So, the lefties took one of their pet problems to the UN. Result?
barely productive wrangling among thousands of negotiators, and the threat of a complete breakdown in talks
It's hard to find anything that 193 countries agree on, and it's downright impossible to negotiate when all those parties must have their say.
the United Nations climate negotiations will never quite work
Indeed, the logo for the Copenhagen conference shows circle of 192 crisscrossing lines. This pattern is meant to symbolize how interconnected we are. Instead, it looks like a ball of tangled string.
As if any of this is new. As if this hasn't been obvious for the past, oh, 40-50 years.
Monday, December 21, 2009
Thursday, December 17, 2009
Tam Got Me Thinking about Auto Racing
repost from my comment on her blog:
My favorite auto racing story is the 1935 German Grand Prix. Nine Nazi-funded state-of-the-art Goliaths versus one Italian Tazio Nuvolari in the David role, driving an obsolete, underpowered Alfa Romeo for Enzo Ferrari. Hitler was there, and eager to see one of the German cars to win. He'd heavily bankrolled Mercedes and Porsche. The German cars were technically superior in every way, and their teams were professionally organized in a way that would be recognizable to a racing team manager today (not so the disorganized French, British, and Italians). The track was the legendary Nurburgring, a 14 mile suicide circuit through forested mountains. Manfred Von Brauchitsch, nephew of the Generalfeldmarschall, held an apparently insurmountable lead going in to the the last few laps. Nuvolari drove brilliantly the entire race, just to keep his hopelessly outclassed car in the hunt, but going into the last few laps he began performing miracles, gaining on Brauchitsch, maintaining the pressure, and forcing Brauchitsch to out drive his tires. Nuvolari nipped him at the wire and stole the German GP from under Hitler's nose.
I can't believe this thing hasn't been made into a movie.
Here is a highlight reel of the race on YouTube:
The white (silver) cars are the Germans. The dark (red) one is Nuvolari.
Watch Nuvolari dirt track sideways at about the 43 second mark. Dude had some serious stones.
My favorite auto racing story is the 1935 German Grand Prix. Nine Nazi-funded state-of-the-art Goliaths versus one Italian Tazio Nuvolari in the David role, driving an obsolete, underpowered Alfa Romeo for Enzo Ferrari. Hitler was there, and eager to see one of the German cars to win. He'd heavily bankrolled Mercedes and Porsche. The German cars were technically superior in every way, and their teams were professionally organized in a way that would be recognizable to a racing team manager today (not so the disorganized French, British, and Italians). The track was the legendary Nurburgring, a 14 mile suicide circuit through forested mountains. Manfred Von Brauchitsch, nephew of the Generalfeldmarschall, held an apparently insurmountable lead going in to the the last few laps. Nuvolari drove brilliantly the entire race, just to keep his hopelessly outclassed car in the hunt, but going into the last few laps he began performing miracles, gaining on Brauchitsch, maintaining the pressure, and forcing Brauchitsch to out drive his tires. Nuvolari nipped him at the wire and stole the German GP from under Hitler's nose.
I can't believe this thing hasn't been made into a movie.
Here is a highlight reel of the race on YouTube:
The white (silver) cars are the Germans. The dark (red) one is Nuvolari.
Watch Nuvolari dirt track sideways at about the 43 second mark. Dude had some serious stones.
Three Health Reform Constituencies
It's pretty clear that something will be passed through Congress and signed by the President, and that something will be labelled "health reform." How each person reacts to the passage of this bill will be a strong predictor of their membership in one of the following groups.
Serious Students of Health Policy
These folks generally recognize that the legislation being proposed does not even begin to address the daunting structural and fiscal problems in our health care system. People in this group do argue about exactly what should be done, but they're pretty much agreed that this mess isn't it. These people recognize that this legislation is, for the most part, a mega-$ handout of taxpayer money to insurance companies.
If you went in believing that reform was needed, but you're utterly demoralized by what's emerging from the process, you're in this group.
Paranoid Big Brother Conspiracy Theorists
These folks look at the proposed legislation as yet another example of Big Government encroachment into private life, and despite their often loony antics, they do have a point. The most substantive element of this legislation is the government holding a gun to everyone's head and saying "buy health insurance... or else." Throw in the fact that the people with guns held to their heads will mostly be the uninsured poor for whose benefit this reform was supposed to be in the first place, and that the main beneficiaries are the insurance companies who were originally made out to be the villains, and you've got to admit, there is a serious Orwellian vibe going on here.
If the impending passage of this bill makes you want to go scream your lungs out at a Tea Party Rally, or stock up on ammo and surgical gauze, you're in this group.
Big Obama Fans and Democratic Party Loyalists
These people are mostly focused on Scoring a Win. Who cares about the details? If we can get this thing through Congress, we can claim victory over the vile, hated Republicans. Hooray!
If you are enthusiastic about the passage of this bill, and ready to hail its passage as Unprecedented and Historic, you're in this group.
To you I would say congratulations on winning the Big Game, but please do not pretend that you have accomplished anything meaningful here.
Serious Students of Health Policy
These folks generally recognize that the legislation being proposed does not even begin to address the daunting structural and fiscal problems in our health care system. People in this group do argue about exactly what should be done, but they're pretty much agreed that this mess isn't it. These people recognize that this legislation is, for the most part, a mega-$ handout of taxpayer money to insurance companies.
If you went in believing that reform was needed, but you're utterly demoralized by what's emerging from the process, you're in this group.
Paranoid Big Brother Conspiracy Theorists
These folks look at the proposed legislation as yet another example of Big Government encroachment into private life, and despite their often loony antics, they do have a point. The most substantive element of this legislation is the government holding a gun to everyone's head and saying "buy health insurance... or else." Throw in the fact that the people with guns held to their heads will mostly be the uninsured poor for whose benefit this reform was supposed to be in the first place, and that the main beneficiaries are the insurance companies who were originally made out to be the villains, and you've got to admit, there is a serious Orwellian vibe going on here.
If the impending passage of this bill makes you want to go scream your lungs out at a Tea Party Rally, or stock up on ammo and surgical gauze, you're in this group.
Big Obama Fans and Democratic Party Loyalists
These people are mostly focused on Scoring a Win. Who cares about the details? If we can get this thing through Congress, we can claim victory over the vile, hated Republicans. Hooray!
If you are enthusiastic about the passage of this bill, and ready to hail its passage as Unprecedented and Historic, you're in this group.
To you I would say congratulations on winning the Big Game, but please do not pretend that you have accomplished anything meaningful here.
Wednesday, December 16, 2009
Needle in a Haystack
This is one of the very few thoughtful, ideology-neutral things I have read about health care reform in the past... um... forever.
The new compromise
To me, the far more disturbing trend here is the nature of the "compromise" that was ultimately reached. It wasn't a compromise between Democrats and Republicans, or "big" government and "small" government, or "liberal" and "conservative", but rather it was a pretty clear compromise between what the party in power wanted to do and what the relevant corporations wanted. The bill is not more friendly to Republicans, but rather more friendly (if not downright subservient) to the pharmaceutical and insurance lobbies.
What should terrify everyone is that this exact same compromise was continuously played out during the Bush years as well. Outside of his failure to pass Social Security Reform -- a move which was staggeringly unpopular with the people -- all of his major policy changes ended up being compromises not with the Democrats but with the relevant lobbies. What was conservative (or liberal) about the prescription drug bill that he passed? What was conservative (or liberal) about the telecom amnesty bill?
There is one major party in the US and even when the Democrats or Republicans appear to be in charge, the results say otherwise.
—pza
The new compromise
To me, the far more disturbing trend here is the nature of the "compromise" that was ultimately reached. It wasn't a compromise between Democrats and Republicans, or "big" government and "small" government, or "liberal" and "conservative", but rather it was a pretty clear compromise between what the party in power wanted to do and what the relevant corporations wanted. The bill is not more friendly to Republicans, but rather more friendly (if not downright subservient) to the pharmaceutical and insurance lobbies.
What should terrify everyone is that this exact same compromise was continuously played out during the Bush years as well. Outside of his failure to pass Social Security Reform -- a move which was staggeringly unpopular with the people -- all of his major policy changes ended up being compromises not with the Democrats but with the relevant lobbies. What was conservative (or liberal) about the prescription drug bill that he passed? What was conservative (or liberal) about the telecom amnesty bill?
There is one major party in the US and even when the Democrats or Republicans appear to be in charge, the results say otherwise.
—pza
Friday, December 4, 2009
The Cat Box Media Strikes Again
From the Bloomington, IN Herald-Times
Permits spiked in the months around the election of Barack Obama as president, prompting gun dealers to refer to “the Obama factor.” This shows a troubling distrust — paranoia? — about the new administration. Our research doesn’t say whether it’s just political or political and racial, but we have our suspicions.
Does the Herald-Times editorial board really believe that anyone who disagrees with the President is automatically a racist? Or is this just their pre-emptive way of discrediting any opposition to the leader they've chosen for us?
Are their incessant attacks on law abiding gun owners pure mindless reflex, based on their ingrained hateful prejudices? Or are they deliberately engaging in a propagandistic campaign to discredit the most demonstrably lawful sub-segment of the population?
I can't read minds to know the intentions behind the Herald-Times' sleazy, propagandistic brand of "journalism," but I have my suspicions.
One of the last of a dying breed. The cat box media is going the way of the dinosaur. And these guys aren't making me feel too mournful about that.
Permits spiked in the months around the election of Barack Obama as president, prompting gun dealers to refer to “the Obama factor.” This shows a troubling distrust — paranoia? — about the new administration. Our research doesn’t say whether it’s just political or political and racial, but we have our suspicions.
Does the Herald-Times editorial board really believe that anyone who disagrees with the President is automatically a racist? Or is this just their pre-emptive way of discrediting any opposition to the leader they've chosen for us?
Are their incessant attacks on law abiding gun owners pure mindless reflex, based on their ingrained hateful prejudices? Or are they deliberately engaging in a propagandistic campaign to discredit the most demonstrably lawful sub-segment of the population?
I can't read minds to know the intentions behind the Herald-Times' sleazy, propagandistic brand of "journalism," but I have my suspicions.
One of the last of a dying breed. The cat box media is going the way of the dinosaur. And these guys aren't making me feel too mournful about that.
If you're not paranoid yet...
...here are eight million reasons you should be.
Techdirt provides this summary:
Sprint provided law enforcement with GPS location data a staggering 8 million times in the last year. Sprint apparently set up some sort of portal that made such requests easier, and it sounds like law enforcement took advantage of that in a major way. The report also notes that this information should have been disclosed to Congress, under a 1999 law, but the Justice Department has ignored the law for the past five years. The rest of the report also looks at some other concerning factors, such as the fact that the government seems to regularly get all sorts of info from service providers, with little oversight. On top of that, it explains why so many service providers agree to it: they charge the government for such info, and it's quite lucrative.
The original source is the dissertation research of this IU grad student.
As often occurs, h/t to Tam for providing my first link to this very disturbing story.
Oh, and by the way, thanks to the cat box media for digging this up (NOT!). Or, at least providing wider coverage once it was discovered (NOT!). Because when the newspapers fold, there won't be anyone who knows what they're doing to investigate stuff and find things out (NOT!).
Techdirt provides this summary:
Sprint provided law enforcement with GPS location data a staggering 8 million times in the last year. Sprint apparently set up some sort of portal that made such requests easier, and it sounds like law enforcement took advantage of that in a major way. The report also notes that this information should have been disclosed to Congress, under a 1999 law, but the Justice Department has ignored the law for the past five years. The rest of the report also looks at some other concerning factors, such as the fact that the government seems to regularly get all sorts of info from service providers, with little oversight. On top of that, it explains why so many service providers agree to it: they charge the government for such info, and it's quite lucrative.
The original source is the dissertation research of this IU grad student.
As often occurs, h/t to Tam for providing my first link to this very disturbing story.
Oh, and by the way, thanks to the cat box media for digging this up (NOT!). Or, at least providing wider coverage once it was discovered (NOT!). Because when the newspapers fold, there won't be anyone who knows what they're doing to investigate stuff and find things out (NOT!).
Sunday, November 29, 2009
Interesting Comparisons
Remember all the fuss when the McCain campaign spent $150K on a new wardrobe for Sarah Palin? Rivers of ink and mega-gigabytes of bandwidth spent on hashing out that story for a couple of weeks.
And now this interesting item about our First Lady. Apparently the woman requires a personal staff of 26 (that's TWENTY SIX), with a combined annual salary topping $1.5 million.
For comparison, the elitist, plutocratic Bush women (Barbara and Laura) only required one taxpayer-funded staff person each. Even Hilary Clinton somehow managed with a staff of three.
Can you imagine the media outcry if a Republican first lady had ramped up the First Lady Court to such a degree, and at such expense, in the middle of a recession?
(h/t to Dean2182 from INGO)
And now this interesting item about our First Lady. Apparently the woman requires a personal staff of 26 (that's TWENTY SIX), with a combined annual salary topping $1.5 million.
For comparison, the elitist, plutocratic Bush women (Barbara and Laura) only required one taxpayer-funded staff person each. Even Hilary Clinton somehow managed with a staff of three.
Can you imagine the media outcry if a Republican first lady had ramped up the First Lady Court to such a degree, and at such expense, in the middle of a recession?
(h/t to Dean2182 from INGO)
Nice Job, Officer Matt
"You're scared now. But soon --I hope it's soon-- you'll transition from that fear to fury. Anger is the correct emotion, and much more useful, in my opinion.
"This... punk... came to your house uninvited, and attempted to enter your residence by force. Who does he think he is?!?
Nice post by a police officer in Texas. (h/t to Tam).
"This... punk... came to your house uninvited, and attempted to enter your residence by force. Who does he think he is?!?
Nice post by a police officer in Texas. (h/t to Tam).
Monday, October 19, 2009
Tuesday, October 6, 2009
Triumph of the Will
George Will, that is, who provides a masterful post-mortem on The Obama's recent speechifying in Copenhagen and at the UN, among other places.
Ever since Obama hit the national stage, folks have commented on what a brilliant orator he is. I think he benefits in this regard from comparison to his predecessor, who certainly will never be remembered among the best-spoken of US presidents. There's no doubt that the man does a very good job of reading a speech. But in my book, a great speaker has to actually say something. To opine that Obama is sometimes lacking in the content department is a bit of an understatment.
Here's Will dissecting some recent Obama utterances:
The president, addressing the United Nations General Assembly, intoned: "No one nation can or should try to dominate another nation." What was the speechwriter thinking when he or she assembled that sentence? The "should" was empty moralizing; the "can" was nonsense redundantly refuted by history.
Becoming solemn in Copenhagen, Obama said: "No one expects the games to solve all our collective problems." That's right, no one does. So why say that?
In addition to vapid but well-spoken cliches, as Will points out, the President's comments often display a level of egotism remarkable even among occupants of the Oval Office.
In Copenhagen, Will notes, both the Obamas gave moving speeches about... themselves.
In the 41 sentences of her remarks, Michelle Obama used some form of the personal pronouns "I" or "me" 44 times. Her husband was, comparatively, a shrinking violet, using those pronouns only 26 times in 48 sentences. Still, 70 times in 89 sentences was sufficient to convey the message that somehow their fascinating selves were what made, or should have made, Chicago's case compelling.
Presidents often come to be characterized by particular adjectives: "honest" Abe Lincoln, "Grover the Good" Cleveland, "energetic" Theodore Roosevelt, "idealistic" Woodrow Wilson, "Silent Cal" Coolidge, "confident" FDR, "likable" Ike Eisenhower. Less happily, there were "Tricky Dick" Nixon and "Slick Willie" Clinton. Unhappy will be a president whose defining adjective is "vain."
Ever since Obama hit the national stage, folks have commented on what a brilliant orator he is. I think he benefits in this regard from comparison to his predecessor, who certainly will never be remembered among the best-spoken of US presidents. There's no doubt that the man does a very good job of reading a speech. But in my book, a great speaker has to actually say something. To opine that Obama is sometimes lacking in the content department is a bit of an understatment.
Here's Will dissecting some recent Obama utterances:
The president, addressing the United Nations General Assembly, intoned: "No one nation can or should try to dominate another nation." What was the speechwriter thinking when he or she assembled that sentence? The "should" was empty moralizing; the "can" was nonsense redundantly refuted by history.
Becoming solemn in Copenhagen, Obama said: "No one expects the games to solve all our collective problems." That's right, no one does. So why say that?
In addition to vapid but well-spoken cliches, as Will points out, the President's comments often display a level of egotism remarkable even among occupants of the Oval Office.
In Copenhagen, Will notes, both the Obamas gave moving speeches about... themselves.
In the 41 sentences of her remarks, Michelle Obama used some form of the personal pronouns "I" or "me" 44 times. Her husband was, comparatively, a shrinking violet, using those pronouns only 26 times in 48 sentences. Still, 70 times in 89 sentences was sufficient to convey the message that somehow their fascinating selves were what made, or should have made, Chicago's case compelling.
Presidents often come to be characterized by particular adjectives: "honest" Abe Lincoln, "Grover the Good" Cleveland, "energetic" Theodore Roosevelt, "idealistic" Woodrow Wilson, "Silent Cal" Coolidge, "confident" FDR, "likable" Ike Eisenhower. Less happily, there were "Tricky Dick" Nixon and "Slick Willie" Clinton. Unhappy will be a president whose defining adjective is "vain."
Pretty Funny
Have you noticed that all the funny stuff comes from the opposition?
When Bush and Co. were in power, most of the good zingers came from the Left. Now it seems to be reversed.
When Bush and Co. were in power, most of the good zingers came from the Left. Now it seems to be reversed.
Here's part of the problem
From Time via Yahoo, regarding the Afghan war debate:
As Commander in Chief, the President is forced to strike a balance between his generals' combat needs and what America is prepared to commit. No President wants to send more young men and women into harm's way than is necessary
Sorry, but this "analysis" is bass-ackwards.
"Sending more young men and women into harm's way than is necessary" is not the problem. The more we send, and the more overwhelming our forces are, the less harm there will be. You don't incur casualties by sending too many troops. You incur casualties by sending too few.
Negotiating a compromise works in politics. It does not work in war. Striking a balance between generals' combat needs and what America is prepared to commit is a recipe for disaster.
There are two options here, as in any war:
1) All out effort, with overwhelming forces, and get the fight over with as soon as possible.
2) Don't go fight.
The one constant in military history is that the bloodiest battles are between evenly-matched forces. The Obama policy (and the Bush-Rumsfeld policy before him, and the Johnson-MacNamara policy before that) was to go to war with "economy of force." Don't send too many troops - that might be unpopular with the public.
I'll tell you what's unpopular with Americans: long dragged out battles being fought with a halfway commitment. Lots of young men in body bags, who would still be alive if they had sufficient forces to do the job.
If I was an advisor to President Obama, I'd be telling him to make up his fracking mind. If we're going to war, go with single-minded determination and all the forces we can possibly muster. If it's not worth an all-out fight, it's not worth fighting for at all.
As Commander in Chief, the President is forced to strike a balance between his generals' combat needs and what America is prepared to commit. No President wants to send more young men and women into harm's way than is necessary
Sorry, but this "analysis" is bass-ackwards.
"Sending more young men and women into harm's way than is necessary" is not the problem. The more we send, and the more overwhelming our forces are, the less harm there will be. You don't incur casualties by sending too many troops. You incur casualties by sending too few.
Negotiating a compromise works in politics. It does not work in war. Striking a balance between generals' combat needs and what America is prepared to commit is a recipe for disaster.
There are two options here, as in any war:
1) All out effort, with overwhelming forces, and get the fight over with as soon as possible.
2) Don't go fight.
The one constant in military history is that the bloodiest battles are between evenly-matched forces. The Obama policy (and the Bush-Rumsfeld policy before him, and the Johnson-MacNamara policy before that) was to go to war with "economy of force." Don't send too many troops - that might be unpopular with the public.
I'll tell you what's unpopular with Americans: long dragged out battles being fought with a halfway commitment. Lots of young men in body bags, who would still be alive if they had sufficient forces to do the job.
If I was an advisor to President Obama, I'd be telling him to make up his fracking mind. If we're going to war, go with single-minded determination and all the forces we can possibly muster. If it's not worth an all-out fight, it's not worth fighting for at all.
Saturday, October 3, 2009
Click on this
"The problem with socialism is that eventually you run out
of other people's money."
—Margaret Thatcher
With a projected $1.8 trillion deficit for 2009, several trillions more in deficits projected over the next decade, and with both Medicare and Social Security entitlement spending about to ratchet up several notches over the next 15 years as Baby Boomers become eligible for both, we are rapidly running out of other people's money. These deficits are simply not sustainable. They are either going to result in unprecedented new taxes and inflation, or they will bankrupt us.
The linked Wall Street Journal article above was written by John Mackey, the founder and CEO of Whole Wallet Foods (I mean, Whole Foods). Dude has some constructive suggestions on fiscal policy and health care, a few of which will be familiar to readers of this blog and a few of which are new.
Worth a look, albeit I'm afraid purely academic at this point. Everything they're doing in Washington seems headed diametrically the opposite direction.
of other people's money."
—Margaret Thatcher
With a projected $1.8 trillion deficit for 2009, several trillions more in deficits projected over the next decade, and with both Medicare and Social Security entitlement spending about to ratchet up several notches over the next 15 years as Baby Boomers become eligible for both, we are rapidly running out of other people's money. These deficits are simply not sustainable. They are either going to result in unprecedented new taxes and inflation, or they will bankrupt us.
The linked Wall Street Journal article above was written by John Mackey, the founder and CEO of Whole Wallet Foods (I mean, Whole Foods). Dude has some constructive suggestions on fiscal policy and health care, a few of which will be familiar to readers of this blog and a few of which are new.
Worth a look, albeit I'm afraid purely academic at this point. Everything they're doing in Washington seems headed diametrically the opposite direction.
Friday, October 2, 2009
Go, David, Go!
IOUSA's David Walker says some unpopular things here, like:
1) Somewhat higher taxes now, or massively higher taxes later. Our choice. Low taxes forever is not going to happen.
2) Universal health coverage will have to mean more modest coverage than the gold-plated Cadillac care that Americans are used to
Not popular, but very true.
He's also right about leadership. No political party or leader is now talking a realistic message about our fiscal situation and what it's going to take to fix it. America needs a sober leader to sit us down and speak some unpleasant facts. Nobody seems to be stepping up.
I would like to see a Fiscal Future Commission as he suggests. Even better, would be if people actually paid attention to such a commission.
Monday, September 7, 2009
Wishful Thinking meets Reality
Check out this post at American Thinker:
http://www.americanthinker.com/2009/09/on_bullying_costco_disconnects.html
Apparently Costco, in addition to their excellent produce, extra virgin olive oil, and value-priced consumer electronics, is now peddling advice to kids about how to deal with bullying. Their 'advice' consists mostly of wishful thinking like this:
“Be nice to kids when they are mean to you, and before long they will stop being mean. This is known as the Golden Rule, and is the solution to bullying.”
American Thinker has some more realistic advice. Worth a read.
This Costco article is written from a perspective I am seeing more and more these days. It's a variety of magical thinking - perhaps a good term would be "Happythink." Happythinkers prefer to think the most pleasant thoughts, regardless of their congruence of incongruence with reality. Thoughts that comply with Happythink ideology are immediately given credence. Thoughts that conflict with Happythink are rejected. So we send kids out in to confrontations that are increasingly lethal, with advice based on ideology and happy thoughts.
http://www.americanthinker.com/2009/09/on_bullying_costco_disconnects.html
Apparently Costco, in addition to their excellent produce, extra virgin olive oil, and value-priced consumer electronics, is now peddling advice to kids about how to deal with bullying. Their 'advice' consists mostly of wishful thinking like this:
“Be nice to kids when they are mean to you, and before long they will stop being mean. This is known as the Golden Rule, and is the solution to bullying.”
American Thinker has some more realistic advice. Worth a read.
This Costco article is written from a perspective I am seeing more and more these days. It's a variety of magical thinking - perhaps a good term would be "Happythink." Happythinkers prefer to think the most pleasant thoughts, regardless of their congruence of incongruence with reality. Thoughts that comply with Happythink ideology are immediately given credence. Thoughts that conflict with Happythink are rejected. So we send kids out in to confrontations that are increasingly lethal, with advice based on ideology and happy thoughts.
Tuesday, August 18, 2009
This guy is good
Click here for an excellent analysis of the structural problems and perverse incentives that contribute to the problems in our health care system today. Offers some interesting solutions, too.
Unfortunately, what he's proposing is rather out-of-the-box. If enacted, it wouldn't clearly be a Win for Obama, or a Defeat for Obama. Therefore, I doubt anyone in the political system will be much interested in these ideas.
One of the article's most powerful passages is a comparison between the relatively free market conditions around LASIK surgery (which is generally paid for out of pocket, and therefore is subject to all kinds of consumer-driven pressures) and MRI's (which generally are paid for by Medicare, Medicaid, or insurance, and therefore are almost completely insulated from consumer-driven pressures). No coincidence that LASIK is getting downright cheap these days, while MRI's are as expensive as ever.
What the author says about the backwardness of the health care system is spot-on. The outfit I rent movies from has infinitely better information management systems than the hospital where I work.
I've been moving fairly close to the article's proposals. The system I've been pondering has two major components: 1) a very basic single payor plan to replace Medicare and Medicaid, that offers minimalistic, bare-bones, strictly cost-controlled coverage, and 2) a free market for anything above and beyond that. The free market would include various plans by insurors, as well as simple fee-for-service. Some combination system like this could offer some of the security people want against extremely expensive catastrophic health problems, while also restoring consumers' power to make choices and make the system responsive to their needs.
Unfortunately, what he's proposing is rather out-of-the-box. If enacted, it wouldn't clearly be a Win for Obama, or a Defeat for Obama. Therefore, I doubt anyone in the political system will be much interested in these ideas.
One of the article's most powerful passages is a comparison between the relatively free market conditions around LASIK surgery (which is generally paid for out of pocket, and therefore is subject to all kinds of consumer-driven pressures) and MRI's (which generally are paid for by Medicare, Medicaid, or insurance, and therefore are almost completely insulated from consumer-driven pressures). No coincidence that LASIK is getting downright cheap these days, while MRI's are as expensive as ever.
What the author says about the backwardness of the health care system is spot-on. The outfit I rent movies from has infinitely better information management systems than the hospital where I work.
I've been moving fairly close to the article's proposals. The system I've been pondering has two major components: 1) a very basic single payor plan to replace Medicare and Medicaid, that offers minimalistic, bare-bones, strictly cost-controlled coverage, and 2) a free market for anything above and beyond that. The free market would include various plans by insurors, as well as simple fee-for-service. Some combination system like this could offer some of the security people want against extremely expensive catastrophic health problems, while also restoring consumers' power to make choices and make the system responsive to their needs.
Tuesday, August 11, 2009
Unpromising political landscape for health policy
I don't see anything good coming from the current line-up of political forces and attitudes.
The Democrats are determined to pass something - anything - so long as they can claim a legislative victory. At this point, I believe the Left would pass a dog turd through Congress and call it 'Health Reform' so long as they can proclaim a Win for Obama.
The Republicans are no better. They're so focused on handing Obama a defeat, they will work tirelessly to sabotage anything the Democrats offered up, even if it really was good health policy.
Nobody seems really invested in crafting a good policy that actually addresses the problems in a realistic way. I don't see how that hard work is going to get done when nobody shows any interest in doing it.
The Democrats are determined to pass something - anything - so long as they can claim a legislative victory. At this point, I believe the Left would pass a dog turd through Congress and call it 'Health Reform' so long as they can proclaim a Win for Obama.
The Republicans are no better. They're so focused on handing Obama a defeat, they will work tirelessly to sabotage anything the Democrats offered up, even if it really was good health policy.
Nobody seems really invested in crafting a good policy that actually addresses the problems in a realistic way. I don't see how that hard work is going to get done when nobody shows any interest in doing it.
Cost Effectiveness in Health Care
I've needed a post like this for a while.
This guy did it for me.
"Price of the hope of immortality" hits the nail on the head. I'm convinced that the main reason this debate is so irrational and counterproductive is that it forces us to confront our own mortality. We don't much like that, and it makes us testy.
This guy did it for me.
"Price of the hope of immortality" hits the nail on the head. I'm convinced that the main reason this debate is so irrational and counterproductive is that it forces us to confront our own mortality. We don't much like that, and it makes us testy.
Sunday, August 9, 2009
Dirty Words in Health Care Debate
Much of the noise in the health care debate revolves around two epithets the left and the right hurl at each other: 'rationing' and 'denial of care.'
Both sides have a point, sort of, but both are being more disingenuous than substantive or honest.
One of the criticisms of the current system of private insurors is that they sometimes deny payment for care. Patients who don't do well on the generic medicine, or whose disease doesn't respond to conventional treatment, naturally would like their insurance to pay for some higher-cost alternative. Insurance companies, faced with pressures to keep premiums down and profits up, naturally don't want to pay for the more expensive alternative when there are less expensive options that usually work for most patients.
People who are critical of private insurance say this amounts to insurors 'playing doctor.' Treatment decisions, they say, should be entirely made by the physician and his or her patient.
One of the criticisms of government-as-payor health care systems is that they 'ration care.' It's certainly true that most national health systems have some kind of board that reviews various treatments and practices for their cost-effectiveness, and then makes decisions about what kinds of care will be provided and what will not.
One such organization is the UK's NICE (National Institute for Health and Clincial Excellence). NICE makes judgements about the safety and efficacy of treatments, much as health specialty organizations in the US do when they issue consensus opinions or clinical practice guidelines. Unlike US organizations, however, NICE also makes value judgements about the social utility of medical treatments. Using measures like Quality Adjusted Life Years (QALY), NICE makes decisions about whether the social value of a medical procedure or treatment justifies its cost. For instance, it might be determined that knee replacement surgery for overweight elderly patients does not render sufficient improvement in overall health to justify its cost.
Opponents of health reform have made great sport of attacking NICE and QUALY lately, and on some level it's hard to argue with this. It does seem heartless to tell an elderly lady, "you're too fat for an artificial knee," or "you probably won't live long enough to justify the cost of that knee replacement." More heartless, perhaps, to tell entire groups of people such things via health policy. Far better to have a system with no rationing or denial of care.
The problem is, every health system has some kind of rationing or some form of denial of care. For example, in a pure fee-for-service model treatment goes to those who can afford it and is denied to those who can't. In the US, private insurors decide what they'll cover and what they won't. Medicare and Medicaid - government payors who are the biggest players by far in the US - certainly do deny many procedures and treatments, but there's no specified system for determining what they'll pay for and what they'll deny. The biggest difference between the US and the UK therefore isn't that the UK rations care and the US doesn't. The difference is that in the UK, they admit that they ration, and they ration according to clearly specified criteria. In the US we pretend we don't ration, and then proceed to ration according to an extremely complex, mostly opaque, multi-player process with no specified criteria and no over-arching goal or guiding principle.
In the current health care reform debate, all the parties are lying about rationing.
The Republicans say they object to changing the health care system because they don't want any rationing or denial of care. That's ludicrous. As outlined above, we are already rationing and denying care as a matter of policy.
The Democrats, meanwhile, say the new reformed health care system they're proposing won't include any rationing. This is equally ludicrous. With rising health care costs, mounting national debt, and the imminent retirement of 48 million baby boomers, there will certainly be more severe rationing in our future. Whether we want it or not, we will eventually have to make some difficult decisions on health care spending because our current muddle projects to completely bankrupt the nation within 15-25 years.
It's time for both sides to own up to the unpalatable but inescapable truth: there's no way to have a fiscally sound health care system without having some kind of rationing. Either we will reform the system and have some new system of rationing, or we will continue our current system of muddled piecemeal rationing. We need to admit this and start talking about it, so we can have an honest national debate about what kind of rationing we will have.
Both sides have a point, sort of, but both are being more disingenuous than substantive or honest.
One of the criticisms of the current system of private insurors is that they sometimes deny payment for care. Patients who don't do well on the generic medicine, or whose disease doesn't respond to conventional treatment, naturally would like their insurance to pay for some higher-cost alternative. Insurance companies, faced with pressures to keep premiums down and profits up, naturally don't want to pay for the more expensive alternative when there are less expensive options that usually work for most patients.
People who are critical of private insurance say this amounts to insurors 'playing doctor.' Treatment decisions, they say, should be entirely made by the physician and his or her patient.
One of the criticisms of government-as-payor health care systems is that they 'ration care.' It's certainly true that most national health systems have some kind of board that reviews various treatments and practices for their cost-effectiveness, and then makes decisions about what kinds of care will be provided and what will not.
One such organization is the UK's NICE (National Institute for Health and Clincial Excellence). NICE makes judgements about the safety and efficacy of treatments, much as health specialty organizations in the US do when they issue consensus opinions or clinical practice guidelines. Unlike US organizations, however, NICE also makes value judgements about the social utility of medical treatments. Using measures like Quality Adjusted Life Years (QALY), NICE makes decisions about whether the social value of a medical procedure or treatment justifies its cost. For instance, it might be determined that knee replacement surgery for overweight elderly patients does not render sufficient improvement in overall health to justify its cost.
Opponents of health reform have made great sport of attacking NICE and QUALY lately, and on some level it's hard to argue with this. It does seem heartless to tell an elderly lady, "you're too fat for an artificial knee," or "you probably won't live long enough to justify the cost of that knee replacement." More heartless, perhaps, to tell entire groups of people such things via health policy. Far better to have a system with no rationing or denial of care.
The problem is, every health system has some kind of rationing or some form of denial of care. For example, in a pure fee-for-service model treatment goes to those who can afford it and is denied to those who can't. In the US, private insurors decide what they'll cover and what they won't. Medicare and Medicaid - government payors who are the biggest players by far in the US - certainly do deny many procedures and treatments, but there's no specified system for determining what they'll pay for and what they'll deny. The biggest difference between the US and the UK therefore isn't that the UK rations care and the US doesn't. The difference is that in the UK, they admit that they ration, and they ration according to clearly specified criteria. In the US we pretend we don't ration, and then proceed to ration according to an extremely complex, mostly opaque, multi-player process with no specified criteria and no over-arching goal or guiding principle.
In the current health care reform debate, all the parties are lying about rationing.
The Republicans say they object to changing the health care system because they don't want any rationing or denial of care. That's ludicrous. As outlined above, we are already rationing and denying care as a matter of policy.
The Democrats, meanwhile, say the new reformed health care system they're proposing won't include any rationing. This is equally ludicrous. With rising health care costs, mounting national debt, and the imminent retirement of 48 million baby boomers, there will certainly be more severe rationing in our future. Whether we want it or not, we will eventually have to make some difficult decisions on health care spending because our current muddle projects to completely bankrupt the nation within 15-25 years.
It's time for both sides to own up to the unpalatable but inescapable truth: there's no way to have a fiscally sound health care system without having some kind of rationing. Either we will reform the system and have some new system of rationing, or we will continue our current system of muddled piecemeal rationing. We need to admit this and start talking about it, so we can have an honest national debate about what kind of rationing we will have.
Monday, July 27, 2009
Not an easy read
This article from the Utne Reader is quite disturbing and not a read for the faint of heart. But it raises some important questions.
Are some people victims by nature?
Are some people made into victims by the way they're nurtured (or not nurtured)?
How can I raise my daughter (or son) to protest, to resist when confronted with evil; if necessary to fight tooth-and-nail, to fight even to the death if need be?
The woman who wrote this story had so little opinion of herself that her reaction to her rapist's prison sentence was "Twenty years? Just for this? Just for doing this to me? Twenty years is a really long time." It is almost impossible for me to imagine the life of someone whose first instinct when confronted by a mortal assault is to avoid being rude to her assailant. I don't want to be able to imagine it. I don't want my kids to be able to imagine it.
The author - a teacher - related a classroom exercise where she asked her students what they were taught by their parents that they didn't want to teach to their own kids. One student replied that she was taught always to be kind to everybody. The student had learnt, probably the hard way, that one shouldn't be kind to everybody. The teacher wondered why she hadn't learned that herself.
Jane. Byron. Listen up: You don't always have to be kind to everyone. In fact, there are some people in the world - just a very few - whom you should shoot dead if ever you encounter them under the wrong circumstances. I hope you never do encounter any of these people. If you do, please do not think you have to be kind to them. And please, please, always believe that yours is an invaluable spirit deserving of humane treatment. If someone treats you inhumanely, don't think for a second that it's something wrong with you. If you encounter this treatment, I want your first thoughts to be, "protest, resist, fight if necessary."
This story reminds me somehow of a Churchill quotation: "You may have to fight when there is no hope of victory, because it is better to perish than live as slaves."
Slavery, when externally imposed, is an institutional judgement that some person or group of people are less than human. It seems to me that the woman who wrote this article is living a slave's life, enslaved by her own opinion that she is less than human. It's too bad she didn't fight more effectively and whole-heartedly against that man; not because she might have prevented the rape (she might or might not have), but because she ought to have had a better opinion of her own worth.
Churchill was right. Better to perish than live that way.
Are some people victims by nature?
Are some people made into victims by the way they're nurtured (or not nurtured)?
How can I raise my daughter (or son) to protest, to resist when confronted with evil; if necessary to fight tooth-and-nail, to fight even to the death if need be?
The woman who wrote this story had so little opinion of herself that her reaction to her rapist's prison sentence was "Twenty years? Just for this? Just for doing this to me? Twenty years is a really long time." It is almost impossible for me to imagine the life of someone whose first instinct when confronted by a mortal assault is to avoid being rude to her assailant. I don't want to be able to imagine it. I don't want my kids to be able to imagine it.
The author - a teacher - related a classroom exercise where she asked her students what they were taught by their parents that they didn't want to teach to their own kids. One student replied that she was taught always to be kind to everybody. The student had learnt, probably the hard way, that one shouldn't be kind to everybody. The teacher wondered why she hadn't learned that herself.
Jane. Byron. Listen up: You don't always have to be kind to everyone. In fact, there are some people in the world - just a very few - whom you should shoot dead if ever you encounter them under the wrong circumstances. I hope you never do encounter any of these people. If you do, please do not think you have to be kind to them. And please, please, always believe that yours is an invaluable spirit deserving of humane treatment. If someone treats you inhumanely, don't think for a second that it's something wrong with you. If you encounter this treatment, I want your first thoughts to be, "protest, resist, fight if necessary."
This story reminds me somehow of a Churchill quotation: "You may have to fight when there is no hope of victory, because it is better to perish than live as slaves."
Slavery, when externally imposed, is an institutional judgement that some person or group of people are less than human. It seems to me that the woman who wrote this article is living a slave's life, enslaved by her own opinion that she is less than human. It's too bad she didn't fight more effectively and whole-heartedly against that man; not because she might have prevented the rape (she might or might not have), but because she ought to have had a better opinion of her own worth.
Churchill was right. Better to perish than live that way.
Sunday, July 19, 2009
DebtWatch: Weasel Words
Here on the Homestead we have always been debt-averse. We don't use credit cards. Our only debts are our home loan and a student loan, and we're working to pay these off at a much-accelerated rate. Recently we have started using the Dave Ramsey Envelope System to reduce our discretionary spending, and so far it is working wonders; freeing up more money to save for future goals and attack those debts even harder. We are a long way from being rich, and many of our goals still look difficult to achieve, but at least we don't have the constant feeling of speeding toward an imminent fiscal catastrophe.
Not so our Federal Government.
As is well documented by fiscal gurus like the Peter G. Peterson Foundation and their sobering IOUSA web video, our nation faces a debt-fueled economic catastrophe in the not-too-distant future unless we radically change our ways.
The largest contributor to our projected national debt is rising health care costs (and the subsequent effect on Medicare and Medicaid spending). One of the frequently cited rationales for health care reform is cost control.
Despite the lip service being paid to cost control, the health reform measures currently being considered will not effect meaningful cost control, as the chief of the Congressional Budget Office recently testified before Congress.
The CBO recently published a Long Term Budget Report that analyzes projections for federal spending, revenue, and debt through 2035 and beyond. They projected alternative scenarios, reflecting different legislative possibilities, but all of the scenarios have one thing in common: the federal debt grows faster than the nation's economy. This is unsustainable. Another common thread: the longer we wait to enact reform, the worse the problem gets.
As the health care reform debate intensifies, pay particular attention to "weasel words" - little qualifiers they throw in to make their statements technically true, but maintaining a misleading overall impression.
Here are a few I've heard from the Obama administration over the past couple of weeks, along with the plain-English translation.
"Deficit-Neutral:" We're still racing toward fiscal catastrophe at the same speed, but at least this bill isn't making things worse.
"Won't add to the deficit for the next ten years:" All the costs are being deferred. Please don't ask us what happens in year eleven.
How's that for Audacity? A massive, 1.5-trillion dollar "reform" plan, with a huge expansion of government power and control over our lives. It doesn't actually solve the problem, or even promise to do so. But at least we're getting a promise that this enormous new program won't make the problem worse... at least not until some other clown is in office to take the blame and deal with the mess.
And remember, these less-than-impressive goals are just the sales pitch promises for their wonderful new plan. Based on past Washington performance, I'd say the odds of this plan living up to the promises aren't all that strong.
Not so our Federal Government.
As is well documented by fiscal gurus like the Peter G. Peterson Foundation and their sobering IOUSA web video, our nation faces a debt-fueled economic catastrophe in the not-too-distant future unless we radically change our ways.
The largest contributor to our projected national debt is rising health care costs (and the subsequent effect on Medicare and Medicaid spending). One of the frequently cited rationales for health care reform is cost control.
Despite the lip service being paid to cost control, the health reform measures currently being considered will not effect meaningful cost control, as the chief of the Congressional Budget Office recently testified before Congress.
The CBO recently published a Long Term Budget Report that analyzes projections for federal spending, revenue, and debt through 2035 and beyond. They projected alternative scenarios, reflecting different legislative possibilities, but all of the scenarios have one thing in common: the federal debt grows faster than the nation's economy. This is unsustainable. Another common thread: the longer we wait to enact reform, the worse the problem gets.
As the health care reform debate intensifies, pay particular attention to "weasel words" - little qualifiers they throw in to make their statements technically true, but maintaining a misleading overall impression.
Here are a few I've heard from the Obama administration over the past couple of weeks, along with the plain-English translation.
"Deficit-Neutral:" We're still racing toward fiscal catastrophe at the same speed, but at least this bill isn't making things worse.
"Won't add to the deficit for the next ten years:" All the costs are being deferred. Please don't ask us what happens in year eleven.
How's that for Audacity? A massive, 1.5-trillion dollar "reform" plan, with a huge expansion of government power and control over our lives. It doesn't actually solve the problem, or even promise to do so. But at least we're getting a promise that this enormous new program won't make the problem worse... at least not until some other clown is in office to take the blame and deal with the mess.
And remember, these less-than-impressive goals are just the sales pitch promises for their wonderful new plan. Based on past Washington performance, I'd say the odds of this plan living up to the promises aren't all that strong.
Wednesday, July 8, 2009
Redneck Contraption No. 1
Every Hoosier homestead needs at least one Redneck Contraption. Some of the essential features of a Redneck Contraption: 1) Obscurity of purpose - it must be difficult or impossible to discern by observation the use for which the contraption is intended. 2) Eclectic construction - a proper Redneck Contraption is made primarily of stuff lying around. Farm or industrial leftovers are particularly favored as Contrapting Materials. 3) Location - must be prominently displayed on the property, preferably in the yard or driveway. Alternatively, may be located adjacent to a barn.
The above is a fair example, if I do say so myself. The purpose was to build a garden composter. These things can be purchased, but tend to the pricey. We wanted one that would be sufficiently high capacity, allow tumbling, and high up in the air for easy unloading into a wheelbarrow.
This picture illustrates some of the pros and cons this project revealed about building things out of plastic barrels. The original idea was to use an old-fashioned steel 55 gallon drum, but the plastic ones are more available. Also, the steel drums tend to be used for more toxic liquids, like petroleum products and solvents. This barrel previously contained a cleaner for food preparation equipment.
PROS: This kind of plastic cuts easily with a sabre saw. It's easy to drill with spade bits or regular drill bits. The material doesn't melt or gum up your bit or blade. It will take self-tapping wood screws and seems to hold them fairly well so far. I did find it a lot easier to drive screws when there was a very small guide hole than trying to use the screw to drill its own hole.
CONS: The only major complaint so far is that this material gets awfully flimsy once you start cutting out pieces of it. I had intended to use plunger locks to keep this closed, but the door was so flex-y that they didn't hold the door closed. The chest hasps shown here do a better job of holding the door in place and preventing it from opening when the tumbler is rotated door-side down. The extra holes around the hasps are from where I had previously mounted the plunger locks. This picture also shows how warped the plastic has become - the door and the hole it was cut from obviously do not match up very well any more.
Baby Jane inspected the garden. Both she and it are growing dramatically now. She looks dubious about the Contraption.
The Homestead Fam: Adrianna, Jane, Byron, and Charlotte the Fearsome Wonder-Dog.
The above is a fair example, if I do say so myself. The purpose was to build a garden composter. These things can be purchased, but tend to the pricey. We wanted one that would be sufficiently high capacity, allow tumbling, and high up in the air for easy unloading into a wheelbarrow.
This picture illustrates some of the pros and cons this project revealed about building things out of plastic barrels. The original idea was to use an old-fashioned steel 55 gallon drum, but the plastic ones are more available. Also, the steel drums tend to be used for more toxic liquids, like petroleum products and solvents. This barrel previously contained a cleaner for food preparation equipment.
PROS: This kind of plastic cuts easily with a sabre saw. It's easy to drill with spade bits or regular drill bits. The material doesn't melt or gum up your bit or blade. It will take self-tapping wood screws and seems to hold them fairly well so far. I did find it a lot easier to drive screws when there was a very small guide hole than trying to use the screw to drill its own hole.
CONS: The only major complaint so far is that this material gets awfully flimsy once you start cutting out pieces of it. I had intended to use plunger locks to keep this closed, but the door was so flex-y that they didn't hold the door closed. The chest hasps shown here do a better job of holding the door in place and preventing it from opening when the tumbler is rotated door-side down. The extra holes around the hasps are from where I had previously mounted the plunger locks. This picture also shows how warped the plastic has become - the door and the hole it was cut from obviously do not match up very well any more.
Baby Jane inspected the garden. Both she and it are growing dramatically now. She looks dubious about the Contraption.
The Homestead Fam: Adrianna, Jane, Byron, and Charlotte the Fearsome Wonder-Dog.
Monday, July 6, 2009
Palin Bashing Pile-On
H/t to Chicks on the Right for sending up this ridiculous Maureen Dowd column.
For an overall look at the phenomenon of Palin-bashing, and Dowd's attempt in particular, it's hard to top what they say here. Tam had an interesting take, too, comparing the Palin-Bashing to Orwell's official state-sponsored hate object, Emmanuel Goldstein.
But there's one passage of Dowd's drivel that really needs an additional comment.
As anyone who's gone to medical or nursing school can tell you, perusing the DSM-IV can be extremely misleading. The diagnostic criteria for psych disorders - particularly personality disorders - read like a laundry list of personality flaws, human weaknesses, and annoying habits. Anyone who's read the DSM without wondering whether at least one or two of the diagnoses apply to him- or herself is a spectacularly arrogant and unreflective soul. Even - or perhaps especially - for the arrogant and unreflective, it is easy to flip through the pages and find a perjorative-sounding diagnosis or two for anyone whom one considers personally disagreeable.
The idea, therefore, that a bunch of liberal journalists and their friends could wander uninformedly through the DSM-IV and come up with a diagnosis for Sarah Palin is hardly newsworthy, let alone diagnostically reliable.
Besides, I thought that being mentally ill was a highly admirable disability among lefty circles? If Sarah Palin really were mentally ill, wouldn't that put her in a Protected Class of Special People Who Cannot Be Criticized? In fact, being female and disabled should make Palin uniquely qualified for high office, at least by Dowd's standards.
Just for fun, I picked up a DSM-IV and tried to find a diagnosis that doesn't apply to Dowd. Still looking...
For an overall look at the phenomenon of Palin-bashing, and Dowd's attempt in particular, it's hard to top what they say here. Tam had an interesting take, too, comparing the Palin-Bashing to Orwell's official state-sponsored hate object, Emmanuel Goldstein.
But there's one passage of Dowd's drivel that really needs an additional comment.
“Several told me, independently of one another,” Purdum writes, “that they had consulted the definition of ‘narcissistic personality disorder’ in the Diagnostic and Statistical Manual of Mental Disorders — ‘a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy’ — and thought it fit her [Palin] perfectly.”
As anyone who's gone to medical or nursing school can tell you, perusing the DSM-IV can be extremely misleading. The diagnostic criteria for psych disorders - particularly personality disorders - read like a laundry list of personality flaws, human weaknesses, and annoying habits. Anyone who's read the DSM without wondering whether at least one or two of the diagnoses apply to him- or herself is a spectacularly arrogant and unreflective soul. Even - or perhaps especially - for the arrogant and unreflective, it is easy to flip through the pages and find a perjorative-sounding diagnosis or two for anyone whom one considers personally disagreeable.
The idea, therefore, that a bunch of liberal journalists and their friends could wander uninformedly through the DSM-IV and come up with a diagnosis for Sarah Palin is hardly newsworthy, let alone diagnostically reliable.
Besides, I thought that being mentally ill was a highly admirable disability among lefty circles? If Sarah Palin really were mentally ill, wouldn't that put her in a Protected Class of Special People Who Cannot Be Criticized? In fact, being female and disabled should make Palin uniquely qualified for high office, at least by Dowd's standards.
Just for fun, I picked up a DSM-IV and tried to find a diagnosis that doesn't apply to Dowd. Still looking...
Saturday, July 4, 2009
Security Theater gets wrists slapped
The federal department of Thousands Standing Around got scolded by a judge for investigating stuff beyond the scope of their authority and their... er... competence.
Here's a nice image to make us all feel safer:
h/t to SIGForum.com member and all-around safe guy a1abdj.
Here's a nice image to make us all feel safer:
h/t to SIGForum.com member and all-around safe guy a1abdj.
Wednesday, July 1, 2009
Even WaPo Gets It?
That bastion of hard line, extreme right wing, small government fiscal conservatism - the Washington Post - has apparently become concerned with the nation's dangerous levels of debt.
This:
To put it bluntly, the fiscal policy of the United States is unsustainable. Debt is growing faster than gross domestic product. Under the CBO's most realistic scenario, the publicly held debt of the U.S. government will reach 82 percent of GDP by 2019 -- roughly double what it was in 2008. By 2026, spiraling interest payments would push the debt above its all-time peak (set just after World War II) of 113 percent of GDP. It would reach 200 percent of GDP in 2038.
This huge mass of debt, which would stifle economic growth and reduce the American standard of living, can be avoided only through spending cuts, tax increases or some combination of the two. And the longer government waits to get its financial house in order, the more it will cost to do so, the CBO says.
and this:
The principal cause of long-term fiscal distress is the aging of the U.S. population, coupled with rising health-care costs -- which, together, will drive spending on Medicare, Medicaid and Social Security to new heights. Unchecked, federal spending on Medicare and Medicaid combined will grow from almost 5 percent of GDP today to almost 10 percent by 2035 -- and to more than 17 percent of GDP by 2080.
are points with which regular readers of this blog will certainly be familiar.
The WaPo notes that His Hopey-Changiness has so far responded to this threat the same way his predecessors have: issue statements decrying deficits and debt, while simutaneously spending his way to yet more debt. Strong words for The One from His True Believers in the legacy media.
It is, needless to say, concerning, that having reached the brink of economic ruin primarily by making expensive health care promises to an increasingly aged, obese, health-resource-intensive population, we are about to embark on a massive new program of expensive health care promises to an increasingly aged, obese, health-resource-intensive population.
This:
To put it bluntly, the fiscal policy of the United States is unsustainable. Debt is growing faster than gross domestic product. Under the CBO's most realistic scenario, the publicly held debt of the U.S. government will reach 82 percent of GDP by 2019 -- roughly double what it was in 2008. By 2026, spiraling interest payments would push the debt above its all-time peak (set just after World War II) of 113 percent of GDP. It would reach 200 percent of GDP in 2038.
This huge mass of debt, which would stifle economic growth and reduce the American standard of living, can be avoided only through spending cuts, tax increases or some combination of the two. And the longer government waits to get its financial house in order, the more it will cost to do so, the CBO says.
and this:
The principal cause of long-term fiscal distress is the aging of the U.S. population, coupled with rising health-care costs -- which, together, will drive spending on Medicare, Medicaid and Social Security to new heights. Unchecked, federal spending on Medicare and Medicaid combined will grow from almost 5 percent of GDP today to almost 10 percent by 2035 -- and to more than 17 percent of GDP by 2080.
are points with which regular readers of this blog will certainly be familiar.
The WaPo notes that His Hopey-Changiness has so far responded to this threat the same way his predecessors have: issue statements decrying deficits and debt, while simutaneously spending his way to yet more debt. Strong words for The One from His True Believers in the legacy media.
It is, needless to say, concerning, that having reached the brink of economic ruin primarily by making expensive health care promises to an increasingly aged, obese, health-resource-intensive population, we are about to embark on a massive new program of expensive health care promises to an increasingly aged, obese, health-resource-intensive population.
Thursday, June 18, 2009
Monday, June 15, 2009
Thursday, May 28, 2009
Range Report: Three Brothers
The Brothers Three went to the DNR Winamac range.
They took with them three US rifle, caliber .30, M-1. Bro the eldest got his from the CMP seven or eight years ago. Bro #4 snagged a couple of CMP Garands just this week, and Bro #3 came along to shoot.
The new ones seem to have had their metal parts refinished; they're a much darker color than the familiar greenish parkerizing of Bro #1's copy (bottom most). The finish on the wood furniture is subtly different also.
Add some of the Greek surplus .30-06 ball CMP is selling these days, and you've got yourself some shootin'
Range Report:
The only real surprise of the day was a malfunction. Yes, we know, Garands are supposed to be in the magical club of Guns That Always Work No Matter What, along with Glocks. Despite this contradiction of The Gun Nut Articles of Faith, one of the new-this-week Garands failed to feed once in about 6 or 8 clips of shooting. It has since repeated this blasphemous behavior, and so will be going back to the CMP for fixery.
We've been doing a lot of .22 and AR shooting lately. Nothing wrong with .22's: in fact, I'd say that shooting a lot of .22 LR is the foundation of improving marksmanship. Nothing wrong with ARs, either: they're relatively inexpensive, amazingly adaptable, and can be quite accurate. But there are some of the visceral pleasures of shooting that .22s and ARs just don't quite satisfy. The heft of walnut and forged steel, the solid kick that says "aren't you glad you aren't downrange?", and above all the lovely booming sound that lets you know you just shot a subtantial bullet at substantial velocity from a Rifle of Substance. Whatever it is that you don't get from shooting .22s and ARs, the M-1 Garand supplies it in abundance.
I don't know when the CMP Garands are going to dry up, but I suspect it will be soon. Don't be caught without one. Go here, meet the requirements, and get your $1000 rifle for $545 while you still can.
A quick word about DNR Winamac. - WOW!. What a great facility. 50, 100, and 200 yard ranges, each protected from the others by berms. No memberships, no range fee. Covered shooting stations. Competent and safe, but non-instrusive range supervision. Nice sidewalks between the shooting stations and the target stands, for those muddy days. Only one caution note: take the bug spray. There are some honkin' big mosquitoes out there. Why can't we get one like this in the middle of the state?
The Greek ammo seems to work just fine. The CMP says it's non-corrosive. It is certainly Berdan primed and doesn't appear to have those annoying primer pocket crimps, so it definitely goes in the "save for reloading" bag. Accuracy seemed quite acceptable: Bro the Eldest was shooting half-dollar sized groups at 100 yards without too much trouble. Bro the Eldest, being a connoisseur of ammo aromatics, finds the nose of this vintage quite appealing.
They took with them three US rifle, caliber .30, M-1. Bro the eldest got his from the CMP seven or eight years ago. Bro #4 snagged a couple of CMP Garands just this week, and Bro #3 came along to shoot.
The new ones seem to have had their metal parts refinished; they're a much darker color than the familiar greenish parkerizing of Bro #1's copy (bottom most). The finish on the wood furniture is subtly different also.
Add some of the Greek surplus .30-06 ball CMP is selling these days, and you've got yourself some shootin'
Range Report:
The only real surprise of the day was a malfunction. Yes, we know, Garands are supposed to be in the magical club of Guns That Always Work No Matter What, along with Glocks. Despite this contradiction of The Gun Nut Articles of Faith, one of the new-this-week Garands failed to feed once in about 6 or 8 clips of shooting. It has since repeated this blasphemous behavior, and so will be going back to the CMP for fixery.
We've been doing a lot of .22 and AR shooting lately. Nothing wrong with .22's: in fact, I'd say that shooting a lot of .22 LR is the foundation of improving marksmanship. Nothing wrong with ARs, either: they're relatively inexpensive, amazingly adaptable, and can be quite accurate. But there are some of the visceral pleasures of shooting that .22s and ARs just don't quite satisfy. The heft of walnut and forged steel, the solid kick that says "aren't you glad you aren't downrange?", and above all the lovely booming sound that lets you know you just shot a subtantial bullet at substantial velocity from a Rifle of Substance. Whatever it is that you don't get from shooting .22s and ARs, the M-1 Garand supplies it in abundance.
I don't know when the CMP Garands are going to dry up, but I suspect it will be soon. Don't be caught without one. Go here, meet the requirements, and get your $1000 rifle for $545 while you still can.
A quick word about DNR Winamac. - WOW!. What a great facility. 50, 100, and 200 yard ranges, each protected from the others by berms. No memberships, no range fee. Covered shooting stations. Competent and safe, but non-instrusive range supervision. Nice sidewalks between the shooting stations and the target stands, for those muddy days. Only one caution note: take the bug spray. There are some honkin' big mosquitoes out there. Why can't we get one like this in the middle of the state?
The Greek ammo seems to work just fine. The CMP says it's non-corrosive. It is certainly Berdan primed and doesn't appear to have those annoying primer pocket crimps, so it definitely goes in the "save for reloading" bag. Accuracy seemed quite acceptable: Bro the Eldest was shooting half-dollar sized groups at 100 yards without too much trouble. Bro the Eldest, being a connoisseur of ammo aromatics, finds the nose of this vintage quite appealing.
Wednesday, May 27, 2009
Another look at the National Debt
Not a bad way of looking at the acceleration of our debt.
I disagree with this guy for saying he was comfortable with Bush's 64 mph but afraid of Obama's 170. Bush's pace of debt growth had us on track for a complete economic collapse (I'm not talking about the minor recession we're having right now; I'm talking about the looming debt melt down that will make our current troubles look like a hiccup).
Yes, Obama will get us to our date with disaster rather more quickly. I don't find a lot of cause for Republican gloating here, though.
One thing the video does not show is the magnitude of the debt problem, or how it threatens to destroy the US economy and any hope of prosperity for future generations. For a more complete analysis of our looming debt problems, check out the IOUSA web movie (link to the right).
Thursday, May 14, 2009
Here's what I'm talking about
Seems that Florida's Miami-Dade County is the first locality to achieve a dubious distinction: in 2008, more babies in Miami-Dade were delivered by cesarean than vaginally.
It had to happen sooner or later. In 1970, the cesarean delivery rate in the US was around 5%. By 2007, that number had reached 31.8%. If these trends continue, soon the whole US may look like Miami-Dade.
By way of reality check, the World Health Organization targets a cesarean rate of around 5-10% to correspond with optimal maternal-child health, and a 2006 study published in the Lancet suggested that when the cesarean rate exceeds 15%, cesareans are causing more harm than they prevent.
What's driving this change? A number of factors are commonly cited: providers' fear of malpractice litigation, their desire to manage their workloads and hours, cost incentives for hospitals, some women's preference for cesarean delivery, and a recent ACOG opinion supporting a woman's right to choose a cesarean even in the absence of any medical reason for it.
A rising cesarean rate entails higher costs. According to this analysis of 2003 data, a cesarean delivery was about two times the cost of a vaginal delivery. I guarantee you they haven't gotten any cheaper since then, but the relative cost of vaginal vs. c-section probably hasn't changed much.
This is a perfect example of why I say we do not currently have a free market health care system. There's no way, in a free market, that the lower cost option - and the option that's healthier for most women - gets gradually driven out of the market.
It's also a great example of what happens when users are separated from costs. Let's say you were planning to go grocery shopping sometime this weekend. Your grocer comes to you on Thursday and says, "I'm going out of town this weekend. How about I go ahead and sell you some groceries today that could endanger your health, and charge you two times what you'd pay for normal groceries?" I think you'd be looking for a new grocer. However, thousands of women accept precisely the same offer from their obstetricians every day. If they actually had to pay the cost of the cesarean out of their own pockets, I think the picture would be a bit different.
I'm not advocating a pure fee-for-service health care system where everyone pays cash for everything. Even if it would work optimally, you'd never get people on board. Also, I think there are some practical problems. Health care bills are just too big and too unpredictable for most folks to be able to budget for them.
What I am saying is that whatever "reformed" health care system we come up with, it better include some form of cost control incentive that is felt where it counts: with the patient. Right now we as patients have none of the consumer power we have when we shop for all the other goods and services we buy. Instead, we have a system analagous to people making purchasing decisions, the charges for which wind up on someone else's credit card statement. I see little chance of costs coming down in a system that works like this.
It had to happen sooner or later. In 1970, the cesarean delivery rate in the US was around 5%. By 2007, that number had reached 31.8%. If these trends continue, soon the whole US may look like Miami-Dade.
By way of reality check, the World Health Organization targets a cesarean rate of around 5-10% to correspond with optimal maternal-child health, and a 2006 study published in the Lancet suggested that when the cesarean rate exceeds 15%, cesareans are causing more harm than they prevent.
What's driving this change? A number of factors are commonly cited: providers' fear of malpractice litigation, their desire to manage their workloads and hours, cost incentives for hospitals, some women's preference for cesarean delivery, and a recent ACOG opinion supporting a woman's right to choose a cesarean even in the absence of any medical reason for it.
A rising cesarean rate entails higher costs. According to this analysis of 2003 data, a cesarean delivery was about two times the cost of a vaginal delivery. I guarantee you they haven't gotten any cheaper since then, but the relative cost of vaginal vs. c-section probably hasn't changed much.
This is a perfect example of why I say we do not currently have a free market health care system. There's no way, in a free market, that the lower cost option - and the option that's healthier for most women - gets gradually driven out of the market.
It's also a great example of what happens when users are separated from costs. Let's say you were planning to go grocery shopping sometime this weekend. Your grocer comes to you on Thursday and says, "I'm going out of town this weekend. How about I go ahead and sell you some groceries today that could endanger your health, and charge you two times what you'd pay for normal groceries?" I think you'd be looking for a new grocer. However, thousands of women accept precisely the same offer from their obstetricians every day. If they actually had to pay the cost of the cesarean out of their own pockets, I think the picture would be a bit different.
I'm not advocating a pure fee-for-service health care system where everyone pays cash for everything. Even if it would work optimally, you'd never get people on board. Also, I think there are some practical problems. Health care bills are just too big and too unpredictable for most folks to be able to budget for them.
What I am saying is that whatever "reformed" health care system we come up with, it better include some form of cost control incentive that is felt where it counts: with the patient. Right now we as patients have none of the consumer power we have when we shop for all the other goods and services we buy. Instead, we have a system analagous to people making purchasing decisions, the charges for which wind up on someone else's credit card statement. I see little chance of costs coming down in a system that works like this.
Monday, May 11, 2009
Rearranging Deck Chairs on the Titanic
It's a tired cliche for focusing on marginal details in the face of a major catastrophe, but it is oh-so applicable to the Obama Administration's "Health Care Reform" media event yesterday.
To summarize from the most recent blog posting:
1) US health care is extremely expensive - we spend about twice per capita what other developed countries spend
2) US health care is a relatively poor value - we aren't getting results commensurate with what we're spending
3) The combination of rising health care costs and the retirement of 78 million baby boomers will burden the US economy with crippling levels of debt. Health care costs are the most imminent threat to our future prosperity as a nation.
I will at least give credit to the Obama administration for recognizing that controlling health care costs should be a top priority. What came out of the vaunted meeting between health care industry leaders and administration officials, however, could only very optimistically be characterized as a drop in the bucket. The product of this high-level meeting was a pledge to reduce - not the actual cost of health care - but the rate of growth of health care costs - by a barely-detectable 1.5% over the next 10 years.
Obama is often compared to JFK these days. If JFK had the kind of audacity represented by this meeting, he would have set NASA the goal of sending a man up a flight of stairs, and returning him safely to Earth, before the end of the decade.
And how did the health industry leaders say they were going to achieve these underwhelming results? By coordinating care, reducing administrative costs, and focusing on effeciency, quality, and standardization; that's how!
Obviously, this [sacrasm] stunningly bold approach [/sacrasm] isn't going to get us anywhere near the savings we need to preserve the fiscal viability of our nation. Real solutions and meaningful cost control are going to involve real changes, not just re-arranging the deck chairs on a sinking ship. Based on my 13 years of experience in the health care system, here are some of my suggestions for where we're wasting real money, and where real money might be saved.
Inapporpriate Use of Emergency Services
The cost of health care changes depending on where it is delivered. A pregnant woman with a yeast infection can be treated for about $90 in an outpatient clinic. If she goes to a hospital ER or OB triage unit, that same yeast infection could easily cost $2500. People who favor universal health care like to pretend that their plans will drastically reduce such inappropriate use of emergency services. The only reason Ms Smith takes her yeast infection to the ER, they say, is because she has no insurance and therefore can't go to the clinic. If she has insurance, she'll go to the clinic and save the nation $2410.
It's a nice thought, but it totally contradicts my experience working in an OB triage unit. In Indiana we have Medicaid coverage for every pregnant woman and an extensive network of Medicaid clinics in the underserved neighborhoods of Indianapolis. And yet, I still see pregnant women - who have Medicaid coverage for their pregnancies and who are registered in clinics - come in to my OB triage unit with yeast infections every day. Obviously, this is not an issue of access to care.
What does motivate people to go to the clinic instead of the hospital? I'll tell you what motivates our family: multi-tiered copays. If we go to the ER, our copay is $120. If we go to the doctor's office, it's $20. Even more of a motivator: if we go to the ER for a trivial reason, our insurance may not cover it. I'll bet it wouldn't take too many times paying the full $2500 for a yeast infection to learn that lesson in health care economics.
Private insurance has applied similar incentives to encourage patients to choose generic medications instead of expensive new meds still under patent, to see their primary provider first instead of going to a brain surgeon every time they get a headache, and to discourage demanding a CT scan every time someone bumps his head getting out of the car.
Problem is, these motivators haven't been applied to the lower end of the income scale. The pregnant women who come to our OB triage unit don't have to pay any copays at all, and there's no chance of them getting stuck with the bill no matter what happens. They never even see the bill. When we can figure out how to apply cost based incentives to recipients of publicly funded health care (ie, Medicare and Medicaid), we stand to save some real money.
Inability to Cope Appropriately with Death
They say death and taxes are the only things in life that are certain, but we spend ridiculous amounts of money trying to pretend it's only taxes that are inevitable. Terminally ill patients routinely spend their last days in intensive care, where literally tens or hundreds of thousands of dollars are spent to delay death another few days. Right now, the decision to discontinue aggressive death-delaying care rests mostly with the patient's family. Essentially, we keep the patient alive until the family can come to terms with the fact that their loved one is going to die. Then we let him or her die.
Losing a loved one sucks, but losing a loved one on Friday isn't half a million dollars better than losing than losing him or her on Tuesday. This kind of end-of-life care will be completely unsustainable when multiplied by the 78 million baby boomers.
We're treating the wrong patient here: the real patients are the family and the correct diagnosis is anticipatory grief. Instead of spending ten or twenty thousand dollars a day on intensive care, how about bringing in a bereavement counselor?
Unrealistic Appraisal of Risks and the Expectation of Perfection
Imagine there's a story in the news today about a woman from Australia who was killed when a meteorite fell from the sky and hit her on the head. Now imagine that President Obama wants every American to go out and buy a $10,000 helmet to be worn on their heads at all times, as a way of addressing the Death by Meteorite problem.
Believe it or not, this is what we do in health care every day.
Whenever there is a maloccurrence somewhere in the health care world, we resolve to Do Whatever it Takes to Ensure This Never Happens Again. Even when the original event is a freak occurrence that's extremely unlikely to happen again anyway, we institute new routines and procedures to make sure It Never Happens Again. In fact, hospitals employ people whose job is entirely concerned with Never Happens Again issues. There's also a hospital accreditation agency that periodically inspects hospitals to ensure compliance with these routines and procedures, and suggest new and improved ones.
Some of these routines and procedures make sense. One good example is the "Pre-Operative Time Out." This started out as a simple verbal routine between the physician and the nurse, prior to beginning a procedure, to make sure everyone's on the same page about what procedure is being done to what body part of what patient. Makes sense so far, but with all these accreditation agencies and Never Happens Again busybodies running around, it never stops at the Makes Sense So Far point. If a simple verbal procedure is a good idea, then a three page form that has to be countersigned seven times by both the nurse and the physician is even better! If it makes sense to complete a three-page Time Out form before a major surgery, surely it also makes sense to do one every time we place an IV line or break a water bag, right? These Never Happens Again procedures keep growing, adding expense and complexity to everything we do. Never Happens Again has become so complex, in fact, that most health care organizations have entire staffs of "compliance officers" whose full time job it is to prepare for the next accreditation visit.
None of this is done with any sense of proportion, or balancing the expense and complexity of the new procedure versus the likelihood of the bad outcome we're supposedly trying to prevent.
Another great example is performing c-sections on large babies to prevent fetal injuries from stuck shoulders. Stuck shoulders is a complication that affects about 1/3000 deliveries. A small proportion of those cause injury to the baby, and a small proportion of those injuries result in lasting disability. So we're talking about a small proportion of a small proportion of a rare occurrence. Still, many obstetricians recommend cesearean delivery any time a large baby is suspected. The American College of OB-GYN recommends against this, noting that a policy of cesearean delivery for large babies would result in nearly 4,000 cesareans for every one baby saved from injury. Most private OBs ignore this recommendation, because in our health care culture, performing 3,999 unnecessary ceseareans for every one necessary one is a perfectly acceptable ratio.
A Common Thread
You'll notice a common thread running through all of these problems: they all relate to the separation of users from costs.
In every other service we buy, we make rational decisions about value versus cost. Nobody pays a mechanic $10,000 to make a car with a blown engine go around the block one more time. Given the choice between a quite-safe Honda and a slightly-safer Volvo for twice the price, I chose the Honda. Knowing groceries cost more at the all-night convenience store, I try to wait until daylight so I can shop at Costco. If my plumber said "let's go ahead and run a fudgippity test on your drains," I want to know what a fudgippity test is, how much it costs, and what the consequences are of not doing it.
When we purchase health care services, however, we don't ask any of these questions or make any of these evaluations of cost vs. value. One of the reasons we don't is that the costs are essentially invisible to us. A key component of health care reform, particularly if cost control is desired, is to make the patient feel the cost of his or her care. Higher costs have to have some effect on us if we're going to change our behavior to choose lower cost alternatives.
Back to the meeting between Obama and the health industry leaders, then. Why didn't they propose anything along these lines? From Obama's perspective, exposing patients to any kind of negative consequences for costly behavior is going to be very unpopular. Politicians don't like to propose things that won't be popular. And the last thing those health care industry leaders want is a bunch of cost-conscious consumers.
To summarize from the most recent blog posting:
1) US health care is extremely expensive - we spend about twice per capita what other developed countries spend
2) US health care is a relatively poor value - we aren't getting results commensurate with what we're spending
3) The combination of rising health care costs and the retirement of 78 million baby boomers will burden the US economy with crippling levels of debt. Health care costs are the most imminent threat to our future prosperity as a nation.
I will at least give credit to the Obama administration for recognizing that controlling health care costs should be a top priority. What came out of the vaunted meeting between health care industry leaders and administration officials, however, could only very optimistically be characterized as a drop in the bucket. The product of this high-level meeting was a pledge to reduce - not the actual cost of health care - but the rate of growth of health care costs - by a barely-detectable 1.5% over the next 10 years.
Obama is often compared to JFK these days. If JFK had the kind of audacity represented by this meeting, he would have set NASA the goal of sending a man up a flight of stairs, and returning him safely to Earth, before the end of the decade.
And how did the health industry leaders say they were going to achieve these underwhelming results? By coordinating care, reducing administrative costs, and focusing on effeciency, quality, and standardization; that's how!
Obviously, this [sacrasm] stunningly bold approach [/sacrasm] isn't going to get us anywhere near the savings we need to preserve the fiscal viability of our nation. Real solutions and meaningful cost control are going to involve real changes, not just re-arranging the deck chairs on a sinking ship. Based on my 13 years of experience in the health care system, here are some of my suggestions for where we're wasting real money, and where real money might be saved.
Inapporpriate Use of Emergency Services
The cost of health care changes depending on where it is delivered. A pregnant woman with a yeast infection can be treated for about $90 in an outpatient clinic. If she goes to a hospital ER or OB triage unit, that same yeast infection could easily cost $2500. People who favor universal health care like to pretend that their plans will drastically reduce such inappropriate use of emergency services. The only reason Ms Smith takes her yeast infection to the ER, they say, is because she has no insurance and therefore can't go to the clinic. If she has insurance, she'll go to the clinic and save the nation $2410.
It's a nice thought, but it totally contradicts my experience working in an OB triage unit. In Indiana we have Medicaid coverage for every pregnant woman and an extensive network of Medicaid clinics in the underserved neighborhoods of Indianapolis. And yet, I still see pregnant women - who have Medicaid coverage for their pregnancies and who are registered in clinics - come in to my OB triage unit with yeast infections every day. Obviously, this is not an issue of access to care.
What does motivate people to go to the clinic instead of the hospital? I'll tell you what motivates our family: multi-tiered copays. If we go to the ER, our copay is $120. If we go to the doctor's office, it's $20. Even more of a motivator: if we go to the ER for a trivial reason, our insurance may not cover it. I'll bet it wouldn't take too many times paying the full $2500 for a yeast infection to learn that lesson in health care economics.
Private insurance has applied similar incentives to encourage patients to choose generic medications instead of expensive new meds still under patent, to see their primary provider first instead of going to a brain surgeon every time they get a headache, and to discourage demanding a CT scan every time someone bumps his head getting out of the car.
Problem is, these motivators haven't been applied to the lower end of the income scale. The pregnant women who come to our OB triage unit don't have to pay any copays at all, and there's no chance of them getting stuck with the bill no matter what happens. They never even see the bill. When we can figure out how to apply cost based incentives to recipients of publicly funded health care (ie, Medicare and Medicaid), we stand to save some real money.
Inability to Cope Appropriately with Death
They say death and taxes are the only things in life that are certain, but we spend ridiculous amounts of money trying to pretend it's only taxes that are inevitable. Terminally ill patients routinely spend their last days in intensive care, where literally tens or hundreds of thousands of dollars are spent to delay death another few days. Right now, the decision to discontinue aggressive death-delaying care rests mostly with the patient's family. Essentially, we keep the patient alive until the family can come to terms with the fact that their loved one is going to die. Then we let him or her die.
Losing a loved one sucks, but losing a loved one on Friday isn't half a million dollars better than losing than losing him or her on Tuesday. This kind of end-of-life care will be completely unsustainable when multiplied by the 78 million baby boomers.
We're treating the wrong patient here: the real patients are the family and the correct diagnosis is anticipatory grief. Instead of spending ten or twenty thousand dollars a day on intensive care, how about bringing in a bereavement counselor?
Unrealistic Appraisal of Risks and the Expectation of Perfection
Imagine there's a story in the news today about a woman from Australia who was killed when a meteorite fell from the sky and hit her on the head. Now imagine that President Obama wants every American to go out and buy a $10,000 helmet to be worn on their heads at all times, as a way of addressing the Death by Meteorite problem.
Believe it or not, this is what we do in health care every day.
Whenever there is a maloccurrence somewhere in the health care world, we resolve to Do Whatever it Takes to Ensure This Never Happens Again. Even when the original event is a freak occurrence that's extremely unlikely to happen again anyway, we institute new routines and procedures to make sure It Never Happens Again. In fact, hospitals employ people whose job is entirely concerned with Never Happens Again issues. There's also a hospital accreditation agency that periodically inspects hospitals to ensure compliance with these routines and procedures, and suggest new and improved ones.
Some of these routines and procedures make sense. One good example is the "Pre-Operative Time Out." This started out as a simple verbal routine between the physician and the nurse, prior to beginning a procedure, to make sure everyone's on the same page about what procedure is being done to what body part of what patient. Makes sense so far, but with all these accreditation agencies and Never Happens Again busybodies running around, it never stops at the Makes Sense So Far point. If a simple verbal procedure is a good idea, then a three page form that has to be countersigned seven times by both the nurse and the physician is even better! If it makes sense to complete a three-page Time Out form before a major surgery, surely it also makes sense to do one every time we place an IV line or break a water bag, right? These Never Happens Again procedures keep growing, adding expense and complexity to everything we do. Never Happens Again has become so complex, in fact, that most health care organizations have entire staffs of "compliance officers" whose full time job it is to prepare for the next accreditation visit.
None of this is done with any sense of proportion, or balancing the expense and complexity of the new procedure versus the likelihood of the bad outcome we're supposedly trying to prevent.
Another great example is performing c-sections on large babies to prevent fetal injuries from stuck shoulders. Stuck shoulders is a complication that affects about 1/3000 deliveries. A small proportion of those cause injury to the baby, and a small proportion of those injuries result in lasting disability. So we're talking about a small proportion of a small proportion of a rare occurrence. Still, many obstetricians recommend cesearean delivery any time a large baby is suspected. The American College of OB-GYN recommends against this, noting that a policy of cesearean delivery for large babies would result in nearly 4,000 cesareans for every one baby saved from injury. Most private OBs ignore this recommendation, because in our health care culture, performing 3,999 unnecessary ceseareans for every one necessary one is a perfectly acceptable ratio.
A Common Thread
You'll notice a common thread running through all of these problems: they all relate to the separation of users from costs.
In every other service we buy, we make rational decisions about value versus cost. Nobody pays a mechanic $10,000 to make a car with a blown engine go around the block one more time. Given the choice between a quite-safe Honda and a slightly-safer Volvo for twice the price, I chose the Honda. Knowing groceries cost more at the all-night convenience store, I try to wait until daylight so I can shop at Costco. If my plumber said "let's go ahead and run a fudgippity test on your drains," I want to know what a fudgippity test is, how much it costs, and what the consequences are of not doing it.
When we purchase health care services, however, we don't ask any of these questions or make any of these evaluations of cost vs. value. One of the reasons we don't is that the costs are essentially invisible to us. A key component of health care reform, particularly if cost control is desired, is to make the patient feel the cost of his or her care. Higher costs have to have some effect on us if we're going to change our behavior to choose lower cost alternatives.
Back to the meeting between Obama and the health industry leaders, then. Why didn't they propose anything along these lines? From Obama's perspective, exposing patients to any kind of negative consequences for costly behavior is going to be very unpopular. Politicians don't like to propose things that won't be popular. And the last thing those health care industry leaders want is a bunch of cost-conscious consumers.
Not quite a baby step
The Annointed One will speak to His people today about health care reform. Reducing the rate of growth of health care spending by 1.5% a year is a far less ambitious goal than what we really need, but at least it identifies the critical goal of health care reform: cost control.
When most people talk about health care reform they focus on side-issues, like government vs. private insurance. Folks, it doesn't matter whether the government takes money out of our paychecks to finance health care, or whether our employers take it out and pay it to a private insuror: no matter how we manage the logistics of payment, we are paying way too much for our health care.
Look at this comparison of health care spending per capita by country. Most developed countries are spending about $2-3,000 per year per citizen for health care. In the US, we're spending about double that. And it's not as if we're getting great value for what we spend, either: it's often stated that the US has "the best health care in the world," but when you compare actual health outcomes (like life expectancy, chronic disease, perinatal mortality), we rank near the bottom of the developed countries. Just one example, this graph shows the US ranking #22 in the world for "healthy years life expectancy" (the average number of active healthy years a baby born this year will live).
So, we're paying Rolls-Royce prices for health care, and getting Yugo quality outcomes. But wait: it gets worse. With the retirement of the baby boomers, annual US health care expenditures are expected to almost double by 2017.
Here is a scary graphic about how rising health care costs will affect financing for Social Security and Medicare:
And and even scarier one about what that will do to our overall national debt:
Containing health care costs, therefore, isn't a "private" vs. "socialized" issue, or just another spending issue for Democrats and Republicans to beat each other about the head with. Rising health care costs are arguably the greatest threat to our future prosperity. If you want your kids and grandkids to have a chance to live a lifestyle comparable to yours, this needs to be your number one issue.
Coming up next: some places to look for cost control in health care.
When most people talk about health care reform they focus on side-issues, like government vs. private insurance. Folks, it doesn't matter whether the government takes money out of our paychecks to finance health care, or whether our employers take it out and pay it to a private insuror: no matter how we manage the logistics of payment, we are paying way too much for our health care.
Look at this comparison of health care spending per capita by country. Most developed countries are spending about $2-3,000 per year per citizen for health care. In the US, we're spending about double that. And it's not as if we're getting great value for what we spend, either: it's often stated that the US has "the best health care in the world," but when you compare actual health outcomes (like life expectancy, chronic disease, perinatal mortality), we rank near the bottom of the developed countries. Just one example, this graph shows the US ranking #22 in the world for "healthy years life expectancy" (the average number of active healthy years a baby born this year will live).
So, we're paying Rolls-Royce prices for health care, and getting Yugo quality outcomes. But wait: it gets worse. With the retirement of the baby boomers, annual US health care expenditures are expected to almost double by 2017.
Here is a scary graphic about how rising health care costs will affect financing for Social Security and Medicare:
And and even scarier one about what that will do to our overall national debt:
Containing health care costs, therefore, isn't a "private" vs. "socialized" issue, or just another spending issue for Democrats and Republicans to beat each other about the head with. Rising health care costs are arguably the greatest threat to our future prosperity. If you want your kids and grandkids to have a chance to live a lifestyle comparable to yours, this needs to be your number one issue.
Coming up next: some places to look for cost control in health care.
Friday, May 8, 2009
Nice Quote (h/t to Doug S)
"The rifle itself has no moral stature, since it has no will of its own. Naturally, it may be used by evil men for evil purposes, but there are more good men than evil, and while the latter cannot be persuaded to the path of righteousness by propaganda, they can certainly be corrected by good men with rifles."
Col. Jeff Cooper, The Art of the Rifle
Col. Jeff Cooper, The Art of the Rifle
Monday, May 4, 2009
Gardening Day
This is our most ambitious garden year yet. It seems like we add one or two new things each year; a policy that will add up on you.
Here's Byron watering in a tomato plant. The patch behind him mulched with straw is the strawberry patch.
Byron showing off the balance beam practice he has been getting in his tumbling class at the Y. We had to build these raised beds to help the soil drain and to assist with improving our Clay Township soil. We've been topping these beds with manure from the farm, plus our own compost, every Fall. The soil is getting better, bit by bit. On A-mom's advice, we don't till or spade. Her motto is "let the worms do the work." Come to think of it, she might have been referring to us kids. Either way, we have twice as many this year as last year.
In the foreground is the newest - and thus least improved - of the beds. So we're using it for the Iffy Potatoes this year. Behind Adrianna and The Amazing Water Hose Boy is our Asparagus patch. It's in its second year, coming along nicely, but still not ready for serious harvesting yet.
Adrianna planting potatoes. We're not too confident about these because they sprouted prematurely in the bag.
Here's the run down on what we're trying to grow this year:
Tomatoes - a perennial favorite. Nothing like real Hoosier tomatoes. This year we are going back to hybrid Better Boys which have generally been our best producers. We're also doing two Romas for making sun dried tomatoes. Last year we tried a Cherokee Purple, a heirloom variety which didn't produce much quantity for us last year, but makes up for it in quality. Dark red-purple meat, and a sweet, rich, low-acid taste.
Bell Peppers - two red and one purple
Brussels Sprouts
Red Cabbage
Broccoli
Bush Beans
Basil
Carrots
Radishes
Potatoes
Asparagus
Zucchini
Cucumbers
Last year we had major bug issues with the Brussels Sprouts. If you have any ideas how to deal with this, please put them in the comments below.
Here's Byron watering in a tomato plant. The patch behind him mulched with straw is the strawberry patch.
Byron showing off the balance beam practice he has been getting in his tumbling class at the Y. We had to build these raised beds to help the soil drain and to assist with improving our Clay Township soil. We've been topping these beds with manure from the farm, plus our own compost, every Fall. The soil is getting better, bit by bit. On A-mom's advice, we don't till or spade. Her motto is "let the worms do the work." Come to think of it, she might have been referring to us kids. Either way, we have twice as many this year as last year.
In the foreground is the newest - and thus least improved - of the beds. So we're using it for the Iffy Potatoes this year. Behind Adrianna and The Amazing Water Hose Boy is our Asparagus patch. It's in its second year, coming along nicely, but still not ready for serious harvesting yet.
Adrianna planting potatoes. We're not too confident about these because they sprouted prematurely in the bag.
Here's the run down on what we're trying to grow this year:
Tomatoes - a perennial favorite. Nothing like real Hoosier tomatoes. This year we are going back to hybrid Better Boys which have generally been our best producers. We're also doing two Romas for making sun dried tomatoes. Last year we tried a Cherokee Purple, a heirloom variety which didn't produce much quantity for us last year, but makes up for it in quality. Dark red-purple meat, and a sweet, rich, low-acid taste.
Bell Peppers - two red and one purple
Brussels Sprouts
Red Cabbage
Broccoli
Bush Beans
Basil
Carrots
Radishes
Potatoes
Asparagus
Zucchini
Cucumbers
Last year we had major bug issues with the Brussels Sprouts. If you have any ideas how to deal with this, please put them in the comments below.
Wednesday, April 29, 2009
OK, one more
I promise, no more video links for a while. After this one. The Red State Update guys do a great job of celebrating and parodying Redneck culture. You never quite know if they're making fun of Bubbas, or everyone else. Probably both.
Language Warning: PG-13
Tuesday, April 28, 2009
Virtuoso Wierdness
OK, so it's kind of a strange thing that these folks are doing. But they do it so well.
Thursday, April 23, 2009
Unburied Treasure
We've gone looking for these things before, but never found any. Today, Adrianna stumbles across one in the grass behind the Art Institute, of all places.They're called Morels and they are highly prized in this part of the country. I guess we can take the scientific name, M. deliciosa, as a hint as to what their essential property is.
Adrianna, by the way, has a knack for spotting things that she didn't necessarily know she was looking for. If a group of people are walking through the forest, she's always the first one to say, "Hey! Look! It's a Hyena!" or whatever the creature was that was trying to sneak past or sneak up without anyone noticing. She is also the only one who can find lost things. We believe these talents arise from an anatomic structure located in the uterus, because it doesn't work when she's pregnant. More about the Uterine Thing Finder later.
Tuesday, April 21, 2009
Walking the Walk
On the Homestead, we try to be choosy about the media in our lives. One program we feel has been both entertaining and inspirational is New Life Live. (Click here for webcast and audio archives)
New Life is a radio/webcast program on the pattern of Dear Abby, Ann Landers, etc. People call in with the kinds of problems that people have in their lives, asking for advice. What makes this program different is the folks doing the listening, asking the questions, and offering the advice: a rotating team of mental health professionals who practice from an explicitly Christian perspective.
The world suffers no shortage of spiritual lessons, nor people eager to share theirs. Most of the major religions and philosophies generally agree on most of them. The difficulty lies in operationalizing spiritual principles - putting them into practical use in our daily lives. This is where the New Life team so excels.
When we listen to the show, we rarely hear callers calling in with the same kinds of problems that we are wrangling with. But we still learn from New Life's thoughtful way of approaching problems and thinking about solutions. One thing that's particularly helpful is when they help callers role-play interactions with other people. They have a great way of fostering connection, while still addressing the problems or issues that need to be addressed.
Listening to this program has changed the way we approach each other and work together on problems.
I would especially commend this program to anyone who can't see the positive, healing, loving side of Christianity. If you think all Christianity is rigid, judgemental, guilty, shameful, or oppressive, this program might show you a glimpse of the positive, loving, redeeming kind of Christianity to which we on the Homestead aspire.
Give it a listen!
New Life is a radio/webcast program on the pattern of Dear Abby, Ann Landers, etc. People call in with the kinds of problems that people have in their lives, asking for advice. What makes this program different is the folks doing the listening, asking the questions, and offering the advice: a rotating team of mental health professionals who practice from an explicitly Christian perspective.
The world suffers no shortage of spiritual lessons, nor people eager to share theirs. Most of the major religions and philosophies generally agree on most of them. The difficulty lies in operationalizing spiritual principles - putting them into practical use in our daily lives. This is where the New Life team so excels.
When we listen to the show, we rarely hear callers calling in with the same kinds of problems that we are wrangling with. But we still learn from New Life's thoughtful way of approaching problems and thinking about solutions. One thing that's particularly helpful is when they help callers role-play interactions with other people. They have a great way of fostering connection, while still addressing the problems or issues that need to be addressed.
Listening to this program has changed the way we approach each other and work together on problems.
I would especially commend this program to anyone who can't see the positive, healing, loving side of Christianity. If you think all Christianity is rigid, judgemental, guilty, shameful, or oppressive, this program might show you a glimpse of the positive, loving, redeeming kind of Christianity to which we on the Homestead aspire.
Give it a listen!
Boring analysis of the ammo shortage
Tam offers an explanation of the ammo shortage that does not involve government conspiracies, black helicopters, malfeasance by manufacturers, or flying saucers.
How boring.
How boring.
Sunday, April 19, 2009
Early Spring on the Homestead
Spring is at least trying to spring. By which I mean, we haven't had any snow for over a week.
Adrianna's seed starts are coming along nicely. For whatever reason, we only ever get a small percentage of our beans to sprout. The basil, onions, and Romas seem to be doing fine.
Byron has a connoisseur's appreciation for mud puddles.
Jane in her first Easter dress, looking a bit dubious. It's her default facial expression.
Adrianna's seed starts are coming along nicely. For whatever reason, we only ever get a small percentage of our beans to sprout. The basil, onions, and Romas seem to be doing fine.
Byron has a connoisseur's appreciation for mud puddles. Jane in her first Easter dress, looking a bit dubious. It's her default facial expression.
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