One of the big challenges is that there aren't a lot of in-between settings for things that can't be managed in a PCP's office.

Say, someone needs IV fluids*or whatever, advanced urgent care is uncommon.

PCPs tell their doctors to go to the ER under these circumstances. I sometimes think PCPs are too quick to do that given the cost to the patient. (even when the cost is ONLY a $200 co-pay)

*Tying he two parts of the post together, I want to note that there is currently a critical shortage of IV bags (largely due to a lack of production in Puerto Rico). You would likely be offered Gatorade instead of IV fluids in the ER.

One of the big challenges is that there aren't a lot of in-between settings for things that can't be managed in a PCP's office.

Say, someone needs IV fluids*or whatever, advanced urgent care is uncommon.

PCPs tell their doctors to go to the ER under these circumstances. I sometimes think PCPs are too quick to do that given the cost to the patient. (even when the cost is ONLY a $200 co-pay)

*Tying he two parts of the post together, I want to note that there is currently a critical shortage of IV bags (largely due to a lack of production in Puerto Rico). You would likely be offered Gatorade instead of IV fluids in the ER.

1&2 last is a grimly perfect reductio ad absurdum for Trumpism.

Already we have to find alternate routes TO the emergency room to avoid getting charged for ambulances. Now this.

Is the plan to get rid of emergency rooms and make everyone go to the "urgent care centers" in the old Blockbuster video stores, and then someone there will triage and see if we deserve to go to the hospital?

4: Some urgent care centers are staffed by ER docs, and those can do a lot, but otherwise YEAH.

You say it's urgent, so urgent, so oh oh urgent.
Just wait and see, how urgent your pain can be.

Our amazing children's hospital has an urgent care center and an ER across the hall from each other and asks patients to self-select but also has staff do triage at check-in and throughout the visit to move patients between them as needed, which works really well. (I haven't been in either in almost six months now. Should I start watching my back?)

I recently went to the ER for the first time in years. In the end it was just the flu, but I was worried because my fever went away and then came back two days later so I was worried about pneumonia. It was 5pm on a Friday. We called the nurse line at Anthem and the nurse said to go to urgent care if there was one open that had a chest x-ray machine, and otherwise go to the ER. I went to a chain urgent care (not my usual one which was closed) and the NP listened to my lung said confidently that it was pneumonia and then left before I could ask about an x-ray (I was out of it) and prescribed antibiotics. An hour later I started vomiting so I went to the ER anyway. They gave me IV fluids and a chest x-ray and it turned out that the urgent care NP was full of shit. So apparently we're not so low on IV bags here. Probably this wasn't a great use of the ER, but it was hard to know at the time. Someone my age died of the flu here this month.

Apparently my state is on the list where Anthem has put in this policy, so we'll see what bill I end up with. I think because urgent care was closed I should be ok. The bill is currently listed as pending with a total cost of $4K.

6 - an opinionated foreigner would have better health care options at home.

Anyway, a controlling plurality of the American electorate has decided that becoming a Third World county is better than remaining a First World country if it saves them money in the short term.

8: All I know is that I get e-mails at work (a teaching hospital) about this everyday and that they are looking in to how they can push meds rather than deliver them by IV, that oral rehydration is preferable to IV if at all possible, and that standard order sets should be changed.

I think my hospital system might be more proactive than others, but it's a big deal.

A shortage of IV bags? Extraordinary. It's not like they're particularly tricky to make... that sounds like having a nationwide shortage of shoelaces or forks or something.

It's like 1984, but with less plausible lies about who we're at war with.

I googled to find out more and yes, indeed, it is so:
https://www.snopes.com/did-maria-cause-an-iv-bag-shortage/

or, more precisely, things were already bad and then the hurricane made things worse:
https://edition.cnn.com/2018/01/16/health/iv-bag-shortage/index.html

If shoelaces or forks needed to be made under stringent GMP conditions because they contain something that's going into the human bloodstream.

As I'm sure you're aware if you've read your Adam Smith, thanks to the magic of capitalist efficiency, the supply chain for every medical supply is dominated by unaccountable monopolies.

Anyway, a controlling plurality of the American electorate has decided that becoming a Third World county is better than remaining a First World country if it saves them money in the short term.

Canonically I think, "Yes, the planet got destroyed. But for a beautiful moment in time we created a lot of value for shareholders!"

13 would be a great mouseover.

a controlling plurality of the American electorate has decided that becoming a Third World county is better than remaining a First World country if it saves them money in the short term means sticking it to the black and brown people.

18: It's a coalition of people who believe one or the other.

I guess maybe some believe both.

Right -- there is not a plurality of people who will in fact make money in the short term out of this deal. Rather, there's a controlling small minority that will make money, leveraging the political might of a bunch of people who are committed to racism.

Though it could also be that lots of people in group 2 erroneously believe (or tell themselves/each other/the world) that they're in group 1.

On the general topic of degradation, disheartened having read this book. A story of people's living standards slowly deteriorating from general Second World level in the 60s/70s (nothing's great or plentiful but there's at least enough), then cheap Soviet fuel goes away, then work stops at the factory, slowly your official rations dwindle, there's an official campaign encouraging everyone to eat two meals a day, you start going on "field trips" with workmates to forage for food, and after years of little steps like this it doesn't seem strange that your ration book gets you literally nothing, you're figuring out how to eat the inside of pine bark, and the train station is full of homeless orphans.

There's a protest march going by my window right now.

Save the Buffalo.

Free the buffalo, actually.

Led my a Native man with a drum, and a bundle of some sort.

That reminds me, when I went out to catch Pokemon for my afternoon constitutional, I saw paper signs pasted to light posts. One said something like "don't work because capitalism sucks" (very rough paraphrase) and the others were just letters and numbers but in the same font.

What do you guys think of this? Our benevolent capitalist overlords protecting us from our evil capitalist overlords?

https://www.theguardian.com/technology/2018/jan/30/amazon-warren-buffett-jp-morgan-healthcare

25: Health care twitter is mostly talking about how vague the press release is - it could be any number of things.

It sounds like they are trying to propose a technical fix to a political problem.

Here's something I've been thinking about. Suppose that in some foreign country that auto workers are very highly paid, and as a consequence that cars were very expensive. Talking heads would all agree that auto sector in that country was very inefficient, right? Pundits are always talking about how inefficient various sectors in Europe are, whenever the workers are highly paid.

The exact same situation prevails in the US health care sector. The workers are extraordinarily well paid, and prices are very high. In economic terms, the health care sector in the US is simply inefficient, while the health care sector in Europe is more efficient. But nobody would ever put it that way, but why is that? Classism? American exceptionalism?

28 is a very good point.

But nobody would ever put it that way, but why is that?

Because the kind of pundit who wants European workers to be paid less doesn't care how much American doctors make?

28 sounds like Dean Baker's beat, and he generally attributes that to classism, or more specifically, protectionism of the rich by the rich.

Pundits are pretty shaky even on the basic point that health costs are mostly about prices/salaries.

Because doctors have fantastic PR. They're life savers and heart breakers. You'd almost have an easier time arguing that soldiers were overpaid.

28: They wouldn't put it that way in the Amerian press, no. Elsewhere, the US is recognised (and explicitly described) as one of the least efficient in the developed world [no direct link as it's paywalled].

Proponents of the NHS often note that politically, we seem to be moving away from one of the most efficient healthcare systems (in terms of outcomes per unit money) to one of the least. It's extraordinarily depressing.

Neither side of the health care debate in the US wants to talk about doctor and nurse salaries as a primary driver of costs. The right because doctors are mostly rich and theyblike the current mess, the left because an overpaid doctor/nurse story greatly complicates the narrative that private insurance companies are the great evil and driver of inefficiency , and because striking against doctor/nurse salaries makes the politics of reform way harder.

Doctors, except GPs maybe, are highly paid in the U.S. However, there are less than 1 million working doctors in the U.S. and about 1/8 of Americans work in health care. The U.S. isn't especially high on numbers of doctors per capita either. Highly paid specialists is part of the inefficient, but it's certainly not enough to explain most of it.

YOU'RE A HEARTBREAKER
DOLLAR MAKER, LIFE SAVER
DON'T YOU MESS AROUND WITH ME

33: If I was a leftwing American, I think I'd go after the insurance companies before the doctors. After all, even Aneurin Bevan stuffed their mouths with gold.

38 - even non-leftwing Americans favor the approach of taking on the insurance companies first, but there's just not enough fat to squeeze out of the insurance companies to get costs even close to levels in the rest of the world. To do that, you have to pay people (doctors, but also nurses and, importantly, hospitals) substantially less, and almost no one on any side of the US debate wants to do that.

Doctors (though probably not primary care doctors, relatively) or mental health professionals, e.g. social workers, are probably overpaid.

Current reform efforts depend on using extenders and outsourcing manual data entry so that doctors can be paid the same to take care of more patients. I think, at least for primary care, patients deserve to have time with their doctors, but that would require paying them less.

35: I don't know that nurse salaries are that high compared to other countries. A quick googling isn't getting me anything. At least around here, a registered nurse doesn't earn anything out of line compared to other jobs that require similar education.

28. Writing about health care is a weird and apparently unpopular niche. Neither Kliff nor Rovner work for a mainstream publication. Gawande has been writing for the New Yorker for a long time, is great, reasonably influential among US healthcare high-level administrators, maybe also with policy people, I don't know.

Parenthetically, maybe I have posted this before, but I found this figure really helpful for my own thinking. All infant hospital care is a negligible portion of US healthcare costs. All ER care is just under 5%.

To some extent everyone is to blame! The biggest rent-extractors are specialist physicians and drug/device companies; insurance companies are also significant but their margins are not all that huge; facility owners/administrators; plenty of others, probably even to some extent skilled nurses and other staff. I don't think their bargaining power where it exists is doing much more at the moment than keep them from the fate of the rest of the middle class, but that could change.

But then whenever there's any serious discussion of this it means any one group at fault can point fingers at half a dozen others to punt the issue. For example, drug companies have been vigorously planting stories with the media blaming PBMs for drug prices.

I don't think it would be possible to pay nurses substantially less here without seriously compromising recruiting. Per Glassdoor, the average salary for an R.N. at our local monopoly is $27/hour. That's a good wage locally, especially with benefits, but it's not like their going to price the school teachers and lawyers out of the housing market.

39. hospitals ACA reporting provisions allow identification of hospitals that are both unusually expensive and prone to bad outcomes. The last one is a big point of Gawande's. Agreed that the US could have many more doctors, a big change. Letting NPs perform more routine care would be good.

Fee for service medical care creates bad incentives for doctors that drive costs up. But the alternatives (the one I know best is Kaiser) don't always seem great. I know a few people who have had less-than-great experiences because Kaiser happened not to have someone with experience relevant to the condition handy.

I didn't mean to single out nurses in particular -- think of it as a subset of system costs. But what is clear is that squeezing insurance companies alone doesn't get you that much (not zero, not that much) because their margins are fairly tight. Or what Minivet, who actually has genuine knowledge in this area, says.

Well, paying doctors less would also involve revamping medical school costs. Right now doctors justify higher salaries because they graduate several thousands of dollars in debt. Obviously there's more to it, but lowering med school costs and easing up on the artificial bottleneck of residencies would be a good start. A part of me feels, if you want free market, lets just start importing lower cost doctors willing to work for a fraction of the price, like we do with other industries. But that's my spiteful burn-it-all-down side talking.

I mean, what insurance companies do get is probably worth cutting out because they have so far not demonstrated added value, and it is a lot of money in absolute terms. But that doesn't bend the curve.

The issue with insurance companies isn't that they make too much money. Even if they were all non-profit, it would still all be administrative spending. The U.S. is spending more than twice what other comparable* countries are spending on administration of health care.

*leaving aside 10.

25: Its interesting that J.P. Morgan is part of it. They've got the best private blockchain product going now; the insurance industry is one where that may actually have applications.

49 - yes, that is true and a good reason to not have insurance companies, but (and Minivet can correct me if I'm wrong here) even cutting out administrative inefficiency and setting it at world levels (if you could do so in anything like the current system given its diversity) doesn't actually save all that much money compared to the other drivers of system costs.

I don't know. I'm sure blockchain won't help. But I'm not sure that how to price out administrative inefficiency in health care. It isn't just the administrative costs because it distorts care.

49/51: Yes, both of you are right. It's excessive costs, but getting rid of it is a one-time improvement - at best it cuts out one of many, many drivers. And even under single-payer you have the cold hand of Baumol.

A little googling suggests that administrative costs here are around 15% of cost as opposed to just over 1% for medicare. That's both a *lot* of money, and not nearly enough to get the 60% cut that you'd need to match the OECD average. On the other hand, it gets you almost halfway to the Netherlands.

This is true even consider all the costs they impose that are ascribed as provider costs - like how even small physician practice often require a full-time billing person.

Salaries are obviously the biggest part of the cost, but I think the issue there is more of how many people are drawing a salary as opposed to high salaries (excepting a small cohort of highly paid executives and a larger, but still small compared to the total number of workers, group of very well-paid specialist physicians). It's one of very eight workers. That number needs to be made to drop. Ideally slowly enough that large scale unemployment doesn't happen.

Glug, glug, glug.

I'm sure I've made this point before, but the US system is so deranged that it is actually less market-oriented than European systems. In Europe, if you have a procedure that's not automatically covered by the government, you can ask and find out how much it costs. You could remove a lot of administrative inefficiency by simply requiring doctors and hospitals to quote a price, and make everybody pay that price.

58. ACA requires hospitals to disclose aggregate prices after the fact, which is progress.

A part of me feels, if you want free market, lets just start importing lower cost doctors willing to work for a fraction of the price, like we do with other industries.

We already do that. It's hard for them to pass the boards here in the US but still tons of them move here and work in health-adjacent jobs or even in research labs while trying to do so.

I don't know about working at a fraction of the cost, but, immigrant doctors are mostly the ones who take advantage of the programs to work in underserved rural areas, because our US-born doctors, being highly educated and ambitious overachievers and lifelong A+ students, don't want to work in rural areas.

At the website for Waynesboro Hospital in PA the "Team" at the bottom includes 17 MDs. They got their medical degrees in:
6 India
3 Iraqi Kurdistan
2 Dominica *
2 USA
1 Dominican Republic
1 Poland
1 Egypt
1 Grenada *

*The Caribbean medical school industry that has cropped up because of the incredibly inadequate number of US-trained doctors is fascinating.

In the defense of doctors, I'm not particularly ambitious and I don't want to work in rural areas either. Especially not post 2016.

Well, at least I've moved towards the better end of Dunning-Krueger on the topic by reading this thread.

I still use a Mr. Coffee.

Agreed that the US could have many more doctors, a big change. Letting NPs perform more routine care would be good.

Yes and no. We can get more NPs, but the ones I know are not trained well enough to do anything remotely complicated. I really feel like this is a way for doctors to protect themselves. We can have more NPs, so we don't need to have more doctors and then we doctors can protect our incomes.

63: you're confusing dunning-Krueger with maxwell-folger.

Auuugh! Fuck the American health care industry!

60 is fascinating. I wonder how that plays in the white rural racism/xenophobia/class anxiety dynamic.

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Whee, someone is actively trying to steal my identity at this moment. Fortunately they're too stupid to pronounce my name so the cell phone company was suspicious and called the primary account holder when they tried to reassign one of our phone numbes to a new device (presumably to intercept 2FA keys to our accounts.)
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Austin Frakt and Aaron Carroll did a long series at "The Incidental Economist" about health care costs and concludes there is no magic bullet or single mustache-twirling villain. Every aspect of medicine is more expensive in the US than in ETE. I forget whether they use the term, but path dependency is a big reason.

Of course there's a single mustache-twirling villain. If we had competent democrats and socialists writing and passing legislation for the past thirty years, we'd be in a wildly different spot. Sure, they'd have to chip away at a complicated problem in many different ways. The single villain, though, is Republicans.

Republicans and paths are the problem.

I honestly thought the state of the union was last night and that I avoided it by watching people in Wales murder each other.

Pretty tame so far, although he sort of subtweeted at NFL players. He hasn't declared war on anybody yet.

72: Hinterland?

Yes. I decided to just watch it again.

if you show up at an urgent care with a real emergency, they'll call an ambulance to take you to the ER, which is a fun way to add $2k to your bill.

Insurance companies aren't problematic because they take such a big cut as profits (they don't), but because they waste so much time and money making everyone else fill out endless forms. Even if it only cuts healthcare costs by 13%, it cuts healthcare pain-in-the-ass by 80%.

Part of the cost for doctors is the extra 4 years of school ("pre-med") they have to do here. Now, the hospital my wife works at is busy making sure all new RN hires have 4-year degrees, not just nursing degrees, and making current staff do night school to get over-qualified too.

I didn't see much of it. I assume he spoke to the importance of strengthening international partnerships, praised science as fundamental to our national well-being, and demanded that Congress pass a massive package to support rebuilding in Puerto Rico?

Something like that.

He finished up with a lengthy denunciation of North Korea. Otto Warmbier's parents were there, as was a defector from DPRK, whose crutches Trump held aloft at the end. Along with his pre-address remarks to journalists about desiring a "major event" to "pull people together"* and Victor Cha's explanation of why he wasn't offered the post of Ambassador to the ROK**, I'm feeling slightly nervous. I have friends in Seoul.

*Reported here:

During a traditional pre-speech lunch with television anchors, Trump said, "I would love to be able to bring back our country into a great form of unity."
"Without a major event where people pull together, that's hard to do," Trump said, according to a White House transcript of his remarks at the private lunch. "But I'd like to do it without that major event, because usually that major event is not a good thing."

**Essentially the interview went something along the lines of:
"First question - how would you feel about evacuating all of the Americans?"
"Er, you aren't seriously thinking of a strike on North Korea, are you? Because that would be an unmitigated disaster."
"Thanks for your time, we'll be in touch."

So, anybody want to brush off the War Powers Act?

Sorry, that was unfair. Trump hopes that he'll be able to unify the US without a major event, although given his skills at bringing people together from all backgrounds in a spirit of fraternity and goodwill, I think we have to at least consider the possibility that he will resort to Plan B.

On the plus side, I have a couple of bets with friends that he would start a war during his first term, so I stand to profit to the tune of about 40 USD.

Totally worth it.

The Victor Cha thing is actually really frightening:

At a time of mounting worries about a possible nuclear confrontation with North Korea, the delay in filling the crucial post of a US ambassador to Seoul is confounding, observers say. It is also potentially damaging to US security interests at a time when understanding nuances on the Korean Peninsula -- home to more than 28,000 US troops -- is critical.

CNN previously reported that the administration had sent Cha's name to Seoul in December, where he received swift approval, two sources familiar with the matter said.

That process -- almost always a quick, rubber-stamp affair -- happens only after candidates have received full security clearance and gotten signoff from the White House.

Cha had even been escorted through the West Wing several months ago to meet people, including senior staff, according to an official and a source familiar with the matter.

...

Cha was asked by the White House whether, as ambassador, he could help support the diplomatic efforts that would surround a pre-emptive strike. He expressed reservations about such a move, a source familiar with the matter said.

After he voiced those concerns, the White House went mostly silent, even as the South Koreans were in the process of approving his nomination in the process known as agrément.

The White House finally informed Cha over the weekend that his nomination wasn't moving forward, but provided no explanation why.

Cha's WaPo op-ed opposing a "bloody nose" strike is also worth reading.

Sorry, that was unfair. Trump hopes that he'll be able to unify the US without a major event...

No, that was totally fair. Trump is completely transparent, he telegraphs all of his moves, and at the same time he's a congenital liar. Put the two together and you know he's thinking of causing this 'major event'.

I don't think you should assume the major event is going to be a war. Maybe he thinking about going on Wrestlemania?

He should challenge Kim Jong Un to fight him at Wrestlemania, and Kim should send Dennis Rodman in his place.

Dwayne Elizondo Mountain Dew Herbert Camacho, thy time hast come round at last.

"given his skills at bringing people together from all backgrounds"

Those marches keep getting bigger and bigger. And a Democrat won a statewide election in Alabama. He may be succeeding at uniting all but 27% of the country.

82 is indeed very worrying. I mean, in principle, yes; if you pick an ambassador to X and you then find out that he's bitterly opposed to some key element of your policy to X, then you should absolutely not give him the job. But the fact that the key policy in question is an unprovoked strike against North Korea...

Security people have been saying for months that DC feels like it did in late 2002. Minus any public discussion.

US healthcare costs remind me of nothing more than UK railways post-privatisation. Nobody can put a finger on where the money is going, but it leaks out of the system diffusely by a thousand cuts.

A hell of a lot of it has to do with the way in which all the actors in the system interact on the basis of contracts. Whenever a train is late, the train-operating company, the government entity that owns the infrastructure, and quite possibly also the leasing company that owns the train and guarantees x% on-time performance to the operator all fire up their claims departments and try to stick the others with the blame.

As a result it's very difficult to say what the price of anything actually is and a lot of money gets spent on lawyering and just managing the process.

Ronald Coase, of course, thought that organizations exist precisely because doing everything on a contract basis would be too expensive and painful, and I kind of think US healthcare and British rail privatisation are essentially giant experiments to prove him right.

I love the argument in 89.4 that I am going to steal it and promptly forget that I didn't think of it myself.

I've already tweeted it, so prior art is mine!

I thought of it independently years ago. I just never mentioned it.

Medical education is probably hard, but "dead people don't move" should be something pretty widely covered.

70. Flippant responses aside, the IE series is worth reading in your spare moments. Assuming a democratic socialist government in power over the last 30 years is somewhat like assuming a spherical cow. There are far more stakeholders in health care than the standard set of mustache-twirling Republican interest groups. Few of the stakeholders would be happy to see a US version of the National Health.

93 is absolutely terrifying. It sounds like the poor man was aware, and might have known that he had been pronounced dead?

Sometimes, when I'm feeling introspective, I wonder how much of the problem is stupidity (the overall downward spiral problem) and how much is malice. Take this case for an example. I assume that for some reason the insurance agent hated that couple and figured that a small town police force might have an officer who doesn't know what marijuana looks like. Or maybe the local police hate the couple too and decided to abuse them this way? I hope this goes to trial because I want to know which is right.

28 doesn't sound like a surprising description at all to me.

So, I realize that in the greater scheme of things this is nothing at all, but I'm sure that the fact that the medical marijuana dispensary by my house is called "Solevo Wellness" is a symptom of something or other that is making healthcare unnecessarily expensive.

It sits on a huge chunk of land in a giant building that could probably hold a year's supply of pot for the whole state, but I think that's because they wanted a location without nearby residences and that is what was available.

Yeah, if they're licensed by city or state they probably had to be within such a zone. Possibly also a distance from schools or even parks.

That sucks. Weed shops ought to be walkable.

It's 7,000 square feet of weed.

But apparently you can't get a concealed carry permit and a legal weed permit.

Yeah, but weed from a big box store is going to be shitty weed. It gets stale sitting on the shelf at those places.

In related news, my first attempt to procure internet weed has failed and now I'm on round two. The first marketplace I went to ended up going down to a DDOS attack soon after I sent in my "Bitcoin Cash," and when it recovered days later apparently I wasn't in the system anymore. Funny that.

So, I had to get some more cryptocurrency to try with another place. Fortunately my local headshop has a Bitcoin ATM.

It would all be so much easier if I could simply buy weed at the headshop, but that's a request which has been known to get people kicked out of headshops.

If this isn't a good thing to ask over the internet, feel free to ignore. What's the advantage of internet weed over conventionally purchased illegal weed? It doesn't seem like it would be safer in terms of avoiding arrest since a package goes through dozens of hands on the way to it's final destination.

For conventionally purchased illegal weed you need a guy and my guy is five states away. Also, better selection.

It's easy to carry a wide range of imaginary weed.

It's the best stuff imaginary money can buy.

I don't use illegal weed, but I have thought wistfully about procuring some legal stuff where it's legal, mostly on the grounds of being able to select varieties for particular effects, edibles with controlled dosage, and so on. The whole "the person who sold me this shit is a criminal, who the hell knows what it is" thing worries me, because I am inherently a scaredy cat. But I don't know about Spike's internet weed.

(I am not doing anything that requires Bitcoin, because I have dignity.)
(That's a lie, I don't have dignity. But I have something that keeps me from considering interacting with Bitcoin as a possibility.)

I actually have professional reasons for keeping an eye on whats going on with Bitcoin, in as much as policy papers on that shit are much in demand. So, I'm counting this as research. Maybe I'll deduct it from my taxes.

I was going to ask my neighbor's kids (back when they were in college and home for summers) if they knew a guy, but something always stopped me.

104 Did you lose your bit of bitcoin in that failed transaction?

I did. I certainly viewed losing it as a risk going into the thing, so no big deal.

I had just happened to have some shitcoins turn up in my wallet one day - it was kind of like a dividend thing? But I figured, free shitcoins, might as well spend them on weed. Easy come, easy go.

Vaguely on the OP and the path-dependence thing, I was struck by a comment on a podcast from someone who used to work on post-conflict recovery. She said people often don't get that a post-conflict government only has whatever has survived the conflict, what used to be there doesn't much matter. Her point being, there's no way to get back to June 2016. If by the time the Republicans fall there's no CDC and cholera is endemic to 25 states, then that's just what you'll have to deal with.

I'm good at pooping, not so good at remaining hydrated when pooping too much.

114: Isn't the length of interruption a big deal? Shutting down the CDC for two years, you could still find people who'd worked there, locate internal manuals, and so on. When you get up to more like a decade, you've really lost things.

116: Sure. The point is, things won't just reset, they'll have to be rebuilt, consciously and over a long period. I know nothing in particular about this, I just think it's an important thing to think about. Also, I think you'll have to assume the manuals would be shredded.

about 1/8 of Americans work in health care.

I'm trying to work out what the 39 million who aren't doctors do.

Well, the NHS in England has 1.16m employees of whom 110,000 are doctors. The rest are nurses and health visitors (318k) midwives (26k) ambulance staff (19k) support staff (356k) scientific and technical (148k) and infrastructure and hotel services (183k). So, very roughly, 450k "doing stuff for patients", 350k "doing stuff for the people who do stuff for patients" and 183k "doing stuff for things" which sounds like a pretty good teeth to tail ratio.

You have to reckon that the US has all of those in roughly similar proportion to the number of doctors, plus all the personnel of a major service-sector industry; so sales, marketing, public relations, government relations, finance, treasury, investor relations, regulatory compliance, accounts receivable, debt collections and so forth. And of course all those people will also need people "doing stuff" for them - processing their holiday requests, arranging their in-service training, fixing their computers, writing their performance reviews and so on.

"Hotel services" btw is a term of art in the healthcare and defence industries meaning doing laundry, cooking meals, fixing lightbulbs, cleaning floors and so on.

"Infrastructure and hotel services" includes 21k managers and 9k "senior managers". The NHS is not exactly overburdened with stuffed-shirt bureaucrats.

The NHS is not exactly overburdened with stuffed-shirt bureaucrats.

Give it time. That nice Mr Hunt is working on it.

Also, 1.16 million in England is well short of 12.5%

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I just had to comfort a fellow staff member who was in tears because of our shitty acting director. I think I will be going upstairs for a talk to senior management next week and let the chips fall where they may.

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Also, 1.16 million in England is well short of 12.5%

The NHS isn't all of healthcare.

I probably should have said 1 of 8 American workers, not Americans.

124: Good luck.

122: The joint cross-party war on NHS management and support staff is one of the biggest threats to it. The real evil of Andrew "let me ask that parliamentary question for you, only £5000!" Lansley's Health & Social Care Act was that it targeted them without touching the charismatic megafauna. Labour worships nurses; the Tories deify doctors; everyone campaigns to keep buildings, and they all blame "management".

So that's why the lifts are so big.

Do the right thing Barry. (If you must.)

The "bariatric" equipment in U.S. hospitals was kind of startling to me. They have basically a giant people-winch in most rooms.

119.2. I thought I'd just toggle over and ask the Google what the comparable numbers are in the US, but it's not broken down in that level of detail on the BLS site. The Incidental Economist series doesn't address it. I'm sure it exists somewhere, but I don't know where.

The number of medical doctors appears to be about one million, though, from various sources (maybe all cribbing from each other).

s/toggle/toddle/

My fingers lead their own lives, wild and free.

89. I know this has moved on, but I've just noticed that Coase published The Theory of the Firm 80 years ago. Shouldn't we be passed the experimental stage by now?

Weed shops ought to be walkable.

We've got lots of walkable ones up here.

104,109: Fly to CA or WA? Denver prohibits week in the airport, but TSA does not look for it, views it as a local law enforcement matter if they stumble on it. H!gh T!mes has informative remarks.