The Healthcare Fix

This note was originally published at 8am on February 17, 2012. INVESTOR and RISK MANAGER SUBSCRIBERS have access to the EARLY LOOK (published by 8am every trading day) and PORTFOLIO IDEAS in real-time.

“Let us not seek the Republican answer or the Democratic answer, but the right answer. Let us not seek to fix the blame for the past. Let us accept our own responsibility for the future.”

-John F. Kennedy


Keynesian dogmas are often criticized at Hedgeye.  While fiscal and monetary policy is often the target for critics, health spending is often ignored.   Perhaps it is easier to comment on growth and inflation metrics in the broader economy than it is in the healthcare sector.  But the similarities are apparent.  Over the last 50 years government health spending has coincided with rising medical inflation and slower growth.  Maybe it is time to try something different.


The health reform debate has a long history, but one that has generally ended with rising demands on public financing.  As of today, government payments account for over half of the total medical spending today in the United States.  Medical spending finds itself again as central issue in the current political debate.  


For all of the public support for the health sector, or because of it, affordability and access continue to be the chronic platforms of the debate.   Since 1999, family insurance premiums have risen at over 8% per year and 3X the rate of wage growth, rising from $5,791 in 1999 to $15,073 in 2011 (Kaiser Family Foundation).  At this rate of increase, a family policy will cost $22,000 in 2016 and $32,000 by 2021.  Meanwhile, the employee share of insurance premiums has risen while wage growth has been stagnant. But worst of all, access is shrinking.  Out of pocket expenses and deductibles make it unaffordable for many to seek care, while of those insured by Medicare and Medicaid, physicians refuse these new patients 13.7% and 28.2% of the time, respectively.


We are hopeful that President Obama’s Affordable Care Act will produce all that has been promised by the President and the Congressional Budget Office, namely improvement in access, lower costs, and reduced federal deficit.   For reasons we won’t elaborate on here, we believe The Affordable Care Act, while different in the details, will have the similar outcome as past expansions of government health spending.  We expect the legislation will reduce access, drive medical costs higher, and worsen the deficit. 



It is cliché at to say health spending rises faster than broad measures of inflation such as the Consumer Price Index.  Despite the widespread belief that this is driven by an aging population, the surprise finding far less spoken about is the miniscule contribution an aging population makes to annual medical inflation.  According to a 2006 study of hospital care, the annual contribution to hospital spending from an aging population is 0.74% (Banker et al, Health Affairs 2006).  In other studies of total medical spending, the aging contributes only 0.50%.  Removing the demographic fallacy, the conclusion should be to focus on prices. 


Putting this in the populist context of Apple and its $108B in fiscal 2011 revenue, an annual price increase on the $2.6T Health Economy adds $130B in additional revenue, or cost, to the system, with a corresponding “value” that is impossible to compare.



We find it a shame that the healthcare sector is entering its second decade of decelerating growth and lower multiples yet enjoy more government support, more regulation, while Americans have a profound need than ever before.  We’d love nothing more than see routine 5% annual price increases and $130B in new spending turn itself into a new industry to analyze.  Unfortunately prices are going up, and the system remains broken and ineffectual.



My bookshelf is cluttered with too many books on how to fix healthcare that I have spent too much time reading.  Many offer intelligent alternatives.  Many are diligently researched.  But all of them lack a simple and practical solution.  Here’s my simple solution: create a National Health Score, or a credit score for your health. 



A National Health Score would convert well known patterns of per capita medical spending and creates a national underwriting table.  With a Health Score, creating a price for a health insurance policy for an individual is turned into a function of age and a few simple risk factors.   Additionally, remove the risk of catastrophic event by insuring and caring for those rare events separately.


On an individual basis, the Health Score would focus an individual on factors they can control.  A  42 year old father of 2, who is overweight, has high cholesterol, and is a tobacco user should pay more than a healthier 42 year old.   However, if by his own effort he slims down, quits smoking, and improves his Health Score, he should pay less.  By consolidating the risk factors into a Health Score and using it to set the monthly premium, an individual has the “skin in game” that consumer directed healthcare advocates so desire, but its centered on things the individual has control over. Over time, the system benefits from lower long term costs.



The fact that the existence of a three tier system is accepted so calmly in the United States (private insurance, government, none) while we lead the globe in per capita health spending at close to $8,000 per capita, should be alarming.   With a Health Score in hand, legislators and policy will be allowed to turn to how much support an individual receives and how to improve the aggregate Health Score of the population. 



The reality for the vast majority of people is that a serious episode of care is a rare event.  For a hospitalization, the percentage of people are admitted to a hospital in a given year is in the single digits.  For those between the ages of 18 and 44, the rate is 5.9%.  For those between the ages of 45 and 64, the rate is 6.9%.   The downside of course is when you find yourself in the group that goes to the hospital.  The high cost of the care, which carries a mean expense of $11,433 and $20,252 for these two age groups, can harm many, and bankrupt others, and make health insurance prohibitively expensive after an individual does get sick.   By treating people who find themselves unlucky enough to have a major episode, they should be considered a separate group and insured and cared for that way. 


The prognosis for the Health Sector is not good.  Decades of expanding government spending appears set to continue.   Growth will continue to decelerate, multiples will move lower, while government expenditure rises to new highs.  Consumer trends will continue to rise in importance, and pricing leverage will continue to wane.  I’ll continue to play the game in front of me, but I am hoping for something different.


Our immediate-term support and resistance ranges for Gold, Oil (Brent), US Dollar Index, and the SP500 are now $1714-1744, $117.81-120.28, $79.06-79.67, and 1348-1360, respectively.


Thomas Tobin

Managing Director


The Healthcare Fix - The Healthcare Dollar 2 EL


The Healthcare Fix - Virtual Portfolio

Growth Crisis

“Europe does not just face a debt crisis, Europe also faces a growth crisis.”

-David Cameron


Growth Slows As Inflation Accelerates. I wrote that in every other Early Look note between February-April of 2008 and 2011 and, unless the US Dollar doesn’t catch a credibility bid soon, I’ll write it again from February-April of 2012.


Why is it that people in our profession didn’t believe me then? Why is it that they don’t believe me now? Do less people believe me less? I really have no idea on what the answers to these questions are. The only thing I am certain of is that my process for intermediate-term economic forecasting using the US Dollar as my lead indicator for Growth and Inflation has not changed.


Sadly, neither has the broken processes of those who had both the 2008 and 2011 Growth Slowdowns wrong.


Back to the Global Macro Grind


Britain’s Prime Minister David Cameron gets this. The Chinese, Indians, and Brazilians get this. So why is it that the Crack Keynesian economists, who got the USA, Japan, and Italy into this mess to begin with, don’t?


That’s pretty simple. It would mean they’d have to hold themselves accountable for structurally impairing the long-term economic growth prospects of Global GDP via Keynesian/Fiat Policies to Inflate.


Got data to support these attacks on the aristocracy of our academic elite?


Let’s look at yesterday’s American Institute of Supply Management Report (ISM) for February (see Chart of The Day):

  1. GROWTH: Slowed -3.1% sequentially (month-over-month) to 52.4 from 54.1
  2. INFLATION: Accelerated +10.9% (month-over-month) to 61.5 from 55.5 (Prices Paid)
  3. POLICY: Dollar Debauchery began January 25th after Ben Bernanke push his Policy to Inflate to 2014

So why didn’t markets go straight down on that yesterday?


I have no idea – they didn’t until May of last year either. Markets will do what they do, until they don’t. The German hyper-inflation of the 1920s saw its stock and commodity markets rise as real (inflation adjusted) German Growth Slowed to all-time lows too.


No worries. According to the Chairman of The US Federal Reserve’s CYA Career Risk Management campaign:

  1. GROWTH: Qe2 (ended Q2 of 2011) was supposed to get us a US Growth acceleration to 3.5-4% (it was 0.36% in Q1 2011)
  2. INFLATION: never – at all-time highs in food and energy prices, you’ll never see it, ever (it ramped to 4-6% in 2011)
  3. POLICY RESULTS? Bernanke said this yesterday and I almost fell out of my chair:

“We’ve had about 2.5 million jobs added … and we’ve seen big gains in stock prices…”


Oh. Ok. Now that the stock market is up, we need to do more of what we did from an inflation policy perspective last year – because, uh, it actually worked? This is the kind of groupthink, dogma, and confirmation bias that almost every behavioral psychologist of the modern Millennium shuns. Enough of the Great Depression fear-mongering thing already.


It’s ok to admit it.


We have a pending Growth Crisis in Japan, Western Europe, and the United States of America. Like an AA meeting, we might have to all say it together: “we are addicted to easy money, inflation, and debt – they structurally impair growth.”


Got math to support these plainly visible claims? Let’s look at how US Growth (GDP) did as the US Dollar Strengthened in Q4 of 2011:

  1. US Dollar Index and American Purchasing Power rose +6.7% from mid October to the end of December 2011
  2. US GDP Growth Accelerated from +1.34% in Q2 2011 (highest inflation quarter of 2011) to +2.98% Q4 2011
  3. US Consumption Growth Accelerated from +0.38% in Q2 2011 (lowest since Q1 of 2009) to +1.17% Q4 2011

The math is so trivial that only an un-elected Central Planner can obfuscate it to the Muppets in Congress at this point.


Facts about US Economic Growth:

  1. US Consumption represents 71% of US GDP – get that right, you’ll get mostly everything else right
  2. Export Manufacturing won’t move anything but the political dial – debauching the Dollar for “export” growth has not worked
  3. Strong Dollar Deflates The Inflation = Higher Real-Inflation Adjusted Consumption = Higher US Growth

Setting aside the accounting irregularities of the US Government on silly things like birth/death adjustments to the US Employment report and using a GDP “Deflator” that’s usually understating US inflation anywhere between 50-1000% (GDP Deflator for Q4 was 0.86%, when CPI and PPI blended averages for Q4 were approximately 500% higher), you should feel better now.


You shouldn’t feel better about America’s long-term Growth Crisis. You should just feel better because I am telling you the truth.


My immediate-term support and resistance ranges for Gold, Oil (Brent), US Dollar Index, and the SP500 are now $1, $123.29-126.41, $78.11-79.22, and 1, respectively.


We’ll be hosting our Sovereign Debt and Demographic Reckoning Conference Call on Japan at 11AM EST. Please email if you are interested in participating.


Best of luck out there today and Happy Birthday to my beautiful little girl, Callie.




Keith R. McCullough
Chief Executive Officer


Growth Crisis - Chart of the Day


Growth Crisis - Virtual Portfolio

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TODAY’S S&P 500 SET-UP – March 2, 2012

As we look at today’s set up for the S&P 500, the range is 12 points or -0.81% downside to 1363 and 0.07% upside to 1375. 












  • ADVANCE/DECLINE LINE: 1033 (-1982) 
  • VOLUME: NYSE 814.48 (-26.71%)
  • VIX:  17.26 -6.35% YTD PERFORMANCE: -26.24%
  • SPX PUT/CALL RATIO: 2.29 from 2.48 (-7.66%)


  • TED SPREAD: 40.85
  • 3-MONTH T-BILL YIELD: 0.07%
  • 10-Year: 2.01 from 2.03
  • YIELD CURVE: 1.73 from 1.74 

MACRO DATA POINTS (Bloomberg Estimates):

  • 9:45am: ISM New York
  • 1pm: Baker Hughes rig count
  • 8pm: Fed’s Bullard speaks on U.S. economy in Vancouver 


    • President Barack Obama visits wounded service members at Walter Reed hospital in Bethesda, Md.
    • House not in session, Senate in session
      • Senate meets to resume consideration of surface transportation bill, 10am 


  • Yelp priced 7.15m shares at $15 each in IPO after offering them at $12-$14 apiece
  • European leaders agreed to provide capital faster for planned permanent bailout fund
  • Settlement talks continue over blame for Deepwater Horizon sinking, oil spill; trial will otherwise begin March 5
  • Sands China profit beat estimates on jump in Macau casino sales; watch LVS
  • President Obama said to have told Wall Street donors that Democrats can’t unilaterally stop accepting money from big- dollar PACs
  • U.S. ITC may announce whether it will review judge’s finding that Motorola Mobility infringed one Microsoft patent and not six others, 5pm
  • Washington state Republican presidential caucuses take place tomorrow 


    • Big Lots (BIG) 6 a.m., $1.74
    • Exelis (XLS) 7am, $0.56
    • Genesco (GCO) 7:35am, $1.67
    • TransAlta (TA CN) 8:54am, C$0.24 


OIL – down 1% this morning but the lines that matter most continue to hold as the US Dollar’s bid remains fleeting. If Iran doesn’t send a missile somewhere soon, we’re going to need another line of storytelling out of Washington, fast. Immediate-term supports for Brent and WTI = $123.29 and 106.12, respectively. 

  • Copper Bull Streak Extends to Longest Since October: Commodities
  • Oil Heads for Weekly Decline After Saudi Arabia Denies Sabotage
  • Cocoa Falls as Rains May Boost Crops in West Africa; Sugar Rises
  • Soybeans Set for Third Weekly Gain on U.S. Sales, Drought Woes
  • Gold May Fall in London on Speculation Fed Will Refrain From QE3
  • Copper May Decline as Shanghai Stockpiles Increase to a Record
  • Bangladesh Plans to Import 100,000 Tons of Sugar From Brazil
  • Palm Oil Posts First Weekly Decline in Four as Exports Weaken
  • Economic Surprises Signal Rising Metals Demand: Chart of the Day
  • Coal to Japan Seen Near Record in Xstrata Talks: Energy Markets
  • Aluminium Bahrain Seeks to Keep Bribery Suit Against Alcoa Alive
  • Palm Oil Imports by Pakistan to Slump as Strike Shuts Factories
  • Oil Prices May Rise Next Week as Gasoline Gains, Survey Shows
  • Oil Falls as Saudi Arabia Denies Sabotage
  • Rubber Gains to 5-Month High as U.S. Data Boosts Demand Outlook
  • Saudis Suffered No Sabotage to Oil Facilities, Ministry Says
  • Russia Plans $8 Billion Siberia Investment to Boost Coal Exports 









RUSSIA – the most popular man with Putin right now has to be The Bernank. Putin gets paid in Petro-Dollars, and with the Petro straight up, Dollar straight down, what more could our comrade want heading into this weekend’s election? Russia +25.2% YTD. That’s probably a depression or deflation signal, or something.






YEN – this is easily the most recognizable downward dog pattern that consensus still isn’t talking about. Straight down again (-0.46%) vs the USD this morning, the Japanese are about to engage in selling more sovereign debt than even the Americans and Europeans could. We have a 100 slide deck and conference call on Japan at 11AM EST today if you want to get up to speed on it.










The Hedgeye Macro Team



The Macau Metro Monitor, March 2, 2012




Some lawmakers have called on the government to extend the gaming ban on public servants to casino staff, as part of a draft bill on restrictions for access, stay and gaming in casinos.  The draft law, which applies to slot parlours,  raises the minimum age to enter and work inside a casino from 18 to 21. 


The law proposal was discussed at the Legislative Assembly’s first standing committee yesterday but the suggestion gathered no consensus.  Lawmakers are now waiting for the Administration to put forward the final version of the bill before signing their report. The proposal could be ready for voting in April.



The Macau Executive Council kept the income subsidy scheme of helping low-salary permanent residents flat YoY at MOP 4,400 despite inflation reaching almost 6% in the last 12 months.  “There are other measures launched by the government to alleviate low-income earners’ living pressure,” Executive Council spokesperson Leong Heng Teng said.

Shorting EWI: Italy Trade Update

Positions in Europe: Short Italy (EWI)


Keith shorted EWI in the Hedgeye Virtual Portfolio today with the etf overbought on its immediate term TRADE duration. Our thesis on Italy remains intact: the country’s public debt overhang will continue to compromise growth and compress tax receipts as PM Monti continues to press the austerity button that should crimp confidence and spending and heighten unemployment.  And recent fundamentals are reflecting this weakness: Retail Sales were down -3.7% in DEC Y/Y vs -1.8% in NOV; Business Confidence fell to 91.5 in FEB vs 92.1 in JAN; the Unemployment Rate rose to 9.2% in JAN vs 8.9% DEC; and CPI remains elevated at 3.4% in JAN Y/Y vs 2.6% for the Eurozone aggregate.


We’re forecasting a long TAIL to Europe’s sovereign debt ‘crisis’, especially under a scenario in which the current Eurozone fabric is maintained (that is to say Greece and Portugal don’t “default” and stay in the Union), which we think is probable given Eurocrat resolve. As the goalposts continue to change (think ISDA ruling on Greek debt) and uncertainty abounds (think structure around the ESM and EFSF or terms and outcome of a “fiscal compact”) we expect volatility ahead across European markets and we’ll tactically take advantage of these price swings.


Matthew Hedrick

Senior Analyst


Shorting EWI: Italy Trade Update - 1. MIB

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