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Episode Notes

Health Care

Who knew health care could be this complicated?

The ACA has increased in popularity since a trough in November 2013.

KFF Health Care Survey

I strongly recommend subscribing to the Health Care Triage Youtube channel for more information about how the health care system in the United States and other countries works, as well as general information about health care and not just its systems.

The RAND HIE (Health Insurance Experiment) is famous and considered a gold standard in health insurance academics. Read about it here.


Despite data about rising premiums generally, premiums are lower under the ACA than they would have been without it—a better benchmark. Not only that, more people are being covered, with more services being provided—meaning that, effectively, premiums have lowered nationally even if they haven’t in traditional measures—the average cost of plans may go up, but it’s easier for people to acquire coverage.

Which is to say, they have more purchasing power than they did before when it comes to health insurance and health care in general consumes less of their resources.

There’s other good evidence that this is true—states that embraced the ACA in some form, including expanding Medicaid with federal grants, saw a depression in prices. States the refused to expand Medicaid saw rates rise 9.6 points higher, on average.

States that fully accepted the ACA and expanded Medicaid, ran exchanges, and fit themselves on the established timeline saw substantially slower rate increases than that. The states that refused ACA saw their rates double relative to the states that fully embraced the ACA.

Not only that, states that embraced the ACA saw budget savings and more robust economic growth.

Here’s a phenomenal New York Times story that digs deeper into why the same health care things just cost more in the United States, and where I drew the colonoscopy example from. CrashCourse uses other examples, like the use of MRI machines and nearly every other service where American consumers (or insurers) shell out 3-4 times as much as similar services (in quality and type) in other countries.

That is fairly typical: in Keene, N.H., Matt Meyer’s colonoscopy was billed at $7,563.56. Maggie Christ of Chappaqua, N.Y., received $9,142.84 in bills for the procedure. In Durham, N.C., the charges for Curtiss Devereux came to $19,438, which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.

In many other developed countries, a basic colonoscopy costs just a few hundred dollars and certainly well under $1,000. That chasm in price helps explain why the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care.

This study digs even deeper to substantiate those claims. And a phenomenal blog series by Aaron Carroll walks through every cause, including the myths about what expands or contracts health care costs with rock-solid data.

Seriously, I strongly recommend this, so I’m linking it again.

It’s all of those things, and more.  Our system costs more because just about every part of it just costs more.  And curbing that spending won’t be easy.  Much of what we choose to spend money on is stuff that we as Americans seem to value.  Much of that value, unfortunately, isn’t all it’s cracked up to be.

Even if we went to a single-payer system, and significantly decreased insurance costs, that won’t touch the bulk of the problem.  Nor would singling out changes to pharmaceutical spending.

All of those things would help; they might even be steps in the right direction.  But there are a few things we all have to own up to.  The first is that most of the “extra” spending is in areas of care.  So, please, let’s stop pretending that cost containment can be painless or unnoticed. The second is that, to make cost reform feasible, we will need to have all these sectors share in the pain.

For all of that extra spending, the United States has markedly lower health care quality and worse outcomes than its relative equals in the OECD. They have the lowest life expectancy (even after controlling for alternate causes), highest infant mortality rate, maternal mortality and the highest years of preventable life lost—despite having lower generalized disease prevalence and a younger population than comparitor countries (G8 minus Russia). Last in every category.

So, the United States pays more and gets less. And here, “less” means an early grave.

And it’s not because of obesity or high prevalence rates of other diseases.

I briefly mentioned high-risk pools. There’s an explanation of the concept here… as well as a rundown on its history of failure.

The ACA was pivotal in modernizing parts of the information system of the health care industry.

Historical data indicates that block grants reduce funding over time. There’s no evidence, at all, that those were made back in gains through efficiency. Why is this the case? Because block grants get renewed, not updated. So when inflation rises by three percent over a renewal period, the budget does not—the same amount of money gets approved.

Programs set to be renewed are also the easiest to cut when a budget debate comes up, and block grants especially so, because their recipients (typically people living in poverty) have the most difficulty mobilizing politically.

A net summary of Trump’s plan results in…

Update: Even the National Review Online doesn’t like the bill


If the United States “tore up” their deal with Iran, they would be left in the cold. The P5 countries would have unique access to Iranian goods and services in an open market—like a $17 billion contract for 80 planes.

Normalized relations are the lynchpin to any movement on Iran. No progress can be made on any other issue—oil, nuclear weapons, support for terrorism, international security cooperation, human rights, basing, trade agreements, ideological internal shifts—without first establishing a normalized relationship. It is bargaining chip one, two and three.

We have had considerable experience, over the years, with incremental or issue-specific approaches to seeking an improved U.S.-Iranian relationship. In Lebanon, Bosnia, and, most recently, in Afghanistan, U.S.-Iranian cooperation has been important to the achievement of U.S. policy goals in challenging environments. Yet, this cooperation has never been able to serve as the catalyst for more fundamental and strategic improvement in the U.S.-Iranian relationship. Disagreements over other critical issues—especially terrorism and nonproliferation—have always undermined the strategic potential of U.S.-Iranian tactical cooperation

Iranian citizens have heretofore had no clear reason to “connect the dots” between their government’s ending its support both for Hezbollah and for nuclear weapons development and having U.S. economic sanctions lifted as a result. If such a connection were made, you might find the majority of Iranians demanding good behavior by their government on these issues because the vast majority wants a better relationship with the United States, as they believe that a normalized relationship with the United States is in their own economic and social self-interest.

That might prevent “axis of oil”-type scenarios, further regional instability or further nuclear proliferation.

Conversely, military action could accelerate proliferation, might require surprising resources given hardened targets and kill any opportunity for moderates to control the Iranian political sphere.

Barack Obama’s negotiations with Iran may be related to the outpouring of support for reformist President Hassan Rouhani in their parliament, a win for moderates.

But Iran is not a beacon of democracy and has a complicated political structure with strong theocratic strains running through it an exerting gatekeeper control, which is why empowering moderates is important in the pseudo-democracy of Iran. That system is what was under attack during the 2009 protests you may remember from when everything was made green on social media.

That reform movement is stronger than it ever has been, and there’s no reason to jeopardize it.

“The resounding message from voters on Feb. 26 was a rejection of hard-liners and an endorsement of President Hassan Rouhani,” wrote Garrett Nada and Katayoun Kishi, Iran researchers at the United States Institute of Peace, a Washington think tank.

Iran’s politicians are generally divided along a narrow political spectrum – with hard-liners who resist change and support Islamic theocracy at one end and reformists who favor greater democracy and social freedoms at the other. In a hybrid political system in which theocrats have the final say, coalitions of lawmakers come together and break apart with each election, depending on the political winds of the moment.

Rouhani’s efforts to repair relations with the West and strike a nuclear deal were opposed by hard-liners but won support among reformists, moderates and even some conservatives who said an agreement would end Iran’s isolation and improve the economy.

Oh, and the biggest opposition to a reformist movement, Ayatollah Khamenei, is bowing down just a little bit.

Supreme Leader Ayatollah Ali Khamenei, the country’s most powerful figure, has given tacit support to Rouhani’s agenda. The economic stagnation in a country in which half the electorate is younger than 35 was a recipe for social upheaval, and Khamenei was said to have been frustrated by hardliners in the last years of Ahmadinejad’s government, who squabbled among themselves and left domestic problems to fester.

Speaking of which, a Trump hotel has been used as a front for the Iranian paramilitary group, the Revolutionary Guard.

And yes, that adds to the complexity. The New Yorker explains:

Iran has two militaries. The Iranian Army is a conventional force whose mission is to protect the country. The Revolutionary Guard is an independent force of about a hundred and fifty thousand soldiers, whose duty is to protect the country’s Islamic system and to preserve the power of the Supreme Leader, Ayatollah Ali Khamenei. The Revolutionary Guard has its own air force and navy, and it has a unit known as the Quds Force, which the United States has identified as a major supporter of Hezbollah and other international terrorist groups. The Guard has developed a shadow economy within Iran to fund its activities and expand its power. It controls all official border crossings and runs several unofficial ports, solely for its own use. The Revolutionary Guard smuggles into the country everything from consumer goods blocked by sanctions to drugs. It also owns seemingly legitimate companies in construction, energy, telecommunications, auto manufacturing, and banking. According to the United States Institute of Peace, the Guard is linked “to dozens, perhaps even hundreds, of companies that appear to be private in nature but are run by [Revolutionary Guard] veterans.”

And yea, that relationship to Hezbollah is a problem.