THE VIEW FROM CHAOS MANOR
View 584 August 17 - 23, 2009
This site looks better if you set your default font to Georgia.
Highlights this week:
For boiler plate, search engine, and notes on what in the world this place is, see below.
For Previous Weeks of the View, SEE VIEW HOME PAGE
If you intend to send MAIL to me, see the INSTRUCTIONS.
This is a Day Book. Pages are in chronological, not blogological order.
August 17, 2009
In theory there has been some progress over the weekend, with the "public option" being eliminated from the health care proposal. In practice that is nowhere near certain. It remains in at least one House bill, there is no actual agreed bill, and a Senate-House "conference" can put almost anything in at the last moment. And Howard Dean wants to "do it right" which will have the "public option" in it "when it is signed in December."
The health care debate will continue. It's time to start from first principles and see what's being debated. It's bigger than "health care."
Health Care Essentials
Assertion: everyone has a right to health care.
Questions: from whence does the right come, and on whom falls the obligation to provide it or pay for it? How is that obligation acquired or imposed?
The are knotty questions. At one time when the US was considered a Christian nation they would not have been asked; everyone knew there was a general obligation to take care of the needy. The federal government may not have had any such obligation (or power) but in general the states did, and most of them tried to provide some minimum safety net. California used to have a fairly extensive welfare system -- but it was available to California residents only, and residents were required to prove they had lived in California for more than a year (and that they were here legally). New York also had a generous welfare program, but had no residency requirement at all. Eventually the Federal Government stepped in and between Congress and the courts all state residency requirements for welfare, voting, and everything else, were eliminated. This was considered progress.
Query: did this put an obligation on the Federal Government since it substituted its judgment on the matter for the state legislatures? Doe the Fed have to fund the programs it has imposed? What about illegal immigrants: whose problem are they?
But the essential question remains: who grants the rights, and on whom falls the obligation to pay? Assume the states have the constitutional right and power to grant the rights and assign the obligation under some residual sovereign powers inherited from the Crown, where did the Federal government get the power to impose this on the states?
Note we have left moral rights and obligations out of this. We are thoroughly modern now, and there are no obligations from Western Civilization, Judeo-Christian principles, or any other religious obligations. We have only legal obligations. All cultures are equal, including, I presume, the worship of Baal. We prohibit sacrificing our children to Baal, providing that they have already been born; one presumes that having a priest of Baal in an abortion clinic is not prohibitable.
But if everyone is entitled to health care, are we all entitled to equal levels of health care? For example, is a face lift "health care"? One can make the case that for some disfigured people it probably is; and one can make the care that it's required for people in certain professions. But what in those cases does "entitled" mean? Are all of us required to pay the fees for yet one more face lift of an aging movie star? Not that she would ask for it -- but why shouldn't she?
Or take another example: a 100 year old grandmother who needs a pacemaker. Should she have it? Is she entitled to it?
And that brings us to another important question: what does "entitlement" mean? What does the right to have something mean? These are not trivial questions. For example: is everyone entitled to a diamond tiara? Surely that depends on what it means to be entitled? If by "entitled" or "right to have" we mean that it is not illegal to go buy one, then yes, enthusiastically we say that everyone has that right; but if by "right to have" we mean that someone else is obliged to pay for a yacht, or a diamond tiara, then I suspect no one believes in that right.
Same for the 100 year old grandmother's pacemaker. No one would dispute that she has the right to buy that medical service, even if her grandchildren, expecting that money as an inheritance, object. If the grandchildren are wealthy enough to buy that service for grandmother, surely they have that right even if many would think that foolish. Note that in some single payer health care systems, the grandchildren do not have that right, and might even be prosecuted if they evade the system and send Grandma to a hospital in Thailand for the procedure; but I think we in the United States can agree that Grandma can buy any medical procedure she or her heirs or friends are willing to pay for.
But if we define "right to have" as "obligation for someone else to pay for" the pacemaker, we have a problem. Do we mean everyone? What about a 110 year old veteran who has been in a coma for 9 years and is kept alive on tubes, and whose only sign of conscious life is that he will squeeze his great grandaughter's hand sometimes? Or make up your own example: I am sure you can come up with a case you will assert does not have the right to an expensive procedure. So who decides? Whatever you call the decision process, the decision will eventually be made by the equivalent of a death committee, even if that committee is a Harvard Professor of Ethics. One suspects that this question and others like it will generate a lot of new work for ethicists.
However we answer these questions they don't go away. If we define "right" not as meaning "you're free to have it if you can afford it" to "you get it without paying for it so someone else has to pay" we are going to have to make some fundamental decisions, because there is no way in this economy in which we can give everyone all the health care that they think they are entitled to. The demand for a free good is infinite, even if most people will be reasonable in their demands. Some won't be. Some will demand tummy tucks, face lifts, pacemakers for the 110 year old veteran, daily pep talks for the morbidly obese, etc.; some will demand things that most of us simply won't be willing to pay for -- and there has to be a mechanism for deciding who gets what.
The Matter of Equality
If we aren't going to let everyone have everything they want and are willing to pay for, then there will be inequalities. By definition. Assume a costly new procedure is developed, one so expensive that there is no question of providing it for everyone, but which significantly prolongs life for those with certain conditions. (We can all think of examples, I suspect.) If everyone can't have it, then should anyone be allowed to buy it? Do we ration this by money?
We ration Cadillac automobiles by money. We ration caviar by money. But no one's life depends on having a Cadillac or a diamond tiara: how can we ration life? Worse, the quality of our publicly provided health care is significantly lower than what is available in private clinics and hospitals. The rich get better health care than the poor! That logic has led to some systems forbidding private clinics and hospitals. It is the logical end of the system.
Freedom is not free. Free people are not equal. Equal people are not free. Niven can afford more than I can; should I be resentful?
Insurance and Rights
The current debate confuses the principle of insurance and the matter of rights. This should be obvious. In an insurance-driven system in which insurance companies cannot refuse you for pre-existing conditions, the best strategy would be to avoid insurance as long as you're well, then at the first signs of distress rush out and buy the best and policy you can get. They can't refuse you. You may or may not change to a lower-cost policy if you're cured.
The real problem with our current health care system is that you can't change jobs. I will let a long term subscriber state the situation:
This is what needs fixing; indeed, if this were fixed I think that would take care of nearly half our health care problems. The other large item is related: when you lose your job you lose your insurance, and the COBRA program (and if you haven't read the mail on that one, do so) while vital, isn't a full answer.
If I were concerned with fixing health care, these are the two matters I would concentrate on. They involve people with jobs -- taxpayers, productive members of society -- who have some real problems. The costs of fixes are reasonably easy to estimate. We do not need to go to a single payer system to fix those problems. The impact on what people have now would be minimal. Insurance companies can adjust their rates to reflect the "transferability" or whatever it takes, and if need be could be subsidized during the adjustment period.
I haven't seen any of this discussed.
Those Not Covered
The last health care problem is those who don't have any coverage at all, either because they don't work at all, or they work for a company that doesn't provide health care. This needs discussion -- and certainly doesn't warrant changing everything else before Christmas in a mad rush to nationalize the system. It's a knotty problem, but before we tackle it, we need to answer the questions asked in the first part of this essay. Who has the right to what, and on whom are the obligations to pay? And whence came those rights and obligations? Until we have clear answers to those questions, we'll get nowhere.
And yes: I understand that those questions have some importance to the transferability/continuation problems discussed above, but I'd argue there are major differences.
In any event, there's enough here to discuss in an attempt gain some clarity.
There is also a lot of mail on this subject (as well as some good stuff on other matters).
It will take a while to get through this Powerpoint slide show, but the data are worth your attention if the subject interests you. As usual, Burt is thorough.
While you are on that subject
It seems to me obvious that we don't really understand climate modeling, and spending much money as directed by the output of those models is senseless. Better would be to spend more on gathering more data and building better models.
As to my own view, I am far more afraid of ice than warm; and I see no reason to believe that ice is not at least as likely as warming.
For platinum subscription:
Platinum subscribers enable me to work on what I think is important without worrying about economics. My thanks to all of you.
|This week:||Tuesday, August
I don't seem to have a lot of energy today. There is mail, and the health are discussions continue. Care to put lipstick on a pig?
August 19, 2009
Disaster! Hurricane Bill will not hit the United States and is not expected to do any newsworthy damage. The silly season continues.
The TSA went and done it. They have detained India's most popular superstar for extended questioning including asking perhaps the best known person in the world (although not in the USA) if there were anyone who could vouch for his identity. Of course this sort of thing was to be expected. I am sure there are some TSA Agents dedicated to our security -- but most of them surely understand that what they do is security kabuki theatre designed to convince the populace that the government is Doing Something. Should we have more respect for those who believe in what they are doing, or in those who know better but cynically go through the motion?
The Navy has been said (in The Caine Mutiny, but the saying is far older than that) to be an organization designed by geniuses for execution by idiots. Now think about those who design TSA procedures.
When I was young, federal agents were heroes (except for revenoors; having a relative who was a revenue agent was considered more embarrassing than having a Republican cousin). This was in Tennessee, not quite the Old South (there were three Republican counties in Tennessee; these were the counties that seceded from the Confederacy and set up, or tried to set up, the independent nation of Franklin). We were taught much about The War Between the States, much sympathetic to The Old Cause; but for all that, much of the US Army came from the South, and VMI , The Citadel, and other Southern military academies were as important in training the officer corps as West Point. Of course we had little contact with the Federal government.
All that has changed. Americans from all regions have begun to fear the government, and with good reason. Part of it is Pournelle's Iron Law, of course. When TSA was first set up, I said its major purpose was not airline security, but convincing the people of the United States that we are no longer citizens but subjects. My friend and colleague Fred Reed has an essay on TSA that is worth your time: http://fredoneverything.net/TSA.shtml
He had said much the same a couple of years ago: http://www.fredoneverything.net/SecurityHokum.shtml
Fred calls it Security Hokum. My term from the beginning was security theater; I later added Kabuki after TSA added some of the more bizarre procedures.
TSA is a system designed by some very well paid people whom we may presume to be bright enough to know what they are doing, for execution by the kind of people who want that sort of job. I see no reason to change my initial assessment: it is a system designed to convince the American people that they are subjects, not citizens; and it does that very well.
I was late getting the mail up, but there's considerable on healthcare and other matters.
August 20, 2009
And here is a very odd development. The American Library
Association is filing an amicus brief on behalf of the sequel author, too.
And we have developments in the Google Settlement. There is a long email to members from the Authors Guild, and then there's this:
The health care debates continue to wind onward. The administration seems desperate to get something passed. My own view remains: if 85% of the people of the US are satisfied with what we have, then clearly what is needed is some adjustments, not an overhaul. I have become more interested in the notion of the supply side: if the nation has to have a stimulus program, why not invest in more medical schools (beginning with medical service academies) and expansion of the County hospital system. Increase the number of health professionals; we'll certainly get a better return on that investment than from many of the "stimulus" packages. (And yes, I know, the danger is that we'll set up some Martin Luther King hospitals; but better to do that than to destroy what we already have).
The effects of free electronic books is discussed at some length in mail. And of course there's the usual mixed bag.
August 21, 2009
The health care debate continues, and becomes more desperate. It's not clear where it will go or what the end of it will be; but we are facing the transformation of the United States from a society of free and responsible individuals into a society that expects the government to take care of them. Not to assist, or insure liberty and choices, but to take care of them, meaning that it will have to be able to tell them what to do. I don't think any single issue has the potential for changing the funadmental nature of the country than this one does -- which is probably why it is being rushed into place before most Americans realize just how far reaching this can be.
It turns out that the difference between a "co-op" with Washington appointed directors financed by Federal taxes and a branch of the government is invisible: particularly if everyone not otherwise insured has to join it. The "public option" will still be in the bill.
As to cost saving: it has been known for a long time that probably the largest single expense in health care is the last year of life. MIT economist Lester Thurow made that point nearly two decades ago in speeches to the AAAS and elsewhere. That represents a significant chunk of money: moreover, the idea of the last year of life brings up the picture of a helpless human vegetable kept alive by extremely expensive heroic measures. That's not a very sympathetic picture. Who would want to be in that condition? Surely everyone would be better off if that didn't happen to anyone. Everyone would benefit.
But of course implementing that decision is more complicated. Who decides to turn grandmother off? I recall nearly thirty years ago a case in California in which a young woman in a vegetative state was being kept alive at horrible expense with the bill being sent to her family. The family went to Court to get permission to turn off the machines. There was a lengthy series of hearings. Lawyers got rich, and the family ended up unable to pay for either the lawyers or the hospital bill. Then there was the Terry Schaivo case, in which her parents wanted her kept alive in hopes that she'd one day wake up, while her husband wanted her sentenced to death by dehydration (as well as starvation), resulting in a State trooper preventing a mother from giving an ice cube to her dying daughter. The case was much complicated by the fact that her husband was openly living with another woman and the children they had produced in the years Shiavo was non compos mentis; it was more than a fair inference that had Schaivo been conscious she would have divorced him for adultery, at which point he would no longer have any power of decision over her. The drama played out as expected, with Schaivo dying of dehydration much like the Roman maiden walled into her bedroom by her mother. The only good news here was that Schaivo's brain was pretty well gone, and we can hope that she didn't feel anything as she died of thirst. As I understand it she wasn't given morphine in her last days. The logic of that escapes me: she was sentenced to what would be an agonizing death for a conscious person. The hope was that she didn't feel anything and morphine wasn't needed. In any event it wasn't approved. Perhaps because there was a danger of addiction?
But such questions will inevitably arrive as we seek to save money on the expenses of the last year of life. Such expenses typically include kidney dialysis, which require expensive equipment and trained medical personnel. The Social Security Act provides for dialysis and kidney replacement: in 1995 the US spent about $13 billion on this, and the trend has been upward; it may be double that by now. There's a "saving" of perhaps $10 billion a year right there: simply determine who is getting kidney treatment in the last year of life, and stop paying for it. If this discussion makes you uncomfortable, be assured you are not alone. A friend's elderly mother recently died after about a year of 3 times a week being transported to a hospital for dialysis; in her case as with many it was a race between terminal cancer and kidney failure as to which would kill her, but death within a year was pretty well inevitable. Think of the money we could have saved for a few dollars' worth of morphine. Whether it cost more to keep her going with dialysis (and some chemo therapy for the cancer) than to keep Terry Schaivo going is not known to me, but I suspect the costs were comparable.
It's easier, of course, to keep these discussions abstract and not think about the actual people involved. Unfortunately, the only way to save money is to deny that year of care to real people. Lester Thurow in his decades ago lecture on the subject digressed by telling of the Inuit and their tradition of choosing "A Good Day to Die." He was right, of course. It is very relevant. He's also one of the few economists honest enough to address this aspect of the subject.
My back of the envelope calculations say that if we could save 80% of the costs of the last year of life, we could afford some kind of medical insurance -- perhaps along the French model -- for just about all the uninsured in America. We'd still have to decide: is this person in the last year of life? Because of course once that label is placed on someone, it will just about inevitably be true.
I've tried to keep this neutral. Clearly at my age I have a larger stake in the answer than my average reader. Who gets to make these decisions, and for whom will they be made? The answers are likely to be hiding in those huge bills, and most of those who vote on them will not know for what they have voted.
August 22, 2009
I took the day off.
August 23, 2009
I am finishing the August mailbag for Chaos Manor Reviews; that, of course, deals with technical questions and items from the Chaos Manor Reviews columns. Today's Mail has other items, including health care questions, and a mixed bag of other items, including a note on the irony of my own health care.
Incidentally, regarding the VA "Death Manual", I would have thought that everyone ought to give some thought to the questions asked there, and I don't know of any easy way to do that. The time to decide the point at which it's not worth continuing by heroic medical means is surely not the time when you no longer have the mental capabilities for making decisions. I've already made my intentions clear. It's not a subject anyone wants to spend a lot of time thinking about, but then life has a number of decisions like that.
The question is, is there any realistic chance that I'll get out of a vegetative state with anything like intact mental faculties? How large a chance? How miserable am I likely to be, and for how long, while making this attempt?
Not easy decisions to make. From what I have heard, the "VA Death Manual" tries to attack this through a series of questions; how competently those questions are framed is debatable, and the qualifications of those framing the questions is not established. Indeed, I'd be hard put to come up with a list of qualifications for framing those questions. Whether this is a matter for government isn't entirely clear, but the government is paying the piper here.
My friends who rely on the VA tell me that it's a good service, but much better if you pay a lot of attention and manage your own case. That doesn't astonish me.
The fact remains that if we are going to expand health care coverage, we have to save a lot of money, and the category of "last year of life" expenses has been known for decades as the largest single block of money that might be savable. Now we've identified what is to be saved: how shall that be done? And by whom? Who is qualified to make this judgment? Where do they get that authority?
And the first question of all: are we citizens or subjects? If subjects, who is master?
This is a day book. It's not all that well edited. I try to keep this up daily, but sometimes I can't. I'll keep trying. See also the weekly COMPUTING AT CHAOS MANOR column, 8,000 - 12,000 words, depending. (Older columns here.) For more on what this page is about, please go to the VIEW PAGE. If you have never read the explanatory material on that page, please do so. If you got here through a link that didn't take you to the front page of this site, click here for a better explanation of what we're trying to do here. This site is run on the "public radio" model; see below.
If you have no idea what you are doing here, see the What is this place?, which tries to make order of chaos.
For platinum subscription:
If you subscribed:
If you didn't and haven't, why not?
Strategy of Technology in pdf format:
For a PDF copy of A Step Farther Out:
For the BYTE story, click here.
Search: type in string and press return.
The freefind search remains:
Entire Site Copyright 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 by Jerry E. Pournelle. All rights reserved.