The soaring cost of healthcare in the US over the past 20 years has been a hugely distorting economic trend as a key driver of personal bankruptcies, by depressing private sector wage growth as employer insurance bills surged and absorbing 17% of GDP or about twice the developed economy average. Are we at an inflection point? Among the various measures of healthcare inflation in the US, the broadest is the BLS calculation of the cost to private sector employers of providing healthcare benefits, now down to 2.4% y/y, the lowest since 1981. A recent survey by payroll processor ADP on the rise in medical insurance premiums paid by large employers has tumbled to 1.7% y/y.
‘Obamacare’ has certainly boosted transparency but technology seems to be finally suppressing healthcare inflation in the way it has in so many other sectors; doctors and nurses now routinely carry tablets to take patient notes, cutting out layers of administration and overlap. ‘Diagnostic algorithms’ are now entering common usage, so much so that the nurses’ union is conducting a media campaign with the punchline “Algorithms are simple mathematical formulas that nobody understands.”Well the geeks in Silicon Valley certainly understand them and investors are slowly waking up to the implications of ‘deep automation’ software spreading across the service economy.
Robotic pharmacists are already being introduced at some hospitals and the Food and Drug Administration has issued a patent for the first ‘human interacting autonomous robot’ for medical use, mirroring developments in Japan. The RP-VITA robot allows specialists anywhere in the world to communicate with patients, has data ports that connect to digital thermometers, stethoscopes and ultrasound imaging as well as integrating medical records. Meantime, the explosion in wearable monitoring equipment for vital data from Apple, Nike etc. will eventually be integrated to deliver pre-emptive healthcare intervention. The best doctors will be freed from mundane patient diagnostics but like the London taxi drivers protesting against Uber’s arrival which I covered recently, their mediocre peers and those relatively well paid nurses will see their wage premium steadily eroded.
That has huge implications on a macro level; firstly, healthcare was the single largest source of aggregate private sector earned income growth in 2000-2009 and it’s hard to see what replaces it; secondly it was the major service sector contributor to CPI growth (alongside college tuition and the associated $1.2trn student debt burden, a sector also vulnerable to tech disruption) and if this downtrend continues, again it’s hard to see what replaces it. Lastly, healthcare costs were the major driver of the long-term structural deficit in the US (via Medicare/Medicaid entitlements) with total spending until recently projected by the CBO and other independent analysts to top 20% of GDP by end decade – a sustained fall in healthcare inflation has dramatic implications for the equilibrium rate for USD (higher)/bond yields (lower)/US fiscal deficit (lower). Indeed, medical spending accounts for 17% of the Fed’s preferred personal consumption (PCE) inflation measure and the slowdown in healthcare inflation means that sustaining the 2% target rate medium term (equivalent to 2.25-2.5% CPI) will be difficult, partly explaining this year’s ‘surprise’ Treasury rally, although investor repositioning from a bearish duration consensus and ECB easing expectations also played a major role.
Tech trends are net bullish for emerging markets as an asset class by allowing development to ‘leapfrog’ infrastructure/human capital constraints but the macro impact on long-term developed world inflation/interest rates/employment market ‘slack’ is still widely ignored as economists stick to their orthodox models. Indeed, that is the basis of predicting a classic if belated wage and investment cycle as the capital stock is getting old, funding costs are at record lows, the utilization rate is climbing to pre-crisis highs etc. That’s all fine in so far as it goes, but of all the investors I talk to, tech VC people seem to understand the wider economic implications of the disruptive business models they’re investing in best. US capex trends YTD remain weak and the core orders segment of the April durables goods data sustained that trend. While there will be some belated cyclical pick-up, we’re almost certainly seeing a structural down shift in investment intensity in GDP and revenue growth as technology related capital goods which have a strong deflation price trend become a bigger share of overall spend. As noted previously (and in stark contrast to Japan and EM) S&P buybacks plus dividends exceeded capex last year, although institutional surveys suggest most US investors now want to see companies ramp up investment.