Health care principles and problems

View 707 Tuesday, December 27, 2011

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I am weary of saying that I am not an apologist for Newt Gingrich, then writing as if I am; but the headlines give me little choice. I have long said that Newt would not have been my first choice for President, but he is an old friend, and he would be a far better President than our current one. The nomination ought to be based on rational discussion, not on headline gotchas. There is a sense in which the future of the Republic depends on this principle. The Internet Age followed rapidly on the TV age which followed the Radio Age, and all of those had enormous effects on the way we choose our national leaders. Now we have Facebook and Twitter, and instant polls, and what gets lost in all this is any rational discussion of issues.

As for example the Wall Street Journal front page headline” Gingrich Applauded Romney’s Health Plan” (link) which begins “Newt Gingrich voiced enthusiasm for Mitt Romney’s Massachusetts health-care law when it was passed five years ago, the same plan he has been denouncing over the past few months as he campaigned for the Republican presidential nomination.”

Way down in the page 4 continuation it says

At the same time, the essay cautioned that the Massachusetts plan may not work. It warned that the state has an "exhaustive" list of health-coverage requirements that prohibit insurers from offering basic plans with high deductibles. It predicted that state residents earning little more than $30,000 a year—the threshold for an individual to qualify for subsidized coverage—would be "in jeopardy of being priced out of the system." Instead, the newsletter said, "we propose that a more realistic approach might be to limit the mandate to those individuals earning upward of $54,000 per year."

It also gave a nod to the concept of making it easier for Americans to purchase insurance across state lines, an idea widely backed by Republicans as a mechanism to make coverage cheaper through competition.

A follow-up August 2006 newsletter from the center called Mr. Romney’s plan "the most interesting effort to solve the uninsured problem in America today." It praised "a Republican governor working with a Democratic state legislature to find a bipartisan reform that is based on market-oriented principles." (link)

The entire article comes closer to a rational presentation, but the entire front page is not. Nor, despite the argumentation posing as a front page news article, is it clear that Mr. Gingrich’s position on the Romney plan for Massachusetts is not consistent with principled conservatism. I would have thought that the notion of state’s rights and allowing the states to experiment with solutions to very sticky problems was almost the essence of the Constitution of 1787.

Certainly the conservative position on health care is that it is not a national “problem” to be “solved” by national action. Whether or not any government actions can “solve” whatever is meant by the problem of health insurance, I for one am glad of the Massachusetts experiment. Like X projects in aerospace, it is an experiment that gives us some data rather than models and theory; and I cannot think that Gingrich’s “approval” of the Romney plan is somehow indicative of any betrayal of conservative principles. If some kind of universal health insurance program is going to work anywhere, it should work in Mass., a wealthy and highly educated state able to afford it if anyone could.

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Any discussion of conservative principles and health care has to begin with some facts. One of those facts is that the courts have in essence nationalized a form of universal health care: they have decreed that emergency rooms cannot turn people away for lack of insurance or other means to pay for the treatment they demand. Moreover, there is, I think, a general consensus among the American People that the spirit of this mandate is acceptable: people should not die in hospital waiting rooms while trying to prove they can pay. Of course that seldom happens, and often the treatment demanded is not urgently needed, but we are agreed that people ought not be denied emergency care.

That simple principle works with some populations with strong moral and ethical principles that include limits on what they think they are entitled to. It works in many American communities to this day. It may work in Massachusetts for all I know. It does not work in Southern California, where eleven hospitals have closed their emergency rooms, and the once world class trauma center network we had is nearly forgotten. The hospitals close their emergency rooms because they can’t afford to keep them open: the alternative would be to close the whole hospital. (Another alternative, triage in the waiting room doesn’t work and subjects the hospitals to crippling law suits. The Courts in essence won’t permit it.)

And that is the essence of the “health insurance problem.” Insurance is not welfare, and requiring equal premiums for all insured – granting the ‘right’ to insurance for those with pre-conditions at the same premium as those in good health – is not insurance at all. The obvious strategy for those with crippling pre-conditions is to buy the insurance, while for those in good health it makes sense to buy no insurance at all until symptoms appear, then rush out and buy it. Given that rational economic strategy of the customers, the obvious rational strategy of insurance companies is to declare bankruptcy, and for their executives to get into some other line of work, possibly as welfare administrators.

As Mitt Romney has repeatedly said, in Massachusetts they had about 8% population without health insurance. Everyone else was satisfied with what they had. The plan, which was passed by a Democratic Party controlled legislature, attempted to deal with that situation and provide for the 8%. In theory it wouldn’t affect anyone else. How well it works is worthy of study, but it is the business of the people of Massachusetts, not mine. In Los Angeles County we have had eleven emergency rooms close down, considerable stress on those remaining, and the loss of our once renowned Trauma Network. I don’t know what the situation is in Boston. Were I in the health care business I would pay more attention.

The real question is, who is obliged to pay for what? If an elderly uninsured person has a heart attack and requires emergency care, who is obliged to pay for it? What is my personal obligation? And for that matter, if I have a heart attack, should you pay for it? (I will quickly acknowledge that when I did have medical problems, I had no lack of free expert advice from readers and subscribers, for which I am extremely grateful; but I think that is a different matter. None of that was compelled.)

That is really the essence of it all: who should be compelled to pay? Should the physicians and technicians be compelled to render their services for free? That seems unfair. It is also unlikely to produce a good supply of highly educated and qualified physicians, nurses, and technicians. And yes: I do understand that the supply has in the past been artificially limited (or at least that this is contended) in order to keep the price of those services artificially high, so the compulsion is not so monstrous as it seems – but that leads off to another question about who is compelled to pay for medical and technical training, the costs of such education, and the monstrous quality of the school system. And we haven’t time to deal with that.

We don’t even have time to deal with the question of “who must be compelled to pay and for what?” – yet that is the essence of the “health insurance” problem. When I was young the matter was simple enough. You paid for your own medical services, and if that proved to be beyond your means you sold property, or borrowed money, or did whatever was required; or you didn’t pay and the doctors gave you what service they thought you might deserve of their charity. There wasn’t much medical insurance as such. There were charity hospitals, mostly run by Christian religious organizations.

Health Insurance became widespread largely because it was a way for employers to compete for good workers during a labor shortage in a time of wage controls: the business could deduct the insurance payments as a cost of doing business, while the insurance benefit was not taxed as income for the laborer. The result was widespread insurance among the employed, and that led to the situation of establishing one’s insurance status when being admitted to hospital – and that led to the horror stories of people dying in the waiting room while filling out forms. And that made health insurance a political problem.

But the political problem never really addressed the question: Who must pay for what? What are you obligated to pay for my health problems?

Once we establish that principle we can look at mechanisms for dealing with it; and having a cold look at this first principle should once and for all establish a simple fact: it is not a federal problem. It may be a state problem: Massachusetts chose to make it one for the people of that state. That will depend on the ethical and moral principles of the people of that state: and given the relentless war on religion, that may be an interesting picture. Perhaps the answer is simple: a relentless drive for entitlement to the masses at the expense of the productive. This has happened before through history. The Framers of our Constitution hoped to avoid this at least on a national level by limiting the power of the federal government: but leaving matters to the states means that states will approach such matters in different ways.

I have no definitive answers here, but it does seem to me that before we talk about the mechanisms of “solving the health insurance problem” we deal with the more fundamental question: “who must pay for someone else’s health care?” and on what moral or ethical principle is that obligation based. Until this is answered we have only the simple principle of “democracy”: You have it, and we want it. Republics fall when that becomes the basis of government, and the rich turn to a protector, usually a ‘friend of the people”. The result is seldom to anyone’s liking, as we say with the Soviet experiments.

Of course that kind of democracy usually does produce a ruling class.

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I do understand that politics takes over from rational discussion. When that happens the trumpets of leadership become uncertain. The personality substituting for Rush Limbaugh, for example, is today in near despair, while desperately proclaiming Newt Gingrich a liar for his comments on Romney’s Massachusetts health care. After all, didn’t he approve it? But it’s a bit more complex than that. Newt is wrong to impute to Romney a desire to impose the Massachusetts plan on the nation. I don’t recall Romney ever wanting to do so. He has, correctly, defended the state’s right to the experiment.

Newt is correct in denouncing Obamacare and saying that the Massachusetts plan must not be imposed on the United States. He was correct when he said it was an interesting experiment. He is playing politics when he attributes to Romney a desire to impose this on the nation. I certainly would not have advised him to do that. I will say that Mr. Gingrich has been far less negative in his campaigning than his Republican establishment enemies have been.

Newt thinks a lot and he says what he thinks. It was true when I was associated with him and it is true now. He generally surrounds himself with smart people who are not afraid to tell him he’s wrong, and he tends to enjoy those discussions. This is a very good practice for a legislator. It is less so for a commander in chief, but it is not a fatal flaw for a president. The President of the United States is not the Emperor. His whimsical decrees do not have immediate effect. The most important requirement for President is a dedication to the Constitution. That, I think, applies to every one of the Republican candidates.

Reagan once told us as a general rule to nominate the most conservative electable candidate. That was good advice then and it still is.

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Early Days of word processing

View 707 Monday, December 26, 2011

Happy New Year.

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A professor in Maryland has an article in the New York Times about word processors and novelist. He doesn’t seem to have done any homework at all. He references a 1985 Stephen King preface, and is apparently intent on digging about in the Microsoft archives, but he hasn’t bothered to talk to the people who were actually writing with computers in the 1979-1984 era. It took mo no time at all to Google up “LORD OF CHAOS MANOR : Hoping for a message from a long-lost friend” from the Los Angeles Times, and it was a quite late development. The LA Times article even mentions the 1982 novel Oath of Fealty, by Larry Niven and Jerry Pournelle, which was a New York Times bestseller and for a while was on the list of the best 100 science fiction novels of all time. Considering that it was written in the dawn of the computer age, it holds up pretty well after all these years, and still sells quite well in eBook editions. Of course it was written on Z-80 computers – Niven had Tony Pietsch build 2 duplicates of Ezekial, one for himself and one for his wife Marilyn on the theory that he’d have a spare if ever needed. I managed to write the first science fiction novel using a computer. The late Dr.Robert Foreward of Hughes Laboratory wasn’t far behind: he used a UNIX system and an early UNIX line editing language called TECO that I had experimented with during a visit to MIT and decided was too difficult.

The LA Times article gets one thing wrong: although old Ezekial, my friend who happened to be a Z-80 computer, was given up for dead, he was revived at the request of the Smithsonian. I got him back together and shipped him off, then went to Washington to unpack him. The Smithsonian only wanted him for a display as the first computer to have been used to write a science fiction novel, but I wanted to wake him up so he could see where he was. I did that, and he got a good look before I put him back to sleep. For years he was in the hall of communications and computers, next to an old Imsai 8080. They closed that wing for refurbishment, and I think he’s back in the basement. For several years I used to say to people “How many people have you met who have their personal computer on display at the Smithsonian? In future the answer will be all of them.”

I wrote the first articles on Writing With Computers for BYTE and an unsuccessful McGraw Hill spin-off back in 1979, and in 1980 I started doing a BYTE column. At first it was just a series of articles on small computers, but BYTE’s Carl Helmers liked it and it became Computing At Chaos Manor. Meanwhile I kept writing science fiction and Niven and I produced Footfall, published in 1985. It was a New York Times #1 best seller.

As to the origins of word processing, the main contenders in the 1978-1981 era were WANG dedicated word processors and S-100 computers running the CP/M operating system. Barry Longyear wrote his SF works on a Wang, and Asimov’s published an article by Longyear and me in the form of a disputation. I contended that it was better to use a general purpose computer rather than a dedicated word processor. Events proved me right.

After IBM came out with DOS the picture changed from CP/M to DOS as the best selling operating system and Microsoft early on saw that word processing would be a major seller, but when Microsoft Word first came out it wasn’t good enough to induce Niven and me to change. We continued to use a series of programs, from the early Electric Pencil to Tony Pietsch’s WRITE to Semantec’s Q&A Write for quite a while until the Microsoft Word Czar Chris Peters asked us what it would take to get us to go over to WORD. We told him, and he did it. Since Microsoft had integrated the CDROM version of Bookshelf, an excellent spelling checker, and a thesaurus into Word we changed over, and we’ve used WORD ever since despite a concerted effort by Word Perfect to get us into their camp. Word Perfect’s spelling and grammar checkers were (then) better than Microsoft’s, but the Bookshelf and Thesaurus features were decisive.

There’s more on this in an old interview I did http://www.whedon.info/Joss-Whedon-SciFi-com-talks-to-SF.html . If Professor Kirschenbaum want to know more about the early history of word processing, I’m easy to find.

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Bette, one of several computers I write with now. Zeke, my old friend who happened to be a Z-80, ran at 1 MHZ, featured 2 64-Kilobyte 8” floppy disks, and 64 Kilobytes of memory. Bette has 4 CPU chips, a terabyte of disk storage space, and 8 gigabytes of memory. And she runs considerably faster than the 2 MHZ that Zeke eventually upgraded to.

Another place to find more on this is http://use.perl.org/~Mark+Leighton+Fisher/journal/30464.

 

And Eric Pobirs has found in one of my anthologies, Black Holes, I mentioned using a computer write this stuff on, including a story of my introducing Niven to small computers. I think I’m probably safe enough on my claims…

 

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I wrote the above after a number of readers referred me to the NYT article. My thanks to all of them. Here’s one:

Word processors and Authors article (NYTimes)

http://www.nytimes.com/2011/12/26/books/a-literary-history-of-word-processing.html

"The literary history of word processing is far murkier, but that isn’t stopping Matthew G. Kirschenbaum, an associate professor of English at the University of Maryland, from trying to recover it, one casual deletion and trashed document at a time."

Mr. Pournelle,

When I read this article I thought back to all the stories you related in the old Byte magazine column you wrote, Chaos Manor. In those stories over the years I got the sense that not only were you an early adopter of technology, but you USED it regularly to get work done. So it occurred to me after reading this article in the NYTimes that the Professor from UMD, was concentrating on what seemed to be a very narrow group of well known and big name authors. People who had money to buy products like Wang word processors (Stephen King) while interesting for historic value, don’t really cover enough of the ‘range’ of the history of word processing software as it came to be defined.

So I wanted to toss this article over the fence to you. And ask, can this guy do a better job of covering the ‘history of word processing’ than he seems to be presenting in this article? I’m sure you have some both historical and anecdotal evidence to further lengthen the timeline beyond the ‘Late ’70s’. But I don’t want to be too presumptuous, I could just as easily be wrong, and off-base by thinking word processing was adopted earlier than the NYTimes covers it. But I thought at least a primary ‘source’ should be consulted, and you were the first person I thought of. Happy New Year to you. All the best. And I will always fondly remember reading, and will continue to read Chaos Manor.

Eric Likness

By the time I got Zeke, there was a technical book store called “American Word Processing” in the Silverlake district in Los Angeles. It wasn’t very large, but it carried books on small computers, and of course sold BYTE Magazine. Most Word Processors were dedicated Wang systems and were mostly used in legal offices. Barry Longyear got a Wang about the time I got Zeke, and we debated over dedicated word processors vs. “real computers” but in private (by letters!) and in published articles.

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While searching for other stuff, I found this early discussion of what this place is about. It seemed appropriate to reference:

http://www.jerrypournelle.com/debates/meta.html

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Christmas

View 706 Sunday, December 25, 2011

MERRY CHRISTMAS

We had a nice day. Roberta sang at the midnight mass Saturday night, and again this morning, so we’ve been a bit short of sleep, and I’m heading for bed.

Merry Christmas to All, and a Happy New Year.

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I have run this on Christmas Eve most years. Last night I didn’t get anything up because we had to get Roberta to the choir on time.

O ye, beneath life’s crushing load,
whose forms are bending low,
Who toil along the climbing way
with painful steps and slow,

Look now! For glad and golden hours
come swiftly on the wing:
O rest beside the weary road,
and hear the angels sing!

Yet with the woes of sin and strife,
the world has suffered long
Beneath the heavenly strain have rolled
two thousand years of wrong;

And man, at war with man, hears not
the tidings that they bring;
O hush the noise, ye men of strife,
and hear the angels sing!

And a Merry Christmas to all who keep the peace.

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It could be a gotcha

View 706 Friday, December 23, 2011

· Silly Defeat or Gotcha?

· Iraq and Kurdistan

·Starswarm by Jerry Pournelle available on Kindle and Nook. Compares favorably to Heinlein juveniles according to many reviewers.

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Absurdity or Gotcha?

The ABC News reporting the AP headline says it all: Payroll Tax Deadlock Ends as House Caves

House Republicans on Thursday caved to demands by President Barack Obama, congressional Democrats and fellow Republicans for a short-term renewal of payroll tax cuts for all workers.

Surprisingly, there was no objection to the “unanimous consent” decree restoring the House-rejected Senate Bill extending the temporary suspension of Social Security insurance payments for two months, after the Tea Party elements of the House had rejected the bill. This is widely touted as a sign of weakness, and “caved” is the most common term used. And of course the Democrats are taking a victory lap.

The Senate quickly approved and sent the Bill to the White House, where the President signed it on his way out the door to his wonderful Christmas in Hawaii; one of the perquisites of being President of these United States.

This is widely proclaimed as a great victory for the Democrats and a humiliation for the Republicans. Perhaps so, but there is another way to look at it.

The bill, a two month extension, was passed. It includes an instruction for the President to decide on the Canadian pipeline within sixty days. It’s his move now. The extension expires in sixty days. And the House comes back to Washington in early January.

Now that it has been demonstrated that the House can act quickly when it has to, it is time to do more. It is time to enact legislation representing what will come forth next year.

Let me suggest some. First, a bill declaring that the United States no longer is interested in federal licenses for those who raise pet rabbits, nor in licensing stage magicians who use rabbits in their acts, and no money appropriated in any budget or act or appropriation or authorization shall be spent in enforcing any act or regulation concerning federal licensing of pet rabbits. Any expenditure on licensing or inspecting pet rabbits must be from a bill explicitly appropriating funds for that purpose. Anyone authorizing expenditure of federal funds in violation of this act shall be dismissed for cause from federal employment, and shall be required to repay to the United States any such money he or she spent or allowed to be spent.

The fact that it takes so many words to end the silliness of paying Federal Bunny Inspectors is revealing – and I bet some smart lawyer can find a way around this. But surely the people we have sent to represent us in the House of Representatives of the Congress of the United States are clever enough to be able to accomplish this?

The bill should be passed and sent to the Senate where the Democrats can either speak in favor of paying Bunny Inspectors, or simply pass the Bill and send it to the President. He can either sign it or veto it. If he signs it then they have to start firing the bunny inspectors. Perhaps we will be lucky and the federal employee unions will strike, possibly shutting down the government in an election year.

I can think of a lot of other regulations that can be defunded by this means. The House should be digging for more. If someone accuses the House of wasting valuable federal time on trivia surely the response, after this long dance over a two month extension, is one of gaiety and mirth?

As I say, I can think of dozens of acts of this sort that can be passed, most of them by unanimous consent, and sent to the Senate; and the Speaker ought to be hard at work on them. As should Representatives Ron Paul and Michele Bachman, who are among those unanimously consenting to this “cave”. I am certain then can find practices in the TSA worthy of the attention of the House. Surely there is much in the Department of Education that ought to be examined. But the list is endless.

My point is that this has been called a humiliating defeat for the Republicans, but regarded properly it is a gotcha.

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Iraq continues to boil. The Shiite Prime Minister has issued an arrest warrant for the Sunni Vice President of Iraq. The Kurds (who have a Vice President of their own) are giving him refuge in the part of Iraq called Kurdistan; in theory Kurdish Iraq is a province of the Iraqi state, but Baghdad’s writ has never run there. We now have a de facto alliance between Sunni Iraq and Kurdish Iraq. The borders of Kurdish Iraq are much clearer than the borders of Sunni Iraq, in part because the Sunni do not accept that they are a minority in Iraq; the official Sunni position is that the Sunni, who include Arabs, Turmen, and Kurds, are actually a majority in the whole country, with the Shiites (mostly Arabs but including Persians) having a majority only in certain areas, Baghdad being one of those.

The presidency of Iraq is a collective office: the President and two Vice Presidents are all in theory equal. The powers of the office have not been tested: one presumes there is the traditional power of pardon which may or may not lead to a way out of this impasse in which the Prime Minister, head of government, is seeking to jail one of the co-presidents on a charge of terrorism. Meanwhile I see little media discussion of Kurdish Iraq, which is tranquil (I wrote peaceful, but that’s not the right word), well armed with well trained militias (mostly American trained), pro-American, Sunni, and unlikely to submit to the writ from Baghdad. The American media don’t seem to have much understanding of the Kurds.

Kurds are not Arabs. Like the Iranians they speak an Aryan derived language, and consider themselves Aryan in descent. Saladin, the Saracen leader who destroyed the Latin Kingdom of Jerusalem and restored Islamic rule to Jerusalem, was a Kurd. He is featured in Sir Walter Scott’s novel The Talisman. His truce with Richard Lionheart effectively ended the third crusade, and he united many of the Muslim states into a new caliphate. The Lion of Saladin is still revered in many places including Kurdistan.

I am no expert on the Middle East, but I would not bet heavily on the survival of a united Iraq; the decision for the United States will come when the Kurds (with parts of Sunni Iraq) claim rights of independence and ask the United States for recognition and help. That is a very likely event in the future. Meanwhile the Sunni faction in Baghdad continues to drive out all the Christians, Sunni, and Baathists, and does not seem hesitant to ask Iran for recognition and help. I foresee interesting times in the Middle East.

Perhaps a pipeline from Canada will look attractive?

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