Thursday, January 15, 2026

 

History offers warning on dollar and deficits


Economic fallout could be severe if the U.S. dollar falls from dominance as the world’s reserve currency


University of Texas at Austin




It’s no secret that Uncle Sam has been living beyond his means. During the past 25 years, U.S. national debt as a percentage of gross domestic product has almost tripled to 98%, according to the Congressional Budget Office. It’s projected to hit 166% by 2054.

The U.S. government has been able to run up that debt, in part, because investors around the world are still willing to buy its IOUs. Last year alone, the U.S. Treasury auctioned off $28 trillion in securities.

But investors may not always be so willing, according to new research from Mindy Xiaolan, associate professor of finance at Texas McCombs. She finds the U.S. government’s fiscal capacity — its ability to raise money — depends on the dominance of the U.S. dollar. Dollar-denominated assets make up 57% of global currency reserves, and dollars are used in 88% of foreign exchange transactions.

Her research highlights potential losses U.S. government bondholders could face if another currency ever replaces the dollar as the global reserve currency. The federal government might have to face significant fiscal adjustments, while investors in U.S. Treasury bonds could take a bath.

“When a country’s fiscal fundamentals deteriorate, and their currency loses its privileged status, its government’s borrowing capacity may become limited,” she says. “The market value of its debt will be lower, and the bondholders will suffer losses.”

Whether such consequences could strike the U.S. is “a trillion-dollar question,” she says.

Fiscal History Repeats Itself

How can Xiaolan make such forecasts? Because it’s happened before.

With Zefeng Chen of Peking University, Zhengyang Jiang of Northwestern University, Hanno Lustig of Stanford University, and Stijn Van Nieuwerburgh of Columbia University, her research compared America’s fiscal trajectory with those of two other countries that once boasted the world’s No. 1 currency.

  • In the 17th and 18th centuries, the Dutch Republic and its florin dominated international trade.
  • After 1800, the United Kingdom and the pound took over the role — until World War II, when the dollar took its place.

“The key common feature of those nations is that they were all the leading economy during their specific time frames,” she says.

While those governments were riding high, investors viewed their bonds as the world’s safest assets. Analyzing historical prices, Xiaolan finds investors paid a premium of 1% to 1.5% for Dutch and British government securities over those of other countries.

Over time, investor demand for safe assets gave both countries room to borrow beyond what was fully backed by their primary budget surpluses, generally to fund wars. Holland’s debt reached more than 200% of its GDP during the age of Napoleon, while the U.K.’s topped 130% of GDP at the end of WWII.

But when both currencies fell from their pedestals, economic reckonings came.

  • Bondholders lost big. Dutch bonds traded 70% below their face value, while U.K. bonds dropped 61% in value.
  • Deficits dried up. Holland’s postwar surpluses averaged 3.3% of GDP, while the U.K.’s were 1.8%.

Will the Dollar Be Next?

Today, Xiaolan says, the U.S. government is treading a similar path. Its fiscal capacity appears to exceed what is justified by its underlying fiscal fundamentals.

The researchers analyzed the federal balance sheet as if it belonged to a private corporation, to assess whether present and projected cash flows are sufficient to redeem its debts.

Before WWII, they were. In the 80 years since, however, they have only been enough to cover 32% of the outstanding national debt, the researchers estimate. That gap has gotten steeper during the past two decades, as the Great Recession and the COVID-19 pandemic have spiked deficits.

For now, global investors are still allowing the U.S. to run up more debt than it can afford, a phenomenon she calls exorbitant privilege.

But she sees warning signs that global investors might be losing patience. The market value of U.S. government debt, reflecting what investors are willing to pay for it, has dropped more than 15% since its high in 2020.

If investors sour on Treasury securities, she says the U.S. might incur greater costs to finance deficits. Like Holland and the U.K., it might be forced to start running surpluses — which it hasn’t done since 2000.

“It may become more difficult to expand the balance sheet if we lose the privilege to borrow at a relatively low cost,” Xiaolan says. That might help reduce the reliance on deficit financing, but it would come at a price: the ability to stimulate the economy with short-term deficits.

No Strong Competition, Yet

For now, she says, the dollar has one thing going for it: a lack of competition. When Holland and the U.K. each faltered, another country and currency were ready to take their place. For America, by contrast, potential rivals such as China and the eurozone are suffering economic woes.

“While fiscal conditions haven’t significantly improved since COVID, the economy continues to grow at a steady pace for now,” Xiaolan says.

History, however, warns that our strength won’t necessarily last. “I think our message is that maybe we should be a little bit cautious as a country,” she says. “We may not permanently enjoy this privileged status.”

Exorbitant Privilege Gained and Lost: Fiscal Implications” is published in Journal of Political Economy.

 

With telehealth coverage on the brink, study shows it hasn’t driven up total visits



Data from 60 million Medicare participants shows even in medical specialties that use virtual care most, total number of visits was stable or declined through mid-2024




Michigan Medicine - University of Michigan

Medicare outpatient office visits before and during telehealth flexibilities 

image: 

Monthly trends in total outpatient office visits (in-person and telehealth video/phone) per 1,000 traditional Medicare beneficiaries seeing providers in low, medium and high telehealth use specialties, from January 2019 to June 2024

view more 

Credit: University of Michigan





With another Congressional deadline looming this month for most telehealth coverage under Medicare, a new University of Michigan study adds more data to the debate.

It shows that the total number of patient visits hasn’t gone up since most patients gained the ability to see doctors and other health care providers virtually.

In fact, among non-surgical medical specialties and mental health providers, the total number of visits stabilized and even declined slightly through June 2024, the most recent period available to analyze. The data come from more than 60 million people who had nearly 539 million appointments during a five-year period.

The findings could help inform policymakers who must vote by January 30 to either temporarily renew or permanently extend Medicare telehealth coverage standards that have been in effect since March 2020.

If they don’t meet that deadline, older and disabled Americans with traditional Medicare coverage could find themselves receiving messages like they did last fall, when there was a lapse in telehealth coverage during the government shutdown that began October 1.

Such letters told them that if they had a telehealth visit during that time, they may be responsible for paying the entire cost, or that their appointment was being converted to in-person or being canceled or rescheduled.

Just before Thanksgiving, Congress authorized retroactive payment for telehealth visits that patients with traditional Medicare had decided to keep during the shutdown.

But the budget agreement only provided for coverage of future care under current standards through the end of January 2026.

New findings could inform telehealth policy

The new findings, published in the peer-reviewed publication Health Affairs Scholar by a team from the U-M Institute for Healthcare Policy and Innovation, build on findings that the researchers published as a preprint nearly a year ago during a prior period of uncertainty about Medicare coverage of telehealth.

The new analysis includes data from January 2019 through June 2024 and breaks down telehealth and in-person visit trends for surgical, non-surgical and behavioral (mental) health care.

Telehealth was possible only under very limited circumstances in Medicare before March 2020. That month, the COVID-19 pandemic prompted a rapid emergency pivot to virtual care. Since then, such care has become routine for most people. In fact, the study shows that telehealth now accounts for 44% of all behavioral health visits and 9% of primary care visits among beneficiaries in traditional Medicare.

However, despite this sustained adoption, the study finds that overall healthcare visits have remained stable or declined over time. The researchers used a special type of statistical analysis to look at visit patterns among specialties with high, medium and low telehealth use.

They found that even in fields where telehealth was widely adopted, the total number of visits, including in-person and virtual visits, stayed steady or even declined over time. Contrary to some predictions, overall visits didn’t climb higher as telehealth became more popular.

Lead author James D. Lee, M.D., M.P.H., said that it’s important to look at the overall trajectory of both telehealth and in-person visits in order to inform policymakers who want to balance care access and flexibility with budgetary responsibility.

“One of the things that is paralyzing the policy debate is uncertainty and concern about whether covering telehealth in parity with in-person care would be associated with runaway utilization. But we don’t see that here,” said Lee, who is a National Clinician Scholar at IHPI and a Clinical Instructor in the U-M Medical School’s Department of Internal Medicine in the Division of General Medicine.

Lee and senior author Chad Ellimoottil, M.D., M.S., led the analysis. They did not include asynchronous patient portal messages, which providers can bill Medicare for under a separate code if they spend a substantial amount of time addressing the patient’s concern.

They also cannot include any visits that patients had with providers who did not bill traditional fee-for-service Medicare, such as mental health providers who patients may have paid for out of their own pocket.

Because half of Medicare beneficiaries have chosen Medicare Advantage plans, which bill Medicare differently, their data aren’t included either.

The fact that the new analysis shows a declining trend for total visits for behavioral health and primary care is also of interest, Lee said. This may reflect the well-known shortage of primary care and behavioral health providers in the United States, including reduction in capacity as burned-out providers reduce the number of appointments they offer. 

In addition to Lee and Ellimoottil, the authors are Elena Chun, M.S., Chiang-Hua Chang, Ph.D., Hechuan Michelle Hou, M.S., former NCSP scholar Terrence Liu, M.D., M.S., Rodney Dunn, Ph.D., Jeffrey McCullough, Ph.D., and Michael Thompson, Ph.D.

The study was funded by the Agency for Healthcare Research and Quality, and the support that Lee receives for his National Clinician Scholars Program fellowship from IHPI and the VA Office of Academic Affiliations.

Citation: The volume of outpatient office visits did not increase for specialties that were more likely to adopt telehealth, Health Affairs Scholar, DOI:10.1093/haschl/qxaf227