Rob Henderson cites research on female aggression; Lynn Kiesling on social roots of progress; Richard Samuelson on Jews vs. Progressives; David Hyman and Charles Silver on Medicare malincentives
I don't understand why Hyman/Silver suggest going straight to "nothing but HSA" rather than the kind of straightforward "HSA + High Deductible" insurance that usually comes with HSAs?
I read the article and they don't seem to address that at all.
I've been on the HSA+HDI sort of plan for years and it's pretty straightforward and easy to understand what's going to happen. You have an incentive to save, and the insurance plays an actual insurance function.
Instead of that, they seem to be suggesting dumping Monopoly money amounts into the stock market via HSAs and then just letting the chips fall where they may. That doesn't seem like a particularly well thought out idea.
So much so that I just question their wisdom in general.
I don't know if HSA+HDI is a good option but i agree it seems far preferable to just HSA, which seems to have no benefit in the current healthcare environment and very little going for it in the best of circumstances.
Medicare Advantage already does what your last link suggests, in effect. It's become and will continue to become the entire Medicare market. We get a set amount based on the Risk Score whenever a member enrolls in our plan.
Of course the insurance offerings that plans can concoct are regulated. Each regulation having its own story for good or ill.
Plans can already basically return some of the money as cash to members (Part B Buyback, Spendables cards). If you could do more while covering less, it would probably just turn into a race after the healthy people. It already is.
It doesn't necessarily do anything for health costs. If I can upcode more, then I have more revenue to have a bigger cash giveback. I do suppose cash is a better use of marginal dollars then lower copays, but government is never going to let the copays get high enough that people complain, and anyway it would destroy your STAR ratings. Mostly this stuff just moves around risk between plans that aren't wildly different in their benefits, some plan is still getting stuck with the high spenders.
The only thing that would really move the needle is if we let people pass money onto their kids in exchange for just letting themselves die. It's all that Hospital and LTC spend at the end that is very expensive and low ROI, but someone else is paying for it so why not.
There is a great deal of turmoil in the Medicare (and other government insurance) markets. Lots of post COVID claims trend and of course the IRA is a dumpster fire.
Any time government actually or in effect gives people money they must spend in a certain way it is a market distorting subsidy. Much of what we have masquerading as insurance is really pre-paid health care so of course people are going to find ways to spend it. The beneficiaries of that spending are also going to fight to keep targeted spending as well.
I don't use healthcare much - have not been inside a doctor's office since 2007, apart from the optometrist; floss religiously; got the shingles vaccine at CVS - and don't know any of this stuff like you guys do.
But I will say as regards pre-paid healthcare: my parents have Medicare, of course, and the supplemental insurance on top of that, and a Medicare prescription drug plan - and so when my father decided they would also enroll in the local concierge doctor's practice, I was thinking, really? Yet more?
(This guy left his practice so that instead of 3000 or more patients he could have 500 or so? getting that secondhand - and not work around the clock.)
And I have to admit - it's great. Especially since my brother and his wife use the guy also, so we have a back-door to family involvement as their minds get feebler. I wish all old people could have a concierge doctor.
We have to understand there are competing demands for what we want health insurance to do. While it is true that pre-paid healthcare is not insurance, we require it, or providers decide it is to their benefit, when we think it will improve outcomes by cheaply buying better health or outright saving money through increased use of those services. Examples include annual checkups and prenatal care.
"The only thing that would really move the needle is if we let people pass money onto their kids in exchange for just letting themselves die."
Several decades ago I proposed that all old-age transfers and benefits be issued in the form of easy, on-demand, no-questions-asked unsecured loans (at zero real interest rates) against the beneficiary's unattached estate, that collect with first priority upon death. That is, if you are broke, your consumption and care is public charity. If you are not broke, you are spending your own money - and that of your spouse, kids, and heirs - first, until you have exhausted it, and then you are a charity case.
One could tweak this so it's not 100%, maybe you get half "free and clear" and only have to "borrow" the other half, or maybe even 90%/10%.
For people who are already old, already in poor health, with some significant savings, this gives them good reason to think twice about saying yes to anything and everything. It also gives their spouse and kids reason to think twice about passionately insisting that medical professionals do anything and everything to save or prolong the life (regardless of quality) of their ill relative.
This seems to me a much fairer system with much better incentives, and thus, practically by consequence of being superior in those factors, totally politically impossible.
This is already the case with Medicaid, which is where a lot of end of life care happens. If your incentive structure is:
1) Be Broke and its free
2) Don't Be Broke and we will take everything you have and leave your kids with nothing
People find ways to "go broke". Medicaid can do five year lookbacks all it wants but all this does is punish people that don't do their estate planning in advance.
I think we should just declare that $X of spending in the last Y years of life is the threshold, and anyone that manages to come in below that threshold can decide who the difference gets left to.
Yeah, I'm both aware that this is supposed to be the case with Medicaid, and, in practice, almost never is, because the advertised intent is far too easy to evade, which for many politicians is the feature, not the bug. Heck, government student loans are supposed to be for-real, actual, normal """loans""", and even stronger since not dischargeable in bankruptcy, but we already see what progressive politicians repeatedly try to do with those. That's why I say doing it for real is a non-starter, due to the "law of conservation of freebies."
You just can't do anything that would cause the pips to squeak and generate a lot of financial pain to important constituencies who have the electoral numbers to vote themselves freebies. You can pretend to, with some new reform law on the surface of its text that seems like it might on first impression, but then eventually, one way or another, the freebies will just show up again in some loopholes to get out of the pain.
There are different theories and practices for the distribution of pain in society. In doctrinaire Marxism, for example, burdens are supposed to be placed on those most capable of bearing them. In American Progressive Democracy, burdens are placed on those least capable of pushback. The politically weak suffer what they must. You know who can't push back? People who don't vote yet. They've got a lot of suffering what they must to look forward to.
The oppressor-oppressed axis has been twisted to be more a successful-failure axis, with those who fail claiming their failure is actually due to the oppressors. Jews, like Chinese in Malaysia, are successful, thus oppressors.
Like most anti-capitalists hate successful businessmen.
There is unfair distribution of good things, especially less than 3% of people having US Citizenship, but also IQ, parental money+, height, beauty, ability/talent. Some folk got 100% to distribute among good traits, some only 50, or only 20. Life is unfair. Luck is real, and unfair.
There is no just way to make life fair.
Anger at this reality has been directed against oppression, and against oppressors, but with so few of real oppression & oppressors, the successful have been relabeled as oppressors. Mislabeled. Like Jews, and Israel.
Rob’s podcast title claims that The Elites Think They’re Oppressed.
As for her disagreement with Smil's position, Smil has the better of the argument, hands down. If you can call it an argument at all. This is like an engineer arguing that one can't build a bridge of a certain span to bear a certain load with an insufficient amount of low-strength materials, and then a psychologist responding that the only real problem is insufficient confidence and daring.
A rigorous and structured intellectual argument requires one to take on the presented contrary evidence head on in its own form and terms, not to evade the concrete questions and be, as they say in court, a non-responsive witness / deponent by a fallacious attempt to escape to higher levels of generality in the form of "great historical tendencies" that when scrutinized don't amount to anything more than wishful thinking and failing to heed the proverbial disclaimer, "Past performance is no guarantee of future results."
You know, a few years back a recurrent topic of discussion in the econoblogosphere concerned the general problem of, and proper intellectual disposition towards, all the - for lack of a better term - 'mathiness' in the field and in the manner by which people processed numerical data, tried to quantify the fuzzy for the sake of ease of analysis (or even the pretense of it being even possible to do meaningful analysis), they way they constructed models, made arguments, or, more to the point, tended to discount and dismiss arguments and assign them and their authors low status if -not- made (or makeable) in the form of impressive manipulations of fancy symbolic equations, that kind of thing.
And yeah, like anything, the mathiness and surrounding attitudes can be (and often were) taken to unjustifiable extremes laying paths to errors stacked upon yet more errors.
However, people also make the opposite mistake, and quickly end up spouting feelgood unfalsifiable gibberish. The thing about "arguing with math" is the -intellectually disciplining- role it plays. You have to show your work; I get to check your work. You have to state your assumptions; I get to test your assumptions, and to understand the limits of the validity of your claims.
There is no possible way to have a generally correct attitude about "innovation optimism" - every sector is really different - and thus no justifiable way to adopt and champion such an attitude. Sometimes there is still "a lot of room at the bottom" and other times there is clearly no low-hanging fruit left to pluck. On very many empirical questions there is simply no substitute for engaging with hard numbers and the hard rules about them.
With regards to energy, matters of physical quantity and laws of thermodynamics are the very heart of the matter, and here is where Economics Imperialism stops and bows as tributary to its Suzerain; there is simply no possibility of serious, rational, rigorous argument that refuses to get into the weeds and show its work. Smil reliably does this, and he does it exceptionally well. His critics, well, not only don't, they don't even seem to be aware that it's embarrassing that it's obvious they aren't even really trying.
I think Jew-Hatred is driven by envy. Yes, the Jews are economically well-off. But more important is they fancy themselves as God's chosen people--they wrote the entire Bible (both old and new testaments) to prove it. So it's no wonder that folks want to knock the Jews down a peg or two.
"attractiveness increased females’ odds of incurring same-sex aggression by 35 percent and decreased males’ by 25 percent. (source)."
It took me a minute to figure out the decreased male aggression but of course males would be more concerned about losing the interest of attractive women.
Beyond that, it's worth noting that attractive women are probably also pandered to more by other women, and of course by men too.
Henderson's statement on the relationship between same-sex aggression and the physical attractiveness of women doesn't ring true to me. It seems to me the popularity of the 2004 film Mean Girls (which has a recent remake and also a musical stage version) reflected its being consistent with typical experience in high school-- the most physically attractive females (the 'queen bees') were the most aggressive towards the less attractive ones, especially the homely girls. Perhaps the statement is about the degree of aggression among the more physically attractive females (as opposed to aggression by less attractive females towards the more attractive ones), who compete among themselves for status and the more attractive males. Also, I have to wonder what criteria are used to determine who is physically attractive, which would seem to be inherently subjective.
Unpleasant statement incoming: I would bet it's likely that female on female violence is very highly skewed toward the lower end of the socio-economic spectrum, much more so than for men (although it's skewed for them too). I'm going to guess that what was depicted in Mean Girls was largely not about actual fist-swingin' violence, and I would also guess that the characters depicted were solidly middle class, at the least. I would warn against extrapolating that to the entire adolescent female experience.
I suspect you are correct about violence but the topic brought up by AK and mentioned by Koshmap was aggression. It's not as clear this is socio-economic class dependent.
I doubt that the word aggression is synonymous with physical violence in this context, but rather that it includes, but is not limited to, violence. An example of non-violent aggression from Mean Girls involved the protagonist causing the Queen Bee to gain weight by telling her that some snack bars are diet food. I suspect you are correct that female on female violence is more common at the lower end of the socio-economic spectrum (based on sources like twitter videos), but it is not clear to me that this violence is associated directly or indirectly with physical attractiveness.
Everything you state could be true without Henderson's statement being false.
I don't know about the method to get the results Henderson states but there are other studies that attractiveness is rated by a totally separate group. Still subjective but it seems to get the needed info.
The accusation of waste actually implies a remarkably efficient and effective program underneath the alleged fraud. Why throw the baby out with the bathwater? And because the elimination of fraud is not costless, that implies the optimal level of fraud is not zero. And given the complaint about not-pre auditing claims, how certain are we that piling on more and more layers of bee-watcher watchers would actually accomplish anything? Given Medicare’s generally remarkable health outcomes, might the status quo actually be closer to the optimal level of fraud relative to the proposed scenario in which 85 year olds are expected to both maximize their allotted sums as well as protect themselves from predatory providers who because they would face even less likelihood of discovery would be even more incentivized to upcode services under Hyman and Silver’s proposed scheme?
I am much reminded of Leonard Hobhouse’s classic book Liberalism. (https://en.wikisource.org/wiki/Liberalism ): “Good government is much, but the good will is more, and even the imperfect, halting, confused utterance of the common will may have in it the potency of higher things than a perfection of machinery can ever attain.” In that spirit, recall Palmerston, the first
Liberal prime minister, admonishing Gladstone for inciting popular reform, “What every Man and Woman too have a Right to, is to be well governed and under just Laws, and they who propose a change ought to shew that the present organization does not accomplish those objects." Perhaps our managerial elite might be held in less contempt if they were to attempt to aspire to such challenges?
Fortunately for the expert technocratic class, I too have a “straightforward solution,” an agenda that can easily be adopted that might improve efficiency and outcomes as well to earn their redemption.
The problem of determining what services are appropriate to provide is perhaps the single most frequently mentioned criticism of the US health care system (and would continue to be so even under Hyman and Silver’s insurance free world. For example, search “colonoscopy” in this substack and a plethora or articles such as https://arnoldkling.substack.com/p/diagnosing-the-us-health-care-system?utm_source=publication-search will appear all claiming that the root cause of the cost problem with healthcare in the US is that consumers game the system to over-consume non-cost effective medical procedures.
But insurance companies and government health programs do no simply cover each and every procedure for which they are billed. Benefits are defined. And the definition of those benefits rely upon entities that review and analyze all the available to make determinations of what is a cost-effective procedure. Rarely are this process or these entities scrutinized. Perhaps the consequential of these entities is the United States Preventive Services Task Force (USPSTF) (https://www.uspreventiveservicestaskforce.org/uspstf/ ) but CDC, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and others have a role. If these entities are failing, then why not reform them instead of attack beneficiaries who are merely complying with their expert recommendations?
But even that would not solve all of the problem. The problem of the necessity of trade-offs in public health care programs needs to be addressed. The federal government’s needs are unlimited and debt-financing has eliminated the discipline of making trade-offs within budgetary limitations. Perhaps not all procedures deemed cost-effective cannot share an equal priority in funding? Yes, I am talking of rationing. Perhaps, because funds are indeed limited mammograms might have a higher priority than colonoscopies? To make these determinations, I propose that states authorize a Citizens Assembly, consistent with Ciceronian and Hayekian notions of isonomy, to deliberatively review expert testimony on cost-effectivess of the coverage of benefits and prioritize those to be paid for with public funds within budgetary limits. Using sortition to offer an appropriate number of recent high school graduates for a set term, suitably compensated, in the Assembly would not only address this problem but offer many salutary second order benefits.
Second, direct employment of health care providers to provide emergency medical as well as Medicare covered services would greatly reduce both costs and fraud. The Veterans Health Administration, Department of Defense hospital system, Indian Health Service, Bureau of Prisons, etc. already employ an army of providers and ought be consolidated, streamlined, and turned over to the states and the lazy, unjust and costly transfers mandated by the Emergency Medical Treatment and Active Labor Act repealed and direct emergency care provided by state governments.
Third, the financial discipline of a hard constraint on grant spending ought to be constitutionally enshrined. For 2024, obligations in the Grants and Fixed Charges object class are estimated to sum to a total of $6,519,489 million of which $1,219,759 million are distributed by DHHS (see page 3 and 71 at https://www.whitehouse.gov/wp-content/uploads/2024/03/objclass_fy2025.pdf ) and very little of this massive mountain of spending would likely meet any cost-effectiveness criteria. It should be relatively simple to prune this to fit a cap of say 2% of total Treasury income tax receipts in the second fiscal year prior.
Of course there are numerous other straightforward solutions one might offer, but I will refrain from carrying on and leave it with these few very low hanging fruit. Baby steps.
"The second half of my book, Crisis of Abundance, makes one proposal, which is too complex to describe here."
It seems that in this Medium piece from 2018 that you dismissed the proposal for health insurance in your book. Why do you bring it up now? Are you back to liking it again?
FWIW, my fuzzy memory is I didn't think it worked either. Of course nothing solves the problem, it's simply a matter of finding the least bad option, or something close. That could mean something completely different than what we do now or it might be relatively minor tweaks that change the current system in small or big ways. I once heard someone (probably on Freakonomics Radio) talk about using many really small changes with an expectation they could add up to meaningful cost reduction and care improvement.
The Richard Samuelson essay is fascinating. First it informs me how little I know about these aspects of history and religion. Second, I note that Samuelson is a professor at Hillsdale College; a college known for allegedly not accepting a penny of government money. I think—if I want to learn more about these aspects of history and religion, perhaps I should pay closer attention to the folks at Hillsdale. But maybe someone can tell me how religious Hillsdale is. I’m not a fan of religious dogma and would prefer not to surround myself by people that believe in invisible spirits. How common is agnosticism at Hillsdale? 1 in 100 of the student body? 1 in 50?
At least with "invisible spirits people" you kind of know where their head is at. You know, roughly, where they got their ideas or their ethics from, even if they themselves are fuzzy about that. You know they didn't get their thoughts that very morning from reading the New York Times or the Atlantic or some such nonsense.
Pretty often they also overlap with the people who can help pull your car out of a ditch.
It's true that the best among them don't exactly foreground the invisible spirits.
Maybe I only read the best of the Atlantic but grouping it with NYT seems badly mistaken.
As for NYT, I switched my subscription to WaPo because I got a better deal (and I haven't read either all that much). WaPo is WAY worse. Based on opinion piece reader comments, the readers are more extreme too.
Huh. That surprises me. I have always thought the WaPo has a much better variety of commentators on their op-ed pages. I don't read their news stories much.
Will is obviously conservative but I give WaPo no credit for that given he is a holdover from when it was a much different paper in a much different media environment.
I like Zakaria and have yet to find him partisan or progressive in a bad way.
I once read something from someone else conservative who seemed like a regular but I never found him again.
Can you give me names of wapo opinion people who aren't far left?
One more thought. When I use the app I never see anything by Will or Zakaria even if I go to Opinions. Searching in the app brings up nothing recent except their pages.
The main reason I ever look at WaPo is for Megan McArdle, whom I like a lot. Jim Geraghty and Ramesh Ponnuru of National Review are also WaPo columnists.
The NYT has still got it, occasionally. I was very impressed by the longform piece they ran the other day, "The Last Shaker". WaPo at least has somebody on the nature beat, even if it's a little Annie Dillard-lite. And kudos to WaPo for - about six or seven years ago? - putting together a very long survey of DoD reports and interviews, many anonymous, with military higher-ups and lower-ups - that was the first real accounting/reckoning with the madness and occasional fraud of the Long War that I have seen.
The Atlantic is ever more embarrassing. Whoever was editor in the late aughts decided they would be "contrarian". Always. That has meant different things but overall it has meant they never wrote a serious word since.
Trying to recall the last really great thing I read in the Atlantic and all I can come up with is the William Langewiesche (sp?) report on the Columbia disaster.
Just this year I read something similarly great about Air France 447 (that happened years ago, but they only recently released the black box transcript) that I thought might have been in The Atlantic, but it turned out it was Popular Mechanics.
Black-box revelations from the June 2009 crash paint a surprising picture of the chaos in the cockpit that led to one of aviation’s greatest mysteries.
I’m remembering now a good piece - and truly contrarian in that it’s the first and last I’ve seen it in print - questioning healthcare spending in terms of opportunity cost of other once-priorities. Who wrote that? I can’t remember. Atlantic, maybe circa 2009.
True. True. And true. Tell me, is there a Christian denomination or any religion, that has the upside of surrounding one’s family with people of character, whose members strive to improve, learn and grow, and who value open inquiry and truth seeking on all topics including invisible spirits, i.e. no dogma?
I dunno! I made sure my child had a grounding in the faith of his fathers, with regular Sunday school and choir and church attendance; but when that requirement seemed to be satisfied - he didn't turn out to embrace it, as he grew, but we had some good times at church, and I can only hope that his ardent love of Lewis and Tolkein will serve him in good enough stead - I left church behind, and reverted to the nature worship that comes more naturally to me. When we used to contemplate moving to a small town, my husband said we would attend church for social/cultural reasons, but we never did do so.
What is "nature worship"? I'm serious. I often enjoy being in "nature". Our honeymoon was a two month camping trip. I appreciate that we couldn't survive without "nature". Without all the "ecological services", without the plants providing oxygen, the decomposers keeping us from drowning in shit and carcasses. But I don't consider myself any kind of worshiper, including nature.
Even if I was the worshiping type, how could I worship something that is so dangerous and cruel, so uncaring of human life or welfare?
So much of what seems like nature worship is as factually inaccurate as the first chapter of Genesis. Something like the Nitty Gritty Dirt Band's "Mother Earth", which begins:
Plenty of Christians have felt the divine in nature. Shinto is a nature religion, though I don't know anything about it.
I'm sorry - I don't see how the Nitty Gritty Dirt Band enters into it. I recall they recorded a well-known version of "Will the Circle Be Unbroken". What circle? Where in the sky (Lord)? What Lord?
These are not things I have ever contemplated before, though I've heard that song a hundred times. Can't say I have any evidence that there is a better home than here, being alive.
I don't consciously "reverence" anything. Now, that may be a failure to know myself but I don't feel "the divine" in anything, because I don't think there is a "divine".
The song is about how Mother Earth is a nurturant, benevolent mother which "cares for me', "looks after me", is devoted to me. This is beautiful nonsense. It is as inaccurate as saying nature is nothing but "red in tooth and claw", which is similarly wrong in the opposite direction.
I was using it as an example of what seems to me to be some sort of nature worship. I was hoping you could point me to something better.
The nature worship idea is a good one, but it lacks people. What is the composition of nature worship that includes people? Speculative and creative answers are welcome.
I've heard that some divinity schools do that. Otherwise, there are individuals and pockets of individuals whoostly do that but pretty much everyone has some kind of irrational belief on one topic or another. Of course that assumes someone else knows that one belief is truly irrational but we can somewhat get around this by comparing people whose beliefs seem extremely rational and looking where they differ. Not all differences imply irrationality but it's where to start.
We could start by shifting everyone out of employer plans into an upgraded ACA. That raises consumer sensitivity to cost a bit and gives insurance companies a bit of incentive to seek more cost-effective care. More importantly it reduces the anti-employment bias particularly of low MP workers of the present system financed by and implicit wage tax.
IDK but I'm skeptical ACA has either of the first too advantages you state. I agree there are many benefits to de-linking health insurance and employers but suspect there are also some downsides I'm not fully aware of.
I don't understand why Hyman/Silver suggest going straight to "nothing but HSA" rather than the kind of straightforward "HSA + High Deductible" insurance that usually comes with HSAs?
I read the article and they don't seem to address that at all.
I've been on the HSA+HDI sort of plan for years and it's pretty straightforward and easy to understand what's going to happen. You have an incentive to save, and the insurance plays an actual insurance function.
Instead of that, they seem to be suggesting dumping Monopoly money amounts into the stock market via HSAs and then just letting the chips fall where they may. That doesn't seem like a particularly well thought out idea.
So much so that I just question their wisdom in general.
I don't know if HSA+HDI is a good option but i agree it seems far preferable to just HSA, which seems to have no benefit in the current healthcare environment and very little going for it in the best of circumstances.
Medicare Advantage already does what your last link suggests, in effect. It's become and will continue to become the entire Medicare market. We get a set amount based on the Risk Score whenever a member enrolls in our plan.
Of course the insurance offerings that plans can concoct are regulated. Each regulation having its own story for good or ill.
Plans can already basically return some of the money as cash to members (Part B Buyback, Spendables cards). If you could do more while covering less, it would probably just turn into a race after the healthy people. It already is.
It doesn't necessarily do anything for health costs. If I can upcode more, then I have more revenue to have a bigger cash giveback. I do suppose cash is a better use of marginal dollars then lower copays, but government is never going to let the copays get high enough that people complain, and anyway it would destroy your STAR ratings. Mostly this stuff just moves around risk between plans that aren't wildly different in their benefits, some plan is still getting stuck with the high spenders.
The only thing that would really move the needle is if we let people pass money onto their kids in exchange for just letting themselves die. It's all that Hospital and LTC spend at the end that is very expensive and low ROI, but someone else is paying for it so why not.
There is a great deal of turmoil in the Medicare (and other government insurance) markets. Lots of post COVID claims trend and of course the IRA is a dumpster fire.
Any time government actually or in effect gives people money they must spend in a certain way it is a market distorting subsidy. Much of what we have masquerading as insurance is really pre-paid health care so of course people are going to find ways to spend it. The beneficiaries of that spending are also going to fight to keep targeted spending as well.
I don't use healthcare much - have not been inside a doctor's office since 2007, apart from the optometrist; floss religiously; got the shingles vaccine at CVS - and don't know any of this stuff like you guys do.
But I will say as regards pre-paid healthcare: my parents have Medicare, of course, and the supplemental insurance on top of that, and a Medicare prescription drug plan - and so when my father decided they would also enroll in the local concierge doctor's practice, I was thinking, really? Yet more?
(This guy left his practice so that instead of 3000 or more patients he could have 500 or so? getting that secondhand - and not work around the clock.)
And I have to admit - it's great. Especially since my brother and his wife use the guy also, so we have a back-door to family involvement as their minds get feebler. I wish all old people could have a concierge doctor.
We have to understand there are competing demands for what we want health insurance to do. While it is true that pre-paid healthcare is not insurance, we require it, or providers decide it is to their benefit, when we think it will improve outcomes by cheaply buying better health or outright saving money through increased use of those services. Examples include annual checkups and prenatal care.
"The only thing that would really move the needle is if we let people pass money onto their kids in exchange for just letting themselves die."
Several decades ago I proposed that all old-age transfers and benefits be issued in the form of easy, on-demand, no-questions-asked unsecured loans (at zero real interest rates) against the beneficiary's unattached estate, that collect with first priority upon death. That is, if you are broke, your consumption and care is public charity. If you are not broke, you are spending your own money - and that of your spouse, kids, and heirs - first, until you have exhausted it, and then you are a charity case.
One could tweak this so it's not 100%, maybe you get half "free and clear" and only have to "borrow" the other half, or maybe even 90%/10%.
For people who are already old, already in poor health, with some significant savings, this gives them good reason to think twice about saying yes to anything and everything. It also gives their spouse and kids reason to think twice about passionately insisting that medical professionals do anything and everything to save or prolong the life (regardless of quality) of their ill relative.
This seems to me a much fairer system with much better incentives, and thus, practically by consequence of being superior in those factors, totally politically impossible.
This is already the case with Medicaid, which is where a lot of end of life care happens. If your incentive structure is:
1) Be Broke and its free
2) Don't Be Broke and we will take everything you have and leave your kids with nothing
People find ways to "go broke". Medicaid can do five year lookbacks all it wants but all this does is punish people that don't do their estate planning in advance.
I think we should just declare that $X of spending in the last Y years of life is the threshold, and anyone that manages to come in below that threshold can decide who the difference gets left to.
Yeah, I'm both aware that this is supposed to be the case with Medicaid, and, in practice, almost never is, because the advertised intent is far too easy to evade, which for many politicians is the feature, not the bug. Heck, government student loans are supposed to be for-real, actual, normal """loans""", and even stronger since not dischargeable in bankruptcy, but we already see what progressive politicians repeatedly try to do with those. That's why I say doing it for real is a non-starter, due to the "law of conservation of freebies."
You just can't do anything that would cause the pips to squeak and generate a lot of financial pain to important constituencies who have the electoral numbers to vote themselves freebies. You can pretend to, with some new reform law on the surface of its text that seems like it might on first impression, but then eventually, one way or another, the freebies will just show up again in some loopholes to get out of the pain.
There are different theories and practices for the distribution of pain in society. In doctrinaire Marxism, for example, burdens are supposed to be placed on those most capable of bearing them. In American Progressive Democracy, burdens are placed on those least capable of pushback. The politically weak suffer what they must. You know who can't push back? People who don't vote yet. They've got a lot of suffering what they must to look forward to.
The oppressor-oppressed axis has been twisted to be more a successful-failure axis, with those who fail claiming their failure is actually due to the oppressors. Jews, like Chinese in Malaysia, are successful, thus oppressors.
Like most anti-capitalists hate successful businessmen.
There is unfair distribution of good things, especially less than 3% of people having US Citizenship, but also IQ, parental money+, height, beauty, ability/talent. Some folk got 100% to distribute among good traits, some only 50, or only 20. Life is unfair. Luck is real, and unfair.
There is no just way to make life fair.
Anger at this reality has been directed against oppression, and against oppressors, but with so few of real oppression & oppressors, the successful have been relabeled as oppressors. Mislabeled. Like Jews, and Israel.
Rob’s podcast title claims that The Elites Think They’re Oppressed.
Ha!
Typo: there's an e at the end of Lynne's name.
As for her disagreement with Smil's position, Smil has the better of the argument, hands down. If you can call it an argument at all. This is like an engineer arguing that one can't build a bridge of a certain span to bear a certain load with an insufficient amount of low-strength materials, and then a psychologist responding that the only real problem is insufficient confidence and daring.
A rigorous and structured intellectual argument requires one to take on the presented contrary evidence head on in its own form and terms, not to evade the concrete questions and be, as they say in court, a non-responsive witness / deponent by a fallacious attempt to escape to higher levels of generality in the form of "great historical tendencies" that when scrutinized don't amount to anything more than wishful thinking and failing to heed the proverbial disclaimer, "Past performance is no guarantee of future results."
You know, a few years back a recurrent topic of discussion in the econoblogosphere concerned the general problem of, and proper intellectual disposition towards, all the - for lack of a better term - 'mathiness' in the field and in the manner by which people processed numerical data, tried to quantify the fuzzy for the sake of ease of analysis (or even the pretense of it being even possible to do meaningful analysis), they way they constructed models, made arguments, or, more to the point, tended to discount and dismiss arguments and assign them and their authors low status if -not- made (or makeable) in the form of impressive manipulations of fancy symbolic equations, that kind of thing.
And yeah, like anything, the mathiness and surrounding attitudes can be (and often were) taken to unjustifiable extremes laying paths to errors stacked upon yet more errors.
However, people also make the opposite mistake, and quickly end up spouting feelgood unfalsifiable gibberish. The thing about "arguing with math" is the -intellectually disciplining- role it plays. You have to show your work; I get to check your work. You have to state your assumptions; I get to test your assumptions, and to understand the limits of the validity of your claims.
There is no possible way to have a generally correct attitude about "innovation optimism" - every sector is really different - and thus no justifiable way to adopt and champion such an attitude. Sometimes there is still "a lot of room at the bottom" and other times there is clearly no low-hanging fruit left to pluck. On very many empirical questions there is simply no substitute for engaging with hard numbers and the hard rules about them.
With regards to energy, matters of physical quantity and laws of thermodynamics are the very heart of the matter, and here is where Economics Imperialism stops and bows as tributary to its Suzerain; there is simply no possibility of serious, rational, rigorous argument that refuses to get into the weeds and show its work. Smil reliably does this, and he does it exceptionally well. His critics, well, not only don't, they don't even seem to be aware that it's embarrassing that it's obvious they aren't even really trying.
I think Jew-Hatred is driven by envy. Yes, the Jews are economically well-off. But more important is they fancy themselves as God's chosen people--they wrote the entire Bible (both old and new testaments) to prove it. So it's no wonder that folks want to knock the Jews down a peg or two.
"attractiveness increased females’ odds of incurring same-sex aggression by 35 percent and decreased males’ by 25 percent. (source)."
It took me a minute to figure out the decreased male aggression but of course males would be more concerned about losing the interest of attractive women.
Beyond that, it's worth noting that attractive women are probably also pandered to more by other women, and of course by men too.
Henderson's statement on the relationship between same-sex aggression and the physical attractiveness of women doesn't ring true to me. It seems to me the popularity of the 2004 film Mean Girls (which has a recent remake and also a musical stage version) reflected its being consistent with typical experience in high school-- the most physically attractive females (the 'queen bees') were the most aggressive towards the less attractive ones, especially the homely girls. Perhaps the statement is about the degree of aggression among the more physically attractive females (as opposed to aggression by less attractive females towards the more attractive ones), who compete among themselves for status and the more attractive males. Also, I have to wonder what criteria are used to determine who is physically attractive, which would seem to be inherently subjective.
Unpleasant statement incoming: I would bet it's likely that female on female violence is very highly skewed toward the lower end of the socio-economic spectrum, much more so than for men (although it's skewed for them too). I'm going to guess that what was depicted in Mean Girls was largely not about actual fist-swingin' violence, and I would also guess that the characters depicted were solidly middle class, at the least. I would warn against extrapolating that to the entire adolescent female experience.
I suspect you are correct about violence but the topic brought up by AK and mentioned by Koshmap was aggression. It's not as clear this is socio-economic class dependent.
I doubt that the word aggression is synonymous with physical violence in this context, but rather that it includes, but is not limited to, violence. An example of non-violent aggression from Mean Girls involved the protagonist causing the Queen Bee to gain weight by telling her that some snack bars are diet food. I suspect you are correct that female on female violence is more common at the lower end of the socio-economic spectrum (based on sources like twitter videos), but it is not clear to me that this violence is associated directly or indirectly with physical attractiveness.
You’re right. I read the OP incorrectly. I swore it said “violence’ not “aggression.” Sorry!
Everything you state could be true without Henderson's statement being false.
I don't know about the method to get the results Henderson states but there are other studies that attractiveness is rated by a totally separate group. Still subjective but it seems to get the needed info.
Because net Medicare outlays in 2023 were just $839 billion (https://www.kff.org/interactive/the-facts-about-medicare-spending/ ), might the claim that Medicare “squanders hundreds of billions of dollars every year” appear somewhat hyperbolic as well as demagogic? After all, Medicare did manage to provide access to health care for a reasonably wide range health care services for the 24 percent of the US population (34% of whom are 80+). How can a program that allegedly wastes hundreds of billions out of $839 billion still provide health care for approximately 62 million beneficiaries (https://www.kff.org/medicare/state-indicator/total-medicare-beneficiaries/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D ), 8.3% in households that have experienced poverty? (https://www2.census.gov/library/publications/2024/demo/p70-193.pdf ). And moreover, health care that a majority of Medicare beneficiaries find satisfactory? Especially in a healthcare morass that is otherwise unequivocably deplorable. (https://www.commonwealthfund.org/publications/issue-briefs/2023/jan/us-health-care-global-perspective-2022 )
The accusation of waste actually implies a remarkably efficient and effective program underneath the alleged fraud. Why throw the baby out with the bathwater? And because the elimination of fraud is not costless, that implies the optimal level of fraud is not zero. And given the complaint about not-pre auditing claims, how certain are we that piling on more and more layers of bee-watcher watchers would actually accomplish anything? Given Medicare’s generally remarkable health outcomes, might the status quo actually be closer to the optimal level of fraud relative to the proposed scenario in which 85 year olds are expected to both maximize their allotted sums as well as protect themselves from predatory providers who because they would face even less likelihood of discovery would be even more incentivized to upcode services under Hyman and Silver’s proposed scheme?
I am much reminded of Leonard Hobhouse’s classic book Liberalism. (https://en.wikisource.org/wiki/Liberalism ): “Good government is much, but the good will is more, and even the imperfect, halting, confused utterance of the common will may have in it the potency of higher things than a perfection of machinery can ever attain.” In that spirit, recall Palmerston, the first
Liberal prime minister, admonishing Gladstone for inciting popular reform, “What every Man and Woman too have a Right to, is to be well governed and under just Laws, and they who propose a change ought to shew that the present organization does not accomplish those objects." Perhaps our managerial elite might be held in less contempt if they were to attempt to aspire to such challenges?
Fortunately for the expert technocratic class, I too have a “straightforward solution,” an agenda that can easily be adopted that might improve efficiency and outcomes as well to earn their redemption.
The problem of determining what services are appropriate to provide is perhaps the single most frequently mentioned criticism of the US health care system (and would continue to be so even under Hyman and Silver’s insurance free world. For example, search “colonoscopy” in this substack and a plethora or articles such as https://arnoldkling.substack.com/p/diagnosing-the-us-health-care-system?utm_source=publication-search will appear all claiming that the root cause of the cost problem with healthcare in the US is that consumers game the system to over-consume non-cost effective medical procedures.
But insurance companies and government health programs do no simply cover each and every procedure for which they are billed. Benefits are defined. And the definition of those benefits rely upon entities that review and analyze all the available to make determinations of what is a cost-effective procedure. Rarely are this process or these entities scrutinized. Perhaps the consequential of these entities is the United States Preventive Services Task Force (USPSTF) (https://www.uspreventiveservicestaskforce.org/uspstf/ ) but CDC, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and others have a role. If these entities are failing, then why not reform them instead of attack beneficiaries who are merely complying with their expert recommendations?
But even that would not solve all of the problem. The problem of the necessity of trade-offs in public health care programs needs to be addressed. The federal government’s needs are unlimited and debt-financing has eliminated the discipline of making trade-offs within budgetary limitations. Perhaps not all procedures deemed cost-effective cannot share an equal priority in funding? Yes, I am talking of rationing. Perhaps, because funds are indeed limited mammograms might have a higher priority than colonoscopies? To make these determinations, I propose that states authorize a Citizens Assembly, consistent with Ciceronian and Hayekian notions of isonomy, to deliberatively review expert testimony on cost-effectivess of the coverage of benefits and prioritize those to be paid for with public funds within budgetary limits. Using sortition to offer an appropriate number of recent high school graduates for a set term, suitably compensated, in the Assembly would not only address this problem but offer many salutary second order benefits.
Second, direct employment of health care providers to provide emergency medical as well as Medicare covered services would greatly reduce both costs and fraud. The Veterans Health Administration, Department of Defense hospital system, Indian Health Service, Bureau of Prisons, etc. already employ an army of providers and ought be consolidated, streamlined, and turned over to the states and the lazy, unjust and costly transfers mandated by the Emergency Medical Treatment and Active Labor Act repealed and direct emergency care provided by state governments.
Third, the financial discipline of a hard constraint on grant spending ought to be constitutionally enshrined. For 2024, obligations in the Grants and Fixed Charges object class are estimated to sum to a total of $6,519,489 million of which $1,219,759 million are distributed by DHHS (see page 3 and 71 at https://www.whitehouse.gov/wp-content/uploads/2024/03/objclass_fy2025.pdf ) and very little of this massive mountain of spending would likely meet any cost-effectiveness criteria. It should be relatively simple to prune this to fit a cap of say 2% of total Treasury income tax receipts in the second fiscal year prior.
Of course there are numerous other straightforward solutions one might offer, but I will refrain from carrying on and leave it with these few very low hanging fruit. Baby steps.
I couln't finish reading your comment but it seemed you were equating waste with fraud. I'd argue that waste includes far more than just fraud.
Is there a link to the 6000 word piece mentioned here:
https://medium.com/hackernoon/the-myths-surrounding-health-care-policy-5989285fbad0
"The second half of my book, Crisis of Abundance, makes one proposal, which is too complex to describe here."
It seems that in this Medium piece from 2018 that you dismissed the proposal for health insurance in your book. Why do you bring it up now? Are you back to liking it again?
FWIW, my fuzzy memory is I didn't think it worked either. Of course nothing solves the problem, it's simply a matter of finding the least bad option, or something close. That could mean something completely different than what we do now or it might be relatively minor tweaks that change the current system in small or big ways. I once heard someone (probably on Freakonomics Radio) talk about using many really small changes with an expectation they could add up to meaningful cost reduction and care improvement.
The Richard Samuelson essay is fascinating. First it informs me how little I know about these aspects of history and religion. Second, I note that Samuelson is a professor at Hillsdale College; a college known for allegedly not accepting a penny of government money. I think—if I want to learn more about these aspects of history and religion, perhaps I should pay closer attention to the folks at Hillsdale. But maybe someone can tell me how religious Hillsdale is. I’m not a fan of religious dogma and would prefer not to surround myself by people that believe in invisible spirits. How common is agnosticism at Hillsdale? 1 in 100 of the student body? 1 in 50?
At least with "invisible spirits people" you kind of know where their head is at. You know, roughly, where they got their ideas or their ethics from, even if they themselves are fuzzy about that. You know they didn't get their thoughts that very morning from reading the New York Times or the Atlantic or some such nonsense.
Pretty often they also overlap with the people who can help pull your car out of a ditch.
It's true that the best among them don't exactly foreground the invisible spirits.
Maybe I only read the best of the Atlantic but grouping it with NYT seems badly mistaken.
As for NYT, I switched my subscription to WaPo because I got a better deal (and I haven't read either all that much). WaPo is WAY worse. Based on opinion piece reader comments, the readers are more extreme too.
"WaPo is WAY worse."
Huh. That surprises me. I have always thought the WaPo has a much better variety of commentators on their op-ed pages. I don't read their news stories much.
Will is obviously conservative but I give WaPo no credit for that given he is a holdover from when it was a much different paper in a much different media environment.
I like Zakaria and have yet to find him partisan or progressive in a bad way.
I once read something from someone else conservative who seemed like a regular but I never found him again.
Can you give me names of wapo opinion people who aren't far left?
One more thought. When I use the app I never see anything by Will or Zakaria even if I go to Opinions. Searching in the app brings up nothing recent except their pages.
The main reason I ever look at WaPo is for Megan McArdle, whom I like a lot. Jim Geraghty and Ramesh Ponnuru of National Review are also WaPo columnists.
The NYT has still got it, occasionally. I was very impressed by the longform piece they ran the other day, "The Last Shaker". WaPo at least has somebody on the nature beat, even if it's a little Annie Dillard-lite. And kudos to WaPo for - about six or seven years ago? - putting together a very long survey of DoD reports and interviews, many anonymous, with military higher-ups and lower-ups - that was the first real accounting/reckoning with the madness and occasional fraud of the Long War that I have seen.
The Atlantic is ever more embarrassing. Whoever was editor in the late aughts decided they would be "contrarian". Always. That has meant different things but overall it has meant they never wrote a serious word since.
Trying to recall the last really great thing I read in the Atlantic and all I can come up with is the William Langewiesche (sp?) report on the Columbia disaster.
Just this year I read something similarly great about Air France 447 (that happened years ago, but they only recently released the black box transcript) that I thought might have been in The Atlantic, but it turned out it was Popular Mechanics.
https://archive.ph/5gbMu
What Really Happened Aboard Air France 447
Black-box revelations from the June 2009 crash paint a surprising picture of the chaos in the cockpit that led to one of aviation’s greatest mysteries.
By Jeff Wise Published: Sep 21, 2023
This is a great article from the Atlantic and it's relevant to today's AK post. Still old but 6 years after the Columbia article you mentioned.
https://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/
I’m remembering now a good piece - and truly contrarian in that it’s the first and last I’ve seen it in print - questioning healthcare spending in terms of opportunity cost of other once-priorities. Who wrote that? I can’t remember. Atlantic, maybe circa 2009.
True. True. And true. Tell me, is there a Christian denomination or any religion, that has the upside of surrounding one’s family with people of character, whose members strive to improve, learn and grow, and who value open inquiry and truth seeking on all topics including invisible spirits, i.e. no dogma?
I dunno! I made sure my child had a grounding in the faith of his fathers, with regular Sunday school and choir and church attendance; but when that requirement seemed to be satisfied - he didn't turn out to embrace it, as he grew, but we had some good times at church, and I can only hope that his ardent love of Lewis and Tolkein will serve him in good enough stead - I left church behind, and reverted to the nature worship that comes more naturally to me. When we used to contemplate moving to a small town, my husband said we would attend church for social/cultural reasons, but we never did do so.
What is "nature worship"? I'm serious. I often enjoy being in "nature". Our honeymoon was a two month camping trip. I appreciate that we couldn't survive without "nature". Without all the "ecological services", without the plants providing oxygen, the decomposers keeping us from drowning in shit and carcasses. But I don't consider myself any kind of worshiper, including nature.
Even if I was the worshiping type, how could I worship something that is so dangerous and cruel, so uncaring of human life or welfare?
So much of what seems like nature worship is as factually inaccurate as the first chapter of Genesis. Something like the Nitty Gritty Dirt Band's "Mother Earth", which begins:
Mother Earth lives on the ocean
Mother Earth sails on the sea
I am blessed with her devotion
Mother Earth provides for me
I expect you reverence *something*.
What is sky God for the matter of that?
Plenty of Christians have felt the divine in nature. Shinto is a nature religion, though I don't know anything about it.
I'm sorry - I don't see how the Nitty Gritty Dirt Band enters into it. I recall they recorded a well-known version of "Will the Circle Be Unbroken". What circle? Where in the sky (Lord)? What Lord?
These are not things I have ever contemplated before, though I've heard that song a hundred times. Can't say I have any evidence that there is a better home than here, being alive.
I don't consciously "reverence" anything. Now, that may be a failure to know myself but I don't feel "the divine" in anything, because I don't think there is a "divine".
The song is about how Mother Earth is a nurturant, benevolent mother which "cares for me', "looks after me", is devoted to me. This is beautiful nonsense. It is as inaccurate as saying nature is nothing but "red in tooth and claw", which is similarly wrong in the opposite direction.
I was using it as an example of what seems to me to be some sort of nature worship. I was hoping you could point me to something better.
The nature worship idea is a good one, but it lacks people. What is the composition of nature worship that includes people? Speculative and creative answers are welcome.
I think going forward that's going to be a dark ages/small monasteries situation.
How many people do you need? :-)
Small monasteries good enough for me, but probably not for my kids when they get to their twenties.
I've heard that some divinity schools do that. Otherwise, there are individuals and pockets of individuals whoostly do that but pretty much everyone has some kind of irrational belief on one topic or another. Of course that assumes someone else knows that one belief is truly irrational but we can somewhat get around this by comparing people whose beliefs seem extremely rational and looking where they differ. Not all differences imply irrationality but it's where to start.
What are your irrational beliefs Stu?
Well, to start, we often hold irrational beliefs because we don't even realize they are irrational so I'm not a great person to ask.
Maybe I'm better than most but I know at times I'm slow to recognize the strength of contrary evidence.
How about you?
I probably have a slight case of NIH.
We could start by shifting everyone out of employer plans into an upgraded ACA. That raises consumer sensitivity to cost a bit and gives insurance companies a bit of incentive to seek more cost-effective care. More importantly it reduces the anti-employment bias particularly of low MP workers of the present system financed by and implicit wage tax.
IDK but I'm skeptical ACA has either of the first too advantages you state. I agree there are many benefits to de-linking health insurance and employers but suspect there are also some downsides I'm not fully aware of.