Why Health Care is so complicated - part I

American health care has been widely talked about lately, not least because of proposals by the President and Congress to radically alter the current system. Some thoughts of mine on the subject follow - I expect this will be a multiple posting topic, as I'll continue to discuss it with others.

Terms

First, we need to define terms properly, which is much harder than it seems at first, and too seldom done. As Thomas Sowell says, for example:

The biggest of the big lies in the "health care" hype is that a lack of insurance means a lack of medical care. The second biggest lie is that health care and medical care are the same thing.

"Health care" is simple enough to define - any action, taken by an individual or another party, that affects the individual's health. If the definition sounds broad, it is; try thinking about something you do which never has any effect on your health.

"Medical care" is a bit tougher to define exactly. I think it works to define it as professional services rendered by doctors, nurses, any medical specialists(including but not limited to opthalmologists, oncologists, urologists, orthopedists, Lasik surgeons), paramedics, EMTs, first responders, and any similar person, performed generally with the expectation they will be paid for their services. (Some EMTs and first responders are volunteers, but this is uncommon and even in this case the EMS service/fire department will often bill for medical supplies and transport expenses.)

"Health insurance" is tougher yet because the term usually describes far more than is meant by "insurance" in any other area, namely the payment of a premium in exchange for the guarantee that a third party will pay a specified sum in the event of certain nonroutine losses/expenses. For reasons to be mentioned below, the U.S. tax code has given a strong incentive for routine expenses such as prescription drugs, annual physical checkups, and dental cleanings to be included under the rubric of "insurance", whereas for example car insurance does not commonly cover an oil change or a trip to the detail shop.

I think for my purposes of explanation, health insurance can be defined as any contractual system by which medical care for a given patient is directly paid for, in full or in part, by a third party(i.e. a party other than the medical professional and the patient). This can include systems like Medicare/Medicaid which are paid via tax revenues, employer-based coverage, or personally purchased policies; but the most important and relevant detail is the third-party payment system. The incentives for conduct of patient and doctor are much different when a third party is paying, as opposed to when the patient is paying out of pocket, and this is the fundamental source of administrative complication in modern medical care.

Next to come - a brief history of modern medical care.

Being "new media" savvy: not a requirement for a Congressman

I recently received an e-mail from my Congressman, Mike Doyle(D, PA-14); like any good elected representative he updates his constituents on a regular basis. I found this a bit amusing, however(...


"One of these new Facebook pages", huh? Come on Congressman, you don't have to make it that obvious you've never used the site before! And telling the reader to search, using your full title? Nope, Facebook's search isn't as smart as Google, and won't get them any results if they do that.
Before you send the e-mail, it's really not too much to ask that you include a hyperlink to the page!

That's all. I wonder if any other local reps are any better with their interweb communication.

Standard American English is right for everyone

The Pittsburgh Tribune-Review recently published an excerpt from this letter:

Dear Sir or Madam,

Letter writer Erin Donnelly(Friday May 29) has given Trib readers a piece of thoroughly academic, well-cited nonsense. Teaching African-American students in vernacular English is a waste of valuable class time, promotes ethnic separatism, and adds nothing whatever to the knowledge demanded in the highly competitive adult world.

Frederick Douglass, Paul Robeson, W.E.B. DuBois, Martin Luther King Jr., (and undoubtedly Ms. Donnelly herself) were educated in what she derisively refers to as "Standard American(white) English". These could certainly speak in the vernacular among fellow African Americans, but they understood the need to interact with the larger society, using a standard tongue.

It's a shame that modern academics reject that unfashionable truth for teaching fads with no track record of success, and in doing so place a phenomenal handicap on the futures of so many bright young African Americans with so much potential.

Sincerely,
Christopher D. Renner
West Mifflin, PA

The letter which I wrote in response to can be found here.

White House quietly trying to shut people up?

Mark Tapscott at the Washington Examiner reports.

Michelle Malkin has also covered this matter.

The White House blog reads as follows:

Friday, May 29th, 2009 at 5:35 pm
Update on Recovery Act Lobbying Rules: New Limits on Special Interest Influence
Another update from Norm Eisen, special counsel to the president for ethics and government reform, in the spirit of transparency as always:

I am writing with an update on the President’s March 20, 2009 Memorandum on Ensuring Responsible Spending of Recovery Act Funds. Section 3 of the Memorandum required all oral communications between federally registered lobbyists and government officials concerning Recovery Act policy to be disclosed on the Internet; barred registered lobbyists from having oral communications with government officials about specific Recovery Act projects or applications and instead required those communications to be in writing; and also required those written communications to be posted on the Internet(this, and all other emphasis in this post, is added). That Memorandum instructed the Office of Management and Budget (OMB) to review the initial 60 days of implementation of the stimulus lobbying restrictions, to evaluate the data, and to recommend modifications.

Following OMB’s review, the Administration has decided to make a number of changes to the rules that we think make them even tougher on special interests and more focused on merits-based decision making.

First, we will expand the restriction on oral communications to cover all persons, not just federally registered lobbyists. For the first time, we will reach contacts not only by registered lobbyists but also by unregistered ones, as well as anyone else exerting influence on the process. We concluded this was necessary under the unique circumstances of the stimulus program.

Second, we will focus the restriction on oral communications to target the scenario where concerns about merit-based decision-making are greatest –after competitive grant applications are submitted and before awards are made. Once such applications are on file, the competition should be strictly on the merits. To that end, comments (unless initiated by an agency official) must be in writing and will be posted on the Internet for every American to see.

Third, we will continue to require immediate internet disclosure of all other communications with registered lobbyists. If registered lobbyists have conversations or meetings before an application is filed, a form must be completed and posted to each agency’s website documenting the contact.

OMB will be consulting with agencies, outside experts and others about these principles and will publish detailed guidance, but we wanted to update interested parties on the outcome of the initial review. We consulted very broadly both within and outside of government (including as reflected in previous posts on the White House blog) and we are grateful to all those who participated in the process.

There are several alarming details in this post, but what most disturbed me was the barely reworded admission("restriction on oral communications") that the executive branch is attempting to restrict free speech and the right to petition government, both rights guaranteed by the First Amendment. Of course the White House can be expected to reply that the restrictions only apply to lobbyists and special interests, but the Constitution protects their rights to free speech and petition as much as it does anyone else's.*

Also, if the rules Eisen lists here aren't more specific in practice, they're basically worthless to the cause of transparency. The requirement to "post on the Internet" could be satisfied by a comment on the MySpace page of the lobbyist's 14-year old child.

Additionally, this and any other restriction on communication with government officials will inevitably handicap the average citizen more than the big K Street lobbying firm, which has armies of lawyers keeping track of new rules that apply to them.

Last thing - though transparency is usually preferable to secrecy, it says nothing at all about the wisdom or foolishness of any government act. It's far too easy to forget this.



*A brief thought on this matter - "lobbyists" and "special interests" are frequently misunderstood political bogeymen, just like "hedge fund managers", "big business", and to some extent "rednecks". Whether or not such people are inherently evil, it's in the politician's advantage to treat them as so because the majority of voters will never closely examine the bogeyman in question enough to know that the politician has misled them.

Lobbyists are good villains because they've apparently always got their hands out, ready to corrupt another otherwise virtuous government official. Who can't be sympathetic to the official when the situation is portrayed this way? But if you think one step further and ask why the lobbyist exists in the first place, the obvious answer is that government officials are extremely profligate with the revenues they receive in taxes, to say the least. More on this matter to come in the future.

On the rule of law(and not of men)

Todd Zywicki, of the Hoover Institution and George Mason University, writes this excellent article on the ideal of the rule of law, and the economic and political dangers of its recent breach with the Chrysler bankruptcy settlement.

I'd only add a bit in one way. Zywicki states:

The rule of law, not of men -- an ideal tracing back to the ancient Greeks and well-known to our Founding Fathers -- is the animating principle of the American experiment. While the rest of the world in 1787 was governed by the whims of kings and dukes, the U.S. Constitution was established to circumscribe arbitrary government power.

The ideal goes even further back than that, to the Mosaic Law. For example, Leviticus 19:15(New American Standard): You shall do no injustice in judgment; you shall not be partial to the poor nor defer to the great, but you are to judge your neighbor fairly.

Update: Richard Epstein(also of Hoover) also discusses the Chrysler bankruptcy here, with focus on bankruptcy procedures.

Sowell on "torture"

From NRO. My favorite part:

Whatever the verbal fencing over the meaning of the word “torture,” there is a fundamental difference between simply inflicting pain on innocent people for the sheer pleasure of it — which is what our terrorist enemies do — and getting life-saving information out of the terrorists by whatever means are necessary.

$2 trillion in healthcare "savings"

From Philip Klein, of the American Spectator, reporting on a conference call with HHS Secretary Kathleen Sebelius. To summarize it, there was a remarkable lack of details on where exactly the alleged savings were going to come from.

Perhaps the most revealing passage:

"Well the discussion today was if we were able to achieve the significant success that the stakeholders today felt was very achievable(emphasis added), we're talking about cutting 1.5 percent out of the rising cost of health care, about $2 trillion over the next decade," Sebelius explained. "So, that would achieve the kind of individualized savings of $2,500 per family."

In other words - we "feel like" we're going to save $2 trillion dollars, and that's all the evidence we need.

New blog

I've started another blog, located here.

The new blog will be primarily focused on transportation and emergency response issues. I'll be posting more regularly on this blog, and focusing on general political commentary, from a conservative/libertarian/classical liberal POV. (Not that I'll apply one of those labels categorically to myself anytime soon, though.)

Happy reading, feel free to e-mail me with questions, gripes, etc.

On Air Force One

I can't believe I've not posted anything in 10 days. What a slacker I am! Anyway, this speaks for itself:

Sowell on Health Care

A quickie. Thomas Sowell reiterates the fact that "health care" and "medical care" do NOT mean the same thing, nor are "insurance" and "medical care" interchangeable.

Probably the best quote from the article:

When it comes to things where medical care itself makes the biggest difference — cancer survival rates, for example — Americans do much better than people in most other countries.

No one who compares medical care in this country with medical care in other countries is likely to want to switch. But those who cannot be bothered with the facts may help destroy the best medical care in the world by falling for political rhetoric.

More on high speed rail

From the New Republic yesterday. The writers there tend to be much more concerned about greenhouse gases than I am, but it seems to be widely accepted that some of the inputs required to achieve "high-speed" are:

• separate rights-of-way(in other words, tracks shared with freight rail are out of the question)
• broad curves
• elimination of steep grades, whether by earth removal or tunnels.

Author Plumer thinks that the trade-offs are manageable, but as I mentioned previously, the terrain of western Pennsylvania would result in a very high cost to build a track with the above qualities(the Tribune-Review says $13 billion), and I really think the money could be better spent elsewhere, particularly on upgrading highways.

That same Trib article, interestingly enough, mentions the current speed of current trains between Harrisburg and Philadelphia as being "up to 110 mph" according to a PennDOT spokesman. Again, though, that part of the state is relatively ideal terrain for transport, as shown below.

The Fredericktown Ferry and the Mon-Fayette Expressway

From the Trib. I've never heard of this ferry before, but it sounds interesting. Its existence is somewhat threatened by the Mon-Fayette expressway, so it seems. The location is shown below.


View Larger Map

The article states that the ferry carries about 130 people/cars a day at $2 each, which adds up to $95,000 a year in revenue; however Washington County and Fayette County also pay about $100,000 per year for its operation.

The ferry is more or less a curiosity in the larger scheme of western PA transportation. What primarily interested me here was the Mon-Fayette Expressway(aka Route 43, Turnpike 43). In 2012, the Brownsville-to-Uniontown section of the expressway will be complete, which means that the entire PA 43 would be finished - except for the glaring lack of progress from Jefferson to Pittsburgh/Monroeville.

I'll be writing more on this in the near future, but it will suffice to say now that I think the incomplete Pittsburgh section of the MFE is the single most urgent transportation project in western PA.

Further reading on the Mon-Fayette plans in general(here) and the Brownsville-to-Uniontown section in particular(here).

High speed rail to Pittsburgh?

Obama's stimulus plan includes $8 billion for a "start on establishing high-speed rail corridors nationwide". One of the 10 corridors identified for possible service is the "Keystone" corridor between Pittsburgh, Harrisburg, and Philadelphia.

I'm really skeptical of this for a number of reasons, most of which are technical.

• Flying is cheap and readily available between Pittsburgh and Philly(as an example Expedia is showing a roundtrip for $119.20*, fees included). Unless the proposed high-speed fares are heavily subsidized I don't expect they'll be any less.
  
  
• Even allowing for airport security hassles it's possible to fly from Pittsburgh to Philadelphia in about 2 hours. To match that a train would have to average 150 mph, counting waiting times.
  
  
• For a train to be considered "high-speed" by Amtrak standards it has to average only 90 mph. I'm not a railroad engineer, but I'd imagine that given the terrain between Pittsburgh and Harrisburg it would take several hundred billion dollars to build a dedicated track that would allow for those kinds of speed.
  
  
• Achieving "high speed" with shared rail lines is generally out of the question. As mentioned in the linked article, the Acela Express over the Northeast Corridor has to slow down almost constantly because of all the slower passenger and especially freight trains on the same tracks. And again, that's on relatively flat terrain. Freight trains in the Appalachians undoubtedly run slower than on the flat lands near the coast.

Basically I think it's well demonstrated that it will be impossible for high speed rail, without subsidies, to be competitive with air travel on the basis of price or travel time.

Obama's justification for the subsidies, which is fairly consistent with what other politicians say in justifying high speed rail, is that it will relieve congestion(both in the airways and on the road), help clean the air, and save energy.

I don't have hard data on these matters, but anecdotally I've never found the PA Turnpike to be particularly crowded. It's probably busier than the average rural Interstate, and does have heavy truck traffic, but I think it could be upgraded to 3 lanes each way, for its entire direction, for a small fraction of what a new rail line would cost.

PIT and PHL do not usually make the list of airports lacking capacity. A frequent concern viced about PIT is that the airlines are offering fewer flights into it, which suggests that congestion there is not a great problem.

As far as cleaning the air, the high speed trains in other countries generally run on overhead electric wires - which means they appear "clean" because they shift the dirty power generation elsewhere. This doesn't of course rule out that high-speed rail usage could result in a net reduction of pollution - but this would depend on the local means of electric generation(coal, nuclear, natural gas) being "cleaner" than the jet engines, diesel buses, and gasoline engined cars that would be used alternatively.

Pollution reduction would also depend on high speed rail being a sufficiently viable alternative to other methods of long-distance mass transit to attract their current users, which as I've demonstrated above isn't likely. (I haven't mentioned the private automobile, but in general the idea that mass transit will 'get people out of their cars' is fallacious. The convenience of always ending up exactly at your destination, making stops at the store on your way home, and making your own schedule outweigh the inefficiency for most private car owners).


*The fare was calculated today(April 16), departing April 30, returning May 5, with flexible times(9 unique departing flights were available at that price). For comparison, Amtrak's current cheapest roundtrip fare for the same dates is $94.00, with a train that leaves once daily. Greyhound ticket with a 14-day advance purchase is $60.00.

An absurdity on veterans and the "right wing"

Fox News interviews Janet Napolitano about the Mexican violence and the controversial memo issued to law enforcement recently, titled "Rightwing Extremism: Current Economic and Political Climate Fueling Resurgence in Radicalization and Recruitment".

On the matter of the memo itself, it's suspect whether "rightwing extremism" was chosen as a label to actually help law enforcement or just to subtly bash the administration's political opponents(As an example on page 4, xenophobia and antidemocratic ideals are described as rightwing, which is utter nonsense. Are the unions who vehemently oppose illegal immigration now 'rightwing'? And does the right advocate legislation by the judiciary or the administrative agencies, probably the biggest internal threat to democracy?).

A footnote(p.2) elaborating on rightwing extremism, which has been rightly criticized:

Rightwing extremism in the United States can be broadly divided into those groups, movements, and
adherents that are primarily hate-oriented (based on hatred of particular religious, racial or ethnic groups),
and those that are mainly antigovernment, rejecting federal authority in favor of state or local authority, or
rejecting government authority entirely. It may include groups and individuals that are dedicated to a
single issue, such as opposition to abortion or immigration.

This definition is basically useless. The groups mentioned have nothing whatsoever in common, other than that so-called "liberals" oppose them. Sometimes. Depending on the specific race and religion of the extremist.

In the video, the most absurd statement of all from Ms. Napolitano came at the 4:46 mark, where she said that "Timothy McVeigh was a veteran, that's where he got his training." There is absolutely not one shred of evidence that any military training he had was the least bit relevant to the Oklahoma City bombing.

The only reason this idiotic statement can be made(and to be fair, Ms. Napolitano's not the only one who I've heard say it), is because there's a stereotype of veterans as being brainwashed, programmed to kill, desensitized, &c.; but it only takes one look at the hard facts to realize how untrue it is.

McVeigh, as a Bradley gunner, was probably taught good gunnery and marksmanship, use of various handheld weapons such as grenades or anti-tank rockets, basic military/outdoor skills, and Army tradition. Perhaps he even operated the Bradley. I challenge anyone to explain what aspect of this training, in the late 80s or now, or ever, has anything to do with creating a 5000 lb. ANFO with a Ryder truck, and placing it next to a building in order to demolish it.

Crash Data for Pittsburgh Highway Corridors

The Southwestern Pennsylvania Commission, I've just discovered, has a great deal of transportation data for our region. Among other things they have a Congestion Management Process which is supposed to collect data on highway congestion so that transportation planners know where it needs to be alleviated.

Of interest to an emergency responder, the SPC posts data on crash location and severity for the regional highway corridors. This I found to be particularly enlightening. For example, here(as a PDF) is the data for I-376 between the Turnpike and Downtown. Some points I thought were interesting:

1. There are noticeably more crashes on Fridays and Saturdays, and I'm wondering why. Instinctively I'd say late night DUI drivers, but that's belied by the next point.
   
   
2. The peak hours for crashes appear to be(in descending order) 14:00, 8:00, 13:00, 15:00, 16:00, and 2:00. Mid-afternoon doesn't seem to me a very accident-prone time, but if these data are correct that obviously needs to be rethought.
   
   
3. 76% of crashes are in non-adverse conditions, which suggests, since Pittsburgh has 152 days annually with rain, snow, sleet, &c., that drivers are less competent or careful when the sun comes out.
   
   
4. 43% of the collisions on 376 were rear-end collisions, and 40% were vehicle into a fixed object(barrier, sign post, and much more).
   

A couple of notes on the data:

The crash data are from PennDOT's CDART crash tracking system. These are "reportable" crashes only, defined by PennDOT and the SPC as "a traffic accident where someone was injured or where one of the vehicles had to be towed from the scene".

The "severity index" they have listed is a weighted average, with the following weights given to each crash type:
Fatal crashes = 12
Major injury crashes = 12
Moderate injury crashes = 3
Minor injury crashes = 2
Unknown injury crashes = 2
Property damage only crashes = 1

On basic chemistry

Al Gore's Repower America project, which I registered for some time ago and receive e-mail updates from, asked me to write letters to the editor supporting the idea of a cap on carbon emissions. I happily obliged them with the following:

Subject: Carbon dioxide is NOT a pollutant, and cap-and-trade restrictions on it will kill the economy.


The Alliance for Climate Protection is currently trying to stir up more hysteria about the "pollutant" carbon dioxide, calling for a cap on "emissions" immediately. This is nonsensical.

First, anyone who knows basic chemistry understands that incomplete, inefficient combustion of hydrocarbon fuels(coal, oil or gas) creates real pollutants like carbon monoxide, sulfur dioxide, and oxides of nitrogen.
Complete combustion produces that bogeyman, carbon dioxide, and the horribly toxic compound, water vapor(incidentally many times better at trapping heat than carbon dioxide).

Second, carbon dioxide is as necessary for plant life as oxygen is for animals. Without it, photosynthesis cannot occur and the plant will die. A GE commercial within the past year showed an anthropomorphic tree embracing an "energy efficient house" with it's limbs, but a more accurate depiction would have had the tree gasping for the precious carbon dioxide that the house was no longer emitting.

In the end, it's rather unfortunate that most of the folks in Washington and in the anti-AGW movement don't seem to be in the category "anyone who knows basic chemistry", for then the ridiculous plan to restrict a compound so essential to life, and handicap future economic growth in the process, would be found strictly on the lunatic fringe where it belongs.

Sincerely,
Christopher Renner

Some thoughts on this blog's purpose

I expect that I'll be posting various random things here - have a Twitter feed, but it's obviously not long enough to explore anything in depth. At this point in my life I don't have a particular focus or area of expertise apart from perhaps car electronic systems, and I can't see limiting this page to one subject.

Transportation has always fascinated me(as an example I think I had almost memorized the general routes of every Port Authority bus by age 11, along with the interstate highway system), and I expect it to be a subject of a number of my posts here.

Also economic and financial issues - economics is relevant to just about anything in life, and arises in a good number of conversations I have as of late.

Other than that, I'm open to write about just about anything.

Comments should be open to anyone. Feel free to offer your input.

Condi on the Tonight Show

Rather interesting...I hadn't watched her speak in a while. She discusses George W. Bush and his ability to grasp ideas very well, even if he's simply horrid at explaining them to others. I can't recall ever hearing otherwise from anyone who knew the former President.

Also she mentions the progress in civil rights, and asserts that the country has come a long way from 50 years ago when her friend Denise McNair was killed in the Birmingham church bombing, to electing a black president.

To be fair, I have to nitpick the factual accuracy(as I do to everyone) of one statement she made, that "we were considered three-fifths of a human being in Thomas Jefferson's original Constitution" - what's wrong with that assertion is that Madison wrote most of the Constitution(Jefferson wrote the Declaration of Independence).

And hasn't the "three-fifths clause" (found in Article I, Section 2 of the constitution) been a thoroughly overused, inaccurate inducement to guilt for long enough? I guess it would have been better if the founders had counted all the slaves as "full" human beings for Congressional representation. They'd still have been enslaved, vulnerable to abuse, and disfranchised, and their masters would have more representation in Congress relative to the free states, but hey - at least the free descendants of said slaves wouldn't feel so bad!

In any case, my distracting rant aside, I have a hunch it'll be at least 5 years until the Bush administration can be evaluated rationally.

Venezuela's Chavez - he's not Marxist, but fascist(in the original sense of the word)

In this excellent article in the New Republic, Enrique Krauze discusses the philosophical background of Hugo Chavez, his successful appropriation of the personality cult surrounding Bolivar, his contempt for liberal democracy, and the anti-Semitism of Argentinian sociologist Norberto Ceresole, a longtime Chavez adviser. Also mentioned are the importance world oil prices have had in allowing Chavez to buy the affections of the masses, and the potential consequences if they remain at their current levels or lower.

The one thing I'd take issue with is that Krauze follows the conventional practice of describing fascism as "right-wing" and Marxism as "left-wing". This distinction usually seems to be made on the basis that Marxism is supposed to be internationalist in its outlook whereas Italian fascism and German National Socialism were obviously nationalistic. While true, I think that these ideas all had in common socialism, commitment to revolution, and contempt for liberal democracy, and that generally the label "right-wing" precludes at least the first two common traits.

It's interesting for me as well to think about what differences exist between the USA and Latin America that could be traced almost entirely to the fact that the 13 colonies had George Washington leading them to independence, and Ibero-America had Simon Bolivar.

A lot of revisionist history has criticized Washington and some of the other founders primarily on the basis of their continued ownership of slaves, and raised Lincoln far above him in the pantheon of American presidents; but this obscures Washington's real contribution to American politics. The office of the Presidency was created specifically for a reluctant Washington, and the precedents he set gave the position the stability which has lasted 220 years uninterrupted, with peaceful transitions of power throughout.

In contrast to this, Bolivar enthusiastically sought to be president for life, and to unite all of the former Spanish empire under his leadership. I suspect that his actions justified more than a little the many future Latin American dictators, presidents-for-life, etc. who desired similar positions for themselves.

Mark Bowden(of Black Hawk Down fame) on torture

Originally published in the Atlantic Magazine, October 2003.

This is definitely the most thorough analysis of the subject that I've ever read - Bowden has interviewed several former interrogators from such diverse organizations as the Vietnam-era USMC, Israel's Shabak[General Security Service], and the NYPD; and he properly distinguishes torture from "enhanced interrogation" and the like, and effective from ineffective interrogation methods; also he cites a few actual examples of the much-hypothesized "ticking time bomb" scenario where extracting information has literally been a matter of life and death for others.

He's more optimistic than I am, however, when he says that "no interrogator is ever going to be prosecuted for keeping Khalid Sheikh Mohammed awake, cold, alone, and uncomfortable. Nor should he be." I think of the "Wall" between intelligence and domestic law enforcement that existed pre-9/11, and I can't rule out the prospect of government lawyers being similarly overzealous in the near future.