How to Rebuild Healthcare Right

By John Mauldin

“I reject the insurance model. I think we should have a free-market approach to healthcare.”

– Gary Johnson

“The goal of real healthcare reform must be universal coverage in a cost-effective way.”

– Bernie Sanders

“The fault, dear Brutus, is not in our stars, but in ourselves….”

– Julius Caesar (I.ii.140–141)

“The numbers [referring to the growth in the aging population and its relationship to Alzheimer’s] point to a disaster that will be the real zombie apocalypse. Western societies simply won’t be able to bear the costs of Alzheimer’s as the incidence continues to rise. Faced with impossible financial, emotional and psychological costs, we would have to funnel so much of our resources into the care of Alzheimer’s patients that the quality of life for everyone would plummet.
“Escape from the zombie apocalypse, on the other hand, is entirely simple: cure aging itself. To be more precise, the solution to Alzheimer’s is to stop accelerated aging. We need to slow the degeneration that leads to Alzheimer’s and other age-related disease.”

– Patrick Cox, from his new book, The Methuselah Effect


Is inflation something to fear, or we should demand that our central bankers craft policy to nudge inflation upward? There are genuine arguments about this, and I have written about the problems we have even tracking inflation, much less guiding it toward a target.
However, one area where we have no problem detecting inflation is medical expenses.

They seem to go nowhere but up, as I described in last week’s “Taking a Wrench to Healthcare.” Millions of Americans are about to learn how much their Obamacare premiums will be next year. But even if you have health coverage through your employer, or you’re 65+ and on Medicare, like me, I can all but guarantee severe inflation in the healthcare part of your budget.
I ended last week by saying I would describe a possible solution to the healthcare quandary. Today we’ll look at the remarkable results the Cleveland Clinic has already achieved with its 100,000+ employees and dependents and with numerous corporations they work with. They are making people healthier and reducing medical costs. It is a model that I think could work on a much broader scale.
Much of what you are about to read came by way of my own physician at Cleveland Clinic, Dr. Mike Roizen. He heads their Wellness Institute and is the author of a best-selling book, This Is Your Do-Over: The 7 Secrets to Losing Weight, Living Longer, and Getting a Second Chance at the Life You Want. I highly recommend it.
Healthcare Inflation Running Wild
Last Tuesday’s US Consumer Price Index lets us attach numbers to the problem.

Here is the official CPI summary table. I have highlighted in yellow the relevant lines:

Direct your attention to the rightmost column, which shows the 12-month change through September 2016. CPI for all items rose 1.5% in the last year. Prices actually fell in the energy-related components, as much as 8.5% for fuel oil. Great news if you are a heavy fuel oil user. Most people aren’t. Fuel oil is used mainly in the Northeast and is less than 0.1% of the overall index. On the other hand, total medical care is 8.375% of the index (and rising).
Most people use healthcare, and those components showed the highest cost increases in the report. The medical care commodities category includes prescription and nonprescription drugs, as well as medical supplies. The medical care services category includes doctors, hospitals, lab tests, etc., as well as health insurance premiums. Both categories popped much higher than any other CPI components in the last year.
Keep in mind that your personal CPI depends on your spending patterns. Medical care is a bigger part of the budget for most retirees, as well as for younger people with chronic conditions. Your own all-items CPI change was probably much more than 1.5%. If you drill down in the full CPI release, you’ll see that the health insurance subcategory rose 8.4% in the last year. That’s money you spend whether you actually use any services or not. It’s also a national average that disguises the much higher increases for many folks.
Incidentally, one of the maddening things about analyzing healthcare costs is that comparisons over time are almost impossible. Very rarely does anyone get to buy the exact same insurance plan that they bought last year. The insurers change terms, raise deductibles and co-payments, exclude certain drugs, and revise their provider networks.

(It was only a few years ago that my deductible was $500. Now it’s $5000 and I am paying more for the insurance.) So not only did your premiums rise by an average 8.4%, they probably also bought less coverage than you had the year before. If it were possible to again buy the exact same coverage, your annual increase would almost certainly be more than 8.4% and possibly much more.
(Sidebar: the people at BLS who figure out what the CPI is use something called hedonics, which allows them to say that the prices of some things, like electronic, are going down because their quality is going up. Even if you are actually paying more, they figure you are getting more for your money, so that’s not inflationary.
The BLS does not apply the same concept to healthcare. Even though the price is rising, they do not adjust for deductibles or reductions in what is covered. If taken into account, those factors spike the healthcare inflation number significantly. Just saying…)
The Six Deadly American Sins
What specific conditions drive rising health insurance premiums and medical costs? We hear about expensive prescriptions and the high costs of surgery and hospitalization. We’ve seen friends and relatives spend their entire life savings on cancer treatments. The numbers are staggering.
I was with a longtime neurological surgeon yesterday at an investment conference, and he critiqued last week’s letter on healthcare costs. He said the real reason for the rise in healthcare expenses is greed. And there is a great deal of truth to that.

We have more hospital beds than we need and in the wrong places. Many procedures are unnecessarily prescribed, and the list goes on and on. The way insurance is provided and the insurance companies that provide it are a big part of the cost issue, too.
There is no price discovery available for many products, so there is no control on cost. I recently found that I can buy an extremely high-quality prime rib from Costco for about 30% of what I pay at local high-end meat markets. Guess where I will be buying my prime rib roast next Thanksgiving? I have no such way to compare healthcare costs. In a world where everything else is available for comparison online, it is criminally negligent not to make healthcare costs publicly available.
Nevertheless, those kind of expenses aren’t the main challenge. In some respects, they are merely symptoms of the real problem. The chart below from a CDC study shows the leading causes of death among adults age 65 or older. It is a few years old, but from what I can see researching online, there has not been much change except that the numbers for these chronic conditions are still going up.

And once you have one of these chronic conditions, the general trend is that you end up with multiple conditions, often as many as five or six.

What is it that makes us susceptible to cancer, heart disease, and other debilitating (and expensive) ailments? Deal with that, and people won’t reach the point where they need expensive care.
Cleveland Clinic says six chronic health conditions cause most of our problems. They are:
  • High cholesterol
  • High blood pressure
  • Excess weight
  • Diabetes
  • Asthma
  • Tobacco use

Keep in mind that we are talking about the United States. These conditions are not so prevalent everywhere. They are spreading, though, as the US goes on exporting its lifestyle to the rest of the world. Diabetes rates are skyrocketing in China, for instance. China now has almost 90 million people with diabetes. People there now consume more calories and burn fewer calories living in cities than they did as farm workers. Similar patterns are evident almost everywhere. The rest of the world can laugh at overweight, unhealthy Americans now, but they are on track to be just like us in 10 years.
Our diet is a key problem. To be blunt about it, Americans eat too much. We could certainly improve our diets by avoiding excess sugar, carbs, etc.; but Mike Roizen says the real culprit is portion size. We live in a culture of excess. Furthermore, producing, distributing, and marketing food is a huge part of our economy. We make money by encouraging each other to eat more than we should. Farm-state politicians get elected by pushing policies that make food cheaper and more plentiful but not necessarily more healthful.
Our national food obsession is literally killing us. It is so deeply engrained (pun intended) that we seemingly just can’t turn it off. And this trend toward obesity is showing up as an increase in disease.

Obesity is one of the biggest drivers of preventable chronic diseases and associated healthcare costs in the United States. Currently, estimates for these costs range from $147 billion to nearly $210 billion per year. Individuals with lower income and/or education levels are disproportionately likely to be obese. More than 33 percent of adults who earn less than $15,000 per year are obese, compared with 25 percent of those who earn at least $50,000 per year. According to the most recent data, adult obesity rates now exceed 35 percent in four states, 30 percent in 25 states, and are above 20 percent in all states. Louisiana has the highest adult obesity rate at 36 percent, and Colorado has the lowest at 20 percent. (source:

Americans spend 20% more per capita than the rest of the world on healthcare, and a big part of the reason is that we are simply sicker, and almost all of that additional illness is self-induced and tied in with behavioral issues.
Type II diabetes can largely be controlled by lifestyle choices, specifically exercise and eating. Yes, I am well aware that that is not the case for 100% of people. (I also note that type I diabetes is not lifestyle-related and is a real problem. My oldest son has had type I diabetes for about 10 years. There are multiple ways to treat type II diabetes. I keep looking for anything for type I diabetes, and while a few drugs are in mid-stage trials, it has been a disheartening search.)
Diabetes has reached epidemic stage, not only in the US but worldwide. There are close to 30 million people in the US with type II diabetes, up from 2.2 million 40 years ago and double the number just 10 years ago. The chart below from the CDC shows that type II diabetes costs almost $250 billion a year in the US.

The Centers for Disease Control now predicts that by 2050 there will be as many as 220 million people (the high-end estimate) with type II diabetes, which would be 50% of the US population.
Enter the Zombie Apocalypse
My friend and Mauldin Economics Transformational Technology writer Patrick Cox and I talk a great deal about the future, biotechnology, aging, and healthcare. He has just written a book called The Methuselah Effect. (He is personally dealing with a father-in-law who has late-stage Alzheimer’s.) Let me offer a few quotes from his book (for which I wrote the forward and which I highly recommend!)
The singular transformation of the 20th century was the near-doubling of life spans in the West. Longer life spans are a good thing, of course, but there is a snake in the garden.
Diseases like smallpox and tuberculosis that once were common and life-threatening nearly vanished in the 20th century West.  Antibiotics turned once-fatal diseases into treatable maladies. Even the old killers, heart disease and cancer, started declining, thanks to new therapeutics.  People began to live much longer lives. As a result, the incidence of Alzheimer’s increased, as did the level of horror it inflicts.

Not only does a formerly healthy individual lose memory and self when hit by AD, the lives of entire families are consumed by the slow devastation of a loved one.
Alzheimer’s patients first lose the ability to remember little things. Eventually they become delusional and forget those who love them and whom they once loved. Next, they lose motor function, moving very much like zombies, and, finally, they die, having drained the people who cared for them.
Unless your family has suffered this directly, you may not know that most AD victims reach a stage marked by hostility and anger. Nearly half of all Alzheimer’s patients assault the people around them with hitting, scratching, grappling, and biting.  Sufferers of Alzheimer’s disease literally turn into the aggressive zombies of George Romero.
Though AD is only the sixth-leading cause of mortality, it is country’s most expensive disease, due to the many years of disabled survival it allows the patient. Despite medical progress in most other areas, Alzheimer’s and its costs continue to grow as the population ages. The zombie plague is spreading.

The numbers point to a disaster that will be the real zombie apocalypse. Western societies simply won’t be able to bear the costs of Alzheimer’s as the incidence continues to rise. Faced with impossible financial, emotional, and psychological costs, we would have to funnel so much of our resources into the care of Alzheimer’s patients that the quality of life for everyone would plummet.
Escape from the zombie apocalypse, on the other hand, is entirely simple: cure aging itself. To be more precise, the solution to Alzheimer’s is to stop accelerated aging. We need to slow the degeneration that leads to Alzheimer’s and other age-related disease.
The accelerated aging Patrick is talking about is to a significant degree caused by the lifestyle choices we make. If we can slow the process of aging (so that we live longer) and increase our health spans, those measures would go a long way toward ameliorating the looming financial catastrophe of escalating healthcare costs. And that tsunami of costs will come about whether we repeal, replace, or reform Obamacare. The issue is not simply healthcare reform – it is lifestyle reform, which is much more difficult but also more rewarding.
(At the end of the letter I will talk about some good things happening on the medical care front that give us hope.)
Incentivizing Healthy Choices
We all know we need to lose weight and eat better. Do that and we mitigate most other health problems. Yet we still can’t do it.
Managing the six conditions mentioned above isn’t especially hard, but it requires motivation and support.  Cleveland Clinic CEO Toby Cosgrove turned his own workforce into a test case back in 2010. His key idea was to give people an incentive to avoid those six key conditions. The incentive is lower insurance rates.
Cleveland Clinic workers all see a healthcare practitioner who monitors weight, cholesterol, etc. and offers help to improve where necessary. The program, which they call Healthy Choice, isn’t mandatory but has proved very popular. That’s because the incentives are enormous. Those who meet their goals or make progress toward them can save 28% or more on their health insurance premiums.

In the process they are opting to be healthier, happier, and longer-lived.
Since the program launched in 2010, almost two-thirds of those with one or more of the six major chronic conditions managed to get them under control, and the vast majority have kept it that way. The incentive system and aggressive monitoring have succeeded in changing people’s behavior patterns. As a result, they have avoided most of the constant health insurance premium hikes seen elsewhere.
The Cleveland Clinic’s chief financial officer was initially skeptical of the program, as it cost hard dollars. He is now a believer. After the Clinic slowed the rise in its healthcare costs, actual healthcare outlays flatlined for a few years, and then last year they actually fell 2%. Very few companies in the United States with an employment population as diverse and large as the Cleveland Clinic’s can say that.
Healthy Choice has been so successful that Cleveland Clinic is helping other companies develop similar programs. One of the first was giant cement company LafargeHolcim. The company’s US unit had been told by its consultants to expect an $80 million healthcare price increase last year. But having implemented the wellness program seven years ago, the company’s actual increase came in at only $40.3 million. They literally cut almost 50% of their projected cost increase. And this is with an aging workforce population.
That’s real money saved. So we see not one but two large organizations in completely different industries both cutting their healthcare cost growth in half or more. Better yet, the employees are healthier and presumably happier, since they share in the cost savings. And similar results have been achieved by numerous other companies.
Is It Scalable?
Thinking about the Cleveland Clinic’s success as I wrote about healthcare costs, I naturally wondered if a similar program would work on a national scale. If so, it would remove one of the main impediments to economic growth.
One aspect of the healthcare challenge you don’t often here about is its drag on everyone’s time. Simply finding a provider who can treat your condition and who accepts your insurance can take several phone calls. Filling a prescription can take even more calls. That’s just for yourself – the burden can multiply if you have children or elderly parents under your care.
All that time adds up across the economy. It takes us away from our work, causes us mental stress, eats up our leisure time – and often we don’t even end up feeling better. It may well explain some of the puzzling worker productivity declines in recent years. Healthcare is both a direct cost and a kind of invisible tax that sucks away time and money we could all use in much better ways.
Before we get too excited, I can think of several reasons the Clinic’s model might not work everywhere.
First, Cleveland Clinic is itself a healthcare organization. Many of its employees are trained in medical disciplines. Even those who aren’t see the healthcare process in their daily work. They’re more attuned to the importance of staying healthy, so they may respond to the incentives more readily than the average American would.
Cleveland Clinic has taken some other steps, too. They removed unhealthy options and reduced portion sizes in their cafeterias. Vending machines no longer stock sugar-laden snacks and drinks. They have on-site fitness centers, yoga classes, and other helpful activities. It all seems to be working, but not every organization is structured so conveniently. At Mauldin Economics, for instance, most of us work from our homes, and we’re spread all over the US and in several different countries. We have no way to monitor what is in everyone’s refrigerators, nor do we want to. (Although I do very actively encourage a few employees to get off their derrières and exercise and lose some weight.

I need them healthy and productive… Not to mention they are my friends, and I want them around for a long time. Thankfully, the large majority of our employees actively select to live healthy and active lifestyles.)
Another point to consider is that the Cleveland Clinic and LafargeHolcim workforces aren’t random samples of the population. By definition, these groups exclude anyone who is fully disabled, unemployed, or elderly. Those categories include some of the heaviest healthcare users.
Still, it would be fascinating to see one or more states apply something like this program to their low-income Medicaid populations. Would people stop smoking, eat healthier, exercise a little, take their meds bring to bring down their cholesterol, and work towards weight loss and other health markers if you gave them a $2,000 cash reward every year?

I suspect many would – and the rewards would be less expensive for taxpayers than treating the behavior-driven illnesses that plague our society today.
The broader finding is key: Give people financial incentives to adjust their lifestyle toward better health, and they will respond. I suspect the same will be true just about everywhere, though the specific incentives will vary. Just about the only thing economists agree on is that incentives matter. With the proper incentives people will change their lifestyle.
Making such programs work across the population will require a delicate balance of carrots and sticks. I think Cleveland Clinic was wise not to make participation mandatory for all employees. Forcing people into something like this against their will, or making it a condition of employment, is not right. But it is right to expect employees to pay more for their healthcare if they choose not to participate. At some point, when healthcare become so expensive that society simply cannot deal with the cost, I think that lifestyle choices should become a big factor in determining how much the public will pay for healthcare.
I said above that diet is a big part of the problem. You could argue that it is the problem.

We have successfully made plentiful calories available to everyone. But the kind of calories that help you stay healthy are not as easy to come by as fast food is. I don’t know how we rebuild the whole food industry to make healthy choices available to all at an affordable price. But incentives will make a difference. And the food industry will respond as more and more consumers ask for healthier choices.

This is not a chicken and egg thing. We know precisely what must come first: consumers demanding healthier choices – and many evidently require incentives to do so.
But first things first. We can spend weeks picking apart these ideas and highlighting the problems with possible solutions. Far better to get started and then keep refining the programs as we learn what it takes to succeed. If next year’s price increases are anywhere near as eye-popping as media stories suggest, the new president and Congress will have plenty of incentive to try new ideas. I think we have a good model here in the Cleveland Clinic’s approach.
Dr. Mike Roizen tells me that there is bipartisan support for that approach, and even that bipartisan bills have been introduced in both houses along these lines. This is not a partisan issue; it’s just common sense. Let’s hope something can get done.
Some Good News on the Healthcare Front
Herbert Stein famously said, “If something cannot go on forever, it will stop.” 

Healthcare costs cannot keep rising on the current trajectory forever without creating a massive crisis that will force the costs to come down, either through rationing or cost controls or other draconian measures.
But there is reason to hope that the market may actually respond to some of the cost pressures prior to the ultimate crisis occurring, and at least soften the blow.
I have mentioned that there is a private company currently undertaking a phase I clinical trial of a silver bullet for cancer. We may actually have an indication of efficacy by this time next year. This is a dream candidate for cancer cures, as the side effects should be minimal and the treatment would require no hospitalization or invasive procedures. A few dozen doctor’s visits, and the cancer would be dealt with.
While this treatment may be optimal, we have no real idea yet whether it will work. As Mike tells me all the time, “Orange juice works in mice.” The animal studies with this drug were extremely encouraging, but now they’re testing how it works in the real world of human beings.
Even if it doesn’t work, there are at a minimum another dozen companies that are making real progress on the cancer front, although they are mostly focused on specific cancers rather than a generic bullet. I am hopeful that by the middle half of the next decade we will see cancer deaths plummet.
We are also seeing some encouraging results from new Alzheimer’s treatments – nothing that would seriously reverse Alzheimer’s in patients that currently have it, but treatments that might slow its onset or prevent it are no longer outside the realm of possibility.
There are numerous companies working on obesity drugs, and I would expect those to come to market by the middle of the next decade as well. Controlling obesity will take us a long way toward dealing with chronic disease in general.
As an aside, as part of research on muscular dystrophy and other muscle-related afflictions, we may find a drug that will significantly reduce the loss of muscle mass and allow those of us who have a little age on us to maintain our muscle viability, with exercise, for much longer.
While I personally do not take human growth hormone (HGH) because of the unknown or negative side effects of synthetic HGH, natural growth hormone is being used in literally hundreds of thousands of animals and causing significant growth and health improvements with evidently minimal side effects. It will not be long before that same process is available to humans. I won’t offer to be first in line to test it, but I will closely monitor results and get in the line if HGH shows the same order of effects that it has in animals. And Patrick is talking to groups working on a growth-hormone-releasing hormone that is even more amazing.
Ditto for treatment of cirrhosis of the liver. (There are phase II trials underway now.)

Here again, personal dietary choices – and especially control of alcohol consumption – may be more significant than any drug. Prevention is the best cure.
I mentioned a few weeks ago that stem cell therapy has been used to actually regenerate severed spinal cords in quadriplegics. A treatment for macular degeneration is in sight, using stem cells. Cures of many infectious diseases are less than a decade away.
There are anti-aging drugs in the works at VERY serious institutes. Pat writes about these things all the time. I get to tag along to some of his meetings, and one of the things I am fascinated by are the significant advances being made in biotechnologies across the spectrum through the use of ever more powerful computers and advances in artificial intelligence that allow for dramatic genetic modeling.
I know I am a techno-optimist, and past performance certainly does not predict future good results, but I think we are in a world where we’re about to see amazing transformations in the way we go about delivering healthcare.
And there are even significant innovations coming in terms of healthcare costs and benefits. Many hospitals and health groups are experimenting with ways to bring costs down and improve the quality of service. There is a hospital in the Cayman Islands, run by an Indian doctor, that performs heart surgery at less than 20% of the cost of the same surgery in the US, with significantly better outcomes and far fewer side effects and hospital infections. This is essentially technology that the doctor perfected in India in the course of performing and supervising 25,000 heart surgeries. Specialization can produce breakthroughs and major benefits, and those benefits are going to become noticed and imitated.
So even as the current trajectory of healthcare should make us very worried, we should all be hoping that politicians do not do anything stupid to break the innovation cycle.
And if our lawmakers were really concerned, they would replace the FDA with a drug regulatory authority designed for the 21st century and not mired in the 1960s. There are drugs and health procedures stuck in the phenomenally expensive and deeply bureaucratic process of the FDA, which is holding back a phenomenal tide of savings and health improvement.
Given a choice of replacing the Federal Reserve, balancing the national budget, or replacing the FDA with an updated system, I would not hesitate to choose FDA reform. We can actually get the biggest bang for our buck, not only in terms of dollars but in terms of health spans, by going that route. Yet you hear very few politicians talking about fixing the FDA.
And on that hopeful but cautionary note, I will close for this week.
Washington DC, New York, and Florida
I am speaking for my friends at the Commerce Street Bank at their annual Investment Conference on Thursday, October 27, at the George W. Bush Library here in Dallas. I am going to have to make trips to Washington DC and New York sometime in November or December, and I have a quick turnaround day in Chicago coming up this week. Also, I need to get to the Tampa Bay/Sarasota West Coast of Florida for a few meetings, some with Pat Cox and scientists looking at the latest research on a new antiaging drug. These are all relatively quick trips, so I don’t really have a heavy travel schedule for the last 10 weeks of the year. But January and February are already filling up, so my travel schedule promises to get much more typical next year. In the meantime I am really pressing on a lot of writing and other projects that have to get done soon.
This was a fun week. I got to spend some time with old friend Chris Wood of CLSA, talking about what is happening in Asia and how it affects the world. Then later that morning I was on a panel with Steve Moore and Mark Skousen (who now runs Freedom Fest) talking about how the presidential election will affect markets and the country. I got to spend some time with my old friend Steve Forbes and Art Laffer, too.
I know I mentioned Patrick Cox’s book a couple times in the letter, but let me call it to your attention again. You can buy it for like 12 bucks at this link: The Methuselah Effect. Patrick really is a special person – one of the few true polymaths I have met in my life. He is uniquely talented, and I am honored and grateful that he works with Mauldin Economics. He writes a free weekly letter on technology and transformation that you really should subscribe to and read. It will help you keep up with what is going on in our fast-moving world. You can get it right here.
And with that recommendation I think it is time to hit the send button. You have a great week. Mine will be busy, with some interesting opportunities for fun. I am meeting with Chloe Stern, who is now an editor but will soon be running the operations for Geopolitical Futures, which is the publishing arm of my friend and partner George Friedman. Not only do we share a mutual interest in geopolitics, we are also both science fiction aficionados.

I am sure my reading list will be a little longer after our lunch.
Your cautiously optimistic about the future analyst,

John Mauldin

‘Grit’: Why Talent Needs Drive to Succeed

What is grit? Angela Duckworth, a psychology professor at University of Pennsylvania’s School of Arts and Sciences, says it is the capacity to work hard and stay focused. In her recent book, Grit: The Power of Passion and Perseverance, she explains why grit is necessary in addition to talent, and why talent needs the drive that grit provides in order for one be successful. Duckworth, a 2013 MacArthur Fellow, discussed her ideas on the Knowledge@Wharton show on Wharton Business Radio on SiriusXM channel 111. (Listen to the podcast at the top of this page.)

An edited transcript of the conversation follows.

Knowledge@Wharton: Could you talk about grit affecting our successes? Where did the idea have its génesis?  

Angela Duckworth: I could date it back to being a teacher, teaching math in the New York City public schools and seeing many kids. Just by sitting next to them and talking to them at lunch time, you knew they were smart enough to learn everything that you needed to teach them, but still weren’t succeeding [and] weren’t fulfilling that potential. I could date my interest in grit to that point, but it would be probably more complete if I dated it to childhood. I grew up with a father who was obsessed with achievement and I think I may [have] modeled or inherited an interest in what makes people successful from him.

Knowledge@Wharton: But taking a job in the New York Public School system after working in a corporate community required a little bit of grit in itself, correct?

Duckworth: Yes. the decision in some ways looked like a left turn or a detour. But in many ways, it was getting back to what was more meaningful to me as a person. I had spent my entire college career working with kids and the community in my spare time. Right after college, I started a summer school for low-income children and ran that full-time for two years. So in some ways, maybe the corporate world was the digression.

Knowledge@Wharton: Does it mean that maybe we need to have a little bit of philosophy in how we teach in schools and maybe what we see in schools?

Duckworth: As somebody that studies an individual’s capacity to work very hard and stay focused on things that matter to them, I would like to say, “Yes, a change in focus,” but maybe not the change in focus that most people would think I mean.

Many times, I hear, “If it really matters how hard you work, I’m going to put the responsibility on the shoulders of these kids. And if they don’t do well, it’s even more their fault than I used to think.”

That’s exactly the wrong message. As educators and all of us in society, when a kid is not focused and when they are not achieving, the first question is, “What are we doing that isn’t actually working?”

The idea is: Can we be more psychologically wise about what we teach and how we teach? In fact, it rarely is exerting kids to work harder.

Knowledge@Wharton: Talent is obviously a factor in this, but sometimes, it’s not always talent. It has to be more the drive to be able to of reach your goals.

Duckworth: It’s not that talent doesn’t matter. I believe that talent exists. Some people prefer a world where we’re all equally talented in everything. Whether you prefer that world or not, I don’t think that world exists. But whatever your talent, you have to engage to realize that talent. We all have seen talent wasted. The engagement, the effort matters enormously.

When people think of the word “drive,” they often think you have it or you don’t, and that’s where we’re wrong. Drive is something that can be encouraged by a wonderful teacher, by a terrific classroom environment, by an awesome soccer team that you are on, and it can be squashed as well.

Knowledge@Wharton: Several people talk about grit being something that you have. You may even be born with it. But you say in your book that this is something that also can be learned.

Duckworth: The “also” is crucial. People have always been asking, “Is it nature or nurture?”

Are you born with it or do you develop it? The answer is, “Absolutely both.” It would be naive to discount the role of genes. But there’s also an enormous role for the people around them to nurture that nature. The real question is, what can we do with our genes, whatever they are, to be our best self?

Knowledge@Wharton: Data will prove whether or not this is proof of future success than, say, the SAT or an IQ test.

Duckworth: I will draw from the research of Jim Heckman, an economist at the University of Chicago. We collaborate closely. He has probably done the most comprehensive work on human capital and what predicts achievement in as many domains as you can name — crime, employment, relationships, stability, income or wealth.

Jim Heckman would say that what’s clear is that in the 20th century, economists thought it was largely a cognitive ability or IQ, and in the 21st century, we’re realizing that these “non-IQ” [factors] or your “character strengths” matter at least as much. Many things matter other than our measured intelligence, so let’s get to work on them.

Knowledge@Wharton: So it’s that next level of learning in society that we’re putting in because we’re in this timeframe where the data and the information are as important as the process itself? 

Duckworth: Yes, one could argue that the 20th century’s major step forward was the semiconductor, because that led to computers. Now, information — like what you’re dispensing right now, talking to each other — is free. So, there are no more barriers to entry to knowledge. What will be the semiconductor of the 21st century? My argument is that the ‘semiconductor’ of the 21st century will be a solution to understanding behavior and behavior change.

Knowledge@Wharton: In terms of passing this information onto students or corporations, what’s the most important thing for them to understand about the difference between grit and talent? There’s probably a large difference between the two and how that can affect your future success.

Duckworth: Well, as Wharton students probably know already, people in business use the word “talent” in different ways. Sometimes HR or the CEO who’s looking for a new hire uses it broadly to mean everything they’re looking for — just everything. Other people use it more narrowly, including me. I define talent as the rate at which you get better at something when you try. To be very talented means you get better faster and more easily than other people or other things that you try.

Effort is your engagement. It’s the quality and the quantity of your engagement ruminatively over time. They multiply, if you will, to produce skill, and once you’ve got a skill and you can do something — you can write well, you can present well, or you’re good at solving problems.

It’s the doers I most admire. As you think about yourself, you think, “What are my talents? What are the things that I’m going to be able to sustain effort in over the long term?” In general, that second question is answered more by your interests and your values than by things like salary.

[Consider] my job. It’s not that there aren’t headaches, or that there aren’t disappointments, but to love what you do requires a level of intrinsic interest. The only thing I want to encourage young people about this is, if you introspect a bit and you think, “Wait, I don’t have a passion,” and you’re panicking, just realize that it develops over time.

Knowledge@Wharton: More and more entrepreneurs and people are following that passion. You may go to work on Wall Street or in a hospital or as a lawyer for a few years, but you make that career shift and follow something else that you have a love for.

Duckworth: The most successful people in life are following something that they could say, “I love what I do.” Most people can’t say, “Oh, I love what I do because I make a lot of money or I love what I do because there are free snacks in the kitchen.” Free snacks are great. But loving what you do is a special kind of happiness.

Knowledge@Wharton: You say in your book about when you were teaching in New York City and at times you were distracted by the talent of some of the kids.

Duckworth: When you are working with young people and trying to teach them something, that isn’t just classroom teachers. So many of us are in that mentoring role. [When we’re] trying to teach a young person something new, we can get easily frustrated by the kids who are not picking it up as quickly as we hoped they would or thought they should.

I would often chalk up their lack of learning to their inability, to their lack of talent. Now, I would say that the question should have been, “What am I not doing here as a teacher? How is it that I can get them to learn faster?” It’s extremely unproductive to just lay the burden and the blame at the foot of the student. It’s almost always the case that the teacher could do something differently or better.

Knowledge@Wharton: Do you think we’re going to see a shift in education because of the understanding that this has to be a factor in success for kids growing up?

Duckworth: Yes, I hope there’s a tectonic shift in how we think about learning. We should think about it as something that we do all the time that is massively influenced by our circumstances and not just by some level of innate ability that we think we can’t change.

Even that is untrue. Your ability to learn is something that changes and depends on your opportunities and your experiences. At the same time, I would urge caution. When we swing wildly from one point of view to another and we think, “Oh, well, grit is the answer to everything and it’s all” — that’s got to be wrong, too. It’s got to be that we are judicious and say, “Okay, well, we’re learning something new here, but let’s not get ahead of ourselves, let’s not, for example, assume that Dr. Duckworth knows everything [about] how to change grit, which Dr. Duckworth does not.”

Knowledge@Wharton: You bring up many examples of different people in this book and there were two — they’re at absolute opposite ends of the spectrum. One is Warren Buffet — many people listening to this channel know the level of success that he has had. Another is Will Smith, the actor and (the lead in the old TV sitcom) the “Fresh Prince of Bel-Air.” How did those two play into the theories that you’re trying to bring forward?

Duckworth: The attraction for me to people like Warren Buffet and Will Smith is they’re a success in that I can try to reverse-engineer who they are. Who are these outliers and what are they like? But actually, it’s more that I find them both to be very psychologically perceptive. When you read Warren Buffet’s annual letters, you think to yourself — or at least, I do — “This guy is a world-class psychologist.”

When I listen to Will Smith — I got to listen to him in person recently, but you watch YouTube videos and you read interviews — he is an extraordinarily psychologically perceptive human being. I feel like they have insights that I see in my own research. But the way that Warren Buffet and especially Will Smith express them, they are just way more fun to listen to.

Knowledge@Wharton: If you think about it from a business perspective, many people might say, “Okay, well, that may be something that’s more geared for the arts. You know, if you’re a musician or if you’re an artist or an actor, whatever that might be.” That’s probably not the case. Warren Buffet, I would think, has a level of passion for business that probably not many people have out there.

Duckworth: I don’t think passion is something that was reserved for the creative arts, though, of course, those people are passionate. But I have met midwives who are passionate about what they do.

I have had middle-level managers and salespeople who are passionate about what they do. If you get into something — maybe when you’re 18 — you couldn’t even anticipate, that you would fall in love. But there are elements, like, “Oh, I love working with people and complex problems. I like jobs where I am on my feet all the time and I am outside.” There are elements that are hard to predict in advance, but they do come to define what you love.

Knowledge@Wharton: Perseverance, which is part of your book’s title, is also being able to adapt when things don’t go right and not just — “Oh, okay, well, now I’m done, I can’t complete this project” — but being able to take the turn in the road and get back on path.

Duckworth: In some ways people think that perseverance must mean bull-headedly just heading in one direction no matter what. But when you keep hitting a brick wall, it’s not perseverance to keep hitting it. It’s perseverance to take a step back, maybe a moment or two to reflect and maybe you need to turn left.

The thing to be sticky about, the thing to be tenacious and uncompromising about are your higher-level values that guide what you are doing, that have many roots to it. Oftentimes what it means to be persevering is to take a day off and to get your bearings or to quit a project even and start a new one, because you realize that this is a better way forward.

Knowledge@Wharton: But is it hard for many people to truly understand that and to be able to want to take the step back to take the two steps forward?

Duckworth: Even for me, it’s hard. That’s the only advice I would offer. This is why friends and advisers and former professors you are still in touch with, and sisters and uncles, are all so important, because it is oftentimes more clear in their mind’s eye what the right thing to do is than your own — you’re so immersed in circumstances. One bit of practical advice is — have a few people you really trust and lean on them. Ask them, “Am I being an idiot here? Or should I be doing something differently?”

Knowledge@Wharton: Is that hard to do at times? If you have friends to help you out, that’s a benefit. But I would think it’s hard to do that sometimes in the corporate environment because of how businesses can be structured, although some businesses are changing that kind of philosophy and it may make it a little easier.

Duckworth: It is a reality that corporate cultures don’t reward vulnerability, and reward dependency on another. But truly, the world-class businesses, the ones that are doing the best and will continue to do the best are ones where people come to work and it’s a high-trust environment and they don’t have to lie. They can say that they had a bad day. Or they can say, “I made a bad decision and I need to actually fix it, but first, I need to own it.”

I hope people will end up in the corporations that have positive workplaces. If you don’t, you can still rely on a confidante that is someone that you met early on and that you trust or sometimes it’s someone outside the workplace.

Knowledge@Wharton: This could have an effect on businesses. It may be another one of those ideas that [could have an impact] if you can get that belief from the C-Suite on down. Most companies want to see bottom-line results, but they also want to see their employees successful and happy in the process of doing it.

Duckworth: The wonderful thing about modern psychology on achievement and on happiness is that it does not seem to be an either/or, and it’s not a trade-off. The happiest workers are almost always the most productive ones and vice versa. I’m not saying it’s easy to do, but you can absolutely strive to build an environment that encourages both happiness and success.

Knowledge@Wharton: That ends up being very important for kids, because many people believe that at some level, education has gotten into this hand-holding, of “What can I do for you, Johnny or Jane?” We’ve almost gone way over the edge in terms of trying to help kids out, rather than them learning things and building a little bit of that tough skin on themselves.

Duckworth: Decades of research on parenting confirms that kids need both love and support, and demands and challenges, to do well. So, if you only give one — if it’s only praise — and there’s never a challenge, that’s not good. What we should strive for is challenge plus support. Another fact from the parenting literature is that consistency is much more effective in parenting that inconsistency.

Knowledge@Wharton: If our kids are learning some of these principles and having more grit as they are coming up through school that will play out in college and then into business, what kind of effect will that have on business when these kids get to that level?

Duckworth: To paint a very optimistic picture — it’s a wonderful world. People on the train — when they open their laptops and you get into conversation, they can say, “You know, I love what I do.” They can be engaged in a way that at the extreme, they could say, “Yes, it’s a calling for me.” That would be a terrific world. Sometimes people say, “Oh, what would happen if everybody were like this? Would that be a terrible thing?” I think quite the opposite. I think it would be wonderful.

The seismic shift going on is if you compare how we interact with each other today versus 100 or 200 years ago, we’re much more empathetic and psychologically wise than our forefathers and our ancestors. In general, it’s not just grit, but many other qualities, like emotional intelligence that we’re learning more about. It’s not just the scientists who know about it — it’s everyone, and that’s a good thing.

Knowledge@Wharton: Is it helped or hurt by the fact that we’re in this digital society and we live on our smartphones, and we don’t communicate face-to-face or on the phone as much as we did when we were younger?

Duckworth: I was recently having a conversation with Arianna Huffington, the founder of The Huffington Post. She said one of her priorities is to get people off their devices. I said, ‘wow, when you’re saying that, I think that really means a lot.’ When people spend a lot of time on social media, they think they’re getting social interaction and they think they’re happier, but in many studies, you actually feel worse about yourself — in part because social media paints a very unrealistic view. It’s always sunset and your hair always looks good. And it’s always your birthday and everybody is always beautiful. That’s not reality.

I’m hoping that digital technology enables rather than hinders human development. That’s not going to happen unless we’re intentional about it. If you just let market forces do what they will, you may not end up with digital technology helping.

The Case for UK Import Substitution

Robert Skidelsky
 .Newsart for The Case for UK Import Substitution


LONDON – The most dramatic economic effect of the United Kingdom’s Brexit vote has been the collapse of sterling. Since June, the pound has fallen by 16% against a basket of currencies. Mervyn King, the previous governor of the Bank of England, hailed the lower exchange rate as a “welcome change.” Indeed, with Britain’s current-account deficit running at over 7% of GDP – by far the largest since data started being collected in 1955 – depreciation could be regarded as a boon. But is it?
Economists would typically argue that the way to balance a country’s external accounts is through a fall in its currency, which would make imports more expensive and exports cheaper, causing the former to fall and the latter to rise. Higher import prices – a net loss for the country – would be offset by the higher employment and wages generated by the more competitive position of the country’s exports.
But in order for currency depreciation to work its magic, more demand for exports must be forthcoming when the exchange rate falls (or, as economists say, the price elasticity of demand for exports must be high). But various studies have shown that the price elasticity of demand for UK exports is low. For example, a recent paper by Francesco Aiello, Graziella Bonanno, and Alessia Via of the European Trade Study Group finds that “the long-run level of exports appears to be unrelated to the real exchange rate for the UK.”
This means that British consumers and producers will have to bear the entire brunt of devaluation: their import consumption will be rationed through a sharp rise in price inflation, with no offsetting gain for exports. This is by no means merely a theoretical proposition. In 2008-09, when the rest of the world was on the verge of deflation, the UK was enduring an inflationary recession, with GDP contracting at a top rate of 6.1% annually, while inflation reached some 5.1%. This occurred because sterling fell more than 21%, peak to trough, from 2007 to 2008.
Moreover, although the current-account deficit narrowed to around 1.7% of GDP in 2011, the improvement was only temporary. After 2011, the current account deficit started to widen once more, even though the pound never clawed back its losses. In economics jargon, the UK seems to be suffering from an extreme variant of the Houthakker-Magee effect – named after two economists who discovered in 1969 that price elasticities for imports and exports could diverge substantially, giving rise to a permanent tendency toward current-account imbalance.
The reason appears to be the massive contraction of the UK manufacturing sector – from around 28% of gross value added in 1978 to less than 10% today. As the economist Nicholas Kaldor pointed out long ago, because manufacturing has higher returns to scale than services, manufacturing exporters tend to beat service exporters.
In addition, structural reforms since the mid-1990s have ensured that British exporters are deeply integrated within global supply chains. As a result, many of Britain’s exports require imported inputs; so when sterling depreciates and import prices rise, the knock-on effect on export prices renders them less competitive. The most recent OECD data show that the import content of UK exports is around 23%, compared to around 15% for US and Japanese exports.
For now, the UK is relying on capital inflows into the City of London to limit sterling’s fall. But, as the exchange-rate collapse of 2008 showed, this source of foreign demand for sterling is highly unstable. When the worm inevitably turns and these flows reverse, both sterling and exports will take another hit.
The worst-case scenario would involve a sharp fall in the value of sterling, followed by sticky inflation that reinforced the rise in British export prices, fueling further currency depreciation. This doom loop would stop only when British consumers suffered a fall in real income of a magnitude not typically seen outside developing countries.
The more likely outcome is a sort of slow rotting effect, with periodic depreciations gradually driving down living standards for all who earn their living in sterling.
What is to be done? Only rapid government action to substitute goods currently imported with domestically produced goods will do the trick. The classic solution is import controls. But other measures that are less damaging to trade rules and international amity are available.
The national investment bank which the Labour Party is now advocating could be given a mandate to invest in industries with a high import substitution potential. An alternative would be to subsidize such industries directly from the Exchequer, with subsidies tied to the quality-adjusted price of the import being substituted. As the domestically produced goods became competitive with the foreign goods, the subsidies would gradually be removed and the industry allowed stand on its own two feet.
Ideally, the British government should aim to bring down imports as a percentage of GDP from the current high of around 30% to pre-1974 levels of around 20%. This may prove too ambitious, and the UK may have to settle for somewhere around 25% of GDP. But if something is not done, Britain risks permanent impairment of prosperity. A depressed economy can be reflated, and an inflationary economy can be depressed. But losing access to crucial foreign markets as a result of currency movements outside the country’s control is largely irreversible.

BoE seeks details of UK exposure to Deutsche and Italian banks

Prudential Regulation Authority sent out request as eurozone banks faced market siege

by: Caroline Binham and Martin Arnold in London

The Bank of England has asked large British lenders to detail their current exposure to Deutsche Bank and some of the biggest Italian banks, including Monte dei Paschi, amid mounting market jitters over the health of Europe’s financial sector.

The request was made in recent weeks by the BoE’s Prudential Regulation Authority as investors sold off Deutsche and Monte dei Paschi, both of which have been the subject of scrutiny over their capital levels.

Supervisors worldwide have attempted to curtail the links between large institutions since the 2008 banking crisis, when the collapse of Lehman Brothers and other big groups threatened to drag down the entire global financial system.
The PRA now regularly speaks to banks about their exposures, particularly to any lender that might be facing difficulty. Over the past few years, the BoE has asked about UK-headquartered lenders’ exposure to Greek banks, for example.

But the BoE’s recent intervention is a sign of continued nervousness among regulators that the interconnectedness of Europe’s largest banks could harm otherwise healthy groups if one of the weakest links were to fall into crisis. The PRA declined to comment.

Normally, exposures to other financial institutions are not disclosed to regulators unless they are particularly large or as part of annual stress tests. That forced the BoE to ask for the latest snapshot of the big UK banks’ exposures to their German and Italian rivals as those groups came under market attack.
Deutsche shares dropped nearly 12 per cent last month amid fears it would have to pay the US Department of Justice $14bn for mis-selling mortgage securities. Monte dei Paschi, which is considered the most stressed large bank in Europe, lost 23 per cent.

Banks can be exposed to one another directly through lending or derivatives but indirect exposures — such as lending to a counterparty of a bank in trouble — also need to be considered.

During the financial crisis, the old City regulator, the Financial Services Authority, was pushed to make banks disclose more about their holdings in one another as authorities tried to limit contagion roiling the markets.
Global rules cap the amount that one bank can hold in another to 25 per cent of the first bank’s capital, while anything above 10 per cent must be disclosed to regulators. Smaller holdings are therefore harder for supervisors to spot.

Paul Sharma, a former PRA official now a consultant at Alvarez & Marsal, said large UK banks were now able to monitor their direct exposure to troubled banks on a “near real-time” basis but that market turmoil could complicate the picture.

“A more serious concern would be the indirect exposure to UK banks from the disruption to financial markets that might occur if a major European bank were to fail,” Mr Sharma said.

“This is far less easy to quantify.”

The International Monetary Fund earlier this year labelled Deutsche Bank as the riskiest bank globally, with its investment and banking units making it highly interconnected with the rest of the financial system.

British regulators are particularly anxious about the impact of litigation costs on Deutsche’s already weak profitability and that large piles of non-performing loans could have a similarly corrosive impact on Italian banks.

Deutsche Bank shares fell to three-decade lows last month after it confirmed receiving the $14bn demand from the justice department; no final settlement has yet been agreed but Deutsche executives have insisted the fine will be far lower.

Germany’s biggest bank still faces serious doubts on whether it will need to raise billions of euros of extra capital and slash costs drastically to strengthen its balance sheet and boost profits.

Analysts expect Deutsche to post a net loss of €610m when it reports third-quarter results on Thursday, largely because they expect the bank to take another large slug of litigation provisions ahead of a potential settlement with the DoJ.

Analysts are split on precisely how much the bank will set aside, but their forecasts range from €250m to €1.5bn according to a consensus report compiled by the bank.

Other unresolved conduct scandals still loom for Deutsche, including a probe into whether so-called mirror trades were used to skirt sanctions for some of its Russian clients.

Monte dei Paschi this week unveiled its plan to raise €5bn of extra capital through a mixture of issuing new shares and swapping debt for equity.

Barclays, Lloyds Banking Group, HSBC and Royal Bank of Scotland — the main banks that the PRA oversees — declined to comment. Deutsche Bank also declined to comment.

Additional reporting by James Shotter in Frankfurt