Dear President Trump, About That Health Care Law

I hope you read this letter. I doubt you will.

I know you’re busy rebuilding Washington, reshaping the international order and doing a lot of other weighty stuff.  Full disclosure, I voted for you.  Not because you promised to repeal the Affordable Care Act, or because you tweeted at me about it, but because our healthcare system is hopelessly broken and requires an overhaul that does not simply convert over to a single payer system.

Recently you were quoted in an interview with Reuters:

“I loved my previous life… I had so many things going… this is more work than my previous life. I thought it would be easier.” Yes. I did too. Welcome to the frustrating world of shaping health care for a nation. It should be about making others’ lives better, but instead it is about padding lobbyist pockets.

There are people who say you’re the wrong man for this job. I think they have it exactly backwards.  You’re famous for your hatred of complicated solutions.  They annoy you. They annoy you because you know they’re a waste of time and energy.  Time and energy that can be put into more important things.

You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. There are more experts in healthcare than any other area of the economy.  Does that tell you something? I think it does.

If you want to be re-elected less than four years from now, we must get cracking on building the healthcare infrastructure from scratch. It is not going to be easy, but you already learned this lesson per your statement above. So how do we streamline health care reform and get ‘er done?

There are two main problems: access (coverage) and runaway cost. The Affordable Care Act provided coverage to many and coupled it with cost control to no one. This made affordability unachievable for the long-term and things will continue to get worse.

Congress is currently on the wrong track headed to an empty station. The general approach of the American Health Care Act is to decrease costs by cutting coverage to the people. Please go back to the drawing board and start again. Throwing support behind the American Health Care Act is just flogging a dead horse. People in this country want affordable healthcare choices and freedom from fear of no access for chronic conditions and unforeseen catastrophic events. They no longer want to worry about health issues bankrupting them. Struggling families are one catastrophic illness away from losing their American Dream and that must change. Step back and take in the big picture.

Stop focusing on the minutiae. Instead, start small to overhaul healthcare one phase at a time. Develop a system which provides immunizations, annual screenings, and simple but necessary medical interventions to every person in the country. Call it Basic Care. You can expand the Community Health Clinic model or utilize the existing Public Health system which is sorely underfunded and underutilized, yet remarkably cost-effective. Physicians are not required to administer immunizations, take blood pressure, and check cholesterol levels. Save money by putting mid-level providers in these roles.

Some basic specialty care could be provided at the public health facilities or community clinics and mid-level specialty providers could fill these positions. If an individual becomes severely ill or injured and requires more specialized care, needs hospitalization, or surgical intervention, then their catastrophic insurance plan will kick in to cover these needs.

This is how insurance was created to work, by covering the expense of unanticipated events. Embrace the idea that health insurance should be for: cancer, heart attacks, car accidents, and other unexpected issues. The cost of health insurance would decrease considerably if it functioned more like actual insurance and less like a system to reimburse physicians for routine, expected health maintenance. Third party payers distance patients and physicians from being cognizant of real cost.

Finally, allow the free market to play a role by giving people options. 80% of healthcare can be handled in a Direct Primary Care practice, where patients pay the physician and enter into a more contractual relationship. This provides the options many physicians and patients are afraid of losing in a single payer system, an idea that was extremely unpopular in the past. Health savings accounts could be set up to cover out-of-pocket costs for those who are interested in care outside of the public health system or name brand medications, which are more expensive than generics.

Last but not least, ignore the special interest groups for the time being. Let them wait. Keep ’em on their toes.  No one else has tried to overhaul health care without kowtowing to them and it is high time someone with big (ahem) aspirations just went for it. You are the right person for an unconventional approach.

The Big Four are: the AMA ($20 million on lobbying in 2016), the American Hospital Association ($20 million), the American Health Insurance Plans (AHIP, $7 million), and Pharmaceutical Research and & Manufacturers of America (PhRMA, $20 million but the industry total was $240 million altogether.) Special interests cannot help you cultivate the Public Health system or grow the network of community clinics. Leave them out of it.

I realize the longer this letter becomes, the less likely it will be read, so I will close by saying healthcare is the SINGLE most important task you must accomplish to have any hope of being re-elected. You have nothing to lose by giving something simple a chance. The AHCA is trying to pound a square peg into a round hole. Find the round peg and with it, the right solution.

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99 replies »

  1. I am a healthcare consultant working at https://www.superbeing.in/, which is a medical tourism provider. We are focused more on delivering alternate treatments to our customers. We have a good number of visitors from US, doing alternate treatments for Arthritis, Weight loss, Back Pain, Preventive treatments, Rejuvenation, Detoxification etc. So i would like to know, with the new government in place, will there be reforms in the American healthcare Act, which can affect medical tourism companies operating in different parts of the world.

  2. I am not lauding Trumps approach to healthcare, rather I am trying to give the guy a pep talk to try something else because he is on the wrong track. the experts that have driven healthcare reform to date have proven they do not know what they are talking about already. That ship has sailed; its probably called something like “titanic”

  3. So my response to you is I do not distrust experts on the healthcare system, because they are practicing physicians not an individual with a degree in economics. The fact you do not automatically realize a physician in practice knows more other healthcare experts about instituting basic care makes you appear to not respect that perspective.

  4. Let me quote your own words.

    “You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. ”

    In an article where you are lauding Trump, this is clearly embracing the rejection of expertise in general. Experts don’t know what they are talking about. That is how we get people deciding that “Moms” know best, or Jenny McCarthy knows best.

    As to Trump and vaccines I think his meeting with Wakefield was a mistake and he has certainly courted the votes of those in the anti-vac movement.



  5. Good, then I will await your response on the other thread where we can analyze and debate the solutions and their methods.

  6. Allan, unfortunately, the answer to your question is yes. This is why I’m an advocate of informed debate starting with an acknowledgement of biases and a commitment to a common goal – a healthier and more secure America. At least then, even if you reach radically different conclusions, policymakers will understand why.

  7. Jason, don’t you think a lot of expertise is wasted by the experts trying to prove their ideology?

  8. I’m quoting you directly here,

    “You’re also well known for your distrust of experts, who you’ve learned to dislike after years of doing business and listening to boring presentations by people who don’t know what they’re talking about. There are more experts in healthcare than any other area of the economy. Does that tell you something? I think it does.”

    I read this as a general distrust of experts on the healthcare system. If I’m wrong, then please feel free to correct me on the record.

    Also, just to clarify, in no way did I say any one body or expert has a monopoly on good ideas – which is why I advocate broad consultation prior to distilling reforms simply and logically. I also certainly did not disparage practicing physicians’ expertise so I’m not sure where that’s coming from.

  9. “steer patients and doctors toward more cost-effective drugs within a therapeutic class.”

    Sometimes that ability to stear pushes physicians into practicing medicine differently than they were trained. That can be both good and bad, but in too many cases the physician, due to time and financial restraints. is being forced to act against his best judgement. I have seen physicians give up practicing the best medicine and yielding to the medicine the payers want practiced for the payer’s financial benefit.

    I think patients should be more involved in these decisions and that is where the great divide resides. Who is in control of the patients body? Government or the patient?

  10. Niran, many times Barry has said he doesn’t like third party payer, but that is true only to a degree. He would gladly dump the tax deduction (a meritorious idea), but if that can’t be done ( he says it is IMPOSSIBLE)he strongly opts to keep third party payer. All other discussions take both sides of the issue, but when pressed he opts for third party payer strongly and has stated that he doesn’t see the great harm of third party payer.

    The same goes for government involvement. He states he would like to minimize it, but every step of the way he provides a restrictive formula for more government intervention. I think he is basically a conservative in most business items until health is involved where he suddenly shifts split between government run healthcare and his desire for business marketplaces. He doesn’t want anyone to have to fund their own healthcare if it causes them to have a significant fall in their standard of living even when that standard of living is many times greater than the standard of living of those paying the bill. This type of thinking extends to other areas of the economy as well.

    He also believes in the “so called experts” and thus his conclusion that the PBM’s are doing a good job.

    Over the years his views have been changing somewhat, mostly for the better, but for the past number of months his changes have been static. However, though in the past he has been against single payer, he made a comment a while ago that sounded as if he might be reconsidering that viewpoint. He bases a lot of his thinking on personal experience and anecdotal evidence. This has nothing to do with his character. He is a good guy and very smart and organized.

    Thanks for Andameds. I never heard of them. I know from my own experience that many drugs that are not on one’s plan can be gotten for a reasonable price through one’s own insurance plan if things are managed correctly. This favors the well off, educated and those that are persistant. Nothing in healthcare touched by government today is a level playing field.

  11. Niran, I personally take six maintenance medications, all for cardiac issues. Under my insurance plan, five of them are either Tier 1 or Tier 2 and carry, as of this year, a zero copay. The sixth one is a Tier 3 drug for which my copay is $100 for a 90 day supply or the full cost of the drug if it’s less than $100. If I get it through my insurer, it costs $77. If I get it at Costco, my cost is $35 and change and still counts toward my total drug spend. No pharmacy is cheapest for every drug.

    While generic drugs account for over 85% of prescriptions written these days, they only account for 25%-30% of the dollars spent on drugs. If you check the price of virtually any brand name drug with no generic equivalent available on Good Rx, you will find very little variance in price among your local pharmacies. Specialty drugs account for only 1% of prescriptions written and only 2% of patients need them in any given year yet they account for 30%-33% of drug costs and the trend is continuing to increase.

    Drug companies negotiate volume based rebates with PBM’s to move market share through favorable formulary placement. PBM’s establish formularies in the first place to steer patients and doctors toward more cost-effective drugs within a therapeutic class. When I needed to go on Eliquis for six months, the insurer had it on Tier 3 and required prior authorization because it wants everyone on Coumadin which is cheap and has been around for decades. Coumadin has dietary restrictions and the patient needs to get his INR checked every couple of months whereas neither is necessary with Eliquis, Xarelto, or Pradaxa.

  12. In Barry’s defense, I don’t think he likes third party payers any more than we do. He really seems to get it overall. He did miss the boat on PBM’s (sorry Barry) but I do not think he knows about the scam the PBM’s are getting away with. By the way, order from Andameds and your price will be pennies on the dollar. 🙂

  13. Whose expertise am I rejecting exactly? Obamacare special interests? Sorry the AMA, AHA, Pharma and Insurance Companies are not experts in delivering medical care to the masses. I am surprised you think they are so great.

    And whose “beliefs” am I following exactly? I threw out some of my ideas about what will work for healthcare and you don’t like them. I can live with that.

    Hmmm to call a physician anti-intellectual seems a bit more personal than one should be on the internet. I will not respond to that part.

    I have not seen Trump working hard to encourage people avoid the MMR vaccinations. Is that one of those “Fake news” things I keep hearing about? Thanks as always for commenting in a constructive way.

  14. Who is resistant to experts? Practicing physicians ARE already experts at delivering good care and keeping costs low. Why are so many resistant to the opinions of those of us in practice? Bipartisan think tanks are great, I am not sure anyone has insulted them. Definitively, I have not insulted academicians or academic centers in any way, shape, or form as I am connected to an academic center myself. What did I miss?

    You know fixing a broken healthcare system is far more difficult than developing a hypertension management protocol. There are experts and data to back up those decisions. Seriously, no one group, think tank, or individual has all the answers for solving the healthcare cost crisis. It might be more simple than you think.

    As far as pharma pricing and other outside subjects, I have been fairly clear in the past external benchmarking with other countries would level the playing field and decrease costs considerably. By the way, Kaiser Family Foundation is one of those fantastic think tanks which present data in a clear and concise way. You should check them out sometime.

  15. Even if we disagree on some major aspects (for instance, I don’t think your approach adequately addresses reducing key burdens on the healthcare system in administrative overhead and pharma prices), your alternate view is one I was glad to consider.

    At the very least, I’m in total agreement that the problem is both coverage and costs. Dealing with one side without a solid plan to tackle the other is ultimately a losing proposition, both politically and administratively. I also agree that trying to cut costs by cutting coverage is a backwards way of looking at improving health options for Americans.

    That being said, why are you so resistant to experts? Subtracting political ideologues, there are numerous bipartisan think tanks and academic centers which offer great analysis of the American system and contrast it with international systems. To say that they’ve failed thus far is unfair given that they’re not the ones responsible for ultimately enacting necessary changes.

  16. Sure. You want to join the anti-intellectual, anti-expert Trump crowd when it meets your needs, then complain when it affects areas you care about. Reap what you sow. (The bad part here is that both you and Trump are really just following the beliefs of a different set of experts who have different ideas about how health care should be fixed. You aren’t really rejecting experts. However you are still fostering the rejection of expertise.)


  17. You got it Niran. Barry thinks that the PBM’d are doing a good job when I am being charged through my insurer a large portion of the ~$350 dollars list price. Blink, however, will charge me around $25 -$60 depending upon location etc. and after appeals and proof of necessity my co pay becomes $7 and change. That tells us a lot about the pharmaceutical market and how the intermediaries are making us pay more than we need to.

    Barry likes third party payers and a lot of government interference. He is afraid of letting patients and doctors make decisions together.

  18. The real payer is you and I. I’ll ask myself and I don’t think they are doing a good job, just like I don’t think the employer can guarantee me the best insurance for the dollar. A lot of people are making money off of healthcare by being intermediaries while the patient gets no benefit.

    You have a lot of rationalizations, but you don’t seem to rely upon economics and logic.

  19. I think we should ask the patients about the PBM’s. For example, amoxicillin costs a few dollars (usually less than $5.) Right now, the PBM’s have the patient pay the $20-$30 copay, give the pharmacy the “few dollars” and keep the remainder. I have been telling patients to ask for the cash price instead and they are saving considerable amounts of money going to pharmacies who don’t already have their insurance information entered. This is one of those asinine ideas the executive intruders dreamed up to “save money”…. oops I mean “skim money off the backs of the middle class.”

  20. If you want to find out whether PBM’s are doing a good job or not, ask the payers who hire them. Presumably, if they didn’t think the PBMs’ services were worth the money, they wouldn’t engage them to help control their drug costs.

  21. If you want to claim that you can’t prove it one way or the other because an alternative universe doesn’t exist, then you shouldn’t have argued in the first place with follow-ups contending that your argument was correct.

    On the other hand we can compare this product to other products and take note that in similar situations the prices of other products fall. Therefore, we can conclude, just as we conclude the sun will rise again, that your premise was faulty.

  22. You can’t prove or disprove how much more or less would be paid in some alternative universe that doesn’t exist and won’t exist anytime soon. Cash payers will pay full list price at a pharmacy because the pharmacy is paying the only slightly lower wholesale price for its drug inventory. It’s the insurers and self-funded employers that collect the volume based rebate paid by drug companies and negotiated by PBM’s.

  23. Add number 4 that an inexpensive drug has been removed by the FDA and then you can probably add a few more numbers.

    Regarding PBM’s do a “pretty good job” that you stated earlier, none of these comments respond to my statement “Barry, I wonder if that is true. If it were true the end purchaser, the patient and insurer, IMO wouldn’t be paying so much.” You are sidestepping the fundamental issue of how good a job the PBM’s are really doing.

  24. A few generic drugs have increased drastically in price in the last few years. They tend to have one or more of the following factors in common: (1) the total market size is relatively small, (2) there are only three or fewer manufacturers, or (3) a new delivery system was created that was patentable.

    If the total market size is small and the FDA approval process is comparatively cumbersome and expensive, there isn’t sufficient incentive for new competitors to enter the market to compete with the two or three existing producers.

    These cases get a lot of negative publicity but the total cost as a percentage of total drug spending is pretty small. It’s still obnoxious behavior but it’s not a significant driver of total drug costs.

  25. Generics have always been cheaper in the US than in Canada as have over the counter meds, but that doesn’t answer the question at hand.

    Why are generic drugs that have been around for 20 years increasing? The production price is very inexpensive (pennies) and the facilities have long been paid off. Additionally many aren’t even being made in the US. Many are made in Asia. With almost everything else this type of situation leads to a drastic fall in prices, but that hasn’t happened.

  26. So as a pediatrician, this is clearly offensive and off-topic. The “anti-expert” position is very clear when it comes to the efficacy of immunizations. NO ONE is actually an expert on what will fix the broken healthcare system. If it was simple and obvious, the system would have been on its way to repair long before now.

  27. Statistics have shown this to be true. Utilization of ER unnecessarily is far more common with Medicaid and Medicare when compared to private insurance where the copay is $150. My patients happen to have lower than average ER utilization, but again, as you pointed out, my practice is small, independent, and I am part-time. If you make changes on a larger scale, costs decrease remarkably.

  28. There are well over 10,000 drugs in the marketplace today. Generic dispensing rates exceed 85% of prescriptions now. Some drugs are falling in price and some are rising. I think 3% growth in non-specialty drug spend with the Medicare population increasing 2%-3% annually is pretty decent performance. Most generic drugs are actually cheaper in the U.S. than they are in other countries. Payers would be thrilled if their total claims costs only rose 3% per year. The fastest rising claims costs are for hospital care, both inpatient and outpatient, and specialty drugs.

  29. My larger point is that you do not understand the value of the way healthcare is being delivered, so I now understand your point of view and the disconnect better.

  30. Steve you should really quote what you are commenting about. Since you are asking “Whoa! Are you really a doctor? Higher prices?” I assume that was directed at me.

    I said “Higher costs.”, not higher prices. Most doctors can read so be careful when you try to dis another person.

    I won’t bother responding to the rest of your comments because obviously you are experiencing a bit of a reading problem. Additionally your comment demonstrates that you have little understanding of the classical free market that is written about by Hayek, Friedman, and Adam Smith.

  31. Peter, how about private surgical clinics?

    Duke and UNC: That is promoted by government regulation and higher Medicare prices for services within the boundaries of a hospital.

    “I understand economics, more than Trump understands health care policy.”

    You can say what you wish, but you haven’t demonstrated that understanding on this blog.

    Your conclusions about earning money and intelligence like many other things you say don’t make sense. Your contention was that Trump was an idiot and mine was that idiots have a tendency to lose their money fast so I wouldn’t be calling Trump an idiot. He has earned billions. Additionally, expertise in one subject doesn’t mean expertise elsewhere so your other comments are silly. You really ought to read more and write less.

  32. Barry, that doesn’t prove that PBM’s have done a good job. If a good job were really being done one might expect the price of medications to be falling except for the newest classes of drugs.

  33. Whoa! Are you really a doctor? Higher prices? Medicare reimburses at lower rates that the commercials for almost everyone. If you compare Medicare reimbursements they are pretty much in line with what the rest of the world pays. Also, no one is advocating Venezuela style policies. We are advocating the kind of stuff you might find in a he##-hole like Sweden, Germany or France. Really, if you want to use Venezuela, then lets just declare that Somalia is the ultimate free market model with no government interference with health care. Cone on, be serious.


  34. Adam Fein, president of Pembroke Consulting and an expert on drug distribution, had a post on this a week or so back on his blog, Drug Channels. Non-specialty drug spend was up about 3% or so year-to-year though specialty drug spend was up closer to 12%-13% from the prior year.

  35. There’s no health policy preventing private clinics, or cash pay. I support any (safe) procedure outside of high priced hospitals. In my area there are hardly any private clinics because the hospital conglomerates of Duke and UNC either buy or start all the private clinics then jack the prices and use them to feed hospital services. How would your understanding of health policy and economics solve that?

    I understand economics, more than Trump understands health care policy. I gladly participate in reality economics every day and did not have a rich dad to hold my hand along the way to clean up my messes.

    As for your thinking that because Trump is richer than me (and I guess you) he must be smarter in health care, I guess then George Soros and Michael Bloomberg must way more smarter than Trump since they have many times his worth. And Warren Buffet must be way smarter on tax policy as well. I guess we agree.

  36. Mismanagement is mismanagement, no matter your ideology. Anybody that bets the farm on one resource then controls prices to below the cost of production is also an idiot.

    Medicare prices are negotiated, not arbitrary.

  37. I used **** so you could pick up the essential points. Venezuela is rich in resources and geography so the people should be rich or at least not starving to death. What we are seeing, at least in part, in Venezuela is the result of policies you support in particular “an economy hobbled by the nationalization of private farms, and ****price and currency controls.****”

    I can’t help it if this is beyond your understanding.

  38. Peter, look at the results of those price controls. Higher costs. By the way, a number of years ago a colleague opened a cash clinic. HIs prices were lower than Medicare and in a couple of years he was earning more than his competition.

    Funny, lower prices than Medicare and earning more money.

    My good friends own a surgical clinic and they make money off of Medicare for the surgical clinic yet for the most popular testing, colonoscopy, the clinic is paid half of what the hospital is paid. I wonder, how come? In a free market even those prices would fall. How come Lasik prices are falling? Take note trucks come around many communities offering certain medical testing and that testing is real inexpensive offered in bundled form even though portions of the bundle aren’t needed by everyone. It’s like ordering two meals in a restaurant so they can lower prices on both since their profit margin can remain the same or be higher.

    You ought to read some stuff by Milton Friedman, Hayek, Sowell, Mises or a lot of other economists that have written books that non economists can understand.

    The complete series of Milton Friedman’s television shows Free to Choose produced for Public Broadcasting decades ago is on the net. After each show there is a debate containing diverging opinions. You would benefit from that show even if you took another side because at least you would have a better understanding of economics. If you can’t find the series I will try and find it for you. It is free on the net.

  39. Peter, you are utilizing a newly arising marketplace that has been able to slip in between the cracks of government regulation.

  40. Health care prices have risen faster than average home prices across the nation. You should have some understanding of comparitive costs, but apparently you don’t.

    I could still treat most patients today at a fraction of the cost forced upon society. You really have no in depth knowledge of the healthcare sector what-so-ever.

    You judge fees and salaries based upon envy not based upon any economic principals. When I discuss healthcare I don’t consider what physicians are worth. I consider the value the end purchaser places upon that physician because the end purchaser has to deal in trade offs. Those trade offs keep prices down. You want to remove trade offs from the equation.

  41. Trump is 70 years old. He had enough time to squander an entire fortune, but he didn’t and is a billionaire. I ask the question again, are you a member of that club? If not, why not? Are you more stupid than Trump? That is not an insult since Trump isn’t a dummy.

    “Not sure how many bankruptcies qualifies you as an idiot. ”

    That only qualifies you to be ignorant regarding business affairs. People go bankrupt all the time. Additionally, he didn’t go bankrupt, companies he was involved with went bankrupt while other similar companies went bankrupt earlier. In some companies he had no or little control because he lends his name.

    As far as candidates go Trump has been pretty honest and consistent as to his desires. You might be used to a dictatorship, but Trump can only act in his position as President. He can’t unilaterally change the nation.

    The real liar was Hillary Clinton, but you probably can’t see it through the thick leftist lenses you wear. Bernie Sanders in contrast, who I don’t like, was reasonably honest.

  42. “Price controls have existed in Medicare for decades”

    That’s why your Medicare rates are so low. All forms of single pay include price management. It’s why other countries do it for about half.

  43. I actually use a small urgent care practice and get great medical service from the PA there. Solving PCP issues of job satisfaction does not touch the surface solving health care costs.

  44. Peter I was just reading this in the WSJ and I thought that it would be good to post so you could take note. It has to do with a woman’s child who is dying from lack of food.

    “ARE, Venezuela— Jean Pierre Planchart, a year old, has the drawn face of an old man and a cry that is little more than a whimper. His ribs show through his skin. He weighs just 11 pounds.

    His mother, Maria Planchart, tried to feed him what she could find combing through the trash—scraps of chicken or potato. She finally took him to a hospital in Caracas, where she prays a rice-milk concoction keeps her son alive.

    “I watched him sleep and sleep, getting weaker, all the time losing weight,” said Ms. Planchart, 34 years old. “I never thought I’d see Venezuela like this.”

    Her country was once Latin America’s **** richest, producing food for export.**** Venezuela now can’t grow enough to feed its own people in an economy hobbled by the nationalization of private farms, and ****price and currency controls.****

    Maria Planchart has had to go through trash to find food for her one-year-old son, Jean Pierre. She is among a growing number of Venezuelans suffering from hunger and malnutrition. Photo: Miguel Gutiérrez for The Wall Street Journal

    Venezuela has the world’s highest inflation—estimated by the International Monetary Fund to reach 720% this year—making it nearly impossible for families to make ends meet. Since 2013, the economy has shrunk 27%, according to local investment bank Torino Capital; imports of food have plunged 70%.”

    Continue at the WSJ

  45. “apparently think Trump’s billion’s arose from stupidity.”

    No, they arose from inheritance and the training and influence of his daddy. Not sure how many bankruptcies qualifies you as an idiot. He’s not an idiot when it comes to hoodwinking investors (and voters) into his schemes when he takes no risk.

    However, in his role as president he is an idiot and apparently able to fool all of his blind supporters all of the time. When are you going to ask yourself when will he stop stating falsehoods.

  46. “Did that include higher coverage for those with greater needs/incomes?”

    I followed the rules and regulations at the time. Sometimes I helped employees out financially outside of my legal obligations. I had a small staff so consider that a personal decision.

    “Hence the mandate.” No. Hence if one didn’t have insurance one would have to pay for their own care.

    Car insurance: Take note that one doesn’t have to buy insurance to cover the costs of repairing one’s own car. Don’t get confused between liability for others and liabiity for oneself.

    “Pooling with a group eliminates individual choice.”

    There is no such thing as pure individual choice so this comment of yours along with many others is pure trite and an ignorant way to form an argument. The choice is whether one wishes to join the pool or not. In a free market the pools will reflect the needs of those purchasing from the pools.

    You state that to make Medicare sustsainable you would instill price controls. Price controls have existed in Medicare for decades, but apparently you don’t know it. Price controls failed for Medicare and in many cases caused costs to rise dramatically.

    Tell us where price controls have worked and been sustainable over a long period of time? Since governments can print money and tax individuals government can try to use price controls because there might be a longer span before insolvency. What government does is provide fixes all along that time period while increasing taxes and printing more money even while the service declines. Governments are not successful in stopping that movement and many countries have gone bankrupt due to that type of policy. Take a look at Venezuela today which should be a rich oil nation.

    Take a look at the classic example of price controls. NYC real estate. That almost bankrupted NYC and caused housing to be in low supply eventually raising real estate rates. NYC grew when it moved away from price controls and there was a building boom.

  47. No, Peter those idiots will lose their inherritance as well.

    You never told us if you were in the billionaire’s or millionaire’s club a question that was asked because you apparently think Trump’s billion’s arose from stupidity. Surely if he is an idiot and your are a rocket scientist then you should have at least millions if not billions.

  48. The rules and regulations that purposefuly influenced the outcomes and created winners and losers is not a free marketplace.

    Managed care can occur in a free marketplace, but there cannot be monopolies, the government cannot favor one type of insurance over another and the patient has to be free to choose what he wishes to buy if he wishes to buy anything at all.

  49. When government is influencing outcomes while picking winners and losers that is not a free market. When government forces the purchase of a private entity’s product that is not a free market. When government limits the amount of earnings of a private corporation can earn that is not a free market.

    Do you get the point?

  50. “you went cash pay”

    I was pretty healthy and had resources as well as time to travel for health care – but I was still taking a chance for a catastrophic event.

    Peoples health care needs differ depending on their health but their ability to afford greater care is finite based on their income. You might think that having those in need beg for charity, but I prefer a system less demeaning and much more predicable.

    “I practiced at a time when healthcare was a fraction of what it is today.”

    You also practiced at a time when house prices were a fraction of what they are today. Have you looked at the rise in medical professional incomes over that time against the ordinary joe who you want to buy their own health insurance?


  51. “I satisfied the needs of my employees as best as possible since they all had different needs”

    Did that include higher coverage for those with greater needs/incomes?

    “If everyone was carrying insurance we wouldn’t have such a problem of pre-existing conditions”

    Hence the mandate. Ever wonder how much car insurance would be without a state mandate?

    “If someone doesn’t wish to pool his money with a group then he can be out of luck”

    Pooling with a group eliminates individual choice.

    “how do you suggest we make Medicare sustainable?”

    Price controls, Medicare for all. How do we make non-government health care costs sustainable?

  52. “Any idiot can invest in real estate and lose every dollar they have.”

    Unless they have a rich daddy to bail them out in the learning curve.

  53. I don’t agree with networks. The patient should be able to go to any doctor. But insurance is about contracting with providers on price and in return promising to send their insured there. That’s not government, that’s a “free market”, if you want that gone then government will have to legislate, but that will cost you higher premiums.

    Single-pay would eliminate networks because everyone would be under the same contract.

  54. Then why are you saying they show up at the ER for every little cough or cold?

  55. Peter, insurers did a lot less micro-management when government was less involved.

  56. Peter, you went cash pay. Everyone should be cash pay and purchase their own insurance based upon their needs and resources. Healthcare costs a lot more today (up to double) because of all the non marketplace interference. Insurance rates would be a lot lower if a free marketplace existed.

    I practiced at a time when healthcare was a fraction of what it is today. As government became more and more involved prices climbed.

  57. “Did your employees get to choose their insurer?”

    I satisfied the needs of my employees as best as possible since they all had different needs, but the tax deduction came to the business. They should all have had the ability to purchase what they preferred.

    pre-existing: If everyone was carrying insurance we wouldn’t have such a problem of pre-existing conditions and there are ways around that problem. If someone doesn’t wish to pool his money with a group then he can be out of luck when he needs to pool with them. Everyone should have been carrying high deductible from the start and insurance should have been covering unexpected and unpredictable events.

    The free marketplace doesn’t exclude charity whether private or governmental.

    Peter, how do you suggest we make Medicare sustainable?

  58. “The individual’s choices, though, are limited basically to the deductible, copay, and out-of-pocket maximum limits, scope of coverage and breadth of the provider network.”

    Barry, that is your world. In my world the individual and insurer jointly work together to create pricing and coverage that satisfy both parties. Our costs of insurance are so high because of the government micro-management of healthcare and third party payer both of which you have supported.

    I expect in a marketplace that the consumer, the insurer and the providers might all feel that they are not getting what they deserve. I thought I paid too much for the car I recently bought and the dealer would have liked me to pay more. That is the nature of free market capitalism. The end result of that transaction is the dealer is happy to get one more car off the lot and I am happy to drive a car.

  59. “The PBM’s have actually done a pretty good job in helping their payer clients keep drug spending growth down through both formulary management and rebates.”

    Barry, I wonder if that is true. If it were true the end purchaser, the patient and insurer, IMO wouldn’t be paying so much.

  60. “The Medicaid plan I still accept met with me a few times as we strategized how to lower unnecessary ER utilization.”

    Barry, take note that Niran is dealing with the Adam Smith model. In this case it is Medicaid where government pays and is the buyer while Niran is the seller while at the same time Niran is buying for her patient. Like you said elsewhere, he who pays the gold calls the shots.

  61. “Any idiot can bluster.”

    I wonder if you are in the billionaire’s club or even the millionaire’s club. Any idiot can invest in real estate and lose every dollar they have.

    The problem with the lack of liquidity restraint that insurance can create is that marginal care skyrockets and that IMO is the biggest cost factor that provides little benefit.

  62. Interestingly, the hospital and pharmaceutical executives are looking to drive revenue and profits up while insurers have an interest in keeping medical claims costs as low as possible. The PBM’s have actually done a pretty good job in helping their payer clients keep drug spending growth down through both formulary management and rebates. The payers capture most of the rebates. The problem is as more patients have high deductible health plans, they get stuck paying the full list price of the drug until they meet or exceed their deductible. That was a big part of the problem with the Epi-pen episode. Payers should be able to figure out ways to address that issue but so far, they haven’t unfortunately.

    The hospital executives have a corporate mindset. They want to keep as much care within the system as possible even when it would be in the patient’s best interest to send him outside the system. The ER quotas are also a problem. I’m not sure how to change that though some good investigative journalism that could shine a bright light on the practice might help.

    Pharmaceutical executives, for their part, are just plain greedy when it comes to drug pricing. They should think about how they and their family members would feel if they were on the receiving end of these bills, especially for the very expensive specialty drugs. I know they have to earn enough profit to provide their investors with an adequate risk-adjusted return on their capital but, at some point, enough is enough.

  63. No give the patient (in this case a child and their parent) A choice. Just one. But a narrow network with NO option if their child gets leukemia or is born with a heart defect really isn’t health insurance now is it?

  64. Correct, I can go 100% cash pay. While that sounds better for me personally and my lifestyle, it would not be good for the poor and disabled children for whom I care. My conscience cannot do it right now. Pediatricians are leaving this county left and right. The illness and disease I see now are far more acute and in need of care than they were even 5 years ago. In addition, what happens if every doc goes cash pay? Access is cut off for those who cannot afford it. There has to be another way to streamline care and maintain quality. Government and insurance unfortunately do not understand much of healthcare (even my tiny little part-time practice as you say) and that is where the disconnect occurs.

  65. Peter, sometimes I think you are learning on this site and sometimes I wonder what on earth you are talking about. Patients know the cost of care if they pay a portion of the bill.
    As to the rest of your questions….My job is to train my families about when to watch and wait with a sick child. My underprivileged rural patients know exactly what they are doing! They are not hillbillies.
    They are parents and I have taught them as much as I can about caring for their childrens’ medical needs. Families have basic supplies at home like silver sulfadine cream for burns (which I prescribe ahead of time), basic eye and ear drops for illnesses on the weekend, basic wound care and how to look for signs of infection, and most can handle simple pediatric fractures by wrapping them up and waiting to see me the next morning.
    What do you think physicians do? Sit and eat bon-bons all day? I consider myself successful if I can teach families to triage on their own and they have proven over the last 16 years to be brilliant, capable, and have solid instincts.
    I rarely have someone in my office for a cough, cold, or simple rash. They know when they need me and that is why our office looks more like an ER or urgent care most days.

  66. Barry, they are also running hospitals and setting admission “quotas” for the patients who show up in the ER. Oh, and the executives running the pharmaceutical companies. Those executives in charge of the Pharmacy Benefit Management companies that are fraudulently double charging customers for medicines that cost pennies on the dollar. These executives you are speaking of are contributing to the escalation of cost without adding much in the way of benefit.
    As to your second question regarding the physician perspective on how private payers could make our lives easier without losing their shirts. Partner with us to provide quality care. The Medicaid plan I still accept met with me a few times as we strategized how to lower unnecessary ER utilization. I recommended simple interventions like magnets with the nurse line phone number and the number to do a telemedical virtual visit, then a line for PCP number they could fill in. We developed pamphlets with information about “when to go to the ER” and “when to call your PCP.” Simple interventions that allow physicians to provide better quality and the company to save money.
    As to prior authorizations, there should be one drug available in each class. Like one antibiotic eye drop and one ear drop. At least we have one choice. When someone has an eye infection, what the heck am I going to prescribe if nothing is available without a prior auth? I can go on and on… but I hope this answers the question.

  67. Peter, you forget I have parents who are on Medicare and am quite involved with many adopted “grandparents” and their care in my small world. There is so much waste, sometimes it is hard for me to believe. My small practice does not give me blinders, however I see medicine through that perspective as it can handle 80% of healthcare problems. I think you are blind to how effective a small practice may be in light of the fact you have little experience in the subject. You obviously do not see your PCP as being able to handle emergent issues, minor procedures, and management of a great deal of one’s medical care. You are missing out on something very important to medicine.

  68. I’ve called my insurer’s nurse hotline on several occasions including once when I was on vacation 2,500 miles from home. Doing so saved me a couple of trips to the ER and one call affirmed a need to go to the ER. The nurse hotline is free by the way or, more accurately, carries no incremental cost after I’ve paid my premium. If access to a doctor outside of the ER is not an option, the nurse hotline is a good choice as long as you’re not bleeding profusely, in excruciating pain or unconscious which are all obvious reasons to get to an ER ASAP.

  69. Niran, just to be clear the useless executives you refer to are not running healthcare. They are running health INSURANCE companies. Insurance is about assuming actuarial risk in exchange for a premium and believe it or not, they’re pretty good at that for the most part.

    While I recognize that you and most other doctors find insurers annoying and their requirements sometimes burdensome, I’ve never heard much in the way of viable alternatives that insurers could adopt to make the doctor-patient encounter more efficient with less friction from payers while still allowing the insurers to sustain their business model. Government paying the bills is not the answer because we would just have rampant fraud like we already do with Medicare and Medicaid. I think the private insurers are much better than government at fraud mitigation and prevention.

    I would love to hear the physician perspective on how private payers could make physicians’ lives easier without losing their shirts financially.

  70. “It means they should consider the cost before running to the ER with every cough or cold.”

    How would they know the cost? How would they know the diagnosis? If they have a sick child how would they know when to wait and for how long? You’re a pediatric doc, but how would one of your underprivileged rural county patients know?

    Would you then support triage at the ER to send people home?

  71. “insurance can have a say, but they make really asinine rules. Huh? Why?”

    I guess you’d have to ask the insurance company. I don’t support insurance, in fact I dumped BCBS to go self pay, but how do you stop insurance from asinine rules?

    You know Niran, you can go 100% cash pay. That would eliminate your government and insurance problems in one step. No rule prevents that.

  72. I advocate for the patient to be intimately involved. Absolutely. That does not mean they “play” doctor. It means they should consider the cost before running to the ER with every cough or cold. People are smart and when using money from their own pockets, “do everything” has new meaning.

  73. Peter, narrow networks can work IF the insurance company understands what they are doing. For example, Premera came out with a plan a few years ago disallowing any pediatric care at Children’s Hospital. This included exclusion of anyone on “courtesy staff” at the pediatric center, of which I am. There is nowhere else to send a child who is born with a heart defect or diagnosed with leukemia for care. They said they would allow “a panel” of insurance experts decide which children were approved for care. My point is much of the insurance managing risk is just stupidity as they end up having to break the rules and allow more open networks because people get sick. This is why true health reform should not be rearranging coverage and should focus on provision of CARE for lower COST.

  74. “For example, when one has Tricare Standard, we are responsible for 20% of our cost to a certain catastrophic level. One will pay more attention.”

    Then you advocate the patient play doctor in determining the necessity and level of care and diagnosis?

  75. Peter, insurance can have a say, but they make really asinine rules. For example, my office was recently audited because a patient complained about the cost of their high deductible and thought it was our billing that made a mistake. We passed the audit 100% compliant. The weird thing is the insurance “suggested” when we give flu shots that we should not answer questions on other subjects and instead have them make another appointment. Huh? Why?

  76. How can Trump be a “deal maker” when he knows nothing about the deal? Any idiot can bluster.

    “You left out insurance as costs passed onto consumers.”

    Well it’s insurance that pays the big bills and they would argue that they take only 15% for overhead and profits. You tend too much to dwell on your own (I believe part time) small practice which gives you blinders to the whole picture. If all we required was the occasional PCP appointment there would be no need for insurance.

  77. Barry, give everyone very basic care. Fund it through government. Then past a certain point, (not yet defined) there must be some personal financial investment if you want that transplant or experimental cancer treatment that buys you a year. Those individuals (be it 7%, 25%, 60%) who wish to do so can buy an additional policy covering more specialized care with greater personal cost.
    The “free market” is not necessarily referring to health insurance, it is more in reference to the initial point of care such as the physicians private office, the ASC, and the other locations where cash rules the transaction.

  78. Interesting question. Consumer-driven healthcare is how we get around legislation. When we have to pay a portion of our costs, we do care far more. For example, when one has Tricare Standard, we are responsible for 20% of our cost to a certain catastrophic level. One will pay more attention.

  79. Barry, as always, I love reading your thoughtful insights. I pretty much agree with your suggestions overall, except you know how I feel about those useless executives running healthcare ;). I am not sure the “cost” of primary care is all that inconsequential when calculated on the larger scale for the entire population. You are correct the cost of primary care per encounter is lower per individual, however when you deliver immunizations, blood pressure and cholesterol screening to the whole population, the cost will add up. Tort reform has been necessary for some time.
    Yes, patients want what they want when they want it and rationing must come into play. End of life care should be handled differently also. Transparency will only help with lowering costs and evaluation of recipients of Medicaid would go a long way toward helping to reduce expenditures too. Your last sentence summed it up. The powerful interests are a large obstacle I cannot figure out how to get around just yet. Give me time 🙂

  80. I take your answer as a yes. Would that then include banning narrow networks, caps, co-pays and deductibles, which also put insurance between the patient and the doctor.

    Have you thought about the cost of premiums when taking away this ability of insurance to mange risk.

  81. Peter, you are correct that hospitals and drugs are cost elephants. You left out insurance as costs passed onto consumers. I will not debate about specialists because I think they meet an important need for a large segment of the chronically ill population. Trump is a deal-maker, that is the value he adds to the equation in my opinion. Neither he nor most lawmakers have ANY understanding of healthcare, that is the reason reform should be driven by consumers and practicing physicians.
    The quote of mine you used does not necessarily imply a single pay system. That happens to be your point of view. I believe it can be accomplished in a basic level of healthcare for all and then insurance to help with the more expensive things as the post clarified. It can be a free market system if we choose to go that route. You know how I feel about the delusional thing and I again, implore you not to hurl insults. This is an academic discussion with no place for name calling.
    Clearly by your final sentence, you do not like Trump. Fine. Here is what I find interesting about watching politics more closely. They ALL end up lying at some point, because they speak on a subject matter in which they have no expertise. They may not know what they are talking about and then sound a little ridiculous. This quality is universal among Republicans, Democrats, and Independents. We do have to vote for someone after all.

  82. I advocate for disintermediating the “risk bearer” in favor of the at-risk and healthcare providing entities managing the “risk” between themselves within the existing framework of laws.

  83. Allan, assuming a given individual can pass medical underwriting and can afford the premium for the policy that works best for him, there may well be a certain satisfaction that comes with policy selection as opposed to just accepting an employer plan or a government funded plan. The individual’s choices, though, are limited basically to the deductible, copay, and out-of-pocket maximum limits, scope of coverage and breadth of the provider network. Providers’ interactions with insurers regarding documentation requirements, prior authorization, etc. will likely be the same no matter which policy the patient in front of him has. So, the freedom to choose his own insurance plan may be less than fully satisfying when it comes time to actually access medical care in a hospital, ASC, imaging center, lab or a physician’s office.

    If he can’t afford even the equivalent of a Bronze level plan under the ACA, then there will probably be a need for subsidies and that means government involvement and taxpayer funding. If he can’t pass underwriting, there will be a need for high risk pools or reinsurance, both of which will be expensive to fund. I’m not saying the current system can’t be improved upon. I am saying that the free market won’t work as well for health insurance as it does for home owner, renter and auto insurance. That’s the case because health insurance is just much more expensive for most people than those other types of insurance. Long term care insurance, for example, is an underwritten product and there are no subsidies to help people buy it. As a result, only about 7% of older folks have such a policy though it’s likely that a much higher percentage of the older population would buy it if it was more affordable.

  84. So you advocate that the insurance company paying the bills have no say in the treatment or the treatment bills?

  85. Peter, health plans routinely interfere with the doctor by requiring authorization for services to be provided. Health plans can literally shape entire provider practices by virtue of their “purchasing power” in markets. And they have good reasons for doing so under the current model.

  86. “that is why in the most personal of relationships, one’s own healthcare, the individual should be choosing his own insurer or agent, not an employer or government employee.”

    You stated that you provided health insurance for your employees. I assume that was a group policy. Did your employees get to choose their insurer?

    If we’re all on the individual market (which is what you’re advocating) what would that do to premiums? What would that do for people with pre-existing? What would that cost older Americans not yet on Medicare like you and I who enjoy a protected and subsidized government program?

  87. “He who has the gold makes the rules.”

    Barry, that is why in the most personal of relationships, one’s own healthcare, the individual should be choosing his own insurer or agent, not an employer or government employee. We all recognize that there are needy people that need help to house, feed and clothe them. They also may need help with regard to healthcare. When that happens there is always charity whether it be private or governmental (unattached from the healthcare market). At that point I agree, he who has the gold makes the rules.

    Unfortunately too many people think the government or the employer should be telling us which private concern we should spend our money on (for insurance), how much and for what. That should be a personal decision and not forced. Healthcare for the most part is not a common good as defined by most economists. The portion that can be covered and for the most part is covered by public health which is a common good (preventing the sread of disease).

    By mixing the common good with private concerns one can never define a line where the “common good” should end. That only creates problems that never end along with huge budget deficits and eventually a program that produces less and less despite ever rising costs.

    Single payer proponents should concentrate on making Medicare (single payer for those over 65) sustainable. If they do that then they would have a model for healthcare demonstrated to work. Unfortunately, to date they have been unable to do that, yet they wish to use an unsustainable model as the healthcare model for the future which doesn’t sound like a smart way of doing things.

  88. He who has the gold makes the rules. Neither government nor private insurers are going to pay medical bills without question or documentation and there will be limits on what both will cover. If you can pay cash for everything from a routine office visit to a heart transplant and from the cheapest generic drug to the most expensive specialty drug, then you can have healthcare your way. If you need an insurer to help pay your bills, you can’t have it your way.

  89. “…my point is that we need to get all intermediaries out of the way and let individual physicians and patients engage directly.”

    Yes, I got your point. But tell me then who and how ‘intermediaries” are getting between the doc and you when discussing your health?

  90. Peter, my point is that we need to get all intermediaries out of the way and let individual physicians and patients engage directly. We need to rethink the entire risk cession model and let individuals and their communities have a say in what they value most. The necessary laws are in place. They will do very well in maintaining or managing the status quo.

  91. kgsubrama, a lot of contradictions in your comment. Can you tell us how we are going to get there without legislation? If a conversation with your doctor, without a middlemen is your ideal, how do you eliminate the insurance company from the conversation when they are paying?

  92. I agree with Niran. Health care is a conversation best had between the patient and their physician. That is the ideal. Technology can certainly help – to provide the quality, performance and price transparency that eliminates the information asymmetry that plagues our system today. Getting to the ideal will take grassroots level effort, not at the Federal level.

    A person’s healthcare journey should begin in the home and end in the home with as few visits to a specialized care facility as needed. This will require the medical professionals to think more carefully about their social obligations in a real, “what will my community think about me” way.

    Let’s not kid ourselves on the repercussions of such a shift, however. We are talking about an industry that is trillions of dollars in size. That is a lot of jobs. That is a lot of communities with many if not most with a single hospital system providing services.

    Yes, there are many vested interests. Yes, there are many efficiencies. And yes, we are not getting back enough for what we pay. We cannot legislate our way of these and other large issues in healthcare, however.

  93. I agree with Barry that primary care is not a large cost driver, in fact it should be expanded. Hospitals, drugs, specialists are the cost elephants we should tackle. But Niran, Trump is not the person you want to rely on to achieve any cost control except to punish patients for using the system. He understands nothing and reads nothing. He does not even know what’s in the new GOP health law or its implications for patients. He cannot understand why an American President is not a king or CEO, and why the system has all these annoying checks and balances built into it.

    “People in this country want affordable healthcare choices and freedom from fear of no access for chronic conditions and unforeseen catastrophic events. They no longer want to worry about health issues bankrupting them. Struggling families are one catastrophic illness away from losing their American Dream and that must change. Step back and take in the big picture.”

    What you describe is largely a single pay system with government cost control, not a “free market” system. You’re delusional to think otherwise.

    One last point on your support for Trump, when are you going to ask yourself the question: “When is Trump going to stop lying?”

  94. Niran, I think the cost of primary care is inconsequential in the context of total healthcare costs. There is plenty of blame to go around for our expensive healthcare system. The attitude among way too many patients are I want what I want when I want it and I expect someone else, either insurers or taxpayers, to pay for it.

    If we really want to tackle healthcare costs, I have several ideas which I’ve written about many times before. First, let’s have tort reform which, to me, means specialized health courts where judges with expertise in healthcare issues are empowered to hire neutral experts to sort through conflicting scientific claims and eliminate juries of lay people who can be easily swayed by a glib trial lawyer suing on behalf of a sympathetic patient and convince the jury to award huge damages even when doctors did nothing wrong. Of course, trial lawyers, who are a key constituency of the democrats, will oppose it with everything they have which is a lot. There should also be safe harbor protection from failure to diagnose lawsuits if the doctors followed evidence based guidelines and protocols where they exist.

    Second, I would like to see a more sensible approach to end of life care. There is still too much futile and marginally useful care provided at high cost in end of life situations. Experts abroad, who generally admire the quality of our doctors and hospitals and our research capabilities, say we don’t know when to stop. Of course, the AARP and some religious groups will probably strongly oppose this idea. At the very least, people should execute a living will or advance directive so their family members know what care they want and don’t want if the patient can no longer communicate or is no longer mentally competent to decide for himself.

    Third, let’s have price transparency for care that can be scheduled in advance like imaging and surgical procedures like hip and knee replacements. Surgical procedures lend themselves to bundled pricing so let’s have that too. Of course, insurers and hospitals will fight to maintain the confidentiality agreements currently in place that preclude price disclosure.

    Finally, for its part, Medicare and Medicaid could invest more in fraud analytics to do a better job of combating fraud. The more fraud there is in these two programs, the more efficient they look in the eyes of liberals by claiming low administrative costs as a percentage of total spending. It’s ridiculous. It’s not a glamorous idea which means politicians won’t be interested in appropriating money to spend more on analytics and it’s not possible to quantify potential savings ahead of time.

    None of these ideas are new but they all have powerful interests arrayed against them. That’s the problem in a nutshell. It’s not corporate profits and it’s not high executive salaries. At least that’s my opinion.

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