Corner of Berkshire & Fairfax Message Board

General Category => General Discussion => Topic started by: randomep on June 01, 2018, 01:17:16 PM

Title: Munger Says We Will Have Single Payer
Post by: randomep on June 01, 2018, 01:17:16 PM

health care in the US........

any thoughts on this?

I am worried because I am invested in the MCOs
Title: Re: Munger Says We Will Have Single Payer
Post by: TwoCitiesCapital on June 01, 2018, 01:55:30 PM
The Libertarian in me hates the idea.

The realist in me thinks its the easiest way forward and most likely to happen. I would support it to get away from the monstrosity we have in place now, though my preference would be for everyone to have high-deductible plans and thus force some semblance of pricing discipline into the system and maybe motivate some real solutions.

Why would a private market option fail to work: We can't have a free market solution if we cannot discriminate against those who don't pay or provide consumers with the information necessary to differentiate between choices.

You can get care for free at any emergency room. They HAVE to treat you. As the burden from free service gets borne by those who do pay, prices will inflate for those services forcing more people to seek the free options and more costs to be borne by fewer and fewer people. You'd expect public outcry, right? Wrong.

Paying consumers don't see the cost because they don't pay - their insurance company does. And most consumers don't pay the bulk of their insurance premiums - their employer does. And the litte bit of the cost that we do carry? Comes out automatically from your paycheck and 95% of the population couldn't tell you how much it was or what % of the total cost it represents. Ultimately, the users of the services are 2 steps removed from the cost of the service allowing for increased usage even at inflated prices.

Further, even if there was pricing discipline with consumers directly bearing the cost and having the motivation to enact pricing discipline into the process, the information isn't there. You can't differentiate based on price for most services received at hospitals because hospitals themselves cannot quote you how much it costs for a service.

A free market solution cannot exist without being able to deny those who don't pay service and allowing those who day the ability to differentiate between products. But we, as a country, don't have the political will to tell people they cannot receive treatment NOR will the government enact a forced pricing scheme on private institutions.

So, a public solution is most likely to work and receive the most support since it can coordinate all of that on the back-end.

Just my two cents.
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 01, 2018, 03:02:00 PM
I also agree that eventually you will get single payer healthcare in the US. But I think it will be quite far in the future. So your investments are likely fine right now.
Title: Re: Munger Says We Will Have Single Payer
Post by: LC on June 01, 2018, 03:56:38 PM
Good poInt TwoCities.

It may be useful to look at another industry which we cannot deny service to: legal council. Unfortunately it not an ideal comparison but it's  the best I can think of and it gets us 60% of the way there.
Title: Re: Munger Says We Will Have Single Payer
Post by: DTEJD1997 on June 01, 2018, 04:59:33 PM
Good poInt TwoCities.

It may be useful to look at another industry which we cannot deny service to: legal council. Unfortunately it not an ideal comparison but it's  the best I can think of and it gets us 60% of the way there.

If medical care in the USA is going to be comparable to court appointed attorneys...we are in for rough times indeed.

Title: Re: Munger Says We Will Have Single Payer
Post by: LC on June 01, 2018, 05:18:50 PM
The point is, if we accept the premise that we are going to have universal coverage, there must be compromises.
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 01, 2018, 09:51:34 PM
Single payer universal coverage is NOTHING alike court appointed legal counsel.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on June 02, 2018, 08:07:17 AM
https://www.nejm.org/doi/full/10.1056/NEJMp1602009
"In short, single payer has no realistic path to enactment in the foreseeable future."
Then again, when reflecting on what happened in 2008, I never considered, in the potential range of outcomes, that banks, AIG and auto manufacturers would be bailed out by a federal rescue program.

Personal anecdote: A while back, was sometimes marginally involved in contracts negotiations for medical devices. After looking at some data, I found out that, for the same patient and the same device, the price paid by the US "client" was at least twice as much as the price being regionally negotiated in Canada. To the question: "How come you charge at least twice as much in the US for the same product?", the best answer obtained: "Because we can".
Title: Re: Munger Says We Will Have Single Payer
Post by: rukawa on June 02, 2018, 09:30:10 AM
Quote
A free market solution cannot exist without being able to deny those who don't pay service and allowing those who day the ability to differentiate between products. But we, as a country, don't have the political will to tell people they cannot receive treatment NOR will the government enact a forced pricing scheme on private institutions.

I don't like the term free market in this context so I will use a different term. Normal market. You can have a pretty good "normal market" solution to this problem. And that is what Singapore has done. Its extremely effective in providing high degrees of health care availability, good outcomes, no lineups and very low costs. Singapore is a multi-payer system and its the single most effective healthcare system in the world.

By "normal market" I mean a system where the vast majority of consumers are paying for thing directly out of their own pockets with money they earned and for their own direct consumption (not to resell to someone else).  I would say that housing, stock market, education, car repair, healthcare are mostly abnormal markets since in these cases the consumers are mostly not paying using their own money directly for their direct consumption. Instead they are using loans, insurance.

Normal markets work well. In most normal markets prices typically decline, quality improves, pricing is rational and there are no large scale societal problems. Clothing, food, consumer goods are examples.

Healthcare is not a normal market since everyone uses insurance. But Singapore found a way to turn it into one. Their system is not a "free" market. But it provides all the true advantages that free markets have. Brad Delong has a solution that essentially accomplishes the same thing and is described here:
http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

Basically the solution is as follows:
1) Compulsory HSA's and everything paid out of the HSAs up to a certain limit which is dependent on income
2) 100% insured coverage if you exceed the HSA limit
Title: Re: Munger Says We Will Have Single Payer
Post by: ASTA on June 02, 2018, 10:55:07 AM
Was in the states on holiday and was stupid to go to ER. For a swab of my 4-month son cost me $7,000 makes me really consider if I ever want to move there. A mix between EU and USA would be good.

I do Have 2 million credit card Insurance so I should be good still have to fill the paperwork. Will test if it works :D but childbirth was 700 Euros in EU :D
Title: Re: Munger Says We Will Have Single Payer
Post by: bizaro86 on June 02, 2018, 10:57:28 AM
If you ever go to the US, you absolutely need travel medical insurance.  A cousin of mine got hit by a car in Vegas breaking his leg, and the bill was over $500k.
Title: Re: Munger Says We Will Have Single Payer
Post by: Schwab711 on June 02, 2018, 12:12:55 PM
ACA + Medicaid expansion incentives + Medicare was our Singapore solution. Healthcare, like every other major policy, is too politically sensitive right now.

HSA + HDHP is the future imo. I also think the US will (mostly because they have to) move towards single payer in a multi-decade stepped approach. ACA was essentially a large step in this direction that was started in the 1980s. Healthcare will continue to cost a fortune until Medicaid expansion is ubiquitous and the market stops changing every couple of years. Insurance for young, healthy folks will need to be compulsory. Then eventually we can tweak ACA and add additional programs to shore up incentives. That's the route I see.
Title: Re: Munger Says We Will Have Single Payer
Post by: LongHaul on June 02, 2018, 03:57:27 PM
I think that was a fascinating comment by Munger and he will probably be right over time.   The US may be the only large 1st world country without universal healthcare.   

If Single payer becomes a reality, the US govt will put the screws to a huge swath of the US healthcare system.  Profits will be massively squeezed at tons of companies.

Then what .. .  Probably cheaper healthcare for everyone per capita but utilization up. 

I am very against socialized medicine of the European pricing type.  For sure in the US there is a ton of waste
but once you get low prices for all types of healthcare, innovation will plummet.  With little incentive
companies, investors and innovators, etc. wont make super important R&D investments and then a big part of the
beneficial innovation of the US and world healthcare R&D system will be gutted.   All types of innovations wont happen and end up killing and reducing healthspans vs what they would of been.  A sad 2nd order effect.     









Title: Re: Munger Says We Will Have Single Payer
Post by: ScottHall on June 02, 2018, 06:20:58 PM
I think that was a fascinating comment by Munger and he will probably be right over time.   The US may be the only large 1st world country without universal healthcare.   

If Single payer becomes a reality, the US govt will put the screws to a huge swath of the US healthcare system.  Profits will be massively squeezed at tons of companies.

Then what .. .  Probably cheaper healthcare for everyone per capita but utilization up. 

I am very against socialized medicine of the European pricing type.  For sure in the US there is a ton of waste
but once you get low prices for all types of healthcare, innovation will plummet.  With little incentive
companies, investors and innovators, etc. wont make super important R&D investments and then a big part of the
beneficial innovation of the US and world healthcare R&D system will be gutted.   All types of innovations wont happen and end up killing and reducing healthspans vs what they would of been.  A sad 2nd order effect.   

3rd order effect: China, understanding the strategic importance of long term investment, picks up the slack, allowing it the distinction of being able to helicopter into developing countries with new medical discoveries it can give away to extend and cement its soft power in countries that are going to be relevant in geopolitics 20 - 30 years from now.

We're in checkmate here folks, we just haven't figured that out yet. We got fat and lazy while the Chinese have been working to throw us off the high horse.

It reminds me of the intro to Rocky 3, where we see that Rocky has lost himself to the glitz and glamour of his fame. TV commercials, magazine photoshoots, the "perfect" family Christmas and his face on merchandise everywhere.

Meanwhile we are introduced to Clubber Lang, a young fighter making his way up the rankings. We see him brutally knock out his opponents while Rocky is beating up a bunch of palookas we later discover were set up as tomato cans for Rocky to squash by his manager Mickey.

https://youtu.be/ZldDvunHQd0?t=2m30s

And while we see Clubber Lang dedicate all of his time to improving himself to better his chances at his chosen profession, we see Rocky making appearances on The Muppet Show and shilling for American Express. Rocky had grown soft and the Rocky brand was more valuable with him beating up tomato cans than risking his title against legitimate competition.

But sooner or later, if you don't take the fight to your competition, your competition will take the fight to you. Rocky couldn't duck Clubber Lang forever, and when he eventually did fight Clubber Lang he discovered that his match ups with the palookas hadn't prepared him to face real competition again.

Ever since the Cold War ended, we've been like Rocky. We've been resting on our laurels and beating up palooka countries like Iraq and Afghanistan, while China has been investing in its domestic infrastructure, building up its soft power around the world and rising up the rankings.

The day is coming soon that the US will get knocked out cold and be unable to answer the 10 count, and it's our own fault for letting our country fall apart. All that wasted money for wars could have been used to reinvest in America and make us more competitive, but I guess reinvesting in your economic moat is a tough sell when many people believe American Exceptionalism alone has imbued us with our gifts, and that philosophy has made us arrogant and lazy.

We're in checkmate; when you're in checkmate, how can you win? You've already lost, and you can't win a game that you've lost. At least, not conventionally. But there is another alternative, famous in Go clubs around Asia... The Nuclear Tesuji. (https://senseis.xmp.net/?NuclearTesuji)

You flip over the board and the pieces go flying everywhere. It's total chaos, and the usual rules and expectations no longer apply because we're no longer playing the same game. China has been besting us by building up their strategically important infrastructure.

It's time we do the same, by issuing trillions of dollars worth of bonds to build up our own domestic infrastructure to catch up with China. And we need to do this while we still have Donald Trump in office, because he is uniquely qualified to deal with the next step of the operation.

Being the first of the major powers of the world to default on its obligations to the others. Donald Trump has had six business bankruptcies so far, that is not an easy skill to hire for. And dare I say it's one we've NEVER had in the oval office before.

We are going to build up our own domestic infrastructure with the money of foreign governments, and leave them holding the bag. It's Economic Judo, and it's something Trump is very familiar of pulling on his creditors. He can do the same thing for ours, but first we need to build as big of a foreign debt as possible.

The more money we borrow, the more we make up for our cumulative trade deficit to these countries since free trade became the flavor of the day. We'll have had the benefit of decades of lower prices and we'll get the last laugh by pulling back all the money that has been sucked out of the pockets of American families by free trade with our Nuclear Tesuji.
Title: Re: Munger Says We Will Have Single Payer
Post by: Spekulatius on June 02, 2018, 07:05:11 PM
I think Scott has been smoking something again. The idea to use other people’s money to build something of value and then default on the mountain of debt that it took to do so, has some merit, although I suspect the devil is in the details. And, I agree that Donald T would be the right person to do so, because he is intimately familiar with defaulting on debts and generally doesn’t overthink complex matters. ;D

Back on that matter, I had an inlaw collapsing in the heat on my visit in Germany. he as taken into and ambulance and a few hours in thr emergency room. I prepaid 100€ on his behalf and the whole bill was 400€. It would ave been up to 1000€ if he had to spent the night in the emergency room. This was for an US citizen without health/ travel insurance in Germany. I am guessing the cost would have been 20x if the had occurred to a foreigner in the US.

Also for those that state single payer =nationalized medicine - well that’s not necessarily true. The German system is single payer, but resembles a mutual Insurance System rather than a nationalized system.
Title: Re: Munger Says We Will Have Single Payer
Post by: Jurgis on June 02, 2018, 10:10:42 PM
I think that was a fascinating comment by Munger and he will probably be right over time.   The US may be the only large 1st world country without universal healthcare.   

If Single payer becomes a reality, the US govt will put the screws to a huge swath of the US healthcare system.  Profits will be massively squeezed at tons of companies.

Then what .. .  Probably cheaper healthcare for everyone per capita but utilization up. 

I am very against socialized medicine of the European pricing type.  For sure in the US there is a ton of waste
but once you get low prices for all types of healthcare, innovation will plummet.  With little incentive
companies, investors and innovators, etc. wont make super important R&D investments and then a big part of the
beneficial innovation of the US and world healthcare R&D system will be gutted.   All types of innovations wont happen and end up killing and reducing healthspans vs what they would of been.  A sad 2nd order effect.   

3rd order effect: China, understanding the strategic importance of long term investment, picks up the slack, allowing it the distinction of being able to helicopter into developing countries with new medical discoveries it can give away to extend and cement its soft power in countries that are going to be relevant in geopolitics 20 - 30 years from now.

We're in checkmate here folks, we just haven't figured that out yet. We got fat and lazy while the Chinese have been working to throw us off the high horse.

It reminds me of the intro to Rocky 3, where we see that Rocky has lost himself to the glitz and glamour of his fame. TV commercials, magazine photoshoots, the "perfect" family Christmas and his face on merchandise everywhile

Meanwhile we are introduced to Clubber Lang, a young fighter making his way up the rankings. We see him brutally knock out his opponents while Rocky is beating up a bunch of palookas we later discover were set up as tomato cans for Rocky to squash by his manager Mickey.

https://youtu.be/ZldDvunHQd0?t=2m30s

And while we see Clubber Lang dedicate all of his time to improving himself to better his chances at his chosen profession, we see Rocky making appearances on The Muppet Show and shilling for American Express. Rocky had grown soft and the Rocky brand was more valuable with him beating up tomato cans than risking his title against legitimate competition.

But sooner or later, if you don't take the fight to your competition, your competition will take the fight to you. Rocky couldn't duck Clubber Lang forever, and when he eventually did fight Clubber Lang he discovered that his match ups with the palookas hadn't prepared him to face real competition again.

Ever since the Cold War ended, we've been like Rocky. We've been resting on our laurels and beating up palooka countries like Iraq and Afghanistan, while China has been investing in its domestic infrastructure, building up its soft power around the world and rising up the rankings.

The day is coming soon that the US will get knocked out cold and be unable to answer the 10 count, and it's our own fault for letting our country fall apart. All that wasted money for wars could have been used to reinvest in America and make us more competitive, but I guess reinvesting in your economic moat is a tough sell when many people believe American Exceptionalism alone has imbued us with our gifts, and that philosophy has made us arrogant and lazy.

We're in checkmate; when you're in checkmate, how can you win? You've already lost, and you can't win a game that you've lost. At least, not conventionally. But there is another alternative, famous in Go clubs around Asia... The Nuclear Tesuji. (https://senseis.xmp.net/?NuclearTesuji)

You flip over the board and the pieces go flying everywhere. It's total chaos, and the usual rules and expectations no longer apply because we're no longer playing the same game. China has been besting by building up their strategically important infrastructure.

It's time we do the same, by issuing trillions of dollars worth of bonds to build up our own domestic infrastructure to catch up with China. And we need to do this while we still have Donald Trump in office, because he is uniquely qualified to deal with the next step of the operation.

Being the first of the major powers of the world to default on its obligations to the others. Donald Trump has had six business bankruptcies so far, that is not an easy skill to hire for. And dare I say it's one we've NEVER had in the oval office before.

We are going to build up our own domestic infrastructure with the money of foreign governments, and leave them holding the bag. It's Economic Judo, and it's something Trump is very familiar of pulling on his creditors. He can do the same thing for ours, but first we need to build as big of a foreign debt as possible.

The more money we borrow, the more we make up for our cumulative trade deficit to these countries since free trade became the flavor of the day. We'll have had the benefit of decades of lower prices and we'll get the last laugh by pulling back all the money that has been sucked out of the pockets of American families by free trade with our Nuclear Tesuji.

ScottHall for Secretary of State!


...

at the very least:

ScottHall for Anthony Scaramucci!  8)
Title: Re: Munger Says We Will Have Single Payer
Post by: ScottHall on June 02, 2018, 10:32:40 PM
I think that was a fascinating comment by Munger and he will probably be right over time.   The US may be the only large 1st world country without universal healthcare.   

If Single payer becomes a reality, the US govt will put the screws to a huge swath of the US healthcare system.  Profits will be massively squeezed at tons of companies.

Then what .. .  Probably cheaper healthcare for everyone per capita but utilization up. 

I am very against socialized medicine of the European pricing type.  For sure in the US there is a ton of waste
but once you get low prices for all types of healthcare, innovation will plummet.  With little incentive
companies, investors and innovators, etc. wont make super important R&D investments and then a big part of the
beneficial innovation of the US and world healthcare R&D system will be gutted.   All types of innovations wont happen and end up killing and reducing healthspans vs what they would of been.  A sad 2nd order effect.   

3rd order effect: China, understanding the strategic importance of long term investment, picks up the slack, allowing it the distinction of being able to helicopter into developing countries with new medical discoveries it can give away to extend and cement its soft power in countries that are going to be relevant in geopolitics 20 - 30 years from now.

We're in checkmate here folks, we just haven't figured that out yet. We got fat and lazy while the Chinese have been working to throw us off the high horse.

It reminds me of the intro to Rocky 3, where we see that Rocky has lost himself to the glitz and glamour of his fame. TV commercials, magazine photoshoots, the "perfect" family Christmas and his face on merchandise everywhile

Meanwhile we are introduced to Clubber Lang, a young fighter making his way up the rankings. We see him brutally knock out his opponents while Rocky is beating up a bunch of palookas we later discover were set up as tomato cans for Rocky to squash by his manager Mickey.

https://youtu.be/ZldDvunHQd0?t=2m30s

And while we see Clubber Lang dedicate all of his time to improving himself to better his chances at his chosen profession, we see Rocky making appearances on The Muppet Show and shilling for American Express. Rocky had grown soft and the Rocky brand was more valuable with him beating up tomato cans than risking his title against legitimate competition.

But sooner or later, if you don't take the fight to your competition, your competition will take the fight to you. Rocky couldn't duck Clubber Lang forever, and when he eventually did fight Clubber Lang he discovered that his match ups with the palookas hadn't prepared him to face real competition again.

Ever since the Cold War ended, we've been like Rocky. We've been resting on our laurels and beating up palooka countries like Iraq and Afghanistan, while China has been investing in its domestic infrastructure, building up its soft power around the world and rising up the rankings.

The day is coming soon that the US will get knocked out cold and be unable to answer the 10 count, and it's our own fault for letting our country fall apart. All that wasted money for wars could have been used to reinvest in America and make us more competitive, but I guess reinvesting in your economic moat is a tough sell when many people believe American Exceptionalism alone has imbued us with our gifts, and that philosophy has made us arrogant and lazy.

We're in checkmate; when you're in checkmate, how can you win? You've already lost, and you can't win a game that you've lost. At least, not conventionally. But there is another alternative, famous in Go clubs around Asia... The Nuclear Tesuji. (https://senseis.xmp.net/?NuclearTesuji)

You flip over the board and the pieces go flying everywhere. It's total chaos, and the usual rules and expectations no longer apply because we're no longer playing the same game. China has been besting by building up their strategically important infrastructure.

It's time we do the same, by issuing trillions of dollars worth of bonds to build up our own domestic infrastructure to catch up with China. And we need to do this while we still have Donald Trump in office, because he is uniquely qualified to deal with the next step of the operation.

Being the first of the major powers of the world to default on its obligations to the others. Donald Trump has had six business bankruptcies so far, that is not an easy skill to hire for. And dare I say it's one we've NEVER had in the oval office before.

We are going to build up our own domestic infrastructure with the money of foreign governments, and leave them holding the bag. It's Economic Judo, and it's something Trump is very familiar of pulling on his creditors. He can do the same thing for ours, but first we need to build as big of a foreign debt as possible.

The more money we borrow, the more we make up for our cumulative trade deficit to these countries since free trade became the flavor of the day. We'll have had the benefit of decades of lower prices and we'll get the last laugh by pulling back all the money that has been sucked out of the pockets of American families by free trade with our Nuclear Tesuji.

ScottHall for Secretary of State!


...

at the very least:

ScottHall for Anthony Scaramucci!  8)

Thanks Jurgis. Stay tuned, because I have a lot to say on the matter of financial responsibility and how we should really be treating our multi-trillion unfunded liabilities. According to Stanford, here in CA we could be facing $1 trillion ALONE through our pension system. But the state is saying $150 billion unfunded, but guess what, they are also saying 7% returns from their pension system going forward. They haven't come even close, on average, over the past decade. And if those mediocre returns keep up, well, the numbers get really big, really quick.

It is going to take some major financial ingenuity to solve these massive obligations we have made to ourselves. I voted John Chiang for Governor because he has been Treasurer or Controller since 2007, finding one rabbit after the other to pull out of the hat to keep us going.

That is the sort of guy we are going to need to navigate the pension crisis. Oroville says the city is going to run out of money in 4 years, and then bankruptcy. Most cities in the state are in the hole big time, many thousands of dollars per resident.

Too bad he is going to lose, nobody loves a technocrat anymore. Then we are going to be stuck with Gavin Newsom, who is a showboat, and most likely this guy John Cox who has campaigned for office 13 times and hasn't won a single one of them.

John Cox has views that just cannot win in modern CA, and he has been turning the election into a base race so that he can coalesce support among conservatives to make it out of California's jungle primary alive.

In CA, everyone running gets places in one giant pool of candidates. No separation by party. The top two vote getters in that pool then go on to the general election. It doesn't matter if it's a Republican and a Democrat, two Democrats, two Republicans, or even third parties/independents.

So naturally this has led to the Republicans running to try to out Trump each other to be the one the conservative wing rallies behind and make it out of the jungle alive. Unfortunately, running a base race in a state where Republicans have 25% and Democrats have 44% is a sure way to lose a general election.

So Goofy Gavin is going to be Governor, and this whole charade continues another four or so years... and then maybe the state turns into Newsom's Nightmare and he takes the blame for being the one holding the potato when the music stops.

Maybe then the local Republicans will have their shit enough together to capitalize on the fallout and win the Governor's mansion for the first time since Schwarzenegger. Or maybe Gavin will just get replaced by another Democrat in the jungle primary and the Republican party stays as irrelevant as ever because of their refusal to budge on social issues.

But one thing is for sure, we need someone with some financial sense running the state. They're bragging now about the $10 billion budget surplus but that surplus is going to be a drop in the bucket compared to what they need if the worst comes to pass. Or, god forbid, a recession comes and whacks the market and the pension's % funded status along with it.
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 02, 2018, 11:07:47 PM
Spekulatius,

I think Scotty is somewhat sober tonight. Initial post:

Quote
Maybe then the local Republicans will have their shit enough together to capitalize on the fallout and win the Governor's mansion for the first time since 1992. Or maybe Gavin will just get replaced by another Democrat in the jungle primary and the Republican party stays as irrelevant as ever because of their refusal to budge on social issues.

Revised post without edit marker:

Quote
Maybe then the local Republicans will have their shit enough together to capitalize on the fallout and win the Governor's mansion for the first time since Schwarzenegger. Or maybe Gavin will just get replaced by another Democrat in the jungle primary and the Republican party stays as irrelevant as ever because of their refusal to budge on social issues.

Sober enough to realize that there was no gubernatorial election in California in 1992 and that California has had a Republican governor from 1983 to 1999 and then from 2003-2011. So maybe just 2 spliffs in?  :-\
Title: Re: Munger Says We Will Have Single Payer
Post by: ScottHall on June 03, 2018, 01:23:30 AM
Spekulatius,

I think Scotty is somewhat sober tonight. Initial post:

Quote
Maybe then the local Republicans will have their shit enough together to capitalize on the fallout and win the Governor's mansion for the first time since 1992. Or maybe Gavin will just get replaced by another Democrat in the jungle primary and the Republican party stays as irrelevant as ever because of their refusal to budge on social issues.

Revised post without edit marker:

Quote
Maybe then the local Republicans will have their shit enough together to capitalize on the fallout and win the Governor's mansion for the first time since Schwarzenegger. Or maybe Gavin will just get replaced by another Democrat in the jungle primary and the Republican party stays as irrelevant as ever because of their refusal to budge on social issues.

Sober enough to realize that there was no gubernatorial election in California in 1992 and that California has had a Republican governor from 1983 to 1999 and then from 2003-2011. So maybe just 2 spliffs in?  :-\

Sometimes I include "mistakes" and don't correct them, but tonight I did on TWO separate posts. Is marijuana the difference, or is it something else entirely?

I know you hate Trump and don't like his tax policy but at the end of the day we may be lucky we have him relative to the alternative we were presented in the last presidential election, a proven failure family who are the embodiment of the east coast elite culture.

The Clintons want too much government overreach and a lot of control in the hands of a few people. But that's not what America is based off of, and the call of the west is about individual liberty and freedom, we're good enough not to need the government to tell us what to do.

That doesn't sit well with the Hillarys of the world and is a big reason we've seen entitlement spending go up consistently. They know that if you can get the population reliant on the government for their nourishment, the government then flips the tables and has control of the people instead of the people having control of the government.

In California, it's the same problem we're facing right now. The state government has promised entitlements it can't afford to get state workers under the thumbs of the Democrats.

What you may not know if you're not a resident of California is that our state is actually under the control of a shadow government that is not actually elected by the people. These people work within the CalPERS pension system, and decide what sort of returns the members of the pension system have to plan by.

Right now it is 7%, and at that rate Oroville and many other cities will be bankrupt in 4 years. The cities are begging for CalPERS to find a way to increase the returns, so that they have to contirbute less to finance the pensions of their employees.

CalPERS decides the rate and then the municipalities have to pay based on that rate. Who elects the board members of CalPERS? Of the 13 board members, 6 are elected by the members of CalPERS, 3 are appointed, 2 unelected state department heads and only 2 are indirectly elected in the elections for Treasurer and Controller.

This has created a situation where state employees, most of them Democrats, have the state and its municipalities over a barrel and there's nothing we can do about it because the vast majority of the positions on the board are not elected.

http://www.sacbee.com/opinion/opn-columns-blogs/foon-rhee/article173426476.html

My original unedited version was actually right, by the way, but I decided to edit it because I just knew many non-Californians would not understand what I meant. It looks like I was right about that. But since you want to know, I will tell you the full story.

There has been a storm brewing in California for decades. It's a storm that is soon to come to a head, and yes, the election in 1992 that won control of the Governor's mansion away from the Republicans forever played a VERY big role in its creation...

But I never said ANYTHING about that win being a Governor's race.

The race I'm referring to was for a ballot initiative, which is a thing that we do a lot in California. Basically what it means for us to vote on a ballot initiative, is that either because of the legislature or enough voters of California signed a petition, a ballot initiative is put on the ballot during election season. And the purpose of the ballot initiative is to vote on a change of the law, for the most part, each one of us with one vote per person.

Everyone in CA gets to be their own representative in a giant legislature, and the cards will fall where they may.

Well, in 1992 there was a ballot initiative placed on the California ballot called Proposition 162. The idea behind Proposition 162 was to amend the constitution and give pension boards essentially full control over the management of the pension's assets AND actuarial function - dictating required contributions by the cities and state - and made it very difficult for the legislature to amend the process for electing board members.

In other words, it was the creation of a shadow government that could make our state and municipal governments bend the knee with the slightest changes of assumptions, and with no oversight. The only Governors that have won control of the Governors mansion in reality since that time have been Democrats, and because the state Democratic party has the backing of most of the state unions.

You can read more about it here:

http://articles.latimes.com/1992-10-25/news/mn-1327_1_pension-fund

https://ballotpedia.org/California_Proposition_162,_the_%22Pension_Protection_Act%22_(1992)

Every future governor was shackled by its passing, but it took all the power away from the Republicans, because the Democrats have the benefit of the pension beneficiaries being a big chunk of their base. It's the policy they already wanted, to bleed the state dry for their patrons and shackle the freedom our ELECTED governors have to implement their own policies.

Just look at what happened when "Mr. Enron" Gray Davis signed SB 400 and sealed our state's fate of inevitable bankruptcy. Between the unelected pension board reigning as the shadow government over state and municipal budgets and the big increase in pension benefits Davis signed, it's going to take a lot of effort to dig our way out of this mess.

Goofy Gavin is likely to win this time, but once the pension crisis starts hitting in full force - in about four years, for Oroville - Republicans may indeed have the chance of winning the Governor's mansion for the first time since 1992.

Because maybe, just maybe, we'll finally be willing to deal with the elephant in the room once we start watching more and more great California cities financially burn to the ground as each week goes by. Maybe we'll be ready for a fiscally conservative, Republican governor who is willing to stand up to the pension board, slay the unelected shadow government once and for all and return power to the PEOPLE of California.

But it certainly WON'T happen if people like John Cox are the ones the Republican party decides to throw its support behind. He has views that are non-starters in CA, and if we're going to take back California for the Gipper, we need to accept the fact that red meat conservatism won't work here. Or the party can continue to stick its head in the sand, and continue its long slide into irrelevance, with control of the Governor's mansion staying with the unelected board of CalPERS.

If that is the case, watch out below because California is due to fall apart and the risk is SYSTEMIC to the entire U.S. financial system. The consequences will be dire.
Title: Re: Munger Says We Will Have Single Payer
Post by: ScottHall on June 03, 2018, 01:44:04 AM
Poor Oroville; they are now saying that bankruptcy could be as soon as two years away! I hope there isn't a market crash because it could get really, really ugly in a lot of places.

http://www.actionnewsnow.com/content/news/Oroville-Takes-New-Preventative-Measures-to-Avoid-Bankruptcy-in-Near-Future-480190303.html
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on June 03, 2018, 05:52:56 AM
Also for those that state single payer =nationalized medicine - well thatís not necessarily true. The German system is single payer, but resembles a mutual Insurance System rather than a nationalized system.

Excellent point. International comparisons can be a useful exercise but improvements must account for intrinsic "cultural" differences.
So is a mutual system compatible with a free market and individual mindset?

Benjamin Franklin who, in a lot of ways embodies the American Spirit (used to anyways) and who, apparently is one of Mr. Munger's heroes, among his numerous accomplishments, set up a fire insurance "society" in Philadelphia (in a physical location probably close to where the Rocky Statue lies these days) in 1750. Along the way, the "father of American Insurance" improved the idea and incorporated the concept of safety reserves and management of float.

The system was built from the ground up, encouraged market-based best practices, included components of innovation, prevention, risk management and personal responsibility and eventually became mutually owned.

Healthcare is extremely complicated in part because of the way it has evolved (structure and incentives) but I would say that present-day policymakers could use inspiration from the principles used by Benjamin Franklin who introduced needed "reform" in a nascent state by building a mutual system from scratch. Don't necessarily need artificial intelligence.

https://www.bankinsurance.com/editorial/articles/pdfs/bim/1998-ben-franklin.pdf
Title: Re: Munger Says We Will Have Single Payer
Post by: Spekulatius on June 03, 2018, 01:13:35 PM
A mutual system should have some self interest in serving its members as well as self preservation in the long run. It isnít a surprise that most mutual institutions are in insurance.

There is a simple economic realty that if something canít be paid because it isnít  affordable then it wonít. The folks running Calpers know this, but canít tell their members, so they kick the can down the road as long as they can.
Title: Re: Munger Says We Will Have Single Payer
Post by: TwoCitiesCapital on June 03, 2018, 07:08:09 PM
Quote
A free market solution cannot exist without being able to deny those who don't pay service and allowing those who day the ability to differentiate between products. But we, as a country, don't have the political will to tell people they cannot receive treatment NOR will the government enact a forced pricing scheme on private institutions.

I don't like the term free market in this context so I will use a different term. Normal market. You can have a pretty good "normal market" solution to this problem. And that is what Singapore has done. Its extremely effective in providing high degrees of health care availability, good outcomes, no lineups and very low costs. Singapore is a multi-payer system and its the single most effective healthcare system in the world.

By "normal market" I mean a system where the vast majority of consumers are paying for thing directly out of their own pockets with money they earned and for their own direct consumption (not to resell to someone else).  I would say that housing, stock market, education, car repair, healthcare are mostly abnormal markets since in these cases the consumers are mostly not paying using their own money directly for their direct consumption. Instead they are using loans, insurance.

Normal markets work well. In most normal markets prices typically decline, quality improves, pricing is rational and there are no large scale societal problems. Clothing, food, consumer goods are examples.

Healthcare is not a normal market since everyone uses insurance. But Singapore found a way to turn it into one. Their system is not a "free" market. But it provides all the true advantages that free markets have. Brad Delong has a solution that essentially accomplishes the same thing and is described here:
http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

Basically the solution is as follows:
1) Compulsory HSA's and everything paid out of the HSAs up to a certain limit which is dependent on income
2) 100% insured coverage if you exceed the HSA limit


This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.

Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 03, 2018, 07:43:21 PM
I think that was a fascinating comment by Munger and he will probably be right over time.   The US may be the only large 1st world country without universal healthcare.   

If Single payer becomes a reality, the US govt will put the screws to a huge swath of the US healthcare system.  Profits will be massively squeezed at tons of companies.

Then what .. .  Probably cheaper healthcare for everyone per capita but utilization up. 

I am very against socialized medicine of the European pricing type.  For sure in the US there is a ton of waste
but once you get low prices for all types of healthcare, innovation will plummet.  With little incentive
companies, investors and innovators, etc. wont make super important R&D investments and then a big part of the
beneficial innovation of the US and world healthcare R&D system will be gutted.   All types of innovations wont happen and end up killing and reducing healthspans vs what they would of been.  A sad 2nd order effect.   

With due respect. I think you're wrong. What you're essentially saying is that if healthcare companies aren't allowed to price gouge they'll pack their toys and go home? No they won't. Healthcare will still be a profitable business - not as profitable as before - but still quite profitable. Capitalism still works. And as long as there's money to be made people will line up to make it. The valuations of certain companies will be lower than before but R&D, inventions, and innovations will go on.
Title: Re: Munger Says We Will Have Single Payer
Post by: longinvestor on June 03, 2018, 09:09:21 PM
Innovation to reduce costs is not even in the lexicon of US Healthcare. Healthcare Innovation has a great likeness to the defense industries. No lower bounds. 17% HC inflation versus 11% in other advanced economies. American industry is at a huge disadvantage. Munger is exactly right, HC practices are deeply immoral towards the last stages of life. Life expectancy increase over the past century can substantially be explained by elimination of infant and child mortality. Innovation is a convenient tag line used to ward off any talk on cost control.
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 03, 2018, 09:30:12 PM
This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.
What you say is true. The US is a mess. You have all sorts of policies programs and ideas etc, etc. If single payer will go ahead I don't see it being a federal thing. Firstly, as I've said the whole system is already a huge, giant mess. Secondly, the US at this point is pretty much divided on everything. For something like this big to work the people working to make it happen have to want for it to work. If anything gets done federally what will happen is that someone will sabotage the whole thing from the beginning.

One way that I can see this happening is that say a state like California that is more united around the issue decides to go single payer. I'm not choosing California just because of politics. It's economy is about the size of Britain. They have a pretty good health care system in Britain. Single payer, equal access, no deductibles, it's got good outcomes, high approval ratings, and it's pretty cheap. Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

Now if you were to implement an NHS like system in Cali and increase its budget by 30% to make it fantastic, you still come out 30% below what you're currently spending. Non medicare/medicaid costs would come in 50% below what they are right now. Those are BIG numbers. If a big state like California successfully implements something like this other states will follow suit. Then the current system falls like dominoes.
Title: Re: Munger Says We Will Have Single Payer
Post by: Schwab711 on June 03, 2018, 09:42:57 PM
Quote
A free market solution cannot exist without being able to deny those who don't pay service and allowing those who day the ability to differentiate between products. But we, as a country, don't have the political will to tell people they cannot receive treatment NOR will the government enact a forced pricing scheme on private institutions.

I don't like the term free market in this context so I will use a different term. Normal market. You can have a pretty good "normal market" solution to this problem. And that is what Singapore has done. Its extremely effective in providing high degrees of health care availability, good outcomes, no lineups and very low costs. Singapore is a multi-payer system and its the single most effective healthcare system in the world.

By "normal market" I mean a system where the vast majority of consumers are paying for thing directly out of their own pockets with money they earned and for their own direct consumption (not to resell to someone else).  I would say that housing, stock market, education, car repair, healthcare are mostly abnormal markets since in these cases the consumers are mostly not paying using their own money directly for their direct consumption. Instead they are using loans, insurance.

Normal markets work well. In most normal markets prices typically decline, quality improves, pricing is rational and there are no large scale societal problems. Clothing, food, consumer goods are examples.

Healthcare is not a normal market since everyone uses insurance. But Singapore found a way to turn it into one. Their system is not a "free" market. But it provides all the true advantages that free markets have. Brad Delong has a solution that essentially accomplishes the same thing and is described here:
http://delong.typepad.com/sdj/2007/06/dealing_with_th.html

Basically the solution is as follows:
1) Compulsory HSA's and everything paid out of the HSAs up to a certain limit which is dependent on income
2) 100% insured coverage if you exceed the HSA limit


This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.

I think it's a bit of a flywheel right now. Costs are out of control so too many folks take advantage of EMTALA for services and then go bankrupt (or hospitals/other HC services don't bother trying to collect). That effectively spreads costs around to everyone. The point of ACA was to avoid having emergency room bills be shared by everyone and instead just give health insurance so that the charges would be lower. We also guaranteed coverage of pre-existing conditions at the same time so I think the country ended up conflating causes. Most research papers I've read point to pre-existing condition, the 80% expense ratio mandate for health insurers, and the lack of Medicaid expansion by many states as the primary contributing factors of rising health insurance and healthcare costs since 2008.

The biggest problems with EMTALA overuse are in non-Medicaid expansion states (as we'd expect). With Medicaid expansion, there's generally a pretty small percentage of people expected to pay the full premium on a HDHP, yet still making meaningfully below median income. No solution will help everyone. If low-income folks paid $50/month on a $5k deductible, I think we'd see a major improvement. Spontaneous $5,000 bills of any type will cause problems for many people but we'd certainly reduce the usage of EMTALA (and thus lower the cost of HC treatment overall). I don't know if most people here have been in this situation but most low-income folks would love to pay for affordable healthcare. Not being sure if you can get/afford healthcare treatment is extremely stressful.

I think if we can lower EMTALA usage (by increasing Medicaid programs in states), HC cost pressure would ease some and more people would be eligible for HSA accounts. More HSA accounts means more people would be putting money towards their medical bills, which reduces the nominal amount of healthcare costs shared among everyone. If HC costs decrease then cash compensation as a percentage of total compensation increases and the relative HC costs decrease by more than the nominal costs. As I said, the US is trapped in a negative flywheel. It can switch to a positive flywheel with small policy changes and a small shift in attitude/political will.

If we are going to deny services then we need to transition to mandatory insurance and HSA account funding (like Singapore). Looking at the US and other countries, full personal accountability doesn't seem to be feasible without mandatory participation. Singapore mandates 8% of monthly income go towards their version of HSA accounts. I think the US max healthcare spending on insurance is 10% or 15% of gross income. If we made it 15% with 8% HSA and 7% insurance, over time the costs would decline and the maximum would be less of an issue for most. I definitely agree with you that mandatory healthcare participation has been a major sticking point, politically, in the US. Without mandatory participation, it's pointless to try to emulate Singapore. At some point, employer-provided insurance will no longer make sense either.

If everyone must participate and someone still decides to not fund or refuses to pay for services then it's easier (politically/socially/legally) to deny them future treatment. The issue now is most folks realistically cannot afford medical treatment and it's bad for everyone (economically and socially) to deny such a large percentage of the population adequate healthcare.

Finally, on denying services, the issue is the most sensible people to deny services is not necessarily folks that cannot afford basic treatment but forcing folks with seriously debilitating illnesses/conditions to pay out-of-pocket (since they *generally* have a lower expected value to society purely through the perspective of contributing to broad funds). If the US was excessively utilitarian about healthcare, you could argue that we'd only provide healthcare for working individuals and abandon folks after retirement. That's probably a stupid idea for all sorts of reasons. I think attempting to deny healthcare treatment should be done with extreme care. Many folks provide excess value to society when we give them free healthcare. There are many ways to create value.

Either way, I think the issue around misusing EMTALA (and thus, the proposed issued of should we deny services and how) is a symptom of upstream issues and not a direct cause of high healthcare costs. Healthcare costs were problematic well before EMTALA of state versions of EMTALA that popped up a decade before the federal law. EMTALA was a band-aid.

As long as we can remove the political polarization from healthcare then the US should at least begin to move in the right direction. The political rhetoric has been way too high for a long time now.
Title: Re: Munger Says We Will Have Single Payer
Post by: Schwab711 on June 03, 2018, 09:47:05 PM
This is generally the solution I would advocate for, but just don't see the political will for it. Someone, somewhere, is going to stand up and say that some people still won't be able to afford it and that even the $30-40/month for a high deductible plan would be too much to pay, let along them being on the hook for a $2-3k deductible.

We don't have the political will to refuse those people service,s o still don't think this would work - though it would certainly be better than what we have now.
What you say is true. The US is a mess. You have all sorts of policies programs and ideas etc, etc. If single payer will go ahead I don't see it being a federal thing. Firstly, as I've said the whole system is already a huge, giant mess. Secondly, the US at this point is pretty much divided on everything. For something like this big to work the people working to make it happen have to want for it to work. If anything gets done federally what will happen is that someone will sabotage the whole thing from the beginning.

One way that I can see this happening is that say a state like California that is more united around the issue decides to go single payer. I'm not choosing California just because of politics. It's economy is about the size of Britain. They have a pretty good health care system in Britain. Single payer, equal access, no deductibles, it's got good outcomes, high approval ratings, and it's pretty cheap. Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

Now if you were to implement an NHS like system in Cali and increase its budget by 30% to make it fantastic, you still come out 30% below what you're currently spending. Non medicare/medicaid costs would come in 50% below what they are right now. Those are BIG numbers. If a big state like California successfully implements something like this other states will follow suit. Then the current system falls like dominoes.

I completely agree on the domino theory. Massachusetts has been pretty close to universal coverage and will likely lead the US in single payer. They are already showing signs of decelerating healthcare costs and it's possible they see costs decline in the near future.
Title: Re: Munger Says We Will Have Single Payer
Post by: DeepSouth on June 04, 2018, 07:42:24 AM

health care in the US........

any thoughts on this?

I am worried because I am invested in the MCOs
\

If the government were to institute a universal coverage system it would most likely be outsourced to MCOs. MCOs run most Medicaid plans today and are taking share quickly and close to half share in Medicare. Government run fee for service plans are not the way forward.
Title: Re: Munger Says We Will Have Single Payer
Post by: flesh on June 04, 2018, 10:00:08 AM
How about a constitutional amendment fixing the cost of nationalized healthcare to a % of gdp plus regular inflation not medical inflation adjustments.

Even if the initial number is nauseatingly high, this would reduce my fears by a substantial majority.

Aside from that, if you zoom out and look at the next century, I believe significantly more lives will be lost to reduced innovation than gained by single payer. The thing is, no one will be talking about that lives that weren't saved due to reduced innovation. Greater than 50% of lives saved from innovation in the last century are not a result of infant and children's death's. Plus, that's backward looking.... forward looking, a better innovation system humming on all cylinders with the tech that will come in the next century with 10 billion people innovating vs less people in the past could produce untold wonders.

What might have happened can't be calculated and isn't news on 99% of folks radar's.




Title: Re: Munger Says We Will Have Single Payer
Post by: Schwab711 on June 04, 2018, 11:33:07 AM

health care in the US........

any thoughts on this?

I am worried because I am invested in the MCOs
\

If the government were to institute a universal coverage system it would most likely be outsourced to MCOs. MCOs run most Medicaid plans today and are taking share quickly and close to half share in Medicare. Government run fee for service plans are not the way forward.

Word. The term 'single payer' is probably misleading for the broad population.

Aside from that, if you zoom out and look at the next century, I believe significantly more lives will be lost to reduced innovation than gained by single payer.

We can show that this this is unlikely to be true. In 2017, approximately 10% of the population didn't have health insurance. It was ~20% prior to ACA. This statement assumes that the remaining 10% are not worth insuring because we could 'save the lives' of 11.1% of the 90% insured (10% of the population). The 90% insured is generally composed of working folks (private [employer] insurance), elderly (Medicare), and the disable/poor (Medicaid). Most likely, the 11.1% we would be saving would come from the Medicaid population since you can't prevent aging and the working class is generally much healthier than any other group (since there's some Bayes Theorem in the sense that if you are healthy, you are able to work).

Pre-ACA, we'd have 20% of the population uninsured and the majority of insured Americans would be on private insurance or Medicare. It would be impossible to find 25% of the 80% on private insurance/Medicare that have inadequate coverage to the degree that those additional Medicaid subsidies would be better spent 'saving' them as opposed to providing basic treatment/services to uninsured. Obviously incremental gains are largest when you have no care (uninsured) relative to at least some care (the presently insured).

I can understand arguments along the lines of 'moral hazard' and they probably have a lot of validity (it's a subjective topic so I'm not sure how we can be any more generous than 'probably'). However, to say that incremental care of insured persons could provide greater healthcare outcomes relative to the gap between no care and basic care doesn't make sense to me. Especially in the numbers you are talking about.


Greater than 50% of lives saved from innovation in the last century are not a result of infant and children's death's.

Where does this stat come from? What metric are you using (or quoting) to determine 'lives saved'? I've never seen any study that even hints at anything other than infant mortality as the primary reason for increasing longevity.

Again, a simple thought experiment will show why.

Say we have 10 people in the country and 20% infant mortality. There lifetimes last (in years):
1
1
60
60
65
65
70
70
75
75

This implies a longevity of 54.2 years.

Let's say we decrease infant mortality to 10% and one of those babies lives to 60. The longevity would increase to 60.1 years.

Now instead, let's leave infant mortality at 20% and increase the life of surviving individuals by 5 years (that's huge innovation!). The longevity would increase to just 58.2 years.

Having more people live a full life is the easiest way to increase national longevity. It's really not even close. The properties of an average/mean dictate this. If the argument is more based on 'standard of living' then there is a lot of subjectivity and it's hard to rigorously conclude anything.


If you invest in biotech you'll know that 'innovation' in healthcare really isn't as impressive as marketing would make you think. Most leading cancer drugs barely provide statistically significant improvements over placebos or the current standard of treatment. The best treatments extend life expectancy of someone with terminal illness by 10% or so on average. The intended patient populations for these drugs are measured in the thousands. Obviously individual experiences may make folks think it's a miracle drug but it just doesn't move the needle for a nation's health. If anything, these types of innovations are the cause of our escalating healthcare costs.

The biggest healthcare innovations over the last 200 years are probably washing our hands, vaccine/inoculations, and penicillin. Simple stuff with mass application goes a long way.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on June 04, 2018, 01:57:04 PM
If you invest in biotech you'll know that 'innovation' in healthcare really isn't as impressive as marketing would make you think. Most leading cancer drugs barely provide statistically significant improvements over placebos or the current standard of treatment. The best treatments extend life expectancy of someone with terminal illness by 10% or so on average. The intended patient populations for these drugs are measured in the thousands. Obviously individual experiences may make folks think it's a miracle drug but it just doesn't move the needle for a nation's health. If anything, these types of innovations are the cause of our escalating healthcare costs.

The biggest healthcare innovations over the last 200 years are probably washing our hands, vaccine/inoculations, and penicillin. Simple stuff with mass application goes a long way.

1+ from my perspective also.
From the what is provided point of view, perhaps we're in a diminishing return temporary plateau but, apart from some breakthroughs, progress at that level has been slow for quite some time.

The quality/cost curve has been unfavorable and whatever the reason (too little or too much government, distorted private incentives or a combination of both), innovation should not be limited to what is provided but also to how it is provided.
Title: Re: Munger Says We Will Have Single Payer
Post by: longinvestor on June 04, 2018, 03:28:08 PM
https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

The purported healthcare innovation is akin to throwing money at the problem.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on June 04, 2018, 04:50:32 PM
https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

The purported healthcare innovation is akin to throwing money at the problem.

Complementary info:
https://www.ncbi.nlm.nih.gov/books/NBK62584/

The first two paragraphs summarize well.
Basically, at the individual or "mutual level", it boils down to an NPV decision to see if potential useful life lost is worth the investment.
The Constitution mentioned that all are created equal and can have a free and happy life (duration not mentioned).
Life expectancy, when the document was written, was estimated in the mid 30's but recently, after incredible progress, in the aggregate, has been dropping for two years in a row.
Multi-dimensional problem but America's best days lie ahead (ref: Warren Buffett).
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 08:04:12 AM
https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

There are about 30 nations who have longer life expectancy stats than the US. One interesting stat is the Health Adjusted Life Expectancy (HALE) (Healthy Years  + Disability Years), which for the US is 69. Full LE is 79. That delta of 10 is in the same ballpark as the 30 higher ranking nations.

The purported healthcare innovation is akin to throwing money at the problem.

Complementary info:
https://www.ncbi.nlm.nih.gov/books/NBK62584/

The first two paragraphs summarize well.
Basically, at the individual or "mutual level", it boils down to an NPV decision to see if potential useful life lost is worth the investment.
The Constitution mentioned that all are created equal and can have a free and happy life (duration not mentioned).
Life expectancy, when the document was written, was estimated in the mid 30's but recently, after incredible progress, in the aggregate, has been dropping for two years in a row.
Multi-dimensional problem but America's best days lie ahead (ref: Warren Buffett).

"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.
Title: Re: Munger Says We Will Have Single Payer
Post by: frommi on June 05, 2018, 08:49:06 AM
"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.
Title: Re: Munger Says We Will Have Single Payer
Post by: jmp8822 on June 05, 2018, 09:14:44 AM
"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

+1

Also, to be rich you need self-discipline.  To eat healthy you need self-discipline.  To limit smoking/drinking you need self-discipline.  Poor people would be extremely unlikely to start eating kale and flax seeds if you gave them an extra $5,000 per year.  Junk food and poverty are a mindset, not an income.
Title: Re: Munger Says We Will Have Single Payer
Post by: sleepydragon on June 05, 2018, 09:50:10 AM
Speaking of flax seed, I gave my chicken that stuff. Lol
According to my wife, flax seed has long chain omega 3 which is very hard for human to digest. But chicken can digest it and turn them into short chain omega 3 in their eggs which is better for human
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 10:48:33 AM
"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

It's quite difficult to tease out the effects of lack of health care access on mortality versus other factors, but to my knowledge the existing data suggests there is a relationship.  See, e.g.,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/   
If you are aware of contrary studies that suggest no link in the US between access to healthcare and mortality, I'd be interested in seeing it.  More anecdotally, do you really believe that poverty has nothing to do with, for example, having hookworm, or that having hookworm has no impact on overall outcomes:  https://www.theguardian.com/us-news/2017/sep/05/hookworm-lowndes-county-alabama-water-waste-treatment-poverty

You also didn't mention a few other factors associated with poverty that likely increase mortality:  (i) more environmental pollution; (ii) more dangerous jobs; and (iii) more overall stress.

Regarding the "self-discipline" argument, I think it's easy (and perhaps comforting) to say that the poor die sooner because they are lazy, impulsive and stupid.  I personally doubt that account and the policies based upon (or justified by) it.
Title: Re: Munger Says We Will Have Single Payer
Post by: jmp8822 on June 05, 2018, 11:14:33 AM
"In the aggregate" there's been a dip recently, but under the hood there's a more disturbing longer-term picture for some:

https://www.vox.com/science-and-health/2018/1/9/16860994/life-expectancy-us-income-inequality

Of course, there's more than just less access to healthcare driving the growing disparity in outcomes.

Based on what i know longevity has nothing to do with healthcare costs, its much more a factor of what you eat, drink, smoke and how much you use your body. No drug in the world will deliver what not smoking and drinking, eating healthy and running/weightlifting 2-3 times a week does for you. And the richer you are the more you know and care about that, its not even about the money directly.

It's quite difficult to tease out the effects of lack of health care access on mortality versus other factors, but to my knowledge the existing data suggests there is a relationship.  See, e.g.,  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760/   
If you are aware of contrary studies that suggest no link in the US between access to healthcare and mortality, I'd be interested in seeing it.  More anecdotally, do you really believe that poverty has nothing to do with, for example, having hookworm, or that having hookworm has no impact on overall outcomes:  https://www.theguardian.com/us-news/2017/sep/05/hookworm-lowndes-county-alabama-water-waste-treatment-poverty

You also didn't mention a few other factors associated with poverty that likely increase mortality:  (i) more environmental pollution; (ii) more dangerous jobs; and (iii) more overall stress.

Regarding the "self-discipline" argument, I think it's easy (and perhaps comforting) to say that the poor die sooner because they are lazy, impulsive and stupid.  I personally doubt that account and the policies based upon (or justified by) it.

Here is what I know about my Midwest city: I grocery shop in the rich part of town every Wednesday and almost everyone is buying healthy food. I then grocery shop in the poor part of town every Sunday and almost everyone is buying junk food.  And the junk food is not cheaper - if anything, it is more expensive. I'm talking brand name everything junk food.  Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that.  But, it is an undeniable, extremely strong correlation and if your answer is 'policies' good luck with that.
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 11:26:21 AM

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

Title: Re: Munger Says We Will Have Single Payer
Post by: jmp8822 on June 05, 2018, 11:43:58 AM

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

The store I shop at in the poor part of town has plenty of healthy, fresh food. Yet, many $200 grocery bills of Gatorade, Ruffles, Krispy Kremes, and Totino's. Perhaps the 'food deserts' are part of a brand new concept called supply and demand. Maybe if you opened a well-stocked farmer's market in poor parts of town it would simply not get enough customers. Seriously, that author seriously believes there isn't one entrepreneur willing to make a fortune opening a healthy store in a poor part of town? BS meter going off.  Victim mentality runs deep.
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 12:08:04 PM

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

The store I shop at in the poor part of town has plenty of healthy, fresh food. Yet, many $200 grocery bills of Gatorade, Ruffles, Krispy Kremes, and Totino's. Perhaps the 'food deserts' are part of a brand new concept called supply and demand. Maybe if you opened a well-stocked farmer's market in poor parts of town it would simply not get enough customers. Seriously, that author seriously believes there isn't one entrepreneur willing to make a fortune opening a healthy store in a poor part of town? BS meter going off.  Victim mentality runs deep.

I think we read different articles.  The author is saying that "food deserts" are NOT the whole story.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on June 05, 2018, 01:19:25 PM
The key variables are cost and coverage.

Invariably, this debate will put to the fore the clash between personal responsibility and social solidarity. The above comments just show how hard it would be to achieve a satisfactory consensus on coverage and "shared" costs.

At a certain point, limited or unaffordable access to healthcare in our increasingly unequal world may eventually prove to be detrimental.

Otto von Bismark is often recognized as the father of state socialism. However, he did not promote reforms out of idealism. He simply wanted to maintain the balance of power. Call it what you want but make it affordable.
https://www.smithsonianmag.com/history/bismarck-tried-end-socialisms-grip-offering-government-healthcare-180964064/

Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 01:55:03 PM
The key variables are cost and coverage.

Invariably, this debate will put to the fore the clash between personal responsibility and social solidarity. The above comments just show how hard it would be to achieve a satisfactory consensus on coverage and "shared" costs.

At a certain point, limited or unaffordable access to healthcare in our increasingly unequal world may eventually prove to be detrimental.

Otto von Bismark is often recognized as the father of state socialism. However, he did not promote reforms out of idealism. He simply wanted to maintain the balance of power. Call it what you want but make it affordable.
https://www.smithsonianmag.com/history/bismarck-tried-end-socialisms-grip-offering-government-healthcare-180964064/

Is it really true that the US must make these very hard choices?  Or is there something fundamentally dysfunctional about our healthcare system that, if addressed, would allow an essentially "free lunch" of more access, better outcomes and less cost?

Studies like this suggest there's something fundamentally wrong with what we're doing:  https://jamanetwork.com/journals/jama/article-abstract/2674671  [only a summary freely available]  How is it possible that we spend at least 550 bps more of GDP and get worse outcomes and less coverage?  Studies like this one are also why it baffles me that people think expanding coverage is "too expensive"?  It seems clear to me that it's whatever we're doing now that's "too expensive". 

Imagine all the things we could do if we could free up 5.5% (or more) of GDP ...
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 05, 2018, 02:11:51 PM
Well you wouldn't really free up 5.5% of GDP. Mostly you'll just reallocate it. I think maybe at most you create 2% of GDP (finger in the air measurement). But that's still nothing to sneeze at.
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 02:16:52 PM
How do you get to only 2%?  What is the reallocation you're talking about?  I'm not saying you're wrong; I'm just not sure what you are referring to.

And your 2% is with near universal coverage, correct?
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on June 05, 2018, 02:20:39 PM
Yea. By the way just so I'm clear. What I'm saying is not that you can't lower HC costs by 5.5% of GDP. If think you can and probably even more than that.

What I'm saying is that if you lower HC costs by 5.5% of GDP you won't also get a 5.5% GDP pop on top of it. The GDP pop would most likely be around 2%.
Title: Re: Munger Says We Will Have Single Payer
Post by: KJP on June 05, 2018, 02:26:45 PM
I see.  I wasn't counting any additional pop.  Just the re-allocation alone would be quite useful.
Title: Re: Munger Says We Will Have Single Payer
Post by: Jurgis on October 07, 2018, 08:00:35 AM
https://www.propublica.org/article/in-montana-a-tough-negotiator-proved-employers-do-not-have-to-pay-so-much-for-health-care
Title: Re: Munger Says We Will Have Single Payer
Post by: Spekulatius on October 07, 2018, 06:24:26 PM

Why are those poorer people buying junk food that will kill them sooner? I'll let you solve that. 

This is an area of significant current research.  Here, for example, are recent thoughts from someone researching this question:  http://www.latimes.com/opinion/op-ed/la-oe-singh-food-deserts-nutritional-disparities-20180207-story.html

Lazy and stupid don't appear to be the reasons.  Instead, the reasons appear to be deeper and, in my view, profoundly sad.  At the end of the day, I think the poor are essentially the same as everyone else -- same hopes, same dreams, same love for their children, same fallibilities -- they just have a lot less money.  If I was working two minimum wage jobs while taking care of a few kids, and the only respite I could find was a bit of nicotine, maybe I'd smoke too.

A lot of the poorer people have very little time to prepare meals, because they work several jobs. I got aware of this because my wife worked and heard what the techs were doing at her facility. Most of them were working two jobs, some of them 3 jobs. There are other reasons and they were undoubtedly wasting money too, but they was one factor that was evident.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 07, 2018, 08:28:02 PM
https://www.propublica.org/article/in-montana-a-tough-negotiator-proved-employers-do-not-have-to-pay-so-much-for-health-care

"The discounts, however, are meaningless if the underlying charges arenít capped. When Bartlett looked at a common knee replacement, with no complications and a one-night hospital stay, she saw that one hospital had charged the plan $25,000, then applied a 7 percent discount. So, the plan paid $23,250.
A different hospital gave a better discount, 10 percent, but on a sticker price of $115,000. So, the plan got billed $103,500 ó more than four times the amount it paid the other hospital for the same operation. Bartlett recalled wondering why anyone would think this was okay."

Hospitalsí negotiated transaction prices for the privately insured typically vary by a factor of +/- 8 or more across the nation and by a factor of about 3 within a region (for equivalent services). Hospital market structure (degree of competition) appears to be a major factor but the relative absence of determined negotiators also plays a role.

Marilyn Bartlett "was a potent combination of irreverent and nerdy, a certified public accountant whose Smart carís license plate reads DR CR, the Latin abbreviations for debit and credit."
Never underestimate an irreverent nerd.
Title: Re: Munger Says We Will Have Single Payer
Post by: rukawa on October 11, 2018, 09:14:05 PM
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.
Title: Re: Munger Says We Will Have Single Payer
Post by: meiroy on October 11, 2018, 09:31:38 PM
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.

The U.K. health service is absolutely fantastic if you have something serious and you literally would not have to pay a pound for it. This is its main purpose.  If, on the other hand, you have a sore throat then you'd do better to just research it on the internet and resolve it yourself.

Of course, it has a lot of crap built into the system but it is still far better than what the US got.

The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.  It's stinky, it has a lot of issues but damn do we look good with that lipstick on.
Title: Re: Munger Says We Will Have Single Payer
Post by: rb on October 11, 2018, 10:11:33 PM
Whatever dissatisfaction with the NHS exists comes from the fact that the NHS rations out care to keep costs low which creates wait times. But you want to spend some more money, the system get better in a hurry. 

This is the problem with US single payer solutions. They don't really understand what makes single payer work. Rationing is key. Without this the costs of single payer will spiral out of control. All good single payer systems include lots of rationing or they use deductibles (a much much much better method) to control costs.

Interestingly Singapore avoids this problem completely. It has much much lower costs that even the NHS and it has much much much much much MUCH MUCH lower wait times. Singapore wait times are measured in hours...British wait times are measure in weeks. This means that Singapore's wait times are more than 100 times shorter than Britains. Its costs are half of Britains. Singaporeans also live longer.

The interesting question is given the incredible wait times in Britain...why aren't their healthcare outcomes much much much worse?! My explanation is simple...its because healthcare mostly does nothing. It doesn't really improve health. Thus single payer works because it rations something that was a useless expenditure to begin with.

A rational system would focus much much more on determining what actually is useful in healthcare and focusing all subsidies on that. Its also important to avoid killing people...something the US healthcare system does very often:
https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/

Its also really shocking to me how little connection there is in the healthcare system between scientific evidence and actual healthcare practice...or even how little concern there appears to about this issue. Given the way healthcare is practiced and the complete lack of incentives for evidence based care I don't see how healthcare could possibly be very effective. The proper way to view modern healthcare is mostly as witchdoctors, voodoo and shamans. That is what healthcare mostly is.
https://retractionwatch.com/2016/03/16/evidence-based-medicine-has-been-hijacked-a-confession-from-john-ioannidis/

Honestly this whole debate is mostly arguing about how to do insane and stupid things in a slightly less ridiculous way but no one questions the fundamental ways the whole system is setup. Single payer is just lipstick on a pig.

The U.K. health service is absolutely fantastic if you have something serious and you literally would not have to pay a pound for it. This is its main purpose.  If, on the other hand, you have a sore throat then you'd do better to just research it on the internet and resolve it yourself.

Of course, it has a lot of crap built into the system but it is still far better than what the US got.

The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.  It's stinky, it has a lot of issues but damn do we look good with that lipstick on.
I actually lived in the UK for a while and I can attest that the NHS is actually pretty damn good. And no, you don't have to worry about your sore throat. I once walked into an NHS clinic with sore throat (and lungs) and walked out 30 minutes later with a diagnosis for bronchitis and a prescription.

While I disagree with Rukawa's conclusion that a single payer system is lipstick on a pig - it's not - he does make a very good point about rationing and outcomes. He's pretty much figured it out. The rationing is due to cutting capacity for non-essential items. Basically dishing out discomfort for cost savings. While anecdotal, I've seen this in my family. My dad had some back pain and had to wait 2 months to see a specialist. My mom once had a hypertensive emergency and got a cardiologist appointment for the next day. For the record, after my dad was done swearing he admitted it was the right thing for the system to do.

Over here in Canada where we have a single payer system. The issue around wait times revolves around these non-critical items. If you have cancer you'll get some pretty quick care. Doctors (looking for more money) run ads about how horrible it is for grandma to wait some for a hip replacement and people don't like it.

In Canada it is illegal to pay in order to jump the line. But I often wonder, since our healthcare costs roughly half as the US, how many of the complainers would be willing to pay double just for the procedure (let alone double for everything) just to shorten the wait time. My guess is that once they see the price tag, not many - complaining is free. 3

Another source is what Canadians consider a national embarrassment is that we ship a good number of people to the US to have procedures like hip replacement. The interpretation is that we can't fix our own people. But the reality is that due to the way the US system is set up they have a lot of excess capacity around things like hip replacements. Due to our size we can negotiate prices and get really good cut rates similar from the US - similar to a hotel that's trying to fill rooms. So really what's perceived as an embarrassment it's actually the government doing its job, saving money for the people.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 12, 2018, 05:27:44 AM
^Interesting.
Few thoughts.
-International comparisons can be helpful but domestic concepts cannot be simply imported, there are no perfect systems and some systems are more broken than others.
-IMO healthcare delivery brings value but the recent trend (last 20-40 years) is based on gradually smaller incremental value gains and gradually larger costs.
-Agree that the challenge is significant but remain optimistic.
-Compounding can be slow but can be wonderful when incentives are better aligned (in the right direction).
-Value-based care is basically a capital allocation decision and we can do better (a lot better).

Recently read the following and thought it was useful:
https://www.amazon.ca/Better-Now-Improve-Health-Canadians/dp/0735232598/ref=sr_1_1?ie=UTF8&qid=1539345551&sr=8-1&keywords=danielle+martin+healthcare
Thought provoking, a lot to disagree with, but constructive grounds for progress.
Title: Re: Munger Says We Will Have Single Payer
Post by: SharperDingaan on October 12, 2018, 07:12:00 AM
You might want to consider what happens under 'right to die' legislation.
Palliative care is a lot cheaper that end-of-life medical/drug intervention, and choosing 'quality of life' over 'longevity of life' is becoming a lot more common in NA as aging boomers approach end-of-life. Reduce demand for the 20% of intevention services that add 80% of the cost, and total cost comes down rapidly.

SD
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 12, 2018, 08:50:10 AM
You might want to consider what happens under 'right to die' legislation.
Palliative care is a lot cheaper that end-of-life medical/drug intervention, and choosing 'quality of life' over 'longevity of life' is becoming a lot more common in NA as aging boomers approach end-of-life. Reduce demand for the 20% of intevention services that add 80% of the cost, and total cost comes down rapidly.
SD
Delicate topic, but agree.
In an era where opportunity costs are estimated and where potentially positive NPVs are discounted in the longevity escape velocity projects, perhaps some consideration should be given to the potential fact that the hospital should be a last resort solution, if quality of life is high on your list.
https://accessh.org/wp-content/uploads/2017/01/Bruce-Leff-April-4.pdf
https://www.commonwealthfund.org/sites/default/files/2018-09/1895_Klein_hospital_at_home_case_study_v2b.pdf
I would say huge opportunities for those putting customers first, single payer or not.
Title: Re: Munger Says We Will Have Single Payer
Post by: rukawa on October 13, 2018, 09:57:28 AM
The fact is that the pig with the lipstick which you mentioned is us.  The single payer system is the best we can come up with, just like how capitalism is the best system we can come up with considering all of our faults and biases and whatnot.

I've pointed out repeatedly that the Singapore system which is a Massively multiplayer system (since each person pays out of pocket for almost everything) is a vastly better system than the UK. Go on studiously ignoring this. Single payer is not the best we can come up with.

Quote
I actually lived in the UK for a while and I can attest that the NHS is actually pretty damn good...While I disagree with Rukawa's conclusion that a single payer system is lipstick on a pig - it's not

NHS, US and Canadian systems are pretty much the same when it comes to the practice of healthcare and even the incentives in the system. The big advantage of single payer is that it costs less. But I regard healthcare itself as fundamentally dysfunctional and broken. Paying less for it is the lipstick. The pig is healthcare itself in any country that practices it (Japan may be an exception).

I'll give one huge example that I keep hammering and yet no one cares...iatrogenic deaths (death due to healthcare). In the US there are estimated to be 250,000 each year. Its the third leading cause of death. In an intelligent system, you would deal with that FIRST. You would deal with that SECOND. You would deal with that THIRD. It would be your only priority until you solved it. Not increasing coverage or single payer. And yet none of you care?!

But this connect to a much larger problem...the complete lack of concern or incentives or even properly conducted research into what works in healthcare and doesn't. And the reason for this is the incentives in the system and way people think about healthcare. For doctors the incentives IN ALL SYSTEMS are to treat more patients for the treatments that have the highest dollar to time spent ratio. For patients all they want is for something to be done and done as soon as possible...whether what is done actually improves the situation is something the patients don't know and often the doctor doesn't even know. For researchers the goal is to publish flashy findings and get grants and funding from industry. Its much easier to conduct bad research and poorly supported findings than conduct good responsible research.

The result is a fundamentally broken system. Paying less money for it doesn't solve anything.

Lets give one example...routine mammogram screening. It is known to be completely ineffective:
http://theconversation.com/routine-mammograms-do-not-save-lives-the-research-is-clear-84110

And yet in Canada:
https://canadiantaskforce.ca/guidelines/published-guidelines/breast-cancer/

NOTICE that in Britain they actually invite women by mail to do this every year. Its basically going out of your way to encourage stupidity:
https://www.nhs.uk/conditions/breast-cancer-screening/when-its-offered/

As I said...healthcare itself is the pig. The mammogram example is also a great example of how all the incentives and thinking align:

1) Patients are in favor it because they remember some person they know where mammograms caught a cancer that was promptly treated or they remember a relative who died because of a cancer that wasn't caught. Obviously they just want something to be done, done quickly and for as much to be done as possible without regard for costs.

2) The doctor is incentivized positively (fees) and negatively (medical malpractice) to conduct more mammograms and treat more patients.

3) The cancer institutes are incentivized by bad press from outraged patients and doctors to keep mammogram screening recommendations in place.
Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 13, 2018, 08:35:46 PM
^Mammography is controversial and poor incentives may result in poor results. OK.

Interesting to note though that in Singapore, there are guidelines for mammographies that are comparable to Canada or the US and, on a recurrent basis, like in most places in the world, they aim to periodically improve their guidelines with best evidence. So the way that services are paid for seems to have little to do with prevention guidelines.

Here's what seems to be their latest version for mammographies:
http://www.smj.org.sg/sites/default/files/5102/5102cpg1.pdf

I would tend to agree with most of what you describe but don't tend to agree on the black and white thinking and on the implicit assumptions that healthcare actors are intrinsically bad. There are poor performers but, in the main, people simply respond to incentives. To err is human and what one may realize with relevant experience and practical involvement is that, mostly, medical errors are not made by bad people, but rather by good people working in bad systems.

I may be biased though because healthcare saved my life and significantly extended the life of several significant persons around me.
Title: Re: Munger Says We Will Have Single Payer
Post by: meiroy on October 13, 2018, 10:47:24 PM
rukawa,

Thank you for your detailed reply. I've beeen a few times to Singapore. The health care system, in practice, is actually mostly Government run and the government pays for many of the public health services, public hospitals and doctors.  It plays a heavy role in keeping costs down and insurers have to compete within this cost frame.   Either way Singapore is a very unique type of an economy, similar only to Hong Kong, perhaps.  The U.S. has little to do with Singapore and cannot be Singapore even if it wanted to.

Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 14, 2018, 08:38:02 AM
This post is for American "friends" who are reflecting on ways to improve their system based on factual analysis.
This post is not about which system is better.
https://www.msn.com/en-ca/news/canada/trump-calls-out-canadians-travelling-to-us-for-health-care-at-kentucky-rally/ar-BBOlip9?ocid=spartanntp

From data, Canadians do spend on US-based healthcare but most of the money spent results from unpredictably becoming sick in the US while being in the US for other reasons (tourism, business etc). There is a small segment of the population who chooses to go to the US for medical care and some of these cases can involve celebrities and political figures. The main reasons to go abroad: certain heart surgeries, substance abuse centers and experimental cancer treatments.

Estimates vary but, overall, between 1 and 3% of expenditures incurred by Canadians are spent in the US.

There are huge line-ups at the USA-Canada border (both directions) but it's not because Canadians are fleeing en masse to access US healthcare. Personally, the main reason I go to the US (frequent) is because I like to meet people there. :)
But when we go, we always buy complementary health insurance. Just in case.
Title: Re: Munger Says We Will Have Single Payer
Post by: meiroy on October 14, 2018, 07:37:45 PM
There are huge line-ups at the USA-Canada border (both directions) but it's not because Canadians are fleeing en masse to access US healthcare. Personally, the main reason I go to the US (frequent) is because I like to meet people there. :)
But when we go, we always buy complementary health insurance. Just in case.

Is the insurance expensive? Does it include emergency evacuation etc.?

I know that when expats, from any country, living abroad (e.g. a French expat in Vietnam) wanting to buy an international health insurance they are often introduced to two types: 1. global including the U.S.A 2. global excluding the U.S.A.  That by itself shows just how bad the situation is with the health system.

Title: Re: Munger Says We Will Have Single Payer
Post by: Cigarbutt on October 14, 2018, 08:38:47 PM
There are huge line-ups at the USA-Canada border (both directions) but it's not because Canadians are fleeing en masse to access US healthcare. Personally, the main reason I go to the US (frequent) is because I like to meet people there. :)
But when we go, we always buy complementary health insurance. Just in case.
Is the insurance expensive? Does it include emergency evacuation etc.?

I know that when expats, from any country, living abroad (e.g. a French expat in Vietnam) wanting to buy an international health insurance they are often introduced to two types: 1. global including the U.S.A 2. global excluding the U.S.A.  That by itself shows just how bad the situation is with the health system.
Travel insurance for medical emergencies, from my perspective, has not been expensive (+ or - about 2 to 3$ per person per day of travel, sometimes much less with "promotions") whether the US is part of the itinerary or not. The process is fast and convenient and, if underwriting is of any interest to you, they tend to focus on a few key questions (inclusion and exclusion criteria) with some criteria of doubtful value and with other important criteria not even being considered if you succeed going through the basic screening. Worth trying a few competitors because criteria and resulting premiums can vary wildly (not an efficient market, it seems). This is the commodity product. No personal experience with utilization of the product but know of people who had to use it with no problems concerning access, payments (no need for upfront fees, deductibles or co-pays) and evacuation if necessary once the medical condition stabilizes. I have a feeling that the companies make decent underwriting profits on this even if premiums are low (low expense ratio, relatively rare claims).

However, I hear that the insurance premiums shoot up very fast when certain criteria are met which define your risk of being sick "suddenly" (age, certain pre-existing conditions, recent medical visit, medication change etc). In these cases, you have to go through a customized process and, if the US is part of your travel plans, premiums shoot up exponentially.

BTW, we take this type of insurance on international trips only for catastrophic medical events but when we go to the US, even a simple visit or a simple ailment can result in a catastrophic bill as care is more expensive and visitors are typically charged the highest margin multiple of the basic Medicare fee but the care received is usually excellent.