. But even language and executive function are not enough. Children must be prepared to participate alongside others (collaboration), to question when they are unclear (critical thinking) (Kuhn, 1999), and to have the persistence needed to stick with difficult problems—grit (Duckworth et al., 2007). These skills have been tested, are predictive of later achievement, have been shown to be malleable and to relate to academic, social, and learning outcomes in school.

Farran argues that we cannot provide high quality preschool because we lack strong measures of quality. Again, there is some truth in her assertion, but it seems to us somewhat confused. Farran mixes together policy benchmarks, measures of classroom practice, and child outcome measures. All are useful, but for different purposes. The first is meant to set a floor across many domains including health and safety. The second is designed for providing feedback on classroom practice. The last allows us to assess children’s wellbeing and progress. Well-designed continuous improvement systems for pre-K have detailed standards for learning and teaching that align with assessments of classroom practice and systems operation as well as with child assessments. Together with program standards these can provide a clear vision of high quality. They set high expectations for children’s learning and development and for pedagogy. Our ability to specify all of this exceeds our ability to measure it with reasonable investments of time and money. Nevertheless, classroom observation measures and child assessments as elements of a continuous improvement system help inform teachers and administrators about where they are and what steps they need to take next (Hall et al., 2012; Sylva et al., 2006; Williford et al., 2013). None of us would argue that this is easy, or that any single measure of classroom quality or child development is sufficient. Providing guidance for the improvement of learning and teaching is hard work and domain specific, but it is not futile.

Farran closes her report by suggesting that “[the] proposition that expanding pre-K will improve later achievement for children from low-income families is premature.” Perhaps instead it is Farran’s prognosis that is overly pessimistic. Research to date indicates that sustained access to high quality preschool does alter the trajectory of low-income children who are otherwise not exposed to early math and to age-appropriate books. In several now classic studies, the effects of a quality preschool education has far reaching consequences linked to not only reading and math, but to fewer incarcerations, teen pregnancies, and higher employment well into adulthood. As economists have shown, high quality early learning programs save money for society—a finding that has been replicated in different programs across the globe—in the United States, Canada, the U.K., and Mozambique.

Do we need to know more about what constitutes high quality and how to harness this reliably? Absolutely. But science offers evidence-based and evidence-informed advice on what has worked and what should work when brought to scale. We have an obligation to use the best science to serve our struggling children. Recent surveys indicate that a majority of the American public—Republican and Democrat—agrees that all children deserve a chance to reach their fullest potential. Let the science progress and let us use what we know at this point in time to meet the promise that all children should have a fighting chance to succeed. Better to light a candle than curse the darkness.

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Forty years after its initial publication, Equality and Efficiency: The Big Tradeoff remains an influential work from one of the most important macroeconomists over the last century, Arthur M. Okun (1928-1980). Okun’s theory on market economies reminds readers of an engaging dual theme: the market needs a place, and the market needs to be kept in its place. Articulated in a way that remains relevant even during today’s discussions on broadening gaps in income inequality, Okun emphasized that institutions in a capitalist democracy prod us to get ahead of our neighbors economically after telling us to stay in line socially.

On May 4, The Brookings Institution Press re-released Okun’s classic work with a new foreword from Former Treasury Secretary Lawrence H. Summers, in addition to “Further Thoughts on Equality and Efficiency,” a paper published by Okun in 1977. The event included opening remarks from Brookings Senior Fellow George Perry, with a keynote address from Larry Summers. Following these remarks, David Wessel moderated a panel discussion with former Chair of the Council of Economic Advisers Greg Mankiw, Economic Studies’ Melissa Kearney and Justin Wolfers, and Washington Center for Equitable Growth's Heather Boushey regarding the history and impact of Okun’s work.

Download a copy of Lawrence Summers' opening remarks.

Ted Gayer, Vice President and Director of Economic Studies and Joseph Pechman Senior Fellow, reads Lawrence Summers's opening remarks.

David Wessel (right), Director of the Hutchins Center on Fiscal and Monetary Policy, moderates a panel discussion with N. Gregory Mankiw, Melissa Kearney, and Heather Boushey.

Janet Yellen, Chair of the Board of Governors of the Federal Reserve System, listens to the discussion from the audience. To Yellen's right is former Congressional Budget Office director, Doug Elmendorf.

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• 40 years later- The relevance of Okun’s "Equality and Efficiency: The Big Tradeoff"

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• 40 years later- The relevance of Okun’s "Equality and Efficiency: The Big Tradeoff"

Transcript

• Uncorrected Transcript (.pdf)

Event Materials

• 20150504_okun_equality_efficiency_transcript
• 050415 Summers Okun Speech

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Education systems in many of the world's poorest countries are now experiencing the aftershock of the global economic downturn and millions of children are still missing out on their right to a quality education. After a decade of advances, progress toward the Education for All goals may stall or be thrown into reverse. Presenting a new estimate of the global cost of reaching the goals by 2015, the report challenges governments and the international community to act urgently to adopt targeted policies and practices to prevent a generation of children from being left without a proper education.

On January 20, the Center for Universal Education at Brookings hosted the launch of UNESCO’s 2010 Education for All Global Monitoring Report (GMR) with Kevin Watkins, director of the GMR. The report introduces a new, innovative tool to identify the "education-poor" who are excluded from accessing a quality education. A panel discussion followed featuring Elizabeth King of the World Bank; Barbara Reynolds of UNICEF; and Brookings Fellow Rebecca Winthrop. Brookings Senior Fellow Jacques van der Gaag moderated the discussion.

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• Reaching the Marginalized: Is a Quality Education Possible for All?

Transcript

• Transcript (.pdf)

Event Materials

• 20100120_education_access
• 20100120_education_access_watkins