Tuesday assorted links


"Yeaaahhh" as in competence would be nice too? Agree on that.

Pretty sad when "honorable" equals "being able to keep your misdeeds quiet."

7. So basically Medicare survives only because having a private sector allows price discrimination. No private sector health, no price discrimination, Medicare goes bankrupt. As an effective political pushback argument sure beats accusing Sanders and Warren of being evil socialists.

Health providers go bankrupt, not Medicare. Basically, it will lead to a supply problem/shortage. Most people know this, except the true believers that make up Warren and Sanders' base.

I wonder what party Sanders states he belongs to?

The evidence says it depends on whether he's currently running for President or not.

Not exactly news that government health insurance recipients have been receiving cross subsidies from private insurance. Government plans will not make up the difference, so there will be more denial of service as is common in government single payer systems. Of course the Democrat cheerleaders in the MSM aren't going to press the point and Warren will just wave her magic wand.

Evidently both so-called journalists and academics are actually Democrat Party shills with bylines and tenure, respectively.

One Andrew Sullivan wins the "Stopped Clock Award" for today, "Elizabeth Warren is unelectable as president. There. I said it ... But she may well get the nomination. She has that quintessential perfume of smug, well-meaning, mediocre doom that Democrats simply cannot resist."

Thank God.

There were plenty of people saying that Trump was unelectable back in 2016. And once upon a time some people even said Obama couldn't win due to the color of his skin.

Obama couldn't win, if the press played fair and the Democrat Party wasn't a bunch of criminals and cheats. But they are, so he did.

Thank our God-Emperor Trump we are in the middle of 8 years of proper leadership to save the country.

#7 is just the tired old cost shifting argument. Here's Austin Frakt a couple of years ago on why this argument does not hold (https://newsatjama.jama.com/2017/01/04/jama-forum-hospitals-dont-shift-costs-from-medicare-or-medicaid-to-private-insurers/). Here is one relevant bit:

"A perfectly reasonable theory suggests that causality may, in fact, run the other way. In Health Affairs, researchers found that hospitals with greater market power charge higher prices, as we would expect. Facing little financial pressure in the market, they also have higher costs. Those costs exceed public programs’ fixed prices, so these hospitals end up with negative Medicare and Medicaid margins. The authors also found that hospitals with less market power, because they face greater competition, charge private insurers less, have lower costs, and therefore earn a profit on public programs’ lower prices."

That's an spurious response. The "hospitals with greater market power charge higher prices," are almost always the flag ship hospitals for an area that treat the really serious and rarer conditions. Whereas the "hospitals with less market power" are going to the be rural facilities without a full specialty staff.

There's no getting around the fact that Medicare rates are going to require a cutback in healthcare. You can't deny the basic math by trying to point out that some of the most basic hospitals can get by at Medicare rates.

First, rural hospitals (or even hospitals in cities with a population of 50,000 people) are actually more likely to have greater market power because there are not enough people to support more than one hospital. The flagship hospitals are usually in more urban areas where there tends to be more competition.

Second, from the relevant study cited by Frakt "To make costs comparable across hospitals, we adjusted for differences in the services provided at different hospitals. We computed costs per discharge by starting with reported costs from the hospitals’ Medicare Cost Reports and adjusted for the severity of cases by classifying Medicare Provider Analysis and Review (MedPAR) file claims according to 3M’s All Patient Refined Diagnosis-Related Groups (APR-DRGs)." Maybe you don't think they can adequately adjust for these things.

Here's another reason why the cost-shifting argument doesn't make sense: "The traditional theory of cost shifting rests on the assumption that hospitals have market power that they will only use if they face financial stress as a result of uncompensated care costs or inadequate payments from certain payers. This assumption implies that hospitals do not maximize profits or maximize revenues."

Bwahahahaha. Nice one JFA... those rural hospitals sure dominate their local markets, raking in those Medicaid, disability, and Medicare patients...

Guess what; if you want to go get your medical degree, the Feds will even subsidize your salary to work at one of these dominating institutions.

Tell you what, I definitely want any of my major health issues to be addressed in one of these cost-conscience no-alternative shittoles... right after you buddy.

> Tell you what, I definitely want any of my major health issues to be addressed in one of these cost-conscience no-alternative shittoles [sic]... right after you buddy.

Well, you would be after a few millions Canadians who by and large have the same overall health outcomes for the same medical events as their American outcomes.

Turns out a Lexus and a Corolla both get you to work near the same time. But one costs a *lot* more (and provides nicer amenities).

Now I suspect that enjoying those amenities is worth more to the majority of Americans than being able to lower costs enough to have universal coverage, but that's more down to cultural differences than being able to provide decent medical care at lower cost.

What you cite about cost shifting is 100% true, but what is referenced in #7 is cross-subsidization, which is not the same as cost shifting (Frakt says as much here: https://newsatjama.jama.com/2017/01/04/jama-forum-hospitals-dont-shift-costs-from-medicare-or-medicaid-to-private-insurers/).

Requiring all providers to take Medicare prices would definitely lead to changes (job cuts, investment decisions, etc.). If this were to happen the cost shifting you mention (which doesn't exist as you correctly point out) would definitely go away, along with cross subsidization.

That doesn't make any sense at all. How would 'lower market power' providers earn *less negative* margins on medicare's *fixed prices* relative to 'high market power' hospitals, all other things equal?

The answer is obvious. All other things aren't equal. The procedures being done at lower market power hospitals may be a subset of all procedures with a less negative medicare reimbursment rate. Reading the source for #7, it seems the most steeply negative reimbursment rates are for procedures like surgeries (i.e. procedures involving anesthesiologists). Could it be the case that smaller, 'lower market power' facilities are conducting proportionally fewer surgeries and more simple primary care?

It's pretty easy to see the holes in the argument that 'market power' explains the price difference, when there's clearly a third variable problem.

No, we raise the tax revenue going to pay for health care, hopefully with a VAT that is less sensitive to changing demographic of workers/retired persons. What's the big deal?

The better President Trump does, the more insane the left gets.
More evidence that universities engender anger, ignorance, and ingratitude: "professor of economics" is all I need to know.

The globalist, elitist party of losers and traitors like the Biden graft syndicate, Bush dynasty, Clinton crime syndicate, McCain, Obama, Pierre Delecto all hate ordinary Americans and the uses they make of their liberties. Both the democrat and Repub party left me years ago.

28 Oct 2019, Richard Fernandez, “What no one wants to remember is that Russian collusion, if it happened at all, happened under Obama. . . . In reality the good old days when ISIS ruled the Middle East, Russia could invade the Ukraine, China steal the OPM data and the South China Sea and kill the entire CIA network in the Middle Kingdom were never that good. Neither Trump nor Brexit nor the Democratic party left wing sprang out of thin air. They sprouted from a crisis.”

He puts America and me first. Trump 2020!

Romney is a capable and accomplished man, but he didn't earn the nickname 'Windsock Romney' for nothing. McCain has some appealing aspects, but he's also got powerful shortcomings. Ditto George W. Bush.

Academics are other-directed people, and their judgment is corrupted by unconfessed motives and superficial motives. They're not your friends. Ever.

I am a cuckold of the old-school!

Hold the presses! Mankiw is a never Trumper! And he will do any drama to express his never Trumper status. Who cares?

"He puts America and me first. Trump 2020!"

You must live in Blue America.

If you live in Red America coal country he's trying to make you sicker, poorer, by getting rid of regulations and coverage of black/white lung, health care access in general, increase the pollution in water and air you consume. If you are an electric customer, Trump wants your electric rates to go up to subsidize coal.

Trump has forced you to see coal for what it is, a very very very bad investment. You can't blame obama for the declining production, declining demand, the bankruptcies.

And Trump refuses to do anything to help coal communities to adapt to a looming post coal world.

I am not "anti coal", but a capitalist. Mining coal must "create wealth", not pollution and temporary consumption, ie, mine coal and iron ore to make steel which will still be "wealth" in a thousand years. Iron ore and coal have used to produce steel for at least a thousand years and almost all the steel produced in the past thousand years is still in use, with only gold recycled more completely. But met coal is only 10% of coal consumption even after huge cuts in steam coal production.

Thanks for the info.

I used to follow coal stocks. The analysts saw value in selling to China and others.

At the moment, I'm long gold and silver is relatively cheap, but it's less a financial asset and commands higher bullion/coin premiums.

One bourbon, one scotch, one beer.

#1. I read the the first volume of The Campaigns of Napoleon a year or two ago, and I haven't been motivated to read the other two. That's a piece of hardcore military history; much more detailed and in depth with regard to blow by blow accounts of each battle than I would have preferred.

7. It's unintentional, but the link actually provides a very good reason to support Medicare for all: it would result in a significant drop in overall health care spending. If spending were cut significantly, providers would be much more attentive in deciding the proper course for both diagnostics and treatment. Throwing money at health care has not made us healthier; indeed, a strong argument has been made that it's done the opposite by providing an incentive for bad health care/life style choices. I am opposed to Medicare for all, but I do support a cut in overall health care spending. It's killing us.

The healthcare industry would collapse and become something else altogether if it could only be reimbursed at current Medicare and Medicaid rates.

Under those kind of financial pressures, we would have to break the whole industry down into its component parts and ask ourselves - what is healthcare?

We would have to identify and define its most basic parts. What is a hospital? What is a nurse? Are these immemorial categories or simply cultural expectations? Could their functions be performed more cheaply under different identities?

Why do we wear white coats and carry stethoscopes? Why do we have all these buildings? Why do I even need to be nice to you, the patient?

Does what we call "healthcare" even work? What does effective healthcare look like? Does healthcare have a single goal, or many goals, or so many goals as to be a single thing at all, but an archaic category for a lot of miscellaneous activities?

While we're answering all these questions, our whole medical infrastructure will be fissiperating, millions of jobs will disappear, and doctors, surgeons and other certified professionals will be waging a kind of farmers vs. sheepherders battle for survival. And when the dust settles, whatever kind of "healthcare" system emerges, will bear no resemblance to the incredibly complex agglomeration of facilities, practices and industrial relationships now covered by that naming convention.

...and dogs will party with cats, the sun will rise in the west, and the Antichrist will manifest.
Come on, I have issue with Medicare For All, too, but hyperbolic predictions of The End Of The World As We Know It only render saner criticisms equally ridiculous.

Oh please. So why has nobody found this pot of gold before?

Kaiser, for instance, is larger than several small European countries. They have fully integrated care. They do profit sharing. Yet somehow they have not come close to Medicare pricing.

Microsoft is self-insured. They have more employees than most cities and a few countries. Yet they have never been able to find providers who will split the take from better use of diagnostics.

TriCare is a full Beveridge system larger than many European countries. It is a closed system with the full power of the federal government, and it can outright give orders to its patients under penalty of law. It doesn't manage to move the cost needle.

Vermont tried to implement such a system and found no significant savings to be had.

What is magical about "Medicare for all" that will allow physicians to order fewer tests than any of the models above? Further how big do you think savings are actually going to be?

After all, imaging is only 10% of total healthcare costs. And much of that is basic screening like mammograms, lung cancer screens, and prenatal imaging. Do you really expect there to be even a 25% drop in imaging use without a lot of people dying? We are then talking about peanuts.

As always, the real costs in healthcare are in the people. Nurses, admins, and all the other numerous employee classes make up the vast bulk of costs in healthcare. But until you plan to fire a couple million nurses, you won't make a dent in costs.

Further, the idea medical decisions result in adverse health decisions is kindof bizarre. The major decisions of impact are: smoking, metabolic syndrome, physical inactivity, excess alcohol consumption, poor diet, high risk sexual behaviors, and air pollution. Which of those is caused by how physicians practice medicine? How could me ordering excess rapid strep tests possibly induce changes in coal power policy? How might me getting an MR instead of CT induce people to sleep around more?

The truth is medicine is getting more expensive because Americans are becoming less healthy. While highly confounded, all the best social arrangements for health are moving in the wrong direction. More of us are single. Fewer of us go to church. We have fewer friends. We eat less of our own cooking. If you want cheaper healthcare, we would need a completely different social order.

Mucking around with maybe a fifth of total healthcare expenditures will get maybe a percent or two gain. There are no pots of gold to be found. Anything which actually moves the needle will be hard and likely require mass changes in society as a whole.

Specialists in America make about 3X what they do in Canada or Europe. Sure, that's not the whole problem, but it's a good place to start.

For health care to cost less, someone (doctors, nurses, drug makers, equipment makers, hospitals, insurers, administrators, etc.) has to make less money. And that's why it's so hard to implement. No one wants to be the one.

+1, It amazes me how people dance around the subject.

To be honest I don't think Sanders dances around the fact that he wants drug makers, insurers, and administrators to make less money though.

Of course Sanders won’t have to give up his 1%er annual income or any of his 3 houses.

None of that is enough to move the needle this much though. Drug makers are 10% of the cost burden if we made them give away everything for free and run the plants at a loss. Insurers are under 10% for their total manpower and profits. Administration is one of those difficult to parse categories. The only way it makes a dent is if we go all the way down to the secretaries and patient coordinators.

And I mean, however bloated and obnoxious you think these portions of healthcare are, we are not eliminating them. We would be wildly crazy to expect even half of them to go away.

Getting to even Medicare prices, let alone significant reductions that Sanders hopes to achieve, is going to mean going after the big guns: nurses, other medical staff, and the support staff.

Would you say that nurses are one of the biggest swing votes out there, spread across geography (including swing states), and composed of the kind of young professional women extremely critical to the political power of the Democratic Party.

They aren't going to touch nurses, which means they aren't going to touch healthcare.

..and if we get rid of the nurses, paraprofessional staff, etc. we are going to need a LOT more doctors. We don't have them. We can return to 1950s-level costs by providing 1950s-level medical care.

The health care system will have to significantly change sometime between 2025 and 2030 since 1) health pills will significantly reduce the rates of obesity, heart disease, diabetes and strokes and probably cancer; 2) treatments for cancer and heart disease will improve so that there won't be a need for repeat hospital stays over time; 3) the elderly won't need long term care and 4) A.I. and robotics will replace quite a bit of what specialists, GPs and nurses do.

The trends of all four will be obvious by 2025.

I love this guy.

What sort of mileage do you get in your flying car?

Sure, please clap back at this knucklehead.

I mean Todd

1) I am not aware of such pills in even phase 0 clinical trials, what are the compounds you have in mind; how do you expect them to get expedited approval to hit the market by 2025?
2) Which treatments do you have in mind here? At best this is mostly just going to push back a lot of hospitalizations. People who survive cancer and CAD tend not to be the healthiest and I would expect more survivors to mean a lot more people developing neurological and pulmonary symptoms which are much heavier drivers of prolonged hospitalization.
3) What, are we going to shoot them?
4) Yes and the physicians will then move on to other things which will make better use of their skills. I mean we have had DaVinci for almost two decades and autonomous operation is still remote as ever. Heck we have not been able to manage to outsource chest x-rays to India.

Much more likely will be a process whereby robotics and AIs allow skilled practitioners to do more. After all dumb programming has drastically increased the rate at which we can read studies, I am told that reading rates are easily double these days. Certainly, the amount of imaging everyone orders has only increased.

Sorry, but no, the only way we see any real decreases is letting people die. The cheapest patients are the dead ones; anything else is just substituting costly healthcare today for costly healthcare tomorrow.

I mostly agree, except on pushing back hospitalization. My suspicion is that there are interventions that prolong health span more than they prolong lifespan. You add up enough of those, and I would think that you eventually start shrinking the gap between health span and life span, and hence start shrinking end of life care. Effective treatment of obesity, high blood pressure, and high cholesterol strike me as all things that should in theory serve towards squaring health span and lifespan.

First, I said that the trends of all four will be obvious by 2025 but will probably take until 2028 - 2030 for health and medicine to have radically changed.

I'm sure that Dr. Sure knows about the small trial of ALS patients that resulted in minor improvements after both four months and a year after taking 1,000 mg of NR (a vitamin B3 derivative) and 200 mg of pterostilbine (a blueberry compound). At $1,900 a year, that outperformed the latest ALS drug that only slows the downward slide by 30% a year for $140,000. A small trial also showed the 1,000 mg of NR/ 200 mg of pterostilbine improved the kidneys of the 3% who get acute damage during heart surgery. Calico, founded my Google, has been working on health pills for 5 years and there are others.

There is no reason to think that algorithms and robotics won't significantly decrease the need for radiologists, cardiologists, dermatologists and ophthalmologists by 2025-2029. (See Chuck Murry's Ted Talk from last year.)

Cancer treatments like immunotherepy keep getting better and stem cells are expected to cure heart failure by 2025-2029. See Dr. Chuck Murry's interesting Ted Talk from last year. The first human trials begin in a few months.

Artificial organs will be common by 2025-2029 and keep people healthy, as will genetic engineering. Tyler said in 2010 that he doesn't expect any breakthroughs until 2030, but they are already occurring.

Average approval time for the FDA for medications and devices is 12 years. The vast majority of advances that will be legal in 2031 have already hit the literature. Absent a complete restructuring of the medical regulatory framework of the United States new artificial organs are not coming online by 2030.

As far as Ted Talks, please. What I know is that every hospital for which I have ever worked is ordering more studies and none of them have fired radiologists. Again, we do not have even working programs today, how exactly they are going to pass scrutiny in a timely fashion and be in clinical practice with full FDA vetting is beyond me.

And so it goes. Pterostilbine is not GRAS and likely faces a lag before it could go into clinical practice. Even then ALS is pittance of patient-years while a 3% change in the minority of patients who get AKI is also a minor percent.

If you want to drop hospital stays by going after primary pathology, I am going to need something that has an effect size more around 50 than 3. My NNT has got to drop massively. Likewise, it would need to be in clinical trials yesterday in order to be approved in the next decade.

1. "Ted Talks, please."

Chuck Murry is a top stem cell researcher for the heart at he University of Washington. He's not credible because he gave a Ted Talk? The University of Wisconsin team thinks patients will have their stem cell patch for heart failure starting from 2024/2025.

2. You are wrong about Pterostilbine. It received Gras status in 2011. I used the ALS and acute kidney disease cases as an example of what NR with pterostilbine can do. There will be many trial results out next year and in 2021 and even more in 2022/2023.

3. " new artificial organs are not coming online by 2030."
Huh? The FDA keeps approving artificial organs as they improve. Medical devices take 3 to 7 years to be approved. There is also fast-tracking for drugs.

4. Of course radiologists aren't being fired in 2019. It was only this year that Google's algorithm outperformed radiologists in detecting lung cancer.

1. Why would I care what top stem researcher has to say about 10 years out? The most unpredictable amount of time in getting medications to patients is not in his purview, it is with the clinical trials. Further, Ted Talks are notorious for people building hype. So no, no Ted Talks. Show me a clinical trial for anything that is supposed to be used in widespread treatment before 2030.
2. It was my understanding the pterostilbine was not GRAS in the doseages used which got results. Has that changed?
3. Perhaps we have different definition of "artificial organs". I am talking about something that will suffice for people with end stage organ failure as a permanent replacement, i.e. something that might conceivably reduce hospital use. Are you talking about temporary or limited functionality things like ECMO, mechanical hearts, or closed loop insulin pumps? 3 - 7 years is wildly optimistic for approval for anything that is going to be as potentially immunogenic or oncogenic as stem cell derived organs.
4. Long before humans become useless, AI should allow human-AI hybrid teams to displace a large number of humans. After all it took 20 years in chess to go from beating champions to the best AI beating AI-human hybrids. Typically, when the computers are taking over things in short order, we see a progression of AIs enabling fewer humans to do more work. Some people think we will have fully autonomous cars soon, but generally I suspect we will limited AI that simply steers semis in convoys that follow a human driver. Regardless of if I am correct, there is major venture capital going into such incremental approaches (similar also to Tesla's tentative steps towards autonomous driving).

Again, we have seen this in a lot of places, AI gets better than humans at some highly repetitive task. Humans use the AI to do more/better work. This leads to redundancy of some humans, so we see reductions in the number of human positions.

Further, it is quite possible that the AIs will prove good enough at reading screens that we will have decade of growing radiologist demands for more complicated studies. And all of that ignores the booming demand for interventional radiologists.

You are making very strong claims, ones I wish would be correct, but your studies are showing effect sizes that are not commensurate with your claims.

The other thing is that I know of multiple radiology groups that are expanding, several of them are using debt financing. If all of this is so obvious that it can proven with a Ted Talk, there are innumerable business professionals who are utterly incompetent and stand to lose quite large sums of cash.

This is only going to be worse as many hospital systems are expanding their radiology footprint, which should result in billions of squandered capital if radiology becomes cheap enough to fire the radiologists.

Ultimately I am left with an internet poster appealing to authority and showing me effect sizes enough to, maybe, trim a couple of days off the average person's lifetime hospital time.

You are a clueless doctor.

Appealing to authority?

You just can't be bothered to look up medical devices take on average 5 years for FDA approval, not 12 years as you claimed. You just can't be bothered to do a 30 second check to learn that Chuck Murry is a top stem cell scientist who has nothing to do with radiology. You just can't be bothered to look up pterostilbine has had GRAS status since 2011.

12 years are for "pills" which you explicitly mentioned. You made claims about radiology, it is not incumbent on me to keep track of which thin evidence your are citing for which claim. And when I did google pterostilbine, the answer was not GRAS. I cop to cheating with google because it is an internet discussion, but again you made wild claims.

That somehow all this new tech will radically change healthcare.

And you respond with small incremental changes that might not even pan out in larger patient trials with more potential adverse interactions.

So spare me your judgement. I want to know the business side of things, because R&D is very rarely 5 years from market ready.

The article from 2011 stated that pterostilbine was granted GRAS status then. In September, the FDA accepted Elysium's application to have its Basis (NR+pterotilbine) be an Investigational New Drug for treating Acute Kidney Injury that puts over 4 million pople in the hospital each yaer. " Clinicians increasingly recognize acute kidney injury as an in-hospital complication of sepsis, heart conditions, and surgery. It is associated with higher likelihood of long-term care, increased incidence of chronic kidney disease, increased hospital mortality, and higher health care costs." 1,000 mg of NR has shown in a small trial to lower systolic blood pressure by 10 percent in healthy non-obese 55 to 79 year olds who have pre-hypertension and doesn't affect those with normal blood pressure. Apparently, that reduces the risk of a heart attack by 25%. We should know what NR does for heart failure patients next spring - NR cured heart failure in mice.

This is Chuck Murry on stem cells curing heart failure, which affects 5 million Americans and is responsible for the most hospitalizations for people over 65:

" Going forward, our plan is to start phase one, first in human trials here at the University of Washington in 2020 -- two short years from now. Presuming these studies are safe and effective, which I think they're going to be, our plan is to scale this up and ship these cells all around the world for the treatment of patients with heart disease. Given the global burden of this illness, I could easily imagine this treating a million or more patients a year.

So I envision a time, maybe a decade from now, where a patient like my mother will have actual treatments that can address the root cause and not just manage her symptoms. This all comes from the fact that stem cells give us the ability to repair the human body from its component parts. "

I know, a Ted Talk, an appeal to authority, etc.

Let's grant that all of the provisional claims in your literature are correct. We drop 25% of heart attacks, and I will spot you 10% of strokes for funzies. How many in-patient days does that buy you? My first order estimate is zero or less.

Say 1 in 10 of those we save go to develop alzheimer's (not an unreasonable assumption). Say 1 in 4 of those ends up needing institutional care. That will require more skilled man-hours than any of the STEMI courses we would see for the general population.

Saving lives in exactly the manner you suggest - curing the afflictions of the 5th - 7th decades of life - typically results in more hospital stays in subsequent years.

Thank you for, belatedly, reporting the specifics requested previously, Dr. Murray notes a start date of 2020 for clinical trials and total worldwide patient population numbering a million or so (maybe give/take an order of magnitude) patients a year, we still are not looking at major paradigm shifts by 2025 and it is an extremely aggressive timeline to get cell treatments approved in 10 years. Car-T cells were first shown in research in 1989. The first FDA approved treatment was in 2017. Unless things have changed recently, the only indication for which they are approved is B-cell lymphoma. Kymriah managed to sprint through approval in about 4 years after being designated as a "breakthrough" technology. Has Dr. Murray managed such a certification?

If not, how does he hope to make it through three stages of clinical trials in order to have any impact on general practice by 2025? How on earth does he hope to distribute his product wildly by 2030?

These are all business concerns. Maybe Dr. Murray has such plans; but I would like to see them. Barring details regarding his legal strategy and production strategy I will be assuming that Dr. Murray is not also a savant at navigating FDA bureaucracy and creating popular agitation for expedited approval, in which case, again your original 2029 timeline is pretty quick. Just because an expert in one topic puts out estimates in another does not mean I afford that excess likelihood of being true.

He certainly is not using any legally binding terms in the quotes you excerpted. It sounds very much like many other brilliant researchers I have heard making similar predictions. Even when their research withstands the clinical trial process, their timelines have historically been terrible.

So again, thanks, but you are tossing out a lot of stuff that either has small effect sizes, just postpones expensive hospital care (e.g. wait until the brain is the problem rather than the heart), or is still very far being generally approved.

Unfortunately, I can't conduct a survey of 100 stem cell researchers who are working on heart failure trials at the U of Washington, the U of Wisconsin, Duke University and Imperial College as to when they expect approval. I can only repeat what a few team leaders say in interviews. One researcher, not connected to those universities, Joshua Hare said last month: "It's a very exciting time right now, because we can look toward next year, to see the release of data from 2 or 3 major clinical [heart failure stem cell] trials." The U of Wisconsin researcher expected the first patients outside of trials to receive treatments in 2025. This isn't just Dr. Murry, and he said around 2028, not 2025.

Speaking of heart failure, I just looked up that Entresto took 8 years to get FDA approval in 2015, much less time than the 12 year average.

Why do you assume there won't be effective treatments for Alzheimer's and other dementia by 2025 - 2029? Leading researcher Rudy Tanzi thinks Alzheimer's will be preventable by 2025. He has a drug in a phase 1 clinical trial in the U.S. and another drug at the end of phase 3 trials in Asia and Europe.

There are also NR trials underway for mild dementia and other cognitive areas. It isn't true that heart disease cures will just postpone hospitalization closer to 2029.

We'll see if he responds.

It's almost like rayward doesn't know what he's talking about.

Depending on your numbers, physician services are around 15-20% of total healthcare costs. But those are gross, not net, figures. With overhead, I would peg it closer to 10-15%.

Given that there are more non-specialists than specialists, you could enslave all the specialists and not make a dent in the cost of care that would last more than a year or two of natural cost increases.

Again, look at the actual budget. The biggest thing is hospital care. The biggest cost in hospital care, and elsewhere, are the more numerous, less remunerated positions. If you want European prices, you will need European nursing ratios. And you will need European hospital stays (e.g. 50% - 100% longer than typical American).

This is true but a little misleading.

Hospitals 33%, Physicians 20%, Prescription Drugs 10% would be the core medical services.

Non-core medical services would be things like, chiropractors, home health care, nursing homes, dentistry, glasses, local clinics, etc.

If you just look at core services the ratios are:

Hospitals: 52%, Physicians 32%, Prescriptions drugs 16%


Sorry, but why would I care about the core services ratios? Patients' teeth are going to need a certain amount of care regardless. Likewise, dropping home healthcare from the books is a good way to inflate overall costs if we can no longer use their costs to do things like prevent inpatient stays or ED visits.

Again, the point is that Medicare rates are going to require a lot more than less physician pay. 22% off for physicians is nothing compared to hospital charges. RAND puts the figures for hospitals as 241% for private reimbursement rates relative to Medicare in 2017 (which was an increase from 2015).

So again, the magic here is not for the physician's salaries. It is for the hospital staff. Which quarter of the staff would you like to let go?


I wonder why we obsess over the cost of health care. Would anyone prefer to be dying of cancer while driving a luxury car home to a mansion or be healthy while walking home to a one room studio in a bad neighborhood? Or even be homeless and healthy? I would rather be healthy. If we consider how valuable our health is perhaps health care should reflect it's value and be the most expensive service we buy.

It already is.

Sure, you and I both know that radiologists, Anesthesiologists, and ER docs don’t provide services comparable to their pay - I’m a specialist myself. People are the cost, as you say. Cochrane Review strongly suggests that CRNAs and PAs provide far more cost efficient care than specialists at 400k/yr. I enjoy the gravy train, but it is time for it to stop.

I also know that docs, in general, are a small part of the budget. I know further that with the exception of Radiologists, all the above are doing what I do - slowly getting replaced by PAs and other physician extenders.

Again, suppose we just enslaved everyone in EM and all the ROADS; great US healthcare is maybe 5% cheaper. Then what?

The savings could be redirected to other parts of the economy that provide more value, like defense contracting and in-app mobile gaming purchases.

Sure: Further, the idea medical decisions result in adverse health decisions is kindof bizarre. The major decisions of impact are: smoking, metabolic syndrome, physical inactivity, excess alcohol consumption, poor diet, high risk sexual behaviors, and air pollution.

Besides directly killing and harming patients through malpractice, physicians do promote and enable a lot of kooky, harmful stuff that has been worse than the conventional wisdom.

"Fat makes you fat", "Stress gives you ulcers", handing out "pain pills" and antibiotics for STDS like candy. Where they don't make the problem worse, often provide band-aids that normalize issues.

Before the 20th century, physicians and medicine were mostly net negative on population life expectancy. Possibly not any more, but wonder how much of what they do still is.

I don't see that this is necessarily especially bad in the US though (the above specific examples are, but other countries may be just as poor).

Yeah, the anti-reform arguments are completely contradictory: "It'll cost too much, it won't cost enough!"

And on another note, I agree that "without price gouging the system will have to change" is not very convincing.

Most likely the change will be that everyone has to wait a lot

"Throwing money at health care has not made us healthier; indeed, a strong argument has been made that it's done the opposite by providing an incentive for bad health care/life style choices."

Based on your view that Africans are healthier and live longer lives because they spend much less on health care?

Or based on the much lower costs of the British NHS and generally better health and longevity of the British which is rather diverse due to immigrants from Britians former colonies and then recently from EU open borders?

I find it bizarre when National Review arguing Bernie got better care because the US doesn't have "single payer" which means to most people the government pays all bills, or evil Obamacare, but Bernie gets all his medical Bill's paid for by government, either by Medicare given his age, or by his government takeover Obamacare which he's forced to use by law instead of the government paid for Federal employee benefit plan.

I guess the argument is that it's impossible for an economy to provide something essential to all who need it, so we must have US citizens dying in famine so the rest of us get to consume enough to become obese, a definition oof zero sum defined by economies having fixed maximum production, instead of the zero sum definition that production minus consumption must be zero which means increased consumption means increased production, and production can increase only if consumption increases.

Why is cutting wages and benefits and killing jobs leading to lower consumption, thus lower production, lower GDP, a good thing?

Innovation like that produced by Tesla requires much higher aggregate costs. Tesla lowers unit costs by multiple economies of scale to grow units sales by factors of ten in short time frames which greatly increases costs to Tesla consumers, mostly by growing the number of Tesla customers.

Note, 100% of EV subsidies are paid to workers, so, the EV subsidies do not "benefit the rich". By getting high income, wealthy people, and even just working class enthusiasts to pay more even after subsidies for an EV instead of an ICE vehicle, US workers get the benefit. Note "cars' being manufactured by US workers is in sharp decline, except for EV cars, the only vehicles Tesla makes today, all made in the US for the past decade or so. (Tesla is starting production in China for China, and will introduce trucks in the next two years.)

Higher costs mean higher worker incomes.

Almost no one calls profits a cost that must be cut. And if they do, economists pretty much attack those that call for cutting profits to cut costs words intending to paint them as some kind of devil, or witch.

God bless you Mulp. Never change. The place wouldn’t be the same without you.

....it would be better.

The real differences in health outcomes between developed countries are due to policy and cultural differences that aren’t directly about health. Mostly they are due to differences in things that affect obesity, drug and alcohol use, and tobacco use, and maybe also loneliness. In the US gun policy also plays a role.

4. Still, I have heard there’s a conspiracy theory floating around that I’m a crypto-restrictionist trying to discredit the cause of liberalization with my extremism.


5. Live free and die, that's the motto of many of the folks who reside in fire prone areas of the west. No, they don't want to be told by some government smarty pants how to build and maintain their houses. Not to pick on the west, down here in the low country houses aren't built to withstand a minor hurricane much less one like Hurricane Michael. House are built with cheap grade materials put together by cheap grade contractors, the goal being speed not quality. I was reminded of stupidity when Hurricane Dorian was bearing down on us as Labor Day weekend approached. One might assume that folks would steer clear of a hurricane that all but destroyed the Bahamas. Nope. The fine folks had made holiday plans and no hurricane would alter their plans. I'm evacuating and tourists are arriving, believing as they do that hurricanes happen somewhere else, that bad things happen to bad people. As it happened, the storm unexpectedly veered far enough east that we were mostly spared. But the experience was a reminder that a large swath of Americans are as ignorant as bricks. Or, for the fine folks out west, a tree trunk.

Managing a forest around town to mitigate fire risk involves discussion, agreements, policy......collective action.

Covering your house windows with plywood before a hurricane aligns better with a rugged individual not scared of a storm.

Which one aligns better with popular culture?

PS. just another sign that people is not rich as they think they are. If you can't afford to pay to mitigate wildfire risk around your property. You're poor.

#2: This reminds me a conversation I am having frequently which is: what does it really mean to "support" a politician? Does it mean voting for it? Does it mean "defending" him/her on twitter? How about "being a Republican/Democrat"? How does that really impact your life and your decisions?
I say that because my gut reaction to the statement "do you support Trump?" is "No". But when I look at the Dems lineup, I am pretty sure I am voting for Trump.
So how are all these "virtue signals" really that important?

People spend way too much of their time caring about that stuff one way or the other. For a certain type, it's all they have to care about, it's their identity, their tribe. Certain posters here would support any Republican or any Democrat, no matter who or what they are. It's their team, and they are happy when their team wins and sad when it loses. Got nothing to do with the country, or even their own lives, which are basically the same no matter who is president.

In other words, morons all of them.

This spake the free rider.

This (sic) spake the grownup.

You seem to be someone who enjoys the fruits of democracy, but calls "a moron" those who seek to defend those same norms.

The morons are not 'defenders of democratic norms'. The morons are the hyperpartisans who treat politics like a football game, cheering for their team and booing the other. The ones who spend all day thinking about it, talking about it, posting about it, when their lives and those of everyone they know are almost completely unaffected by whomever is president.


But that's what you think is happening when people defend the law and call for Trump's impeachment.

You think because Democrats are holding up their end, it has become "partisan."

Not what I meant at all. But of course as a partisan you can't comprehend it. For you it's "those guys over there are partisan morons, MY team is defending the nation from disaster". The reality, of course, is that it matters far less than you think it does whether Trump is impeached or not.

See. There you go. Actual crimes, actually enumerated by the founders, don't matter.

Worse, policing them is "partisan."

It really doesn't matter who the president is. Trump is awful, but life goes on.


And nothing they think, say, or write affects who is president, either. Or anything else about the federal government, for that matter.

That is an excellent way to circle the drain, with each worse infraction called more of the same.

Aren't you a genius. You got just the future and the government you wanted.

Well, do tell. Did you get the future and government you wanted?

A long arc of history that bends toward justice.

Well, not just that.

Truth, justice, and the American way.

That is not in the cards, sorry. It's ignorance, cruelty, and tribalism from here on out. Get used to it.

Let's hope, for the sake of our democratic nation, that in the end there are more of me than of you.

Naive idealists repeating middle school civics class slogans aren't the solution to any problem, much less the difficult ones facing us now.

The likely prospect of Trump v Warren is pretty depressing. Although, a brokered Democrat Party convention would almost be worth it just for the outrage and inevitable fallout. And hey we might even end up with a Trump v Yang.

Is there a middle school slogan for that?

Jock vs Nerd.

Glad to hear that Greg favors "honorable" men like Pierre Delecto.

#7: "The term "Medicare for all" is an enticing concept." Well, no, it's not: it's a sales pitch. And like all sales pitches, it may contain some truth. Yet surely no one but an absulute sucker expects a sales person to provide not just "some' truth, but all of it.

Do you really expect the sales staff to point out not just how big, powerful and roomy that truck-based SUV is, but also point out its dismal gas mileage? Do you expect the sales staff to point out that that subcompact gets great mpg, but it's really small and not very comfortable (and you'll be forever trying to see around that giant SUV in front of you)?

An honest salesperson may tell nothing but the truth; nonetheless, the truth that's presented will be only that portion of the truth that promotes the sale. And that's assuming you've actually found an honest salesperson.

Arguably those who have the most to lose here are those who are already on Medicare, as "Medicare for All" can only mean the destruction of the Medicare they now have. And it's replacement by rationing, via queues or QALYs or some other means.

Because, not only do most medical problems get better by themselves, but, the ones that don't also go away if you wait long enough (because they're no longer treatable, or the patient has died).

Elizabeth Warren is going to take away your Medicare and replace it with "Medicare for All". Vote to keep Medicare. Vote Trump.

Scene: Older woman in a doctor's office: "Doctor, will I still be able to see you if they change Medicare." Doctor, shaking his head: "I don't know, Sally, I just don't know."

These ads just write themselves.

But how can THAT compete with ‘Orange Man Bad’? :-)

You are 100% correct.

I can’t wait to see all those wonderful ads. The eventual Democrat nominee won’t be able escape xer own words.

President Trump is likely, as with most incumbent Presidents, to be easily re-elected.

Trump is an outlier, and as such his course is unpredictable. He was barely elected the first time, and he has not gotten more popular despite a robust economy. In fact over half the people want him impeached. That does not augur well for his reelection.

Mankiw's reasoning is just the flip side of the much-derided idea of voting for someone because you could see yourself having a beer with him. He's putting personality and his personal taste above any consideration of principle or policy goals. I suspect that Mankiw's would be entirely unable to articulate why he was a Republican in the first place.

7. There is no proof in that link that switching to Medicare for all will bankrupt any hospital. For example, it claims that physicians will on average experience a 22% pay cut due to lower Medicare cost but it doesn't consider the fact that this 22% cut may be essentially applied to intermediaries (for-profit insurance companies) and not to the hospitals per se.

"...it doesn't consider the fact that this 22% cut may be essentially applied to intermediaries (for-profit insurance companies) and not to the hospitals per se."

Exactly how much money to you think health insurance companies earn?

"A 2010 Congressional Research Service study showed that among large, publicly traded health insurers, profits averaged 3.1 percent of revenue"


Sergey is right, in 2017 insurance premiums were equivalent to about 30% of total personal consumption expenditures on healthcare. Personal consumption expenditures on health insurance were about 10% of total healthcare spending. There is a massive insurance industry soaking up money.



The question isn't about health insurer profits, it's their revenues. An insurer can be full of actuaries and inflated expenditures that cost consumers and weigh on profits, but don't produce better health outcomes.

" insurer can be full of actuaries and inflated expenditures that cost consumers and weigh on profits..."

No they can't!

These are capped at 15% and 20%, down substantially for small business and individual insurance customers. 80% of premiums for individuals small groups must be paid to medical providers, and 85% for large group, mostly employer benefit plans. Employers who self insure often negotiate lower management fees if they have large numbers of employees.

Profits come out of the 15%/20% so the incentive is for higher over all costs of providing medical care. If you cut payments to "increase profits", you are required to cut your profits below what you would have been allowed plus refund the "profits" from denying treatment back to the premium payers. Best case, the refunds are in rates below costs plus 20% the following year instead of cutting checks, which means your lower premiums will attract more customers, but that will likely result in higher provider costs and lower profits a year later.

The only reason to deny provider payments is to make premiums set too low to gain market share work.

mulp 's numbers are correct, but I'll add a further point. The 15% and 20%, cap is not for profit but total costs. In other words insurance companies have to pay for all of their overhead, people, buildings, taxes, utilities, advertising out of that amount.

At the end of the day, the long term industry profit is in the single digits.

You're saying that 15-20% of the cost of care goes to insurance activities, and another 5-10% goes to insurance company profits. I think we're all arguing the same point: the insurance market seems to be driving up cost, without improving care.

In 2018 total insurance company administrative costs were $92.4 billion. Net earnings in 2018 were $23.4 billion. Added together that gives a whopping $115.8 billion. Total healthcare costs are $3.65 billion. If you liquidated everything in insurance and replaced nothing (including all the Medicare they currently manage) you would drop healthcare prices a whopping 3.17%.

Insurance companies, let alone insurance company profits are peanuts.

The bulk of the money goes to patient care and government mandates.

So again, which quarter of the nurses do you want to fire?

3.65 trillion. I'll chalk that one up to autocorrect.

Don't underestimates the likelihood of fatigue. I post a lot of times on here when I am bored on call and suffering from insomnia or while travelling and jetlagged.

But yes 3.65 trillion.

22% is peanuts.

The real money is in the hospitals. There private insurance pays over 200% of Medicare rates. Per RAND that figure dwarfs the entire discretionary budget of insurers.

Further we can take this from a different angle. There 870,000 employees in the health insurance sector per the Department of Labor. Give them a fantastical average salary of $150,000 per annum to capture their full cost. Insurance bloat can be no more than $130 billion. Which again in a 3.6 trillion dollar industry is small potatoes.

You cannot get from current private payer prices to Medicare prices without going after the core employees of the hospitals: nurses, janitors, admin, respiratory therapists, PT, OT, social work, etc.

This is not figuring out how to squeeze an extra nickel out on the dollar, this is going after anything that is manpower intensive.

If it cuts doctor pay, good! We have a ridiculous system where doctors must complete a four year BS before starting medical school. Then risk a no-match in residency stranding them with a 200K useless degree on top of a useless 200K BS. For this they demand risk compensation. Cut the salaries, create pressure to rationalize medical education.

For the hospitals, they are very labor intensive — completing paper work. Nurses spend hours completing charts, typing at computers. For patients, the price is high and the standard of care is low. The nursing staff is doing busy work. Cut the funding, end it. Lower price per patient will lead to fewer wasted labor hours per patient.

ER visits involve interminable delays in expensive rooms waiting for staff to free themselves from data entry. More time with patients means faster clearance through the ER and less intensive use of expensive capital.

Labor waste today extends to passing instructions to orderlies who in turn forget, don’t get the message, do the wrong thing. Let the nurses do it.

So purge purge purge. It’s a cost plus, parasitic system. The treatment is first cut the reimbursement rate across the board and let the medical staff use their smarts to cut the fat and drain the feted pus of the medical complex.

The problem with your course of action is that physicians have other options. For the non-specialists you will see a large move into concierge medicine. For everyone, we desperately need to keep down the pace of retirements and dropping physician pay will result in many just retiring a few years early. This will lead to some hefty waiting lists and, of course, put a lot of pressure back on the system to rise pay.

And remember, salaries have a huge effect. In primary care there is over $100,000 in annual compensation differentials between the most and least desired locales for practice. Going after bulk price is going to drastically reduce the incentive to practice in rural, poor, and heavily minority areas (i.e. the places where they will do loan forgiveness if you practice there for a few years).

As far as busy work and "purge, purge, purge"; that would be illegal. Our documentation requirements are heavily driven by CMS itself. If you want less paperwork, we need less Medicare and Medicaid. Staffing ratios may also be fixed by law. Certainly I am laden with numerous requirements due to legal mandates (e.g. translation services, social work) and I cannot simply fire people.

Again though, why has nobody made your model successful before this? Why doesn't Vermont pass a bunch of laws getting rid of the BS paperwork and cut the support staff? Why doesn't Kaiser do anything similar. If you offered to split the savings for doing less paperwork and getting patients out quicker is there an ED doc anywhere who would not take it?

The truth is we have tried getting away from cost plus, capitation does not really move the needle. We have tried many, many options and none of them have resulted in drastic savings.

So again, before nuking the entire health system from orbit, let's see one entity manage what you propose. TriCare, Kaiser, Cleveland Clinic, Vermont ... anyone really. Absent a sustained demonstration model I will continue to hold the most rational belief - billion dollar savings don't exist because no cost conscious entity, public spirited or rapacious capitalist, has managed to find the pot of gold.

If they ever were, physicians are no longer intuitive agents with magic powers over trauma and disease. They question a patient, order tests, compare test results against known parameters and prescribe accepted treatments. Does this require extensive education and a high six figure income? Automobile mechanics and HVAC repairmen have duties just as sophisticated but less remunerative, although usually not life and death affairs. They don't get to bury their mistakes, however.

Let me know when the mechanics are able to fix my car while it is driving, then we can talk.

If I could turn the patient off, swap out broken parts for new OEM parts, and then reboot my job would also be vastly easier and require far less training. If every human came with a complete set of manufacturing specs, fully elucidated control systems, and built in diagnostic ports, again life would be easier.

Unlimited green cards for anyone with a MD from a developed country & China/India. No residency requirement.

Unlimited green cards for anyone with a nursing degree from anywhere that’s not a failed state (slightly sarcastic)

Unlimited HB1s for orderlies/whatever. Strictly tied to employment as orderlies at minimum wage only. They have to do 10 years to convert to green cards.

Medical malpractice insurance for green card holders and any hospital where over 70% of total payroll is under green card program is subsidized 90% by the government.

When the average doctor salary is less than $70,000 a year keep it at equilibrium. When the average nurse wage is less than $15/hr keep it at equilibrium.

We pay insane prices for medical care because the equilibrium for labor is prevented. Must be a few million doctors in China, India, and Europe that would move here for $70,000.

Oh not this again. At $70,000 per annum the only Western European docs that would gain any cash at all are Greece and Portugal. The latter of which would earn a whopping $6000 more per annum. Of course the cost of living its through all of that.

But suppose we did drain China and India of docs. How many of them will stay here as opposed to moving on to greener pastures? How many of them will exit medicine for something with better pay for the hours (e.g. real estate)?

And let us not forget that we have trouble getting docs to practice in less desirable locations even with premiums of over $100,000 per annum. How exactly are you going to staff these ones? Likewise, how exactly do you plan to staff hospitals in metropolitan areas that require a lot more than $70,000 to buy a house?

And of course, lest we forget, only a tiny percentage of Indian medical school graduates even bother applying for US residencies (thus avoiding the double residency issue). Even with several hundred thousand in compensation differential, most Indian and Chinese docs don't even bother. Lest we forget their odds of succeeding weighted against the current remuneration differential are higher than your proposed new option with 100% success rates.

And lastly, about 1/4th of docs are already foreigners. Exactly how much of a dent do you expect from doubling or trebling that figure?

2. Congratulations. And welcome all.

Personally I left at this moment. Truth must come first in a democracy.

#3: I am curious about Trump's deregulatory success, but I don't have much faith in wapo to truthfully report.

Mercatus shows no change in regulation from this tracker since inauguration.

"More than 90 percent of the Trump administration’s deregulatory efforts have been blocked in court, or withdrawn after a lawsuit... The low success rate is unusual. In a typical administration, the government wins about 69 percent of the time in cases involving challenges to agency action"

It could be Trump administration incompetence, or it could be the activist judiciary and deep state sabotage.

He could also be showing poor judgement, loosening regulation on known environmental (and human) harms.

He's telling California that we should have more smog, is that actually good for us?

Every semester I have to explain to freshers that the socially efficient quantity of air pollution is probably not zero. But they do get it, mostly.

But that's not the same as an argument that 49 state rules better approximate maximum utility than California's.

Especially as harms from air pollution become more documented.

Thank you for those links. That WaPo article is pure trash, kind of surprised Tyler linked to it.

4. Are open borders the final barrier for the centuries-old wave of Liberalism to break down, or is it the barrier upon which that wave will break and recede? Current political trends suggest the latter, but the next 50 years could change that. The freedom of migration is destined to be the 21st century's most important human rights issue, given the demographic and climate trends. It will be interesting to see what happens when human populations stabilize and start to shrink, as I think they will. Paradoxically, the pressure caused by today's closed borders is one of the chief difficulties in opening them. The initial flood of movement would be calamitous.

People don't like strangers; they don't like change. I don't see open borders as a practical political goal in the next generation, but we could change our walls into speed bumps. If we limited most immigration to those willing to pay a fee (perhaps over time), that creates an impediment that will serve to limit flow while still being effectively open for the most determined. Surely that is better than our current system of quotas and lotteries.

"Over the years politicians have been able to cut Medicare and Medicaid provider reimbursement rates, even below the providers cost to offer those services, because health care providers can make it up by charging commercial insurance more."
I don't understand this logic. If they can charge a commercial insurer $X, won't they charge them $X regardless what medicare is paying? Like if I get a plot of land and build apartments on it, I'll charge the same rent to my tenants regardless whether inherited the land for free or paid dearly for it. But I have heard this argument applied constantly to health care and I don't get it.

No. The commercial insurer will pay what is "usual and customary," which is conditioned on cost shifting. No cost shifting means lower reimbursements by commercial insurers, who are all in competition with each other to offer low rates to employers.

2. If he had explicitly said more about these "misdeeds" and what he thinks about them, I would have found this more forgivable. Instead, he vaguely calls it "the Party of Trump" without elaboration.

Republicans arent all supporting Trump. Some do. Others recognize the impeachment inquiry for what it actually is: an attempt to overturn the election of someone they hate. The I-word has been thrown around since the morning after his election, just long enough for Democrats to get over their shock and awe and allow their delusions to begin shaping their strategy.

What began as a shameless, unethical, and illegal tactic by Hillary to dig up dirt on Donald backfired on her. They got caught advancing a false and fabricated document to obtain warrants to investigate anyone even remotely tied to the Trump campaign. That comeuppance will soon arrive from Barr's investigation.

Democrat employees of the Deep State have been resisting and undermining Trump since Day 1. This is not only obvious, it is admitted.

Democrats have gone full out deranged and delusional. They are a cult like Jonestown. They violently attack anything even remotely Trump related. They insult and threaten him relentlessly, and then complain when he fights back. He is the first Republican president to do so.

Mankiw lives in Massachusetts. His votes are meaningless. Theres no way Warren loses, and no way that state votes for anyone but the Democrat nominee. True, voting Republican doesnt help him either. This makes his loud departure even more pathetic.

Bye Felicia! We needed to ferret out the RINOs anyway.

Yeah! Go Republicans! Boo Democrats! Rah rah sis boom bah! 23 skidoo! Play the fight song!

Mankiw is an influential professor. His influence is clearly limited, as he wasn't able to stop Trump's 2016 victory. But I think Mankiw's support is important. TC's support is more so, and he is clearly strongly anti-Trump.

On the flip side, I don't see McCain or Romney as "honorable" at all. I see Trump "populists" as justified. And people like Mankiw and TC pushing more strongly and aggressively against Trump is a bad sign for Trump. It also lowers my respect for Mankiw and TC.

You don't think Pierre Delecto is an honorable man?

you are a cuck, Trump has a beautiful wife, and you are a cuck.

Reflect on that, you cuck,

not only are you a cuck, you are also too fucking stupid to understand what is going on in this world.

sorry that you are the sort of person who thinks you are triumphing by saying

"it never occurred to me"

that some guy who is doing the best he can to make this world a better place


and to stop being cucks.

You are welcome for the good advice.

"some people view"

wake up little dude

Romney Bush McCain Obama Biden Gore are not on your side

Trump is on your side

The only things deranged and delusional are your bizarre conspiracy theories.

Trump is an unindicted co-conspirator in Michael Cohen's criminal case for campaign finance violations, acted in ways to shut down an investigation that wasn't necessarily even about him in the first place (when you voluntarily associate with people who engage in criminal conduct, you may find your name occasionally coming up in federal investigations -- who knew?), and has abandoned any pretense of avoiding conflict of interest in his private business dealings.

2. Greg Mankiw quits the Republican Party.
Yada yada yada

5. Does wildfire mitigation work?
Yes, but not in California.

The legislature will just hand the handbook to PGE and order them to reorganize society instead of delivering energy.

Observers of California rarely learn that the legislature if fairly stupid, barely literate. It will be two or three years before they even know about mitigation. They have top wait for an explanation from some one in authority and all they have is Gavin.

Institutions are increasing failing. Give them more money and power.

I was in CA in the early 1970's when, the state was functional. Reagan was governor. Back then, they also had Santa Ana winds and wild fires, but not like this.

Is CA the only US state with Summer dry weather and overhead power lines? AZ, NM, Inland Washington state come to mind. Do those states have similar wild fire issues?

Asking for a friend in Freemont, CA.

Only one “e” in Fremont. Does your “friend” know that?

There were dry seasons and Santa Ana winds, and wild fires, but not the insanely awful forestry practices that prevail now. If you can never cut down a tree, establish fire breaks, build defensible spaces, or have a controlled burn, there will be really big fires much more often.

California is the only *high-population* state with dry summer weather and overhead power lines. Washington has had its share of fires too.

7. “…paying Medicare rates on behalf of all patients would literally bankrupt the system we have.“
Then why is Liz demanding Zuck deny liar political ads?
Her whole campaign is about lying on the medicare cost issue. Something has gone wrong in her head somewhere. If she puts up a medicare for all ad, she will be hounded for the lie about cost.

I noticed this with here. Like on forced busing of kids, she jumps out in support to get knee jerk clicks on the web. Then later realized what a dumb move that was. Her head is not clicking.

6. Good Ted Nordhaus thread on the fires.

" Policymakers will have a choice in short to medium term. Accept continuing widespread blackouts, indemnify PG&E in exchange for less widespread blackouts and accept higher fire risk, or take over PG&E and take direct responsibility for fire proofing and fire liability."

PGE has been out of the energy loop for 20 years, going all the way back to Gray Davis and his energy problems. Like this quote, PGE has long ago accepted the hopelessness of their situation. It is as far from a private sector corporation as you will get.

PGE will let the forest burn or cut off power indefinitely until Gavin and the legislature get clues, likely never.

7. State's electricity system has been responding to all sorts of demands for all sorts of things. Equity, low rates, renewable energy, efficiency, liberalization. Until very recently, climate resilience and wildfire risk were not high on that list, if were on list at all.

Exactly and precisely.

But our ignorant legislature still has not read the report from the 1999 failure of regulation much less this report. I mean, not even looked, they just went on adding social engineering functions to PGE.

Our legislature out here is failed Hispanic state, we are a step short of Mexico.

"Our legislature out here is failed Hispanic state, we are a step short of Mexico."

Finally someone said it.

It is as VDH describes in his book "Mexifornia: A State of Becoming".

That is where we are headed.

#3. This article is nakedly hyper-partisan... This sentence is almost comical:

> Like, imagine you run a company whose business model depends on dumping lead, mercury or arsenic into the water; pumping methane or fine particulates into the air; or using pesticides that give kids brain damage.

So, Trump exaggerates his deregulation, and when the Trump Administration did deregulate anything, it was either criminally fraudulent or to assist cartoon villains to use pesticides that give kids brain damage. With some googling, it seems the brain damage thing is in reference to "chlorpyrifos". I have no idea how credible or bogus these claims are. But it is telling that I can't find any mentions of it on this site.

I'm noticing an uptick in TC linking this kind of partisan propaganda...

Yeah I don't necessarily doubt that the Trump Administration has let us down here, being that they let us down in so many ways. But man, this article is reeeeeaaaaaally bad. Basically says "all of the deregulation is bad, so there hasn't been any deregulation." Par for the course with WaPo, but still.

4. Bryan Caplan on his new graphic novel with Zack Weinersmith, Open Borders.
What does the novel say about the Turkish border and the 3.5 million,left over Mohummer dudes? No one seems to want them. What about Sweden, women hiding indoors for fear of violence?

In fact, how does Brian's plan avoid mass evolution?

Go back to Canada you useless ninny.

But keep up the good work!

Good luck, I'm not going to bother trying to find the least worst Democrat. I won't vote for Trump. I might end up voting for Pence.

I would take a look at this chart before jumping to that conclusion


2. hmm. so, he's gonna sit it out until we can get back into lying our way into ruinous murderous wars.

kewl. i can dig it

7. Yes, there will be an adjustment for the providers. Suitable transition would be wise.

I will shed no tears for them though; they've had a good run of sucking the US economy and middle class dry.

That's the genius of capitalization though, someone will line up and figure out how to make money at it.

re: deregulation
This Bloomberg headline says it all: "Trump White House Wants Direct Control Over Where Cars Are Made"

Will Compound W remove warts on my bunghole? How many times should I rub it on?

That is the impersonator.

6. "More distributed generation and storage won't obviate need to transmit large volumes of electricity across substantial distances and is not alternative to grid power for most places. But will allow rich homeowners to insulate themselves from blackouts and feel virtuous."

Bogus. Tesla is offering a premium solar roof plus battery storage for roughly $60,000 for new construction or retrofitting an existing home.

The roofing system is not flammable asphalt, thus its compared to clay tile at $40,000. My guess is standing seam steel would be less than clay tile, slate, which increase costs due to load ( weight). Tesla uses tempered glass tiles, which have advanced a lot from competition between Apple and Samsung et al. Ie, thin high impact, high strength glass and high volume manufacturing.

Integrating solar into the roofing cuts marketing and installation costs, mostly by combining installing solar labor with the roofing job labor costs, plus dealing with the appearance hurdles.

And then making adding battery storage to both deal with utility rate issues, potential utility revenue opportunities, and providing power 24×7×365 at a baseload level selected by the customer. Pay a little more and never draw power from the grid, or less and not do washing, welding in the shop, charge your EVs at home for long drives.

When a typical home built 40 years ago for $50,000 sells for $1,000,000, or more typically $500,000, paying an extra $25,000 for reliable power is hardly a big expense.

And if replacing the old roof, or building new, spending extra to go nonflammable along with ensuring all vents, etc block sparks, is a small expense to reduce the risk of fire loss.

Judging costs as if the year is still 1970 or even 1980, is stupid. As I keep telling myself as I think houses should cost $100,000 or less, but working class incomes should not be $18,000 or less. I bought a house in 1980 for the price of $85k which was much higher than my married peers paid in the early 70s, but depressed due to 19% mortgage rates, while I was earning $18,000 a year as a computer engineer, an income higher than my dad with college degrees and decades of white collar professional experience. In 2000 I was earning over $100K plus tens of thousands in tax exempt benefits, and my second house, bought at a peak price of $200k in 1986, was now priced at over $500k, after falling to under $150k in 1990, rising slightly before crashing to $400k in 2009.

I have adapted to ground beef not costing 25 cents a pound, the same price as gallon of gasoline, but, but not to the price of stuff today in the tens of thousands, that in the 70s were bought only by government and big corporations for millions of dollars.

But emotion is not reality, and making a house in California grid independent during power outages is not that expensive if you can afford to buy a home in California. And doing so will create jobs in California that pay middle class wages, while costing the same as buying a premium cup of coffee to create low income food service jobs over the 25 warranted life of the system.

To all of the commenters suggesting that Mankiw is a fake conservative or fake Republican, you really need to wake up. Mankiw is and has always been a conservative, having defended many aspects of conservative thought on his blog over the years (low taxes, regulatory restraint, etc.) and having worked in the George W. Bush administration. But he is a thinking Republican, willing to concede points made by more liberal economists. In short, exactly what a person would like to see in an intellectual economist. I say this as someone who is left of him but who has always respected his intellect. Calling him a liberal, who has always been a liberal is like saying the same of George Will.

Mankiw is pro-choice.

That makes him far-left.

He is not a serious intellectual, he is just some dude who knows how to manipulate academia.

To all of the commenters suggesting that Mankiw is a fake conservative

Mankiw is a conventional academic whose record of defending propositions that would be deal-breakers in a faculty rathskellar is just about nil. Get back to me when Mankiw offers a critique of the abortion license, of the corruption of arts and sciences faculties by political patronage ("women's studies"), of employment discrimination law; or of federal subsidies to housing, grocery purchases, or higher education. Get back to me when he says in cold print that Paul Krugman is an embarrassment.

Are the only rathskellars faculty ones? Or are there other rathskellars?

in the mid 90s, there was a really good one ( a bar called a rathskeller) in DC about halfway between the Chinese Embassy and the only Michelin starred restaurant of the day, the Citronelle, it was next to the Barnes and Noble on M Street which had a really cool staircase but not nearly as cool as the HUGE HUGE fishtank in the corresponding bookstore in Boston - I remember.

But i remember lots of things, so maybe the fact I remember is not quite as poetically as significant as I think.

Then again, maybe you remember and that would be great!

"Mankiw is a conventional academic whose record of defending propositions that would be deal-breakers in a faculty rathskellar is just about nil."

That wasn't the claim under discussion -- no one said Mankiw was an iconoclast. He has been, rather, a moderate but loyal Republican who served in the GWB administration. Ever since, he has positioned himself as a relatively staid public figure who stakes out center-right positions on economic issues and otherwise avoids criticizing Republican politicians. He is a Republican technocrat hoping for a second shot as a senior government adviser, not an aspiring Fox News contributor.

And I'm pointing out to you that none of that matters in his social matrix. Mankiw refuses to critique anything a critical mass of the professoriate regards as non-negotiable. Robert George is willing to do that. Mankiw isn't. And, no, George doesn't make his cases on Fox News.

Mankiw is a classical liberal, like me. I have changed my voter registration from Republican to Libertarian, pending the Republican Party (which is where my heart is, if not my brain) regaining its sanity and decency.

Andrew Roberts' discussion of five books about Napoleon is quite excellent, although obviously nothing to compare with an Open Borders comic-book.

# 5. There are topics for many PhD's, economics, political science, sociology, etc. First, are they all successes, did the investments have positive NPV's? If they were, why didn't other home owners, state and municipalities do the same? Unique knowledge? For private actors, did they get discounts on their fire insurance? Since they are exceptions, what prompted them, there and then?

I swear, "truth, justice, and the American way" always ends up getting clipped, one way or another.

5. For what it's worth, the Getty Fire looks to have been caused by a tree branch blown from outside the clearance zone onto power lines.

Maybe even visitors have a memory of the Sepulveda Pass. Narrow. Steep. There can be high winds. A branch blown off on the slope could carry a long way.

The Mayor is calling it an Act of God. So he doesn't seem to be blaming SCE.

2. "Maybe someday, the party will return to having honorable leaders like Bush, McCain, and Romney."

So let's see here, Mankiw wants:

(a) the guy who dragged us into at least one, and arguably two, useless and ruinous wars;

(b) the guy who seriously thought about attacking Iran (and sang "bomb Iran" during the campaign!), and was a major proponent of the first two wars;

(c) the dude who told a cabal of plutocrats that "47%" of Americans were shiftless bums, and also wanted to bomb Iran.

Apparently all of these things are "honorable", but being a Twitter loudmouth is just too much for the "honorable" Prof. Mankiw.

I think Mankiw attempted some "positioning" in his statement. He called Warren a "populist" too. I think that's pretty silly. The proper criticism is "technocrat."

#2. Why the heck did my totally innocuous comment on #2 get deleted?

Was it in reply to my rude non-innocuous comment that also got deleted? Or to the Mercatus employee whose job duties include sh!tposting on this site?

I swear it wasn't me!

No. I basically just said I was going to have to vote for the least crazy democrat in the democratic primary.

I approve of the mods deleting stuff.

Also, Mankiw is a personal friend of at least one of the guys who run this website and they ARE COMPLETELY RIGHT to delete comment threads that call out Mankiw in a personal way, from people who do not know him.

There are too many people here working out their personal issues .... even if they are intelligent people, that is just not right.
Stick to the issues, leave the personal attacks for those moments when you are angered at the defective can-opener or frustrated to tears by the difficulties of home-ownership ....
leave the dogs and cats and academic celebrities alone!!!!!!

I critique his writings and draw conclusions about his general dispositions. A reasonable conclusion discredits the premise incorporated into pointing to Mankiw changing his party affiliation. Your complaint is humbug. I expect that from academics who alternate between being corruptly clubbable and disgustingly catty.

Ahh, that explains it.

#7 Big problem with Medicare is alignment of quality reporting programs at the Centers for Medicare & Medicaid Services (CMS), but new value-based care incentive programs are evolving with programs like Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). These are still being reviewed by the Office of Management and Budget, which could leverage success for these programs. Not sure if this will standardize reporting and outcomes, but it’s something.

The problem with "experts" on Napoleon is, that they're most of the time quite opinionated, tilting towards benevolence, as one would guess if he's to consider how an individual starts his endeavor of researching Napoleon: As a kid full of admiration.

Thus it is no wonder that Andrew Roberts is able to declare that Napoleon was not an aggressor at all, citing his Russia campaign as only his second offensive war. Of course it remains opaque to the reader how France would have to be on the defense all the time until it gets a border with Russia out of nowhere.

Let there be no doubt: Napoleon didn't spread the enlightenment across Europe, he/France just increased the pushback against it in other countries. By the time of his rule, France incorporated this polarization in other countries deeply into its foreign policy and national concept, using the polarization to play a conquered society's groups off against each other.

Napoleon was to be the revolution and France was to be the enlightenment. So say goodbye to speak your own language you counter-revolutionary, reactionary cretin, or why else wouldn't you speak French?! Without Napoleon's anti-German policies e.g., Germany would be a different country today. From the inception of nationalism in Germany, almost all enlightenment and liberal concepts came with debts inherited from the French foreign policies and were deemed un-German.

A problem reiterated later in history in many other places (Arabic countries last but not least since Desert Storm, Iran after the Shah, Turkey after Atatürk, Russia after the cold war, China today etc), where foreign policies of one country deforms another country's national identity and jostles its society into a needless detour, deviating from progress.

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