" a basic bundle of valuable services that is publicly financed for all, while allowing individuals to “top up” by purchasing additional coverage, "

This describes basically every attempt to reform our health care financing system that has occured in my lifetime. It was what Obamacare/Romneycare was supposed to be. It pretty well describes what Medicare is today. Almost every expert who looks at the problem comes up with the solution but nobody wants to implement it. It is vigorously opposed by the 'equity'/Medic(aid) for all crowd who think all healthcare should be 'free'. It is opposed by more doctrinaire conservatives who don't like 'socialized medicine'. It is opposed by big healthcare organizations because they don't want to be tied exclusively to government fee schedules. It is opposed by health insurers because it wrecks the current group insurance market. It's opposed by most groups that have negotiated first-dollar insurance coverage instead of salary increases.

It's the obvious solution and it's never going to happen.

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The https://www.therandomwalk.co/p/consider-the-everything-bubble is great, especially on housing, with his:

>> latest attempt is to posit some cognitive dissonance between two recently popular claims that “we have a banking crisis” and “we have a shortage of homes.” ...

both of these statements cannot be true:

if only we’d invested less in real estate, then things wouldn’t be so bad

if only we’d invested more in real estate, then things wouldn’t be so bad ...

another way of saying that “individual homeowners are ‘trapped’ by their cheap mortgages” is that they can’t find anyone who can afford their home at now-prevailing rates. If they had to sell, it would be at a loss (and so they prefer not to sell). Individual homeowners are, in other words, sitting on piles of unrealized losses.5 Remember, banks are people too, y'know.


Just like SVB 2% T-Bills lost huge market value when the current market rate is 4%, higher interest rates mean lower sale prices.

>>My affordability, is your deflation ...

building more would make housing more affordable . . . in the same way that new 4% Treasuries made SVB's assets more affordable.


SVB's assets went DOWN in sale price value (more affordable to buyers!)

Nobody who owns a home wants the value of THEIR home investment asset to go down.

MOSES STERNSTEIN said it very well and in more detail.

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Re: urban population density

The Couture and Handbury piece states:

“As the rich got richer, their time became more valuable. They also had more disposable income to spend on services like restaurants, bars, gyms, and beauty salons. They sought to avoid spending valuable time commuting and found proximity to downtown concentration of amenities and jobs more attractive. Downtown amenities are also meeting places for networking, friendships, and dating, which makes them particularly popular with richer people who are unmarried and childless. As a result, the rising incomes of young college graduates and their reduced propensity to marry and have children early in life both contributed to downtown gentrification.”

The New York Times once carried a piece describing this alleged phenomenon as “the downtown decade.” https://www.nytimes.com/2021/09/01/upshot/the-downtown-decade-us-population-density-rose-in-the-2010s.html . Somehow this notion that people are clamoring to live in high-density urban areas seems like a just-so story concocted for other purposes. Other observers provide alternate explanations. For example, Pew has reported that “ immigrants were just as likely as the U.S. born to have a bachelor’s degree or more (32% and 33%, respectively).” And they have reported elsewhere that “Immigrants, along with their children and grandchildren, have accounted for the majority of U.S. population growth since 1965. But immigrants are more concentrated in cities and suburb…” They further report that

“There are four main drivers of population gain or loss at the county level: births, deaths, new immigrants coming from abroad or leaving, and people moving to or from other U.S. counties (including immigrants already living in the U.S.). The census numbers show that these factors are affecting cities, suburbs and rural communities differently.

Urban areas gained 1.6 million net new migrants since 2000, with a surplus of immigrants more than offsetting a loss of people who moved out to suburbs or rural areas. As a group, urban counties had 9.8 million more births than deaths, further bolstering their populations” (https://www.pewresearch.org/social-trends/2018/05/22/demographic-and-economic-trends-in-urban-suburban-and-rural-communities/ )

And US born residents generally indicate that they would prefer to live in a single family dwelling in the suburbs. The great Randal O’Toole offers a competing view that appears to align more closely align with reality:

“Surveys say that around 80% of Americans prefer or aspire to live in single-family homes, not apartments or condos. More than 80% of the populations of many states with minimal rural land-use regulation, including Delaware, Pennsylvania, Utah, and much of the Midwest, do in fact live in single-family homes.

Despite this clear preference, city planners want to force most urban Americans to live in multifamily housing. By scaring people about disappearing farmlands, pollution, and climate change, they have persuaded state and regional governments, mainly in coastal states, to restrict development of new single-family homes, thus creating artificial housing shortages that prevent many people from realizing their preference of living in a single-family home.”

Perhaps nowhere is O’Toole’s observation better illustrated than in Montgomery County, Maryland, bordering the District of Columbia, with its 93,000 acre agricultural reserve. https://en.wikipedia.org/wiki/Montgomery_County,_Maryland_Agricultural_Reserve Driving out I-270 from the city, one can see where Montgomery County ends (the highway goes down to two lanes in either direction) and you start seeing the massses of new high density apartment dwelling developments around Frederick. Perhaps I am just cranky about this but even in the remoter area of Maryland in which I live the encroachment is palpable and with it the tension. The months of the year we spend on a quiet lake where my wife enjoys having space to garden and sit out back where we can see deer, eagles, the rare bear, and all is very relaxing and definitely beneficial for mental health.

Which is why it is not hard at all to find reasons why people would prefer lower density living. There is a vast, easily accessible literature documenting the strong correlation between the prevalence of mental health diagnoses and population density. And this correlation is manifested in concrete ways. For example, during the period of 2006 to 2016, roughly the New York Times’ “Downtown Decade” suicides among the 25-44 year old population increased by 20 percent, per the CDC. Frank and Glied really ought consider population density as one of their economic factors related to mental health.

The war on the internal combustion and the inane industrial policy mandating electric cars will further aggravate housing problems. Look for the USA to follow Canada’s example where, according to probably not the best sources, plans are apparently underway to simply euthanize the homeless. But the important thing is that people get cleared off the countryside to make way for ever larger solar and wind farms. The great energy transformation is eventually going to require some actually noticeable climate warming and there is no better way to achieve that than by carrying out the plans to cover 1/3/ to half the country with solar panels and wind turbines to achieve maximum temperature increases:

solar farms raise local temperatures around 5.4-7.2 degrees (https://phys.org/news/2016-11-solar-island-effect-large-scale-power.html and wind farms “large-scale wind farms were built, would warm average surface temperatures over the continental U.S. by 0.24 degrees Celsius.” (https://news.harvard.edu/gazette/story/2018/10/large-scale-wind-power-has-its-down-side/ ). But really, the Great Immiseration is but a small price to pay so that the climate bed-wetter know-it-alls can finally say “told you so.”

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"Just listen to the music of the traffic in the city

Linger on the sidewalk where the neon signs are pretty

How can you lose?"

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great excerpts today. The premium medical idea reminds me of a story I heard from a friend who was an senate appropriations staffer in the 1990s. When they were earmarking a bill, my friend suggested a list of the best projects to fund. His boss said, “See what you are doing there is talking about the best policy. What I’m talking about is the best politics and I don’t ever want to hear that s#!% out of your mouth again.”

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The statement: "In general, economic publications have a very strong bias in favor of papers that show what government can do to solve problems." is what would be expected. With the reality of the increasing complexity in the world that results from "specialization and trade" having progressed to the point where no individual or internally communicating institutions or group of institutions has the band-width to understand all the relevant details of modern problems, honest economic publications would have to admit the government doesn't understand what they are doing. Neither do businesses, but they try more things and junk failures faster.

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Recent (and past) research on nutrition and mental health focuses on metabolic health. Finally RCT studies are being carried out, funded by Baszucki Group (billionaire Roblox founder). Bret Scher and Julie Milder run Metabolic Mind, providing education). Chris Palmer is leading research (author of Brain Energy). Georgia Ede articles and talk "Our Dietary Descent into Madness" suggest mental health epidemic in colleges is consequence of diet. I have posts and links on Normal Nutrition substack page. Also, reforming federal dietary guidelines is proposed as national high school debate topic.

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Arnold, I can't speak to whether you are a libertarian or a crank, but you are old, at least in the sense of having experience. And experience teaches, at least to those who are open to learning from experience, that government programs don't always work like their proponents say they will work.

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Older? Yes you are. Libertarian? Probably. Crank? Absolutely not!

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Re: Baicker, Chandra, Shepard

Regarding the provision of health insurance, they predict that “the current US system will propagate inefficiencies in our patchwork approach” Yes, although it is hard to imagine how the overlapping melange of federal bureaucratic employment programs falling under the header “health” (VHA, TRICARE, FEHB, IHS, BOP, the new USPS system, HHS community health centers, etc etc) could get any more inefficient. Given the impending passage of legislation to allow the imposition of trillions more in debt and perpetual interest payment service on future generations, one would think consolidating and streamlining this mess would be relatively low hanging fruit.

They also state “undocumented immigrants are not eligible for subsidies or Medicaid under the 2010 law, affecting perhaps 4 million people (or 13 percent of the uninsured).” Maybe a large portion of undocumented immigrants live in Illinois (where the cost of their program for providing health insurance at no cost to beneficiaries unexpectedly exploded to $11 billion), who knows? And nobody really has any idea how many undocumented immigrants are actually living in the US anyway, so this figure strikes me as extremely low with what must be an enormous margin of error and casts a pall of suspicion over the rest of the piece. That said, during my first extended stay in a certain rnodern country with a modicum of demonstrable electoral integrity and proportional representation, when I needed to get some prescriptions refilled, I just had to walk down the street to the local community health clinic where it took 5 minutes to enroll me, a non-citizen, in the national health system. I left 10 minutes later with my prescriptions which I was able to have filled at no out-of-pocket cost at the pharmacy on the way back. This country spends about a tenth per capita on health care as the United States and the health system is highly popular. I won’t name it because it already being overrun with Americans: just this week an American couple moved in down the block.

Bernie Sanders was probably headed more or less in the right direction when he was trying to fold all the federal insurance programs into the VHA and then make that the national health system. Taking note of the article’s finding that a large percentage of the “uninsured” are already eligible for various federal health program,Timothy Taylor commented the other day:

“For many people–including some people who in fact have health insurance– access to health care isn’t just about insurance. Financial issues are of course part of the picture. But access to health care is also about being able to navigate the system in other ways, like knowing who to contact, where to go, how to get an appointment, and what can be provided at that location.”

Having tried to assist a young person recently with selecting an Obamacare plan I can certainly attest to the wisdom of that insight.

To their credit, as one rarely sees this in health insurance policy papers, the authors recognize the implicit social floor created by the 1986 enactment of the Emergency Medical Treatment & Labor Act requiring hospitals to provide emergency services (“stabilizing treatment”) regardless of the individual’s ability to pay. The ability to freely access care in emergencies likely contributes to the failure of health program insurance eligibles to bother enrolling. And the authors also provide estimates of the cost of this program: “about $40 billion in annual uncompensated care and $11 billion in grants for community health centers, paid for by a mix of public funding and health system cross-subsidies.” Since the cross-subsidies are largely paid through premiums for employer sponsored care, they might be viewed as an employment tax.

Re: “’But “health outcomes have not improved’ is what you always observe when insurance coverage rises and health care spending goes up.”

Yes, but the Das and Do article is particularly interesting because it, essentially, lays the blame on physician malpractice, citing a 2023 Bannerjee study: “52–78 percent of this avoidable medical expenditure is due to misdiagnosis and incorrect care rather than over treatment based on a correct diagnosis.” This figure is undoubtedly much worse in the USA, given the woke medical education system, and even before taking into account the enormous health care expenditures attendant to the mania among our anti-populists betters for neutering and spaying (“general affirming care”) their offspring.

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It's not clear how "use 1975 medicine" could be implemented?

I use modern insulin. My Dad used a very primitive form of insulin. Would 1975 medicine mean I'd have to use primitive insulin? What about insulin pumps and continuous blood sugar monitors?

My Dad went to the hospital a lot due to low blood sugars, and to avoid that he often ran high blood sugars (which damages your body).

By contrast all this modern insulin and technology has allowed me to control my blood sugars and I've never gone to the hospital for low blood sugar. I can't see giving up this technology as reducing healthcare costs, even putting aside the massive benefit to quality of life.

When we talk about healthcare for diabetics, it's not improving technology to help Type 1 diabetes like me and my father that drives it. The massive increase in Type 2 diabetics (90% of diabetics) caused by people getting fatter is the driver. And that modern insulin isn't even expensive. It's just that the drug rebate system drives up list prices even as net prices stay the same.

We could expand this to other items. What doctor would do a 1975 procedure when a 2023 procedure would be much better? They would get disbarred. Many people might not even know how to do the 1975 procedure anymore.

Bureaucracy, over utilization, deteriorating public health, and more desperate end of life care seem like they could drive up costs all on their own no matter the year of technology used. In most cases when a new medical drug or device is introduced people at least make a pitch as to how it will reduce overall health costs (say Hep C drugs curing Hep C so people don't need organ transplants).

Ironically, the #1 way using worse medicine might drive down healthcare costs is if people just died sooner.

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May 24·edited May 24

What is the cost of health care? Recent experience: hospital charges $719 for a procedure, insurance company gets a discount of $527, and the remaining charge paid is $192. Is the cost discussed by policy makers $719 or $192?

Analysts and headlines always seem to take the $719 as the "cost of healthcare"--it's the amount billed to those 12% without insurance. But $192 is more representative of the charge to the insured 88%.

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