TheHealthofNations-DepartmentofEconomicsWord文件下载.docx

TheHealthofNations-DepartmentofEconomicsWord文件下载.docx

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I.Introduction

Nationsgenerallymeasuretheireconomicperformanceusingtheyardstickofnationaloutputandincome.Itisnotwidelyrecognized,however,thatconventionalapproachesdoapoorjobofcapturingimprovementsinthehealthofthepopulationinourgrossdomesticproductorincomespercapita.Howwouldstandardeconomicmeasureschangeiftheyadequatelyreflectedimprovementsinthehealthstatusofthepopulationaswellasothergoodsandservices?

Thisisthequestionaddressedinthepresentstudy.

Thefirstsectiondiscussesthetheoryofthemeasurementofnationalincome,examinessomeoftheshortcomingsoftraditionalconcepts,andproposesanewconceptthatcanbeusedtoincorporateimprovementsinhealthstatus.Inthesecondsection,wediscusshowtheproposedmeasurefitsintoexistingtheoriesofconsumptionandvaluation.ThethirdsectionappliestheconceptstotheUnitedStatesoverthetwentiethcentury.

Attheend,weconcludethataccountingforimprovementsinthehealthstatusofthepopulationwouldmakeasubstantialdifferencetoourmeasuresofeconomicwelfareoverthetwentiethcenturyintheUnitedStates.

II.IncludingHealthStatusinMeasuresNationalIncome

CurrentApproachestoMeasuringtheContributionofHealthintheNationalAccounts

WhiletheGDPandtherestoftheNationalIncomeandProduct

Accounts（NIPA）mayseemtobearcaneconcepts,theyaretrulyamongthegreatinventionsofthetwentiethcentury.Muchasasatelliteinspacecansurveytheweatheracrossanentirecontinent,socantheGDPgiveanoverallpictureofthestateoftheeconomy.SincetheirfirstconstructionbySimonKuznets,whowontheNobelprizeinEconomicsforhiscontributionstonationalincomeaccounting,enormousstrideshavebeentakenindevelopingandimprovingindexesofeconomicwelfare.Startingwithrudimentarymeasuresofnationalincomeandoutput,nationsnowhaveawiderangeofindexesthatnotonlyincludeconventionalconceptsbutalsodisaggregatetheseforindustriesandregions,useimprovedtechniquesforaggregation,anddisplayawealthofdetail.

Nevertheless,sincethebeginning,therehavebeenconcernsthattheaccountsareincompleteandmisleadingbecausetheyomitmostnonmarketactivity.Tomeetthiscriticism,privatescholarsaswellasofficialstatisticalagencieshavebegunextendingthenationalaccountstoincludeseveralnonmarketsectors,includingnationalresources,theenvironment,transportation,leisuretime,andunpaidwork. SeeEisner[1989].ArecentreviewofenvironmentalandotheraspectsofnonmarketaccountingiscontainedinNationalResearchCouncil[1999].

Onequestionthathasbeenvirtuallyignoredinattemptstoextendthenationalaccountsistheneedtoaccountadequatelyforimprovementsinhumanhealth.Itislittleunderstoodoutsidethepriesthoodofnationalaccountantsthatthereisnoseriousattempttomeasurethezzrealoutput"

ofthehealth-careindustry.Thetechniquesusedtomeasurethepriceandquantityofhealthcarearehighlydefective,andtherearenoattemptstoaccountforimprovementsinthelengthoflifeintocurrentmeasuresoflivingstandards.

Itmightbearguedthatincludinghealthstatusissomeradical,far-out,andwoolly-headedattempttoincorporateintangible,non-economiczandsociologicalmeasuresintooursocialaccounts.Thisargumentiswrong,forhealth-careexpendituresarealreadyincludedinmeasuresofnationalincomeandoutput.IndeedtheyareagrowingfractionofGDP-thefractionofpersonalconsumptionexpendituresdevotedtomedicalcarerosefrom5.1percentin1959to15.3percentin1998.Whatisradicalisnottheinclusionofhealthcarebutthenotionadvancedherethatweshouldmakeaseriousattempttomeasuretheoutputofthehealthcaresectorandtovaluethisoutputcorrectly.

Bothcommonsenseandrecenteconomicstudiessuggestthatthereislittleconnectionbetweenmedicalspendingandthemeasuredeconomicvalueofhealth-statusimprovements.Atacommon-senselevel,thelackofconnectioncomesbecause"

real"

medical-carespendinginfactmeasuresspendingoninputsratherthantheresultsinhealthoutcomes.Thecurrentapproachistomeasurehealthoutputprimarilybythenumberofphysicianvisits,thenumberofhospital-days,andsimilarmeasuresratherthantheactualdeliveryofservicesorchangesinhealthstatus.Itwillcomeasasurprisetomostnon-economiststhatimprovementsthatcomefromnewproducts,suchasthediscoveryofantibioticsorthesubstitutionofdrugsforinvasivesurgery,arecompletelyomittedincurrentmeasuresofrealoutput.

Attemptstomeasureimprovementsinthehealthstatusofthepopulation—includingeverythingfromvaccinations,microsurgery,andnewdrugstoairbags,exercise,andanti-cigarettesadvertizing—poseanewanddifficultchallengetomeasuringnationalincome.Recently,economistshavebegunprovidingbetteroutcome-orientedestimatesofthepricesandoutputsinthissector.OneofthemoststrikingfindingscomesfromastudybyCutleretal.,whoestimatedthatatruepriceindexforthetreatmentofheartattackswouldriseabout5.5percentperyearmoreslowlythanthecorrespondingcomponentoftheCPL Cutler,McClellan,Newhouse,andRemler[1998].

SimilarresultswerefoundinstudiesoftreatmentforglaucomabyShapiroandWilcoxandforcataractsurgerybyShapiro,Shapiro,andWilcox. SeeShapiroandWilcox[1997,1999].

Giventhelikelihoodthatwearedramaticallymismeasuring,andalmostcertainlyunderestimating,thecontributionofimprovementsinhealthcaretoeconomicwelfare,thisraisesthequestionofhowtoproceedtoobtainbetterestimates.Oneapproachwouldbetocontinuetheapproachjustdescribedofconstructingbettermeasuresofoutputandpricestoreflectthe（literal）declineinthecostofliving.ThisapproachwasadoptedbytheBoskinCommissionandisthethrustofmuchcurrentresearchonhealtheconomics.SeeAdvisoryCommission[1996]andMurrayandLopez[1996].

Anotherquitedifferentapproach,whichisusedinthepresentstudy,istoobtaindirectmeasuresofhealthstatus,weightthemwithappropriateprices,andthenestimatethevalueofimprovementsinhealthstatus.Thisapproachtreatsmedicalcareasaninstrumentalinputandsubtractsitfromconsumptionexpenditures.Wewouldinsteadadjustrealincometoreflectthevalueoftheimprovementofhealthstatus.Thisapproachisactuallymuchsimplerthan"

fixing"

priceandoutputindexesbecausemeasuresofhealthstatusaregenerallymuchbetterthandataontheimpactsofparticulartechnologiesonhealthstatus.Wewillseethatfollowingthispathhasradicalimpactsonourmeasuresofrealincomeandoutput.

AlternativeMeasuresofNationalIncome

Beforeproposingalternativeconcepts,itwillbeusefultodescribedifferentapproachestomeasuringnationalincome.Theconceptsofsocialincomeandnationalincomegobackcenturies.Theyarelargelybasedontheanalogousdefinitionsofindividualincomewithappropriateadjustmentsforaggregationandnationalboundaries.Wecandistinguishtwofundamentallydifferentapproachestomeasuringincome-onebasedonproductionandonebasedonutility.（Utilityinthiscontextmeanspreferences,notusefulness.）Theformeristhebasisofmodernnational-incomeaccountingwhilethelatterismoreappropriatewhenconsideringsustainableincomeandthecontributionofimprovementinhealthstatus.

Production-basedmeasures（HicksianIncome）

ThemodemtreatmentofsocialincomedatesfromthewritingsofJ.R.Hicks.Wheneconomistsandaccountantsmeasurenationalincome,theyhavealmostuniversallyrelyupontheHicksiandefinition.ThediscussionofsocialincomeinValueandCapitalstates,"

Thepurposeofincomecalculationsinpracticalaffairsistogivepeopleanindicationoftheamountwhichtheycanconsumewithoutimpoverishingthemselves.'

*Hicksthengoesontoprovidehisfirstdefinitionofsocialincome:

IncomeNo.1isthusthemaximumamountwhichcanbespentduringaperiodifthereistobeanexpectationofmaintainingintactthecapitalvalueofprospectivereturns...;

itequalsConsumptionplusCapitalaccumulation. Hicks[1939],p.172.

Hicks[1939],p.173,178,emphasisadded.ThisdiscussionignoresthesubtletyofHicks'

discussionofpricechanges,interestrateeffects,thedifferencebetweenexanteandexpostcapital,andanumberofotherfactors.

Thisdefinitioniswhatiscalled/zHicksianincome"

-themaximumamountthatcanbeconsumedwhileleavingcapitalintact.Inpractice,thismeansthatincomeequalsconsumptionplusageneralizedmeasureofcapitalaccumulation.

TheHicksianconceptisthestandarddefinitionofnetnationalordomesticproductusedinthenational-incomeaccountsofvirtuallyallnationstoday,whereconsumptionandinvestmentarelimitedtothoselegalgoodsandservicesthatpassthroughthemarketplace.Itisproduction-basedinthesensethatitattemptstomeasuretherateofproductionatagiventime.Suchmeasuresarenotconcernedwiththehealthstatusofthepopulationorwhetherpeopleareenjoyingthatproductionforalongerperiodoftime.

Utilitv-basedmeasures（Fisherianincome）

Whilestandardconceptsofincomeareusefultoolsformeasuringcurrentproduction,itisdifficulttoextractanywelfaresignificancefromthem.Theshortcomingofthetraditionalapproachisclearwhenweconsider