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The Weeds: Can the government trick you into dieting?


On this week's episode, Ezra, Sarah, and Matt debate a little known Obamacare program, learn all about Nordic economies, and take on a new white paper forcing health economists to rethink deductibles. 

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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
The following podcast contains explicit language: hello, I'm a host low, welcome to the third episode of the weeds, faxed outcomes policy focused on the Panoply network, Matthew cs here with me, as always my colleague, Sarah Cliff as recline, causing on going past, is an amazing weak for policies. But we had a really weeds debate, which we will talk about later. But first I want to talk about something that has sort of been going on for a few years now and and gets a little bit lost, but its back when the portable care actor Obamacare was being debated in Congress. It was such a big law that one of the things that happened is that provisions on their own sort of would have been a huge deal and big
national debates and all kinds of up ads and hot takes written about them could The kind of just kept smuggled in and go along for the ride and one of with this law, which you ve probably seen. The impact of at your local Paulet Mcdonald's, whenever it so that fast food, restaurant, chains with not fast food restaurants but chain restaurants with more than twenty branches need to put calorie labels on their menus. in this. You know it follows on what we ve had forever, which is that packaged food items univee by a pack of Eminem. Is you can look on the back and I'll? Tell you. You know how gross and unhealthy This is a disaster. It's really sad, as we have in our office in Eminem she and an eminent Delicious, but in the dispenser you'd you don't see exactly how much it is killing you. I assume the theory was that if we put these labels on restaurant chain menus something
It happened that would be different either people would start ordering healthier things or restaurants would have incentives to change a book. items they offer because of course you know if your cookies, food for yourself, you certain, no well, ok. I could probably make this tastes better by throwing the whole stick of butter in, but you also know you know that's kind of guy. but if you come to a restaurant, you know you don't know, what's in it right, so you're incentive as a restaurant. Turkey is the sort of put everything maximum fat maxim. Salt people gonna think it's delicious and then you just say: oh it's a chicken sandwich and who knows, so this label idea, you know it seems kind of reasonable. It has been really furious. Lobbying around it and there's also been some research into does this make a difference and does it help at all? Sarah knows that actually better than me. I just know that popcorn is involved yeah man isn't right. Favorite regulatory fights very excited to talk up ass, a likeness like knowing that you ve, like should have a top ten. It's one of your favorite reserve funds.
guiding medical illustration is probably my favorite. I've heard output, menu labels, strong second arms, and it will get to do until our talk at some point you to the rich on car labels from what I can tell looking through. It is its generally. It's pretty mix, there's some studies in favour, some studies against, but generally negative, studies. The night just don't show an effect. And they show these labels go in people due notice that people like actually see labels are there, but in terms of employment people, I know, there's one thirty out there now find it and put it in the show notes. Where people see the civilly labels and they say yes, they're gonna change. I order look at how they order and like nothing changed it also, people are thinking, it's changing. Probably them convincing, study, ebbing away. You're really interesting, study in favour of these. Was this really giant study about Starbucks, which Starbucks actually started implementing these label for the Asia requirements and
if you ve ever been to Starbucks you, Sir, to realising oh shit, that muffin has like five thousand calories and at its very upsetting, and they did fine using one of the biggest data, sets its and looked at a six percent decrease in calories order, and it was all on foods not injured thanks and is there wasn't from substitution? It wasn't people saying. Oh, I get it, the other gallery muffin. Instead of Orange gallery muffin, it was people just skipping food or there's a Starbucks studies, the best case. We have in favour of these, but generally the evidence is like pretty much studies changing behaviour, so I think it's intuitive actually that, on the demand side, you would not see a tremendous change. I mean it's worth saying what the problem that was trying to be addressed was my favorite example or on menu. Labeling was at the macaroni grill. These too high a scallop in spillage salad and have like, if I, went to the macaroni grill and I was trying to eat well ordering the scallop and spinach salad. That would have been a good bet and it was over. One thousand two hundred calories and so people has had no way of knowing that kind of thing.
that one of the long term questions about many labeling is whether it has an effect whether macaroni old, Danny's, Mcdonald's, etc begin to, on the march and cut down the caloric load of their items, because it will look. We are to try to serve people scallop and spent herself, but that particular, ample that I gave about the salad I think having actually speaks to why it is probably won't be effective for individual people. The people were probably gonna and if it the most from menu labeling, are gonna needed, the least so you're dealing with people who, they come in and they see a bunch of labels they like a choice to forego the thing they want and get nothing or get something. Alot lighter and some people with death. We do that. Then we will have an effect that I am one of those people like. I will go in and I don't buy the eminent missed as I know what is in a minute freaks me out, but a lot of
people who really do struggle with waiter alot of people who policymakers are trying to change. Their behaviour are not confused. There is What thing in New York a couple years ago, where MIKE Bloomberg, with trying to outlaw the giant soda. Probably giant said was not that nobody knew that was really bad to drink like a bucket of Coca COLA, its it they wanted to drink, cook a corner willing to make that trade off, and so one thing folks who feel that way, is it menu? Can there is a little bit of evidence on this Emily it's great, but I do think it suggests Does that mean you? Labeling can have an adverse impact because people go and they have five bucks to spend a lunch. look at what is a maximum number of calories hanging by for about five bucks. So I do but one of them the potential issues here is that you I end up helping folks who pride it need not much help and actually giving, we were not eating, well sort of an ability to actually even worse and buy them.
With all that, I still support, and I think it is perfectly good for people have information and for them to make decisions on it. I dont think that decision should be overly morally waited, but I'm not shock. It doesn't work. I think it's kind of bunch of sort of fit health conscious help? policymakers, make party a little bit by introspection, unlike what what what would work for them. But so here is where I would put it as I've taught us public health researchers for a story. I never did a writing an action, probably right a dumper both at this. Now, the case they made was actually vibrating. Impelling is that there are some studies like suggesting that you know it leads like a handful. Fewer calories ordered it's an expensive policy intervention units are some evidence that it reduces calorie consumption. You not go for it is not the thing that solves the obesity crisis. But if it's like the small knowledge that, like knocked ten calories off of an order and I think the evidence on this ordering more, I actually have not seen the rate we have to look and see that
that is at issue is probably bad for the access by accident were arguing. I agree, I think many Lebanon is a totally, is a totally good idea in part, because I dont think people should go to the macaroni grilling good if they wanted to order. Salad, so they could keep on their diet. They shouldn't be completely tricked over it. It's not an expensive right hind of mandatory. They should get like the sandwich because they give your guy a twelve enter. Keller he's gonna kill. You actually want this. Yes, I gotta weep. We teach this a little bit before, but one thing that makes me feel somewhat more positive about the potential impact for this kind of rule, particularly its implied nowhere bust way over the long term. Is the lobbying around We have cases of vendors of very unhealthy food who did not spontaneous by saying shore mode right down next or movie, theater snacks, how many calories, or in the popcorn and nobody's gonna care what they do. instead was they hired lobbyists to furiously battle?
in the age as our progress here to be able to not do this right, I think if we assume that people who are in the business of selling snack food know something about their own business, it tells us something that movie theatres and amusement parks and other places like that have been fighting so hard to get themselves exempt from this sort of thing, the particularly because those aren't restaurants. They aren't places that people go to sort of four meals, their places that people go to for movie viewing or for four rides right for entertainment, but a lot of fun these days is consumed at non meal times as just sort of incidental to the ups and downs of life, it seems like people or selling food in those circumstances really fear that their sales are going to go down right. There's other people going to go to the movie theater and make healthy choices at the movie theater snack bar as if to say you know, know I here to see the the ventures someone just watch the movie
let me put on the on the other side of that, actually on a again, I'm profaning tabling, but maybe the devil's advocate in this discussion here I think you're too We went, there is great researchers. Actual my fair papers is by David caught. Learn a couple color cars, and it basically show is it that if you look at where Americans increased Clark, consumption is coming from, it is coming from between. Meals is not coming from meals and they've, a really good technological argument around there. So they basically make the point that in nineteen thirty or one thousand nine hundred and forty, it was perfectly possible to make a very heavy casserole. was very hard to do was to make shelf stable, snack food you weren't near your kitchen. It was hard to have easily accessible food at all times and that its Four adjuration preservatives have made things like bag of chips possible, but I think that goes exactly to the point that if you Look at where be calories at a really making people heavier are, they are coming from
source it is actually unusually labelled already they're coming from cans of Coca COLA or Pepsi or sprite, they are coming from bags of ships from candy bars from things that people buy. between meals. So I think that if manual labor was gonna, stop that I think that that would summer where we wouldn't be seeing the kind of rises we are. Instead, what we see is that the amount of food people can whom at meals, which are typically unlabelled, has state pretty Eddie, whereas the amount of food people consume in these much more labelled, interstitial it has gone way out at sea. I think the labels on those snacks are really bad, that we ve let in three get away with. If you remember old cigarette warning labels, where used to be like
cartoon of come on. It's like smoking is amazing and then there's this little taxes, like actual he's, gonna kill you and overtime right as the government buildings, real political consensus in the United States that we were gonna, take tough regulatory action. Those kind of labels got bigger and more so crazy, and you know really you something if you get a beggar, Doritos White it'll, say something crazy. Like it's a hunch, Ten calories like all that's on so bad, but it That's a hundred ten calories per serving and somehow individual pack of Doritos as three and a half servings I mean we know right. you just ask someone: was it healthy, Doritos between meals, again say? No? No, it isn't the people, don't we I understand that a moment to moment basis the consequences, weather, going and be that's because the labels that are on their dont convey that no real kind of way? It's not a coincidence right that industry, like to keep those labeling norms really sort of vague and weird and monkey round with the serving size. It's not
coincidence. The movie theatres want to keep the labels off their things. That there is a real concern in the industry, not so much that a single week world from age ass is gonna change. Things but that is sustained, really rigorous effort to keep doing this and make it salient, people would change right, two things, one down the kind of snacking point: you have your seeing a bit of a counter trend to that we're soda consumption is following a lot right now. I think there's a growing awareness of the cattle So maybe it's Bloomberg push. but something else Margo singer com The upshot is doing a great serious about how eating is changing and she does at a great piece recently about how, if you look at, accessing they'll busy crisis kind of, like maybe peak, telling a little bit and the reason using the plateaus actually drop and soda consumption. So there are some kind of counter trans going on there.
on the labels. I think there's some like very fascinating public health research on this, about how to construct a better calorie label and there's ways that industry games. That's like, like, I think, of Eminem's. They often have now there that live on the front that says like two hundred and ten calories and something around there. If you put the green or red it'll vastly change. Whether people think it's healthier, not help is, of course, Theo ever make that Mars. Whoever makes Eminem will like put the getting calories, unlike a green background, instead of a red background and then you're more likely do you know I am there's really great research showing if we take cholera labels to include like how much exercise would take to walk offer off something that people understand better than like this nebulous thing cholera. But we run into this problem with their color labels and Obamacare to wear in when you going the Palais. It says you notable they burrito between two hundred and seventy and like twelve million Calhoun. Unlike what work is this thing doing for YO and that there is
paper about about a year ago. Those looking like what are actually the things underpinning this label. It turns out two hundred and seventy whatever number it as it is, is literally a tortilla with beans like that? Is the lower bound, and I would argue I mean- maybe I would argue that it up tortilla with beans does not fit the classical definition of Brito as a Californian Oda grew okay and also its actually, if you think about it, the right way, which isn't that Oh, this is somewhere between two hundred seventy and eighty, but Gillian but think about it that justice torture, I have is a hundred ninety calories right. If you look at the difference between the burrito in the Brito Ball, it's like again, I was gonna pushed this point a little began. I, like people, have this information. think they should be able to make these decisions. But I just think it is not the case that the problem was. People are confused about Chapeau Labour Marinos. A heavy meal to consume rely. I don't think I think confusion is the wrong way. To put it, though,
question is in our people confused. If you sit down and just ask them what's going on, which is the salience in their day to day? That's why I think it's interesting we're not seeing a bigger effect like to be totally upfront like you to go back to my old writing. I thought we would see more of an effect from any labeling. Initially looking for the studies began coming out, I was much more optimistic about menu labeling I remember there being studies it had some some very small effect from any labeling, basically a bunch of studies, it said no real of Yad. I seem to remember one that had a small positive effect and clerk consumption, but I'd have to go back and find it, logic that that's why I'm skeptical here, because I think that like, if you take these arguments seriously, what you would say, okay, many labeling is gonna have an effect, but it actually hasn't done that much, and so I think, like that, should make us update our sort of mental model of like what was going on here, I will say anything goes to your point about the movie theater popcorn. I do think there
an outer edge. Where you have food retailers who are offering foods that will give people a kind of sticker shock that popcorn bucket is so big that when people see the Abuja whenever it is, four thousand calories was something that that's actually going to be so far out of the realm. For them, they're gonna, you know or end like adapt, Coronel one where I think it's a golf, cart and sound. There's one through this disconnect, we think of the popular in you may get home. It's like fine and you don't. Even stand. Him I'd Heller is I just like those edge cases or not. Gonna have a huge aggregate effect on what's going on. Here I mean even the soda. Something is a really good example, but what changed on soda. It was not menu labeling like we had labels on soda for a very very long time. One thing that I became very, convinced of like reporting on a bunch of different sort of health care efforts to deal with pretty sick people or people per day. Hitler, maladies or particular behavioral problems. Was there very easy for us to assume that the issue
is just the sort of substandard delivery or sub standard information. When you know a lot of the problems when I talked to providers and said people work on public health is people who just really are willing to make that off like whether that is rational or whether or not we approve of it. Lotta people to sort of comfortable at some margin eaten shitty food and I just think that one reason many labeling is not working as well as a lot of people thought is it. I think that folk sort of interest speck if they were not comfortable with that sort of extrapolated out from their own experience, and that's why we're not seeing mark is like for the people who do order. this food they weren't confused enough for their labels to make a big difference in their and our consumption habits, and also to make that differences is a really great point that Julia Believers, our medical writer, she read a great piece about weight, loss and lock stock, combine wonderful, lugging reality ass. One should go. Read this wonderful website on yes, unlike its podcast on Itunes, yeah yeah, to do that she had a great
What about you know that the real people who end up losing weight that they have to be so much more not till his way, like so much more funding like delicious food, and you have to This agree. Extrinsic Golan innovation, you're working? For else, it's just not going to work. The information in the world is not going to create that Stern, all motivation and maybe like getting diagnosed with diabetes or like seeing you know someone else struggling with weight loss. That might be the thing, but the information is not a except, like you know these popcorn cases a thing, that's losing one of the things I think would really work right, and this goes into there's no way beyond many labeling, but Julie's Ulster, bunch of work on this, like back in the day like, I always wanted to write a behavioral economics diet book. I thought it would be like the fantastic funny, but I talked to Donner Ellie, who Isabel Economists has written a bunch of great books on the subject about how do you eat a thanksgiving Gabriel economists needs like well. You should come to
having wearing a very tight shirt, you should keep the food in the kitchen. She can't it's kind of reach over the table like yourself, another helping a mashed potatoes. You should only have food in the house before that needs to be cooked in order to actually be edible, and I actually think that stuff is really important right. Joking about the eminent in the office a couple minutes ago, but the eminence officer, fucking disaster and I hate them and I would not leave the brain- is no way. Why would walk to see vs two blocks away to go via that? Even now, if you suggested that to mean the middle the day like, if you said, hey Azra, do you want to go? Get some Emmett have said that this addition cod, but like it's not that much harder, but that little bit of friction really matters, and I think that We were really serious about this and I am not sure we should, because you do get into real issues of autonomy and and and liberty here, but I do think that we would want to think about friction about. Not. Giving people information, but about making things harder. I went to the Cleveland Clinic a couple years
go and they play a huge number people, tens of thousands of our member and they actually and the cost curve on their employees. Health expenditure is under member talking about how they did it and the answer fundamental. Was it created a police state? They fired people, they fired. The doctors for smoking on the premises evasively said like if you work here like you, cannot smoke anywhere in the in the general vicinity. They didn't allow anyone to sell sugared. So it s, there is actually one Mcdonald's it with super profitable because they had a long term least though Cleveland. Can it couldn't change and likely there walking through what they are doing, they were doing testing on people's like limpid profiles like Youtube, look at what they were doing and it worked completely see how it works, but it what it really convinced me of it. If you want to pay those kinds of changes in people's health? You just have to go
way further and people are comfortable. Doing was like the Bloomberg yen approach to public health right leg. You outline trans bad. You try not lie big, so does that fails in the courts, the menu labels for pioneered in New York before they are part of the Arroyo. So this is like very much. The Michael Bloomberg School inside banned smoking that smoking bans reality really work right. It like you actually have to like leave the bar to keep smoking in there. Been. No single policy passed him. I dont lifetime that has had ass much of a direct improvement on my life as the smoking ban because ice the bar with a bunch of friends all the time and I'm not naming any names Matt who smoke and I You just be like being and set a long and like all my clothes would stink, and then the smoking ban came into effect in D C and you eat You wouldn't think it was. A big of a duty does have to walk right outside, but a lot of my friends quit simultaneously, including including, I believe you indeed, you really work. I think I That raises an interesting issue that
can be a certain flaw in taking a very literal look at specific policy into djinns that I think, if you look at the move to get people smoke, alas, it is ultimately been very successful and it is ultimately wired very heavy, handed rules right, it seems like you, should be able to say what luck, if any, prefers bars that don't allow smoking and bars allowed to ban smoking inside that, like the market, should reach an equilibrium or non smokers. Have these things- and you know everything's good, the actual experience had is that you can get people do not smoke through real high taxes really aggressive regulations cutting down where you can do it. Big con social stigma as things like that, but it does start with lower why interventions where people start saying. Well, maybe we should nudge behaviour little bed, anything
had kind of done. The cigarette packs labels and send out this didn't change that much pledges give up right. You wouldn't have ever sort of achieve that in some ways. It's like bullets. Try this! Let's try another thing: let's try another thing: let's try another thing and that's ultimately, how you get there and what really makes a difference is You have a point: nickel, sort of consensus we want, to crack down on this industry and get people do not use its products. or do you have kind of wishy washy tinkering around the edges so so you know with smoking. We got the right at some point in the nineties. It just became a thing where politicians were not Venice I'm going to stand up for smokers, rights dominoes started following one by one by one. So, as you say, one of the big divides in american life right now in american politics. Right now is between a sort of more capitalistic outlook on how to change people's behaviour and
or socialist, stick outlook on us and work mandatory wrote. Would you say we saw something about socialism in a political debate reason you know, I would if I would say that what a smooth trend that we are just nailing. These transition, this transition that is going to bring that up and eager take later to remind us. We did something: it's broken its produce food within stock to pat ourselves on the gas. I'm able do legislature, nevermind, hey guy, much anything Hamilton where's also you made it weird, an excellent podcast by PETE Homes, part of to begin podcasting inverse bus, so there a free area. Ire and other parties have Bernie inhaler sovereignty, namely so there was a democratic debate recently and it had a really fascinating exchange should have right towards started with theirs onset that one of the most interesting exchanges. I've heard it in a presidential campaign, debate in years, but when we play it and then will comment on it. You don't get serious alpha. Capitalist, though, do
consider myself part of the casino capitalists process. by which so few have so much, and so many have so little by which Wall Street greed and reckless this wreck this economy. No, I don't, I believe, in a society where all the doktor I have just made clear is our any bill. Anybody else on this stage, who's, not a capitalist, but let let let me follow up on that Anderson, because when I think about- capitalism. I think about all the small businesses that we're started, because we have the opportunity in the freedom in our country, for people to do that and to make a good living for themselves and their families, and I don't think we should confuse what we have to do every so often in America, which is save capitalism from itself and I think what Terrorists Anders as saying, certainly makes sense in the terms of the inequality that we have, but we are
Denmark I loved Denmark, where the United States of America and its our job to rein in the excesses of capitalism, so that it doesn't run amok and doesn't the kind of inequities that we're seeing and our economic system, but we would be making a grave mistake to turn our backs on what built the greatest middle class in the sooner centres every body, but we are a great interpret oriole nation. We have got to encourage that. Of course, we have to support small and medium sized businesses but you can have all of the growth that you want and it mean anything if all of the new income and wealth is going to the top one percent for what we need to support small and medium sized businesses, the backbone of our economy. But we to make sure that every family in this country gets a fair trade, we're ability and have a lot. So I think
what you hear, there is two things right: there's a superficial level political analysis which is dead. Hillary Clinton, actually levelling of frontal assault on sand of socialism, suggests the seriousness with which was begun picking his challenge. I think a lot of people have expected Clinton to not be attacking were trailing when the poles, by name for for quite a bit longer, but I think deeper than This is actually really important and interesting fight in the Democratic Party right now, and you know centres and saying hey. We agree, we both think small and medium sized businesses should be supported. But there is a real difference where Clinton comes out of this new democratic tradition is tradition in many ways that was brought the dominant, robotic party by Bill Clinton by her husband was continued with Brok Obama but its appeal reagan tradition? It's a tradition that argues and believes that the Gulf and has a lot of virtues, but it is very bad
It is very inefficient at the provisioning of of major services, and the free market is just more fish and it will generate growth, its which generates employment and the proper of government is to try to curb the excesses of the FAO. Market, but really let businesses take them line in allocating capital that, whilst we take a front in allocating capital, businesses take the front in providing services and growing the economy, and then the government can come. And regulate around predatory activity tat the gains in order provide a social safety net and and so on and so forth, and so What comes out of this much older democratic tradition that doesn't over things like Obamacare Clinton care, but actually twist to get private insurers out altogether? He's got a plan of civil and should on the podcast before to move pharmaceutical a adds to apprise system that, where the government of deciding what different drugs are really worth he's
You know really intent on trying to get money and put big money, corporate money out of politics. I'm! U good on the list are on the things he cares about private prisons. He is a very deep scepticism of bigness on two levels, both in terms of whether it really is that good at providing services. He often those at the innovations it get. Powdered are really free riding on public research or They are only for the rich and they don't end up being of much utility to the poor, who are were locked out for price reasons, but also that when corporations get very very big, they end up getting a lot of power. They get too much power to set compensation. So sort of pressure, in unionized economy. You don't have much ability for workers to extract adequate Sanders would see, their fair share and when they get there, money, they begin to develop a really strong voice in the political system and this to a place where Clinton disagrees, like normally she more comfortable with their role in the economy, which is much more comfortable. Their role in the political system is a very
one moment in two thousand and eight at the yearly coasts convention now called I think nation. We. She was asked. Why should takes a lobbyist money and she defended lobbyists and defended corporate lobbyists in particular? Saying no a corporation employ people should basically says they deserve a voice, and this is not, I think, a fight that we would have expected to be seen in a real way. The democratic party eight years ago I mean Obama, whose pretty liberals very much with Clinton on this, but after the financial crisis, where it felt like, instead of providing that growth sort of untrammelled capitalism created a massive massive levels, economic dissociation, because the gains of growth are being shared very unequally. The party seems much more comfortable. The sanders like critique of sort of the fundamental role of the corporation and then posted since United there so much
level of concern over corporate political power. So this is, I think, a really fascinating fight, because even if Sanders does not be content in the primary, he can really show the potency this in the Democratic Party Force Clinton to respond to it, push other democratic politicians in this direction, and so there is talk of socialism for capitalism. But I really think it's a fight between different kinds of Democrats, a much older kind of democratic and animal newer kind, a democrat- and I think it's important one eye. We cannot say for sure how it's gonna fall out yet so I think Sanders is actually just confused and then His discussion of this point showed I think some real limits to his thinking he is someone who talks a lot- and I think quite rightly, about the successes of nordic social democracies in promoting the kind of social outcomes that he favours. He also has a foot or to feed or all of his feet very far, Molly planted in this kind of tradition,
american world agrarian populism and he's from Vermont. So he has this talk. about. Well, you know we got a support, small businesses, but somehow doesn't favour the existence of big companies, but he should look at the countries that he actually admire. Sweet. And what you see is that these Denmark, Sweden, Finland, there's countries are on the smaller side, but have some really big businesses that are headquarters in them and be The countries are small and the companies are big global companies there actually much bigger I would have to the local political system that any companies in America are Norway's biggest company, as it is called a p Mueller Maersk. They I'm high ass. They drew out a confident pronunciation yeah, it's probably wrong. You have probably seen them now actually around. They make
being lives in shipping cargo containers. Why did this huge global enterprise and their revenue is not as big as apples revenue? That's the biggest company in America, but it's about a quarter of the size of apples revenue. and Denmark has five point. Six million people and America has three hundred forty million people right so that companies a huge Sweden is home to agent em. It's Hunter, Volvo, its hummed Derek's, and these are big global enterprises and its in entry of nine million people and these companies do have a ton of political clout right, it's exactly as you might fear, and in some ways it's much crazier than anything that happens in Amerika. I remember a few years ago when Nokia was still sort of a going enterprise that everyone whose anyone had iphones or maybe androids animal how can one guy who worked in the finnish embassy and he was like pulling out phone. I was, I call it so funny and he was like
so sad wrangles and asked why, and he said I work. The finnish state. So I have to use the nokia- and I was a will- you mean that's like embassy, policy or something, and he was like? No, I just I have to. It's because you can enjoy. You can drive an important choice. Yeah, I mean exactly where you certainly couldn't be like the chief of staff of the governor, Michigan her right and be driving a japanese car. It would just be unthinkable, it wouldn't be done and its because that's exactly what you see right and so bending Jerry's is a big deal in Vermont, because if the closest thing to like a big company, that's headquarters there whatever it is, never loves about what he's a very neurotic like he's, a very close relationship with Bennett and Jerry's has talked about how the greatest ice cream in the country, scream of the great Lakes but it isn't right, but I think that shows the point ready, graduating Bernie Sanders has to say Contra to reality, the betting, Jerry
the greatest I see in the world, and this because he's a senator from Vermont and it's silly as it sounds as Vermont ICE Cream company has incredible political clout and mine. But it's just not true that this kind of big business political clout stops countries that want to build large and effective way states from doing that, I'm gonna break in here, just as a fact checking situation. Gonna thing that ensures is now owned by Unilever. So I just want to point out. This is a J, his eyes in Asia and don't forget that part of pointing out the bending jerry's isn't even Vermont Company anymore. It's a subsidiary of Unilever of Unilever, an anglo Dutch packaged goods can long, but Bernie still loves them, because I know now, if they support campaign anyway. I'm trying to say is, corporations, especially corporate, is that are big relative to governments. Are a hundred percent compatible with the kind of social vision that Bernie Sanders wants to espouse and he should think harder. But this question:
and in some ways right there actually an easier it's an easier transition. That kind of man dates. You want for things like single pair they're, much harder on small businesses just because they have less staff it in order to be just out of working through those sorts of channels and employer mandates and so forth, were asking how many organizer would they rallied reside, organise a supermarket or like a cute butcher a little dairy guy. Canada has a much more concentrated banking system than we do, and that was one to like. There was an easier thing to regulate. It was less complex it You may think. Mats point speaks to something we talk about the pod gas last week, where we are talking about single payer and could single bear happened in America in as ring up the argument from famed healthcare economists, such rockstar Ervay Reinhard, at Princeton that America's to Corrupt America's, like dear friends but mats point. There are big and It's in smaller countries, it's easier for big interests to be a begin. In a small pond in a way, I think this gets it
He doesn't the things we, like alike to think are distinct in a bad way about the? U S might not always be actually look at the number is distinct a bad. I don't even know if there are, I don't know if their, if they're, good or bad in that way, I do think mats point is really interesting that there a sort of conflict within the sandwiches etiology within his idea of the kind of models that he looks towards, which I think I have actually a lot of tendencies towards bigness within them. I mean the sort of relationship between unions and companies that exist in european countries. It has worked better with big companies like they can be on the boards, and I mean it helps that kind of cooperative relationship, whereas a really sort of churning economy of small and insurgent companies is gonna, be much more anti union because they have lawless, like value to x, glass capacity to to be up. We're being at the start of the extra processes air I do want to serve push
a bit of his point here, because I do think it's interesting sanders does believe. He is very sceptical of big business efficiency in a way that fundamental Clinton is not he's very sceptical of advice from big business. It comes from legitimate place. Sand think is not issues not impressed with the profit motive, as Clinton is and do something that I don't feel that I know the answer to is where party comes down on that right now? But I mean this is a real, consistent difference within their policies. Could in one regulate big business is primarily big not only though in or to sort of achieve the goals. government wants so universal health care. Whatever sanders once too often take the goal away from the business and provided through the government explicitly or Can we from big businesses, as in his proposal, to break up the biggest banks and basically be split that business among smaller and Yes, and it is a really consistent thing so mean sent
May not. He may not be as actually on board for the scandinavian experiences he thinks, but but it is it internally here and ideology, actually his scepticism. It might be something different than scandinavian one, but that doesn't mean I am a little sceptical that in some ways but doesn't mean it's wrong. Why? I think that you you're making a point, and I think that this is the side of Sanders ISM that I would like to hear more about and that I think that has more merit to it than the surf scepticism of big business per se. But is the optimism that he has the ability to build high quality public services. I think that you see up particularly with Bill Clinton, but that sort of Clinton night turn this kind of beat ISM arise inside the Democratic Party about the prospects of creating public agencies. And you would say right if it didn't exist. Obviously we can't have some like big government scheme to construct enormous boats that people than a fly airplanes off if far
too complicated. Emma we're gonna need to do is create vouchers where each the military combatant commands- is allowed to purchase aircraft carrier services from a provider of their choice, and then we can have a ring latorre board to ensure that goes. I punching creating libraries in this ideological colleague exactly right. It's Isaac psychotic. Exactly my we're gonna have a just a building. Only five hundred Ethel of books, owned by the end of every city right. the customary every time now appreciate it, and- and I think that one of the things that we have seen a bird in the open, the years and also in the in the job W Bush years- is that it's true. That is really difficult to build good, effective public agencies. It's true that a lot of government provided services are kind of crappy and they don't go out of business
due to a lack of competition, but did once you acknowledge that we're we're gonna have to have regulators looking over company shoulders to make sure the incentives align. You ve already built that whole problems or into the cake, and who has been very challenging to create a regulatory environment for, for example, for profit colleges that makes them work. Well, it's been difficult oversea the insurance industry and looking over her shoulder its been problematic to sort of one, the pharmaceutical industry, and so it's true. They do really hard to sort of have every college run the way we run local high schools and is also true that a lot of our local high schools are like not one very well, and you would improve things to make them better, but you can evade that problem. I think in quite the third way Clinton night way that was once home to say: well, we're gonna have private service providers, but with some kind of hazy public direction it just hard either way.
That was a good point, so I think that this is a play, this place. I would really fault the Obama administration. Actually, I think I am. I think clear the roll out of a bomb care was total fucking disaster, I dont our set of our slave. What what happened in Healthcare Dhaka was was terrible and Ukraine for internet traffic. Yes good for that. If you talk to them after that, really put a lot of weight on the problems in the government procurement process, I mean you had a bill was relying very heavily on the IP department of the Centre from Medicare and medical services within the Department of Health and Human services, and I don't want to say, two unkind here too one I'm sure, hardworking public servants, but the aid. Department to see him. Ass was probably not staffed and have the rules and so on.
He'll be managing a technical left that complexity and There's a lot of talk about how procurement works about where it goes in the government about what kinds of company can bid and how can they bid and there is energy- on it and I would hear continuously from the Obama administration. They were working on this at this they were gonna, be presenting a really big set of concrete solutions. Done some things have created the? U S, digital service, which I think is a really interesting, sir, Small unit within the government is trying to upgrade technical skills and give a kind of backup assertive capacity, and you know that there is some cool things happening, but really have not, even in these kind of waning years, take real effort at upgrading the qualities of government services, digital or non. This is something that to be fair to They really did try reinventing government under Al Gore was a serious effort. The uniting is often remember, is a joke, but my
standing as illicit had real political capital behind at when it when it began like that, president- was going on the Leno show in or you know, really serve selling. This idea that you know something that that Democrats going to try to do as a party of government was make argument, work better and I don't think that is something that the Democratic Party send about. I think that it is easy to underestimate how much damage healthcare of gave to the idea that government could do these big things. Well, I think correctly, I think, would be hard for somebody. say today. You know years afterwards that those problems have fundamentally been faxed health, gonna, God has been fixed, but another. The process it led to a really rare did you saw at the end of the healthcare archive debacle, like you know what a rush, of people to fix it, I mean, if you want to flip at a level that like when they actually the problem they had to fix? I was surprised given the cow it was when they wanted, they were actually able to fix it and
people to register for health insurance. They were able to mobilise people it s like crisis mode, but then have Gov works like works by now the energy behind this totally dissipates. You see like this movement that was starting unlikely, twenty thirteen it would have been. I don't think it again anymore. I don't think anyone's expecting any serious changes tat. We contract, which I think is you know, a shame, because you really could improve This helped geared up debacle on how these things are. Actually our say more optimistic view of this. I think one of the areas under law of initial too about how they were going to reform the contracting system and that that was banned in because essentially is unworkable and they hit upon a better idea, which was that they need to be the: U S Digital service and that, ultimately, if the government is going, have the kind of first rate information technology services has they are going to have.
To find a way to create an agency that has high morale and high procedure associate with it and that people come into and that the problem with the contracting wasn't the details of how it works is actually the concept that there was this idea, and I think it was a problem of the reinventing government initiatives that we could solve problems by stripping down the number of clear public servants we employed and instead rely on this sort of spot outsourcing of things and that to be very problematic because it would be, on the one hand, really easy devil lack system give the contractor, whoever you want and that's really open to corruption, or you can but they created, which was a lot of compliance, will to avoid corruption, but then You create a game in which, instead of the job going to the people who are the best of doing the job, the job goes to the people who are the best at writing the grant proposals and you viewed specialist around it, and I think it was a.
really bad system, and that were beginning to see some headway made on the correct solution, which is that, like running. The CIA is really hard and the way you do it is you have to hire some spies. I really. I think it is a really good point about the problem, but I don't think that really overestimates what the? U S digital service can do. I mean I've talked to those folks, a bunch there's a lot, they can do in terms of providing expertise. But there is never gonna be big enough they enable did on the power I mean a lot of stuff is decided through law right where these contracts need to be. were from who is implementing them. It isn't something that the executive branch always has discretion over? I actually don't think, What you can do a sort of just try to push it over here. That there was indeed is a really good step, but it is just not big enough. And I think, does not. It does not solve some of the core pray. I guess I'm just saying that I think the solution is going to have to be things like that
its viewing the hard work of creating small government teams do a really good job, but can't get all the work done and then making those teams a little bit bigger and a little bit bigger that crying to have a sort of rule book approach. There was a sort of market utopian ism about it right, that's like ok, if we just put it up for auction. Obviously This can be better because competition law hooray and that's a real misunderstanding of what kind of situations market competition is going to produce good results for this so many principle, age and problems and government contracting there's so many potential problems with corruption, there's so much complexity in the wool writing system, it's just sort of a bad idea and as hard as it is to say we're just gonna, roll up our sleeves and do a good job dislike, not a real alternative. I wanna pushed
Other part of the debate that I think actually relates to this discussion, which was, I thought, one of the other surprising parts in the weeks preceding the debate. Hillary Clinton released. A very detail financial regulation plant and it ended aid. She really argued with Sanders whose plan has been in a really to break up the big banks, but he's not police, a very detailed regulatory plan downstream from that and she really argued that her plan, which does not break up the big banks, but as a lot more to regulate the shadow banking sector and so forth, is tougher and I thought that was a really an inn sting moment of fight. You may not have expected heard a pick, but also and actually kind of important one because are very different theories of regulation being articulated. Do you want it? run through that Cleanse argument, which I think makes its a little
it to one side of whether we should break up big banks or not, but I think the totally valid points she raises is that if you just take the sort of big, diverse financial institutions, that J P Morgan's the Bank of America as the city groups, if you just split them up so, instead of five or six giant thanks. You have like twenty or thirty pretty big banks. some of them are investment banks. Some of them are insurance company. Things like that that you haven't actually solved the probable that what we saw in the financial crisis that a layman brothers when edgy, which were they were big companies having to be clear. There were not little mom and pop operations, but they weren't the most giant banks and they certainly weren't the kind of diversified institutions that centres wants to crack up there, still cause really serious systemic risk problems You need a comprehensive regulatory, so the weather, the banks are big or small, whether their mano liner Universal you need regulate the risk in the system, and I think
that Sanders he has this great line to say if the bank is too big to fail. It's too big to exist, and we all plaid- and you know that makes a lot of sense, but it doesn't actually answer the question of what do you do when it turned out. Some banks have been hiding risk by buying it derive gives from an insurance company, as now insurance company, which isn't a bank, is holding all of the risk in the bay system and now that insurance company might go bankrupt, so all the banks might fail right. That's a kind of problem that the Federal Reserve that the Treasury Department wrestling with and break banks, whether it's a good idea or not. It doesn't address it at all and cleanse plan wait longer and more boring than that with this, because it's a long, boring problem? I do think, though, that sort of shit her to one of her real advantages in the debates, I think Sanders. Cinders has for a legislator, a lot of very big ideas, are actually translated into legislation. He's got a carbon tax splendidly
she real legislation? He's got a plan to break up banks. I mean he really does Big theories about how things should work, this sort of a prize system for pharmaceuticals, any any rates it down and bill form, but he is not nearly as detail Orient dead on the sort of like mechanics of of even I think his policies as Clinton is on her she's, real sort of like technocrats. in that way, her ideas are often not is sweeping, but is she really sort of sort of digs into them? And I think this is boosting difference in any idea. Therefore, to semi what role the president is, but also what is an appropriate way to regulate these things have been built. The criticism you can make of Sanders. Is that Big ideas fall apart in the details that these things are good applause lines, but they do not sufficiently account for the complexity of the sectors which regulate the credit. His mother, you make of Clinton These much more tightly focus much more complex system,
are easier to game. They have more points of failure there. It is much regulatory discretion, sort of subjects. jokes I and bigger simpler rules while they are how's more industry. Opposition are actually a better thing, but I think you know when you look at the difference between to them. You see, I feel, like I understand more, like what a Clinton presidency would look like. We ve got like a clearer spelling out of, like you know, here's what I would do Android, The cure is, like you know, my colleague tax repeal, I don't think, obviously, all of it what but we have a kind of these road maps. hinders. I think you know your point as we haven't gotten that as much weight we ve seen like the legislation come our way in the Senate. We see like there's like a single parents like Medicare for all bill in the Senate But then, when you look at the campaign sight of it, you don't see those like particular proposals and I'm kind of curious. If we're going to get those going the liner kind of you know if, when those big ideas become, like actual
and pain, I am inclined to give him a bit of a pass on this. If only because Clinton thus had this much bigger campaign, much bigger policy apparatus for a very long time now- and so did I mean just building the number of specific policy plans you need to run a campaign like it's a real. Staffing job, and you know a lot of staff pie weren't joining Sanders until pretty recently he did seem like quite as hot air ticket, you know six months ago, as he does today were six months ago. A lot of I remember Your commissar were set at two hundred economists were advising Hillary Clinton, whatever men tee. I think the word advising is being used to bit loosely did speak to the size of the country. CALL C network. I think Santos surges pretty recent even even still and he's some pretty detailed plans you to eat a prescription. Drugs plan hit a detailed plan. The college caught on college costs. Rather,
this. I think I think we will continue to see it. He is somebody who likes releasing those plans, but I think even when they come out just his approach is to upend the system based on some big principles. It's not a lot of, points in his plan. It's a big idea. I like another place, you see. This is the difference in education policy, where Sanders is like looking at this sooner free tuition for all and we pushed as pushed back on that thing you know. Well, though, it does actually mean, like Donald Trump KIDS, get ready to issue, and why don't we tether it income and she is more of an idea- this debt free college, this difference between free in debt, free kind of speakers to that policy. Space you're talking about. We must see what services more exciting speak right, because we're gonna tax, the banks to give. everybody. Freeing haulage, like sounds really great, but it opens right. That's a pretty like you're wasting a lot of money on the children of rich good, sir, when I think it shows the difference between on the stump right Sanders is approaches much better. He paints in broad strokes has a vision
some people are going to hear the vision and say no. I hate this vision, but people who have sort of rod, Lee Progressive instincts can see a picture that Bernie Sanders is painting for you at worst. Hilary speeches are kind of it's like a little it seems like she's may be trying to not really tell you what she really really thinks like lost in the weeds. When you get up on a debate, though it completely flaps and here three has such an array of things. We can say and positions she has, and so ex that she's fluent in and different direction, she can go where Sanders has like these talking points, but when he gets in the mix, Clinton can actually confuse him by saying. Oh, no, my plans tougher and talk about a specific plank of the plan. That is tough, enters you know, he doesn't sanders respond quickly. Some clarification one as it was it's too complicated like forgot. For all the ground is much like a push back on the lake Mccain
of exactly in in the debate, dialogue were people interrupt each other with a go back and forth things like that cleanse approach, I think, looks compelling she seemed confident and calm like she knows what she's talking about like she's, all kinds of ideas about everything we're sanders, I mean was literally up there like yelling, like a weird old man and its, but the script said he won the debate, while Yankee and maybe it had. I mean different things are well suited to different material and, if you're going to go for Bernie Sanders after all, so I'm so tired and turn about Bernie turn about nordic nobody. I won't hold I'd cast on the side of action, as I think this is a problem for Sanders, though, which is that when you look at the kinds of places that he admires right, you don't create something as effective as the finnish publics, call system or the Copenhagen Metro by just kind of writing down. Let's have great public school,
and you don't even do it by saying: let's have great public schools and let spend a billion dollars on it. You have actually do it right. It's it's hard to do things, and it worked wires some notion of like what are you going to do in specific details to make them go? Peace peace, otherwise it doesn't work. You just like say Ok, here's a huge budget go, do something and in a way it it relates to the above care that Healthcare Gov problems or talking right. It's like it's easy for the president and like the age secretary, to say what we need this website and like right down. it's supposed to do and then forget about it, a different thing to build the website
this, like circles back to actually to the menu regulations, because whether this is actually worth my favorite regulatory fight, like everyone like criticise Asia, AIDS to long it's, you doesn't pages and medical loss ratio. Is your right right line whatever it's a good one and has even my life is so vague. Everyone talks about you, nobody cares do complicated. They printed out, they put it on their dies and it's not complicated. But then you look at this like menu regulation that ok, we want to regulate menus which menus are going to regulate, and that's where you got into this movie. Theater thing you know: do the ice cream parlors get regulated, they did movie theatres, they got out, and in the first draft movie, theater were excluded movie, theater lobbyists or a static, they done their job final bad movie, theater back in their not good at their jobs, but there is actually there so many. This is like just like putting numbers on menu boards, but there are links these steps in between, like idea of what we want. Keller information more available I'll actual, follow the thrill of doing that,
I think it might be time for a white paper the week. I think it is such a good one. every disease, and you feel not awaited real excited about this thing that isn't really a white papers Hallo Guide. Now we need to call this research of the week over paper. We may ass well of all work on the ideas of name it if you wanna emails, weeds at vocs our com and in name suggestions for the segments after you really I think. Yes, after after it as an item, I would call it we used to have a tag. It won't blog. The biogas are no use to work on like live every day like it the be our day. That's if we're doing a and b shares national beer of economic Research on Mondays. They release new neighbours and we are talking today about an envy. Our paper by Adam got rid the name of economists acknowledged glory on the weeds sets for kind of brought Goldberg, I'm atop Sondra, Benjamin Handle and Jonathan Cold that- and they did this super cool healthcare study that I've thought was fascinating, where they looked at a very large company, they dont name the company that in time
thirteen. They shifted. Seventy five thousand people from a noted, the plan to a plan with about four thousand dollar deductible, so others that in people had been shopping decisions they are responsible before before they could use. The doktor? Their coverage kicked in right away. Now they would have to pay out of pocket this. penny, apparently very benevolent unnamed company also put in a equivalent. The deductible anyhow savings accounts, so they said. Look you deductible, but were also giving you the money to pay the doktor ball in his tax advantaged health savings, You now have four thousand are deductible, but you also have four thousand ox yet ruffle. It's not cloud, but you might think people just went about their normal business. They sat all united seductive all. I have this money always use the money and go to the doktor. When I want to surprise twist, not true. So what you start seeing images. I was quite surprised that
that there's a theory that when you have hired a doctor, balls people become better shoppers. They. You know, I think, maybe I don't have one six hundred hours and an mri. Maybe I could go to the four hundred dollar mri George more dollars, my each essay account that maybe I can roll over to the next year. They work similar for one case we can hold onto the money the year afterwards What they saw was at spending. Definitely drop spending dropped about a thousand dollars per person just in one year, which is pretty significant else. I'm you going from like thousand four thousand dollars per person but people who still have to go into the doktor as much they just didn't use as many medical services and didn't shop virtue prices. They didn't try and find the cheaper mri. They just said this seems a complicated. I don't really want to spend my each essay and didn't shot for care and a curse it's cold water, and this notion that health economists like to talk about that when you put skin in the game. When people have to think about prices, though you know, go into some praise, shopping tool will find them
prices, and it suggests we don't to do that and there's a variety of theories on why we d like to do that, but that Americans are not exactly excited or planning on shopping for healthcare right and one of things about the study. This really interesting was it the medical you of sick people dropped disproportionately and you you wouldn't expect that because they're gonna blow through their deductible anyway, but rather because scared of doing ed or their worried about you haven't liquidity later in the year. Whatever it was, they really went down and that's actually dangerous, because there was into a health, tracking and study. We don't know sick people were sicker under under these plans, but it is deaf. A possible for people to skimp on needed care From a big past study the ran health insurance study. We know that people don't really have a good idea of how to distinct. Between necessary and we notice in this study choose what an interesting things they showed. Is that just all types of care
Like you inside decline in mental health services. Would you wouldn't think is something that has a much plasticity and what talk to Jonathan calls down when the researchers and kind theory, even these sick people, who you know you look at of condition as outsiders. They, of course, they're gonna blow through the deductible. Why not get their care there's something about spot it- is about the thing you pay at the moment, you're paying at their really to be more of a deterrent than we're thinking about and that its possible you do. We don't psychology inside these sicker people work in a blow to their doktor balls, but maybe there often maybe they're bringing this year, I'm gonna be healthier all roll over some of my age. You say if I just like really cut back, I care I'll be to do it, but those like spot prices. They really change how people interact with the healthcare says to address. It gets a little funny that people found this surprising at all, because the big problem, Kenneth error, I think worthy where the white paper of this
tree in the twentieth century back in the fifty is about health care in, and he says like this to big problems, the free market and health insurance, and one of them is the step that adverse selection that Obamacare supposed to deal with, but the there and, I think, even more profound one is that this information asymmetry right that the doktor knows what a sick person needs. A sick person doesn't know anything that's. Why you're going in these terrified right? That's why you're going to see the doctor and- in general you have no way of knowing who is a good doc. Who is a bad one and if you think about it, baseline level If you said to me, hey MA do you want to send your son to the discount pediatrician order, the really expensive pediatrician? I think I was the expensive pediatrician right. You not like a great deal on my son's. Healthcare goes like. Maybe you got a terrible deal right because ultimately
the price of the health care service is important right at me. You care. Did you pay a hundred dollars they two hundred dollars, but you care so much more about the quality red budget is. I would point out that the maddening about the healthcare system is there's just no link between quality and price, and I guess you know I mean I know you know this probably, but of course we thank you now more expensive cars are nicer than should require that a first class ticket is nicer than a coach ticket. Why? Why and a better doktor be wearing a more human you out source you cause with a lot of these things. Right I mean with with the first cause. Worst coach is actually observable difference right, but if you think about something like you go to shop or a car, if you don't know anything about cars, you know that other people know something about cars and so probably, if access is more expensive than the toy Yoda. That's because the people who- have research car quality? Have some determination is worth paying extra for sitting with healthcare. You have a lot of people who don't know what they're doing They know they don't know what they're doing
and they have maybe a vague assumption that somebody else does who right and so they're not gonna, go try to redo the research themselves, but it is a very confused situation, but one thing I think this kind of fury of healthcare shoppers gets really wrong. the purchasing, really care about right, because everything in health care really comes down to what a sick people lie: sick people, five percent or about fifty percent cos. The sickest twenty percent roughly eighty percent across a minute, it's really bad those per Cities are not like when you to the supermarket and you decide I'm going to buy some bread and I'm also going to buy some ice cream and I'm also going to buy. You know some fruit, there cascading you go to the doctor and that first purchase. Maybe you did search for your doktor. Maybe you asked around. Maybe you did look at pricing I mean. Maybe you did like work really hard to choose a doctor, but when you go to that doctor and not doctor says you need ass. You need an mri and all of a sudden, you're afraid and Europe.
technically outmatched you dont know who does good memorizing, who doesn't in the study talks about how this corporation gave its employees like a lot of comparison shopping tools, but you're going into where you need secondary and further on down the line downstream care things have the accelerated beyond the ability of most of us too easily keep up and do easy comparison, shopping, see, said the doktor or who do you think she My mri, who do you think I should do this in de replacement, who You think who do you think you think and its one recent into of care too visions that I'm a lot more optimistic about interventions change the decision making of doctors and hospitals and nurses and other players with both formation and credibility to make decisions than about costs. numerous? I think the argument for hiding the ball- is the argument for high levels of cost. Sharing is primary early that you think Americans use too much healthcare any view
we could just cut like twenty percent of it off the top, with no real adverse impact on our health. Then this is a really good idea really does work to do that, but if you're trying to say is that what people should do is just use better health care then I think you really want to be looking at things like medical bundling, and you know other kinds of change to the way sort of doctors are reimbursed so they were both in. based on what the patient needs and what the sitter probabilities different things will help. The patient are, and also the stability with the patient to make the decision. So they may different calls It may be. I think, there's totally a good argument that we just too much healthcare that we overestimate the effective healthcare in that we should do less and if so, great huh animals all the way, but if what you want is just healthier people, I don't think it makes any sense at all.
Maybe we definitely there's evidence. We use a lot of inefficient care. The hard part, as we don't know, which of the care is inefficient and like we as consumers, are like not great at fearing that out. one thing I would argue which probably like not politically the argument that I think there's more of a role for insurance companies to be a bit of like more of a gatekeeper, ending, it's gotta speaks to like the interventions you were talking about like healthcare it will know about accountable care organisations where you of this group of doctors who band together, they accept like a flat fee and if they It can deliver a same quality with lower costs. They get to keep some of those savings. One thing I should love that happened with my insurance companies, access to healthcare nerd as others so exciting. I have a foot, injury that won't won't got ways we did x rays. It's still there and I D get MRI and my aim orthopedic doctor. Where's made a J W which charges like some exorbitant amount, because there an academic center. I had no idea about this. Just a sketch of my appointment are ensure called me up those like would you
and going to this other place the charges a third of the cost, because I'm healthcare nerd as like? Oh that's like oh I'm, so proud of you guys we're doing that. It's a commodity that, yes, I will save you this money, but as a opera had like no incentive to go to this place? I've never heard of instead of going to this university, that's very well known, and I think it He speaks to some of these Ike incentives. There's a lot of why and why does the insurance company like offer your kick backers it is not part of our benefit policy changes they, I mean two hundred dollars or any maybe they could also before we were on our current insurance, which will remain nameless ass. I was on Gaza permanently, which I really really liked and endless unusual about cause a permanent day for people who are familiar with it is it
It's an insurance company that also implies a doctor's also owns its own. Hospitals. Is an integrated provider, basically like many single parent single pair, so their incentives are really aligned. So you you know, you're insured does have an interest in not just getting you to use cheaper care, but also keeping you healthy, because if you get really sick, it's gonna be on them. You know your doctors who, in their context have every incentive to over Prescribed EU because you'll be happier- Hilda doing everything we can to keep you healthy and water. all more money for them. They know their paid salaries cause a permanent day there, trying to keep sort of well costs down while still keeping you healthy but so something I really appreciated. Bokassa permanent day was it. It helped cake this kind of weird feeling out of it. Something that that Bernie Sanders for one really does a good job hitting on when he talks about the single pair is an amendment. You talked about this in a previous podcast. It's a
really bad feeling as someone who is afraid, you're sick, that the people who who are necessary to keep you healthy, not really be on your side that you're ensure may not really want degree. Let your treatments because its expensive that your doktor may have a recent or treat you because it puts money, their pocket, the hospitals reason over treat you wanting Keyser, but also about single pair system, two issues to feeling that everybody is a little bit more aligned, and I just think that is you know you- you give that story about your doktor calling announcing hey. We found a place, a cheaper and, as you said like as a health, won't you liked it but like if you weren't a health walk, you have it in and forget. If it was you baby, it's your kid your medical providers calling up it be unlike well, hey that really important test. We found somebody who does it for a bargain. You may not be
replied anywhere acquired a you know, has on my hand I had to change. The appointment died away in another room, but I was like you know: a good work, Isaac I'll do it because I am healthcare tired, but I dont think I had absolutely no incentive to go to no name radiology and do it. There are more than the goodness of my own, and there is also the question of choice. Swayed, I mean there's this sort of fantasy of the shopping around and then there's the us containment reality that that Ezra outline do you know of a Keyser model or of an? chess UK style model and with Keyser, when I was on their insurance, there was a to lie about it, but there was also a real hassle factor that I wanted to get my eyes checked, get an updated glasses prescription and with Heizer. I couldn't just go to the convenient optician. The eye glasses store. I d schlep over to the Kaiser facility harder, their integrated model. Now one thing that happened there was that there is a certain amount of waiting around with. Basically everything in life
and while I was waiting around there, they strapped there's things on my arm and check my blood pressure smart ride. So if you are at twenty something man who doesn't have any chronic health conditions, you really don't need to see a doctor regularly. You don't need that much in the way of healthcare, but blood pressure. Monitoring is a really valuable thing to do so. What kind does is they takes any excuse, like you're, in the building slap in Wisconsin, and it's really smart that there really smart people, it's a smart company, but the fact of the matter is, I could get my eyes check down the block and instead I had to go over to like three blocks from union station and it was annoying and one thing people like about conventional certain. Sharon's options is the ability to go. Do what you want go to the doctors most convenient to you go to people who you have a good were poor with to follow your aunt sallies recommended and things like that. The problem is that we're not actually savvy health, consumers so all that consumer choice doesn't have a health benefits,
but it does have a I don't like life and feeling good about your afternoon benefit the flip side of Europe. You cancer experiences, so I don't have a regular general practitioner right now, Sir I went on Zadok, which is kind of Iphone out that lets you sort of slot into debt. his around around you and a sort of convenient time- and you know reviews he can look after all viewed and I found the one that was war viewed and to him- and you know what I needed was particular medication, which I knew what it was and I needed. I want your blood work done and he really treated me. You know possibly trying to be respectful of my time. Like a consumer like I told him what I wanted and he gave me exactly. That will be We know examination whatsoever. He didn't mean it. my blood pressure and I was furious. That's, because I actually in I know enough about about healthcare policy, to know that, like you're really always supposed to do the blood pressure- and I mean this
It fell to me, like the opposite, that I really was being treated like a consumer like when I wanted to be treated like a patient like I wanted to be treated. You know I wanted to in developing relationship with a doctor and someone I could go back to, but his incentives he wishes. It seemed a burning through Zadok referrals and so like he had. A very busy schedule took me a long time when I was there to to get to the appointment of a sort of overbooked Again, it is a goes to the incentives notches doctors, but also that the patience and something I think that we, often have trouble with is well. How would you your quality, even if you tried has one of the things it is really difficult is what is a good patient exe rience me, a good patient experience. May me in that you did not get testing that you find unpleasant. It may mean that your doktor did not give you a shot, because you know you don't enjoy. Shots are hidden scold, you about your smoking or she didn't tell you to lose weight or whatever
I'll, be there a lot of things. Doctors do they're, not Superfund, but are actually like part of being a good doctor and One thing it's really hard to figure is when you Somebody did they have a good experience and they the gas. Are you getting a read out on that doctor? Having provided appropriate care to them are getting arena doktor having a good bedside manner. You getting a read out on that doctor, actually catering to the patient above the sort of what would be good medicine. do somebody from the same problems reoccur even when you're really looking at what kind of testing the doktor does, because they're just allow You don't know about what a doctor It should have been looking for asking about that. Wouldn't you show up on the chart some issues, its view, hard to to develop, really good decision measures of quality, but the way a lot of a lot of organizations particular sort of any up air are trying to do. It were people to go and rate doctors or rate their medical experience. I give his Amazon and they buy television is actually the idleness, it's bad, but
he's, probably measuring something that is actually related to, but definitely not identical to quality yeah. I think that this, I think there's a decent costs. Compare tools at their of your ensure decides to buy one like every something standard like an mri, you know, I would feel comfortable choosing the cheapest option. I think somebody would still actually is. two on the reverse of what you want and be like. Oh, the most expensive Emory. I will go to that one, but when it do you know like primary care? physicians. Surgeons that, like Eddie pieces and quite there yet and there's some really interesting work going on right now, where Yelp and pro public car, which is a great investigative journalism. Now that are doing, to add ratings onto doctors and hospitals, Yelp sides, and that been pretty controversial. There's been a good debate and the health care one curry worlds of Alec, weather good or bad for patients and doktor, is, I think, that quality space It's a growing controversy, we're starting to turn rely on quality. Metrics, more
what things that actually is heartening is, if you look at the literature, pigeon as factors and actual quality do actually seem to align. Look pretty nicely issue. Shod Harvard has done some great work on that, but the howdy metrics like there it game like their easy to like manipulate the second area where I'd say Medicare as like, struggling a little bit right now, they're trying to reward doctors for quality, but this definition of, do is definitely not sorted out well in its because but, alas em he now it doesnt work. No, I mean, I think it is because cabin some is lovely and what capitalism desert it's a is an engine for producing consumer satisfaction right and if you look at a really successful capitalist company wide, like Apple TIM Cook, tells you you know he doesn't just look at profit and loss in this corridor. Is it you want to build a business for the long term, so it looks. It is consumer satisfaction. Survey. Swayed people should be happy with their transactions with apple
and that's great for them, because their making smartphones and really like the job of the smartphone, is to make you feel good about having spent whatever hundred dollars a smartphone. But it is not true that that's the job of a doctor right. The job of a doctor is sometimes to deliver some hard truths to you to deliver some real time and to say you know what you gotta stop eating the food that has all the calories it right you ve got to exercise more like. I can't help I could give you a prescription drugs for that, but, like really, what you need to do is changing if sty you don't need an antibiotic, you have a virus right, yeah, very big, you won't. It won't help. I could do a point test on your back, but the reality is that the current state of medical science is that we don't know what causes low back right. That's responsible medical treatment, but it would be really much more satisfying to see it.
With your low back pain and have him tell you? Oh he's got like a great cure. He's gonna put you on this treatment programme and because placebos work, it would even be sort of effective right to give you this whole sort of fakes treatment, but as a society weed want, isn't socially effective to have medicine be practised? The way like used car dealers operate a, but that's that's capital, and I think that speaks to likewise evil, talks about how great Keyser is much like you loved being Keyser when things You look at Keyser. They haven't really like taken over the health care, while leaving California they did in California, but they haven't and they came out to sea. They like a little bit and EAST coast presence. I've had a conversation with how the economists about you know why If they're delivering like high customer satisfaction relatively low cost, is it out You know that people don't make it because they want thereabout back pain tests or is it just like an organizational vaguely meters, they can't sign providers
will they could you know they came entities. Seas is presumably they know how to Lake go into my. Its and build new personnel in ITALY. We should look into it at greater. We could do we could do like the journalist yeah. I guess This leave it at that and Rights news article. I would say that that liked him cook. I pay a lot of attention to our customer service reviews on Itunes and also to of criticism session at the end of our podcast care about what we think we got wrong? Here we are again every week everywhere, I really miss. One from today it's not really. This is really a criticism. It is more an anxiety that have begun to be beset by during our podcasting. We Are self consciously running this kind of like wonky evidence driven podcast summer, like bringing up a lot of studies and when I do A kind of writing- and I like remember, I read a study. What I do is I go. Look hats Hetty, unlike make sure, remember right like now, you have me, I'm senior like my godlike did Ike did I read
studies showing that there can be a positive, caloric, effective many labeling, or do I did I reasoned argument or have I miss remembered it? It's like kind of anxiety producing to be like trying to remember research. He read five years ago on the fly. Yes, I think that's. I hope it will be gentle with us. If we fight, we will I think we therefore am at least on our website fox dot com to, if there's any, wrong ideally begin again. they shouted out there. We can bring it up in the five out in the Itunes Worldliness B, o something somebody asked on our are emo vocs it we'd stuck com was for some way to find the shown its more easily, so we will creep A group on box dot com it'll be box. Stockholm such of the weeds- yes,
and you'll be able to find the sort of every to the podcast post with Joe notes there and yeah, and you know, try to keep us honest as Ezra said we're talking about a lot of complicated stuff without proper research materials ahead of us, and we have an email address with zip box dot com that you can reach us at with the comments, we've also been looking at suggestions for future topics. We have a little document where we're thinking about things. A lot of those are suggestions that came from readers. We really appreciate that stuff keep writing do you guys have any criticisms are also arose. Attack, criticism! It's an observation. I am confident that once more, but I have heard comments love another have, however, this segment. Will we really a bit longer this time and I'm curious how readers field or timing readers, listeners oaks. Nobody urban audience Thriven, I ants Marvel called one might say the weeds some curious. how people think about the show, length and communist hot,
I have very guy I'm curious to know what my wife will think about me being late to get home and carry out my mom made it this far in the podcast. Somebody is worthy of the easy producer answer from somebody who works on progress No, ok. I have a weird because of the progress I like. I have a weird sort of affection for like long pike us, but also like pod, So I can let the thing breathing, I feel like in our job as content providers and editors of oxen outcome. We spent how much time I can thinking about like what is like the optimal packaging to send something ricocheting like forever across the internet, I really does I like the idea that We can have a conversation that, like I'm sort of doing this, because it's fun, and so I don't. I don't wanna honestly like.
I am sure that, like pylon, people do prefer surefire test, but I just can't it oh care. We want to thank our show producer, a signal debts, thank you and this, is the weeds box, dot, com and panoply network, and if you can find Matt, Serenite Box dot com and we will be back with another podcast next week,.
Transcript generated on 2021-09-15.