Health Economics and Policy

The following sections are included:

• Praise from Experts
• Dedication
• Other Health-Related Books by Victor Fuchs
• Contents
• Foreword – Sir Angus Deaton, Ph.D.
• Foreword – Victor J. Dzau, M.D.

Fifty years ago health economics was a minor sub-specialty in economics with little attention from academics or the general public. Now it is a large field with thousands of professionals around the world. It is a rare week in the United States that does not feature at least one major health economics story: sky-high drug prices, contested merger proposals, rising insurance premiums, a surge in suicides, or other health issues. It is the responsibility of health economists to provide understanding of the complex interactions of patients, physicians, drug companies, hospitals, insurance companies, and other stakeholders in the more than three trillion dollar a year U.S. health economy. Some health economists teach in economics departments, others in schools of business, public health, medicine, or public policy. Some are researchers in industry, government, or non-profit institutes…

Health economics is an applied field in which empirical research predominates. It draws its theoretical inspiration principally from four traditional areas of economics: finance and insurance, industrial organization, labour, and public finance. Some of the most useful work employs only elementary economic concepts but requires detailed knowledge of health technology and institutions. Policy-oriented research plays a major role, and many important policy-relevant articles are published in journals read by physicians and others with direct involvement in health (e.g. Enthoven, 1978)…

Health care affects and is affected by the economic system in so many ways as to preclude any attempt at complete enumeration or description. The objective of this paper is more modest. I shall assume that the reader is reasonably familiar with health care, its institutions, technology and personnel, but is less familiar with an “economic system” that is used by economists to describe and analyze economic behavior. Therefore, major emphasis will be given to indicating the place of health care in this system and showing how related economic concepts can contribute to an understanding of problems of health care in the United States. I shall also attempt to indicate some of the limitations of economics in dealing with such a complex area of human activity and concern.

The Great Health Care Debate of 1994 was like the uses of this world to Hamlet — “weary, stale, flat, and unprofitable.” Why did so much effort by so many produce so little understanding and no reform? The finger of blame has pointed in many directions: “the Clinton Plan was unworkable”; “the plan was poorly explained to the public”; “the political strategy was misconceived”; “special interests triumphed over the general interest.” Each of these explanations has some merit, but I believe the fundamental reason has been the unwillingness of policy makers and the public to make the difficult choices that are inevitable if the U.S. is to improve its approach to health care. What are the difficulties?

This paper discusses health economics as a behavioral science and as input into health policy and health services research. I illustrate the dual role with data on publications and citations of two leading health economics journals and three leading American health economists. Five important and relatively new topics in economics are commended to health economists who focus on economics as a behavioral science. This is followed by suggestions for health economists in their role of providing input to health policy and health services research. I discuss the strengths and weaknesses of economics, the role of values, and the potential for interdisciplinary and multidisciplinary research. The fourth section presents reasons why I believe the strong demand for health economics will continue, and the paper concludes with a sermon addressed primarily to recent entrants to the field.

This article applies major economic concepts, such as supply, demand, monopoly, monopsony, adverse selection, and moral hazard, to central features of U.S. health care. These illustrations help explain some of the principal problems of health policy-high cost and the uninsured — and why solutions are difficult to obtain.

Wealth and health are the cornerstones of a good life. Yes, there are other things that matter as Saadi, the medieval Persian poet, reminds us,

Most people, however, place a high value on health, especially when dealing with its opposite…

Gertrude Stein, confidante of the leading writers, artists, and intellectuals of her time, lay dying. Her closest friend and lifetime companion, Alice B. Toklas, leaned forward and said, “Gertrude, what’s the answer?” Gertrude looked up and with her last breath said, “Alice, what’s the question?”…

Schooling is significantly correlated with health status, but is the relationship causal? This paper tests the hypothesis that schooling causes differences in an important health-affecting behavior: cigarette smoking. The most striking result is that for persons with 12 to 18 years of completed schooling, the strong negative relation between schooling and smoking observed at age 24 is accounted for by differences in smoking behavior at age 17, when all subjects were still in the same grade. Causality from schooling to smoking, and by implication from schooling to health, is rejected in favor of a ‘third variable’ hypothesis.

Income, education, occupation, age, sex, marital status, and ethnicity are all correlated with health in one context or another. This paper reflects on the difficulties encountered in deriving robust scientific conclusions from these correlations or drawing reliable policy applications. Interactions among the variables, nonlinearities, casual inference, and possible mechanisms of action are discussed. Strategies for future work are suggested, and researchers are urged to pay special attention to possible interactions among health, genes, and socio-economic variables.

Belief in the importance of the social determinants of health is gaining wide acceptance; this useful development will undoubtedly contribute to better public policy and clinical practice. Although the general concept is not contested, several caveats and nuances should be considered…

In recent decades the US black population has experienced substantial gains in life expectancy, now approaching the life expectancy of the white population. Between 1995 and 2014, the increase in black life expectancy at birth was more than double the white increase: a gain of 6.0 years from 69.6 years to 75.6 years for black people compared with a gain of 2.5 years from 76.5 years to 79.0 for white people. The difference in the percent per annum rate of increase was also more than double: 0.44 for black people, 0.17 for white people…

If there is one red hot health subject that never seems to go away, it is the high cost of medical care. In 1927, Ray Lyman Wilbur, physician-president of Stanford University, became chair of a national committee to look into the high cost of care. The committee was later staffed by Rufus Rorem (1894–1988), one of the first health economists and one of my mentors. He taught me a great deal about health care through stories such as the following: Rufus published an article, “Why Hospital Costs Are So High” and was deluged with requests for reprints from hospital administrators. He then published another article, “How to Keep Hospital Costs From Going Higher.” There were no requests for reprints…

The following sections are included:

• Introduction
• Demand for Medical Care
• Supply of Medical Care
• Summary of the Demand-Supply Analysis

Many physicians and laymen believe that the only solution to the alleged “doctor shortage” is a massive increase in the number of physicians; other observers, however, have been calling attention to the under-utilization of physicians in those tasks which long years of training have equipped them to perform. With the social cost of college plus medical school now well in excess of $100,000 per student, it is essential that the question of effective and efficient use of medical manpower receive careful study…

This paper presents a multiequation, multivariate analysis of differences in the supply of surgeons and the demand for operations across geographical areas of the United States in 1963 and 1970. The results provide considerable support for the hypothesis that surgeons shift the demand for operations. Other things equal, a 10 percent increase in the surgeon/population ratio results in about a 3 percent increase in per capita utilization. Moreover, differences in supply seem to have a perverse effect on fees, raising them when the surgeon/population ratio increases. Surgeon supply is in part determined by factors unrelated to demand, especially by the attractiveness of the area as a place to live.

To gain insight into the possible consequences of prospective payment for university hospitals, we studied 2025 admissions to the faculty and community services of a university hospital, measuring differences in case mix, costs, and mortality in the hospital. The faculty service had more of the patients with costly diagnoses, but even after adjustment for diagnosis-related groups (DRGs), costs were 11 percent higher on the faculty service (95 percent confidence limits, 4 to 18 percent). The percentage differential was greatest for diagnostic costs. The differential was particularly large — 70 percent (95 percent confidence limits, 33 to 107 percent) — for patients with a predicted probability of death of 0.25 or greater.

The in-hospital mortality rate was significantly lower on the faculty service after adjustment for case mix and patient characteristics (P < 0.05); the difference was particularly large for patients in the high-death-risk category. Comparision of a matched sample of 51 pairs of admissions from the high-death-risk category confirmed the above results with respect to costs and in-hospital mortality, but follow-up revealed that the survival rates were equal for the two services at nine months after discharge.

The effect of prospective payment on the cost of care will be closely watched; we conclude that it will also be important to monitor the effect on outcomes, including hospital mortality rates.

President Obama is the most recent in a long line of US presidents to seek reductions in health care spending through elimination of “waste.” However, the stakes this time are unusually high — the president has reported that eliminating waste is needed to fund two-thirds of the approximately $900 billion needed (over 10 years) for expanded health care coverage. To achieve this goal requires defining waste, identifying contexts in which it occurs, determining why it occurs, and implementing policies that prevent reoccurrence…

Most physicians want to deliver “appropriate” care. Most want to practice “ethically.” But the transformation of a small-scale professional service into a technologically complex sector that consumes more than 17 percent of the nation’s gross domestic product makes it increasingly difficult to know what is “appropriate” and what is “ethical.” When escalating health care expenditures threaten the solvency of the federal government and the viability of the U.S. economy, physicians are forced to reexamine the choices they make in caring for patients…

Probably the most important and simplest way to appreciate the high cost of health care in the United States is to compare it with costs in other high income democracies. The first three papers and the op-ed in Part 4 make such comparisons. In the U.S., health care consumes approximately 18 percent of the GDP; in other high spending countries, the share is approximately 12 percent. Given U.S. GDP of over $18 trillion, the extra spending in the U.S. amounts to more than one trillion dollars per year. This excess is far more than the U.S. spends on national security or on education. It amounts to more than $3,000 per man, woman, and child, or about $10,000 per three-person household. In my opinion, there are no more important tasks for health economics and health policy than to determine what the public derives from this extra spending, evaluate it, and explain why the U.S. has a system that generates such high spending…

As a percentage of the gross national product, expenditures for health care in the United States are considerably larger than in Canada, even though one in seven Americans is uninsured whereas all Canadians have comprehensive health insurance. Among the sectors of health care, the difference in spending is especially large for physicians’ services. In 1985, per capita expenditure was $347 in the United States and only $202 (in U.S. dollars) in Canada, a ratio of 1.72. We undertook a quantitative analysis of this ratio.

We found that the higher expenditures per capita in the United States are explained entirely by higher fees; the quantity of physicians' services per capita is actually lower in the United States than in Canada. U.S. fees for procedures are more than three times as high as Canadian fees; the difference in fees for evaluation and management services is about 80 percent. Despite the large difference in fees, physicians' net incomes in the United States are only about one-third higher than in Canada. A parallel analysis of Iowa and Manitoba yielded results similar to those for the United States and Canada, except that physicians' net incomes in Iowa are about 60 percent higher than in Manitoba. Updating the analysis to 1987 on the basis of changes in each country between 1985 and 1987 yielded results similar to those obtained for 1985.

We suggest that increased use of physicians' services in Canada may result from universal insurance coverage and from encouragement of use by the larger number of physicians who are paid lower fees per service. U.S. physicians' net income is not increased as much as the higher U.S. fees would predict, probably because of greater overhead expenses and the lower workloads of America's procedure-oriented physicians.

Background. Expenditures per capita for hospitals are higher in the United States than in Canada. If the United States had the same spending pattern as Canada, the annual savings in 1985 would have exceeded $30 billion.

Methods. We used data from published sources, computer files, and institutional reports to compare 1987 costs for acute care hospitals on three levels: national (the United States vs. Canada), regional (California vs. Ontario), and institutional (two California hospitals vs. two Ontario hospitals). Expenditures per admission were adjusted for the casemix of patients, prices of labor and other resources, and outpatient visits.

Results. The United States had proportionately fewer hospital beds than Canada (3.9 vs. 5.4 per 1000 population), fewer admissions (129 vs. 142 per 1000 population), and shorter mean stays (7.2 vs. 11.2 days). Higher costs per admission in the United States were explained in part by a case mix that was more complex by 14 percent and by prices for labor, supplies, and other hospital resources that were higher by 4 percent. Hospitals in the United States provided relatively less outpatient care, particularly in emergency departments (320 vs. 677 visits per 1000 population). After all adjustments, the estimate of resources used for inpatient care per admission was 24 percent higher in the United States than in Canada and 46 percent higher in California than in Ontario. The estimated differences between the two pairs of California and Ontario hospitals were 20 and 15 percent.

Conclusions. Canadian acute care hospitals have more admissions, more outpatient visits, and more inpatient days per capita than hospitals in the United States, but they spend appreciably less. The reasons include higher administrative costs in the United States and more use of centralized equipment and personnel in Canada.

The U.S. delivers roughly three times as many mammograms, two-and-a-half times as many MRI scans, and a third more C-sections per capita than the average OECD country.

Despite the news last week that America’s healthcare spending will not be rising at the sky-high rate that was once predicted, the fact remains that the U.S. far outspends its peer nations when it comes to healthcare costs per capita. This year the United States will spend almost 18 percent of the gross domestic product (GDP) on healthcare—six percentage points more than the Netherlands, the next highest spender. Because the U.S. GDP in 2014 will be approximately 17 trillion dollars, those six percentage points over the Netherlands amount to one trillion dollars in additional spending. The burden to the average household through lost wages, insurance premiums, taxes, out-of-pocket care, and other costs will be more than $8,000…

The Honorable Prime Minister of Malaysia, YAB Dato Seri Dr. Mahathir bin Mohamad; Yang Amat Berbahagia Mulia RajaTun Mohar, Chairman of the Board of Trustees of the Program for the Prime Minister of Malaysia’s Fellowship; other Trustees of the Fellowship Program; distinguished guests; ladies and gentlemen…

United States health care, often hailed as “the best health care system in the world,” is also faulted for being too costly, leaving many millions of individuals uninsured, and having avoidable lapses in quality. Criticism often draws on comparisons with other countries of the Organisation for Economic Co-operation and Development (OECD). This Viewpoint also makes such comparisons, over a broad range of variables, and reaches one inescapable conclusion — US health care is very different from health care in other countries. Potential reasons for the differences are discussed, leading to the conclusion that future efforts to control cost, provide universal coverage, and improve health outcomes will have to consider the United States’ particular history, values, and political system.

Health care expenditures in the United States, 18 percent of GDP, greatly exceed spending on food or clothing or transportation or other items of consumption. Moreover, the amount of care consumed varies greatly across individuals in any given year and usually varies greatly over time for any given individual. While nearly one-quarter of the population has no contact with a physician or a hospital in a given year, about 5 percent account for about 50 percent of total expenditures…

Almost a century ago Prince Otto Eduard Leopold von Bismarck, the principal creator and first chancellor of the new German nation-state, introduced compulsory national health insurance to the Western world. Since then, nation after nation has followed his lead until today almost every developed country has a full-blown national health insurance plan. Some significant benchmarks along the way are the Russian system (introduced by Lenin after the Bolshevik Revolution), the British National Health Service (Beveridge and Bevan, 1945), and the Canadian federal-provincial plans (hospital care in the late 1950s, physicians’ services in the late 1960s). In nearly all cases these plans built on previous systems of medical organization and finance that reflected particular national traditions, values, and circumstances…

The U.S. is the only developed country without some form of national health insurance. Yet, public opinion polls have consistently reported solid majorities in favor of such a system. In this paper, we examine whether attitudes toward different roles of government and beliefs that may be related to those attitudes are consistent with widespread support for national health insurance. Our analysis is based on the premise that a system of national health insurance would require government redistribution and government intervention in health care markets. We find that people who have favorable attitudes toward government economic intervention are 27 percentage points more likely and those with favorable attitudes toward government economic intervention are 18 percentage points more likely to favor national health insurance than those with unfavorable attitudes. The most intense support for national health insurance, strongly favoring as opposed favoring it, is among people with favorable attitudes toward both roles of government. Consistent with research from other social programs, we find that the beliefs regarding racial minorities, as well as beliefs regarding individual control over life, limit support for national health insurance in the U.S. On the other hand, negative beliefs regarding businesses are an important source of support for national health insurance. We conclude that significant changes in either attitudes and beliefs or their relationship with support for national health insurance are probably necessary to create a strong majority in support of such legislation.

The Universal Healthcare Voucher System (UHV) achieves universal health coverage by entitling all Americans to a standard package of benefits comparable to that received by federal employees. Enrollment and renewal are guaranteed regardless of health status, as is the individual’s right to buy additional services beyond the standard benefits with after-tax dollars. Health plans would receive a risk-adjusted payment based on their enrollment. UHV is funded entirely by a dedicated value-added tax (VAT) with the rate set by Congress. A VAT of approximately 10 to 12 percent would insure all Americans under age 65 at a cost no greater than current public and private health care expenditures…

When asked who pays for health care in the United States, the usual answer is “employers, government, and individuals.” Most Americans believe that employers pay the bulk of workers’ premiums and that governments pay for Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and other programs…

Health care differs from other consumption goods and services in many ways; one of the most important is the increase in utilization at older ages. Precise figures are not available, but it is safe to assume that per capita expenditures for health care by those 65 and older are at least double and possibly as high as triple the expenditures of those under age 65. The ratio is particularly high for long-term care in nursing homes and home care. The ratio is probably higher in the United States than in countries that have universal coverage because Medicare provides universal coverage in the U.S. at ages 65 and older; virtually all of the uninsured in the U.S. are under age 65. The increase in utilization of care by the elderly comes at a life-cycle stage when the income of most elderly decreases because of a big decrease in employment…

The original “demographic transition” describes a process that began in Europe by the early 1800s with decreases in mortality followed, usually after a lag, by decreases in fertility. According to Lee and Recher (2011), p. 1, “this historical process ranks as one of the most important changes affecting human society in the past half millennium.” The increase in life expectancy associated with this demographic transition has been accompanied by rising levels of per capita output, which have in turn spurred further improvements in population health through better nutrition and living standards and, especially since World War II, through advances in medical care. At the same time, increases in life expectancy have resulted in a higher proportion of each cohort living long enough to participate in the production of goods and services. Reductions in fertility are also closely linked to higher labor force participation rates among women…

Less than one score years ago this nation brought forth a new system of financing health care for the elderly — Medicare. This system, conceived as part of a broad thrust toward a “Great Society” and dedicated to the proposition that high-quality medical care should be freely available to all persons aged 65 and over, is now the subject of intense reexamination. It is altogether fitting and proper that this be done. The rapid rate of growth of health care expenditures, the growing resistance to further increases in governmental taxes or deficits, and the changing circumstances of the elderly make this an appropriate time to ask (and attempt to answer) basic questions about the economic and social forces that affect this age group and this program…

“May you live to a hundred and twenty.” This traditional Jewish blessing was inspired by the last chapter of the Torah, which describes the death of Moses at that age with “his eyes undimmed and his vigor unabated” (Deut. 34:7). Unlike Moses, many people experience a more troubled old age. In addition to the loss of family and friends and a diminution of status, nearly all older persons face two potentially serious economic problems: declining earning power and increased utilization of health care. The decline in earning power is attributable to physiological changes and to obsolescence of skills and knowledge, and is exacerbated by public and private policies that reduce the incentives of older persons to continue working and increase the cost to employers of employing older workers. Increased utilization of health care is undertaken to reduce or offset the effects of declining health…

“Grow old along with me! The best is yet to be,” wrote Robert Browning in his poem Rabbi Ben Ezra. A century later, Robert Butler, a former director of the National Institute of Aging, took a more dismal view of aging, epitomized in the title of his book Why Survive? Being Old in America (1975). Why the change in perspective? One possible reason is that an elderly person was a rarity in Browning’s time; as the twentieth century drew to a close, however, mortality tables showed that three out of four Americans would reach the biblical “three score and ten.” Just being old no longer carries any special distinction…

Since 1900, life expectancy at birth has increased by an unprecedented 30 years in the United States and other developed countries. Before World War II, most of the gains resulted from improvements in nonmedical factors: nutrition, sanitation, housing, and public health measures. Since World War II, however, biomedical innovations (new drugs, devices, and procedures) have been the primary source of increases in longevity. These innovations have also been the most important reason why health care expenditures have grown 2.8 percent per year more rapidly than the rest of the economy over the past 30 years. Will the future simply be a rerun of recent decades? Probably not. Current demographic, social, and economic forces will create new priorities for future biomedical innovations: more emphasis on improving quality of life and less on extending life, and more attention to value-enhancing innovations instead of pursuit of any medical advance regardless of its cost relative to its benefit…

Throughout a long career in health economics, I have not spent much time (or ink) in partisan policy disputes. I have, however, been deeply interested in health policy and in reform of what seems to me to be a dysfunctional health care system in the United States. The first two papers in Part 7 offer extended statements about policy and reform. The first was prepared when I had been in the health field only a little over a decade; the second after 30 years…

Two hundred years ago the industrial revolution was figuratively and literally beginning to pick up steam. In a few Western countries agricultural advances, which came faster than population growth, enabled some men and women to escape from grinding poverty. Life for most, however, was still “nasty, brutish, and short.” Infant mortality rates of 200 or 300 per 1000 births were the rule, and life expectancy in Western Europe was not very different from what it had been under the Romans. The great majority of men and women worked on farms, producing barely enough to feed themselves plus a small surplus for the relatively few workers engaged in the production of other goods and services. Widows and orphans, the sick, the elderly, and the destitute relied primarily on family and church for help in their time of need…

Interest in health economics has soared over the past three decades, stimulated by intellectual innovations, greater availability of data, and, most importantly, a surge in health care spending from 6 to 14 percent of GDP. An 11-fold increase in the number of Ph.D.s has enabled many professional schools, government agencies, and research institutes to add health economists to their staffs. Nevertheless, the health care debate of 1993–1994 benefited much less than it could have from the results of their research…

Last spring, in his elegant commencement address to the Harvard Medical School, Dr. Atul Gawande appealed for a dramatic change in the organization and delivery of medical care. His reason, “medicine’s complexity has exceeded our individual capabilities as doctors.” He accepts the necessity of specialization, but he criticizes a system of care that emphasizes the independence of each specialist. Dr. Gawande is not alone in thinking that scientific, technologic, and economic changes require reorganization of care. Larry Casalino and Steve Shortell have proposed Accountable Care Organizations (ACOs); Fisher, Skinner, Wennberg and colleagues at the Dartmouth Medical School have focused on reforming Medicare, and many others have also called for major changes…

An early draft of the bylaws of the American Economic Association states that economists who have attained a certain age are entitled to present papers that begin “Reflections on —.” The exact age is unclear because the manuscript is faded, but I have been assured by competent authorities that whatever that age is, I have surpassed it. The purpose of entitling a paper “Reflections on —” is to warn the audience not to expect either a comprehensive or a systematic treatment of the subject. “Reflections” seems preferable to its synonyms, “meditations” or “ruminations.” The former is too “new age,” while the latter suggests the chewing of cud…

By addressing the essentials — coverage, cost control, coordinated care, and choice — policymakers can take important first steps toward health system reform, with details to be worked out along the way…

The current transformation of physicians in the United States — from self-employment to salaried employment, from fee-for-service to “bundled” or capitation payment, from providing acute care to providing chronic care, from inpatient to ambulatory settings, and from solo or small group practice to “team care”— complicates the future of the medical profession…

Identification of paternity can be controversial, especially in academia where there is no reliable laboratory test for intellectual DNA. I believe, however, that my presence at the scene in the 1960s, when modern health economics was born, and my participation in the field ever since, qualifies me to identify the “founding fathers.” In my judgement, Kenneth Arrow, Gary Becker, and Martin Feldstein, each in their own distinct way, deserve recognition for important original contributions, which transformed a field that until the 1960s was primarily descriptive and institutional…

This volume celebrates the 40^th anniversary of the publication of Kenneth Arrow’s classic article, “Uncertainty and the Welfare Economics of Medical Care.” By reprinting the article which launched modern health economics, along with more than a score of stimulating new papers by scholars from a half dozen disciplines, Duke University Press performs a valuable service for teachers, students, and researchers in health economics, health services research, health policy, and related fields…

In September 1952 The American Economic Review published a note on multi-country trade written by an obscure Princeton undergraduate. Two months later a paper on monetary theory by the same student and one of his Princeton instructors appeared in Economica. Thus was launched the career of one of the most influential social scientists of the second half of the twentieth century, a career that was recognized by the Nobel Prize Committee for Economics in 1992 with its award to Gary S. Becker…

This is the best study of health services ever written by an economist. It is also probably the best book on the British National Health Service to emerge from any discipline. The fact that it was produced by an American in his middle twenties as a Ph.D. thesis (at Oxford) lends additional luster to the achievement…

I am most grateful for this opportunity to add my voice to the many that will honor Mike Grossman on the 30^th anniversary of the publication of his seminal monograph, The Demand for Health: A Theoretical and Empirical Investigation. As one who was “present at the creation,” I have special memories and feelings about Mike and his career, a few of which I would like to share with you in this brief tribute. As Paul Samuelson has written, “The immediacy of experience while it is happening—the contrast with what went before and what will happen later — is something which, if you don’t have it there is no way you can get it.” (Paul A. Samuelson, “Has Economic Science Improved the System?” in Winthrop Knowlton and Richard Zeckhauser (eds.), American Society: Public and Private Responsibilities, Ballinger Publishing Company, Cambridge, MA 1986, p. 300.)…

It is a great privilege and high honor to present the ASHE Award for Lifetime Achievement in Health Economics to Joe Newhouse. Congratulations to Joe, and congratulations to ASHE for recognizing Professor Newhouse’s extraordinary contributions to the field…

“Philosophy,” wrote, Cavell (1979) is “the education of grownups.” This paper recounts my “education” in a broad sense, including the impact of family, religion, schooling, the Army, business, and fellow economists. The reader will discern the effects of this education in my views about economics, research, teaching, and politics.

The following sections are included:

• Acknowledgements
• List of Co-Authors
• List of Journals
• Author Index
• Subject Index