I'm a former academic health care person and a current critical care nurse. One thing that should probably be added to this conversation is that Medicaid subsidizes everyone's health care in the hospital in ways that are probably not obvious.
Just to take one example, the high-end equipment in a major urban hospital is incredibly expensive, plus it has high hourly operating costs (the labor or technicians, the drugs used in imaging, etc.), and you have to pay for the labor even if you don't use the machine because you need to keep the techs on hand for emergencies. If someone has a stroke at 4 am, you need to know whether it is a brain bleed or a blocked blood vessel, because the treatment for one will kill the patient with the other. So the machine effectively has a constant baseline operating cost even when it is not running. To make that equation work financially, the hospital needs that equipment to run 24/7--this is why I'm often rolling patients back to radiology at 3 am.
But you can't fill that imaging suite with paying patients unless you have the patients to start with. That's where Medicaid and -care come in. Medicaid, especially, pays lousy reimbursement rates, but lousy reimbursement is way better than nothing, particularly when nothing is actually a constant operating loss.
So even if you are a wealthy person with very fancy insurance, the bottom line is that you can get imaging when you come to my hospital because the machine's operating costs are being subsidized by all the poor people in the rooms all around you. There's just not enough wealthy patients to make the math work otherwise. You encounter this phenomenon in smaller and rural hospitals; it's one of several reasons why they just flat don't have the kind of equipment that you find in the major urban medical centers. There are simply not enough patients to subsidize the equipment.
You're anecdote reminds me of one of the biggest "glass shattering" moments I had when I first started getting deep in the weeds of policy probably from reading a Paul Krugman column; how much we subsidize rural living*.
I try not to take it personally if someone from rural area rants about New York City and how many "welfare queens" there are or "takers (not these exact words of course, but the sentiment is there) from New York City. But man oh man it's hard for me not to be like "f**k you. My tax dollars subsidize you're lifestyle ass hat".
Now I know this not a sentiment I should be having. Apropos to this post, my tax dollars going to Medicaid is top of the list of where I want my tax dollars going. And I'm aware that we're the weirdos who follow the news every day, most people are not paying attention to the day to day craziness of Trump show 2.0 and weren't really paying close attention to the 2024 election. And that a lot of people have very random and esoteric reasons they voted for Trump; reasons that even if I don't agree with I can at least understand. These proposed Medicaid cuts and these ludicrous tariffs on Canada are going to harm some very good people who voted for Trump.
But you know what. To the die hard MAGA heads in these areas. The ones who do supposedly pay attention to the news, fly the flags, etc. You reap what you sow dickheads. You're party is the party of personal responsibility? Well here it is, you get to experience the consequences of your choice. Have fun with this gigantic hit to your export based economy and have fun with rural hospital closures due to lack of Medicaid funding. Sorry not sorry that a blue haired transgender activists was too shrill on Twitter and pushed Kamala Harris to take an untenable position in the 2020 primary. You little snowflakes, you're getting what you deserve at a certain point.
The cities have won, dude. Rural America is demographically moribund and will only become moreso as we further automate much of the secondary sector fields which support agricultural, forestry, mining, and O&G work.
Sure, the rural areas are voting like fucking morons because of that resentment, but the spite is unnecessary, they're hurting themselves most of all.
Ain't gonna be nobody out in bumblefuck in another century but the robot combines, the temporary, month-on-month-off workers servicing them and the automated silos and processing facilities, and a scattering of people who hate dealing with other people and live on their own little 5-acre plot with a well, a septic tank, a big-ass battery, and a big-ass solar array.
Sort of oddly too; it's in GOP self interest to continue to subsidize rural living. I know urban areas had a shift to Trump in 2024, but in general it's still demonstrably true that the more urban area the more likely to be Democrat and vice versa.
The fact that we subsidize rural living as much as we do means there are a whole lot more people who live in rural areas than probably should. Which means there's a whole lot of people who are voting Republican for cultural reasons that would probably be less likely to be voting Republican if they lived closer to cities (if I'm not mistaken the politics of immigration have this quality. Again, with caveat that the areas of cities that seemed to shift most to GOP are recent immigrant communities that were more likely to have to deal with on the ground recent migrant arrivals. The duh point of the day, reasons why voters shift preferences can be multivariate and there are countervailing forces at play).
Upshot is this is why I'm still a little skeptical (though that skepticism is diminishing) that GOP will actually follow through with Medicaid cuts considering how acutely damaging it is to their own constituents and how damaging it could be electorally.
Most of the subsidies for rural living are mechanistic consequences of "we build infrastructure to get rural goods to urban markets for sale, processing, or export," "we don't let retirees starve or die of preventable illness," and "we have a basic safety net for the very poor."
Are they also subsidizing rural living? Yes. Is that their purpose? No. Philadelphia receives extensive federal and state money for the same reasons.
We can quibble about "economic agglomeration," "productivity," "free-riding suburbs" blah blah blah... and I agree about all of those points, but to the middle-class suburban American median voter, urban cores are subsidized in exactly the same way as rural regions, and this understanding isn't really wrong.
"As I noted the other day, West Virginia overwhelmingly votes for Republicans, yet the state is deeply dependent on federal programs, especially Medicaid, that Republicans have singled out for savage cuts. One thing I didn’t point out is that these programs do more than provide red-state residents with health care and help families put food on the table. They are also, directly and indirectly, one of the few major sources of jobs. There are more West Virginians working in hospitals — largely supported by Medicare and Medicaid — than there are mining coal."
So you're saying DOGE will cut rural subsidies, and rural voters ( I think the word is overused here and is kind of standing in for smaller cities, too) will move to cities / bigger cities and vote Democrat? It's Elon's 4d chess plan to elect a Dem in 2028?
I'd distinguish between subsidies for the poor which pay out regardless of where one lives, like Medicaid, where areas like the rural South just happen to have more poor people, with direct subsidies for rural areas like rural free delivery from the post office. I'm opposed to the latter, not to the former.
To be clear, I'm very against Medicaid cuts. I mean my whole second paragraph is devoted to the fact that I think it's cruel as hell to punish people with Medicaid cuts; whether they are rural Trump voters or urban Trump voters or rural or urban Harris voters.
But yeah, I'll stand by claim that for the hardcore Trump supporters, the ones who voted him with enthusiasm supposedly eyes wide open, yeah you're getting what you voted for, there's a certain part of me who really does say "you deserve this".
But that feeling I should be clear, that contempt, is way way way stronger for those at the top of the income scale; Wall Street titans who gave him money. "Bro" ligarchs and the such. All of them, if you brushed off this Trump threat as "lib hyperventilating" every single of one you can go completely hell if nothing else for exposing yourself for being complete and utter idiots. "Wait the, 'leopard who eats faces' guy is actually trying to also eat my face?!". Yeah, who could have guessed based on the most cursory reading of history books. Heck, I'd say go ask those Russian oligarchs who were shoved off balconies in London if you could.
It's alright I'm much more libertarian than you. I'm completely fine with cutting off all of the indirect subsidies for rural living. Keep the neutral programs that pay regardless of location. Let the chips fall where they may. All the people who bitch about cities will move to a nursing home that's most likely within a metro area. They'll bitch but they'll get over it.
And yeah, the fact that Trump may fuck over farmers is hilarious.
Hell, even what equipment there is in rural hospitals exists because of Medicaid and Medicare. No way in hell there's a healthcare services market outside the top 100 metros or thereabouts at all without them.
Hello again, btw. How's nursing in Philly treating you?
In some ways, it is a deeply selfish thing. Last time around on the Trump clown car, I had to reckon with it in my actual job. I had to go into my public health classes and talk to students about what was going on and so on. And the news is so profoundly sad right now. Global health was one of my specialties, so when I read the news about stuff like USAID and the PEPFAR cuts, it feels so bleak. Sometimes I just kind of genuinely want to cry.
But when I go to the hospital, I'm on for 12 hours, and I don't have to think at all about that stuff. I have this guy in front of me with a gunshot wound that blew his neck away, and we're dealing with those problems, and that is more than enough to consume all of my attention. Plus I go home so exhausted that I fall into bed.
It also feels incredibly satisfying to put all of the stuff I preached as an academic into practice. All the esoteric training I did in stuff like bioethics comes up in ways that impact my nursing practice almost every day. Because of the type of unit I work on--high acuity, burns, traumas, addiction issues, end-of-life patients--I have a lot of opportunities to confront and work on the public health problems that have always interested me. But I also see a lot of complicated and interesting medical problems that keep the puzzle-solving causal-analysis academic-y side of my mind engaged.
And I love the manual work. Doing dressings on someone with severely burned hands is genuinely difficult problem. You have to do the wrappings in ways that allow for the mechanical action of the fingers and also design everything such that it doesn't rip the skin off and cause the patient intense pain. I treated someone this weekend who screamed when I undid the prior person's wrappings, but the next day mine came off cleanly, and by day three I had worked out some really nice little gloves. When you get a hard-to-stick patient on the first try for blood or an IV, that's just so deeply satisfying (flip side: when you miss and have to do it again, it is so intensely frustrating to cause your patient additional pain).
I still have so much to learn, and that is also exciting. I'm not a good nurse yet because there is simply no substitute for practice--the only way to get better at sticking people is to stick people, and I am flatly not as good of a nurse as I will be a year from now. But I can see the improvement, and that feels rewarding.
So I love being a nurse. At a time when it feels like America is relentlessly embracing and celebrating cruelty, and by "America," I mean "my own family in Texas," I get paid to go help people and put my values into practice, at least at the individual level.
There are enormous problems in health care. All the systemic and policy failures that I could describe in agonizing detail as an academic: they are all there. I live them, every day. It's frustrating. But I think that because I knew all that stuff going in, it doesn't hit as hard, and at least now I can fight the good fight on the actual ground.
No, it isn't, it's completely warranted and psychologically healthy. I have completely checked out of the 24-hour news cycle this time around, I chat here and elsewhere about policy, I'll write my congressfolk when very warranted, and I'll vote, but I ain't following the minutiae because it accomplishes nothing.
"I have this guy in front of me with a gunshot wound that blew his neck away"
Hopefully, given the vast improvements in public safety in Philly from when you started training for this career through today, fewer of this sort of thing than was the case a year ago?
"And I love the manual work."
Tell me about it. I spent the last year overseeing and doing a huge amount of the physical work for the building of a 3rd story on the house. Much more fun and much more satisfying than my day job.
I am glad this is a more fulfilling way to work than your last career, your enthusiasm shines through when you talk about it.
We have to corral a Philly SB meetup soon and see who else is still around. Kareem pops in occasionally, I know.
"But when I go to the hospital, I'm on for 12 hours, and I don't have to think at all about that stuff."-->You're severed from Trump's World for 12 hours!
You raise a good point that some Medicaid dollars indirectly benefit others by increasing the patient pool. Even with low reimbursements, if they’re above marginal costs, they help cover part of the hospital’s fixed costs. But this typically isn’t called a subsidy. It’s more like a senior discount at a movie theater—if the price is above marginal costs, it helps cover overhead, but we wouldn’t say seniors are "subsidizing" other moviegoers.
In both cases it's usually framed the opposite way; full-price ticket payers are subsidizing seniors, or private insurance is subsidizing Medicare/Medicaid patients.
You're right that in either case it's not truly a subsidy, it's price discrimination by the provider (distorted in healthcare by the legal and negotiating leverage of Medicare/Medicaid).
I guess we could have a weird argument about what, precisely, constitutes a "subsidy" but I use the term to mean that the government provides resources--in this case I mentioned Medicaid, but the reality is that there are a lot of different revenue streams coming from the government and even some in-kind services, all of which directly impact not just the hospital's budget but the availability and price of specific hospital offerings--to keep prices on a desired service--in this case, the availability of hospital care--lower for members of the public.
In the absence of that government provision, certain kinds of medical care would be unaffordable for a majority of the public who might desire it. As I said, you can see this mechanism in action in rural areas. Anyone with enough money can absolutely get any kind of medical scan they want if they live in rural Texas; helicopters and airplanes are a thing in the world, and for enough money one will fly you to anywhere you want to go for any kind of medical imaging you want to get. But as an ordinary person, if you get injured in Crockett, TX (where my family is from), certain kinds of medical care are simply not available, period, on any kind of realistic timeframe because they are de facto "too expensive," once you factor in the cost of transport. As another commenter pointed out on these threads, even the existence of a hospital in Crockett is maintained only by direct, explicit government subsidy.
Is Medicaid, in particular, a "subsidy"? You can obviously quibble with how you want to describe these policies, especially one like "Medicaid," which is really more like an umbrella term for a whole basket of different policies, revenue streams, and funding mechanisms. I taught health care policy in a number of undergraduate settings over the years and have a pretty good handle on the underlying legal frameworks. The subject of EMTALA alone is really fascinating, and we could blow a day talking about whether it gives the U.S. an under-the-table "universal healthcare" system (my answer: kind of! but in the stupidest, least efficient possible way). But I think we're kind of veering into pedantry, here; the bottom line, as you agree, is that wealthy patients in my unit benefit from the presence of the non-wealthy patients all around them in ways that are not necessarily obvious to laypeople.
I thought a bit about what you wrote, presumably because it's my day off, so I have the time, and I'm kind of a weirdo that way.
I think the key thing about your senior discount example is that you are misunderstanding how Medicaid works. Medicaid is more like a scenario where the government pays for seniors' movie tickets as a matter of policy in order to make it possible for seniors to see movies, but the reimbursement is only $5 per senior or whatever and only for qualifying seniors under certain economic circumstances and for particular classes of movie and movie theater.
Also, the movie tickets are provisioned under what is essentially a shared governance and financing structure involving both the state and federal government.
Okay, and a lot of other stuff. Sorry, I'm thinking it through as I type.
Bottom line: the movie ticket thing probably doesn't really work as a model for understanding the medical system.
But extending that analogy way too far, the government would be taxing non-seniors to pay for the senior discount. So overall it would be a subsidy from non-seniors to seniors.
In this particular case, since maybe a minority of the population goes to movies, maybe an in-depth analysis would conclude that both senior and non-senior movie goers on net benefit from the tax to pay for discounted senior movie tickets and it's an overall subsidy from non-movie goers to both seniors and non-senior movie goers.
But I suspect that doesn't extend to healthcare where practically the entire population is covered by private insurance if they don't have government insurance. I'm open to evidence showing otherwise, but I strongly suspect it's on net a subsidy from non-Medicaid individuals to Medicaid individuals (even if it's not quite a 1:1 subsidy because of some indirect benefits such as the ones you cited)
It's a genuinely interesting question. Thinking it through off the top of my head, I think your initial analysis is broadly correct: it's a subsidy from taxpaying non-users to all users.
You have to remember that even though the general population, as you point out, is covered by private insurance, a huge portion of the general population is not making use of medical services--certainly not of hospital services. And the private insurance is partly built on this model; statistically speaking, you expect to make maximum use of hospital services when you are older, and your private insurer hopes by that point to offload you to Medicare (or at least to move you into a government subsidized plan Medicare Advantage plan).
If you look at the premium structure, private insurance really doesn't pencil out if the insured have to use the services. It is--and always has been--a bet by insurers that the insured (and their employers) will pay the premiums without accessing all of the theoretically-covered services. That's why the whole system would more or less collapse without Medicare: old people use the covered services at financially catastrophic levels. It's also why, even though we think of Medicare as the "old person" insurance and Medicaid as the "poor person" insurance, there are programmatic carve-outs for certain forms of care--dialysis is the classic case--that are totally unrelated to those frameworks. Dialysis was just straight-up too expensive to afford when the technology first became available, so Congress was just like, "Eh, whatever, anyone can have dialysis, regardless of age, and we'll stick it under Medicare."
I can tell you for certain that a majority of patients in the hospital are covered under either Medicare (including Medicare Advantage) or Medicaid, and since end-of-life care consumes the most services and resources, an even larger share of the money for in-patient care comes from those two revenue sources. That's why I think the proper description is probably subsidy from taxpaying non-users to all users.
But you also have to account for availability of services. For a lot of specialized forms of care, you can't raise prices enough to justify offering the service without the subsidized patients; this is why that care functionally does not exist in lots of places.
So if there are, for example, eighteen beds on a specialized burn unit, and only two of them are used by privately insured patients (and that ratio more or less accords with what I actually see), are the two patients subsidizing the other sixteen? It's the wrong question. Absent the other sixteen, you wouldn't have the specialty unit. The two private patients would have to make do on a regular med-surg unit, and they simply would have to get along without nurses and doctors who have specialty burn training, which means the care would be a little worse, full stop. Probably not catastrophically worse, but worse.
That's why I think that subsidizing demand is an important part of the story. But I do think you are correct that the subsidy is largely flowing from younger, taxpaying non-users to older or sicker (i.e. the young person with end-stage renal disease requiring dialysis) users, with private insurers essentially providing a certain level of catastrophic coverage and administrative support to the younger taxpayers and then offloading them into the taxpayer-supported system once the person begins consuming services because they become too sick, too old, or both.
Intermediate Surgical ICU. It’s kind of a catch-all for ED cases who are not strokes or heart attacks. In theory we are primarily traumas, nec fasciitis, burns (our hospital is a burn center), but we also see a lot of emergency vascular of various flavors, the bad withdrawals (because we can do drips), and the long-term vent/liver/wound cases that get bumped down when the hospital is desperate for ICU beds (that’s how we end up with anoxic brain injuries).
The wide variety is a big reason why I like the unit. you never know what you’re getting when you walk in the door. Sometimes we’re running a tele med surg unit, sometimes it’s a poor man’s ICU with too few nurses for the acuity level, and sometimes it’s a psych ward. eventually, I would like to move down to the ED, get a couple years experience, and join a trauma team. But I might be too old.
Edit: based on your other comments, I’m guessing ED or trauma ICU. Cheers to that. I’m a pharmacist and really enjoyed my clinical rotations in a level 1 trauma center. I ask because my husband is a neuro ICU nurse and because of that a fair proportion of my group of friends are critical care nurses.
Intermediate Surgical ICU. It’s kind of a catch-all for ED cases who are not strokes or heart attacks. In theory we are primarily traumas, nec fasciitis, burns (our hospital is a burn center), but we also see a lot of emergency vascular of various flavors, the bad withdrawals (because we can do drips), and the long-term vent/liver/wound cases that get bumped down when the hospital is desperate for ICU beds (that’s how we end up with anoxic brain injuries).
The wide variety is a big reason why I like the unit. you never know what you’re getting when you walk in the door. Sometimes we’re running a tele med surg unit, sometimes it’s a poor man’s ICU with too few nurses for the acuity level, and sometimes it’s a psych ward. eventually, I would like to move down to the ED, get a couple years experience, and join a trauma team. But I might be too old.
I work in healthcare and the amount of care that is done to placate families rather than help the patient seems notable.
Sending patients post anoxic brain injury to vent farms until they die years later of pressure sores is common, pointless, and cruel. Likewise is subjecting the Alzheimer's elderly lady to forced dialysis, again, for years. Dementia patients in general are treated poorly - they don't understand the painful things we do to them, yet we do them anyway.
We've done a lot to eliminate the paternalism in medicine. This is (probably) broadly a good thing. However, the family members of these patients would do well to have someone make a decision for them, to remove the guilt that they have for 'giving up' on their parent. The economic benefit of treating these patients is nil and the moral injury is high. Yet we do it anyways. This isn't the case in other countries.
We need government panels of experts to determine what sort of treatment late stage patients can get, have it balance the improvements to their lives and the financial hit on the healthcare system.
Sometimes the care is done for the bottom lines of the facilities.
In her last years of life, my mother had a stroke. She went to a rehab place, and got great treatment. But then she went to a step-down rehab, and although she got treatment and was making some slow improvement, it was clear to us, her children, that she would be better off going home to her senior community. She had Alzheimers and was declining, and we wanted her to be able to enjoy what life she had remaining instead of being locked up in rehab jail, spending all day in a hospital bed.
So we tried, and tried, and tried, to spring her, and the facility would not discharge her. For weeks. They threatened that if we discharged her against medical advice, Medicare would stop paying for all her care.
Finally, after about a month, might have been even more, someone told me about the state Medicare ombudsman. I called, they scheduled a site visit, and suddenly the facility said Mom was ready for discharge. I'm still bitter
Putting feeding tubes in patients who won't/can't eat due to dementia is another example of wasteful, hurtful intervention. Studies have shown that feeding tubes in demented patients are associated with numerous complications and don't even prolong life.
My understanding (based on a hazy recollection, quite possibly wrong) is that stopping eating and drinking is actually a relatively peaceful way to die.
People feel bad not feeding people, and even if feeding tubes don't actually decrease choking, feeding people by mouth who actively choke on their food seems unpleasant.
EDIT: Also I presume a happy by product is tube feeding is more efficient; you can set it and somewhat forget it rather than helping actively feed someone.
It turns out not to be true that it is more comfortable to have a feeding tube. If you are so demented that you won't or can't eat, there is little evidence that you suffer by not being fed. On the other hand, if you have a tube, you're likely to try to pull it out, leading to emergency care, or you need to be restrained, which is a different kind of misery.
They may be the customer, but they're not the patient. My first responsibility is to the patient. And I need to try to keep costs in mind. I'm not just selling widgets.
Edit: to be clear, except for minor stuff (keeping a dying patient on a ventilator long enough for the family to come say goodbye), it's poor medicine to do futile, expensive, and possibly harmful things just for the family.
But the family is making the decisions at that point, so what they say goes unless you get multiple physicians together along with an Ethics committee.
It is done to placate the families and also to avoid lawsuits. We need tort reform in the medical space. Keep the ability to sue doctors -- they make mistakes, sometimes egregious ones -- but cap the liability at reasonable levels so insurance isn't prohibitively expensive.
Are health costs appreciably lower in Texas? A quick Google suggests that the biggest studies in the impact of 2003 tort limitations is either zero or possibly even negative (in the sense of insurer losses per enrollee going up slightly, although premiums also decreased so who knows.)
In some places, Texas had notably high costs for reasons mostly unrelated to liability. This is an interesting exploration of McAllen, which I think was once known for having the highest healthcare costs in the country but apparently has changed a lot. https://www.vox.com/2015/5/6/8560365/health-care-gawande-mcallen
It is drilled into doctors from the first day of training that the greatest sins are to miss a diagnosis they could have made or to get the diagnosis wrong. they shoot for literally no mistakes. That's what causes all the supposed CYA procedures, it is deeply instilled in them that they have to be as sure as is medically possible.
Huh. Rare disagree here. I think uncapped liability is the free market doing its job. If we're concerned about the supply of doctors, there are a lot of other policies we can pursue to fix that.
We already have caps on punitive damages. See examples of Texas and SCOTUS. And these are important because (two examples)
Gun toters love the PLCAA because it lets them making guns without fear of being buried in civil suits. And the general aviation industry would be decimated if the general aviation revitalization act doesn’t limit their liability either.
Pretty much the only times I have ever cried after work was when I was trying to help families to work through this set of issues.
When we get a certain kind of anoxic brain injury--especially when it's a young person with a certain kind of religious family--you can basically just watch a cloud settle over the unit. It's not just that it's so f-ing sad; it's so intensely frustrating and infuriating. The family doesn't mean to gaslight you, but that is basically what they are doing. It's like the proper response to what has happened is to mourn, and when you see sad and tough stories on the regular, I feel like you learn how to mourn pretty quickly. But then when people aren't ready to mourn--when they resent you for your mourning--it really hurts something deep inside.
I’m not disagreeing, just asking what you propose then.
No dialysis for an old lady with Alzheimer’s- ok, makes sense. What happens if you forgo her dialysis? Metabolic waste products will build up in her blood and eventually kill her. How long will that take? How painful is it? If it’s painful, what do you do, just keep her drugged so she can’t feel it until she dies?
What do other countries do?
I’ll come right out and say it: under what circumstances is euthanasia the right choice, including for a patient who isn’t mentally competent to understand what’s going on?
No dialysis is one of the better ways to go. You can just put people in hospice care, either at a facility or at home. Ironically when patients go on hospice they get much more paid for care support than they get at other times of their lives.
Huh. I assumed toxic waste buildup in the blood would be painful, am I wrong? Does the person without dialysis just kind of painlessly become unconscious and slip away? How long does that take?
Any medical professionals, I'm too lazy to Google, can someone comment on this?
You get itchy and nauseous, and generally feel poor in general. All of this can be managed with medications. As for how long, it varies.
My grandmother died at home in a couple of weeks. If its in hospital hospice, it's a couple of days usually because if its any longer we really do try and get them home. Nobody wants to die in a hospital bed.
I interpreted "no forced dialysis for Alzheimers" not as a cost-saving measure (although it is) but as a human decency measure. They're being strapped into a machine and they don't know why.
Yeah... Don't work in healthcare but have witnessed this first hand. Witnessed a family friend's wife drive him to chemo every week at age 87. He looked like hell, but I could tell she didn't want to let go. I don't know how you have that conversation.
I am deeply committed to having those conversations with families, and I have to tell you that it is really, really hard. You go slow. You try to kind of open the door and help them to start seeing it a little bit at a time. It's really rewarding when you get there. But a lot of times they just reject it, and sometimes they reject you for trying. I don't cry very often after work, but every single time it was over some version of this issue. It's way more painful than having your patient die.
I intend to have this conversation with my family before I'm at that point. If I'm past... I don't know, 85 or so, and it doesn't look good, just give me palliative care please.
I shadowed a doctor in college while debating life paths, and one patient we checked in on stuck with me. It was a woman in maybe her 60s who was hooked up to tons of machines to do what her organs couldn’t—I didn’t even know some of those existed up to that point. The doc I was shadowing mentioned she wouldn’t be waking up again (no clue what happened to her).
The woman’s husband was there when we stopped in and he thanked the doc for everything. It was surreal because clearly the doc thought it was all pointless. Of course she didn’t mention this to the woman’s husband, but it was so strange.
I had a healthcare job and I remember the first time I saw a report for a screening colonoscopy performed on a patient with advanced dementia. I don’t want to think how terrifying it must have been for those patients, but stuff like this happens because families are not willing to let the person go.
There is a scene in the movie "The Savages" that has stuck with me years after seeing it.
Very quick summary is the movie stars Laura Linney and Philip Seymour Hoffman as brother and sister trying to figure what to do with a father who is clearly slipping into dementia. They're debating which facility to put there father in. And well, let me show you the clip because man o man it gets to the heart of what you're getting at:
I'm very much in favor of ending heroic end of life care. It's cruel to the patients and a waste of money. If patients actually want to waste their own money doing so (and they usually don't) then fine. But it shouldn't be tax payer money.
Resources are limited. There are tradeoffs in life.
I don't see it posted yet here, so I'll share my personal touchstone for this concept, an old SlateStarCodex post from when Scott was a young doctor working in hospitals:
You should probably note the actual dollar amount, here? Not that I really disagree with your overall point, but I am growing increasingly of the mind that any discussion that is focused on a cost that is less than 1%, say, is probably not that notable?
Should we pursue making things better there? Absolutely. But this begs the question that we aren't doing so. Is that the case?
End of life expenses, though, is a rather large bucket. Examples used in post were brain damage survivors and dialysis. Which will you cut? And how much is each of those in this bucket? My gut is that each of those is almost certainly smaller than 6%.
So, is there a single segment of "end of life expenses" that would be an easy target that makes a dent? If not, which segments would you target?
Each part of a large line item is by definition smaller than the total, so I'm not sure how useful this line of thinking is. Yes, we want to make a dent in costs overall, but there's no simple "healthcare for people over 80" style segment that's going to cut costs in one fell swoop. And if there were, it probably wouldn't be politically feasible. Or if you think there is, I'd love to hear what it might be.
In practice, the government would need to make a large number of changes that are individually meaningful and also add up to a big total.
My point is the talking points will be over the emotionally charged parts, ignoring that the majority of this large item is not something that can be saved. All the while, any productive conversations that could be had elsewhere are being drowned out by the emotional charge that is attached to these.
Putting it with my other thread. You can have two goals here. Effective and humane end of life care. Or optimizing the existing end of life care to make it more efficient.
That is, making it more efficient is not changing it. It is looking to do what we are currently doing, but with fewer resources.
I don't think this is an area where anyone has done detailed research, unfortunately.
However, I see daily people with no meaningful quality of life wasting away on vents, and I work at a hospital. As in, that is precisely where we try not to keep those people because of the cost. My brother works in a long term acute care, which is where ultimately they end up.
These are people who do nothing all day, do not respond to their name, perhaps briefly flutter their eyes to their loved ones, are fed via a tube from their skin tunneled to their stomach, soil themselves, have a urinary catheter, and with us only show at best a reaction to what we call noxious stimuli. Or in layman's terms, pain.
You can exist in a state like that for a prolonged period of time. We're generally good at keeping people in a state of flux, where they repeatedly are treated for recurrent infections, pressure injuries make small amounts of progress, and perhaps their vent settings decrease to 'room air' oxygen. But their mental state never improves. I can't imagine many of them would choose to live like this.
I would certainly cut that first. Facilities like my brother's shouldn't exist. Truthfully though, I have no idea how much of total healthcare spending that really is.
In general I feel that if you don't have a mental quality of life we shouldn't be performing heroic efforts.
Again, in a discussion about cutting spending, I insist on centering it on costs.
Normally, I would say it is fully fair that we can work on all of these things. That is almost certainly true. That is, I am not saying we shouldn't also get better at end of life care. Both smarter and more humane.
But when discussing costs, it is hard not to see highly emotionally charged diversions as... well, diversions.
I'll continue to favor leaving those decisions up to families rather than disinterested panels of supposed experts. There is no actual expertise that can be deployed because each instance is unique and involves decisions about quality and value of life that are simply not subject to objectivity.
Will some families get those decisions what I would consider wrong, sure. But so would whatever other human being we assigned the choice to. And broadly speaking we do not get it wrong.
I've made that hard decision twice now for a parent and a sibling, and I didn't actually consider it that hard, but I don't think there was anyone else who could have contributed any greater wisdom to it than my other siblings.
Objective facts so that we can can make a well informed decision is the role of the professionals, after that their wisdom is no greater than ours.
But I think an important point is getting people to have these conversations with their families before the patient is too far gone to talk. If you haven’t planned ahead, then you will default to spending extra money keeping the person alive and in pain while you decide whether the person would rather remain alive and in pain or die in peace.
Agreed, in general. My objection here is how much of the spend is this specific set of categories? Specifically, how much is each bucket of tax funded expenditure?
This entire field of discussion is dominated by hypotheticals and misdirection. Will start talking about saving government spending, but then quote a ton of general public spending as if it is the same. And will hyper focus on specific examples that nobody defends.
Is akin to the complaint that people on welfare are out buying complicated lattes from starbucks. It is just another culture war that has infiltrated some discussions that are important.
Fair enough. But a great place to start might be just don't put people on machines to extend life if in your professional judgment there is less than a 10% chance they will ever get off the machines.
Then go from there.
It's obviously a difficult task, and you certainly don't want to 2nd guess doctors all the time.
On the flip side, we need to get past spend whatever it takes to prolong life for very short periods of time.
Waste is not an objective term here. Two more months or two more years of grandma interacting with her grandkids isn't something you can objectively place a dollar value on. As Matt says in the piece it's a matter of values not efficiency. And families are also taxpayers. They are in no way spending someone else's money than you would be if you received a diagnosis of cancer today and needed expensive treatment to control it. We taxpayers can collectively decide that many costs of end of life care are worth paying, and we can choose who makes those decisions, including family members.
Resources are limited, but we are nowhere near those limits.
I’m all for improving efficiency and reducing waste in healthcare, including “wasted” care throwing the kitchen sink at known hopeless cases, but we really do need broad based progressive tax increases to pay for what’s left over, which will still be a massive number.
Meh, some cultures are stupid and wanna keep brain dead relatives alive because they’re too dumb or religious to make the right decisions, and then other people want to keep brain dead grandparents alive to keep collecting the social security check. Healthcare needs heavy doses of paternalism in these cases.
It seems that the focus of DOGE are program cuts that will inspire crying among Democrats and smiles among Republicans. Tough calls on healthcare are a tough fit for that model.
I suspect a big part of what's driving DOGE is Elon Musk's gross ignorance of public policy (this goes without saying wrt Donald Trump). I don't deny he's a very, very smart human being. And a true visionary in business. We haven't seen his like, maybe, since, I dunno, Henry Ford? Andrew Carnegie?
But I've seen hints and clues here and there that he doesn't know what he's doing when it comes to government finances, and I fear he actually thinks the state can be restructured as readily as a social network platform. I furthermore fear he's sufficiently clueless to think his cuts will make a difference when it comes to the country's fiscal trajectory (it won't: as Matthew points out, the only serious money is to be found in defense, healthcare, and retirement programs). There's a strong bull in China shop vibe about Musk and DOGE.
People as rich as Elon Musk tend to surround themselves with lickspittles, sycophants, and other rich people with the same blind spots. He's looting the Treasury and clearly on drugs. It's insane that we've let our culture come to the point where this person is allowed in the White House.
Also, let's not forget that he seems to have a serious Ketamine problem that undoubtedly is affecting his day to day thinking on just about anything.
Was listening to the "Very Serious" podcast and Megan McCardle noted a viral chart that apparently did a scatter plot of when Musk seems to tweet and that based on this scatter plot it seems like the man genuinely does not seem to be sleeping at all. Anyone who reads anything about sleep deprivation can tell you how damaging that can be to your brain (especially someone in his 50s).
Just like Trump and his very noticeable mental decline, I feel like there is this reticence to call out the fact that one reason Musk seems to be a completely different person from five years ago is that he very possibly is a very different person; the combo of ketamine and lack of sleep is very possibly and very likely turning his brain into mush.
I mean in theory yes. Which also at least suggests to me there is other "chemicals" in his system as well. Hard to know of course, but I feel like your question invites that possibility for sure.
FWIW, I heard someone else (maybe it was Katie Herzog?) make the argument that it could just mean he has an irregular sleep schedule and is up late one night but up early a different day.
Musk may be a "true visionary" as a CEO and principal owner, but his relation to the federal government is neither. He's not answerable for results and he has no financial incentives (other than, perhaps, corrupt ones). Practical intelligence is only transferrable without training/experience within reasonably similar frameworks (stated much too simplistically!). Musk does not appear to understand that and the result is overconfidence that will amplify incompetence. Twenty years ago President Trump finally turned out to be highly skilled at something: hosting reality TV in a manner that would draw eyeballs to the screen. We're all paying for his belief that this meant he was a master of the universe.
In retrospect, the fact that he was good at reality tv helped make sense of Trump’s career in the 80s and 90s, putting his name on big money-losing projects and then strategically using bankruptcy in ways that made profit.
I mentioned this elsewhere, but I think the focus on punching down rather than saving real money is entirely intentional and strategic. This is a sop for MAGA voters and their desire to own the libs.
That's independent of whether Musk understands how various government programs run.
I've seen talk in various quarters over the years of "The Realization": one thinks Musk is a genius until he wanders into an area one knows more than a typical layperson about and one then sees that he's not that knowledgeable (making basic factual mistakes).
DOGE is not that savvy. They’re going after National Parks and the National Weather Service and a bunch of other things where there is absolutely no political upside for cutting. The simplest explanation seems to be they’re cutting everything because Elon doesn’t care about anything the government does.
It's more ideological than you think. I know the National Weather Service cuts were discussed in Project 2025, and without having looked I'm going to guess that the Parks cuts were too.
Right. The primary problem, from the conservative POV, is that the NWS provides a vital service for free and does so without regard to delivering a profitable product. They are correct that, were this function to be privatized, there are almost certainly a number of firms willing to pay for high quality weather forecasting (in the absence of competitive free options). That forecasting could then slice their market into buckets -- do you really need this hyper-granular forecasting that tells you which hour of the day it will rain? Or are you content to simply know the total probability of rain on a given day? And charge accordingly, further increasing their profits. I am sure that, with all this being done together, a private version of the NWS would be a net profitable business that does not require state subsidy.
A liberal looks at all this and says, Jesus Christ, you're looting the commons and destroying a public service when there are no problems with the existing model. An ideological market reactionary looks at the situation and says it is not *necessary* for this service to be available for free to the public, and therefore it *should not be* available for free to the public.
One of the many problems with libertarianism/market reactionary fundamentalism is a belief that it is morally wrong for the public to decide via its collective voice, the government, to provide itself a service.
We want to have accurate weather forecasts for a myriad of reasons that may amount to we just fucking want to, and if enough of us want it that is justification enough to have it.
I actually think that weather forecasts are quite a valuable public service and we should keep them. That being said, if the public wants to raise *their* taxes (not just someone else) to pay for these services than that's reasonable. But if you go to the public and ask if they want to raise their taxes to pay for this instead of doing it on debt, I bet their answer is no.
Google says the National Weather Service costs everyone $4 per year. I won't even bother to check that stupid box to give $3 for elections (despite it being free), but I would gladly pay $4 for weather info.
Oh does SpaceX have weather radars, and ocean buoys, and ground-mounted equipment? That would be a no.
The weather radar in my area, KMUX on Mount Umunhum, has been down since Saturday, allegedly because it needs a part and credit cards were frozen. Also allegedly the people in DC who are suppose to respond when weather radars go down have been fired. Thanks DOGE. And, surprise! None of the weather apps have a replacement because of course they don't.
I believe what they're trying to do (or at least claim to be trying to do) is eliminate only the public-sector forecasting and continue to have the government collect the data.
That's true. This White House has been seized by revolutionaries. And I don't think Musk is very much concerned about the GOP's electoral hopes (and Trump doesn't have to run for reelection, either). Fear of the electorate is yet ANOTHER guardrail that isn't operating properly.
I think Musk and people like Vance believe that their actions are more popular than they really are, but more importantly, they believe that the time to do unpopular things is now because they will have time to recover before 2028 (if not 2026). Vance in particular is a far-right ideologue, but also a strategic, self-aware, data-driven person. The unpopularity of right-wing policies is a problem that can be overcome through analyzing lab data from successful right-wing initiatives from states, localities, and other countries, and creatively adapting those solutions to the national/U.S. context. Probably this would involve some combination of gesturing showily toward the center in the 18 months or so before the election, devising strong new wedge issues to be rolled out in the year of the election, and degrading the quality of our democratic processes in under-the-radar ways.
Sure, I know NWS cuts were in Project 2025, so yes there are some people in favor, primarily conservative think tank analysts. I just don’t think these specific cuts are particularly popular with Republican voters. Trump spent the entire election disavowing Project 2025 because it was so toxic.
I'm not disagreeing with any of that exactly. I'm just saying that this isn't just Musk doing random stuff out of ignorance. It's part of an elite conservative consensus on these issues.
But the entire reason DOGE is doing this unilaterally is that there isn’t conservative consensus about this. Republicans control both Congress and presidency. They haven’t passed a bill with these cuts and I’m extremely skeptical they would be able to.
What about the argument that there is a conservative consensus about this, but they recognize that it's actually politically unpopular? So elected officials won't brag about it, but if they can do it while trying to avoid the public noticing the specifics they'll absolutely support it.
The original comment I replied to made two points: (1) That there is no political upside to cutting NWS. (2) That they're only cutting NWS because of Elon's idiosyncrasies. I was mainly responding to Point (2): These cuts are not something that only Elon Musk wants for idiosyncratic reasons. Rather, they are something that many Republicans want. I was not really responding to Point (1), and I would agree that cutting NWS is probably not popular with the public; but on the other hand, I doubt that even swing voters, let alone Republican voters, think this is an important issue, and in any event, whether there is "political upside" from doing something that is broadly unpopular but appeals to a key component of your base is a widely disputed question in politics. Obviously, Slow Boring readers like us have a particular viewpoint on that question, but it's not like the opposite viewpoint is uncommon or mystifying.
Republicans don't like National Parks? Republicans don't like weather forecasting? Republicans don't want to be warned about hurricanes, tsunamis, tornados, and wildfires? Republicans don't like cancer research? Really?
To steelman it, they believe, incorrectly, that if the government didn't provide those things the private market would, and so we would have them all any way.
Why they're not provided any where in the world without government intervention, or why they weren't provided anywhere before government intervention is just hand waived away.
I think healthcare spending is hard because there is really no limit to how much people can consume. If I had a on-call doctor, I would be messaging him anytime my throat hurt.
I now live in the US but I'm still messaging our family doctor back in Europe every time I feel sick. The difference is that he will say something like "Take Ibuprofen and get back to me under x, y, and z conditions.", while my experience with American doctors so far is that they'll say "Cool, let's run some tests. It will cost you x, y, and z.". The doctor in Europe also asks for tests from time to time (when I'm home at least), but he's paid with a flat monthly fee regardless. Not having a financial incentive to order tests is more important for costs than doctor's availability, I think.
Like others said, I'm not sure it's direct financial incentives as much as a culture of testing. The culture might be springing indirectly from the financial incentives, but most of the time the doctors running the tests aren't getting more money out of them.
I agree about the culture bit. I'm in a testing spiral right now. I had a doctor order a test yesterday, even though she admitted the treatment would be the same regardless of how it turns out. Then why test, I asked? The answer was because then we would know the cause of the issue. I'm a scientist in my professional life, so that sort of reasoning appeals to me. But, I can also recognize what a waste of time and money it would be if I decide to go through with it.
I’ve had several uncomfortable discussions with my doctor where she recommends a test that won’t have an effect on prognosis and I decline because if it doesn’t make a difference I don’t care and I do worry about them finding something that’s out of range triggering long follow up only to find out there was nothing to be concerned about. In the end, I think of it as a philosophical difference. For me it balances out so that the testing isn’t worth it but for someone else it will be
Yes, and the culture of testing is because of the malpractice incentives. If you test too much, unnecessarily, nothing bad happens to you, but if you skip a test that might have caught cancer or some such, and the patient dies, you might get sued.
American primary doctors generally do not have a financial interest in testing unless it is something actually run in their office. Labs or other doctors / testers cannot kick back to them for using their services.
Referring to a testing center that you have an ownership in would, absent a limited number of exceptions, violate the Stark Law. Doctors can't refer Medicaid/Medicare patients to other providers that they have a financial relationship with.
Group practice referral requirements are well defined within the Stark Law. But that's different than John's claim that a provider can simply refer an individual out to a testing center that they have an ownership stake in. That is very clearly impermissible and subject to significant penalties.
Every time I've been to a clinic here in the US, everything was done without leaving the site. Is this uncommon? The Americans I know haven't told me that I'm doing something wrong.
Many people have a primary care physician (PCP), who serves as a first point of contact for all care decisions. This physician then refers the patient to specialists or testing centers as needed.
I believe using clinics as a PCP is more common for younger people.
I technically have a pcp, but it takes weeks to see him, so outside of physicals, I haven’t used him for any of my other healthcare related issues (knee surgery, rolled ankles, urgent care clinics when the kids infect me).
Do they not have MyChart (or similar)? There’s a few months lead time on actually getting an appointment with my PCP, though I can walk in during business hours and see a different doctor in the same practice. But 9 times out of 10 I send my PCP messages on MyChart if i have an acute issue or just questions or concerns, and she or her proxy always responds within a business day. If it’s something complex, they’ll bill insurance for the chat like it’s a telehealth consult.
It’s wonderful! If your doc doesn’t participate fully in modern communication tools I would almost say it would be worth it to find a new one! (And I’m a Luddite, so for me to rave about modern technology I must really like it!)
I don't think I know any American with a PCP. Maybe it's an age thing, I don't know. (I would hope that people who have been raised in this country AND are diligent enough to get grad degrees would have been able to guide me here. Maybe I'm using the system wrong!)
The point of the PCP is to have a person who tracks your health and is kind of a specialist in "YOU" (among many others).
It's the kind of thing you're much more likely to get when you've settled down. And they are in shorter supply than most other types of doctors, so it can be a pain depending on where you live.
Eh, having a PCP is really, really easy to forgo in America especially if you’r a younger / healthy person. If you don’t feel compelled to get an annual physical I’m honestly not sure what the case for having one is (other than asinine referral requirements for certain insurances that won’t just let you go directly to a knee specialist if you have a knee problem). Anything that needs urgent attention is going to be more swiftly covered by urgent care (side note: I’m glad urgent care centers have cropped up so much) or the ER, anything that can wait a few weeks probably warrants a specialist, and PCP wait times are more like on the order of months.
I have a PCP; she's a nurse-practitioner and I've been going to her for 19 years now. I love her. She knows me, she knows my minor medical problems (if I had serious problems I'd go to a specialist MD). We chat about how we were both lifeguards in high school and I know her kids' names. She believes me when I tell her that I think I have another UTI. It works the way it's supposed to. But I don't know that it's that common, and I've told her she is not permitted to retire. I suspect that she'll retire eventually anyway (sob).
Hmmm. We have a primary care doctor for ourselves, a different one for the in-laws, and primary care pediatricians for our kids. None of them has a financial interest in testing, and all of them act as you describe your physician back in Europe acting.
Most prominently, when we call about an illness the pediatricians provide incredibly clear guidance about what circumstances warrant coming in and what further ones warrant going to a hospital.
I don't think anyone in my immediate family has ever been referred for testing which was not downstream of a compelling symptom which required diagnosis and led to treatment.
Thanks for sharing! Healthcare is my main non-sentimental concern about whether I would like to still live in this country in 10 years, and that's a very reassuring comment!
My understanding, having had Dutch friends back in Beijing with whom I discussed this sort of stuff, and my wife having friends from school back in China who have French residency and bitch endlessly about their healthcare costs and quality... if you are middle-class or better you will likely pay a smaller fraction of your income in healthcare premiums compared to the taxes-plus-premiums you're paying for access to healthcare in either of those systems. When you have a serious issue that requires extensive healthcare in the course of a year, under many or most plans you'll pay about that same amount again in out-of-pocket expenses here, whereas cost-sharing in either of those systems is quite a bit lower, even zero for some things.
So in years when you need a ton of non-routine care, you'll pay more of your income than your French or Dutch counterpart of the same relative economic status. In years when you don't, which for most people is most years until quite late in life (after Medicare kicks in if you're lucky), you'll spend less of your income.
In absolute terms the costs are much higher... but 60th percentile American you also makes 45% more than your Dutch counterpart at the 60th percentile, and 60% more than your French one.
Part of the intractability of healthcare policy here is that the system genuinely does work fine for many people; most anyone with stable employment from lower-middle to professional class has access to healthcare of decent quality at a capped annual maximum which will almost certainly not bankrupt them, though will be very, very unpleasant for a lower-middle class household. There are huge opportunity costs that they're leaving on the table, but those are much less effective as a motivator than real ones.
There's no direct financial incentives to order tests. Some tests are probably CYA medicine. Some are useful but not covered in other healthcare systems. Labwork generally is also not that expensive relative to other healthcare costs anyway.
Sure. Even Warren Buffett may prefer a pickup truck to a Ferrari, though he can easily afford the latter. Maybe he's just not into sports cars. Maybe he likes to haul gardening supplies home from Lowe's. Maybe he doesn't want to appear pretentious to his neighbors.
But he probably will shell out $5 million for an experimental treatment for his gravely ill grandchild.
I think it is also important to add on that spending extra money actually gets you stuff, which makes the efficiency decision tree much more complicated. Like, fifty years ago if you had cancer, you mostly just died. Today, you can spend a ton of money on treatments and you really will not die, which is great. But those treatments do cost actual money.
So the question of, for example, "should we treat Grandma's cancer?" is just a much more complicated question because it involves genuine tradeoffs in things like money and quality of life in an environment where outcomes are highly uncertain and you are making idiosyncratic value judgements.
My dad is a family physician and I definitely called him for every weird health issue until a few years ago lol. (He’s getting old—retiring this year—and I don’t want to bug him.)
There's an argument that health care expenditures can be driven by extra disposable income, and the US has higher health care per capita spending because we also have higher levels of disposable income.
If you think about it there are probably three buckets of healthcare expenditures, 1: truly necessary (my arm won't stop bleeding, doctor says I need to start chemo immediately), 2: "luxury" (it would be nice to get this rash taken care of, my knee's been bothering me in the morning), and 3: diagnostic to determine the difference (should I be worried about this lump, are these sudden migraines a bad sign).
All else equal, you would expect richer people or people with more highly subsidized care to increase their spend on buckets 2 & 3.
The 2nd article is particularly good. The term futile care is something that should actually be openly discussed. Matt's claim that we don't know who is in the last year of life rings somewhat hollow. Obviously we don't know perfectly in every case, but there's a lot of expensive, cruel and futile care we do know about going in.
Hard to imagine that conversation: "There's an 80% chance that grandma will die within a year no matter what we do, and 20% chance she'll live another 5 years with this expensive treatment. So... not gonna do it."
Having been there with my parents, it’s even worse than you might imagine. Doctors are trained to do things, and sometimes will keep trying to do them past the point of absurdity. When you’re trying to stop this on behalf of someone you love who is not in a position to decide for him/herself, you can start to doubt yourself or even feel like some kind of monster.
I'm a doctor, and I had to face this myself with my own mom. I think I'm pretty hard-headed, but, even when she was obviously dying, I wondered (and beat myself up about) whether we'd really done enough.
It's the worst. It seems easy in the abstract -"of course I/she/he wouldn't want to live like that!" - but the weight of the decision is immense.
Trying to think clearly in hindsight, I think my mom would have been better off without chemo for her Stage IV lung cancer, because the time it bought her was IMO low-quality. But I'm not sure she would have agreed, and tbh selfishly I was grateful to be able to spend more time with her.
My father had a weird attitude toward death. He'd served in WW2, fought in the Battle of the Bulge and many other battles, saw and inflicted a ton of death. Boy was he traumatized. His attitude was "I don't want to die. Keep me alive at all costs." I didn't, though. He had a huge brain bleed and he wasn't coming back from it. I ordered palliative care only. I apologized to him several times (he was unconscious, obviously) and I sometimes feel guilty. But there we are.
That's a hard conversation. "There's a 95% chance that Grandma will die within a year no matter what we do, and a 5% chance she will live an indeterminate amount of time past that with poor quality of life" is not as hard. Once you agree on the principle that there exists some bucket of care for the elderly that is pointless or even net negative, the problem becomes finding the line, and reasonable people can disagree on where the line is (and adjusting it is a perfectly reasonable domain for the government to spend a lot of effort figuring out)
My impression is that outside of the US this is handled by the doctor simply not offering the 20% chance as an option to the patient. And this could leave the patient better off and happier.
Restricting patient choice might improve outcomes, spending, health, and even satisfaction. It's very un-American, though.
My experience in the UK is a mixture of "The NHS does not offer this treatment" (and they have been known to go through the courts to block people taking clinically braindead patients to America or Spain or wherever for more treatment) or you get given the same option with the same "you will suffer but might live an extra few years" disclaimer.
Now if only my vet could give me straight cost / benefit / probabilities on our 10 yo diabetic cat, instead of acting like I obviously would be willing to shell out $10k a year to keep "our family member" alive.
There are a few problems with that point of view, and I don't think doctors' pay is relevant here. One problem is that you assume that the decision is clear, and it is not. It might be more worthwhile to try a mild hail-Mary on a happy, vibrant, active grandma than on a grandma who's thrown in the towel. And there are cultural and religious points of view that complicate these decisions as well.
Moreover, we've progressively moved away from traditional medical paternalism, whereby the doctor just tells patients and their families what their treatment is going to be. Perhaps we need to move back to that model a bit, but we generally think it's a good thing for patients and families to be involved in important medical decision-making.
It's also hard to back off on treatment once you've given something a try. You do a potentially life-saving operation on an old person, it doesn't go perfectly, and they end up in a sort of miserable holding pattern. At what point do you just say, let's stop intervening?
The NHS (in the UK) can just say categorically, "No dialysis for anyone over 80." I don't think we'd accept that in the US.
Saying well-paid doctors just "need to make those kind of decisions" does not make for effective healthcare policy. (Not trying to sound rude, and sorry if it does sound that way.)
Yeah, sorry, that was probably a bad example. But I've read examples of the NHS just having hard criteria for certain treatments, which I think would be much harder to implement in the US.
With regard to medical paternalism, I think you have to be careful what you wish for. I think it's a good thing that we've turned away from saying, "Sorry, dear, you don't need your breast at age 70; we're going to do a mastectomy rather than a lumpectomy."
That's exactly what they do in many countries. I have a friend who is a U.S. doctor now practicing in NZ. (I've asked her to come over here and comment, it's so useful to hear from her). Americans would find NZ end-of-life care startling, to say the least.
My experience with actuarial models is that they are often quite accurate and there are probably actuarial models that are pretty good at predicting who will die soon. There is an enormous incentive to get these models right so that organizations can appropriately price risk and figure out how much cash they need on hand.
Are they accurate on average or for individuals? Deciding on care is a decision that needs to be made for each individual, while costs can average out.
More recently, Scott also looked at the argument from the final paragraph, about whether large indiscriminate cuts to healthcare spending could be made without adversely affecting health outcomes. TL;DR: Probably not.
Any chance of commenting on the "making healthy lifestyle choices is the most cost-effective way to reduce total healthcare spending" argument?
There's clearly SOME merit there, but I don't trust the claims I hear some people making. Also, not sure we have a great plan for how to really get people to live healthier lives (without getting totally fascist on them).
Many health insurance plans have programs available to people with chronic diseases like heart disease, obesity, etc that tries to make those people healthier. The idea being that it's in the financial interest of the insurance company for the patient to make better health decisions.
My mom spent her entire career managing those programs. She says it's really really hard!
That is interesting. My neighbor runs a program at our local hospital to help people with/in danger of diabetes change their lifestyle. It is opt-in, so people want to be there, and it is much more hands on with more supports than the health insurance incentives, and she still says it is really hard. She says there are so many people who have so many stresses in their lives (many people in the program are low income) that it is hard to focus on this. I sometimes wonder if we had more of a basic safety net, like most European countries do, if it would help.
Here in the UK there is a health insurance company that offers younger people cheap rates alongside a gym membership and fitness tracker contingent on them actually hitting a minimum level of physical activity.
That we live less healthy lives is one of the drivers of our higher health care costs relative to eg Europe. So we could definitely save money in some sense by making everyone more healthy. But given the current massive rebellion against the cheapest and most effective public health measure we have, I don't think that's going to happen.
Meaningful long term costs for either probably come in for less than 10-20% of victims. Given the numbers, I'm not sure it's more than a decimal point somewhere of difference
Based on the most recent available data (typically from 2020-2022), here's a ranking of OECD countries by the percentage of population that smokes daily:
1. Greece: 32.2%
2. Turkey: 30.7%
3. Hungary: 25.8%
4. Latvia: 24.1%
5. Croatia: 23.8%
6. Poland: 23.5%
7. Chile: 22.6%
8. France: 22.4%
9. Estonia: 21.6%
10. Portugal: 20.9%
11. Slovenia: 20.1%
12. Spain: 19.8%
13. Austria: 19.3%
14. Lithuania: 19.2%
15. Czech Republic: 18.7%
16. Belgium: 18.5%
17. Italy: 18.3%
18. Slovakia: 17.9%
19. Japan: 17.5%
20. Germany: 17.3%
21. Luxembourg: 16.8%
22. United Kingdom: 15.9%
23. Ireland: 15.5%
24. Korea: 15.2%
25. Switzerland: 14.6%
26. Netherlands: 14.3%
27. Denmark: 13.8%
28. Israel: 13.5%
29. Canada: 13%
30. Australia: 11.2%
31. Sweden: 10.4%
32. Mexico: 9.3%
33. New Zealand: 8.7%
34. United States: 8.6%
35. Norway: 8.3%
36. Costa Rica: 7.5%
37. Colombia: 7.2%
**Notes:**
- Data sources include OECD Health Statistics and national health surveys
- Percentages represent daily smokers aged 15 and above
- Data may vary slightly depending on the specific year and survey methodology
Interesting that for the US this seems to have been 25% in 1990 and over 40% in 1960. That's a real policy win. (Though I think these numbers exclude vaping.)
Fun fact: Swedens low rate is to large part due to an early harm reduction program in the ‘90’s where they got people to switch from smoking to something called Snus. When they entered the EU, the Nordics successfully negotiated an exception to the EU’s near ban on Snus because they didn’t want people to go back to smoking. Last time I checked the EU was trying to crack down on Snus and dismissing the public health case for Snus because people shouldn’t be addicted to nicotine period.
It reminds me of the fights over vaping here in rhe US. What’s always struck me as odd is that my local health department is very anti-vaping but also very big on providing needles, pipes and narcan for people who use illegal drugs while dismissing things like abstinence based treatment.
It's a driver of our lower life expectancies, but I'm not sure that it's a driver of our costs. Like Matt wrote in the article, a huge amount of healthcare spending happens in the last year of life, and the last year of life comes for everyone, eventually.
I think we mostly spend more because we are wealthier, and in particular we are wealthier at the higher end. Our millionaires and higher 6 figure salaried probably have European life expectancies, but they can also afford to spend several times their equivalents in Europe.
A large % of our spending, particularly in medicaid, is for polychronic patients (often type 2 diabetes or hypertension + other diseases), much of which is driven by lifestyle factors (obesity, lack of exercise, poor diets)
It's secondary to cost-disease factors, but it's definitely a driver.
How does this balance against my assumption that such patients die a decade or two earlier? At the fiscal level, it's not clear to me that they would cost more than the healthy person who lives to 87.
This gets really complicated, and some studies do show that the net cost reduction of health improvement is very low, since no patient spends less money than a dead one. I just googled it and there are serious-looking studies saying these factors totally cancel each other out, and others saying that obesity and morbidities dramatically increase lifetime spend.
Other factors:
1. Poor health prior to retirement age contributes to lack of labor force productivity - many of these patients can't/don't work.
2. Their last year of life looks a lot like a healthier patient's last year of life, it just comes earlier.
To point out the obvious, it also matters whether total spend (% of GDP or whatever) is what you're tracking or spend per life year or whatever. That our life expectancy is lower than other countries makes our spending differential even worse (since lower lifespan should save us $ all else equal.)
Thanks for these responses these are helpful and informative. I'm kind of shooting-from-the-hip when it comes to spending on diabetes vs last year of life, etc.
From my end, the only part I wanted to point out was that our relative wealth and relative abundance of millionaires by itself makes it very hard to close the spending gap. There are plenty of other factors that contribute to expensive healthcare and are worth striving to fix, but my sense is if we did "fix" healthcare in the US, we'd still have a spending gap due to wealth and a life expectancy gap due to drug overdoses, car crashes, homicide and obesity.
This is an argument for less cost sharing, in a way. If you want to live less healthy, cool, you're free to do so. Just don't make me subsidize that choice.
The thing is, we understand fairly well that willpower around food and exercise, both cravings for and the body's response to foods, pain responses and tolerance, etc... are all downstream of the genetic lottery.
I'm fine with the genetic lottery more or less determining everyone's class and achievement; as a matter of practicality, it's not avoidable... communism didn't make people equal, and didn't work even if it had.
I'm un-fine with the genetic lottery determining everyone's access to healthcare.
If I have to choose between the libertarian argument Allan articulated and nationalizing the whole mess of a system into an American NHS, the latter, despite manifest flaws, is by an overwhelming margin the lesser of two evils.
The issue with the "making healthy lifestyle choices" argument is: how do we get people to make such choices?
There's a libertarian argument that says adults should have the right to trade life expectancy (and quality of life when aged) for the pleasures of stimulating certain pleasure centers of the brain (fast food, alcohol, video games instead of rigorous exercise, etc) when they're younger. Who are we to judge?
In practice pretty much no one makes such a tradeoff consciously. And surprisingly few of us are willing to let unhealthy older people go without healthcare treatments. (Part of that may be the realization it's pretty likely we too, will end up like that at some point, even if we're very careful and make healthy choices when we're younger).
Which is all just to say: blaming individuals for poor metabolic choices feels like a bit of a scam. I'm not a slave to consequentialism, but I'm still enough of a consequentialist to suspect that, when many millions of people become obese in some countries but not in others, the problem isn't at the level of the individual, but in the way society itself is set up.
Despite being quite pro-capitalism and pro-libertarian, I too worry about society.
I think we're missing something in terms of societal recognition for making prudent choices and living a responsible life.
I know, that sounds like every middle-aged paternalist scold ever. But there's truth in it. Eat your vegetables! (Literally and metaphorically!) But there's not really an audience for that, not really a good profit margin for that, and we've lost some of the community institutions that used to balance in that direction.
Agreed. Left wing people with a focus on government policy (so SB readers, and MY) often have a blindspot for how much society and culture drive certain things and how much government policy is limited with those same things. The blind spot is understandable, but I think we'd do better if we recognized and acknowledged the limitations more often.
First we could better prioritized policies, second, we might recognize when partnering with cultural leaders and role models might do more than policy could.
I would argue that there is value in doing things that are hard or you don’t like becaue the end result is something you want. And if you’re doing that with your health on a regular basis, it’ll make it easier for you to do that for things like learning a new skill
I put on 17 lbs last year. And am currently 2 months in on my low carb diet this year, and have got rid of them all. So about half way to my goal weight of 200 lbs.
Going low carb is the only way I've found to manage my food cravings. I haven't tried a GLP1 yet, but frankly don't have the cash for one right now.
I love dairy too much to go low carb, though I’ve ballooned (from 180 to 230) over the past three years. And at 230 it hurts to move. I have just been doing the tirzepatide for a couple of months and am still titrating the dose up. I’ve been eating and drinking a lot less but my body is fighting any change right now, I’ve only lost like 5 pounds. But it least I’m not on an upward trajectory and I think I’m consuming fewer calories most days than I expend, so I hope to see some results.
I include dairy in my low carb. I do non fat plain yogurt with frozen mixed berries for my breakfast/lunch about 10. Then I do some mixed nuts and jerky around 1.
Then finish things up with steak and salad around 6 with plenty of cheddar cheese on the salad (I love the combination of the cheddar with black olives)
Whether I'm strictly in Keto I don't know, but it works for me and my cravings are managable.
Sometimes I add in some fresh blueberries or even some pineapple (yeah the last probably isn't very low carb, but I seem to be able to do it fine, probably because of the fiber, and it's only once a week).
Either way, good luck, I know losing weight is by far the hardest thing I've ever done. Getting my CPA and MBA was definitely easier.
Yeah, if they're not going to do coercive action it really doesn't change much. The government already does ad campaigns to promote healthy choices- there's only so much you can do at that point.
To me this is crazy talk. I don't believe for a second that we've even scratched the surface of what concerted action could do if you really focused and aligned behind it.
Look at smoking, for example, where the rates have plummeted and we're far head of Europe. The government was heavily involved in that change. Just because other campaigns have been less successful doesn't mean there's nothing left to try, especially because it's very hard to measure the counterfactual.
As a schools guy, that's where my brain goes. My suggestion is not totally free of coercion but it's wrapped up in the already accepted coercion of schooling. Here goes:
Let's make Physical Education Great Again. PEGA.
You (okay, maybe not you but the average person) may be surprised to find that half of high schoolers only attend PE once a week. Only a quarter attend PE five days a week. That average is actually misleading because in some cases they're only required to take PE for one semester or one year, often 9th grade, which means that the other 3-3.5 years they have zero PE. I study high school entrance and departure and one of the weird data points is that PE is often one of the classes kids fail that stops them from graduating (it is a graduation requirement in, I think, every state). They skip, they refuse to "dress out", etc. Seriously! When I looked at Chicago public schools a few years back, failing PE was, on average, one tenth of the kids who weren't graduating high school.
Anyway, we have a situation where 95+ percent of kids are going to attend public high schools. Let's make them take PE every day for four years (maybe with some smart exemptions for student athletes or whatever) and let's have required participation. Okay, so, I guess I don't know what to do if a kid shows up and refuses to put the shorts on, hence the failure rates, but most will participate and we can iron out the rest as some best practices get discovered. We know that even small amounts of moderate physical activity each day can have a big impact on outcomes. Build that habit early! Make PE Great Again.
I think pretty much every president since Eisenhower has a PE initiative; I remember taking the Presidential Fitness Test in the GWB era. And who could forget this gem! https://www.youtube.com/watch?v=BY5sB7GvabY
I love this and let's make sure we are actually teaching them how to stay fit for life. And make sure they understand the metrics and how much it matters.
Have them do a combination of strength training and cardio. Yeah, that would require bigger gyms, but I think that would be well worth the money
Okay, but I'm not playing team sports. Not ever again. Not interested in being screamed at abusively because I kicked the ball wrong. I'll do yoga or dance or spin or individual weight training or a variety of other things. But no team sports.
Maybe they should stop requiring dressing out, which is basically theatrical humiliation for insecure kids for no real reason. It didn’t bother me, but I do know people for whom changing in front of others was just a dealbreaker, and didn’t graduate high school for that reason. It’s dumb, but it is a thing.
PE was hella dumb though. I hated it and was very happy to only need 1 semester of it. Most people don’t become unhealthy until after their teenage years, though that’s probably changing with video games.
Smoking is the exception since there was a clear externality (second-hand smoke) that meant it could be regulated without reeking of paternalism.
In my more conspiratorial moments I wonder if any public health apparatus is working on a similar concept for other health choices. Is there such a thing as second-hand obesity where you're more likely to be fat if you see a fat person? Does the smell of booze on someone's breath lead to cirrhosis?
A lot of the reason we were able to regulate tobacco advertising, despite that being prima facie unconstitutional, is because we were able to sue them, and then as part of the judgement, had the restrictions imposed. There's a similar agreement about alcohol advertisements to children, though that one's just a gentleman's agreement, rather than law.
People can live just fine without tobacco. Not the case with food. And there's absolutely zero prospect of violently ratcheting up the cost of calories through taxes. We're up against 4 billion years of evolution and the relentless cost pressures exerted on farmers (resulting in ever-growing agricultural productivity).
It seems pretty telling that US obesity levels seemed to peak at the very moment MDs began prescribing Semaglutide for weight loss.
We banned smoking from a bunch of public places, that's coercive action. I don't think we're going to ban overeating the same way. We also banned cigarette advertising (effectively, it was done through a lawsuit).
Well then my sarcastic response is: "there's nothing, at all, that could be tried."
But I disagree, with creative thinking we could probably try a hundred other things.
But I should add that I think the limitations are generally within society more than in government. It would be harder to ban junk food from gas stations, for example, because lots of people enjoy it, especially on occasion.
I think the social and government limitations are somewhat interlinked- if we tolerated say, strict rationing, that would be available as a solution, but we won't so, I don't bother with it. You've seen how bad the reaction is to trying to do anything to limit junk food availability.
I mean, i'm open to new suggestions, but the tools i know just aren't in the toolbox right now.
For what it's worth, I also don't think the reduction in smoking comes down entirely to the corrective action- though i think it helped. The broad progress of de-(in person) socialization of human beings over the 2000s and 2010s has reduced teenage smoking, teenage drinking, teenage sexual activity, etc which also i think contributed to the reduction.
It depends on what sort of “coercive” things you’re considering though. A ban on soft drink cups over 32 oz was too politically radioactive to pass, despite being only minimally coercive (I suspect it’s like congestion pricing, where once it’s in place for a year, people are happy with it, but people hate hate hate the transition). I bet that a ban on the industrial use of food colorings would also drastically cut the amount of certain types of junk food people eat, just by making it less visually appealing - and you could still allow all the food coloring you want in commercial and home kitchens. There are probably many things of this sort, that allow most of the freedom that people actually care about, while stopping the things that hijack our decision mechanisms.
Japan's "Metabo Law" seems to have generated a statistical improvement. I know here in 'Merica we love our personal freedoms and exceptionalism included our exceptional fatness but I have no problems with Federal pressure to increase the "costs" of being fat.
I think what’s hard now is that we’ve transitioned from a generally correct view that healthy living improves health outcomes to a less defensible view that healthy living is all you need and will do more than vaccinations or antibiotics. Call this the Marjorie Taylor Greene stance (I’d actually name it after my dad but it’s catchier to use a public figure). All that’s needed is some exercise, some vitamin D, some nutritional supplement powder, and a supply of ivermectin cure-all.
In practice, and now that this stuff has moved out of wealthy wheatgrass-slurping circles, this most often results in the worst of both worlds (unhealthy lifestyles + anti-vax)
Yeah my understating is healthier lifestyles (and a lot of preventive care) don’t actually save money in the long term because you just get sick later.
The unhealthy person gets cancer at 65 and dies at 70, the healthy person gets cancer at 85 and dies at 90. The healthy person surely is costing Medicare more.
Right, if lifestyle is the difference between a fatal heart attack at 55 and a stroke at 65, it might drive a lot of savings. But in most of the country the marginal change is 75 to 85, which means more medical care is needed, not less.
Making people healthier is expensive because they live longer and so consume even more healthcare. Smoking is terrible but it reduces spending on Alzheimers care.
Are we sure? I've seen stats that a quarter of healthcare spending is on diabetes-related issues. In total I'm seeing claims that 75%-90% of healthcare costs are for chronic conditions. Not saying all those can be solved through healthier lifestyle, but clearly there can be a big impact, right?
It is a complicated equation with lots of secondary and tertiary effects, but my impression is that making people healthier and live longer significantly increases the burdern of chronic diseases.
Alzheimers and Diabetes are the two most expensive conditions, making people healthier increases Alzheimer's cost and reduces costs for diabetes. I think more chronic diseases (weighted by cost)are like Alzheimer's .
I don’t want to pretend like defining some healthy lifestyle choices is a complete mystery, but getting people to agree on even that is pretty fraught.
A regular refrain of the MAHA movement is that the food pyramid was a scam and a lie, and that real health is forgoing vaccinations and drinking raw milk.
On an individual basis, this is clearly true. For most people, stopping smoking is more important than whether or not you get a physical, and driving on the highways or taking illegal drugs are more likely to kill you than cancer up to age X (I don't know what X is but it's probably 50 if I had to guess).
What this means for the aggregates, I don't know exactly, other than to say that there's a lot of misplaced blame on our healthcare system as a result of our lower life expectancies, which are generally due to obesity, drug ODs, violence and car accidents.
1. Place a HIGH tax on sugar and other high calorie sugar substitutes.
2. Use those funds to give people generous cash amounts for staying fit and at an appropriate weight.
Also make it so food stamps etc can't be used to buy junk food.
If that doesn't work then make staying thin and fit a requirement to get government healthcare. If we are paying your health bill, then you'd better damn sure do your part.
I’m so glad Matt cited that Oregon study and the libertarian crowing over it. A little anecdote to get into why I found this reaction on a gut level repulsive (almost as a piggyback to Matt’s personal examples).
I’ve noted on here before that I’m a pretty hardcore about working out. Six days a week at the gym with a mixture of weight lifting and cardio. Up until five years ago that cardio portion included a decent amount of running; including at least once a week 5-6 miles of outdoor running.
Starting about 6 years ago I started noticing real discomfort in both the bottom of my feet and then my Achilles. A modest discomfort became real pain with my feet and increasing discomfort with my Achilles. So I go to the doctor who recommends a podiatrist…who within five minutes was able to diagnose me with planter fasciitis. Good news? Easy fix which was that I need to wear orthotics in my shoes…and stop running as part of my cardio routine. The bad news? Orthotics are not covered by my insurance. Had to pay out of pocket for the inserts. And five years later I had to pay again for replacements out of pocket. All told I’ve probably spent close to $1,500.
Now I’m lucky. I have the financial wherewithal to pay for this out of pocket without too much problem. But I’m well aware for even middle class people, this would be a pretty major financial hit to pay for. And for people at the bottom end of the income spectrum? Forget it.
So let’s say I didn’t get orthotics because I couldn’t justify that out outlay. What happens? Two different specialists told me the same thing..I very likely eventually tear my Achilles.
So a few points to make. One, “likely” and “eventually” are doing a lot here. It’s at least possible the tear never happens. And if it did, the when was also very muddy; would it be 1 year, 3 years or 5 years later? Who knows. Point being if you were to ask me 3 years after I first diagnosed and I didn’t get orthotics I might have said “oh yeah mostly fine, do have some pain in my feet and Achilles but it’s manageable”.
Second, let’s say I did tear my Achilles. I have an office job. I would very likely still be able to work; have a coworker who was able to work while recovering from a serious ACL tear. And I likely would eventually recover and be able to live a mostly normal life.
And here’s the kicker. As far as I can tell from libertarian crowing about this Medicaid study, me tearing my Achilles due to lack of ability to pay out of pocket for orthotics would be a perfectly fine outcome. Which is absolutely asinine. The pain from the tear itself, the intense recovery and the likely permanently reduced mobility (again even if still able to mostly live my life) would have made my life so so so much worse than just getting the orthotics*. And yet somehow this not supposed to matter.
*Also, my insurance wouldn’t cover orthotics as it wasn’t strictly “necessary”..but it would cover my surgery and physical therapy for a year. I’m a nutshell one of the reasons our health care costs are so much higher than necessary.
An interesting third option is you grab a pair of the pre-fab ones which are $14 on Amazon and which, at least according to this study, provide "no statistically significant differences". I'm fine limiting our federal and insurance spending to things that provide actual statistical differences. I personally take an number of supplements and all the research I can find shows only the creatine and glutamine I take provide any statistical benefit. I think I can feel a difference so I don't care and even if it's just placebo - that's money well spent. Still, I don't think anyone else should pay for those.
I actually tried exactly what you suggested; I went to CVS and got Dr. Scholes. Even stood on that machine they have to get the "right" ones. Did square root of f**k all for the pain.
Second, my Mother in law was a physical therapist. And she was the one who told me to ditch the store bought inserts in part because she had seen this tried with patients of hers to no effect.
So at least for me, was quite necessary (it seems) to get the custom made inserts. I can tell you quite soon after getting them the pain went away and I've been pain free since.
Don't want to just say "fake news" to this study. That would be dumb. Entirely possible the specific issue I had required custom made inserts and someone with maybe less severe planter fasciitis could have gotten by with store bought ones. Who knows.
I would say my own experience tells me that "more research required" is probably answer.
I will say last that even leaving aside that with my specific issue you may be completely right (maybe I just didn't get the right store bought ones). But my general points I think stands; measuring health insurance effectiveness purely on the metric "did you die in 5 years or not" is a wildly incomplete way to look at health care and its efficacy. And second, all sorts of "elective" procedures not covered by health insurance really should covered if you're concern is saving money or general human welfare.
But you’ve argued that treating an ACL tear is a waste as it’s not a matter of life and death. If someone’s mobility is severely restricted that’s just too bad.
Edit: My apologies to David in Chicago I got him confused with one of the other Davids.
You argued that life expectancy was the only metric that should be judged. If someone gets a hip replacement and can walk again for 10 years but will still die at the same time - no value add.
Three years ago I was running 40 miles per week when I was diagnosed with plantar fasciitis. After wearing a boot for a couple of weeks I wore the strassburg sock from "the sock dot com" every night for three weeks or so while sleeping. I was running again pain free in less than a month, and it hasn't returned. Other folks with plantar usually take about 6 months to get back to running.
It remains absurd that there's more political will to cut medical benefits to the poor and elderly than to means test social security. I don't know how you could argue that there's any systematic waste in the entitlement system more clear cut than paying social security benefits to people who are comfortable without the money.
Means testing social security would discourage saving for retirement, which is something that really really needs to be encouraged. Semi-forcing people to save for retirement as they do in Australia is the best strategy, though it would help to start 30 years ago.
If you make the program no more generous than it is, perhaps even lop off the top quarter or so of its payment structure, then I don’t think you’ve introduced much more of a disincentive for savings among the middle classes, because who the heck wants to live on $2000 a month?
That said, means-tested programs die or are starved into ineffectuality in this country quite quickly so… not sure how to deal with SS, aside from that this magnitude of transfer from the young to the elderly is immoral and unsustainable.
There are lots of means-tested programs that don't die (most never die) or are starved. SNAP, Medicaid, the Disability part of SSDI, the EITC, tax rebates of various types, Roth IRA deductibility are all "means tested" and have grown over time. We could -- and probably should -- do the same with Social Security.
Perhaps. That said, a means-tested program that takes almost 13% of your paycheck is uncharted territory.
I'm more inclined to reduce the generosity moderately and also make all the income fully taxable at all levels, as well as tweaking every aspect of local taxation about 10 notches further against "age in place."
We've run much of the economic policy of the last 50 years as an incredibly generous transfer from young to elderly and it's weighing on our demographics, faith in the future, economic dynamism... if SS collapses entirely it'll be because the Boomers wanted all the seed corn for themselves.
I think you want to encourage people to downsize their home in their 50s or 60s, and then age in place from there. Not age in place in the house where you raised your kids and they moved out, and not move to a facility where you never see anyone younger than 75.
Why against "age in place?" I ask because governments in my area actively support "age in place" programs in part because it saves them money.
However, I recently learned an alarming fact about my state -NY - that may not be true elsewhere. In NY State, not just the city, there has been a 50% increase in older adult poverty even as there was a 22.4 % decline in poverty among the under-65 population.
It's yet another distortion of the housing market that degrades the demographic trends necessary to sustain any of the anti-poverty or health insurance programs we use to support seniors. If we don't course-correct on affordability of family-friendly housing and direct support for child-rearing we are literally doomed, and huge chunks of the next generation of old people will starve on the street.
For the second part... I would have to see the exact measurement used, because on the face of it that seems completely unbelievable.
Every dime that goes to my elderly mom through SS out of my sister’s and my taxes comes back to us in the end so long as we can avoid expensive skilled nursing care at end of life. I don’t see why it’s such big deal.
If the means testing reduced benefits 1:1 then why save if you won't end up with more.
If it was say .9:1 then I'm making a _little_ more in retirement in return for having less disposable income now, and I also probably reduce my savings.
At the other end at .1:1 it will barely reduce retirement savings, but also not save much money.
We could do 0.5:1, and that's my gut feeling, but some savings will be reduced, and so our budgetary savings will also go down
My apologies I must be totally missing something. Why would reducing how much social security benefits an affluent person gets reduce anyone's incentive to have brokerage IRA or 401k savings?
Let's suppose if I save my 401k I can "guarantee" a $60,000 income(current SS Max) and add that to my SS income(60,000).
Great! I've doubled my income.
Now suppose instead you look at my savings then and say"you're rich enough to make the $60,000 on your own, so SS pays $0".
I could have spent that 401k savings on more vacations when I was younger or other fun things. If I'm basically "throwing it away" because I effectively don't get to keep it, I might.
I probably wouldn't end up reducing to $0( employer match, tax advantage), but it seems very plausible I'm less inclined to save.
Again that's at the harshest cliff. If you scale down me benefits more slowly it helps a lot.
How do you operationalize the idea of an “affluent” person? Do you say that social security payments are cut $1 per month for every $100 in savings you have above some threshold?
Anything like that, where the more savings you have the less social security you get, discourages people from saving (because they can spend the full amount now and also get some extra social security later, rather than just save the full amount for later and get less social security).
If you can find some way to define “affluence” that doesn’t look at how much savings people have, you might be able to do this better, but I’m not sure how you do that without making it easy to game.
Honestly, the fact that we don't take a much more serious and systematic look into end of life care is for Medicare is insane to me. While I get that there's politically a very strong incentive to demagogue, and I certainly wouldn't trust this crew, we're talking about $230 billion a year in spending if it's a quarter of Medicare. And how much of it makes people more live longer, happier, more comfortable?
My guess is at least half of that $230 billion is probably wasted by most objective measures.
And that's not including long term care under Medicaid.
The estimates I found on social security means testing were in the $6-$8 billion savings range, if reductions start at $40k per year. One can't really avoid the medical spending issues.
It's hard to imagine agreeing on reasonable choices for rationing care (which is really what you're describing). Heck, the ACA allows states to mandate coverage for interventions of dubious value, like acupuncture and chiropractic, in subsidized marketplace insurance plans.
I'd like to know what you think the objective measures are that you'd use to deny ex ante futile care. You would like it to be obvious, but I'm not so sure it is obvious.
In practice social security has always been redistribution. Which is fine! It's a good program but it is simply redistribution from the working age to the old, and has been since the start of the program.
I guess I feel like "redistribution" is a funny way to put it when the working age become the old at an extremely high rate. It's like saying that when I buy a CD I'm redistributing from my present self to my future self.
You are correct, but that's because some people have a somewhat romantic misunderstanding of social security. You're not going to get your money. Someone else is getting your money on the promise that you eventually will get a different someone else's money yourself. It's intergenerational redistribution
I’m curious why you’re so in favor of means testing. In Germany if you’re the CEO BMW or a hotel maid and you kid gets into the University of Munich it’s €120. And everyone generally thinks they are getting good value for their tax money.
I'm making a more limited case. Specifically, I argue that IF we must cut entitlements to curb the deficit, means testing social security would be the least harmful cut to make.
I argue that (again, IF we must trim these programs) it's immoral to cut Medicaid or SNAP or any other program that specifically benefits the needy instead of cutting social security benefits to people who are well off.
Because they can't make the case for increasing taxes, so instead they argue for a very complicated way of making rich people pay more that distorts everything.
As I said in a discussion with Avery yesterday, there is no reason st all to believe that we can bring (admittedly ballooning) public-sector healthcare spending by looking only at that spending, and not the entirety of the sector, including providers, vendors, private insurers, and state-level regulators.
No one has the spine to do it at present and I don’t know what it would take for enough politicians to grow one on the topic and take *everyone* to task.
I don't know that a courageous politician even can change health care all at once (as much as the WSJ editorial and others might wish otherwise.)
But I think Chris Pope has a pretty good idea[1] *on the margin* to both prevent wealthy states spending Medicaid funds on all sorts of new things and maintain core benefits of the program for the poorest Americans among us.
I'd love to know what Matt Yglesias thinks. His post today feels very Obama-core, which is not crazy given some recent GOP proposals. But the debate over enrolling able-bodied adults into Medicaid on the margin and the Oregon study, well, it's missing the main story of the Biden years which is states increasingly using Medicaid money for literally anything [2].
Like I wish I was exaggerating, but this is what's actually happening. From Chris Pope's report in November[1]:
"Various states now claim Medicaid funds to pay residents to “sit at home” with their elderly relatives—with the cost in New York alone surging from $0.3 billion in 2016 to $9.1 billion in 2023.
Notoriously, all 50 states have increased the fees that their Medicaid programs pay for hospital services, thus entitling them to higher reimbursements from the federal government, while simultaneously imposing taxes on those facilities to finance the supposed state contribution to the program’s expenditure. Often, states have used publicly owned hospitals to capture Medicaid funds as a way to improve their general fiscal situation."
Matt can correctly say the condition of blue state governance should reign in the Democratic party's priorities. Matt can also correctly predict that Democrats could form a popular "hands off my Medicaid" front against any reforms and punish Republicans electorally.
But put together, the latter is clearly helping promote problems in the former.
WA pays relatives state minimum wage + state employee health insurance as in home caregivers to keep people out of nursing homes, and while I’m sure there’s some abuse of the program, I think it’s considered to be wildly successful both from a cost and an outcome standpoint. Nursing homes are really horrible places!
Ah well my preferred pay-for is a lot more on the Medicare side of things, alas the Obama-Boehner talks breaking down on that altered our timeline forever.
I mean... give up on extending the TCJA at all, much of it is spectacularly bad, distortive policy, and there is just no way, and you know this, that we're going to squeeze enough to close the deficit without raising taxes somewhere.
Letting federal revenues creep all the horrific way up to 20% of GDP is the least of the possible evils in front of us.
If you need some kind of sop to the SME-owner base, simplifying and lowering corporate taxes and easing capital and R&D expensing are *good* Republican ideas, use those please. Pay for them by unfucking the foreign revenue accounting standards permanently.
As for Medicare, site-neutral payments and expanding drug pricing negotiations are a freebie, in that we need not cut anything to wring substantial savings out of them. Not sure what else is out there you think worth doing.
But at the end of the day, without dealing with how opaque, convoluted, and simultaneously over- and underregulated the private side of healthcare and health insurance has become, it's going to be very difficult to keep Medicare and Medicaid from helping bankrupt us in the long-run.
Matt said it in passing but it need saying again this is all about maximizing the size of the tax cut. Democrats should have been railing about the 2017 Tax Cuts for the Rich and Deficits act since then and killed it in 2021 as part of the way to pay for recession relief.
The simplest explanation for why Democrats do not raise taxes/undo TCJA with their trifecta is that they do not have the votes and do not agree as a coalition to raise taxes. So operationally, the party isn't really in as stark disagreement with Republicans on tax rates as they can appear.
The stark disagreement is whether to slash Medicare and pocket the deficit savings, or slash Medicare and use the CBO scores for partisan bill funding.
The thing that I find most hypocritical about this is that republicans are essentially saying "we KNOW that there is lots of criminal fraud in the Medicaid program, so we are going to defund the Medicaid programs by that amount. That will result in the fraud being eliminated without having any negative impact on beneficiaries, services, or providers."
When progressives (stupidly, IMHO) proposed the exact same thing ("we know that there is a lot of bad policing going on, so we're going to defund the police to eliminate the bad behavior and this will result in less crime") everyone on the right (correctly) pointed out how absurd the claim was. Now they're turning around and making an identical claim in the health care space.
To be clear, I'm aware that they're doing this because they're full of crap and lying. But the hypocrisy is especially galling to me.
Indeed, insofar as the goal of cultural expenditure is to enrich the lives of the mass public, space flights do this to a far greater extent than the fine arts (because the masses literally could not give less of a shit and are deeply unimpressed by art being produced today). If you've seen a little boy watch a rocket takeoff from the Cape, and then you've taken that same little boy to the Met, this becomes immediately obvious.
It's not waste. You're doing literally the thing the conservatives are doing, where you disagree with the objective and then say the money is waste. The government is purchasing manned space flight missions for a certain amount of money. The fact that you don't think the government should be purchasing manned space flight missions is irrelevant to the question of how much waste there is in government spending. It would be waste if we were trying to purchase "manned space flight to Mars" and then we kept spending money on manned space flights that aren't going to Mars, or something.
Also, it goes without saying, but zeroing out the budget for manned space flight is not actually a significant reduction in government expenditure. It's not the Apollo program where absurd sums are going to it every year, it's a very modest program that hasn't even sent someone beyond Earth orbit in ages.
I struggled to respond to this but it really is a perfect comment esp. given your handle, it should be in the DNC party platform. Really encapsulates the liberal mindset. I mean this unironically. Of course, I completely disagree.
Yes, agree with you totally, a large part of the program was kicked off by the Dems! Would like it if this kind of viewpoint didn't appear so dominant on the left though
I think this take is out of date. Gil Scott-Heron is dead. Whatever NASA opposition remains on the left is totally drowned out by “I fucking love science” celebration of space exploration: the rovers, the Webb telescope, all that. (It’s true liberals love to hate private space exploration, but we’re talking about government waste here.)
Obviously it can depend on the circumstances, but for big investments yes, bigger is better.
For example, I just read a WSJ article on how Larry Ellison one of the Co-Founders of Oracle is trying to transform farming. He's already lost 500 million doing it.
But since he's so rich, he can afford to try and do a real moonshot.
Every time "efficiency" comes up, I will forever post that efficiency is a process you pursue to something you are already accomplishing. And it is a red herring in any other discussion.
That is, any discussion about trying to bring efficiency to a system is about as helpful as discussions that you should run faster to win a race. To a useless degree, this is certainly true. The question is how.
And with spending, if you don't build a system where you are comparing the ROI of different expenditures, then you are blindly cutting spend in a vain hope that you will strike gold.
Making "efficiency" the goal, though, is ludicrous. You don't pursue efficient solutions, you pursue solutions and optimize on working ones to make them efficient. Any other effort is akin to telling an artist that they cannot make prototype works. After all, every prototype is wasted effort in the path to a final product. And if you try to cut resources to working solutions without an eye to what they were accomplishing, you are likely to kill more than you are to increase efficiency.
I'm starting to think schools should focus more classes on basic gardening. A mental model of pruning trees is more effective than whatever mental model is leading many of the cuts we're seeing.
"My 10-year-old child has, fortunately, never had any major health problems."
Heyyyy, anecdote time!
One day, when I was ten years old, I felt a weird pain in my abdomen. It wasn't even that bad, but I mentioned it to my mom. Her instinct/Spidey Sense told her something was up, and she took me to the emergency room, even though I thought she was overreacting.
The nurse at the ER palpated my abdomen, said to my mom "Oh my God, her appendix is about to burst, WHY DID YOU WAIT SO LONG TO BRING HER IN" and wheeled me into the OR asap. (Apparently I'm built in a weird way such that even severe inflammation of the appendix caused me only mild discomfort?)
Without that, I would have died at the age of ten, probably very painfully.
This is the thing about medical care: you don't need it, until you do.
I'm a former academic health care person and a current critical care nurse. One thing that should probably be added to this conversation is that Medicaid subsidizes everyone's health care in the hospital in ways that are probably not obvious.
Just to take one example, the high-end equipment in a major urban hospital is incredibly expensive, plus it has high hourly operating costs (the labor or technicians, the drugs used in imaging, etc.), and you have to pay for the labor even if you don't use the machine because you need to keep the techs on hand for emergencies. If someone has a stroke at 4 am, you need to know whether it is a brain bleed or a blocked blood vessel, because the treatment for one will kill the patient with the other. So the machine effectively has a constant baseline operating cost even when it is not running. To make that equation work financially, the hospital needs that equipment to run 24/7--this is why I'm often rolling patients back to radiology at 3 am.
But you can't fill that imaging suite with paying patients unless you have the patients to start with. That's where Medicaid and -care come in. Medicaid, especially, pays lousy reimbursement rates, but lousy reimbursement is way better than nothing, particularly when nothing is actually a constant operating loss.
So even if you are a wealthy person with very fancy insurance, the bottom line is that you can get imaging when you come to my hospital because the machine's operating costs are being subsidized by all the poor people in the rooms all around you. There's just not enough wealthy patients to make the math work otherwise. You encounter this phenomenon in smaller and rural hospitals; it's one of several reasons why they just flat don't have the kind of equipment that you find in the major urban medical centers. There are simply not enough patients to subsidize the equipment.
You're anecdote reminds me of one of the biggest "glass shattering" moments I had when I first started getting deep in the weeds of policy probably from reading a Paul Krugman column; how much we subsidize rural living*.
I try not to take it personally if someone from rural area rants about New York City and how many "welfare queens" there are or "takers (not these exact words of course, but the sentiment is there) from New York City. But man oh man it's hard for me not to be like "f**k you. My tax dollars subsidize you're lifestyle ass hat".
Now I know this not a sentiment I should be having. Apropos to this post, my tax dollars going to Medicaid is top of the list of where I want my tax dollars going. And I'm aware that we're the weirdos who follow the news every day, most people are not paying attention to the day to day craziness of Trump show 2.0 and weren't really paying close attention to the 2024 election. And that a lot of people have very random and esoteric reasons they voted for Trump; reasons that even if I don't agree with I can at least understand. These proposed Medicaid cuts and these ludicrous tariffs on Canada are going to harm some very good people who voted for Trump.
But you know what. To the die hard MAGA heads in these areas. The ones who do supposedly pay attention to the news, fly the flags, etc. You reap what you sow dickheads. You're party is the party of personal responsibility? Well here it is, you get to experience the consequences of your choice. Have fun with this gigantic hit to your export based economy and have fun with rural hospital closures due to lack of Medicaid funding. Sorry not sorry that a blue haired transgender activists was too shrill on Twitter and pushed Kamala Harris to take an untenable position in the 2020 primary. You little snowflakes, you're getting what you deserve at a certain point.
The cities have won, dude. Rural America is demographically moribund and will only become moreso as we further automate much of the secondary sector fields which support agricultural, forestry, mining, and O&G work.
Sure, the rural areas are voting like fucking morons because of that resentment, but the spite is unnecessary, they're hurting themselves most of all.
Ain't gonna be nobody out in bumblefuck in another century but the robot combines, the temporary, month-on-month-off workers servicing them and the automated silos and processing facilities, and a scattering of people who hate dealing with other people and live on their own little 5-acre plot with a well, a septic tank, a big-ass battery, and a big-ass solar array.
I mean you're harsh but possibly right.
Sort of oddly too; it's in GOP self interest to continue to subsidize rural living. I know urban areas had a shift to Trump in 2024, but in general it's still demonstrably true that the more urban area the more likely to be Democrat and vice versa.
The fact that we subsidize rural living as much as we do means there are a whole lot more people who live in rural areas than probably should. Which means there's a whole lot of people who are voting Republican for cultural reasons that would probably be less likely to be voting Republican if they lived closer to cities (if I'm not mistaken the politics of immigration have this quality. Again, with caveat that the areas of cities that seemed to shift most to GOP are recent immigrant communities that were more likely to have to deal with on the ground recent migrant arrivals. The duh point of the day, reasons why voters shift preferences can be multivariate and there are countervailing forces at play).
Upshot is this is why I'm still a little skeptical (though that skepticism is diminishing) that GOP will actually follow through with Medicaid cuts considering how acutely damaging it is to their own constituents and how damaging it could be electorally.
Most of the subsidies for rural living are mechanistic consequences of "we build infrastructure to get rural goods to urban markets for sale, processing, or export," "we don't let retirees starve or die of preventable illness," and "we have a basic safety net for the very poor."
Are they also subsidizing rural living? Yes. Is that their purpose? No. Philadelphia receives extensive federal and state money for the same reasons.
We can quibble about "economic agglomeration," "productivity," "free-riding suburbs" blah blah blah... and I agree about all of those points, but to the middle-class suburban American median voter, urban cores are subsidized in exactly the same way as rural regions, and this understanding isn't really wrong.
From Mr. Krugman
"As I noted the other day, West Virginia overwhelmingly votes for Republicans, yet the state is deeply dependent on federal programs, especially Medicaid, that Republicans have singled out for savage cuts. One thing I didn’t point out is that these programs do more than provide red-state residents with health care and help families put food on the table. They are also, directly and indirectly, one of the few major sources of jobs. There are more West Virginians working in hospitals — largely supported by Medicare and Medicaid — than there are mining coal."
I don't see how this is a rejoinder to what I said above.
So you're saying DOGE will cut rural subsidies, and rural voters ( I think the word is overused here and is kind of standing in for smaller cities, too) will move to cities / bigger cities and vote Democrat? It's Elon's 4d chess plan to elect a Dem in 2028?
sounds like someone just watched Interstellar (not a pejorative, it was interesting seeing the "farms of the future". pretty depressing sight)
* Sort of on cue, but basically the subject of one Krugman's most recent substack posts. https://paulkrugman.substack.com/p/the-economics-of-left-behind-regions
I'd distinguish between subsidies for the poor which pay out regardless of where one lives, like Medicaid, where areas like the rural South just happen to have more poor people, with direct subsidies for rural areas like rural free delivery from the post office. I'm opposed to the latter, not to the former.
To be clear, I'm very against Medicaid cuts. I mean my whole second paragraph is devoted to the fact that I think it's cruel as hell to punish people with Medicaid cuts; whether they are rural Trump voters or urban Trump voters or rural or urban Harris voters.
But yeah, I'll stand by claim that for the hardcore Trump supporters, the ones who voted him with enthusiasm supposedly eyes wide open, yeah you're getting what you voted for, there's a certain part of me who really does say "you deserve this".
But that feeling I should be clear, that contempt, is way way way stronger for those at the top of the income scale; Wall Street titans who gave him money. "Bro" ligarchs and the such. All of them, if you brushed off this Trump threat as "lib hyperventilating" every single of one you can go completely hell if nothing else for exposing yourself for being complete and utter idiots. "Wait the, 'leopard who eats faces' guy is actually trying to also eat my face?!". Yeah, who could have guessed based on the most cursory reading of history books. Heck, I'd say go ask those Russian oligarchs who were shoved off balconies in London if you could.
It's alright I'm much more libertarian than you. I'm completely fine with cutting off all of the indirect subsidies for rural living. Keep the neutral programs that pay regardless of location. Let the chips fall where they may. All the people who bitch about cities will move to a nursing home that's most likely within a metro area. They'll bitch but they'll get over it.
And yeah, the fact that Trump may fuck over farmers is hilarious.
Hell, even what equipment there is in rural hospitals exists because of Medicaid and Medicare. No way in hell there's a healthcare services market outside the top 100 metros or thereabouts at all without them.
Hello again, btw. How's nursing in Philly treating you?
I f-ing love being a nurse. It's so great.
In some ways, it is a deeply selfish thing. Last time around on the Trump clown car, I had to reckon with it in my actual job. I had to go into my public health classes and talk to students about what was going on and so on. And the news is so profoundly sad right now. Global health was one of my specialties, so when I read the news about stuff like USAID and the PEPFAR cuts, it feels so bleak. Sometimes I just kind of genuinely want to cry.
But when I go to the hospital, I'm on for 12 hours, and I don't have to think at all about that stuff. I have this guy in front of me with a gunshot wound that blew his neck away, and we're dealing with those problems, and that is more than enough to consume all of my attention. Plus I go home so exhausted that I fall into bed.
It also feels incredibly satisfying to put all of the stuff I preached as an academic into practice. All the esoteric training I did in stuff like bioethics comes up in ways that impact my nursing practice almost every day. Because of the type of unit I work on--high acuity, burns, traumas, addiction issues, end-of-life patients--I have a lot of opportunities to confront and work on the public health problems that have always interested me. But I also see a lot of complicated and interesting medical problems that keep the puzzle-solving causal-analysis academic-y side of my mind engaged.
And I love the manual work. Doing dressings on someone with severely burned hands is genuinely difficult problem. You have to do the wrappings in ways that allow for the mechanical action of the fingers and also design everything such that it doesn't rip the skin off and cause the patient intense pain. I treated someone this weekend who screamed when I undid the prior person's wrappings, but the next day mine came off cleanly, and by day three I had worked out some really nice little gloves. When you get a hard-to-stick patient on the first try for blood or an IV, that's just so deeply satisfying (flip side: when you miss and have to do it again, it is so intensely frustrating to cause your patient additional pain).
I still have so much to learn, and that is also exciting. I'm not a good nurse yet because there is simply no substitute for practice--the only way to get better at sticking people is to stick people, and I am flatly not as good of a nurse as I will be a year from now. But I can see the improvement, and that feels rewarding.
So I love being a nurse. At a time when it feels like America is relentlessly embracing and celebrating cruelty, and by "America," I mean "my own family in Texas," I get paid to go help people and put my values into practice, at least at the individual level.
There are enormous problems in health care. All the systemic and policy failures that I could describe in agonizing detail as an academic: they are all there. I live them, every day. It's frustrating. But I think that because I knew all that stuff going in, it doesn't hit as hard, and at least now I can fight the good fight on the actual ground.
Nominated for comment of the week candidate.
Comment of the year!
"In some ways, it is a deeply selfish thing."
No, it isn't, it's completely warranted and psychologically healthy. I have completely checked out of the 24-hour news cycle this time around, I chat here and elsewhere about policy, I'll write my congressfolk when very warranted, and I'll vote, but I ain't following the minutiae because it accomplishes nothing.
"I have this guy in front of me with a gunshot wound that blew his neck away"
Hopefully, given the vast improvements in public safety in Philly from when you started training for this career through today, fewer of this sort of thing than was the case a year ago?
"And I love the manual work."
Tell me about it. I spent the last year overseeing and doing a huge amount of the physical work for the building of a 3rd story on the house. Much more fun and much more satisfying than my day job.
I am glad this is a more fulfilling way to work than your last career, your enthusiasm shines through when you talk about it.
We have to corral a Philly SB meetup soon and see who else is still around. Kareem pops in occasionally, I know.
Amen and keep preaching. You seem to be genuinely God's work and I salute you for it.
"But when I go to the hospital, I'm on for 12 hours, and I don't have to think at all about that stuff."-->You're severed from Trump's World for 12 hours!
Thank you for what you do. Godspeed!
You raise a good point that some Medicaid dollars indirectly benefit others by increasing the patient pool. Even with low reimbursements, if they’re above marginal costs, they help cover part of the hospital’s fixed costs. But this typically isn’t called a subsidy. It’s more like a senior discount at a movie theater—if the price is above marginal costs, it helps cover overhead, but we wouldn’t say seniors are "subsidizing" other moviegoers.
In both cases it's usually framed the opposite way; full-price ticket payers are subsidizing seniors, or private insurance is subsidizing Medicare/Medicaid patients.
You're right that in either case it's not truly a subsidy, it's price discrimination by the provider (distorted in healthcare by the legal and negotiating leverage of Medicare/Medicaid).
I guess we could have a weird argument about what, precisely, constitutes a "subsidy" but I use the term to mean that the government provides resources--in this case I mentioned Medicaid, but the reality is that there are a lot of different revenue streams coming from the government and even some in-kind services, all of which directly impact not just the hospital's budget but the availability and price of specific hospital offerings--to keep prices on a desired service--in this case, the availability of hospital care--lower for members of the public.
In the absence of that government provision, certain kinds of medical care would be unaffordable for a majority of the public who might desire it. As I said, you can see this mechanism in action in rural areas. Anyone with enough money can absolutely get any kind of medical scan they want if they live in rural Texas; helicopters and airplanes are a thing in the world, and for enough money one will fly you to anywhere you want to go for any kind of medical imaging you want to get. But as an ordinary person, if you get injured in Crockett, TX (where my family is from), certain kinds of medical care are simply not available, period, on any kind of realistic timeframe because they are de facto "too expensive," once you factor in the cost of transport. As another commenter pointed out on these threads, even the existence of a hospital in Crockett is maintained only by direct, explicit government subsidy.
Is Medicaid, in particular, a "subsidy"? You can obviously quibble with how you want to describe these policies, especially one like "Medicaid," which is really more like an umbrella term for a whole basket of different policies, revenue streams, and funding mechanisms. I taught health care policy in a number of undergraduate settings over the years and have a pretty good handle on the underlying legal frameworks. The subject of EMTALA alone is really fascinating, and we could blow a day talking about whether it gives the U.S. an under-the-table "universal healthcare" system (my answer: kind of! but in the stupidest, least efficient possible way). But I think we're kind of veering into pedantry, here; the bottom line, as you agree, is that wealthy patients in my unit benefit from the presence of the non-wealthy patients all around them in ways that are not necessarily obvious to laypeople.
>I guess we could have a weird argument about what, precisely, constitutes a "subsidy"
One of my rules for life is to never argue over definitions!
That's a good rule.
I thought a bit about what you wrote, presumably because it's my day off, so I have the time, and I'm kind of a weirdo that way.
I think the key thing about your senior discount example is that you are misunderstanding how Medicaid works. Medicaid is more like a scenario where the government pays for seniors' movie tickets as a matter of policy in order to make it possible for seniors to see movies, but the reimbursement is only $5 per senior or whatever and only for qualifying seniors under certain economic circumstances and for particular classes of movie and movie theater.
Also, the movie tickets are provisioned under what is essentially a shared governance and financing structure involving both the state and federal government.
Okay, and a lot of other stuff. Sorry, I'm thinking it through as I type.
Bottom line: the movie ticket thing probably doesn't really work as a model for understanding the medical system.
But extending that analogy way too far, the government would be taxing non-seniors to pay for the senior discount. So overall it would be a subsidy from non-seniors to seniors.
In this particular case, since maybe a minority of the population goes to movies, maybe an in-depth analysis would conclude that both senior and non-senior movie goers on net benefit from the tax to pay for discounted senior movie tickets and it's an overall subsidy from non-movie goers to both seniors and non-senior movie goers.
But I suspect that doesn't extend to healthcare where practically the entire population is covered by private insurance if they don't have government insurance. I'm open to evidence showing otherwise, but I strongly suspect it's on net a subsidy from non-Medicaid individuals to Medicaid individuals (even if it's not quite a 1:1 subsidy because of some indirect benefits such as the ones you cited)
It's a genuinely interesting question. Thinking it through off the top of my head, I think your initial analysis is broadly correct: it's a subsidy from taxpaying non-users to all users.
You have to remember that even though the general population, as you point out, is covered by private insurance, a huge portion of the general population is not making use of medical services--certainly not of hospital services. And the private insurance is partly built on this model; statistically speaking, you expect to make maximum use of hospital services when you are older, and your private insurer hopes by that point to offload you to Medicare (or at least to move you into a government subsidized plan Medicare Advantage plan).
If you look at the premium structure, private insurance really doesn't pencil out if the insured have to use the services. It is--and always has been--a bet by insurers that the insured (and their employers) will pay the premiums without accessing all of the theoretically-covered services. That's why the whole system would more or less collapse without Medicare: old people use the covered services at financially catastrophic levels. It's also why, even though we think of Medicare as the "old person" insurance and Medicaid as the "poor person" insurance, there are programmatic carve-outs for certain forms of care--dialysis is the classic case--that are totally unrelated to those frameworks. Dialysis was just straight-up too expensive to afford when the technology first became available, so Congress was just like, "Eh, whatever, anyone can have dialysis, regardless of age, and we'll stick it under Medicare."
I can tell you for certain that a majority of patients in the hospital are covered under either Medicare (including Medicare Advantage) or Medicaid, and since end-of-life care consumes the most services and resources, an even larger share of the money for in-patient care comes from those two revenue sources. That's why I think the proper description is probably subsidy from taxpaying non-users to all users.
But you also have to account for availability of services. For a lot of specialized forms of care, you can't raise prices enough to justify offering the service without the subsidized patients; this is why that care functionally does not exist in lots of places.
So if there are, for example, eighteen beds on a specialized burn unit, and only two of them are used by privately insured patients (and that ratio more or less accords with what I actually see), are the two patients subsidizing the other sixteen? It's the wrong question. Absent the other sixteen, you wouldn't have the specialty unit. The two private patients would have to make do on a regular med-surg unit, and they simply would have to get along without nurses and doctors who have specialty burn training, which means the care would be a little worse, full stop. Probably not catastrophically worse, but worse.
That's why I think that subsidizing demand is an important part of the story. But I do think you are correct that the subsidy is largely flowing from younger, taxpaying non-users to older or sicker (i.e. the young person with end-stage renal disease requiring dialysis) users, with private insurers essentially providing a certain level of catastrophic coverage and administrative support to the younger taxpayers and then offloading them into the taxpayer-supported system once the person begins consuming services because they become too sick, too old, or both.
It's a real Rube Goldberg machine.
Intermediate Surgical ICU. It’s kind of a catch-all for ED cases who are not strokes or heart attacks. In theory we are primarily traumas, nec fasciitis, burns (our hospital is a burn center), but we also see a lot of emergency vascular of various flavors, the bad withdrawals (because we can do drips), and the long-term vent/liver/wound cases that get bumped down when the hospital is desperate for ICU beds (that’s how we end up with anoxic brain injuries).
The wide variety is a big reason why I like the unit. you never know what you’re getting when you walk in the door. Sometimes we’re running a tele med surg unit, sometimes it’s a poor man’s ICU with too few nurses for the acuity level, and sometimes it’s a psych ward. eventually, I would like to move down to the ED, get a couple years experience, and join a trauma team. But I might be too old.
Are you a neuro ICU nurse?
Edit: based on your other comments, I’m guessing ED or trauma ICU. Cheers to that. I’m a pharmacist and really enjoyed my clinical rotations in a level 1 trauma center. I ask because my husband is a neuro ICU nurse and because of that a fair proportion of my group of friends are critical care nurses.
Intermediate Surgical ICU. It’s kind of a catch-all for ED cases who are not strokes or heart attacks. In theory we are primarily traumas, nec fasciitis, burns (our hospital is a burn center), but we also see a lot of emergency vascular of various flavors, the bad withdrawals (because we can do drips), and the long-term vent/liver/wound cases that get bumped down when the hospital is desperate for ICU beds (that’s how we end up with anoxic brain injuries).
The wide variety is a big reason why I like the unit. you never know what you’re getting when you walk in the door. Sometimes we’re running a tele med surg unit, sometimes it’s a poor man’s ICU with too few nurses for the acuity level, and sometimes it’s a psych ward. eventually, I would like to move down to the ED, get a couple years experience, and join a trauma team. But I might be too old.
I work in healthcare and the amount of care that is done to placate families rather than help the patient seems notable.
Sending patients post anoxic brain injury to vent farms until they die years later of pressure sores is common, pointless, and cruel. Likewise is subjecting the Alzheimer's elderly lady to forced dialysis, again, for years. Dementia patients in general are treated poorly - they don't understand the painful things we do to them, yet we do them anyway.
We've done a lot to eliminate the paternalism in medicine. This is (probably) broadly a good thing. However, the family members of these patients would do well to have someone make a decision for them, to remove the guilt that they have for 'giving up' on their parent. The economic benefit of treating these patients is nil and the moral injury is high. Yet we do it anyways. This isn't the case in other countries.
We need government panels of experts to determine what sort of treatment late stage patients can get, have it balance the improvements to their lives and the financial hit on the healthcare system.
The acronym for it should spell out DOGE.
With some help from chatGPT: Department of Optimal Geriatric Expenditures
Optimal Geriatric Expendables
Sometimes the care is done for the bottom lines of the facilities.
In her last years of life, my mother had a stroke. She went to a rehab place, and got great treatment. But then she went to a step-down rehab, and although she got treatment and was making some slow improvement, it was clear to us, her children, that she would be better off going home to her senior community. She had Alzheimers and was declining, and we wanted her to be able to enjoy what life she had remaining instead of being locked up in rehab jail, spending all day in a hospital bed.
So we tried, and tried, and tried, to spring her, and the facility would not discharge her. For weeks. They threatened that if we discharged her against medical advice, Medicare would stop paying for all her care.
Finally, after about a month, might have been even more, someone told me about the state Medicare ombudsman. I called, they scheduled a site visit, and suddenly the facility said Mom was ready for discharge. I'm still bitter
I am so sorry to hear this, but not surprised. I have similar stories. I don't blame you for being bitter.
Putting feeding tubes in patients who won't/can't eat due to dementia is another example of wasteful, hurtful intervention. Studies have shown that feeding tubes in demented patients are associated with numerous complications and don't even prolong life.
My understanding (based on a hazy recollection, quite possibly wrong) is that stopping eating and drinking is actually a relatively peaceful way to die.
I think that's right, even though it seems counterintuitive.
People feel bad not feeding people, and even if feeding tubes don't actually decrease choking, feeding people by mouth who actively choke on their food seems unpleasant.
EDIT: Also I presume a happy by product is tube feeding is more efficient; you can set it and somewhat forget it rather than helping actively feed someone.
It turns out not to be true that it is more comfortable to have a feeding tube. If you are so demented that you won't or can't eat, there is little evidence that you suffer by not being fed. On the other hand, if you have a tube, you're likely to try to pull it out, leading to emergency care, or you need to be restrained, which is a different kind of misery.
This has been well studied.
The family is much more comfortable feeding the demented patient, however. And that’s who the customer is at that point.
They may be the customer, but they're not the patient. My first responsibility is to the patient. And I need to try to keep costs in mind. I'm not just selling widgets.
Edit: to be clear, except for minor stuff (keeping a dying patient on a ventilator long enough for the family to come say goodbye), it's poor medicine to do futile, expensive, and possibly harmful things just for the family.
But the family is making the decisions at that point, so what they say goes unless you get multiple physicians together along with an Ethics committee.
It is done to placate the families and also to avoid lawsuits. We need tort reform in the medical space. Keep the ability to sue doctors -- they make mistakes, sometimes egregious ones -- but cap the liability at reasonable levels so insurance isn't prohibitively expensive.
Are health costs appreciably lower in Texas? A quick Google suggests that the biggest studies in the impact of 2003 tort limitations is either zero or possibly even negative (in the sense of insurer losses per enrollee going up slightly, although premiums also decreased so who knows.)
In some places, Texas had notably high costs for reasons mostly unrelated to liability. This is an interesting exploration of McAllen, which I think was once known for having the highest healthcare costs in the country but apparently has changed a lot. https://www.vox.com/2015/5/6/8560365/health-care-gawande-mcallen
Tort reform doesn’t change treatment choices.
But it makes doctors less likely to do CYA type procedures.
It doesn’t. They act identically as they did prior. We have lots of experience and data on this in Texas, where we did tort reform 2 decades ago.
Well that’s annoying.
E.g., https://www.nejm.org/doi/full/10.1056/NEJMsa1313308
It is drilled into doctors from the first day of training that the greatest sins are to miss a diagnosis they could have made or to get the diagnosis wrong. they shoot for literally no mistakes. That's what causes all the supposed CYA procedures, it is deeply instilled in them that they have to be as sure as is medically possible.
Agreed. I think most practitioners hate realizing they made a mistake that harmed or killed a patient far more than they hate a lawsuit.
I wouldn't want a doctor that didn't hate that.
Huh. Rare disagree here. I think uncapped liability is the free market doing its job. If we're concerned about the supply of doctors, there are a lot of other policies we can pursue to fix that.
A monopoly of a jury panel is hardly a free market
What do you propose?
We already have caps on punitive damages. See examples of Texas and SCOTUS. And these are important because (two examples)
Gun toters love the PLCAA because it lets them making guns without fear of being buried in civil suits. And the general aviation industry would be decimated if the general aviation revitalization act doesn’t limit their liability either.
35 states have already instituted tort reform that caps non economic damages. It doesn't change medical practice.
I want to pound-the-table endorse this comment.
Pretty much the only times I have ever cried after work was when I was trying to help families to work through this set of issues.
When we get a certain kind of anoxic brain injury--especially when it's a young person with a certain kind of religious family--you can basically just watch a cloud settle over the unit. It's not just that it's so f-ing sad; it's so intensely frustrating and infuriating. The family doesn't mean to gaslight you, but that is basically what they are doing. It's like the proper response to what has happened is to mourn, and when you see sad and tough stories on the regular, I feel like you learn how to mourn pretty quickly. But then when people aren't ready to mourn--when they resent you for your mourning--it really hurts something deep inside.
I’m not disagreeing, just asking what you propose then.
No dialysis for an old lady with Alzheimer’s- ok, makes sense. What happens if you forgo her dialysis? Metabolic waste products will build up in her blood and eventually kill her. How long will that take? How painful is it? If it’s painful, what do you do, just keep her drugged so she can’t feel it until she dies?
What do other countries do?
I’ll come right out and say it: under what circumstances is euthanasia the right choice, including for a patient who isn’t mentally competent to understand what’s going on?
I assume most palliative care is pain management. The dialysis may prevent this pain, but not the next thing’s pain.
No dialysis is one of the better ways to go. You can just put people in hospice care, either at a facility or at home. Ironically when patients go on hospice they get much more paid for care support than they get at other times of their lives.
Huh. I assumed toxic waste buildup in the blood would be painful, am I wrong? Does the person without dialysis just kind of painlessly become unconscious and slip away? How long does that take?
Any medical professionals, I'm too lazy to Google, can someone comment on this?
Well, as long as you can manage the nausea and the fluid buildup doesn't get too bad, they will then get to a point of sedation.
You get itchy and nauseous, and generally feel poor in general. All of this can be managed with medications. As for how long, it varies.
My grandmother died at home in a couple of weeks. If its in hospital hospice, it's a couple of days usually because if its any longer we really do try and get them home. Nobody wants to die in a hospital bed.
I interpreted "no forced dialysis for Alzheimers" not as a cost-saving measure (although it is) but as a human decency measure. They're being strapped into a machine and they don't know why.
I understand that, my question was "if this patient doesn't get dialysis, that will cause pain/death, what are we doing about that?"
Yeah... Don't work in healthcare but have witnessed this first hand. Witnessed a family friend's wife drive him to chemo every week at age 87. He looked like hell, but I could tell she didn't want to let go. I don't know how you have that conversation.
I am deeply committed to having those conversations with families, and I have to tell you that it is really, really hard. You go slow. You try to kind of open the door and help them to start seeing it a little bit at a time. It's really rewarding when you get there. But a lot of times they just reject it, and sometimes they reject you for trying. I don't cry very often after work, but every single time it was over some version of this issue. It's way more painful than having your patient die.
I intend to have this conversation with my family before I'm at that point. If I'm past... I don't know, 85 or so, and it doesn't look good, just give me palliative care please.
I shadowed a doctor in college while debating life paths, and one patient we checked in on stuck with me. It was a woman in maybe her 60s who was hooked up to tons of machines to do what her organs couldn’t—I didn’t even know some of those existed up to that point. The doc I was shadowing mentioned she wouldn’t be waking up again (no clue what happened to her).
The woman’s husband was there when we stopped in and he thanked the doc for everything. It was surreal because clearly the doc thought it was all pointless. Of course she didn’t mention this to the woman’s husband, but it was so strange.
I had a healthcare job and I remember the first time I saw a report for a screening colonoscopy performed on a patient with advanced dementia. I don’t want to think how terrifying it must have been for those patients, but stuff like this happens because families are not willing to let the person go.
You're right it can be terribly traumatic for them. Here are some anecdotes of invasive care from a /r/nursing thread.
https://www.reddit.com/r/nursing/comments/1ghupx0/gutwrenching_feeling_after_straight_cathing/
There is a scene in the movie "The Savages" that has stuck with me years after seeing it.
Very quick summary is the movie stars Laura Linney and Philip Seymour Hoffman as brother and sister trying to figure what to do with a father who is clearly slipping into dementia. They're debating which facility to put there father in. And well, let me show you the clip because man o man it gets to the heart of what you're getting at:
https://www.youtube.com/watch?v=UIhOrVE1wIs
You should check out “The Pitt,” it’s a new medical show and the first ever hyper-realistic one.
I'm very much in favor of ending heroic end of life care. It's cruel to the patients and a waste of money. If patients actually want to waste their own money doing so (and they usually don't) then fine. But it shouldn't be tax payer money.
Resources are limited. There are tradeoffs in life.
Also spend more money on anti-aging research.
I don't see it posted yet here, so I'll share my personal touchstone for this concept, an old SlateStarCodex post from when Scott was a young doctor working in hospitals:
https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/
You should probably note the actual dollar amount, here? Not that I really disagree with your overall point, but I am growing increasingly of the mind that any discussion that is focused on a cost that is less than 1%, say, is probably not that notable?
Should we pursue making things better there? Absolutely. But this begs the question that we aren't doing so. Is that the case?
"in 2019, 10% of all healthcare costs in the U.S. were spent on end of life expenses, for a grand total of $365 billion. "
That's probably about
https://www.ethos.com/life-insurance/end-of-life-expenses/
According to this costs have increased 13.13% since then (which seems low, but whatever)
https://www.officialdata.org/Medical-care/price-inflation/2019-to-2024?amount=365
So total cost of about 6% of total federal government spending.
So pretty significant
End of life expenses, though, is a rather large bucket. Examples used in post were brain damage survivors and dialysis. Which will you cut? And how much is each of those in this bucket? My gut is that each of those is almost certainly smaller than 6%.
So, is there a single segment of "end of life expenses" that would be an easy target that makes a dent? If not, which segments would you target?
Each part of a large line item is by definition smaller than the total, so I'm not sure how useful this line of thinking is. Yes, we want to make a dent in costs overall, but there's no simple "healthcare for people over 80" style segment that's going to cut costs in one fell swoop. And if there were, it probably wouldn't be politically feasible. Or if you think there is, I'd love to hear what it might be.
In practice, the government would need to make a large number of changes that are individually meaningful and also add up to a big total.
My point is the talking points will be over the emotionally charged parts, ignoring that the majority of this large item is not something that can be saved. All the while, any productive conversations that could be had elsewhere are being drowned out by the emotional charge that is attached to these.
Putting it with my other thread. You can have two goals here. Effective and humane end of life care. Or optimizing the existing end of life care to make it more efficient.
That is, making it more efficient is not changing it. It is looking to do what we are currently doing, but with fewer resources.
I don't think this is an area where anyone has done detailed research, unfortunately.
However, I see daily people with no meaningful quality of life wasting away on vents, and I work at a hospital. As in, that is precisely where we try not to keep those people because of the cost. My brother works in a long term acute care, which is where ultimately they end up.
These are people who do nothing all day, do not respond to their name, perhaps briefly flutter their eyes to their loved ones, are fed via a tube from their skin tunneled to their stomach, soil themselves, have a urinary catheter, and with us only show at best a reaction to what we call noxious stimuli. Or in layman's terms, pain.
You can exist in a state like that for a prolonged period of time. We're generally good at keeping people in a state of flux, where they repeatedly are treated for recurrent infections, pressure injuries make small amounts of progress, and perhaps their vent settings decrease to 'room air' oxygen. But their mental state never improves. I can't imagine many of them would choose to live like this.
I would certainly cut that first. Facilities like my brother's shouldn't exist. Truthfully though, I have no idea how much of total healthcare spending that really is.
In general I feel that if you don't have a mental quality of life we shouldn't be performing heroic efforts.
Again, in a discussion about cutting spending, I insist on centering it on costs.
Normally, I would say it is fully fair that we can work on all of these things. That is almost certainly true. That is, I am not saying we shouldn't also get better at end of life care. Both smarter and more humane.
But when discussing costs, it is hard not to see highly emotionally charged diversions as... well, diversions.
I'll continue to favor leaving those decisions up to families rather than disinterested panels of supposed experts. There is no actual expertise that can be deployed because each instance is unique and involves decisions about quality and value of life that are simply not subject to objectivity.
Will some families get those decisions what I would consider wrong, sure. But so would whatever other human being we assigned the choice to. And broadly speaking we do not get it wrong.
I've made that hard decision twice now for a parent and a sibling, and I didn't actually consider it that hard, but I don't think there was anyone else who could have contributed any greater wisdom to it than my other siblings.
Objective facts so that we can can make a well informed decision is the role of the professionals, after that their wisdom is no greater than ours.
But I think an important point is getting people to have these conversations with their families before the patient is too far gone to talk. If you haven’t planned ahead, then you will default to spending extra money keeping the person alive and in pain while you decide whether the person would rather remain alive and in pain or die in peace.
The problem is that it's not the family members footing the bill but tax payers.
Families should of course be free to waste their own money. But why should tax payers spending a couple of hundred grand on heroic end of life care.
Resources are limited.
Source? Many of the examples people will bring up are not necessarily tax funded. Quite the contrary, for many?
We are talking about heroic end of life care. That's almost entirely elderly people.
Young people tend not to be at the end of their life barring rare circumstances. And the number of people facing that is pretty low.
Either way, if the intervention is unlikely to extend life by more than a year we should be having a serious discussion about whether we should do it.
An important note, most doctors choose NO for themselves
https://www.saturdayeveningpost.com/2013/03/how-doctors-die/
Agreed, in general. My objection here is how much of the spend is this specific set of categories? Specifically, how much is each bucket of tax funded expenditure?
This entire field of discussion is dominated by hypotheticals and misdirection. Will start talking about saving government spending, but then quote a ton of general public spending as if it is the same. And will hyper focus on specific examples that nobody defends.
Is akin to the complaint that people on welfare are out buying complicated lattes from starbucks. It is just another culture war that has infiltrated some discussions that are important.
Fair enough. But a great place to start might be just don't put people on machines to extend life if in your professional judgment there is less than a 10% chance they will ever get off the machines.
Then go from there.
It's obviously a difficult task, and you certainly don't want to 2nd guess doctors all the time.
On the flip side, we need to get past spend whatever it takes to prolong life for very short periods of time.
Waste is not an objective term here. Two more months or two more years of grandma interacting with her grandkids isn't something you can objectively place a dollar value on. As Matt says in the piece it's a matter of values not efficiency. And families are also taxpayers. They are in no way spending someone else's money than you would be if you received a diagnosis of cancer today and needed expensive treatment to control it. We taxpayers can collectively decide that many costs of end of life care are worth paying, and we can choose who makes those decisions, including family members.
Resources are limited, but we are nowhere near those limits.
"Resources are limited, but we are nowhere near those limits"
That is factually incorrect. We are way past those limits we are borrowing money we don't have to try and pay for consumption instead of investment.
There's over a hundred TRILLION dollars in unfunded entitlement promises (SS and Medicare)
https://www.cato.org/blog/federal-debt-unfunded-entitlement-promises
There's literally no way we will be able to borrow that much money.
I’m all for improving efficiency and reducing waste in healthcare, including “wasted” care throwing the kitchen sink at known hopeless cases, but we really do need broad based progressive tax increases to pay for what’s left over, which will still be a massive number.
Meh, some cultures are stupid and wanna keep brain dead relatives alive because they’re too dumb or religious to make the right decisions, and then other people want to keep brain dead grandparents alive to keep collecting the social security check. Healthcare needs heavy doses of paternalism in these cases.
It seems that the focus of DOGE are program cuts that will inspire crying among Democrats and smiles among Republicans. Tough calls on healthcare are a tough fit for that model.
I suspect a big part of what's driving DOGE is Elon Musk's gross ignorance of public policy (this goes without saying wrt Donald Trump). I don't deny he's a very, very smart human being. And a true visionary in business. We haven't seen his like, maybe, since, I dunno, Henry Ford? Andrew Carnegie?
But I've seen hints and clues here and there that he doesn't know what he's doing when it comes to government finances, and I fear he actually thinks the state can be restructured as readily as a social network platform. I furthermore fear he's sufficiently clueless to think his cuts will make a difference when it comes to the country's fiscal trajectory (it won't: as Matthew points out, the only serious money is to be found in defense, healthcare, and retirement programs). There's a strong bull in China shop vibe about Musk and DOGE.
People as rich as Elon Musk tend to surround themselves with lickspittles, sycophants, and other rich people with the same blind spots. He's looting the Treasury and clearly on drugs. It's insane that we've let our culture come to the point where this person is allowed in the White House.
Also, let's not forget that he seems to have a serious Ketamine problem that undoubtedly is affecting his day to day thinking on just about anything.
Was listening to the "Very Serious" podcast and Megan McCardle noted a viral chart that apparently did a scatter plot of when Musk seems to tweet and that based on this scatter plot it seems like the man genuinely does not seem to be sleeping at all. Anyone who reads anything about sleep deprivation can tell you how damaging that can be to your brain (especially someone in his 50s).
Just like Trump and his very noticeable mental decline, I feel like there is this reticence to call out the fact that one reason Musk seems to be a completely different person from five years ago is that he very possibly is a very different person; the combo of ketamine and lack of sleep is very possibly and very likely turning his brain into mush.
I know this is irrelevant, but isn't ketamine a tranquilizer? Shouldn't he be sleeping?
I mean in theory yes. Which also at least suggests to me there is other "chemicals" in his system as well. Hard to know of course, but I feel like your question invites that possibility for sure.
I’m sure he’s sleeping just erratically
FWIW, I heard someone else (maybe it was Katie Herzog?) make the argument that it could just mean he has an irregular sleep schedule and is up late one night but up early a different day.
Musk may be a "true visionary" as a CEO and principal owner, but his relation to the federal government is neither. He's not answerable for results and he has no financial incentives (other than, perhaps, corrupt ones). Practical intelligence is only transferrable without training/experience within reasonably similar frameworks (stated much too simplistically!). Musk does not appear to understand that and the result is overconfidence that will amplify incompetence. Twenty years ago President Trump finally turned out to be highly skilled at something: hosting reality TV in a manner that would draw eyeballs to the screen. We're all paying for his belief that this meant he was a master of the universe.
In retrospect, the fact that he was good at reality tv helped make sense of Trump’s career in the 80s and 90s, putting his name on big money-losing projects and then strategically using bankruptcy in ways that made profit.
I mentioned this elsewhere, but I think the focus on punching down rather than saving real money is entirely intentional and strategic. This is a sop for MAGA voters and their desire to own the libs.
That's independent of whether Musk understands how various government programs run.
I've seen talk in various quarters over the years of "The Realization": one thinks Musk is a genius until he wanders into an area one knows more than a typical layperson about and one then sees that he's not that knowledgeable (making basic factual mistakes).
DOGE is not that savvy. They’re going after National Parks and the National Weather Service and a bunch of other things where there is absolutely no political upside for cutting. The simplest explanation seems to be they’re cutting everything because Elon doesn’t care about anything the government does.
It's more ideological than you think. I know the National Weather Service cuts were discussed in Project 2025, and without having looked I'm going to guess that the Parks cuts were too.
Right. The primary problem, from the conservative POV, is that the NWS provides a vital service for free and does so without regard to delivering a profitable product. They are correct that, were this function to be privatized, there are almost certainly a number of firms willing to pay for high quality weather forecasting (in the absence of competitive free options). That forecasting could then slice their market into buckets -- do you really need this hyper-granular forecasting that tells you which hour of the day it will rain? Or are you content to simply know the total probability of rain on a given day? And charge accordingly, further increasing their profits. I am sure that, with all this being done together, a private version of the NWS would be a net profitable business that does not require state subsidy.
A liberal looks at all this and says, Jesus Christ, you're looting the commons and destroying a public service when there are no problems with the existing model. An ideological market reactionary looks at the situation and says it is not *necessary* for this service to be available for free to the public, and therefore it *should not be* available for free to the public.
One of the many problems with libertarianism/market reactionary fundamentalism is a belief that it is morally wrong for the public to decide via its collective voice, the government, to provide itself a service.
We want to have accurate weather forecasts for a myriad of reasons that may amount to we just fucking want to, and if enough of us want it that is justification enough to have it.
I actually think that weather forecasts are quite a valuable public service and we should keep them. That being said, if the public wants to raise *their* taxes (not just someone else) to pay for these services than that's reasonable. But if you go to the public and ask if they want to raise their taxes to pay for this instead of doing it on debt, I bet their answer is no.
Google says the National Weather Service costs everyone $4 per year. I won't even bother to check that stupid box to give $3 for elections (despite it being free), but I would gladly pay $4 for weather info.
Where would these private weather forecasters get their data?
Satellites owned by Elon Musk's SpaceX, of course! I thought that part was obvious 😁
Oh does SpaceX have weather radars, and ocean buoys, and ground-mounted equipment? That would be a no.
The weather radar in my area, KMUX on Mount Umunhum, has been down since Saturday, allegedly because it needs a part and credit cards were frozen. Also allegedly the people in DC who are suppose to respond when weather radars go down have been fired. Thanks DOGE. And, surprise! None of the weather apps have a replacement because of course they don't.
I believe what they're trying to do (or at least claim to be trying to do) is eliminate only the public-sector forecasting and continue to have the government collect the data.
That's true. This White House has been seized by revolutionaries. And I don't think Musk is very much concerned about the GOP's electoral hopes (and Trump doesn't have to run for reelection, either). Fear of the electorate is yet ANOTHER guardrail that isn't operating properly.
I think Musk and people like Vance believe that their actions are more popular than they really are, but more importantly, they believe that the time to do unpopular things is now because they will have time to recover before 2028 (if not 2026). Vance in particular is a far-right ideologue, but also a strategic, self-aware, data-driven person. The unpopularity of right-wing policies is a problem that can be overcome through analyzing lab data from successful right-wing initiatives from states, localities, and other countries, and creatively adapting those solutions to the national/U.S. context. Probably this would involve some combination of gesturing showily toward the center in the 18 months or so before the election, devising strong new wedge issues to be rolled out in the year of the election, and degrading the quality of our democratic processes in under-the-radar ways.
Sure, I know NWS cuts were in Project 2025, so yes there are some people in favor, primarily conservative think tank analysts. I just don’t think these specific cuts are particularly popular with Republican voters. Trump spent the entire election disavowing Project 2025 because it was so toxic.
I'm not disagreeing with any of that exactly. I'm just saying that this isn't just Musk doing random stuff out of ignorance. It's part of an elite conservative consensus on these issues.
But the entire reason DOGE is doing this unilaterally is that there isn’t conservative consensus about this. Republicans control both Congress and presidency. They haven’t passed a bill with these cuts and I’m extremely skeptical they would be able to.
What about the argument that there is a conservative consensus about this, but they recognize that it's actually politically unpopular? So elected officials won't brag about it, but if they can do it while trying to avoid the public noticing the specifics they'll absolutely support it.
But they're not popular with the public, even Republicans.
The original comment I replied to made two points: (1) That there is no political upside to cutting NWS. (2) That they're only cutting NWS because of Elon's idiosyncrasies. I was mainly responding to Point (2): These cuts are not something that only Elon Musk wants for idiosyncratic reasons. Rather, they are something that many Republicans want. I was not really responding to Point (1), and I would agree that cutting NWS is probably not popular with the public; but on the other hand, I doubt that even swing voters, let alone Republican voters, think this is an important issue, and in any event, whether there is "political upside" from doing something that is broadly unpopular but appeals to a key component of your base is a widely disputed question in politics. Obviously, Slow Boring readers like us have a particular viewpoint on that question, but it's not like the opposite viewpoint is uncommon or mystifying.
Isn’t one of the big donors the owner of AccuWeather who wants to privatize weather forecasting completely?
Weather = climate science.
And Trump is too dulled at this point to know stay abrest of details.
Republicans don't like National Parks? Republicans don't like weather forecasting? Republicans don't want to be warned about hurricanes, tsunamis, tornados, and wildfires? Republicans don't like cancer research? Really?
To steelman it, they believe, incorrectly, that if the government didn't provide those things the private market would, and so we would have them all any way.
Why they're not provided any where in the world without government intervention, or why they weren't provided anywhere before government intervention is just hand waived away.
I think healthcare spending is hard because there is really no limit to how much people can consume. If I had a on-call doctor, I would be messaging him anytime my throat hurt.
I now live in the US but I'm still messaging our family doctor back in Europe every time I feel sick. The difference is that he will say something like "Take Ibuprofen and get back to me under x, y, and z conditions.", while my experience with American doctors so far is that they'll say "Cool, let's run some tests. It will cost you x, y, and z.". The doctor in Europe also asks for tests from time to time (when I'm home at least), but he's paid with a flat monthly fee regardless. Not having a financial incentive to order tests is more important for costs than doctor's availability, I think.
Like others said, I'm not sure it's direct financial incentives as much as a culture of testing. The culture might be springing indirectly from the financial incentives, but most of the time the doctors running the tests aren't getting more money out of them.
I agree about the culture bit. I'm in a testing spiral right now. I had a doctor order a test yesterday, even though she admitted the treatment would be the same regardless of how it turns out. Then why test, I asked? The answer was because then we would know the cause of the issue. I'm a scientist in my professional life, so that sort of reasoning appeals to me. But, I can also recognize what a waste of time and money it would be if I decide to go through with it.
I’ve had several uncomfortable discussions with my doctor where she recommends a test that won’t have an effect on prognosis and I decline because if it doesn’t make a difference I don’t care and I do worry about them finding something that’s out of range triggering long follow up only to find out there was nothing to be concerned about. In the end, I think of it as a philosophical difference. For me it balances out so that the testing isn’t worth it but for someone else it will be
Yes, and the culture of testing is because of the malpractice incentives. If you test too much, unnecessarily, nothing bad happens to you, but if you skip a test that might have caught cancer or some such, and the patient dies, you might get sued.
American primary doctors generally do not have a financial interest in testing unless it is something actually run in their office. Labs or other doctors / testers cannot kick back to them for using their services.
Sometimes (often?) they will have an ownership stake in the testing center. This happens most often with standalone imaging centers.
But their biggest financial incentive toward excessive testing is to avoid lawsuits.
That’s generally a radiologist. But the average primary care doctor doesn’t have an interest in Quest labs or whatever
Referring to a testing center that you have an ownership in would, absent a limited number of exceptions, violate the Stark Law. Doctors can't refer Medicaid/Medicare patients to other providers that they have a financial relationship with.
oftentimes doctors are part of a group though. And that group provides a lot of different services.
Group practice referral requirements are well defined within the Stark Law. But that's different than John's claim that a provider can simply refer an individual out to a testing center that they have an ownership stake in. That is very clearly impermissible and subject to significant penalties.
It's about malpractice risk.
Every time I've been to a clinic here in the US, everything was done without leaving the site. Is this uncommon? The Americans I know haven't told me that I'm doing something wrong.
Many people have a primary care physician (PCP), who serves as a first point of contact for all care decisions. This physician then refers the patient to specialists or testing centers as needed.
I believe using clinics as a PCP is more common for younger people.
I technically have a pcp, but it takes weeks to see him, so outside of physicals, I haven’t used him for any of my other healthcare related issues (knee surgery, rolled ankles, urgent care clinics when the kids infect me).
Do they not have MyChart (or similar)? There’s a few months lead time on actually getting an appointment with my PCP, though I can walk in during business hours and see a different doctor in the same practice. But 9 times out of 10 I send my PCP messages on MyChart if i have an acute issue or just questions or concerns, and she or her proxy always responds within a business day. If it’s something complex, they’ll bill insurance for the chat like it’s a telehealth consult.
It’s wonderful! If your doc doesn’t participate fully in modern communication tools I would almost say it would be worth it to find a new one! (And I’m a Luddite, so for me to rave about modern technology I must really like it!)
I don't think I know any American with a PCP. Maybe it's an age thing, I don't know. (I would hope that people who have been raised in this country AND are diligent enough to get grad degrees would have been able to guide me here. Maybe I'm using the system wrong!)
The point of the PCP is to have a person who tracks your health and is kind of a specialist in "YOU" (among many others).
It's the kind of thing you're much more likely to get when you've settled down. And they are in shorter supply than most other types of doctors, so it can be a pain depending on where you live.
Eh, having a PCP is really, really easy to forgo in America especially if you’r a younger / healthy person. If you don’t feel compelled to get an annual physical I’m honestly not sure what the case for having one is (other than asinine referral requirements for certain insurances that won’t just let you go directly to a knee specialist if you have a knee problem). Anything that needs urgent attention is going to be more swiftly covered by urgent care (side note: I’m glad urgent care centers have cropped up so much) or the ER, anything that can wait a few weeks probably warrants a specialist, and PCP wait times are more like on the order of months.
I have a PCP; she's a nurse-practitioner and I've been going to her for 19 years now. I love her. She knows me, she knows my minor medical problems (if I had serious problems I'd go to a specialist MD). We chat about how we were both lifeguards in high school and I know her kids' names. She believes me when I tell her that I think I have another UTI. It works the way it's supposed to. But I don't know that it's that common, and I've told her she is not permitted to retire. I suspect that she'll retire eventually anyway (sob).
Hmmm. We have a primary care doctor for ourselves, a different one for the in-laws, and primary care pediatricians for our kids. None of them has a financial interest in testing, and all of them act as you describe your physician back in Europe acting.
Most prominently, when we call about an illness the pediatricians provide incredibly clear guidance about what circumstances warrant coming in and what further ones warrant going to a hospital.
I don't think anyone in my immediate family has ever been referred for testing which was not downstream of a compelling symptom which required diagnosis and led to treatment.
Thanks for sharing! Healthcare is my main non-sentimental concern about whether I would like to still live in this country in 10 years, and that's a very reassuring comment!
My understanding, having had Dutch friends back in Beijing with whom I discussed this sort of stuff, and my wife having friends from school back in China who have French residency and bitch endlessly about their healthcare costs and quality... if you are middle-class or better you will likely pay a smaller fraction of your income in healthcare premiums compared to the taxes-plus-premiums you're paying for access to healthcare in either of those systems. When you have a serious issue that requires extensive healthcare in the course of a year, under many or most plans you'll pay about that same amount again in out-of-pocket expenses here, whereas cost-sharing in either of those systems is quite a bit lower, even zero for some things.
So in years when you need a ton of non-routine care, you'll pay more of your income than your French or Dutch counterpart of the same relative economic status. In years when you don't, which for most people is most years until quite late in life (after Medicare kicks in if you're lucky), you'll spend less of your income.
In absolute terms the costs are much higher... but 60th percentile American you also makes 45% more than your Dutch counterpart at the 60th percentile, and 60% more than your French one.
Part of the intractability of healthcare policy here is that the system genuinely does work fine for many people; most anyone with stable employment from lower-middle to professional class has access to healthcare of decent quality at a capped annual maximum which will almost certainly not bankrupt them, though will be very, very unpleasant for a lower-middle class household. There are huge opportunity costs that they're leaving on the table, but those are much less effective as a motivator than real ones.
There's no direct financial incentives to order tests. Some tests are probably CYA medicine. Some are useful but not covered in other healthcare systems. Labwork generally is also not that expensive relative to other healthcare costs anyway.
Sure. Even Warren Buffett may prefer a pickup truck to a Ferrari, though he can easily afford the latter. Maybe he's just not into sports cars. Maybe he likes to haul gardening supplies home from Lowe's. Maybe he doesn't want to appear pretentious to his neighbors.
But he probably will shell out $5 million for an experimental treatment for his gravely ill grandchild.
I think it is also important to add on that spending extra money actually gets you stuff, which makes the efficiency decision tree much more complicated. Like, fifty years ago if you had cancer, you mostly just died. Today, you can spend a ton of money on treatments and you really will not die, which is great. But those treatments do cost actual money.
So the question of, for example, "should we treat Grandma's cancer?" is just a much more complicated question because it involves genuine tradeoffs in things like money and quality of life in an environment where outcomes are highly uncertain and you are making idiosyncratic value judgements.
My dad is a family physician and I definitely called him for every weird health issue until a few years ago lol. (He’s getting old—retiring this year—and I don’t want to bug him.)
There's an argument that health care expenditures can be driven by extra disposable income, and the US has higher health care per capita spending because we also have higher levels of disposable income.
If you think about it there are probably three buckets of healthcare expenditures, 1: truly necessary (my arm won't stop bleeding, doctor says I need to start chemo immediately), 2: "luxury" (it would be nice to get this rash taken care of, my knee's been bothering me in the morning), and 3: diagnostic to determine the difference (should I be worried about this lump, are these sudden migraines a bad sign).
All else equal, you would expect richer people or people with more highly subsidized care to increase their spend on buckets 2 & 3.
You don’t? That’s what MyChart is for, and it’s the best thing ever!
Atlanta Fed now has Q1 GDP growth at -2.7% and will update with new data tomorrow and Friday.
RIFs, a government shutdown, and tariffs. Nothing looks good and another yield curve inversion.
Guess we'll need even bigger tax cuts for the wealthy to stimulate the economy, and even bigger cuts to Medicaid to pay for them!
It is unfortunate but a lot of healthcare cost does involve pointless, expensive and cruel treatment of people right at the end if life.
Scott Alexander as a doctor looks into it
https://slatestarcodex.com/2013/07/17/who-by-very-slow-decay/?fbclid=IwY2xjawIzvrNleHRuA2FlbQIxMQABHaLpQJHKit2ZowQOIQkhPGwBZWnMFSl_Er73p0HawIF9qj0tuvtqmwQwew_aem_lcOKM8w3KEUQFvBVr-vLng
https://www.saturdayeveningpost.com/2013/03/how-doctors-die/?fbclid=IwY2xjawIzwARleHRuA2FlbQIxMQABHSKrzUZY-ZFBjbVqduxPZW8KG-xdgSxpcEKcK-SO8BNoPYK3AvwBN1Kdnw_aem_YhbL4VKI8txcNAJtIgy5lQ
The 2nd article is particularly good. The term futile care is something that should actually be openly discussed. Matt's claim that we don't know who is in the last year of life rings somewhat hollow. Obviously we don't know perfectly in every case, but there's a lot of expensive, cruel and futile care we do know about going in.
Hard to imagine that conversation: "There's an 80% chance that grandma will die within a year no matter what we do, and 20% chance she'll live another 5 years with this expensive treatment. So... not gonna do it."
Having been there with my parents, it’s even worse than you might imagine. Doctors are trained to do things, and sometimes will keep trying to do them past the point of absurdity. When you’re trying to stop this on behalf of someone you love who is not in a position to decide for him/herself, you can start to doubt yourself or even feel like some kind of monster.
I'm a doctor, and I had to face this myself with my own mom. I think I'm pretty hard-headed, but, even when she was obviously dying, I wondered (and beat myself up about) whether we'd really done enough.
It's the worst. It seems easy in the abstract -"of course I/she/he wouldn't want to live like that!" - but the weight of the decision is immense.
Trying to think clearly in hindsight, I think my mom would have been better off without chemo for her Stage IV lung cancer, because the time it bought her was IMO low-quality. But I'm not sure she would have agreed, and tbh selfishly I was grateful to be able to spend more time with her.
My father had a weird attitude toward death. He'd served in WW2, fought in the Battle of the Bulge and many other battles, saw and inflicted a ton of death. Boy was he traumatized. His attitude was "I don't want to die. Keep me alive at all costs." I didn't, though. He had a huge brain bleed and he wasn't coming back from it. I ordered palliative care only. I apologized to him several times (he was unconscious, obviously) and I sometimes feel guilty. But there we are.
That's a hard conversation. "There's a 95% chance that Grandma will die within a year no matter what we do, and a 5% chance she will live an indeterminate amount of time past that with poor quality of life" is not as hard. Once you agree on the principle that there exists some bucket of care for the elderly that is pointless or even net negative, the problem becomes finding the line, and reasonable people can disagree on where the line is (and adjusting it is a perfectly reasonable domain for the government to spend a lot of effort figuring out)
I agree, more or less. But (as I'm guessing you know) it's not like you enter all the data in a computer, and it spits out the statistics.
My impression is that outside of the US this is handled by the doctor simply not offering the 20% chance as an option to the patient. And this could leave the patient better off and happier.
Restricting patient choice might improve outcomes, spending, health, and even satisfaction. It's very un-American, though.
My experience in the UK is a mixture of "The NHS does not offer this treatment" (and they have been known to go through the courts to block people taking clinically braindead patients to America or Spain or wherever for more treatment) or you get given the same option with the same "you will suffer but might live an extra few years" disclaimer.
It is hard to have that conversation but doctors are paid a lot and need to make those kind of decisions.
Now if only my vet could give me straight cost / benefit / probabilities on our 10 yo diabetic cat, instead of acting like I obviously would be willing to shell out $10k a year to keep "our family member" alive.
I am with Berlusconi on this, beloved pets should get state funded healthcare.
https://www.luxtimes.lu/europeanunion/berlusconi-and-his-poodle-promise-new-deal-for-italian-pets/1306591.html
Cats yes dogs nah
There are a few problems with that point of view, and I don't think doctors' pay is relevant here. One problem is that you assume that the decision is clear, and it is not. It might be more worthwhile to try a mild hail-Mary on a happy, vibrant, active grandma than on a grandma who's thrown in the towel. And there are cultural and religious points of view that complicate these decisions as well.
Moreover, we've progressively moved away from traditional medical paternalism, whereby the doctor just tells patients and their families what their treatment is going to be. Perhaps we need to move back to that model a bit, but we generally think it's a good thing for patients and families to be involved in important medical decision-making.
It's also hard to back off on treatment once you've given something a try. You do a potentially life-saving operation on an old person, it doesn't go perfectly, and they end up in a sort of miserable holding pattern. At what point do you just say, let's stop intervening?
The NHS (in the UK) can just say categorically, "No dialysis for anyone over 80." I don't think we'd accept that in the US.
Saying well-paid doctors just "need to make those kind of decisions" does not make for effective healthcare policy. (Not trying to sound rude, and sorry if it does sound that way.)
If only we could do that in the UK.
Medical paternalism was just a good thing, untrained emotional people make bad decisions.
Yeah, sorry, that was probably a bad example. But I've read examples of the NHS just having hard criteria for certain treatments, which I think would be much harder to implement in the US.
With regard to medical paternalism, I think you have to be careful what you wish for. I think it's a good thing that we've turned away from saying, "Sorry, dear, you don't need your breast at age 70; we're going to do a mastectomy rather than a lumpectomy."
That's exactly what they do in many countries. I have a friend who is a U.S. doctor now practicing in NZ. (I've asked her to come over here and comment, it's so useful to hear from her). Americans would find NZ end-of-life care startling, to say the least.
My experience with actuarial models is that they are often quite accurate and there are probably actuarial models that are pretty good at predicting who will die soon. There is an enormous incentive to get these models right so that organizations can appropriately price risk and figure out how much cash they need on hand.
Are they accurate on average or for individuals? Deciding on care is a decision that needs to be made for each individual, while costs can average out.
More recently, Scott also looked at the argument from the final paragraph, about whether large indiscriminate cuts to healthcare spending could be made without adversely affecting health outcomes. TL;DR: Probably not.
https://www.astralcodexten.com/p/contra-hanson-on-medical-effectiveness
https://www.astralcodexten.com/p/response-to-hanson-on-health-care
https://www.astralcodexten.com/p/highlights-from-the-comments-on-hanson
Hey, I was going to share Scott’s “Who by very slow decay” piece, you beat me to it! Highly recommended
Here is article I have shared with friends and family regarding this issue. BTW, I am a 69yo semi-retired pediatrician.
Why I Hope to Die at age 75
https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/?gift=boITFnjOC6i8p4a7e8kAWz0GELaKjXanbfdDXJN-nt4&utm_source=copy-link&utm_medium=social&utm_campaign=share
This attitude is sick.
Any chance of commenting on the "making healthy lifestyle choices is the most cost-effective way to reduce total healthcare spending" argument?
There's clearly SOME merit there, but I don't trust the claims I hear some people making. Also, not sure we have a great plan for how to really get people to live healthier lives (without getting totally fascist on them).
Many health insurance plans have programs available to people with chronic diseases like heart disease, obesity, etc that tries to make those people healthier. The idea being that it's in the financial interest of the insurance company for the patient to make better health decisions.
My mom spent her entire career managing those programs. She says it's really really hard!
That is interesting. My neighbor runs a program at our local hospital to help people with/in danger of diabetes change their lifestyle. It is opt-in, so people want to be there, and it is much more hands on with more supports than the health insurance incentives, and she still says it is really hard. She says there are so many people who have so many stresses in their lives (many people in the program are low income) that it is hard to focus on this. I sometimes wonder if we had more of a basic safety net, like most European countries do, if it would help.
What elements of a basic safety net do you think would help?
Cradle to grave luxury UBI
European countries don't have luxury UBIs. They do have basic safety nets.
Here in the UK there is a health insurance company that offers younger people cheap rates alongside a gym membership and fitness tracker contingent on them actually hitting a minimum level of physical activity.
That's what we need to be doing. Tax unhealthy living and then use the money to offer cash for people being thin and fit.
That we live less healthy lives is one of the drivers of our higher health care costs relative to eg Europe. So we could definitely save money in some sense by making everyone more healthy. But given the current massive rebellion against the cheapest and most effective public health measure we have, I don't think that's going to happen.
After living 4 years in Europe… they smoke a lot. Most of the savings are from telling people to take a pain killer.
Yes, they smoke more, but for example rates of obesity and diabetes are lower, they get in fewer car accidents, they shoot each other less, etc.
If police listened to Matt and cracked down on bad driving and illegal guns it would create healthcare savings. Not huge but noticeable.
Yes police doing their jobs would be a significant benefit in many ways.
They were doing a lot more proactive work before 2020, but the public asked for less and a lot less police remain employed today.
Get shot and dying in a car crash don’t seem like lifestyle induced diseases with long term reoccurring costs.
You are aware that sometimes people survive both car crashes and gunshots, right?
Meaningful long term costs for either probably come in for less than 10-20% of victims. Given the numbers, I'm not sure it's more than a decimal point somewhere of difference
Smoking more leads to less obesity.
Also smoking kills off your elderly.
That got me thinking....Per Claude:
# OECD Countries Ranked by Smoking Rate
Based on the most recent available data (typically from 2020-2022), here's a ranking of OECD countries by the percentage of population that smokes daily:
1. Greece: 32.2%
2. Turkey: 30.7%
3. Hungary: 25.8%
4. Latvia: 24.1%
5. Croatia: 23.8%
6. Poland: 23.5%
7. Chile: 22.6%
8. France: 22.4%
9. Estonia: 21.6%
10. Portugal: 20.9%
11. Slovenia: 20.1%
12. Spain: 19.8%
13. Austria: 19.3%
14. Lithuania: 19.2%
15. Czech Republic: 18.7%
16. Belgium: 18.5%
17. Italy: 18.3%
18. Slovakia: 17.9%
19. Japan: 17.5%
20. Germany: 17.3%
21. Luxembourg: 16.8%
22. United Kingdom: 15.9%
23. Ireland: 15.5%
24. Korea: 15.2%
25. Switzerland: 14.6%
26. Netherlands: 14.3%
27. Denmark: 13.8%
28. Israel: 13.5%
29. Canada: 13%
30. Australia: 11.2%
31. Sweden: 10.4%
32. Mexico: 9.3%
33. New Zealand: 8.7%
34. United States: 8.6%
35. Norway: 8.3%
36. Costa Rica: 7.5%
37. Colombia: 7.2%
**Notes:**
- Data sources include OECD Health Statistics and national health surveys
- Percentages represent daily smokers aged 15 and above
- Data may vary slightly depending on the specific year and survey methodology
- Rates are for adult population (daily smokers)
Interesting that for the US this seems to have been 25% in 1990 and over 40% in 1960. That's a real policy win. (Though I think these numbers exclude vaping.)
https://www.lung.org/research/trends-in-lung-disease/tobacco-trends-brief/overall-smoking-trends
Yes, the US has done well on this score. Nice to see.
Yeah lots and lots of people only vape now
Fun fact: Swedens low rate is to large part due to an early harm reduction program in the ‘90’s where they got people to switch from smoking to something called Snus. When they entered the EU, the Nordics successfully negotiated an exception to the EU’s near ban on Snus because they didn’t want people to go back to smoking. Last time I checked the EU was trying to crack down on Snus and dismissing the public health case for Snus because people shouldn’t be addicted to nicotine period.
It reminds me of the fights over vaping here in rhe US. What’s always struck me as odd is that my local health department is very anti-vaping but also very big on providing needles, pipes and narcan for people who use illegal drugs while dismissing things like abstinence based treatment.
It's a driver of our lower life expectancies, but I'm not sure that it's a driver of our costs. Like Matt wrote in the article, a huge amount of healthcare spending happens in the last year of life, and the last year of life comes for everyone, eventually.
I think we mostly spend more because we are wealthier, and in particular we are wealthier at the higher end. Our millionaires and higher 6 figure salaried probably have European life expectancies, but they can also afford to spend several times their equivalents in Europe.
A large % of our spending, particularly in medicaid, is for polychronic patients (often type 2 diabetes or hypertension + other diseases), much of which is driven by lifestyle factors (obesity, lack of exercise, poor diets)
It's secondary to cost-disease factors, but it's definitely a driver.
How does this balance against my assumption that such patients die a decade or two earlier? At the fiscal level, it's not clear to me that they would cost more than the healthy person who lives to 87.
This gets really complicated, and some studies do show that the net cost reduction of health improvement is very low, since no patient spends less money than a dead one. I just googled it and there are serious-looking studies saying these factors totally cancel each other out, and others saying that obesity and morbidities dramatically increase lifetime spend.
Other factors:
1. Poor health prior to retirement age contributes to lack of labor force productivity - many of these patients can't/don't work.
2. Their last year of life looks a lot like a healthier patient's last year of life, it just comes earlier.
To point out the obvious, it also matters whether total spend (% of GDP or whatever) is what you're tracking or spend per life year or whatever. That our life expectancy is lower than other countries makes our spending differential even worse (since lower lifespan should save us $ all else equal.)
Thanks for these responses these are helpful and informative. I'm kind of shooting-from-the-hip when it comes to spending on diabetes vs last year of life, etc.
From my end, the only part I wanted to point out was that our relative wealth and relative abundance of millionaires by itself makes it very hard to close the spending gap. There are plenty of other factors that contribute to expensive healthcare and are worth striving to fix, but my sense is if we did "fix" healthcare in the US, we'd still have a spending gap due to wealth and a life expectancy gap due to drug overdoses, car crashes, homicide and obesity.
Matt said that a quarter of Medicare spending is end-of-life. But Medicare is only 21% of all health care spending.
I think the 1/4 is in the ballpark of what non-Medicare health spending on end-of-life is, too.
This is an argument for less cost sharing, in a way. If you want to live less healthy, cool, you're free to do so. Just don't make me subsidize that choice.
At that point just outlaw insurance entirely, lol.
It just depends on the degree, so it is a "more? or less?" type thought, not a binary yes or no.
The thing is, we understand fairly well that willpower around food and exercise, both cravings for and the body's response to foods, pain responses and tolerance, etc... are all downstream of the genetic lottery.
I'm fine with the genetic lottery more or less determining everyone's class and achievement; as a matter of practicality, it's not avoidable... communism didn't make people equal, and didn't work even if it had.
I'm un-fine with the genetic lottery determining everyone's access to healthcare.
If I have to choose between the libertarian argument Allan articulated and nationalizing the whole mess of a system into an American NHS, the latter, despite manifest flaws, is by an overwhelming margin the lesser of two evils.
The issue with the "making healthy lifestyle choices" argument is: how do we get people to make such choices?
There's a libertarian argument that says adults should have the right to trade life expectancy (and quality of life when aged) for the pleasures of stimulating certain pleasure centers of the brain (fast food, alcohol, video games instead of rigorous exercise, etc) when they're younger. Who are we to judge?
In practice pretty much no one makes such a tradeoff consciously. And surprisingly few of us are willing to let unhealthy older people go without healthcare treatments. (Part of that may be the realization it's pretty likely we too, will end up like that at some point, even if we're very careful and make healthy choices when we're younger).
Which is all just to say: blaming individuals for poor metabolic choices feels like a bit of a scam. I'm not a slave to consequentialism, but I'm still enough of a consequentialist to suspect that, when many millions of people become obese in some countries but not in others, the problem isn't at the level of the individual, but in the way society itself is set up.
Despite being quite pro-capitalism and pro-libertarian, I too worry about society.
I think we're missing something in terms of societal recognition for making prudent choices and living a responsible life.
I know, that sounds like every middle-aged paternalist scold ever. But there's truth in it. Eat your vegetables! (Literally and metaphorically!) But there's not really an audience for that, not really a good profit margin for that, and we've lost some of the community institutions that used to balance in that direction.
Agreed. Left wing people with a focus on government policy (so SB readers, and MY) often have a blindspot for how much society and culture drive certain things and how much government policy is limited with those same things. The blind spot is understandable, but I think we'd do better if we recognized and acknowledged the limitations more often.
First we could better prioritized policies, second, we might recognize when partnering with cultural leaders and role models might do more than policy could.
I would argue that there is value in doing things that are hard or you don’t like becaue the end result is something you want. And if you’re doing that with your health on a regular basis, it’ll make it easier for you to do that for things like learning a new skill
We tax alcohol and cigarettes, why not sugar and other high calorie sugar substitutes?
Heavily tax those and then use the money to give people cash for staying thin and fit.
Maybe free GLP1 drugs
As someone spending $400/month on compounded tirzepatide, I’m all about socialized GLP-1s!
I put on 17 lbs last year. And am currently 2 months in on my low carb diet this year, and have got rid of them all. So about half way to my goal weight of 200 lbs.
Going low carb is the only way I've found to manage my food cravings. I haven't tried a GLP1 yet, but frankly don't have the cash for one right now.
I love dairy too much to go low carb, though I’ve ballooned (from 180 to 230) over the past three years. And at 230 it hurts to move. I have just been doing the tirzepatide for a couple of months and am still titrating the dose up. I’ve been eating and drinking a lot less but my body is fighting any change right now, I’ve only lost like 5 pounds. But it least I’m not on an upward trajectory and I think I’m consuming fewer calories most days than I expend, so I hope to see some results.
I include dairy in my low carb. I do non fat plain yogurt with frozen mixed berries for my breakfast/lunch about 10. Then I do some mixed nuts and jerky around 1.
Then finish things up with steak and salad around 6 with plenty of cheddar cheese on the salad (I love the combination of the cheddar with black olives)
Whether I'm strictly in Keto I don't know, but it works for me and my cravings are managable.
Sometimes I add in some fresh blueberries or even some pineapple (yeah the last probably isn't very low carb, but I seem to be able to do it fine, probably because of the fiber, and it's only once a week).
Either way, good luck, I know losing weight is by far the hardest thing I've ever done. Getting my CPA and MBA was definitely easier.
Yeah, if they're not going to do coercive action it really doesn't change much. The government already does ad campaigns to promote healthy choices- there's only so much you can do at that point.
" there's only so much you can do at that point."
To me this is crazy talk. I don't believe for a second that we've even scratched the surface of what concerted action could do if you really focused and aligned behind it.
Look at smoking, for example, where the rates have plummeted and we're far head of Europe. The government was heavily involved in that change. Just because other campaigns have been less successful doesn't mean there's nothing left to try, especially because it's very hard to measure the counterfactual.
As a schools guy, that's where my brain goes. My suggestion is not totally free of coercion but it's wrapped up in the already accepted coercion of schooling. Here goes:
Let's make Physical Education Great Again. PEGA.
You (okay, maybe not you but the average person) may be surprised to find that half of high schoolers only attend PE once a week. Only a quarter attend PE five days a week. That average is actually misleading because in some cases they're only required to take PE for one semester or one year, often 9th grade, which means that the other 3-3.5 years they have zero PE. I study high school entrance and departure and one of the weird data points is that PE is often one of the classes kids fail that stops them from graduating (it is a graduation requirement in, I think, every state). They skip, they refuse to "dress out", etc. Seriously! When I looked at Chicago public schools a few years back, failing PE was, on average, one tenth of the kids who weren't graduating high school.
Anyway, we have a situation where 95+ percent of kids are going to attend public high schools. Let's make them take PE every day for four years (maybe with some smart exemptions for student athletes or whatever) and let's have required participation. Okay, so, I guess I don't know what to do if a kid shows up and refuses to put the shorts on, hence the failure rates, but most will participate and we can iron out the rest as some best practices get discovered. We know that even small amounts of moderate physical activity each day can have a big impact on outcomes. Build that habit early! Make PE Great Again.
I think pretty much every president since Eisenhower has a PE initiative; I remember taking the Presidential Fitness Test in the GWB era. And who could forget this gem! https://www.youtube.com/watch?v=BY5sB7GvabY
I love this and let's make sure we are actually teaching them how to stay fit for life. And make sure they understand the metrics and how much it matters.
Have them do a combination of strength training and cardio. Yeah, that would require bigger gyms, but I think that would be well worth the money
Okay, but I'm not playing team sports. Not ever again. Not interested in being screamed at abusively because I kicked the ball wrong. I'll do yoga or dance or spin or individual weight training or a variety of other things. But no team sports.
Maybe they should stop requiring dressing out, which is basically theatrical humiliation for insecure kids for no real reason. It didn’t bother me, but I do know people for whom changing in front of others was just a dealbreaker, and didn’t graduate high school for that reason. It’s dumb, but it is a thing.
PE was hella dumb though. I hated it and was very happy to only need 1 semester of it. Most people don’t become unhealthy until after their teenage years, though that’s probably changing with video games.
Smoking is the exception since there was a clear externality (second-hand smoke) that meant it could be regulated without reeking of paternalism.
In my more conspiratorial moments I wonder if any public health apparatus is working on a similar concept for other health choices. Is there such a thing as second-hand obesity where you're more likely to be fat if you see a fat person? Does the smell of booze on someone's breath lead to cirrhosis?
A lot of the reason we were able to regulate tobacco advertising, despite that being prima facie unconstitutional, is because we were able to sue them, and then as part of the judgement, had the restrictions imposed. There's a similar agreement about alcohol advertisements to children, though that one's just a gentleman's agreement, rather than law.
A non-externality
People can live just fine without tobacco. Not the case with food. And there's absolutely zero prospect of violently ratcheting up the cost of calories through taxes. We're up against 4 billion years of evolution and the relentless cost pressures exerted on farmers (resulting in ever-growing agricultural productivity).
It seems pretty telling that US obesity levels seemed to peak at the very moment MDs began prescribing Semaglutide for weight loss.
We banned smoking from a bunch of public places, that's coercive action. I don't think we're going to ban overeating the same way. We also banned cigarette advertising (effectively, it was done through a lawsuit).
Well then my sarcastic response is: "there's nothing, at all, that could be tried."
But I disagree, with creative thinking we could probably try a hundred other things.
But I should add that I think the limitations are generally within society more than in government. It would be harder to ban junk food from gas stations, for example, because lots of people enjoy it, especially on occasion.
I think the social and government limitations are somewhat interlinked- if we tolerated say, strict rationing, that would be available as a solution, but we won't so, I don't bother with it. You've seen how bad the reaction is to trying to do anything to limit junk food availability.
I mean, i'm open to new suggestions, but the tools i know just aren't in the toolbox right now.
For what it's worth, I also don't think the reduction in smoking comes down entirely to the corrective action- though i think it helped. The broad progress of de-(in person) socialization of human beings over the 2000s and 2010s has reduced teenage smoking, teenage drinking, teenage sexual activity, etc which also i think contributed to the reduction.
we also taxed it heavily.
Free semaglutide! And next gen drugs will be better, still.
Here's hoping.
It depends on what sort of “coercive” things you’re considering though. A ban on soft drink cups over 32 oz was too politically radioactive to pass, despite being only minimally coercive (I suspect it’s like congestion pricing, where once it’s in place for a year, people are happy with it, but people hate hate hate the transition). I bet that a ban on the industrial use of food colorings would also drastically cut the amount of certain types of junk food people eat, just by making it less visually appealing - and you could still allow all the food coloring you want in commercial and home kitchens. There are probably many things of this sort, that allow most of the freedom that people actually care about, while stopping the things that hijack our decision mechanisms.
Japan disagrees. Apparently there's actually a lot you can do.
https://www.dailymail.co.uk/femail/article-12982523/Inside-worlds-anti-fat-nation-Japan-uses-variety-controversial-tactics-encourage-thinness-including-weighing-people-work-apps-shout-hey-fatty-exercise.html
Japan's "Metabo Law" seems to have generated a statistical improvement. I know here in 'Merica we love our personal freedoms and exceptionalism included our exceptional fatness but I have no problems with Federal pressure to increase the "costs" of being fat.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5760033/
I think what’s hard now is that we’ve transitioned from a generally correct view that healthy living improves health outcomes to a less defensible view that healthy living is all you need and will do more than vaccinations or antibiotics. Call this the Marjorie Taylor Greene stance (I’d actually name it after my dad but it’s catchier to use a public figure). All that’s needed is some exercise, some vitamin D, some nutritional supplement powder, and a supply of ivermectin cure-all.
In practice, and now that this stuff has moved out of wealthy wheatgrass-slurping circles, this most often results in the worst of both worlds (unhealthy lifestyles + anti-vax)
For *an individual*, yes, that's the best thing to do. Because encased within the question is the assumption that you do it.
For *a population* telling them to [just eat a goddamn vegetable] https://www.youtube.com/watch?v=BOyebcrVWb4 doesn't produce the same level of change.
holy sh*t that is amazing and I can't believe I had never seen it before.
Yeah my understating is healthier lifestyles (and a lot of preventive care) don’t actually save money in the long term because you just get sick later.
The unhealthy person gets cancer at 65 and dies at 70, the healthy person gets cancer at 85 and dies at 90. The healthy person surely is costing Medicare more.
Right, if lifestyle is the difference between a fatal heart attack at 55 and a stroke at 65, it might drive a lot of savings. But in most of the country the marginal change is 75 to 85, which means more medical care is needed, not less.
Making people healthier is expensive because they live longer and so consume even more healthcare. Smoking is terrible but it reduces spending on Alzheimers care.
Are we sure? I've seen stats that a quarter of healthcare spending is on diabetes-related issues. In total I'm seeing claims that 75%-90% of healthcare costs are for chronic conditions. Not saying all those can be solved through healthier lifestyle, but clearly there can be a big impact, right?
It is a complicated equation with lots of secondary and tertiary effects, but my impression is that making people healthier and live longer significantly increases the burdern of chronic diseases.
Alzheimers and Diabetes are the two most expensive conditions, making people healthier increases Alzheimer's cost and reduces costs for diabetes. I think more chronic diseases (weighted by cost)are like Alzheimer's .
Alzheimer's risks are also directly related to healthy living. So less chronic diseases less Alzheimer's
Isn’t there some offset with their economic productivity at an older age. With declining birth rates isn’t this helpful?
I wish I knew how often people work in various capacities in their late 60s and 70s.
Yes I don’t have data to support my conjecture. You do hear stories of people not retiring and younger people not moving forward in their careers.
We know that POTUS’s are getting older.
I don’t want to pretend like defining some healthy lifestyle choices is a complete mystery, but getting people to agree on even that is pretty fraught.
A regular refrain of the MAHA movement is that the food pyramid was a scam and a lie, and that real health is forgoing vaccinations and drinking raw milk.
These initiatives have a long history. Is there a secret code to cracking the issue that only these guys know?
Walking and high taxes on consumption
Is this something the administration is advocating?
No. Just explaining why Europeans generally have better health and consume less calories
Didn’t mean to crack wise. The OP seemed to be suggesting there was something to the administration’s idea of health promotion.
What comment are you looking for MY to make?
On an individual basis, this is clearly true. For most people, stopping smoking is more important than whether or not you get a physical, and driving on the highways or taking illegal drugs are more likely to kill you than cancer up to age X (I don't know what X is but it's probably 50 if I had to guess).
What this means for the aggregates, I don't know exactly, other than to say that there's a lot of misplaced blame on our healthcare system as a result of our lower life expectancies, which are generally due to obesity, drug ODs, violence and car accidents.
fun fact, being fit is still a bigger driver for longevity than smoking
1. Place a HIGH tax on sugar and other high calorie sugar substitutes.
2. Use those funds to give people generous cash amounts for staying fit and at an appropriate weight.
Also make it so food stamps etc can't be used to buy junk food.
If that doesn't work then make staying thin and fit a requirement to get government healthcare. If we are paying your health bill, then you'd better damn sure do your part.
I’m so glad Matt cited that Oregon study and the libertarian crowing over it. A little anecdote to get into why I found this reaction on a gut level repulsive (almost as a piggyback to Matt’s personal examples).
I’ve noted on here before that I’m a pretty hardcore about working out. Six days a week at the gym with a mixture of weight lifting and cardio. Up until five years ago that cardio portion included a decent amount of running; including at least once a week 5-6 miles of outdoor running.
Starting about 6 years ago I started noticing real discomfort in both the bottom of my feet and then my Achilles. A modest discomfort became real pain with my feet and increasing discomfort with my Achilles. So I go to the doctor who recommends a podiatrist…who within five minutes was able to diagnose me with planter fasciitis. Good news? Easy fix which was that I need to wear orthotics in my shoes…and stop running as part of my cardio routine. The bad news? Orthotics are not covered by my insurance. Had to pay out of pocket for the inserts. And five years later I had to pay again for replacements out of pocket. All told I’ve probably spent close to $1,500.
Now I’m lucky. I have the financial wherewithal to pay for this out of pocket without too much problem. But I’m well aware for even middle class people, this would be a pretty major financial hit to pay for. And for people at the bottom end of the income spectrum? Forget it.
So let’s say I didn’t get orthotics because I couldn’t justify that out outlay. What happens? Two different specialists told me the same thing..I very likely eventually tear my Achilles.
So a few points to make. One, “likely” and “eventually” are doing a lot here. It’s at least possible the tear never happens. And if it did, the when was also very muddy; would it be 1 year, 3 years or 5 years later? Who knows. Point being if you were to ask me 3 years after I first diagnosed and I didn’t get orthotics I might have said “oh yeah mostly fine, do have some pain in my feet and Achilles but it’s manageable”.
Second, let’s say I did tear my Achilles. I have an office job. I would very likely still be able to work; have a coworker who was able to work while recovering from a serious ACL tear. And I likely would eventually recover and be able to live a mostly normal life.
And here’s the kicker. As far as I can tell from libertarian crowing about this Medicaid study, me tearing my Achilles due to lack of ability to pay out of pocket for orthotics would be a perfectly fine outcome. Which is absolutely asinine. The pain from the tear itself, the intense recovery and the likely permanently reduced mobility (again even if still able to mostly live my life) would have made my life so so so much worse than just getting the orthotics*. And yet somehow this not supposed to matter.
*Also, my insurance wouldn’t cover orthotics as it wasn’t strictly “necessary”..but it would cover my surgery and physical therapy for a year. I’m a nutshell one of the reasons our health care costs are so much higher than necessary.
An interesting third option is you grab a pair of the pre-fab ones which are $14 on Amazon and which, at least according to this study, provide "no statistically significant differences". I'm fine limiting our federal and insurance spending to things that provide actual statistical differences. I personally take an number of supplements and all the research I can find shows only the creatine and glutamine I take provide any statistical benefit. I think I can feel a difference so I don't care and even if it's just placebo - that's money well spent. Still, I don't think anyone else should pay for those.
https://www.ncbi.nlm.nih.gov/books/NBK595390/
So two parts I left out of the story.
I actually tried exactly what you suggested; I went to CVS and got Dr. Scholes. Even stood on that machine they have to get the "right" ones. Did square root of f**k all for the pain.
Second, my Mother in law was a physical therapist. And she was the one who told me to ditch the store bought inserts in part because she had seen this tried with patients of hers to no effect.
So at least for me, was quite necessary (it seems) to get the custom made inserts. I can tell you quite soon after getting them the pain went away and I've been pain free since.
Don't want to just say "fake news" to this study. That would be dumb. Entirely possible the specific issue I had required custom made inserts and someone with maybe less severe planter fasciitis could have gotten by with store bought ones. Who knows.
I would say my own experience tells me that "more research required" is probably answer.
I will say last that even leaving aside that with my specific issue you may be completely right (maybe I just didn't get the right store bought ones). But my general points I think stands; measuring health insurance effectiveness purely on the metric "did you die in 5 years or not" is a wildly incomplete way to look at health care and its efficacy. And second, all sorts of "elective" procedures not covered by health insurance really should covered if you're concern is saving money or general human welfare.
But you’ve argued that treating an ACL tear is a waste as it’s not a matter of life and death. If someone’s mobility is severely restricted that’s just too bad.
Edit: My apologies to David in Chicago I got him confused with one of the other Davids.
I've never argued that.
You argued that life expectancy was the only metric that should be judged. If someone gets a hip replacement and can walk again for 10 years but will still die at the same time - no value add.
I've never argued that.
EDIT: I think you're thinking of David Abbott. That sounds like something he would say. I would never say that.
Ha, I was thinking the same thing "Probably David Abbott."
See this is the benefit of using my full name here—I never get confused for anyone, even though someone comments here with the name "Tom H"!
Ohhhh sorry!
Three years ago I was running 40 miles per week when I was diagnosed with plantar fasciitis. After wearing a boot for a couple of weeks I wore the strassburg sock from "the sock dot com" every night for three weeks or so while sleeping. I was running again pain free in less than a month, and it hasn't returned. Other folks with plantar usually take about 6 months to get back to running.
I wore the strassburg sock for too long and got hypermobility and chronic pain in my big toe 🙃
It remains absurd that there's more political will to cut medical benefits to the poor and elderly than to means test social security. I don't know how you could argue that there's any systematic waste in the entitlement system more clear cut than paying social security benefits to people who are comfortable without the money.
Means testing social security would discourage saving for retirement, which is something that really really needs to be encouraged. Semi-forcing people to save for retirement as they do in Australia is the best strategy, though it would help to start 30 years ago.
If you make the program no more generous than it is, perhaps even lop off the top quarter or so of its payment structure, then I don’t think you’ve introduced much more of a disincentive for savings among the middle classes, because who the heck wants to live on $2000 a month?
That said, means-tested programs die or are starved into ineffectuality in this country quite quickly so… not sure how to deal with SS, aside from that this magnitude of transfer from the young to the elderly is immoral and unsustainable.
There are lots of means-tested programs that don't die (most never die) or are starved. SNAP, Medicaid, the Disability part of SSDI, the EITC, tax rebates of various types, Roth IRA deductibility are all "means tested" and have grown over time. We could -- and probably should -- do the same with Social Security.
Perhaps. That said, a means-tested program that takes almost 13% of your paycheck is uncharted territory.
I'm more inclined to reduce the generosity moderately and also make all the income fully taxable at all levels, as well as tweaking every aspect of local taxation about 10 notches further against "age in place."
We've run much of the economic policy of the last 50 years as an incredibly generous transfer from young to elderly and it's weighing on our demographics, faith in the future, economic dynamism... if SS collapses entirely it'll be because the Boomers wanted all the seed corn for themselves.
I think you want to encourage people to downsize their home in their 50s or 60s, and then age in place from there. Not age in place in the house where you raised your kids and they moved out, and not move to a facility where you never see anyone younger than 75.
Why against "age in place?" I ask because governments in my area actively support "age in place" programs in part because it saves them money.
However, I recently learned an alarming fact about my state -NY - that may not be true elsewhere. In NY State, not just the city, there has been a 50% increase in older adult poverty even as there was a 22.4 % decline in poverty among the under-65 population.
It's yet another distortion of the housing market that degrades the demographic trends necessary to sustain any of the anti-poverty or health insurance programs we use to support seniors. If we don't course-correct on affordability of family-friendly housing and direct support for child-rearing we are literally doomed, and huge chunks of the next generation of old people will starve on the street.
For the second part... I would have to see the exact measurement used, because on the face of it that seems completely unbelievable.
Every dime that goes to my elderly mom through SS out of my sister’s and my taxes comes back to us in the end so long as we can avoid expensive skilled nursing care at end of life. I don’t see why it’s such big deal.
Assuming most every young person will become an elderly person, why is it immoral? And it’s perfectly sustainable by raising taxes
Wait, why would means testing distributions in SS discourage ex ante and external to SS retirement saving among middle class?
If the means testing reduced benefits 1:1 then why save if you won't end up with more.
If it was say .9:1 then I'm making a _little_ more in retirement in return for having less disposable income now, and I also probably reduce my savings.
At the other end at .1:1 it will barely reduce retirement savings, but also not save much money.
We could do 0.5:1, and that's my gut feeling, but some savings will be reduced, and so our budgetary savings will also go down
My apologies I must be totally missing something. Why would reducing how much social security benefits an affluent person gets reduce anyone's incentive to have brokerage IRA or 401k savings?
Let's suppose if I save my 401k I can "guarantee" a $60,000 income(current SS Max) and add that to my SS income(60,000).
Great! I've doubled my income.
Now suppose instead you look at my savings then and say"you're rich enough to make the $60,000 on your own, so SS pays $0".
I could have spent that 401k savings on more vacations when I was younger or other fun things. If I'm basically "throwing it away" because I effectively don't get to keep it, I might.
I probably wouldn't end up reducing to $0( employer match, tax advantage), but it seems very plausible I'm less inclined to save.
Again that's at the harshest cliff. If you scale down me benefits more slowly it helps a lot.
How do you operationalize the idea of an “affluent” person? Do you say that social security payments are cut $1 per month for every $100 in savings you have above some threshold?
Anything like that, where the more savings you have the less social security you get, discourages people from saving (because they can spend the full amount now and also get some extra social security later, rather than just save the full amount for later and get less social security).
If you can find some way to define “affluence” that doesn’t look at how much savings people have, you might be able to do this better, but I’m not sure how you do that without making it easy to game.
Think about the marginal case.
The problem of course is that it turns SS even more into a welfare program than it already is. Which lowers support for it.
Honestly, the fact that we don't take a much more serious and systematic look into end of life care is for Medicare is insane to me. While I get that there's politically a very strong incentive to demagogue, and I certainly wouldn't trust this crew, we're talking about $230 billion a year in spending if it's a quarter of Medicare. And how much of it makes people more live longer, happier, more comfortable?
My guess is at least half of that $230 billion is probably wasted by most objective measures.
And that's not including long term care under Medicaid.
The estimates I found on social security means testing were in the $6-$8 billion savings range, if reductions start at $40k per year. One can't really avoid the medical spending issues.
It's hard to imagine agreeing on reasonable choices for rationing care (which is really what you're describing). Heck, the ACA allows states to mandate coverage for interventions of dubious value, like acupuncture and chiropractic, in subsidized marketplace insurance plans.
Actually heroic end of life care is around 400 billion a year now. And I would venture the amount wasted is probably 80 or 90%
https://www.saturdayeveningpost.com/2013/03/how-doctors-die/
I'd like to know what you think the objective measures are that you'd use to deny ex ante futile care. You would like it to be obvious, but I'm not so sure it is obvious.
Social security is supposed to be forced retirement savings, not redistribution.
In practice social security has always been redistribution. Which is fine! It's a good program but it is simply redistribution from the working age to the old, and has been since the start of the program.
I guess I feel like "redistribution" is a funny way to put it when the working age become the old at an extremely high rate. It's like saying that when I buy a CD I'm redistributing from my present self to my future self.
Most people (including me) don’t think of it that way and social security would be less popular if they did
You are correct, but that's because some people have a somewhat romantic misunderstanding of social security. You're not going to get your money. Someone else is getting your money on the promise that you eventually will get a different someone else's money yourself. It's intergenerational redistribution
I’m curious why you’re so in favor of means testing. In Germany if you’re the CEO BMW or a hotel maid and you kid gets into the University of Munich it’s €120. And everyone generally thinks they are getting good value for their tax money.
But you’re opposed to this, why?
I'm making a more limited case. Specifically, I argue that IF we must cut entitlements to curb the deficit, means testing social security would be the least harmful cut to make.
I argue that (again, IF we must trim these programs) it's immoral to cut Medicaid or SNAP or any other program that specifically benefits the needy instead of cutting social security benefits to people who are well off.
Because they can't make the case for increasing taxes, so instead they argue for a very complicated way of making rich people pay more that distorts everything.
As I said in a discussion with Avery yesterday, there is no reason st all to believe that we can bring (admittedly ballooning) public-sector healthcare spending by looking only at that spending, and not the entirety of the sector, including providers, vendors, private insurers, and state-level regulators.
No one has the spine to do it at present and I don’t know what it would take for enough politicians to grow one on the topic and take *everyone* to task.
I don't know that a courageous politician even can change health care all at once (as much as the WSJ editorial and others might wish otherwise.)
But I think Chris Pope has a pretty good idea[1] *on the margin* to both prevent wealthy states spending Medicaid funds on all sorts of new things and maintain core benefits of the program for the poorest Americans among us.
I'd love to know what Matt Yglesias thinks. His post today feels very Obama-core, which is not crazy given some recent GOP proposals. But the debate over enrolling able-bodied adults into Medicaid on the margin and the Oregon study, well, it's missing the main story of the Biden years which is states increasingly using Medicaid money for literally anything [2].
[1] https://www.washingtonexaminer.com/opinion/3242868/how-can-republicans-reform-medicaid/
[2] https://x.com/CPopeHC/status/1896566579141444009
Like I wish I was exaggerating, but this is what's actually happening. From Chris Pope's report in November[1]:
"Various states now claim Medicaid funds to pay residents to “sit at home” with their elderly relatives—with the cost in New York alone surging from $0.3 billion in 2016 to $9.1 billion in 2023.
Notoriously, all 50 states have increased the fees that their Medicaid programs pay for hospital services, thus entitling them to higher reimbursements from the federal government, while simultaneously imposing taxes on those facilities to finance the supposed state contribution to the program’s expenditure. Often, states have used publicly owned hospitals to capture Medicaid funds as a way to improve their general fiscal situation."
Matt can correctly say the condition of blue state governance should reign in the Democratic party's priorities. Matt can also correctly predict that Democrats could form a popular "hands off my Medicaid" front against any reforms and punish Republicans electorally.
But put together, the latter is clearly helping promote problems in the former.
[1] https://manhattan.institute/article/slowing-optional-medicaid-spending-growth
Isn't it cheaper to pay someone to sit at home with their elderly relative than it is to have that elderly relative in the hospital?
Well the state of New York is always welcome to pay for their new cost-saving ideas and lead the rest of us through example.
WA pays relatives state minimum wage + state employee health insurance as in home caregivers to keep people out of nursing homes, and while I’m sure there’s some abuse of the program, I think it’s considered to be wildly successful both from a cost and an outcome standpoint. Nursing homes are really horrible places!
Yeap. I don't think enough people fully grasp how massive the spending increase was.
https://fred.stlouisfed.org/series/W824RC1
That's Medicare, which looks about right for the trend line increase in elderly enrollees. You want this one: https://fred.stlouisfed.org/series/W729RC1
yeap. Sorry. Had them both up. Thanks!
Hmm. I am definitely on-board with "Medicaid is not a catch-all program to hand money to states for various welfare-adjacent schemes."
It occurs to me that the correct way to deal with that is probably to just federalize it outright, but I don't expect you'll agree.
I do agree, and sure enough, Chris Pope is the one who convinced me of this as a good idea lol: https://thehill.com/opinion/healthcare/4022852-a-better-way-to-rein-in-medicaid/
Ok, cool, we're more or less on the same page, on this specific issue.
Now if you'll just give up on extending most of the TCJA using Medicaid as a pay-for...
Ah well my preferred pay-for is a lot more on the Medicare side of things, alas the Obama-Boehner talks breaking down on that altered our timeline forever.
I mean... give up on extending the TCJA at all, much of it is spectacularly bad, distortive policy, and there is just no way, and you know this, that we're going to squeeze enough to close the deficit without raising taxes somewhere.
Letting federal revenues creep all the horrific way up to 20% of GDP is the least of the possible evils in front of us.
If you need some kind of sop to the SME-owner base, simplifying and lowering corporate taxes and easing capital and R&D expensing are *good* Republican ideas, use those please. Pay for them by unfucking the foreign revenue accounting standards permanently.
As for Medicare, site-neutral payments and expanding drug pricing negotiations are a freebie, in that we need not cut anything to wring substantial savings out of them. Not sure what else is out there you think worth doing.
But at the end of the day, without dealing with how opaque, convoluted, and simultaneously over- and underregulated the private side of healthcare and health insurance has become, it's going to be very difficult to keep Medicare and Medicaid from helping bankrupt us in the long-run.
> It occurs to me that the correct way to deal with that is probably to just federalize it outright
As is true of most things!
Yes! Best to address this as a supply side issue first.
Matt said it in passing but it need saying again this is all about maximizing the size of the tax cut. Democrats should have been railing about the 2017 Tax Cuts for the Rich and Deficits act since then and killed it in 2021 as part of the way to pay for recession relief.
The simplest explanation for why Democrats do not raise taxes/undo TCJA with their trifecta is that they do not have the votes and do not agree as a coalition to raise taxes. So operationally, the party isn't really in as stark disagreement with Republicans on tax rates as they can appear.
The stark disagreement is whether to slash Medicare and pocket the deficit savings, or slash Medicare and use the CBO scores for partisan bill funding.
Yes. Too few have been reading Radical Centrist. Hopefully that will change. :)
The thing that I find most hypocritical about this is that republicans are essentially saying "we KNOW that there is lots of criminal fraud in the Medicaid program, so we are going to defund the Medicaid programs by that amount. That will result in the fraud being eliminated without having any negative impact on beneficiaries, services, or providers."
When progressives (stupidly, IMHO) proposed the exact same thing ("we know that there is a lot of bad policing going on, so we're going to defund the police to eliminate the bad behavior and this will result in less crime") everyone on the right (correctly) pointed out how absurd the claim was. Now they're turning around and making an identical claim in the health care space.
To be clear, I'm aware that they're doing this because they're full of crap and lying. But the hypocrisy is especially galling to me.
Manned space flight is 100% waste. All of it should be zeroed before a single grandma is kicked out of a nursing home.
All the spending on art, culture and cathedrals could be described in the same way.
Indeed, insofar as the goal of cultural expenditure is to enrich the lives of the mass public, space flights do this to a far greater extent than the fine arts (because the masses literally could not give less of a shit and are deeply unimpressed by art being produced today). If you've seen a little boy watch a rocket takeoff from the Cape, and then you've taken that same little boy to the Met, this becomes immediately obvious.
Well, except for maybe the Egyptian tomb room.
Absolutely true!
Frankly, it's a crying shame the government isn't funding more Egyptian tombs to create more Egyptian tomb rooms in every state in the country.
It's not waste. You're doing literally the thing the conservatives are doing, where you disagree with the objective and then say the money is waste. The government is purchasing manned space flight missions for a certain amount of money. The fact that you don't think the government should be purchasing manned space flight missions is irrelevant to the question of how much waste there is in government spending. It would be waste if we were trying to purchase "manned space flight to Mars" and then we kept spending money on manned space flights that aren't going to Mars, or something.
Also, it goes without saying, but zeroing out the budget for manned space flight is not actually a significant reduction in government expenditure. It's not the Apollo program where absurd sums are going to it every year, it's a very modest program that hasn't even sent someone beyond Earth orbit in ages.
Would you say the same about heavier than air flight? Should we have never pursued heavier than air flight and instead spent the money on the poor?
Or is the only reason we can have nursing homes because so much wealth is thrown off by various inventions and resulting industries?
I struggled to respond to this but it really is a perfect comment esp. given your handle, it should be in the DNC party platform. Really encapsulates the liberal mindset. I mean this unironically. Of course, I completely disagree.
This liberal finds this to be a libel. Look up what presidents gave us the space program!
Yes, agree with you totally, a large part of the program was kicked off by the Dems! Would like it if this kind of viewpoint didn't appear so dominant on the left though
I think this take is out of date. Gil Scott-Heron is dead. Whatever NASA opposition remains on the left is totally drowned out by “I fucking love science” celebration of space exploration: the rovers, the Webb telescope, all that. (It’s true liberals love to hate private space exploration, but we’re talking about government waste here.)
There’s really positive NPV to shooting Elon into the sun!
Hard disagree. Our future is the stars. Not borrowing money for consumption today
Every billlionaire is a waste of at least $990 million.
Hard disagree. Where do you think the investment money comes from that drives economic growth and quality of life improvements???
It comes from rich people risking their money for the possibility of returns.
Venture capital is good. Rich people are good. We want them investing their money.
People like Bill Gates did far more good making their money than they ever will giving it away
The question to me is more like "Did Bill Gates do more by making $2 billion than he would have by making $500 million?"
I'm skeptical that people need the same obscene portions of returns to motivate them.
The point of the returns is they then turn around and reinvest it and generate even more wealth. that is good for society.
I guess I wonder if one person having $2 billion equals more investing and better results than four people each having $500 million.
Obviously it can depend on the circumstances, but for big investments yes, bigger is better.
For example, I just read a WSJ article on how Larry Ellison one of the Co-Founders of Oracle is trying to transform farming. He's already lost 500 million doing it.
But since he's so rich, he can afford to try and do a real moonshot.
Every time "efficiency" comes up, I will forever post that efficiency is a process you pursue to something you are already accomplishing. And it is a red herring in any other discussion.
That is, any discussion about trying to bring efficiency to a system is about as helpful as discussions that you should run faster to win a race. To a useless degree, this is certainly true. The question is how.
And with spending, if you don't build a system where you are comparing the ROI of different expenditures, then you are blindly cutting spend in a vain hope that you will strike gold.
Making "efficiency" the goal, though, is ludicrous. You don't pursue efficient solutions, you pursue solutions and optimize on working ones to make them efficient. Any other effort is akin to telling an artist that they cannot make prototype works. After all, every prototype is wasted effort in the path to a final product. And if you try to cut resources to working solutions without an eye to what they were accomplishing, you are likely to kill more than you are to increase efficiency.
I'm starting to think schools should focus more classes on basic gardening. A mental model of pruning trees is more effective than whatever mental model is leading many of the cuts we're seeing.
"My 10-year-old child has, fortunately, never had any major health problems."
Heyyyy, anecdote time!
One day, when I was ten years old, I felt a weird pain in my abdomen. It wasn't even that bad, but I mentioned it to my mom. Her instinct/Spidey Sense told her something was up, and she took me to the emergency room, even though I thought she was overreacting.
The nurse at the ER palpated my abdomen, said to my mom "Oh my God, her appendix is about to burst, WHY DID YOU WAIT SO LONG TO BRING HER IN" and wheeled me into the OR asap. (Apparently I'm built in a weird way such that even severe inflammation of the appendix caused me only mild discomfort?)
Without that, I would have died at the age of ten, probably very painfully.
This is the thing about medical care: you don't need it, until you do.