Thursday assorted links


1. In my meeting last night with some physicians I mentioned this article and the report it summarizes. The report concludes that, contrary to conventional wisdom, nothing about U.S. health care (% of primary care as compared to specialty care, utilization, hospitalization, etc.) in the US. is much different from other comparable countries. With two very glaring differences: "There were two areas where the United States really was quite different: We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs."

So did you ask them if they were willing to work for OECD standard physician pay rates? ;)

Bingo. If health care costs less, someone is making less.

Don't gore my ax, don't gore yours.

Gore the axe of that guy that snores.

John Edwards could not be reached for comment. Trial lawyers and the Democratic Party hardest hit.

Some times that is a feature not a bug.

Did you bother reading the article? It was pretty specific in saying malpractice and "defensive medicine" aren't meaningful contributors to US high health care costs.

Why would SMFS need to read the article to spew childish partisan talking points?

Dude, isn't it obvious from the flippant tone of that post that it was meant flippantly?

And anyone who claims that defensive medicine and lawyering is not a significant cause of medical costs is lying or a fool. It is the NYT so probably both.

Did you bother reading the article? It was pretty specific in saying malpractice and “defensive medicine” aren’t meaningful contributors to US high health care costs.

You didn't read it either. It didn't mention those things at all. "Defensive" and "malpractice" don't appear anywhere, and "legal" only in the footer.

The closest the article gets to discussing defensive medicine is talking about scans, and says those could be used to save money.

I get that SMFS said something and you assumed it was wrong, and I get why you make that assumption, but, please.

edit ... and says we could save money by reducing scans ...

Profits are small relative to wages in the healthcare sector. If you reduce healthcare spending, you reduce wages and employees plain and simple. That may very well be what needs to happen but one must consider the implications. Reducing healthcare spending to rates to other western countries is as large a decision as de-industrialization was in terms of impact on society and GDP. It would have a larger impact, than did the loss of manufacturing, on the education sector as well.

Yes, reduce wages. But not employees. The doctor shortage due to the AMA cartel is driving the high prices.

I have a good friend who is an emergency room doctor in the 2nd largest city in Texas. Last year he made more than $350K and this year may well make more than $500K. I don't know if that is a lot or fairly common pay for a doctor.. But there are two facts about this doctor. One is he pulls double shifts and works more than 80 hours to 100 hours a week. He does this because he loves his work. But that is the reason he makes a lot of money he puts in a lot of hours. The second fact is he told me he saves half dozen lives a week. He has an assortment of broken bones, whiney kids, drug overdoses, heart attacks, stabbings and shootings and he saves 6-7 lives a week. How much is that worth??? .

Well assuming that the ER doc works 100 hours a week for 50 weeks of the year, or 5000 hours a year, and makes $500k a year, it would seem like it is worth $100 an hour. I have definitely seen ER docs with higher rates than that, but mostly in rural hospitals.

If someone else would do the same for less, then it is worth a negative amount.

"Bingo. If health care costs less, someone is making less"

If the rent seekers get zero, is that a problem?

Take a lot of drugs. The price is many times higher than costs.

That delta is the rent seeking.

However, rent seeking is considered bad even by conservatives, so, lots of spending is done to eliminate the outrage from rent seeking being obviously harmful, like complex rebate programs.

Ie, a prescription is filled by a pharmacy with contracts with the drug benefit manager plus a secret deal with the drug company, all embedded in the software so only drug and pharmacy marketing understand it.

Step 1, bill the drug plan the maximum.
Step 2. bill the patient the maximum.
Step 3. Compute the size of a rebate based on how new the prescription is, the rebate paid out of the rents
Step 4. If patient is established on the treatment, bill the patient the rent not already paid by drug plan or patient copay
Step 5. Require the patient to either get the drug plan to negotiate a higher rent payment, or negotiate with drug company for coupons to reduce rent payments

Note the patient is working without pay to obtain a reduced rent is they are not paid well by employers. High income workers probably pay the excess rent, or are able to get the insurer to pay the rent because the employer self insures and it just results in higher effective employee pay.

All these costs are unproductive, and if they increase GDP, it's not by the full cost. And to the degree that the rents are paid by debt, say US Treasury debt from borrowing internationally, or selling off assets, ie, selling IRA assets, there rents are profits from reducing net assets. If profits flow out of the US to international shareholders, given current account deficits, they are reductions in US net assets. Reductions in net US assets means the US is spending more than the US pays US workers.

Thus, the workers paid by the excess rents are workers in the past, or workers to be paid in the future, in both cases, workers who consume less than they produce.

Only since the rise of free lunch economics with Reagan has rent seeking been considered a virtue. Rent seeking needs cuts in paying workers to build productive capital so capital becomes scarce allowing extraction of rents, with the rents driving prices of assets far above depreciated labor costs.

Because physicians don't work to help sick people get better, they only work for the money.

Embrace the healing power of and.

They have proven this to be true by refusing to allow competition. They know this costs lives but increases their salaries.

It's easy for us non-doctors to say doctors make too much. That doesn't make it untrue.

(guy who always picks the lowest bidder and wonders what went wrong)

Perhaps you could give more autonomy and authority to physician assistants.
Perhaps you could give more autonomy and authority to nurses.
Perhaps you could let foreign trained doctors work here without so many hoops to jump through

Perhaps you could let Medicare negotiate drug prices.

What I would really like to see would be one patient portal for each patient instead of one patient portal for each doctor you see. In other words if I see a doctor he/she sends test results and other documents to my portal. All doctors that I see would do the same. There would be one portal for each patient.

You all might want to investigate medical tourism, too. US citizens travel overseas for joint replacements because it is significantly less expensive than having the surgery here in the states. And the surgery is just as good. You can have the surgery done and recover on a beach in Costa Rica.

You all might also want to investigate why hospitals in rural areas are disappearing.

You all might also want to investigate why an organization called RAM now works in the US. It used to be that it served rural areas overseas. Now it serves under served areas in the United States.

There's lots wrong with medical access and treatment in America.

I wish it were better.

The only reform to the health system that is likely to work is to give consumers some skin in the game. At the moment, in Europe as well as in America, the consumer does not pay. In Europe the government usually does which means the government is under a lot of pressure to deny people services and treatment to keep costs down. Or more commonly, the government simply drags its feet in making changes so new facilities are not built, new treatments not offered, wages not adjusted for inflation and so on.

In America the insurance companies pay. So everyone is engaged in ripping them off. They can just pass costs on so they don't care either.

The only solution likely to work is to force more people into private health savings accounts. So that routine medical costs come out of their pocket. Or more likely, high deductible plans. That seems the path of least resistance.

If by "only reform" you mean "reform that comports with your ideological beliefs" then maybe it's the "only reform". But since in Europe the providers are paid less (and the article makes it clear the high earnings of providers of all types are the major contributor to our high health care costs) through government saying "you are going to be paid X and like it" rather than "consumer skin in the game", maybe it isn't the "only reform to the health care system that is likely to work".

Skin in the game only makes a difference when said person has sensible choices. US regulatory capture takes all the choices away. Billing obscurity, builds and monopolies make market forces not apply anyway.

Deregulate first, including opening borders to doctors, and then reexamine what prices look like.

France's healthcare system is superior to the USA's at a substantially reduced cost per capita.

I don't believe you've ever been to Europe.

efcdons March 15, 2018 at 9:20 pm

But since in Europe the providers are paid less (and the article makes it clear the high earnings of providers of all types are the major contributor to our high health care costs) through government saying “you are going to be paid X and like it” rather than “consumer skin in the game”, maybe it isn’t the “only reform to the health care system that is likely to work”.

Actually I did specifically say that is what the Europeans do. But while it keeps costs down, is it likely to work in the long run? It is not working out so well in the UK. You cannot artificially hold prices down for doctors, nurses and new medicines without some long term effects. Britain cannot get enough nurses in the UK. New drug development in a problem. But in the short term, forcing down wages will certainly reduce costs.

20 Bob March 15, 2018 at 9:53 pm

Billing obscurity, builds and monopolies make market forces not apply anyway.

Bill obscurity comes because no one cares. If the consumer was paying with their own cash, they would want to know what they were paying for. And, in fact, as a lot of people point out, paying in cash often leads to very different bills.

21 carlospln March 16, 2018 at 5:55 am

France’s healthcare system is superior to the USA’s at a substantially reduced cost per capita.

Indeed it is. So what? Well, it is very good quality for the money - whether that is the same as being superior to the US I do not know. I suspect not but let's agree it is in the same ball park. So what?

"The only reform to the health system that is likely to work is to give consumers some skin in the game. At the moment, in Europe as well as in America, the consumer does not pay."

So, the opposition to Obamacare is based on it not forcing consumers to have skin in the game so they shop around?

The complaints about the high premiums of the different insurance options are that the premiums are too low?

That the cheaper bronze insurance does not require consumers to pay enough out of pocket for the medical care they shop around for?

Note, opponents to Obamacare claim insurers go bankrupt offering insurance to consumers, so, the insurers are not profiting, nor paying costs without consumers paying, consumers who shop around because they have skin in the game.

Before 1990, especially before 1980, employer benefits and other informal cross subsidies did eliminate consumers from paying out of pocket if white middle class. Since then, conservatives and the GOP have been promising that forcing consumers to pay out of pocket will cut health care costs. In the 90s, higher copays, high deductibles, etc have been forced on most of the white middle class, with the informal cross subsidies have hiked to out of pocket costs to everyone else beyond their ability to pay.

Please tell me you resent the fact your employer health benefit is structured like that of your German or French or Swiss peer universal health care mandated insurance, and you want high deductibles and copays so you "have real skin in the game".

"Perhaps you could give more autonomy and authority to physician assistants. Perhaps you could give more autonomy and authority to nurses."

Both are good ideas.

"Perhaps you could let foreign trained doctors work here without so many hoops to jump through"

Also a good idea. A large percentage of US Doctors are already immigrants, but I believe they must go through pointless retraining to practice in the US.

3. I listened to the Caplan "conversation" too late to comment on it, but the whole mistaken idea seemed to boil down to this: Things Bryan feels strongly are authentic, and things other people feel are signaling. Because surely, at our core, we are all little copies of Bryan.

That might sound a bit harsh, but really it has to be. Bryan's idea is that there is one kind of people, and he is it.

He has quite a bit of data he cites. You plan to just hand wave it all away?

Feel free to link any data you like. I was responding to the audio track. In it Caplan sees intellectual curiosity (his) as authentic, and empathic compassion (not his) as signalling. That seems a pretty tin ear to the great variety of people we have in the world, including those who have genuine empathic compassion while at the same time a deficit in intellectual curiosity.

What audio track? .

Plenty of data cited here to get you started:

Holey Smokes. I have made a grievous error.

In my defense (and I know I am on the back foot here) I think your link does dovetail with my "wrong guy" criticism.

If you normalize to "a student" experiencing "an higher education" it is hard to show progress. But that's a pretty toy model. In fact I think we might agree that the addition of more students and softer programs is separate from the "higher education" that came before.

I guess I could never wrote One Book To Explain It All is that I do see people doing a lot of different things for a lot of different motivations (some highly cognitive, some relatively non-cognitive, some conscious and some unconscious).

That sentence changed direction a couple times too often, but you can probably puzzle it out.

I wonder how many people circled their answers on the literacy test.

I probably would have. I did try clicking though!

Assuming you answer every question, it's harder to get yourself classified as illiterate than it is to get in top ('college') bracket.

Each generation has a different way of doing things. Underlining was very common at the time. You can trust me because I am on the Internet.

3. Naturally Jake's approval falls in the same vein. Since there is one kind of person, they ... I mean he .. is only ever getting one thing from it.

4. Pretty sure "Irony" is being used to mean "stuff having to do with the manufacture of iron" in this context. This thing is basically a vocabulary test.

I suppose the test answer might be "no", but it wouldn't really be super crazy to think someone might shorten "ironmongery" to "irony", would it?

The question is whether you know what irony means or think it has something to do with iron

If you heard someone use it that way in conversation would you think "That dumb person doesn't know what irony means" or would you think "hmmm, they must be using it in a different way to mean ironmongery".
Your answer says a lot about you as a person.


Why assume you know all possible meanings of a term?

If the context suggests that the word was being used as something to do with iron, "He studied metallurgy and now works in irony," then it would hardly be clear that it was being used incorrectly, rather than in a specialized technical sense.

4. Some of those seemed a bit sesquipedalian.

How long have you been waiting to pull that one out? :)

good point but
isn't it also possible and about 40 percent more likely that 1 out of a couple dozen
economists who appreciate good goat when its been barbacoaed in mexico
might also have a refined appreciation
for genital joculairtity
when its done tastefully and with tact

Senor Los Kardashians will eat ur brains,
Are you suggesting a tacit tactical yet tactful approach to genitalia inclusive of jocularity?


Q: Are prenicious pedestrians translucent?

Having taken the LSAT and Bar Exams, I would circle yes and no. What can be more prenicious than not being seen? That would be horrendous; maybe not as bad as being prenicious and also being opeque.

You have the question backwards. All translucent pedestrians may indeed be pernicious, but that doesn't mean that all pernicious pedestrians are translucent.

I agree. Furthermore, Pernicious Commentator was supposed to underline the answers, not circle them. Zero credit. Not ready to fight the Kaiser.

pernicious or prenicious
define your dialectic and
make up your minds you postmodernmorons
the antecedent is antediluvian
the penultimate is antebellum

Senor mostobjectivemiddleclassmediacritic
no nerve agents for you
your amygdala is appalling

#6 - on the invention of tribes - it took a lot of text just to say the British invented tribes to colonize Africa more effectively. That said, Africa has the most diverse DNA around (China has some of the least, or at least the Han Chinese do) meaning that African 'tribes' do have a historical ethnic component since Africans historically did not mix as much as say the Han Chinese did, possibly due to the tyranny of distance in landlocked Africa. By contrast since the Han dynasty the Chinese, or at least the educated ones, were pretty 'international' in their marriage partners. Generally however, local is the yokel. By contrast, I,like Jason Derulo, "got lipstick stamps on my passport, international", spreading my DNA in a non-ethnic manner, akin to the Soviets who also in a sort of proto-globalization way tried to stamp out ethnic differences in the USSR (usually to disastrous effect).

Your DNA hasn't actually gone anywhere until a baby results.

That's what Bill Clinton thought.

the middle class would be gobsmackedtothegills if any of the
clintons or their goatyogaacolytes
had any lucid thoughts ever about dna

dejar de clonar kardashians

Si senor
el clon de Kardashian también se comerá tu cerebro

Africa also has the most linguistic diversity. It was quite a bottleneck ...

There's been a lot more DNA data collected in recent years, and I expected that article to cite some studies using it. Instead it never did, just listed a lot of people asserting it wasn't the case. James Scott, whose work I've found very interesting, claimed something similarly about tribes in southeast asian highlands, but my understanding is that DNA evidence is against him. So I'm guessing The Elephant is wrong about the fictitious nature of tribes in Africa until I see a DNA study backing them up.

#5 - I'm surprised to see now mention of the parallels to Imagined Communities by Benedict Anderson, and the clear parallels that exist between the creation of tribes and the creation of national identities.

So I guess we'll just ponder the Straussian reading of silence then.

Rich people have too many hospitalisation in the US and poor people not enough. The average might be the same as other OECD countries but since health care has diminishing marginal returns it creates inefficiencies.

alto horno
o mensajería de clase media en el barato.
el presupuesto de mensajería de clase media ha sido destripado y
hasta cero dólares por década.
el grito de la clase media excede nuestro alcance.
nos urgentlyneed más huevos

Ten cuidado.
las Kardashians se comerán tu cerebro

taurus excreta cerebrum vincit

Las cosas mas importantes de la vida.

Automobiles mas rapidos
Novias mas jovenes
Mas Viejo guisquis
Mucho mas dinero

Señor Vivisector,
excelente punto.
El año pasado el presupuesto ruso de mensajería ruso era de 100 grandes y también tenían el uso gratuito de la empresa agente nervioso.
el americano Richard Russo ni siquiera tenía un libro.

you need a nerve agent like the russians and the syrians
we got you covered.
how much do you need dawg?
have you seen the new movie about the death of stalin
with that monty python hombre and peter lorre?
its supposed to be prescient

I have long wondered how my dad became an orificer in WW1.

That is an amazing typo. Was he stationed to France (I remember hearing on NPR that some ridiculously large percentage of French women worked as prostitutes during World War II, so it wouldn’t surprise me if something similar happened in WWI).

In pre-colonial societies, as Young explains, ethnicity was a fungible cultural artefact, one that was not necessarily encoded into one’s genes, attached to particular homelands or imbued with ideas of political sovereignty.

So it is not a claim the British invented tribes but the British brought paper and writing? Before the colonial period if your village was conquered you could claim that you were not from the old ruling group but from the new ruling group and no one would be the wiser. But the evil Colonialists came with paper and they made you write your ethnic identity down. Which means your grandchildren were stuck with being Kikuyu or whatever. So sad.

Much the same is said of Indian caste. A ruling group like the Gupta probably had a lower caste origin but Indians were not keen on writing history - presumably because everyone had a lower caste origin - and so they could just invent a better caste background. But by the time the British came, everyone was stuck.

But we can begin a national conversation about who we really are as people and how we build a Kenya for Kenyans and an Africa for Africans

That is the point. African intellectuals want the completely artificial colonial constructions we call countries to over-ride the organic, natural, evolved political identities Africans actually have. That is, their tribal origins. To build the nation of Kenya they have to persuade everyone that they are not Kikuyu or Luo or whatever but Kenyans. They have to give up their languages and speak English or Swahili or whatever.

Personally I find this objectionable. It is culturally impoverished for one thing. But it is also an incredible imposition of the state on society. This is the way Africans are. The tribe is a natural and genuinely African identity. The nation is a colonial imposition. The state should accept its voters they way they are and not seek to remold them in more convenient ways.


I would add, the guy mentioned in the article wanted to switch from Kikuyu to Jaluo, as if they are equivalent they don't share the same language nor do the languages have the same roots. The Kikuyu speak a Bantu derivative and the Jaluo a Luo derivative - they are mutually unintelligible, but heck let's not get bogged down in details. We can be whatever we want to be, any gender, any ethnicity, whatever. I would like to have the IQ of an Asian and the jump shot of a black, so from now on I am going to be a Blasian. I'm going to play go and speak jive and wear lots of bling. I'm even going to be tall and play in the NBA. The tape measure is a racist invention used to measure and steal tribal lands.

Impressive man made of straw you got there. It's so big, and ridiculous.

Everything after "unintelligible" is unintelligible.

Lighten up! ;)

How do you feel about Catalunya?

I would support it if not for all the other people who support it. Catalan independence seems to be a place that Communists go once the Soviet Union died.

The purest essence of stupid partisanship. I oppose anything the other team supports, even stuff I support. You're a clown.

This is why Trump should oppose building a wall, and why Obama should have opposed health care expansion. Both would get what they really wanted.

Thank you. I work on it. Except it is more than stupid partisanship - alas. Time and time again the Hard Left uses United Front tactics to create a front organization that campaigns on some other mild moderate issue. But in reality their purpose is to push a hard left agenda. We have just seen it with Gun Control. The ANC is a good example - being nothing more than a vessel for the South African Communist Party.

So the question is what is the ultimate purpose of Catalan independence? I would support a free, democratic and liberal Catalonia. But I have a reasonable belief that the people running the present Catalan independence movement want a People's Republic of Catalonia. That I cannot support. Nor should you.

That is just common sense.

Recent DNA studies show that caste goes VERY far back in India. It was definitely not invented by British colonial officials.

By the way, nothing on Elizabeth Holmes?

“There were two areas where the United States really was quite different: We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs.”

So the only thing that makes American health care different is that it's more expensive. OKAY, how about they explain WHY it's so expensive?

This article was a waste of time. We already knew that American health care has roughly average results for absurd costs.

One way to make health care "less expensive", is have the government pay for college education of health care professionals. Reducing the costs of training will reduce the salaries health care professionals demand. It will increase costs elsewhere, but accounting masturbation is something Proggers pride themselves on to distort the truth.

Next time a Progger sources wealth statistics from the SCF, remember that they are using statistics that assume accrued social security benefits due to households is $0. To state that in less wonkish terms, Proggers are assuming we could end social security tomorrow (taxes and payments) and zero households would be worse off.

Football and basketball players go to college for free and then get elevated salaries in professional leagues. Wouldn't heart surgeons that seldom botched a transplant make a lot more money than dentists that specialize in extracting teeth?

Brush up on your Latin. Ceteris paribus. Your response has nothing to do with my comment.

I think that you missed the point of the article. The US doesn’t have higher costs because it has different patterns of utilization of healthcare resources (like primary care doctors or hospitalizations) but instead had high costs because it’s payments for each unit of a healthcare resource are higher than other nations. That is to say, US healthcare costs are high because of high unit prices. The article doesn’t explain the reasons for high unit prices.

You have to smile at an article published in the "American Medical Journal" that basically says everything is fine in American medicine.

Teachers, be careful as you can be punished for saying things that hurtz de Proggers fealingzsss...

3. The Elaine Ou case for Bitcoin: no governance.

The original idea still stands, bitcoin is a hedge against central banks creating artificial hedges. Works great,

It strikes me that Ms. Ou knows a lot about cryptocurrency technology and almost nothing about money, what it is, what it does, etc.

The dollar is "burdened" with effecting monetary policy? Huh?

#1. Those “administrative costs” are mostly people, and I would guess mostly women. I wonder how cutting 80% of those jobs would be received?

I'm sure you are similarly concerned about the job prospects of people who are impacted by changes in government policy in all types of industries. Like unionized factory workers who lost jobs in part due to changes in our trade laws.

The people who seem most vocal about cutting medical costs seem to believe (at least publicly) that all the savings - perhaps 6 to 10% of GDP to get down to Eurozone levels - are going to come from pharma CEOs and $2 million a year docs. I.e. it’s not only painless to their constituency, it punishes the other guys. I don’t think it’s going to work out like that.

I expect AI will eventually have a big impact here. Medical coders making $45K + benefits are going to be at least as compelling a target as MDs reading imaging tests.

I took the comment as speculation that the nation (or especially the left) would balk at actually cutting the administrative fat out of healtcare because it mean a lot of women (read democratic voters) would lose their jobs and careers.

Health care jobs are the best and fastest growing job category out there for both men and women (due to demographics). Cutting health care costs will have major effects there. The rebuttal is that with money saved on health care, demand will increase for other things creating jobs there. So maybe it won't be so bad.


Can we take a moment to appreciate how ridiculous an idea this is? Brits show up, tell the locals you lot are X, you lot are Y etc totally out of the blue and they followed and continue to believe that?

This either suggests that the Brits were extremely persuasive or the locals were extremely stupid. I prefer thinking that the authors were extremely stupid, and that the people of Kenya deserve a better examination of their past.

The Brits are extremely persuasive. One time they persuaded some gullible former colonials that a Kenyan was born in Hawaii!

The Russians persuaded some Turkic peoples they were Uzbeks, Kazakhs and so on. To the point that after the Soviet Union was dead, they were still willing to murder each other over those labels.

The Soviets invented the Uzbek and Kazakh nations? Such power! I learn so much from this guy.

Umm, yeah they did. You do learn so much from me. It is just rare to see you acknowledge it. You don't have to thank me but the occasional note might be nice.

The Soviets did put a lot of work into messing with the writing of their Turkic subjects:

On bitcoin, the lack of human control is an illusion: See what happened in ethereum when important enough people lost money. If you think bitcoin mining is far more decentralized than the fed, I have a bridge to sell you.

Ethereum is not bitcoin. Bitcoin users want faster transactions with lower fees, but currently the blocksize is impeding that to the extent that even Bitcoin conferences won't accept it as payment. If they could all coordinate, they'd just switch over to a larger blocksize (as Satoshi Nakamoto & Hal Finney expected would happen after they originally introduced the size limit), but that hasn't happened.

#5: Blame everything bad in modern Africa on “colonialism.”

#4 What's the desired answer to "Is misuse of money an evil"?

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