Health Reform: Changing the Insurance Model
At 18% of GDP, health care is too big to be revised in one step. We advise collecting interest on the revenue, using modified Health Savings Accounts. After that, the obvious next steps would trigger as much reform as we could handle in a decade.
HEALTH SAVINGS ACCOUNT: New Visions for Prosperity
If you read it fast, this is a one-page, five-minute, summary of Health Savings Accounts.
Second Edition, Greater Savings.
The book, Health Savings Account: Planning for Prosperity is here revised, making N-HSA a completed intermediate step. Whether to go faster to Retired Life is left undecided until it becomes clearer what reception earlier steps receive. There is a difficult transition ahead of any of these proposals. On the other hand, transition must be accomplished, so Congress may prefer more speculation about destination.
Handbook for Health Savings Accounts
New volume 2015-07-07 23:31:01 description
Consolidated Health Reform Volume
To unjumble topics
SECTION THREE: Classical Health Savings Accounts: Many Surprises
Let's do some simplified math. The ancient Greeks, possibly Aristotle, discovered that money at 7% interest will double in ten years. By remembering this simple accident, you can follow the math of Health Savings Account in your head, without writing anything down. If you remember that life expectancy is now 84 years, you have eight, going on nine, opportunities to double your money. Go ahead and do it: 2, 4, 8, 16, 32, 64, 128, 256, 512, 1024. At the rate things are going, a dollar at birth becomes 512 dollars at age 90, and it isn't unreasonable to hope for a thousand-fold increase in the future.
The current expectation is an average of $350,000 in lifetime healthcare costs per person. A gift to the newborn of $350 will almost pay for it. If he sets this aside for a lifetime, forgets he has it, or just doesn't spend it, it will cover his costs. Medicare is about half of the lifetime cost, so $175 at birth would pay for a buy-out. The individual is already paying a quarter of Medicare as payroll deduction, and another quarter as premiums. So, it would cost something like $87.50 at birth to pay for the rest. Whether it's a gift of his family or a government subsidy, that is manageable. It's close, but it's manageable.
How do we get 7% interest? We assume an index fund of the total stock market will produce 11% per year, because that's what it produced for the past century, in spite of wars and recessions. We assume 3% inflation, for the same reason, leaving 8% net return. Because every 28 years on average we have a "black swan" stock market crash of 30-50%, you have to ride it out. Therefore, the conventional advice is to invest 60% in stocks and 40% in bonds, reducing your net return to 5%. But unlike a college or a museum, we have no payroll to meet, so we only use 60/40 after the age of 50, when major illness costs begin. That brings us up to 6.5% overall after the HSA gets past its early transition costs. Since index fund investing is now readily available for less than a tenth of a percent management cost, we ignore the present fees of ten times that, which are customary. If you are forced to it, just put the certificate in your bank lockbox and have it opened when you die.
How much you actually invest at birth, or whether some other payment method is employed, are political decisions. The point to be made right now is that passive investing of this sort is close to being feasible. It is close, but a cure for cancer or diabetes might make it a sure thing. The points to be made are two:
1. Adopting this approach with the Classical Health Savings Account, may or may not pay for the whole health system for everybody, but it would pay for a mighty big chunk of it.
2. The rest of this book attempts to find a few other improvements which really would pay for the whole system with some confidence. There's no way to prove it was successful except to conduct some pilot programs. I would expect that dozens if not hundreds of other people would try to find other refinements.
That's the good side of C-HSA. What continued to bother me was it was close to providing lifetime healthcare financing, but without much latitude. Perhaps it would be better to settle for half, or a quarter, which would certainly have plenty of latitude for revenue shortfalls. Better still, perhaps a way could be found to phase it in, but stop when it runs low on money. Because it contained so many little pleasant surprises, however, I decided to press onward to see if others could be found.
Whole-life insurance is more profitable than term insurance, but it requires more capital.
What emerged were these new ideas:
1. Multi-year policies. To go from a term-insurance model to a whole-life model, using the life insurance approach. This would take advantage of the uptick of the yield curve in compound interest discovered by Aristotle long ago, inflecting at about the forty year mark. And advances in science would provide some extra years of longevity, to take advantage of it.The addition of some or all of the above seven or eight features would provide more than enough extra money to fund the entire medical system until such time as it was forced, by scientific advances, to become a retirement fund with a small medical component. We have the rough estimate of $350,000 average lifetime medical cost, but no way at all of judging the average retirement cost, so this concept will have to terminate in fifty years or so, or when the data catches up with the theory. After all, the limit of desirable retirement income is not infinite for everybody, but it is obvious it is infinite for some people.
2. Escrowed Sub-Accounts. Instead of one big balance, it became apparent that some funds were intended for long-term use, and were therefore entitled to different interest rates ( checking account, savings account, investment account), which the account manager would wish to have locked for a given time or purpose (66th birthday, ten-year certain, $10,000 minimum, etc.).
3. No age limitations. Further longevity could be introduced by making HSA a lifetime compounding experience, cradle to grave, but how to fund it remains an issue concentrated on the life alternatives facing those, age 21-66.
4. Birth and death insurance, catastrophic, disability, etc. Exploring the idea of HSA from birth, I came to realize the extra cost of the first year of life was a serious impediment to all pre-funded health schemes, since one can scarcely expect a newborn child to finance a debt of 3% of lifetime costs, in advance. To make matters worse, the same is even true of the 8% of lifetime costs up to age 21. Thinking that one over, I came to see why nobody had ever devised a really adequate scheme for lifetime coverage. Seen in that light, it became clear the consequences justified solutions which might upset ancient viewpoints about a vital and sensitive subject. Whether recent turmoil (about same-sex marriage, unmarried mothers and the like,) would soften resistance or harden it, was just a guess. The result of this thinking was birth-and-death insurance, covering only the first and last years of life. Furthermore, it became easier to contemplate the issue of perpetuities, or inheritance from grandparent to grandchild. The laws already sanction inheritance to 21 years after the birth of the last living descendant, generally adequate for the purposes in mind here. All such special-needs insurance tends to reduce the remaining liability of general-purpose insurance, and typically is not workable unless the two insurers coordinate with each other and keep adequate records of their compacts.
5. Passive Investing and Dis-intermediation.The whole concept of "passive" index investing was borrowed from John Bogle of Vanguard and Burton Malkiel of Princeton. Recent difficulties in the fixed-income market make stocks seem just as safe as bonds to more people, and generally they provide more yield. The historical asset tables of Roger Ibottson of Yale inspired further confidence in the approach. Having absorbed this lesson, the concept of replacing an advisor with a safe deposit box emerged, although custodial accounts are not expensive. This maneuver could shift the "black swan" risk from the agent to the investor, assuming the agent has not shifted it, already. Ownership of common stock may not be entirely perpetual, but partial ownership of an index fund containing a trillion dollars worth of common stocks, certainly does seem perpetual enough for ordinary purposes.
6. Zero-balance protection devices. The potential that someone might figure out a way to game this system had to be considered, in view of the staggering magnitude of this proposed funding system if it caught on. The brake which suggested itself was to force the balances to return to zero at least once in a time period, and possibly many times oftener, if necessary. Offhand, I do not see how this system could be gamed, so the power to impose zero balances at a trigger level of balance, is a credible threat if it impends.
7. Total-market Index funds as a currency standard. One throw-away idea emerges from this analysis. The world economy went off the gold standard some years ago, and since then has adjusted its currency by inflation targeting. In the recent credit crash, however, the Federal Reserve has been unable to reach the 2% goal for some time, for unknown reasons. If the reason for this remains unclear, or if the reason is unsatisfactory, it seems to me the total market index of the nation's common stock would be a superior proxy for re-basing the currency on the national economy. If other nations copied this standard, their central banks could agree on a system of leveraging it between currencies, but the essential fact would remain that each nation's currency was a proxy related to its national economy, ultimately based on the marketplace. That might even restore matters to where they stood before 1913, when the Federal Reserve was created. This certainly would be superior to what some people accuse the Federal Reserve of plotting (expunging our considerable debt to the Chinese by inflating our currency.) As people say, this matter is above my pay grade, but it certainly would have the advantage of stabilizing the medical system, and ultimately the retirement system. The need for protection against bit-coins might be kept in mind. If it prevented entitlements from off-the-books accounting, I would consider index funds as a currency standard, a considerable advance.
This synopsis of the additional concepts for Health Savings Accounts concentrates on paying for healthcare with a cash cushion in reserve, so it does not dwell on technicalities, favorable or unfavorable. It does however skip over one theoretical issue of some importance: where does this money come from? Linked to that is the wry observation that it proposes to reduce medical costs by spending gambling money from the stock market. Since people who would say that, show no reluctance to hurt my feelings, let me make a forceful reply.
The designers of the Medicare program in 1965 faced a huge transition problem, too, and nevertheless, plunged ahead in spite of badly underestimated future costs. So, although revenue surfaced in the HSA proposal had been there all along, it was never gathered and put to use -- wasted, let us quietly say. I do not blame Wilbur Cohen or Bill Kissick for making concessions to get it started. There is little else they could do from 1965 to 1975 except adopt a "pay as you go" strategy. But sometime after 1975 that was no longer the case, and the new opportunity was neglected in a befuddled realization that costs were going to escalate rapidly, although hidden from sight. A great many free-loaders were added during the transition, and there was little to do except wait for them to die. So, yes, things were allowed to get worse than they needed to get, but as a nation we happened to be even luckier than we deserved to be, as scientists eliminated dozens of diseases we might have had to pay for. Until the end of that race between costs and revenues had come into sight, it was not possible to guess which one would win.
So now it is our turn to make proposals. We must face similar daunting problems of transition by a partially paid-up constituency, headed into a fully-expanded set of benefits for at least thirty years. Plus a huge and undeclared national debt from borrowing to pay for previous mistakes. I have tried to be generous in my assessment of the 1965 achievement, which was considerable. Let us see whether the opposition party can bring itself to respond generously and without intransigence, however vigorously they may subject the issue to adversary process. It doesn't mean to be a punishment, it means to be a rescue.
The cost of retirement living is probably already larger than the average lifetime cost of healthcare, or about $350,000. That's almost the same as saying nobody but a millionaire has a chance. But longevity is constantly lengthening, and healthcare will probably get cheaper eventually. So right now, retirement at $35,000 a year for 20 years is twice as expensive as healthcare, retirement at age 60 for 40 more years would cost four times as much as healthcare. Somewhere along the line, someone will suggest we make healthcare a minor component of retirement costs and roll the two together to save administrative costs. By that time, I expect healthcare to be largely an experience of retired people, anyway. With half the nation retired, the architects will have to design housing for that expectation. But the greatest challenge will be to find something for those people to do with their time. It might as well be -- it almost has to be -- something remunerative. Even assuming unlimited wealth, it's pretty hard to imagine people going on four ocean cruises a year, year after year. Or playing eighteen holes of golf, six days a week. I've known a few people who did things like that, but it's hard to imagine a whole nation doing it. And out of that synthesis will come some way to pay for retirement, including healthcare.
Buy and Hold. Don't pay high fees. 6% Returns or Know the Reason.
The alternative is to have no money. Alternatives to watching television aren't attractive, and in fact, they aren't much different from going to jail, except it is reported it costs more to be in Leavenworth than to go to Harvard. It's sixty or more years into the future, so it isn't my problem to re-design a civilization to fit its coming demography. All I can do is mention that having a regular check come in, won't be enough to occupy the time of half the country, so they better get started, developing something else. Meanwhile, here's how to arrange to get that check
For most of the past decade, saving for a rainy day has been in an interest-rate environment which made the usual saving process almost useless. Let's compare today with a generation ago. When my mother died at the age of 103, she had been living for decades on her savings account at the bank, with certificates of deposit and interest rates which were quite generous. She had a few stocks, but interest on fixed-income sources was the main thing, not just for her but for all the elderly folks in her generation. Well, for nearly a decade things have been entirely different for investors. The government has been trying to fight a recession with zero interest rates, and the Federal Reserve has accumulated trillions of dollars worth of bonds it will someday try to sell. Much of this has been financed artificially in ways most of us could not possibly understand, but we do understand two things:
1. A lot, if not most, of this maneuvering, has been at the expense of old folks. They were taught to depend on a fixed income, but interest rates right now are smaller than the rate of inflation, while the price of bonds has been driven high by the government owning trillions of them. They threaten to crash if things go back to normal, so somebody wants them to remain low. The Chairman of the Federal Reserve wants to be calm and reassuring, but essentially admits she isn't certain what to do.
2. When the Federal Reserve starts to raise interest rates back to normal, it will sell bonds, perhaps trillions of them. The bond market may not plummet immediately, but only if the Federal Reserve makes spelling mistakes. Cash may be king in this situation, but only if investors don't freeze, like deer in the headlights..
So, It's a little hard to imagine buying bonds, living on bank accounts, or doing most of the other things we watched our parents do with great success. That would include Health Savings Accounts, wouldn't it? No, it wouldn't. The HSA is a good place to buy common stocks, and the best of all places to park your spare cash. You can invest in anything you please with HSA, with or without coupons, because a tax-free account doesn't care about tax consequences. If your HSA has any limitations to what you can do, it must be caused by your broker or your advisor, not because the HSA program gets in the way. Overfunding the HSA account is always a good alternative, although mostly a passive investment in a low-cost index fund of the entire American market will work out better. Let's put it this way: if you start investing when you are fairly young, you will probably come out well enough. If you start investing when you are nearing retirement age, you had better be lucky, because you won't have time to ride it out.
1. The first weapon you will have is compound interest. It has great power because its secret is its effective interest rate rises at the far end. A small amount early in life is better than a big amount near the end, but any time is better than never. The tax-exempt feature is a treasure. Thirty years extra longevity this century extend it longer, and longevity continues to increase. But remember this: the net income must be larger than the rate of inflation. If you don't know the rate of inflation, just guess it is 3% a year.
2. The second weapon is passive investing. Don't try to beat the market, just try to equal the market, and you will eventually get where you are going. But don't pay high fees. Lots of brokers have great track records until you subtract their fees. In fact, it is probably impossible to have a great record unless you charge low fees. Instead, buy an index fund of the entire U.S. Stock market, and act like you forgot you have it. And don't establish a Health Savings Account with the first agent you happen to meet. I once overheard my mother advising my daughter, "Don't marry the first man who asks you."
A standard deviation is the amount of deviation which is seen in two-thirds of cases, and usually refers to the minor dips and bumps seen in a year. The standard deviation of the stock market in a year is about 2% -- and can be ignored for this discussion. A much larger set of crashes occurs about once every thirty years and is characterized by a crash of 30 to 50 percent. No one can afford to ignore something like that.
Protecting the investor against black swans is one of the few legitimate reasons for an investment return of less than 12%. Let's first look at how most big endowments handle the issue. A museum or university typically depends heavily on its endowment to keep it going. If it spent the full 12% of potential average endowment income in the good years, it might be unable to keep its door open during a black swan. It could set aside 30-50% of its endowment as a reserve for such contingencies, but income between recessions might go up to 15% and they would have missed it. A more conventional response has been to adjust the investment portfolio, so it maintains an annual investment return from a portfolio which is 60% stock and 40% bonds. In the long run, that typically starts with a stock return of 12% and reduces it by a third to 8%, while investing the remaining third in bonds yielding 5%. Unfortunately, the long term experience is that inflation will nevertheless reduce all yields by 3%. So by prudent management of the endowment, a stock market yield of 12% is reduced to a spending rule of 5% (after inflation) representing what can safely be spent. Ouch! .
30% Dips, lasting several years, Every 28 years, on average.
Now, just a moment. We are talking about a Health Savings Account, not a university or an art museum. We aren't paying a big staff during hard times, we are investing for the far future, except for the fact the far future holds a different sort of terror for some than for others. The young person may think he needs to pay his rent more than his drugstore bill. But he has so many years ahead of him, that may prove to be a very bad bargain, since depleting his account by a few hundred dollars may cost him thousands of dollars after he retires. If he can possibly borrow from his family, or reduce his college expenses right now, he should try to do it. A table should be prepared by his financial advisor at the HSA to convince him what is in his true best interests. It's a decision he should agonize over, not act on impulsively.
The converse is obviously true of a seventy-year-old, choosing between a new car and botox injections. Either one might be fine, but growing a fund he will never live to spend, is not so smart. And there are hundreds of situations between the two extremes. Here's one possible alternative, which straddles the issues:
Although the majority of situations vary from one extreme to the other in response to how old the person may be, financial managers often prefer solutions which tend toward one-size fits all because it creates a bigger pool, and maybe better returns. But it definitely wouldn't be wrong to get better returns for a little more risk. Especially for younger people when better returns cast a long shadow. Perhaps the portfolio should have a larger common stock content for clients up to age 50 than 60/40, perhaps 80/20 or even 90/10. The age of 50 is selected because health problems tend to increase after age 50. Or the ratio might be adjusted for the increased obstetrical costs of age 25-35, particularly for females. Actuaries should be consulted for more complicated issues. Since we definitely frown on kickbacks and other manipulations, perhaps fees should reflect the value of actuarial advice of this sort.
A recent article in the Wall Street Journal announced to the world that Health Savings Accounts were a better bargain for the investor that was 401(k). That's certainly true if you spend the money in an account for approved medical expenses, or if you roll it over into an IRA at the time you receive Medicare. But it's also even arguably if you spend it in any other circumstance.
Let's put it this way: If you had an IRA or 401(k) but not a Health Savings Account how would you justify it? The HSA gives a double tax exemption for health services, but you are no worse off if you remain healthy. Of course, you are better off with an HRSA. Of course, that may change, but then the oceans might someday pour over Chicago.Most of the arguments for having an HSA rather than a 401(k) boil down to saying they are the same thing, but HSA gives you some healthy options in addition, so why not have them. However, it is possible that your employer has selected a poor 401(k) vendor, one who adds unnecessary fees and requires investments which themselves have poor performance because they are loaded with more fees. So, if you are dissatisfied with 401(k) results through your employer, you may wish to shop around for a better deal, and you might as well pick one with some health benefits attached. After all, the Affordable Care Act mandates high-deductible insurance, so that part of the requirement is likely to be fulfilled already. Since you picked it because of disappointment with your employer's 401(k) investment results, you may encounter some resistance from the Human Relations Department. All in all, there is little value in switching until the employer mandate issue is settled -- except the value of the uproar you create, trying to get treated more fairly. However, there are a few other issues if you have an agreeable employer.
Well, you can't have an HRSA if you are under 21, over 65, or covered by a health insurance policy that doesn't have a high deductible. The Affordable Care Act mandates high deductibles for everybody, but there are still occasional loopholes, probably soon to be closed. If your policy has co-insurance features, that's actually probably an argument to switch out of it. You can't have an HSA if you are also covered by some other government plan. All three plans are sometimes subverted by self-serving intermediary fees, but you just have to shop around for the ability to choose your own investments. That may cause you to pick an inferior health insurance plan, so keep looking. Eventually, some people will reach their limits and need more than one retirement plan, but that's different. Although Health Saving Accounts are spreading nicely, there must be a hundred million people who have no reasonable answer to the question of why they have a 401(k) but not an HRSA, so please read on.
Claims Adjusting for Trivial Claims. In the first place, the HSA wanted to make it possible to skip the middle-man cost and oversight, and simply pay bills with a debit card. So an "allowable" medical expense is more broadly defined than what a health insurer might allow, or at the very least it dispenses with the cost (and delay) of insurance review prior to payment. Since the Account part of the HSA was mainly intended to pay for deductibles, it didn't seem cost-effective to subject extra costs to fruitless but expensive insurance scrutiny. It also eliminated the delay occasioned by remaining on the desk of the hospital billing department for several weeks before someone submits it to the insurer to pay -- when the debit card could just as well have paid it immediately. Just how much these thoughtless design features actually add to the cost is uncertain, because it's used as an excuse for delays which may have other causes.
Skipping Insurance Claims Entirely for Small Claims. As things have turned out, forty percent of HSA accounts have never submitted a claim. Maybe they don't get sick, but more likely the client calculates it is cheaper for him, in the long run, to pay his small out-patient charges in cash, while letting the Account gather compound interest. Aristotle is said to have complained that most debtors don't realize how compound interest is itself compounded, and rises with time. But maybe debtors are now smarter than Greeks in a Toga. A debit card directly adds 2% to the cost, while interest rates vary with the economy. Incurring costs greater than the net is a waste of money, largely growing out of a supposition the employer is paying for this as a gift, and taking a tax deduction at higher corporate rates. That's only true half the time, but the other half hasn't marshaled their lobbyists to equalize the tax exemption. Apparently, Congress believes the self-employed don't deserve this tax exemption as much as employees of major corporations do. Or possibly eighty years isn't long enough for Washington to fix the flaw. Let's go on with this, a bit.
Non-trivial Returns From Saving Small Scraps. We were saying HRSAs were a better investment than 401(k). To go forward with the logic, the client is effectively taking out a loan from his 401(k) when he pays his medical bills from it, or in cash if the purpose is to preserve the preferable interest-bearing account. Assuming both accounts pay the same (you didn't get sick), the result is a wash. But as time goes on, the effective compound interest rate will steadily rise; so the extra profit was made without incurring any extra risk. That may not seem like much until you employ the old maxim that money at 7% will double in ten years. Two, four, eight, sixteen, thirty-two -- it rises 3200% in fifty years. The stock market may rise or fall during those fifty years, and the client may get any one of a thousand diseases. Inflation may intervene, wars are likely to break out. But the relentless superiority of this riskless choice will persist. And get this: at the conclusion of the exercise, the client who gets sick pays no tax, while the one who was scared to do it, pays the higher progressive tax rate he attains later in life. The hypotheticals have to be carefully chosen to reach any other conclusion. But remember to get started young, because to wait ten years will reduce the multiplier from 32 to 16. The millennial generation complains the tax laws are stacked against them, but I don't see it. They are offered the chance of a lifetime, but they will only get one bite at the apple.
Is that all? Well, no, but there are competitors. The deposits in a Health and Retirement Savings Account, just as surely as the deposits in a 401(k), are occasionally subject to rather extreme middle-man costs. The stock market has steadily risen by 11% for the past century. Never mind that it's true past results can be unsound future predictions, just recall that even the "buy and hold" philosophy has seldom presented the investing customer with more than 5% net-of-inflation return. That's because inflation took away 3%, and hedging against "black swan" crashes (by putting 40% of the portfolio into bonds) has taken away 2% more. That leaves about 1% for the customer and the broker to fight about. More than anything else, this slim working margin has driven the investor to choose "buy and hold" over "market-timing". The evidence continues to accumulate that "buy and hold" is at least as successful as "market-timing", but people continue to market-time when they are desperate for the occasional big winner, never mind that big loser outnumber them. To me, the conclusion is clear the public will increasingly squeeze their friendly advisors for a wider slice of the pie. And in this, our central theme is repeated; the HRSA will out-perform the 401(k). Because the shopper for an HSA manager is the customer, whereas the choice of a 401(k) manager is made by the employer. Pass all the laws you wish about kickbacks; allowing the customer to select the manager will usually beat letting the employer do it for him. There's often nothing so expensive as getting something free.
A subscriber with both Medicare coverage and an HSA may die with a balance left in his HSA account. That's what we would like to see since it suggests ample provision for two universal needs. But what is the most useful re-direction of the surplus? Having died he can no longer use it, and his will may or may not indicate his wishes. True, he originally deposited the money in the account but escaped income tax, so the government retains some sort of ownership right to the principal and its income.
If the government follows my suggestion, it will have established a first and last year of life re-insurance program. In that case, a thing likely to result in a surplus at grandpa's death would be to use it to reduce the cost of health insurance for the grandchild. As they say, possession is nine-tenths of the law. Here, it seems a valuable thing to encourage, since it reduces the reluctance to fund the health expenses of a vaguely-related or even unrelated grandchild. Society not only has an incentive to soften the burden of maintaining the population but it probably also has the incentive to diminish its frictions. The less it costs, the more it eases the friction of odd-ball relationships, making it less likely for divorces, gender-changes and unrelated hostilities to end up in court. It thus suggests a welcome candidate for a default use of the money. Everyone who considers these matters deeply should remember, the traditional judge of such matters once was the family unit.
Having considered such a contingency, the next question arises whether all surplus in the HSA of someone who dies should be treated the same way-- that is, adding it to a first and last year-of-life pool. It would thus assist a basic function of everyone, and leave the burden of proof on those who feel a particular family situation has a higher claim on the money than society as a whole. A somewhat different approach might be to recognize newly-deposited money in an HSA is mostly original fully-taxed money, but over time a growing proportion of it comes from investment interest on the tax deduction. That is, the funds of younger people are mostly their own, but toward the end of life, the government tax exemption has a growing claim to ownership. It would not seem unreasonable to switch the ownership presumption at the age of retirement, or some other surrogate for advancing age and changing responsibilities. These things change with time; consider how many orphanages there were a century ago, and how few there are today.
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