Achieving fiscal solvency by not letting private equity bros torture grandma to death

An idea I hope we can all agree should at least be considered

This is my The Boyd Institute post on how America can escape its fiscal trap, which I wrote because my epistolary buddy Sol Hando specifically called me out and requested it - so just a note to anyone else out there, you should definitely call out posts from Substackers you want posts from! It costs nothing, and sometimes it works.

“How does America escape its fiscal trap?”

Okay, so what IS America’s fiscal trap?

We’re 1 year GDP in debt, about $30T, and this means our debt service is ~$1T or 3% of GDP per year, more than Defense or Medicare.

We take in ~17% of GDP and spend ~23% of GDP every year, federally, and that is guaranteed to grow because of our demographic pyramid (everyone is getting older and having fewer kids) and the fact that healthcare spending is crazy and goes up faster than almost any other sector.

I worry that the numbers I just said seem too reasonable

23% doesn’t seem THAT far off of 17%, right?

But if you think of it purely at a person level, only half of Americans work, around 162M, the rest are dependents, ie old people (~70M), kids (~70M), students (11M), SAHM (11M), or layabouts (~12M).

Just to keep the math simple, from the working people, the government takes in $6-11k in taxes ( $6-7k median or ~$11k mean), and then spends $45k in benefits per working person. That’s a pretty severe mismatch, roughly 4-6x. We do take in some taxes from other sources, mainly corporate taxes and tariffs, but ~84% of all intake comes from income and payroll taxes, and that 16% extra certainly doesn’t close the gap (and honestly, we shouldn’t have most of the tariffs if we care about economic growth).

Most of this $45k, roughly $33k, is entitlements, ie social security and medicare/medicaid. Of the fraction that isn’t, about $12k is spent on defense and education and other “common” stuff that theoretically benefits everyone. So we don’t even break even from our workers’ tax contributions for basic common goods like defense and roads and the NIH and FAA and such.

If you broke down where the entitlements go among the categories, it would be something like this:

Everyone: $6.1k per person (~$12.2k per worker), roughly 29% of all spending

The remaining 71% splits like so:

Workers: $5.4k per worker (20% of spending, mainly Medicaid / ACA, and federal pensions)

Kids: $6k per kid (9% of spending)

Students: $10k per student (0.3% of spending)

SAHM: $10k per SAHM, (0.3% of spending)

Layabouts: $10k per layabout, (0.3% of spending)

Old People: $57k per old person (70% of non-everyone spending), nearly 10x more than we spend on kids, who are literally the future.

The sky vampires

Imagine an infinite array of sky vampires, tiling the sky as far as the eye can see, each one sucking $33k from young working people in some combination of debt, inflation, and taxes, 3-6x+ more than they can actually pay, so it’s mostly directly eating their futures with debt and inflation. This is literally reality.

A barely stylized representation of our current fiscal system

All the sky vampires are rich and old, as befits vampires everywhere - and they have most of the assets in the country.

We spend ~$7T a year in federal spending. We’re taking ~$5T trillions of dollars in taxes AND ~$2T trillions of dollars of debt, all sucked from younger working people, who have essentially no assets, to pump $4 - 5 trillion dollars into old people, who have essentially all the assets, every single year.

The fundamental problem is that people want to work for only ~40 years, but they live until they’re 80 (or older), so they’re not working for half that.

Then our system is so profoundly dumb that we take in their widows mite of taxes during the 40 years (as an example, <$1k a year in the 70’s), immediately spend it, then promise to pay those same people a million jillion dollars every single year for each of the 20-40 years that they’re older and richer and not paying anything in (ie $57k per year now for old people).

What do actually smart countries do? They invest those taxes, so they actually grow over the 40 years, then when things are crazy expensive 40 years later due to inflation and regulatory capture and moral mazes, at least part of the gap has been covered by growth over time. Surprising nobody, we are NOT smart here in the US.

So obviously to close this gap, as with any budget, we need to spend less or make more, and the various framings above can help inform us as to where the leverage is.

Making more

“Make more” can mean two different things - increase taxes, or increase economic growth.

Obviously “increase economic growth” is the better road there, but just as obviously, that’s harder than you might think, especially on a $30T basis. And also, “increasing growth” is already more or less maximally pursued in our current system, in the sense that all the biggest and smartest companies in America are deploying ~$1T+ in Capex building AI minds so capable that they can fire 140k+ employees already.

I am going to ignore “increasing economic growth” as a potential lever in this post, because we should be doing that anyways, the growth interventions aren’t really under direct political control in the same way taxes and spending are, and one can spend less in any future we end up in.

If you Fermi estimate it, we’d need to more than double our current GDP growth rates to even make a dent in our problems over decades. So we’re either in a situation where we will NOT get the outsized growth from AI that most famous economists thinks is impossible, and will need to control spending, or we will be in a growth situation and could still benefit from spending less, and so in this post I will focus on “spending less.”

I will note that I personally think that all the AI talent working on “inventing God and asking Him for money” is actually our best shot at fiscal solvency at this point, and that this shows more than anything how deeply unserious we are about our country and / or existing into the future.

But ignoring “increasing growth” leaves us only with “increasing taxes” in this lever.

So let’s take a look at increasing taxes.

Increasing taxes

I feel like most people think this is a high leverage area, so I’d like to show that there’s really not a lot of leverage here.

As you might or might not know, the top 1% of earners in the US already pay 42% of the taxes, and the bottom ~50% pay only 3% in taxes (nearly all via payroll taxes).

Tax billionaires? Even if we just outright stole 100% of all the money the ~1k billionaires in the US have (~$8T), so the definition of a one-time, one-way move that would immediately ensure everyone with assets and the ability to found companies moved out and renounced American citizenship, we’d be able to take the deficit down by less than 1/3, and we’d still be spending more than we take in every year. It fixes nothing, even in the short term, much less the long term. Also, the ~10M jobs those billionaires have directly created would probably be in danger after this.

And in terms of “ongoing” taxation, the top 1% already makes ~21% of all income and pays ~42% of all taxes. This is WAY more progressive than any Scandinavian country - we have a 2x multiplier, and all the Nords (Denmark, Finland, Sweden, Netherlands) have a 1.6 - 1.7 multiplier. France, Italy, and Germany? All 1.7. We’re already 18% more progressive than all the flagship egalitarian EU countries everyone thinks are taxing people fairly.

Billionaires in particular are able to allocate away from regular income, due to being able to arbitrage corporate structures across multiple countries, allocating income towards capital gains, and taking low interest loans against assets for cash flow.

So not only are we already more progressive than all the flagship EU countries, given those strictures, half of which rely on other countries and fundamental property rights, you really can’t do all that much to move the needle here and tax billionaires more.

Tax corporations? Probably not. Nearly all (84%) of tax intake comes from income and payroll taxes. Corporate taxes currently only contribute ~11% of total tax revenues. If we brought corporate taxes back to the 18% they were before the 2017 Tax Cuts and Jobs Act, this would prospectively net us ~6-7% more of current receipts, which is only ~$300B incremental, basically rounding error on the $7T we spend every year.

Tax regular workers? Definitely a dick move, but you know, it’s the government, those are the only moves they make any more, apparently.

But back to the $6-$11k in vs $45k out discrepancy, it’s pretty obvious there’s not a lot of juice in that squeeze, certainly not enough to close the gap, especially given the median income is $60k pre tax, and they generally pay local and property and sales taxes on top of federal. So you’re going to take 10 - 18% just on federal, then they probably lose another 10% - 20% on the other taxes, and they’re down 20 - 38% and taking home $37k - $48k take home. How much more of that do you think you can even take?? Again, not much. And even if you DID take more, you’re not going to even approach closing the literal ~4-6x gap that exists there at the medians / means. Womp womp.

Tax “rich people?” As we went over, people with high incomes already pay all the taxes, with the top 1% paying 42%+ of all taxes, 2x more than their 21% income share, and people at the medians and below, so 50%+ of the population, paying only 3% of total taxes, all payroll taxes.

Okay, so we already tax rich people. What about “upper middle class” people? A top 20% household income is ~$150k, a top 10% HHI is ~$235k, and a top 5% is $335k. Let’s see how much they’re paying.

Sadly, it’s not a super clean match, these aren’t breaking down by percentiles, but we can eyeball it.

Okay, so top 1% ers (current threshold $700k+ in HHI) are 2x, but the top <10%-ers pay only 1.14x their income share (still more than EU top <10%-ers!), and some top 20%-ers actually pay less than their income share. About 26% of the US is in the $100k - $200k income share bar up there. We can’t address more than half that, because they’re below the $150k threshold, and everyone above that was already paying more than their income share. So it’s maybe 10% of the pop.

When you do the math,¹ you can only get an incremental $24B from these people by moving them to parity in income to tax share. If you move them up to 1.14 like the top 10%-ers, you can get maybe $28B out of them. Even if you doubled it, it’s nothing. Again, we spend $7T a year, that’s less than rounding error, I’m sure there’s Senators literally taking craps more expensive than that, as we speak.

It’s pretty clear there’s not a lot of leverage in “tax more.”

Yes, everyone wants to soak the rich, but we are ALREADY getting more from them than all the flagship EU countries, and nobody else has any money. Additionally, part of being rich is being able to pay accountants and set up trusts and S-corp structures that let you take comp in capital gains and things like that, so we’re already at the part of the Laffer curve where “higher tax rates” is likely to net you “less tax receipts” overall.

Again, we are already more progressive than all the flagship egalitarian EU countries. Tax more? Good luck.

So if increasing taxes isn’t going to do much, what else is there?

Let’s look at our Federal incomings and outgoings

So it’s pretty clear most of our intake comes from income and payroll taxes (84%), and most of our outgoings are healthcare and social security (entitlements), at 60% of outgoings and 74% with debt, which I think is fair to allocate to “entitlements” because we’re literally sky-vampiring all our young people’s futures to pay for it.

So what are our options to spend less?

What about the perennially popular idea of firing bureaucrats? Unfortunately, as DOGE found out, our system is so profoundly broken + dumb that the federal government only employs 2M direct non-defense employees at $300B, it’s why DOGE didn’t work. All the rest are 2-4x as expensive contractors who can’t be fired federally. And $300B isn’t going to make any difference either way, it’s literally rounding error.

All the growth in spending is in entitlements, ie old people, and they’re also the biggest category of spend in absolute terms. This is also going to keep growing as people get older, and as healthcare spending keeps vastly outstripping inflation.

So what can we do about entitlements?

SS entitlements and SSI and other retirement stuff - $2T per year, or ~29% of all federal spending.

Medicare and Medicaid - $1.5T, or 22% of all federal spending.

Together, this is 51% of all federal spending, essentially all going to old people.

Yup, that certainly seems like where all the leverage is. Politicians like to pretend these are untouchable by putting them in a “mandatory” spending category, but you know, that’s obviously fake. Words are just things, and laws are just egregores, as they say.

Why should we pump 70% of all non-everyone federal spending by taking $33k a year from younger working people AND loading them with debt and inflation for life, into the old people with all the assets again?

When SS was originally rolled out, average life expectancy was ~60, and benefits didn’t start until 65. It was an “insurance” type deal, for people whose lifespan outran reasonably projected savings, not a permanent pension scheme for 20+ years. But now people want to work for 40 years, paying the equivalent of <$1k a year in taxes, and then retire for 20 years being paid the equivalent of $57k+ a year in taxes.

But surprisingly, means testing and raising retirement ages can’t really do much to move the needle either

Just one measure here - means testing SS payments, would move the needle only $300B at a fairly aggressive $750k asset cutoff. And it’s worth pointing out that this will not actually result in that stated savings, because there’s already a thriving industry built around partitioning old people assets into trusts and other vehicles to avoid the 5 year lookback rule and maximally soak the government for paying for old people torture-farms / nursing homes, and if suddenly you were doing this on a broader scale, those interventions and that industry is going to be a lot more utilized.

And once again, $300B is rounding error.

If we raised the retirement age to 73, which would move us back to the original 1935 ratios, we’d move the needle by only $300B of savings per year. Once again, practically nothing on a $7T outlay.

Even if you stacked both of these and maximally pissed off every elderly voter forever, you’d only close <33% of the ongoing yearly deficit, so basically nothing, for a move no politician or party will condone, because the infinite vampire-tiled sky of angry old people will vote for the other party forever if it ever happened.

What if we thought about some fair-and-easy-to-understand rules based program?

Classically, people used to have a bunch of kids in the times of high child mortality so enough would survive to take care of them in old age. What if you have enough kids to reach neutrality, then you qualify for your old age vampire trillions?

Let’s look at that.

A simple rules based program, ie if you have enough kids, you’ll have SS and medical care in old age - this also won’t work because it would need to be 6+ kids per person - if the mean taxpayer pays ~$11k and the mean “everyone” tax expenditure is ~$12k, you need 1 kid to pay your “everyone” expenditure, then 5 more to pay for your old age, and you STILL haven’t paid for your spouse or your kids’ government outlays. So, that’s not very practical either, nobody even has kids any more, certainly not 6 kids, only 2-3% of families would qualify, so once again you’re at the “this really does nothing” at any reasonable cutoff, and “angry sky vampires will vote for the other party forever” at any cutoff that did anything that mattered.

So if trying to reduce retirement spending in reasonable ways doesn’t work, where else can we reduce spending?

What’s the other big dog? Healthcare. Medicare and Medicaid together are another ~$1.5T per year, that keeps growing to infinity. It mostly goes to old people.

A large part of this is morbidity and end-of-life care.

Health Interventions

What is the single biggest thing you can do personally to reduce morbidity (poor health) and reduce your all cause mortality? Exercise.

Force everyone to exercise - As I went over in my recent longevity in <20 min post, exercising gives anyone over forty 3-5x all cause mortality buffs, and decades long morbidity buffs. Morbidity is the years (decades) of poorer health and higher medical spend caused by things like diabetes, obesity, CVD, and so on, which to a first approximation affects ~80% of the US population over 40, because ~80% are overweight and sedentary.

And to give you an idea, 3-5x all cause mortality effects are twice as large as smoking, so everyone is doing the equivalent of smoking a pack a day and chugging a fifth of everclear by not exercising.

But as huge as these effects are individually, they would actually be net negative at the fiscal level, because once again, people live for 80 years and want to work for only 40 years, then retire and have infinite money pumped into them by ever-fewer young people forever. The problem is structural.

So even if we mandated that everyone exercise AND made them actually do it, this would just wreck our budgets even more, because they’ll live even longer in the “infinite money pumped into them by ever-fewer young people” regime.

Most spending is concentrated in the last year / months of life, and unhealthy sedentary people only cost $1-$3k more per year until the last 5 years or so, while the exercisers live 5-15 years longer. Disability years are ~2.5x more expensive than healthy years, and exercisers have half as much, but the most this nets is $100k NPV per person, and the exercisers start costing more at about 7 years increased lifespan, because of more total years overall. Exercisers do live 7 years longer, generally 5-15 years. The last year of life, the most expensive medical cost ($80-$100k) and 10% of all lifetime medical costs, is the same for both.

So sadly, although this is certainly optimal for yourself in terms of better and more years, it won’t work at the population scale to save any spend, because people will live longer overall.

So the real problem is becoming obvious, and it’s structural

The real problem is just plain demographics. It’s age - everyone is getting older and living longer, and sucking up trillions from young people while doing so, immiserating the future of their own kids / country.

Nobody is going to have kids, or buy houses, or even get jobs, if literally everyone is yoked to a sky vampire sucking away more than their own take home pay every year, which is where we are already, today.

And this is getting worse! As everyone with eyeballs can see, current generations are fatter and in worse health than prior generations - well, these guys actually did a meta-analysis and crunched the numbers, and twice as many people in current generations are obese or diabetic at a given age as past generations, MUCH more have worse mental health, and more have chronic diseases. Each generation sucks more than the one before it, AND they’re still going to live for 80+ years (probably longer), and they’ll be doing it with much worse health, for many more years. That’s going to cost us still more money, on top of the ever-present healthcare growth in spending. We are systematically set up to fail, here.

Think immigration is the answer? An interesting post by Arctotherium looked at the numbers behind this, to point out that this is indeed a structural problem that immigration cannot solve, because even those immigrants will get older and want to retire for 20+ years, and that 20+ years will be ever-increasing, and the expenses incurred therein will also be ever-increasing. For instance, to use immigration to bring South Korea’s demographic / economic pyramid back to 1980 numbers, would require 5.1B immigrants to filter into South Korea. It’s just vastly infeasible.

The real problem is all those life years! A dedicated smoker or alcoholic who never exercises is actually the true hero we all need, because they die sooner and cost way less over a lifetime.

Which brings us to our more outre, and actually effective, possible interventions.

And before we get into these, I feel like a framing orientation is in order

The dominant option today for those high morbidity and high expense years at the end of life (ie the last 3-7 years) is nursing homes and being in and out of hospitals. Average nursing home tenures are 3.7y for women and 2.2y for men, with about 20% spending more than 5 years in long term care, and about 60% of old people overall ending up in long term care as of 2017.

In terms of hospitals, people generally average 2-8 hospitalizations in their last year, with an average tenure of ~21 hospital days.

Both hospitals and long term care at end of life are terrible. As Scott Alexander famously wrote about in Who by Very Slow Decay, you’re basically putting yourselves into machines that are designed to keep your increasingly-suffering half-corpse alive as long as possible, to milk the most money possible from the conjoined ever-suffering entity of your half corpse + the government.

You will become bedridden, unable to walk or even to turn yourself over. You will become completely dependent on nurse assistants to intermittently shift your position to avoid pressure ulcers. When they inevitably slip up, your skin develops huge incurable sores that can sometimes erode all the way to the bone, and which are perpetually infected with foul-smelling bacteria. Your limbs will become practically vestigial organs, like the appendix, and when your vascular disease gets too bad, one or more will be amputated, sacrifices to save the host. Urinary and fecal continence disappear somewhere in the process, so you’re either connected to catheters or else spend a while every day lying in a puddle of your own wastes until the nurses can help you out. The digestive system isn’t too happy either by this point, so you can either have a tube plugged directly into your stomach or just skip the middleman and have an IV line feeding nutrients into your bloodstream.

Somewhere in the process your mind very quietly and without fanfare gives up the ghost. It starts with forgetting a couple of little things, and progresses until you have no idea what’s going on ever. In medical jargon, healthy people are “alert and oriented x 3”, which means oriented to person (you know your name), oriented to time (you know what day/month/year it is), and oriented to place (you know you’re in a hospital). My patients who have the sorts of issues I mentioned in the last paragraph are generally alert and oriented x0. They don’t remember their own names, they don’t know where they are or what they’re doing there, and they think it’s the 1930s or the 1950s or don’t even have a concept of years at all. When you’re alert and oriented x0, the world becomes this terrifying place where you are stuck in some kind of bed and can’t move and people are sticking you with very large needles and forcing tubes down your throat and you have no idea why or what’s going on.

So of course you start screaming and trying to attack people and trying to pull the tubes and IV lines out. Every morning when I come in to work I have to check the nurses’ notes for what happened the previous night, and every morning a couple of my patients have tried to pull all of their tubes and lines out. If it’s especially bad they try to attack the staff, and although the extremely elderly are really bad at attacking people this is nevertheless Unacceptable Behavior and they have to be restrained ie tied down to the bed. A presumably more humane alternative sometimes used instead or in addition is to just drug you up on all of those old-timey psychiatric medications that actual psychiatrists don’t use anymore because of their bad reputation.

Moreover, did you know that nursing homes and hospital systems in particular are primary targets for private equity?

They’re so rich in excess, and so bloated with administrators and poor practices, that PE guys can often come in and make a bunch of cuts and significantly improve margins. But, inevitably, staffing gets cut, quality of care declines, and coding gaming and overprescribing of profitable meds and interventions goes up, because that’s how the game is played.

Private equity loves torturing old and sick people

Private equity acquisitions of nursing homes / assisted living, hospitals, emergency rooms, and hospices have been increasing.

Here’s just nursing homes:

This covers many hundreds of thousands of units, with ~150k of them attributed to various PE firms by state below:

Do you get worse care in PE homes?

And how! The center of medicare advocacy compares non-PE nursing homes to PE homes, and finds zero abuse in the non-PE facilities and abuse in 26% of the PE ones, more than 15x the number of federal fines, with the fines more than 20x higher, and 12x the payment denials in PE vs non-PE (due to getting aggressive / ambitious with submitted bills).

What about hospitals? A 2025 Senate report finds about PE acquired hospitals that they systematically cut costs in care-harming ways, load them with enough debt to bankrupt them, and then pay themselves massive bonuses - and it should be emphasized, those massive bonuses are literally achieved via more people dying, in aggregate:

“As our investigation revealed, these financial entities are putting their own profits over patients, leading to health and safety violations, chronic understaffing, and hospital closures.”

“Despite gross financial and operational mismanagement of its hospitals, LGP took home $424 million of the $645 million that PMH paid out in dividends and preferred stock redemption during LGP’s majority ownership—in addition to over $13 million in fees—that left PMH in severe financial distress. In order to pay out these distributions, PMH was forced to take on hundreds of millions of dollars in debt, eventually leading to PMH running out of cash and defaulting on its loans.”

And this WAPO article about one of the same (very profitable) PE hospitals avers that:

“They died in hallways. In line. Alone,” wrote the Boston Globe of Steward’s patients. “Their deaths are the human cost of Steward’s financial neglect.”

When it comes to Emergency Rooms, this article goes over them, pointing out that PE ER’s cut staffing, reduce time with patients, impair patient outcomes, and systematically change insurance practices to stick patients with higher bills for those worse outcomes:

“Private equity firms and other corporate interests owned nearly 9 percent of ER doctor groups in 2009; by 2019, they owned 22 percent. The wave of takeovers and consolidations peaked in 2021 but carries on all over the US, especially in Florida, Texas, and other parts of the South and West where the firms have been most aggressive.”

“[T]he owners faced a tough choice: “‘Do I do what is ethical and feels right … and I get a nice going-away party and maybe a watch or something — or do I get $10 million?’”

“To avoid having to negotiate those astronomical bills with the expert hagglers at insurance companies, firms kept their ERs from participating in many insurance networks. It was easier to collect on a so-called balance bill — the portion of a medical bill not paid for by a patient’s insurer — if the care a patient had received wasn’t covered by their insurance at all.”

When it comes to hospice, PE firms have more complaints and deficiencies, cut staffing, and systematically target Alzheimers patients because they’ll live longer and can generate more billing:

This paper analyzes hospice complaints from 2005 - 2015 and finds that for-profit agencies were 1.33 and 1.52 times more likely relative to not-for-profits to have a complaint allegation and deficiency, respectively.

This one points out that PE hospices explicitly target Alzheimers patients at much higher rates, because they’re more likely to live more than 6 months, and they can bill a lot longer for them.

“Doctors have a harder time predicting whether a patient with Alzheimer’s disease or another form of dementia has less than six months to live, the eligibility criterion for enrollment. For-profit hospices enroll those patients anyway, Teno said, and stand to profit the longer those patients live.”

Private equity isn’t who you want to be running health systems.

Although I’m always a fan of cutting administrators, because I think America has a uniquely bad “administrative bloating disease” in most institutions, private equity goes well past that, and systematically impairs patient outcomes, at the cost of people’s health and suffering and lives, while loading their institutions with debt and paying themselves big bonuses. I agree that economically PE has a place, much like vultures and bacteria and other carrion eaters have a place in any ecosystem. But healthcare shouldn’t be “for profit” to begin with,² and you shouldn’t let vultures and carrion eaters dismantle systems in ways that torture and kill people.

Broadly, Private Equity has acquired from 10-30% of the market for most end-of-life care endpoints, and that fraction keeps growing, and the outcomes for patients are noticeably worse. It’s enshittification, but for medical and end-of-life care, and which directly tortures grandmas.

And back to the original For Who By Slow Decay point, even the non-PE ones are already basically hell, which no reasonable person should want for themselves or their loved ones. So “hell but 20% worse” is really quibbling about dust motes while we’re ignoring beams in your eye.

And obviously, PE are just optimizers on the landscape - they’re just taking the portion they’re acquiring to the natural optimization endpoint a little faster, and it’s a good bet they’re going to eat more of that landscape as long as it’s profitable to do so, AND that endpoint is likely to be moved towards even by the non-PE organizations.

Why do we want this?

So it is literally Moloch torturing our elderly for 2-7 years, to milk as much possible money from all of us as they can, keeping their increasingly-suffering half-corpses alive for as long as possible for fun and profit.

Average long term care costs range from $120k - $200k a year depending on geography, and hospitals cost about $5k per night, so the ~21 days in their last year is roughly $100k.

What’s the harvestable surface there? 60% long term care * 70M old people = 49M old people at $150k a year * 3 years + 100k final hospitalization year = $550k times 49M is $27 trillion dollars. And again, that’s current costs, all this is only going up.

Why exactly did we want to pay Moloch / Private Equity bros $27 trillion to literally torture our elderly to death for as long as possible?

Particularly when we can probably come up with several ways where you / they could go out actually enjoying your final years, and / or as a hero to your direct descendants via improving your grandkids’ lives while dying with some actual dignity?

Death with dignity

For myself, this certainly isn’t how I want to die! I don’t want to be tortured by heartlessly amoral revenue-optimizers for years that feel like eternities, just so they can harvest trillions of dollars from me and / or the government!

So what’s a good death?

Obviously the best death is dying in glorious battle and ascending to Valhalla, but since Odin is pretty thin on the ground these days, there’s an older guy in his late 70’s at my gym who routinely pushes 3+ plates in squat and bench who I’ve always admired. My second best death is being older but still in good health, and getting up a monster 5+ plate deadlift in an age-class deadlift record, and going full aneurysm lights-out at the top after successfully grinding it up and locking out. Third best is the perennial “dying while having sex,” like former vice president Nelson Rockefeller or Lord Palmerston, which is only third here out of consideration for the mental health of my inamorta in that scenario (and even then, I feel like the right partner might see it as a compliment that they were so good that you literally ascended to heaven on an O so powerful it turned the lights out on the way out?).

I guess these are pretty hard to arrange or do with any sort of intention.

So what did people do historically to die with dignity?

The Greeks, Romans, Inuit, South Asians, and Japanese in various time periods were all big on suicide, by various means. According to Tacitus, when Petronius found out he was going to get purged by Nero, he threw a suicide dinner party and:

“declined to tolerate further the delays of fear or hope; yet still did not hurry to take his life, but caused his already severed arteries to be bound up to meet his whim, then opened them once more, and began to converse with his friends, in no grave strain and with no view to the fame of a stout-hearted ending. He listened to them as they rehearsed, not discourses upon the immortality of the soul⁠ or the doctrines of philosophy, but light songs and frivolous verses. Some of his slaves tasted of his bounty, a few of the lash. He took his place at dinner, and drowsed a little, so that death, if compulsory, should at least resemble nature. Not even in his will did he follow the routine of suicide by flattering Nero or Tigellinus or another of the mighty, but — prefixing the names of the various catamites and women — detailed the imperial debauches and the novel features of each act of lust, and sent the document under seal to Nero. His signet-ring he broke, lest it should render dangerous service later.”

THAT sounds like a death with dignity!

A lot of elderly Hadza / hunter gatherer men die in hunting accidents or in falls from tall trees while foraging honey. If the tree were tall enough, that doesn’t seem that bad.

I mean, falling out of a tree sounds merely “okay,” but it beats the hell out of being tortured to death for years!

Okay, so what are the themes and elements of a death with dignity here?

1. It’s chosen voluntarily

2. They happen while you’re still physically capable enough to enjoy and do things

3. They often have elements of enjoyment (sex, battle, lifting, dinner parties)

4. They often have elements of social responsibility or contribution (battle, dinner parties, hunting or harvesting honey)

So in our context, any Westerner can hit all 4 marks if they voluntarily decide to do this before their physical decline makes it impossible to enjoy anything or physically carry out any suicidal acts, provided they do so in full knowledge it’s denying private equity / Moloch the joy of torturing them for years and leaving their families and societies better off and with more money, hitting point 4.

So first, obviously a lot of discourse and communication needs to happen here, because right now we do not let our seniors go gently into that good night, we just ignore them and let the private equity bros swoop in and pin them down and start stabbing them with needles for fun and profit when they’re too weak to fend them off. Clearly suboptimal!

Messaging towards death with dignity, particularly messaging that the alternative is the private equity Torment Nexus end that a full 60% of seniors are going to be subjected to, should be societal priority #1 here.

And if we were a FUNCTIONAL society, ie one that doesn’t torture their elderly to death for years via private equity bros, we could actually set up some things to facilitate a happier and quicker end.

What are some options on this front?

1. The Grand Farewell - are you past 65? We want you to actually have some fun in life before you go out! You sign a DNR order, and we will, for FREE, let you try every drug or vice, participate in base jumping, demolition derbies, motorcycle racing, and more. We’ll have special centers staffed with hookers, viagra, gambling, and every drug known to man that are open 24/7, all completely free for our great American seniors! It’s Las Vegas and Burning Man and Red Bull-style extreme games for seniors. Wouldn’t you rather go out with a smile on your face than be tortured to death by nursing homes and hospitals over a decade? I know I would!

Think this is crazy? Think it’s “undignified” for grandpa to go out while actually enjoying his twilight years?

Fine, I’ll stipulate that. I agree, no grandpas married to loving grandmas or tending loving grandkids should do this, let’s just take all fun forever from them, and let them take one for the team and get tortured by private equity bros for years instead.

Even under those restrictions, 46% of 65+ people are unmarried. 30% have no grandkids, as in ZERO grandkids, and that’s getting higher every year. These are HUGE chunks of older people. Let’s call the conjunction a third, and then lets say only half of them, or ~10M, will opt into the Grand Farewell. 15% of the 65+ pop dying 15 years sooner nets you $15T in spending savings,³ AND it’s a much better way to go out than being tortured to death by nursing homes!

And that’s using average yearly $57k values. Because you’re eliminating the last year of life (the most expensive in terms of medical spending), and the 5-10 years prior to that (also more expensive), and the extreme growth in spending that would have taken that to $156k a year (if you average the last 3 years Medicare / Medicaid growth and apply it forward), you actually save more than just taking the average yearly values.

That cranks you up to ~$22T in savings in the aggregate, over the 10M seniors.⁴

Think operating a motorcycle race track and brothel / base jumping center in a mini Las Vegas for seniors is expensive? Not compared to $22T it isn’t! That pays for itself so many times over we’ll probably be tempted to let grandpas, espoused seniors, and non-seniors opt in, which I’m also in favor of - once again, totally opt-in and voluntary. Respect people’s choices to live (or end) their lives as they wish, and definitely a better death than the alternative.

And again, this is maximally conservative, in a no-spouse AND no-grandkids situation. But plenty of people with grandkids and spouses could opt for this too, and each one who opts in is going to save us $2.2M in spending assuming an age 65 exit.

Okay, okay, obviously the gender ratios are going to be pretty skewed here. A lot of old ladies just want to putter around in the garden and watch Matlock instead of going out by doing speedballs and banging three hot 20 year old hookers at once.

What is our option for our old ladies and non-vice oriented male seniors?

What is our neighbor to the north doing? MAID and lots of it!

Canada has gone from ~1k MAID (Medical Assistance in Dying) deaths in 2016 to ~16.5k in 2024 (and an estimated 18k in 2025). That’s ~5% of total annual deaths in Canada now, and it’s now the number one cause of death for anyone there.

Lots of people think that’s a BAD thing, but look at the alternative! Moloch torturing old people for many years is WAY more monstrous! And it’s bankrupting us and immolating all our young people’s futures!

Well everyone knows America is bigger and richer and does things to the Xtreme - we need an American MAID program, and given our absolutely bonkers fiscal situation, we can afford to heavily incentivize it.

Encourage / incentivize MAID at 1/3 the net positive to the government

Why pay awful nursing homes a jillion dollars a year to literally torture you to death when you could go out a hero to your direct descendants and improve your grandkids’ lives?

Once again, the math is pretty compelling - $2.2M per person, and those savings permanently drop out of the federal cost structure.

And even without incentives, the people themselves will preserve significant wealth they can pass down to descendants or charities, instead of paying all that to a nursing home to torture them for years. What do nursing homes cost? The national median is now $115k per year. An actually nice one is $150k+. In Tier 1 cities they run $180k - $200k. That grows to $155k - $300k over 15 years even only using “regular” inflation of ~3%. All this is per year!

And once again, they milk you as long as they can, and there’s a sweeping wave of private equity takeovers of nursing homes, because they’re such sweet targets. You REALLY want to give Moloch / some private equity bros $1M+ of your hard earned money to torture you to death, while your mind goes and every day is an endless hell?? OR you could leave that money to people or causes you care about, AND go out with your dignity and mental faculties intact. Gee, tough choice. Once again, I know which one I’d choose!

So yeah, how about if you sign up for MAID, we’ll give you an extra $500k to do whatever you want with. Give it to people you care about, donate it to a cause you care about - you do you! I’m sure the world will be a better place however you choose to spend it.

Same numbers, let’s say we get only a 15% opt in, or 10M seniors. This saves $17T, because $500k is going to the people / families from the $22T as incentives.

So at a stroke, we’ve just saved $22T + $17T at pretty conservative numbers, WHILE letting 20M fewer old people get literally tortured to death by Moloch / private equity bros.

You know what they say - $22 trillion here, $17 trillion there, pretty soon you’re talking real money!

What does our $39T in savings actually save over 15 years?

$2.6T a year, or more than 100% of our entire annual deficit.

We have eliminated the deficit, and done it by thumbing our noses at private equity bros who want to torture our elderly people for years, AND given our elderly a much more fun and / or dignified death!

Keep in mind the remaining 50M seniors are opting into literally being tortured to death for years, and this is vastly suboptimal for everyone. We should definitely push for moving the opt-in numbers higher on both ends.

If we pushed it to merely half of our seniors being tortured to death, we’d not only have no deficit, we’d have a $2.5T surplus every year.

This makes sense fiscally and morally

And once again, what do you want for YOUR parents? You want them to live the Who By Slow Decay agony, and be tortured by amoral profit-oriented systems squeezing their suffering half-corpses for additional dollars for years?

What about for yourself?? Nobody should want ANY of this!

I’ll stress that this is a strictly better option even if AI takes off and we double our economy and get way richer! Being way richer and keeping the current system isn’t a “win,” it’s a moral monstrosity! You’re going to celebrate the fact that we can keep torturing tens of millions of seniors for years? That your parents, and eventually YOU are going to have that happen to them? Please, listen to your heart, and then your mind! Any reasonable person should be lining up a more dignified exit for themselves and their elderly family members right now!

This is purely a messaging and cultural uptake problem, coupled with Molochian incentives on the hospital / nursing home / private equity bro end. Death with dignity is possible, and it’s only because we’re lazy and don’t want to think about what’s happening to old people that it’s not happening.

What is the solution when dealing with adversarial systems? Don’t opt in!

Don’t eat fast and junk food, don’t install or use gambling or social media apps, don’t lay around staring at screens for ~11 hours a day like the median person. Well, here’s another one to add to the list: don’t let yourself or your loved ones get tortured to death for years by Moloch / private equity bros.

Plan for a death with dignity while you still have physical capacity, and the capacity to enjoy things in life.

Vote and advocate for better options than “being tortured to death by private equity bros,” and “Who By Slow Decay” end-of-life, which nobody should want for themselves or their loved ones.

Not only are the Grand Farewell and MAID better options for fiscal solvency, they’re the better options morally, and they are better options for YOU and your loved ones!

1. So, there’s ~10 % of the UMC here that we might be able to milk. 162M workers, so that’s 1.6M people.

If we brought them up to parity and they paid 25% of taxes to match their income share, we’d get 1.3x more from them. Right now people at the 80th percentile pay a little over $50k in income and payroll taxes. So we’d now get $50k * 1.3x out of them, or ~$15k in incremental taxes per worker over 1.6M workers. 1.5e4 times 1.6e6 = 2.4e10, or $24B.

So $24B in additional tax revenue. Lol. Not really moving the needle is it? Again, we need $7T a year.

2. But healthcare is finite and needs to be allocated according to some rationing scheme! Yes, but we should be allocating by impartial judges (or AI’s) looking at QALY’s per intervention, not by executives deciding they want another ski chalet or a $400M bonus.

3. 10M old people * $57k a year * 15 years = $8.2T in savings, plus the $57k would have grown quite a bit in the 15 years.

Medicare and Medicaid have grown from 4-11% per year every year for the last 15 years. If we average the last 3 years, they’re both at 7-8% annual growth. Even if we take the lower number of 7%, over 15 years, that $57k becomes $157k per year in annual spend in year 15. If you sketch this out by year over the next 15 years, it is $1.5M per person summed over the 15 years.

That’s actually $15T in savings at 10M seniors.

That’s $1T in savings per year AND a much better death.

4. Last year of life: $80k - $100k. With the 7% averaged last 3 years growth rate, this will become ~$300k+ in 15 years.

The last 3-7 years are in assisted living, adding another $100 - $200k at current non inflated rates. Even if they track “regular” inflation which has averaged 3% the last 3 years, it becomes $155k - $300k per year over 15 years. So the last 3 years of life will cost $225k * 3 + $300k hospital bills in 15 years, or $975k. Let’s call it $1M.

Now the “regular” spending on seniors over the 12 years before this, with the spending growth over 15 years (using average of last 3 years YOY growth) was calculated in footnote 1, and will be ~$1.2M over the 12 years leading up to the last year of life.

Total savings: ~$1.2M + $1M last year of life, means $2.2M in savings per participant. Over ~10M participants, that’s $22T savings.

The funniest part about this is that given the median / mean taxpayer discrepancy, and the fact that you only break even in government spend vs taxes if you pay a top 5% income tax rate for 40 years, I’ve literally just proved that it’s 100% net fiscally positive for the government to kill as many non-top-5%-income people as possible. Like, vastly net positive. I really hope nobody in government crunches the same numbers here.