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Monday  August 17, 2009

Health Care Crisis 

Dr. Pournelle,

"Health Care Crisis" seems to be a semantic term without real meaning.


Donna Shalala, then Secretary of the U.S. Department of Health and Human Services, wrote an Op-Ed piece for The Washington Post of 1/25/94, at the height of the last time the nation was deep[ in the throes of a bout with "Health Care Crisis":


"Perhaps the most astounding assertion I've heard during the current debate over health care reform is that there is "no health care crisis in America." This statement often comes before arguments that comprehensive health reform is unnecessary or that the current system just needs a few adjustments and fine tuning.

Let's not pull any punches: This argument is bogus. It's destined to fail because millions of Americans are experiencing a health care crisis and they know it. And, frankly, deep down in their hearts those who deny that there is a problem know it too."

That was in 1994. Yet “Hilary-Care” failed to pass. The “Health Care Crisis” continued. Unabated. For fifteen long years. Presumably making the current “Health Care Crisis” that much worse than all previous iterations.

Reality Check:

American life expectancy, combined for men and women, in 1995 (a year deeper into the "Health Care Crisis" of 1994), was 75.9 years.


American life expectancy, combined for men and women, in 2008 was 78.06 years.


After fourteen years of unresolved “Health Care Crisis", we got an increase in life expectancy of 2.16 years, or 2.85 per cent.

La Shalala also wrote in 1994 of "A health care system that consumes nearly 15 percent of our gross domestic product, while only one other country (Canada) is above 10 percent..."

Fifteen years on into the “Health Care Ci sis”, and we're still at roughly 15 percent of GDP for health care expenses? So we've held national health care spending to the same rate, while we also increased national life expectancy by nearly three percent, after fifteen years of "Health Care Crisis"?


This is crisis so drastic we have to Do Something Right Now, this summer?


Anybody wanna buy a watch?



Re: health-care figures

Be careful when drawing conclusions from any figures cited in a health-care debate.

One of the biggest complaints about the US system is "we spend so much and get so little!" That's not true. We spend a lot, and we GET a lot--for the people we spend the money on. There are a lot of other people who we don't spend anything on at all, beyond the secular equivalent of last rites.

-- Mike T. Powers

And we spend quite a lot at places like USC/County -- where the patients get a lot. That's in California, of course.


What French health care does

> I'm not all that familiar with what the French do and how they do it.

Some of the details can be found here:


In particular, "France reimburses its doctors at a far lower rate than U.S. physicians would accept. ... the average yearly net income for French doctors, a third of what their American counterparts earn."

France eases the financial burdens on their doctors in some ways that would please the American left-wing (free medical school, selectively lower taxes) and some that would please our right-wing (reduced malpractice lawsuit risk). But somehow I doubt that the results compensate for the gross (in both senses of the word) difference.

So when we plan on emulating France's system... who gets to be the one to break the bad news to the doctors? "Thanks again for the decade of grueling higher education and those soul-crushing work weeks, but we'd like to give you a six-figure pay cut now!" If we're already short on doctors, making the job less desirable might not be a good idea in the long run.

This isn't to say that doctor's salaries in the USA aren't too high, but if that's part of our health care problems then addressing the root causes might be preferable to rationing and price controls. Two suggestions:

Medical school capacity - my straight-A premed friends at a top-tier private college had to send in dozens of applications to be sure of finding a slot. In addition to turning away some potential doctors entirely, you can predict what the laws of supply and demand are doing to the tuition bills for the rest.

Residency "hazing" - the 90 hour work weeks are most criticized for putting patients in the care of sleep-deprived doctors, but scaring away potential future doctors is just as concerning.

--- Roy Stogner

[emphasis added]


Health care in France

If you want to find out how France is handling things, this article might be a good place to start.


It would be useful to cut through the social Gordian knot and find out just what makes socialism so damn appealing despite the lessons of half a century of history. One side effect of the Iron Curtain falling and Germany being reunited is that we lost another crystal-clear example of the two systems side by side.

Tom Brosz


Oh Health Care in France

Hi Jerry,

First, I have just read both Inferno and Escape from Hell and found both of them a good read. Recommended, even more so for regular visitors to your blog as they will understand why certain people ended at certain levels in Hell... ;-) Escape was easy to get from Amazon Europe (fortunately they seem to have a large warehouse somewhere in France where they store a lot of English-language books; it's almost the only way to get English books in a deeply rural area of France); Inferno took a bit longer but still arrived.

In the recent mail discussion on health care the French system was again mentioned (still no 1 on the WHO ranking list). You stated: "I have no idea what criteria the WHO uses to determine who is "first" and who is 37th in health care provision, and I have no familiarity with the French system. If the French system is so outstandingly better than the US (but much cheaper), and quite a lot better than the British (for a few percent of GDP more), I wouldn't think there would be much room for debate." There probably isn't.

It seems that there must be an important difference to give one country the no 1 position and the other no 37.

I live in France and see it in action. Being Dutch I am still insured through my Dutch health insurer (the major difference being that regular things like dental care get reimbursed after I pay for them first, but expensive procedures and hospital care will be billed to the insurer directly, while the French people carry chipcards - the 'Carte Vitale' - that work like direct payment cards in hospitals, clinics, pharmacies and the like. If there is anything left for you to pay yourself you pay that on the spot or (in case of hospital treatment) after getting invoiced.

Most people have a supplementary health insurance at fairly modest premiums (I'm talking about a handful of hundreds of euros per annum, not thousands), and the whole Carte Vitale system is smart enough to know that your (private) insurer pays whatever is not covered by the national health system. If you are poor, you get 100% coverage and don't need supplementary private coverage (private is often in the form of non-profit cooperative organisations linked to certain professions or regional governments, btw). If you suffer from a chronic illness, any treatment to do with that disease will be covered 100% (once the bureaucrats have stamped lots of forms) without a need for supplementary coverage. So basically, the poorer and sicker you get, the better the coverage.

A lot of work is done by small private clinics. My spouse, who has a fair load of health problems, gets her scans and X-rays at a specialized radiology lab across the street from a regional hospital. Her gastro-specialist has her practice in the same street and also practices at various hospitals. If needed the health system even pays for car mileage to reach a hospital or clinic. And there are hardly any waiting lists for things like hip replacements - in the Netherlands that is a real problem, even though the health system there is more expensive than the French one.

One thing I like is the fact that patients retain control of their own medical files. The radiologist will interpret the x-rays and supply his comments, but you also get the original images to take home and to show them to another specialist if needed. Meaning you also have older ones to compare them with, even if you go to another doctor.

We know a fair number of British people who either moved into our area altogether or who have a secondary home here, and they are without exception extremely relieved to enjoy the French system compared to the British one. For the numerous Dutch immigrants the difference is less important, but they also rate the French system as better than their own national one, especially due to the lack of waiting lists. French medical personnel are clearly well trained and knowledgeable, which is no surprise in the country of the Sorbonne and the Laboratoires Pasteur...

So yes, one can have a top-ranking health care system in a sizeable country (65 million inhabitants, as opposed to the few million in Sweden or Switzerland) for a substantially lower percentage of GDP than in the US. Of course for it to work the whole country probably needs to be organized differently. France is definitely 'socialist' compared to the US...


Frank Schweppe


To Jerry Pournelle,

You said earlier this week:

"If the French system is so outstandingly better than the US (but much cheaper), and quite a lot better than the British (for a few percent of GDP more), I wouldn't think there would be much room for debate."

The French system (from a user point a view) is the best in Europe, and probably in the world. There shouldn't be room for debate - if the US had the same culture as France.....

Systems depend on a country's culture, specifically the view of the role of the State in Society. A copy of the French system probably wouldn't work in the US. If you export the Danish welfare state, industry, education and health system to an average African country, don't expect Danish standards of living - expect dismal failure.

The US will have to find its own version of healthcare, and yes, apart from a relative fortunate few as yourself, the current US system needs to change, as it fails (a very expensive failure at that) the majority of its citizens.

You could look to France, but maybe Canada is closer to the US culture and history. And as you said, politics is the art of the possible.


Bo Andersen Denmark


A "Right" to Health Care?


Our Society has had very large problems, over the last Century or so, distinguishing between Rights and Privileges.

I don't believe that there is much controversy of the Right to the pursuit of Life, Liberty and Happiness. However, I would contend that these Rights do not automatically grant certain Privileges.

Let us first look at the Privilege to operate a motor vehicle. It certainly is a Privilege and not a Right since it is granted only if certain prerequisites are fulfilled and can be taken away if certain prohibitions are not observed.

Voting is also a privilege. Once again, certain prerequisites must be met, age citizenship and registration being the primary ones. However, if one is a Citizen, meets the age requirement and is not prohibited to vote by being a convicted Felon etc., then it could be said that that person had a Right to register.

Nowhere in the Constitution is anyone granted the Right to free goods or services. The Congress of these United States has passed Legislation which does grant the Privilege of certain free goods and services to those that meet certain prerequisites. Undoubtedly, this kind of Legislation will continue to be enacted.

While the Congress can grant the privilege of free goods and services, and many would feel that there Morally there is a Right to same, there is no Absolute Right under our Constitution to free goods and services.

It is extremely dangerous to confuse Rights and Privileges. It is also dangerous for Republics to become Moral Arbiters over and above their Constitutional obligations.

Bob Holmes



Dear Dr. Pournelle,

Regarding David Couvillon's letter about the peccadillo's of CMS/Medicare/Medicaid. It is even worse than he describes; if a patient shows up and needs a shot of cortisone (for example) for poison ivy or some other contact dermatitis, the reimbursement for the doctor is frequently less than the cost of the medication. If you are a participating or non-participating doctor, you cannot bill the patient for the true cost of the medication, nor can you accept payment from the patient for true cost even if they do not want to 'bill' medicare for that particular service or visit. The only choices are: do not provide the service, or give the patient a prescription for the medication and when they fill it have them return to your office and give the injection, or 'opt out' of all medicare/medicaid patients for at least 2 years and charge the patient your regular fee (which means that your patients cannot even be reimbursed by M/C for the medication or service). Violations of these regulations cause some very draconian punishment for the 'offending' doctor, such as loss of ability to bill medicare or medicaid, jail time, and fines of up to $25K for each occurrence. Also, much like when dealing with the IRS you are presumed guilty until you prove your innocence.

As Colonel Couvillon says, CMS frequently reimburses at less than usual and standard fee, and less than 'cost'. This is more easily quantified when there are medications or devices involved, but when the ability to get a service decreases substantially because no one is willing to do the work for the amount paid, you can say that the fee is less than the 'cost'. Worse, private insurance is less and less willing to have cost-shifting onto their patients, so they frequently tie their payments to MC/MC 'fees' at some low multiplier. This leads to de facto rationing of services since the available number of providers willing to perform a task is less than the demand. A good example of this is Medicaid dental services...very long waits for simple problems such as repair of a cavity and even difficulty getting in for preventative care.

Many of the problems of medical access could be improved if we simply got the patient to have financial responsibility and incentive for their decisions. If an employer or government pays for health insurance (or a large percentage of the insurance) and there are no disincentives for over utilization many people demand the latest medication advertised or the MRI for simple headache. I see several families in the ED repeatedly simply because it is convenient for them and because they have no direct cost at the time of their visit; they are not here for emergencies (situations that threaten life or permanent disability) or even urgencies (child with an acute problem) but simply because they don't have to wait 1-2 days to see their private physicians or don't have to pay their copay upfront. This is worse with Medicaid patients, but I am seeing a rising number of people with private insurance in the ED as well. Again, there is no immediate penalty for misutilization of the system.

I would like to see people buy their own insurance, either individually or by forming buying groups. Employers that choose to help with medical insurance pay a straight stipend to the employee for private purchase of insurance. Make a tax deduction for people for reasonable cost of insurance and tax incentives to employers that subsidize employee insurance. This would solve the portability problem and also mitigate costs for people and employers. Hopefully, when people have incentive to keep their own utilization controlled (live a healthy lifestyle and don't overdo utilization or premiums go up and cost is passed directly to the patient) then we will see people opting for health care such as Kaiser that tries to maintain health by prevention and early treatment chronic conditions to prevent complications.

Government control and payment clearly does not work. I think we could forever eliminate the desire for public health insurance by giving every person in the US a voucher for treatment of one health problem at the VA or Indian Health Service facility of their choice; once a person has gone through that bureaucracy they would never want government to have anything to do with their health-care again. I have gone so far as to write my congresscritter to ask that VA Medical and Tricare be eliminated except for treatment amputations and PTSD (VA seems to be better at this than anyone else); everyone else that qualifies for care would receive the best available private insurance in their location. This would keep vets/families from having to travel long distances from home for care, help keep local access to hospitals/physicians open (by bringing care and money back to local providers) and wipe out a large bureaucracy. I don't know if there would be any direct cost savings (I suspect yes), but I do know care would be better. Surprisingly, the VA is one of the best systems for EMR, at least for access from an outside agency. I can call, give a patients name and last 4 digits of SSN, and know what tests, xrays, procedures have been done and what is pending in minutes. I don't know how easy it is to enter that info in the system.

Finally, I can understand when ordinary people make silly statements like "doctors would rather do a tonsillectomy than treat allergies because they get paid more", or "instead of treating diabetes they would do an amputation because they get paid $30,000 dollars" (to paraphrase President Obama). But when the leaders of the debate say stupid stuff like this, they are either woefully misinformed (scary) or intentionally being disingenuous (even more scary, given their goals). The speed of the process, the demonizing or belittling of anyone in opposition, and the fact that no one that thinks this is such a great idea will subjugate themselves or their families to the proposed systems leads me to believe this has very little to improving health care access and a lot to do with controlling another large chunk of the economy. As you have said, let them show they can develop a good system with the areas already under direct control. Fix Medicare/Medicaid/VA/Indian Health Service/CHIPS and then maybe I would look at suggestions from these people.

Doug Lewis, MD


Letter from England

Riding my bicycle, I had a head-on with a car on Wednesday. A teenager was driving and had just turned into the wrong lane. He drove right through me. The bike is in the shop, and I'm aching.

I see California is burning again...

Lockerbie bomber deal comes under criticism. Newspapers claiming there's a cover-up. <http://tinyurl.com/on5ean>  <http://tinyurl.com/lamfgf

BBC compares healthcare around the world. <http://tinyurl.com/ns8gea

Health Secretary accuses a Tory Member of the European Parliament of being unpatriotic for attacking the NHS. <http://tinyurl.com/l8ybce>  Other stories <http://tinyurl.com/ktqncl>  <http://tinyurl.com/o8wnzq>  Economist's analysis of the US healthcare system--a big waste of money, even worse than NHS <http://tinyurl.com/mblfq4>  (which I think is a reasonable judgement).

-- Harry Erwin, PhD "If you can't be a good example, then you'll just have to be a horrible warning." (Catherine Aird)


University of Rochester Study shows that oceans have major climate impact

From the press release:

"Physicists at the University of Rochester have combed through data from satellites and ocean buoys and found evidence that in the last 50 years, the net flow of heat into and out of the oceans has changed direction three times.

These shifts in the balance of heat absorbed from the sun and radiated from the oceans correlate well with past anomalies that have been associated with abrupt shifts in the earth's climate, say the researchers. These anomalies include changes in normal storm intensities, unusual land temperatures, and a large drop in salmon populations along the western United States.

The physicists also say these changes in ocean heat-flow direction should be taken into account when predicting global climate because the oceans represent 90 percent of the total heat in the earth's climate system...."

Link to the press release: http://www.rochester.edu/news/

Here are links to the author's home pages David Douglass http://www.pas.rochester.edu/~douglass/ 

Robert Knox http://www.rochester.edu/college/rtc/Knox.html 

Douglass' page has a link to recent publications. One of the papers is "A Comparison of Tropical Temperature Trends with Model Predictions," which was published in the International Journal of Climatology. http://www.pas.rochester.edu/~

Here is that paper's abstract --

ABSTRACT: We examine tropospheric temperature trends of 67 runs from 22 ‘Climate of the 20th Century’ model simulations and try to reconcile them with the best available updated observations (in the tropics during the satellite era). Model results and observed temperature trends are in disagreement in most of the tropical troposphere, being separated by more than twice the uncertainty of the model mean. In layers near 5 km, the modelled trend is 100 to 300% higher than observed, and, above 8 km, modelled and observed trends have opposite signs. These conclusions contrast strongly with those of recent publications based on essentially the same data.

This is from the end of the paper's summary -- "The last 25 years constitute a period of more complete and accurate observations and more realistic modelling efforts. Yet the models are seen to disagree with the observations. We suggest, therefore, that projections of future climate based on these models be viewed with much caution."

Apparently someone else agrees with you that scientific models' predicted results should have a reasonable approximation to the data actually found in the observations.

Here's hoping that rigorous scientific analysis will come back in fashion. Either that or maybe the scientists could just disband this reality and elect a new one.

--Gary Pavek

Astonishing! The oceans have something to do with Earth's temperature! Who would have thought it!




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Tuesday,  August 18, 2009

WHO Ratings

Hi Jerry,

Peter mentioned in Friday's mail

The World Health Organisation and the Economist journal provide cost and quality assessments which should, but probably won't, influence the healthcare debate. In 2000 the WHO ranked the world's health systems, while the Economist's "Pocket World in Figures 2008 edition" listed the amount spent on healthcare by different countries; these figures make interesting reading:

France - WHO ranking - 1 : healthcare expenditure - 10.5% of GDP
UK - WHO ranking - 18 : healthcare expenditure - 8.1% of GDP
USA - WHO ranking - 37 : healthcare expenditure - 15.4% of GDP

These assessments suggest that the US medical system should be revised to improve healthcare and make significant cost savings.

To which you replied

I have no idea what criteria the WHO uses to determine who is "first" and who is 37th in health care provision

This article gives some more information relating to the criteria used by WHO in their rankings


1. Health Level: 25%
2. Health Distribution: 25%
3. Responsiveness: 12.5%
4. Responsiveness Distribution: 12.5%
5. Financial Fairness: 25%

which would mean 63 % of the ranking is not really related to health, but rather to fairness and distribution.

Rgds Ewan

Given that France still allows wealth to influence what's available I'm astonished they rate Number One.

The conflict is between the "right" to a procedure as meaning you have the right to buy it, the "right" to have it as meaning someone else must pay for it, and the "right" to forbid anyone from having it if all cannot have it. Those rights are in eternal conflict so long as there is any shortage of resources.

And I have no idea how one would rate "fairness." For example, is it "unfair" not to pay for illegal alien access to the health care system? Would it be unfair to require escaped felons to turn themselves in before getting free health care? Who defines "fairness" for the WHO?


In re: to Mr. Peter D. Morgan's comments on 14 Aug, 2009

Greeting Dr. Pournelle, I think Mr. Morgan's comments on health R&D largely misses the point of the previous letter. Yes, European and Japanese health care researchers spend approximately the same on R&D as their US counterparts. But Mr. Wityk's statement concerned the price paid for the resulting products of said R&D. Single pair, socialized, or highly regulated, the European health programs are only willing to pay based on the manufacturing costs of these drugs. When they calculate the price they are willing to pay, they discount the money spent on R&D for the drug and even more importantly, all the drugs for which R&D failed. This is whether the firm producing the drug is US, European, or Japanese. And regardless of whether the firm is US, European, or Japanese, they all put their products on the US health care market and charge as much as the market will bear. US consumers are the only major market that allow the firms to recoup their R&D costs. If they refuse to do business under government price controls they know the governments will allow their patents to be ignored or nationalized in favor of generic products. They will surely not recoup costs that way. It is a legitimate concern of Mr. Wityk, me, and others that if the US engages in price controls as reform proponents suggest, we will strangle the golden goose that provides many medical innovations.

On the subject of the WHO rankings, many people have examined their criteria. Right off the bat is the glaring inclusion of a "fairness" ranking (based on spending as a percent of income) and a distribution ranking which is often decried as being nothing more than a measure of how socialized a nations health care system is. It should be readily apparent that such a metric will bias any conclusions on policy stemming from the WHO report. And that is 50% of the weight in the WHO's report.

That's two of five criteria. Another is life expectancy (which bundled into health level is 25% of the weight). Often proponents of universal health care simplistically state that of course x country has a higher life expectancy than the US, it has universal health care. But the reality is that life expectancy is heavily influenced by things like highway accidents and murder rates, probably dwarfing healthcare once a country reaches a certain level of health care competence. Robert Ohsfeldt, a health economist at Texas A&M, along with U of Iowa health consultant John Schneider made an attempt at statistically accounting for this affect for the 16 wealthiest nations using data between 1980 and 1999. Accounting for murders and accidents put the US in the lead. But their study is criticized for not trying to deal with the fact that better (in terms of performance) health care saves more would-be murder and accident victims. Of course, on the level of the emergency room, US health care is universal. It is illegal to turn people away from an emergency room in the US, even if a "wallet biopsy" proves grim. A study on infant mortality showed a similar result; the US has more teen mothers than Canada, which results in more low birth weight babies, which results in more infant mortality. If Canada had as many, their life expectancy advantage disappears. Universal health care isn't going to change the urge of teens to have sex.

On the matter of costs, there are simple facts that reform must deal with (and will not) in order to lower costs. One is the fact that doctors in the US make three times what they do in France and similar disparities exist across most nations ( http://www.scrivener.net/
uploaded_images/Doctorsmoney-747044.jpg )  . Some wonks have even suggested that since education of doctors is subsidized in Europe, that should be included in the health costs, since US doctors rates are driven strongly by having to pay off medical school bills. France already has doctors striking and demonstrating in the streets of Paris over their government mandated rates. The specter of that (or more doctors showing up at townhalls to dress down reps) will be strong pursuasion for Congress not to mess with the AMA and their members rates.

There's also the fact that while the US leads in percent GDP spent on healthcare, it does not lead in the rate at which that percentage is increasing. It's rather middle of the pack among industrialized nations in that regard. The average growth rate for health care costs for the 23 OECD countries since 1990 is 1.62%. The US was 1.66% (and 9th in rank) compared to 1.87% in France and 2.08% in the UK. This makes it questionable that reform in the US will "bend the cost curve down" as our President claims.

That's not to say there aren't things worth emulating in the French system, which I also have experienced to a small degree. I don't like having to go somewhere else to get bloodwork done (or that I pay my doctor to get prescribed bloodwork then pay him again to talk about it). I do like that it means the results go through me and I can see them and be prepared ahead of time to discuss them. I also like the lean system French doctors run, to the point that I pay them in cash or credit across the same desk we consult over and it is the doctor that gets me from the waiting room (but that's also why I have to go across town to do something as simple as urinate in a cup). I like that half my doctors time seems to be open clinic hours. But I don't see Congress providing reform that magically provides for these differences.

Cheers, Jet Goodson

And the discussion goes on. The demand for a free good is infinite.





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Wednesday, August 19, 2009

Dr Pournelle, 

I read in your Aug 18 mailbag that according to the WHO,  France is spending only 10.5% of its GDP for healthcare.

 That is utterly wrong.

 First, a point of vocabulary: The French call "Social Security" the administration that provides the "free" government-regulated health insurance -- a state monopoly, of course. That comes at a hefty price, BTW, as any worker in France can tell you -- typically a third of your pre-tax salary. A French pay stub is not a stub with 4 or 5 line items like in the US, it's a page-long document (sometimes 2 pages) overflowing with withholding, deductions, "contributions" and other poetic names for taxes.

 A French governmental document (in French, obviously), located at http://www.minefi.gouv.fr/performance/

tells us that the French Social Security administration spent a hefty 22% of France's GDP in 2007. The 2008 figures are not available yet but they should not be lower.

 But wait, the state insurance does not pay for all of healthcare. An ever- growing list of medications are only reimbursed for 60% or less of their price. Patients have out-of-pocket costs. The cost of a specialist in a private clinic, for example, is not reimbursed. Moreover,  since the system creates shortages, bribery is common in some places, and that expense is of course off the record. As a Frenchman, I know more that one people who bribed a doctor to get on a treatment schedule more quickly or get an operation in week vs. months.

 In summary, the percentage of GDP absorbed by the French healthcare system is even higher than the 22% quoted here. Conservative estimates place it at 25%.

 So the WHO figure is, at best, a mistake.

 But since France spends so much on healthcare, at least it means that the State is really concerned with its citizens' health, isn't it?

 Far from it.The safety of healthcare in France  has an execrable track record. The sector is rife with the basest corruption. For instance, Prime Minister Fabius got caught in a scandal when the state monopoly for blood drives failed to adequately screen donated blood (especially from drug addicts in prisons!) and thus infected about 4000 transfused patients with HIV during the 80s. Evidence shows that the screening was delayed to grant juicy contracts to friendly companies. Fabius walked free, thank you.

(http://news.bbc.co.uk/2/hi/europe/293367.stm) On a positive note, France owes Fabius the lowest percentage of living haemophiliacs in Europe, since half of them died.

 Similar scandals erupted about contaminated Human Growth Hormone

 , prion diseases


scandal-greater-than-first-thought.html),  Chernobyl fallouts

0481_28778.html ), and many more. Every time, the state healthcare monopoly showed the most callous disregard for the life and health of taxpayers, with the tacit approval of the highest governmental authorities.

 That's what a quarter of the GDP buys you if the state controls it.

 Thank you,

   --Fred Mora

Thanks. I have no data on the French system.


French health care, Vietnamese perspective

Dear Dr Pournelle,

Over the years, I have received treatment at the Phap Viet (Franco Vietnamese) Hospital in Sai Gon. This is a French privately owned for profit hospital that employees a number of French Doctors. The doctors love working in Viet Nam. While the pay at Phap Viet is slightly lower than it is in France the cost of living is much lower. The quality of care is excellent and Tricare will reimburse.

Due to the fact that I have found a strictly Vietnamese Hospital that I like better, its been a few years since I have used Phap Viet.



Coming at Healthcare backwards

I believe the whole debate is being framed improperly.

Arguing about what procedures, drugs, etc should be covered is a never ending debate (the landscape is always changing). At this point the debate should be "what portion of our GDP/government budget should be spent on providing a floor of medical services for our citizens?". If people know that the cost of the program is controlled, agreeing to a basic level of group insurance is likely to be more palatable. Talking about what should be covered before determining what you can spend is nuts. It's like deciding all the home features you want before deciding how much you can afford.

Once we have a number, the debate can move to how to best deploy those dollars. One example might be to have a federally run major medical style policy (so travelers don't run into problems and to simplify doctor office paperwork), and then to have block grants to the states so that each state can decide how to best deploy the remaining money. Some states might run their own state insurance system, others might provide vouchers, and others might come up with something completely new. Furthermore, states would be free to direct these dollars towards health problems that are special concerns to their state (e.g., black lung, diabetes, skin cancer, etc).

And of course, since this is the United States, none of this prevents anyone from purchasing additional insurance or paying for uninsured procedures out of pocket.

If the debate starts with what should be covered we have already lost. Maintaining the status quo is also problematic. Employer based healthcare is a huge problem for those of us with pre-existing conditions.


-- David B. Jacobs, Ph.D., CFP®, NAPFA-RA Pathfinder Financial Services

Precisely. Figure out what you will spend, and then how to spend it, and let private means take care of the rest.


Thank for bringing to the conversation an issue that appeared to have been lost in this debate; i.e., the question of positive rights and the constitutional limitations on the Federal government. The fact that these issues are not even part of the discussion nationally seems a good indicator that original basis for the Union--a Federal government with limited, enumerated powers--is now null and void. This is not new information to anyone who pays attention, but is disheartening nonetheless.

For a good thumbnail history of health insurance in the United States, see http://eh.net/encyclopedia/article/
thomasson.insurance.health.us . The running thread through the history of health insurance is that it has been driven at least as much by providers as it has by patients. Health insurance, in many ways, insures the doctor and hospital of payment. This is especially pertinent in view of the fact that there is not a health care crisis in this county so much as there is a health insurance crisis. Heresy? Not really. As you have pointed out, emergency rooms are required to provide treatment, regardless of ability to pay. No one in our society will be left without treatment for any serious illness or injury. What is at risk is the ability of the providers to receive payment for their services. Don't misunderstand me, I think that's a very valid concern; but it is not the basis on which the alleged crisis is being presented.

As with any major legislation the question to be asked--always--is qui bono? In the case of "Health Care Reform", the parties who benefit are the providers and, interestingly, the insurance companies. Providers benefit because there will no longer be cases where they receive nothing for their services. Insurance companies benefit because every version of the bills being considered contains a mandatory insurance provision. By sweeping into the net those persons who, actuarially, have little to no need for insurance the pool of available money to pay for those who do (and for profit) is greatly increased. Note that the pharmaceutical industry has apparently reached an agreement which prevents any reform bill from infringing on their pricing, even by negotiation.

If providing comprehensive basic health care to those unable to afford it were the goal; the now defunct system of county hospitals, combined with county or municipal clinics, would be much more effective. They would also, even if funded in whole or in part by federal funds, be much more constitutional.* However, that system does not benefit either health care providers or insurance companies, and so will not be seriously considered.

If there were any truth in advertising, the bill would named the "Doctors, Hospitals and Insurance Companies Protection Act of 2009."

Jim Keech

* Congress' authority to spend money is found in Article I, Section 9. I do not find any authority in Article I to require anyone to purchase insurance, or to regulate the business of either insurance or health care.

County hospitals: LA County has County/USC, considered one of the best in the world, and until it was closed after 20 years of horror, Martin Luther King...

MLK was politically untouchable and thus unreformable, and the culture was about what you would expect. Eventually no one could stomach it.


And then there's the supply side:

Hi Jerry,

I've been reading the conversation on your site about health care with great interest. I've seen you mention it once or twice, but no one else seems to get the true importance of the simple matter of supply. One can argue all the fine points of rights and who gets what and when, but the simple fact is there is a finite supply of medical services and service providers available. The costs for those are rising for a number of reasons but I would wager a guess that a good part of that reason is the demand is rising faster than the supply.

If we're going to spend a trillion dollars over the next 10 years for health care anyway; and I'm slowly beginning to think there is just no stopping that spending train, then why not spend it on increasing the supply? Why not offer to pay for the complete tuition, books, room, and board of anyone wanting to become a doctor or nurse? Assuming a cost of roughly $500,000 for each, that would put 2 million medical professionals into the system over the next 10-20 years. And yes, I know the schools can't do that now but let the colleges of the U.S. know they can get a chunk of a trillion dollars and I guarantee there soon will be more than enough places to train doctors and nurses.

Will there be fraud and abuse? Of course, there is with all programs of this size. I would wager there would be less with an education program than there would be with handing out free health care to everyone while the government pays.

Will we end up with a lot of poorly trained medical professionals? Yes, but they will get weeded out just like they do now. The horror stories will be terrible, but there will also be miracle stories of how an emergency room actually had the staff to respond to an emergency in time to save a lot of people's lives.

It wouldn't be perfect, but what is? I'd be willing to pay for new doctors. I'm not sure I'm willing to pay for a guy living under a bridge drinking his life away getting a new nose.

Braxton S. Cook

You would think that with the trillions being bandied about there would be enough to found three medical academies modeled after West Point etc., where qualified medical students would be paid to attend (paid as in the nominal pay of cadets), and on graduation would serve their internships in the Armed Forces or in VA hospitals. We can work out the details of how many years are owed for having received a free medical education. Assuming that worked -- and we have good reason to think it would -- we might consider expanding the program. Add a District of Columbia academy. Encourage the states to do something of the sort with subsidies. 

Of course at one point we thought the state university systems with nearly free tuition would have similar results, and the Land Grant Colleges would furnish officers for the militia rather than enslaving students with debts. The Iron Law dictated that the state university system would end up charging more and more money while -- well I don't comment on the quality of the expensive educations it provides. With doctors we might have some hope of preserving standards for both admission and graduation. We might. Of course we might be creating King/Drew all over again...


WSJ on gov't efforts to push home ownership 

It makes some interesting points....not completely right, but overall a useful read.



Doug Hayden

Note that Vermont didn't buy into the pitch...


Competition and prizes win big, 


I know you are a big fan of prizes to advance technologies. Dig this:


"For several decades, the U.S. Department of Defense has been trying to build a robotic vehicle. But in early 2004, the Department of Defense decided to try something different, and give enterprising civilian organizations a chance to show what they could do. DARPA (Defense Advanced Research Projects Agency) held the DARPA Grand Challenge. Put simply, the first robotic vehicle (moving completely under software control, with no human intervention) that could complete a 240 kilometer course, would get a million dollars for its designers. No one even came close. But a second Challenge, held in late 2005, yielded several finishers, and the first one picked up the million dollar prize for navigating a 212 kilometers cross country course in just under seven hours. All vehicles operated under software control, as true robots. The third "Challenge" race was held in late 2007, and had a two million dollar prize for the first vehicle to complete a 60 kilometer course through an urban environment (an abandoned air force base) in under six hours."

After several iterations of this competition:

"Earlier this month, two T2 vehicles equipped with sensors and control equipment, successfully passed realistic tests. One of the test subjects, controlled from a Stryker wheeled armored vehicle, successfully approached a village (equipped with mannequins set up as pedestrians along the streets), did a perimeter sweep at speeds of up to fifty kilometers an hour, then patrolled the streets, avoiding the pedestrians, and finally departed the area."

"The DARPA Challenge races have been a bonanza in terms of advancing the state of the art for robotic vehicles. For less than $10 million in prize money and expenses, the Department of Defense has created new technology that would have otherwise cost more than $100 million, and taken a lot longer to perfect."

It would never work in space, of course. We have to use the NASA monopoly. Of course..


I have never understood why prizes are not popular. They cost almost nothing -- perhaps a million a year total to fund a commission that determines if a prize should be awarded -- and you know the total to be paid. A ten billion prize for a Lunar Colony Prize (keep 31 Americans alive and well on the Moon for 3 years and one day) would either get us a Moon Base or it would cost nothing. A reusable space ship prize of 5 billion (send the same ship to orbit 13 times in one year) would again get us a space ship or would cost nothing. We spent more than half that on the X-33 fiasco.










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Thursday, August 20, 2009

ASIP is going to the 9/12 march on the Capitol -- photos and videos to follow (in a few weeks, that is)

To all and sundry:

My wife Sandra and I have had it. We are flying from Denver to Washington next month in order to rouse rabble and monger evil. I will personally hand-draw a sign and stand outside of the Capitol, chanting some clever slogans (frankly, I'm happy to go with "No justice, no peace!" Let's see how the shoe feels on the other foot!) Here are details:


I promise lots of photos and videos. We actually will arrive on the 9th, so I'm happy to buy a drink for any of you who show up or are already there (and I say that as someone who doesn't drink). ..bruce..

Bruce F. Webster http://and-still-i-persist.com 

-- Bruce F. Webster

Bruce is an old friend and associate. I'm not a big fan of marching on Washington, but I'd sure like to see him again. Ah, well.


Cory Doctorow on giving it away.


-- Roland Dobbins

Eric Flint of Baen Books has had much to say on this subject as well. My experience (corroborated by many friends) is that giving away one book of a series works quite well (by "works" I mean in generating sales of printed copies), but it is unclear what effect giving free e-copies will have on sales of unconnected books. What we don't have a handle on is how many readers want printed copies of books they have already read in some convenient electronic format.

Back when reading an electronic book meant sitting at a desktop screen reading in the old Gutenberg format, the temptation to buy the book in printed form was high. When reading eBooks became more convenient that effect seems to have diminished.

I don't have sales statistics on Doctorow's novels, so I have no idea how well his printed books sell. For myself, I think I'd be a bit alarmed to learn that some enthusiast had emailed 60,000 copies of one of my novels to his closest friends. At the same time, it would be an interesting experiment.

I have mixed emotions on all of this. Very few people make a living writing science fiction. Many writers like Harlan Ellison have condemned the "science fiction ghetto" and science fiction writing as a ticket to the poor house, and have other means for making a living. On the other hand, at least at one time, science fiction novels had guaranteed sale; small, but sure.

All this changed with the Internet and the collapse of the paperback book distribution system, and my crystal ball isn't working. Note that I could never have made a living from sales to the traditional science fiction market. I long ago figured that we needed to break out of category and Niven and I were fortunate enough to have Lucifer's Hammer sit as #2 on the Times best seller list for 14 weeks. That was early enough in our careers to assure that some of our other works would also break out of category and sell to the general public.

I very much doubt that giving away electronic copies of a book will boost print copy sales into the print copy best seller list; at least I don't know of anyone managing to do that. As to the effect on the traditional science fiction market (the small but guaranteed sales), I don't think the returns are in. It's pretty clear that if you have a series of books already available, getting a lot of people to read the first book of the series (even if you have to give it away to do that) is an effective marketing tool. Whether that would work for the first book of an as yet unwritten series, I have my doubts. And beyond that, I don't have a lot of data.

Eric Flint's views are expressed here
http://www.counterpunch.org/flint0419.html and here
http://baens-universe.com/articles/salvos7 . He has more data than I do. On the other hand, the book market is changing drastically with the collapse of the distributions companies and particularly the paperback distribution system. We have also seen a drastic reduction in the number of book stores in malls. Those were the traditional recruiting grounds: that is, if someone goes to a Barnes and Noble store they clearly intended to buy a book; not so if the book was purchased because it caught the attention of someone shopping for shoes in a mall and happened to pass a B Dalton display.

Eric is certainly right about the opacity of the book market. It's certainly possible that giving books away makes it more likely that an author will achieve name recognition and thus generate printed copy sales. Whether it would be useful for established writers is not so clear. I do know that income from eBook sales, while not trivial, are a tiny fraction of what authors used to get from paperback sales.  Baen Books sells early eBook copies of coming hardbacks from favorite authors at premium prices, and that may be an exception. Baen Books also works very hard to maximize early hardbound sales.

The publishing trade has changed enormously, and there are more changes to come, and my crystal ball is no better than anyone else's. I do think there are likely to be many distinct markets in future, and the key to success is to understand one's own.


Health Care for Seniors

I received the following email...sent somewhat tongue in cheek...I suppose:


While discussing the upcoming Universal Health Care Program with my friend the other day, I think we have found the solution. I am sure you have heard the ideas that if you're a senior you need to suck it up and give up the idea that you need any health care. A new hip? Unheard of. We simply can't afford to take care of you anymore. You don't need any medications for your high blood pressure, diabetes, heart problems, etc. Let's take care of the young people. After all, they will be ruling the world very soon.

So here is the solution. When you turn 70, you get a gun and 4 bullets. You are allowed to shoot at 2 senators and 2 representatives. Of course, You will be sent to prison where you will get 3 meals a day, a roof over your head and all the health care you need!!! New teeth, great!!! Need glasses, no problem. New hip, knee, kidney, lung, heart? Well bring it on. And who will be paying for all of this? The very same government that just told you that you are too old for health care. And, since you are a prisoner, you don't have to pay any income tax ... a Perfect Solution!!!


One question occurred to me, which I leave as an exercise for the reader.

Charles Brumbelow


Far more difficult than Burt Rutan suggests.


I've kept out of the "scientific" debate on climate change on your site, because of my complete lack of expertise in that arena. I have an interest in the discussion, because of all the furor.

Bert Rutan's powerpoint slides are interesting, but I'd suggest he also far oversimplifies the arguments. I say this as a scientist, but not one in climate science.

A far,far more difficult read, and perhaps a better starting point than Mr. Rutan's is here:


I'd considered linking it some time ago, but decided against it at that time!

It would take me years to read and understand the science outlined in Professor Schneider's site, but it suggests that the questions raised by Mr. Rutan have been discussed for years by climate scientists.

I find it a more balanced presentation than Burt Rutan's.


I note that Schneider was concerned with cooling trends in the 1970's. The point I have been trying to make is that we don't know enough to bet a large part of humanity's wealth on the accuracy of our models. Schneider's conservative Genesis Strategy (see his 1976 book with that title) advocated storing up food as Joseph did in Pharoahnic times against lean years.

I am far more afraid of ice than of warming. This isn't based on estimates of liklihood (although the long term trends of planetary climate would predict ice) but on the consequences. A return even to the Little Ice Age, much less to England covered with glacial ice, would be far more disastrous than temperature rising at the current or predicted rates.


Tidal Power -




More Horrors of Global Warming

Dr. Pournelle --

I saw this in the Telegraph:

"Best wines will come from Scotland if climate change is not stopped, French chefs say "


"Prominent French chefs have given warning that the country's wines will lose their complexity and the best produce will come from Scotland if the effects of climate change are not tackled."

Is there a contemporaneous ranking of wines produced during the Medieval Warm Period? That would be an interesting tidbit.

Of course, this story suggests the obvious question: What wine goes best with Haggis?


The horror!




My mind is blown by this amazon.com discovery:






You are likely familiar with this "ancient" (1946) work, but it may be new to some of your readers.

Charles Brumbelow

Now if you could find copies of Burnham's Machiavellians...


Moore's Law is not dead!  


People have been wringing their hands over the impending end of Moore's Law. Silicon transistors are getting to the point that they can't be shrunk much further, we're told. Now we have a potential new approach - speeding up the circuit by a factor of a thousand, using photons. Hence, the "spaser:"


I guess the Red Queen wins this one.



Time to move to London




'Alas, the sad truth is that the CIA, despite its Bourne Identity reputation, has become a timorous, risk-averse bureaucracy.'


 Roland Dobbins

Alas indeed. There was a time when The Company was formidable. The Indonesian recovery as an example...


Nuke-nobbler raygun 747 scores 'surrogate' test success

Indicates potent Nork splash capability, says Boeing

By Lewis Page

Posted in Science, 14th August 2009 09:31 GMT

The USA's amazing jumbo-jet-mounted blaster cannon, the Airborne Laser (ABL), continues progress through flight testing. Lead contractor Boeing announced last night that the ABL has successfully detected and locked onto a test rocket and held a "surrogate" low-power beam on it. Had a full-bore blast been fired, the rocket would have been destroyed.

Full story:


Tracy Walters, CISSP


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Friday,  August 21, 2009

Health Care vs Insurance conversation 

Dear Jerry -

The debate going on is indeed an example of some of the best things about your daybook. It is both polite and passionate, a rare combination. :)

There is a point that I think you have touched on, but perhaps has not been explored in enough depth as it pertains to health care and insurance. That is the role of the federal government vs. the states.

Partly, the federal government is needed because all of the major insurance companies are national, or very nearly so in scope. Part of the job of the federal government is precisely to regulate interstate commerce - and rightly so. Yes, most of the insurance companies are organized in such a way as to appear to be state level entities, and certainly they will point to requirements to meet state insurance board policies and regulations. However, this is a situation very analogous to what Rockerfeller did when he made Standard Oil a "trust." That clever bit of organization got around state laws that limited the scale of companies, and made him wealthy - incredibly wealthy.

And his scheme worked well into the early years of the 20th century. (My memory fails me here, but he came into conflict with the feds during or shortly after WWI.)

The insurance companies today are organized in ways that, at least on the surface, appear very similar and with similar purpose. At this point, I think it would be impossible to get them "right sized" to fit into a state by state system. And of course, in the early years of the 21st century, people move around a whole lot more than they did 100 years ago. It is important to people that coverage be national, or even international these days. Those are issue that are again, properly in the purview of the federal government.

Or in other words, it is too late to put the genie back into the bottle with respect to health insurance companies.

Another, far more minor point. Several of your correspondents have brought up the point that what we call health insurance today is not really "insurance." They appear to be defining insurance only as paying a small premium against catastrophic failure. Defining insurance in that way is far from accurate; rather insurance should be defined more as risk management. Health insurance, when the idea of HMO and PPO became popular in the late 1970's and early 1980s, began to sell a lot of additional products to manage the financial risk associate with health care. As a direct consequence, the quality of health care for the vast majority of Americans improved dramatically.

And, just as directly, your Iron Law came into place and health providers found ways to "game" the system and make a lot of profit. This is self evident by the number of standalone independent "radiology" or "medical imaging" companies around. A typical MRI costs around $1500 - and takes less than 20 minutes.

The fact that there are so many of them, often managed to maximize profit even at the cost of accuracy and workmanship, speaks to at least a certain amount of gaming in the system. Not all of course, but enough to drive prices way up.


Alas, everyone will game the system. That includes the bureaucracies who organize into unions whose major purpose is lobbying.

The problem with making something federal is that it become eternal. Were the Hatch Act still in place that might have slowed down the operation of the Iron Law, but the Hatch Act was gutted long ago. One question: if improved health care comes with profits, is there some reason to object? One can be very dubious of high profits in companies that fail to deliver -- such as the financial system companies and the Ratings outfits -- but if they deliver the goods should we begrudge them the profits? I ask seriously.

I prefer that the states be the primary "sovereignty" in these United States. I would also give the states power to define who is a citizen with residency requirements, and make health insurance and free colleges far more available to resident citizens than to transients. I have many reasons for that preference, most of which I have given many times in the past.


A story on education and a comment on health care 

I've been watching the criticism of the NHS, and can see a lot of it is unfair. It's good meat and potatoes health care for the average person, but it's not accidental that very little drug research is done in the UK. Today, the most promising drugs are quite specific in who they treat and quite unspecific in what they treat. That is, if it helps you, it works for a lot of things that ail you. That doesn't fit the drug efficacy models used by the NHS. That suggests to me that NHS- style health care in America would be adequate, but most Americans would be dissatisfied.

The competition for university places is worse than expected: 131000 trying to fit into 22000 places <http://tinyurl.com/m4o6vs> .

-- Beware Outside Context Problems--Harry Erwin, PhD

There are whole essays in your casual mention of drug efficacies. The FDA has far too much power to forbid drugs on grounds of efficacy. Take them off the list that government will pay for is one thing: forbid them to private parties is another. But then I have long asked what Constitutional Amendment gave Congress the power to pass the equivalent of the Volstead Act regarding drugs. Forbid in interstate commerce, perhaps; forbid inside a state is another.


Another article

Here’s a different article with respect to melt, etc:



But if this be true, then the debate over human caused warming goes where?


Re: The Death of Gallium 

Dr Pournelle

In 1929, some geologist prophesied that the world would run out of oil the year I was born.

Didn't happen.

The year I was born, some business Wunderkind prophesied that the world would run out of zinc the year I turned 25.

Didn't happen.

There must be a great deal of money in being a prophet of doom and scarcity, for so many practice it.

"I am an old man and have known a great many troubles, but most of them never happened." -- Mark Twain

Live long and prosper

h lynn keith


Jerry: Looks like the Utes are taking a shot at biofuel from algae:


Tribalism conquers capitalism? “They have always been very prudent,” Mr. Jacob said, “looking out into the next generation.”

Also, there's a running debate on teacher credentialing:


All the opinions seem to coalesce on paying teachers for performance (as measured by standardized tests). If I were a teacher in such a pay system, I'd try to get a classroom full of orientals, and stay away from the inner city schools. Smart teachers will be tempted to cherry pick.

A classroom full of former crack babies and children with fetal alcohol syndrome is going to need a very good teacher indeed, to show any improvement at all.



Hydropower accident?


This is a link to a report of an accident at a hydropower plant. http://www.bloomberg.com/

How can you get a catastrophic "pressure surge" at a hydro plant? The only possibility that I can imagine is that the plant had some type of valve or gate immediately above or below the turbine that can be closed rapidly. The momentum of the water in the penstocks might then cause a water hammer effect similar to what can happen when you turn off the faucet rapidly in your home. This would be a stupid design. My bet is that they simply had a structural defect near the turbines that failed under normal operating pressure.

Jim Crawford

Generating power involves control of a lot of energy. It's astonishing how low the accident rate is. And of course nearly all incidents at nuclear plants are on the generating side, not the nuclear side.


strafing with an F-15E 

Dr. Pournelle,

10 years ago if someone told me we’d be doing this, I’d have called BS.


Strafing in a $55+ million nuclear strike fighter. Who woulda thunk it. The funny thing is that in my opinion, the F-15E is a nearly perfect platform for the type of air support in that area. It has great endurance, a nice large and varied weapon loadout, a WSO to ensure precision delivery and to help coordinate what can be a chaotic and complex close air support mission, and yet it somehow seems absurd that an aircraft originally designed for pure air to air combat, modified to become a superb deep strike bomber, is putting 20mm rounds into a treeline. Even more absurd, we won’t be buying any more of these supremely flexible platforms because they are obsolete.

The whole thing is ridiculous. We thought we’d never use the F-15E in that role (CAS) because it was a national asset and too expensive, yet it has shown itself to be a superb CAS platform. Therefore we won’t buy any more of them and instead of replacing it, we will buy a lot more less capable and more expensive F-35s, which are essentially stealthy F-16s with better avionics but with the same short range, limited payload, and single crewmember. So much for platform agnostic effects based thinking…


The problem is that the Air Force doesn't want close support missions, and certainly doesn't want aircraft like the Warthog that are designed to provide it; yet they won't give up the mission. Air Force johnnies don't like my solution to the problem, which is to abolish the Air Force as a separate service, abolish DOD, and go back to a senior Department of War and a Department of the Navy. Let their differences be reconciled in the President's office where such resolutions belong. But that will never happen. In USAF being assigned a Warthog is a career ending move -- yet the primary mission of the Air Force is establishing Air Supremacy -- done -- and then supporting the Field Army. WW II would have ended a year earlier if USAAF hadn't had so much independence.


UK News 

Tax revenues have crashed, so taxes will go up. Business groups now worry over the possibility of a double-dip recession. <http://tinyurl.com/mlf9uz > . A few years ago, I did a computational study of the late neolithic carrying capacity of Wessex, and discovered that if you didn't control your population when times were good, you aggravated the famine when times were bad. Labour does like to spend money--as opposed to investing it--and it appears that has made things harder in this recession.

The public and grammar schools have managed to game the A-level system, leaving about 110,000 students from state schools without a university place. (An 'A' grade in the A-level system corresponds to what you and I would have considered to be a 'B' in high school.) Guardian stories: <http://tinyurl.com/m8pk8w>  <http://tinyurl.com/ mv2hfs> . Of course the public and grammar schools base their popularity on their ability to game the system, so we shouldn't be too very surprised.

-- Beware Outside Context Problems--Harry Erwin, PhD

When I was a lad you got to go to the University of Tennessee with a B average provided you took the Academic Track in high school (as opposed to the general, commercial, or technical track). But that was a long time ago. And a high school diploma meant something.






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Saturday, August 22, 2009

I took the day off.




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Sunday,  August 23, 2009     

Was your brain cancer a life ending disease that shouldn't have been treated? Roe vs Wade and privacy.


The conversation about the expense of treating people during the final year of life should be alarming to most people, you in particular. You can make a cogent argument that it is foolish and perhaps even inhumane to "waste" money providing sophisticated medical treatment to people who are "just going to die anyway." However; there are some practical questions to consider. I suggest that you consider them in context of your own recent experience with brain cancer.

How do you predict who is going to die and who will survive?

How high does the survival rate have to be in order to qualify your treatment as life saving medical care rather than merely a futile waste of money on someone who's just going to die anyway?

Should your age and probable life expectance even if treatment is successful be a factor in deciding if you get treatment?

Do we want the Feds making these decisions for us?

Should we retain the right to get unapproved treatment by paying for it out of our own pocket or do we want to have a single payer system that makes it illegal to get medical care outside of the system? This is analogous to banning private shools, tutoring and suplementary instructional materials such as your wife's reading programs.

Should we grant the government a vested interest in restraining the development of sophisticated and thus expensive, life prolonging medical treatments such as radiation treatments for brain cancer so that there will never be a demand for these expenditures?

Jim Crawford

Those are relevant questions. In my case there was another factor: since they could not diagnose what kind of brain cancer I had, there was no "standard" treatment, and some oncologists have told me they would not want to order treatment of an unknown tumor. Fortunately the Kaiser physicians ordered the radiation treatment -- no chemo therapy because they didn't know what the tumor was, but the radiation seemed indicated. I do not know what decision might have been made by a government commission that sets standards; would the new health care authority give such discretion to local pysicians?

I don't know.

At the moment we have a system that about 80% of the population are satisfied with. The identifiable problems are (1) transferability of insurance on changing jobs, and (2) a number of people with no health insurance. Of that second category, a number are younger people who are self-insured and don't want to spend money on health insurance (as I didn't when I was young; I bought "dread disease" and a very high deductible "disaster" policy, and otherwise we paid our own medical bills. As we got older and had more children, health insurance seemed indicated, and eventually we got into the Kaiser program, which we have stayed with for at least thirty years now).

The question is, do we make major changes in a system that satisfies 80% plus of the population in order to "fix" the two 0utstanding difficulties?

Of those two, one would presume that there's an affordable "fix" to the first.

The second raises the moral question: who is "entitled" to health care paid by someone else? If that be everyone, we can't afford it; we will have to ration health care resources, meaning cutting back on what is offered to those at present insured. There is no way to afford "insurance" entitling everyone to what those insured at present get.

And of course the notion that those who don't at present have insurance might be covered by some minimum benefits policy is not at all considered: equality trumps liberty here as with organ transplants. (The very wealthy can get around the waiting lists imposed by equality by going out of the country, and the very very wealthy have shopping options from organlegger nations, but that is seldom discussed.)

Freedom is not free. Free people are not equal. Equal people are not free. And it is not at all clear that it is "equality" to give to those who didn't buy an insurance policy the same benefits as are given to those who did. But perhaps that is another discussion.

But it is very clear that the changes intended in the present health care proposals would end the present system and take us inevitably toward the intended result of a single payer universal system. It is also clear that a majority of the nation doesn't want this. It is not entirely clear that the present government cares what the people want, since the people don't always know what's best for them. "Arguing with you is like trying to have a conversation with the dining room table." Our masters know what's best for us. We don't.

Incidentally, we still won't have equality: members of Congress will not be forced into the single payer system.



Data for the US for 2006:

Number of deaths for leading causes of death

(1) Heart disease: 631,636
(2) Cancer: 559,888
(3) Stroke (cerebrovascular diseases): 137,119
(4) Chronic lower respiratory diseases: 124,583
(5) Accidents (unintentional injuries): 121,599
(6) Diabetes: 72,449
(7) Alzheimer's disease: 72,432
(8) Influenza and Pneumonia: 56,326
(9) Nephritis, nephrotic syndrome, and nephrosis: 45,344 S
(10) epticemia: 34,234


The first thing that jumps out at me in these numbers compiled by the CDC is that the top 4 and number 6 have a lot in common.

According to the Mayo Clinic, "Many forms of heart disease can be prevented or treated with healthy lifestyle choices and diet and exercise."


The American Cancer Society says, "Regular use of some established screening tests can prevent the development of cancer through identification and removal or treatment of premalignant abnormalities; screening tests can also improve survival and decrease mortality by detecting cancer at an early stage when treatment is more effective."


The National Stroke Association says, "Up to 80% of all strokes are preventable."


The American Lung Association (and many others) link Chronic lower respiratory diseases (COPD) with cigarette smoking.


As for diabetes, the American Diabetes Association says, "Most Americans who are diagnosed with diabetes have type 2 diabetes", and "Small changes in diet and exercise can prevent type 2 diabetes from developing or slow it in its tracks."


Those 5 causes of death in 2006 are over 87% of the listed total, and all share a high expectation of prevention and/or control with early detection and treatment. Preventive care is in the scope of healthcare reform.

If there is a significant increase in the obituaries that begin with "died peacefully at home", I can't help but think that there would be a likelihood of a corresponding decrease in the total costs for that last year of life.

Your recent dance with the radiation treatments seems to anecdotally bear that out. You don't appear to be lingering in that last year just yet (and I for one am happy for that).

I do find some irony in the observation that by virtue of marrying the right woman and being eligible for Medicare, you enjoy the benefits of affordable, high quality healthcare.


I do not understand your definition of irony. As to life choices, thirty years ago I decided that the evidence was clear: smoking costs about ten years. Since you can get a lot done in ten years, I quite smoking (after some forty years; when I started everyone smoked and the Army provided cigarettes in the ration packs). I don't quite understand the reference to marrying the right woman. I did that fifty years ago, and health care choices were not part of the decision. As to eligibility for Medicare, I was offered no choice in the matter, but I have paid self-employment taxes for very many years, so if anyone would be "eligible" it should be me.

In any event, I would not have described my experience as a dance, but I will take some credit for marrying the right woman and and paying my self-employment taxes for forty years.

As I have been saying for some time: to make everyone eligible for the same benefits is beyond our financial capability without lowering the benefits for all, which is to say, rationing. How the rationing is to be done is a major part of the debate (and inability to agree on how it should be done a major part of resistance to this "reform"). Of course a private insurance company that offers premium reductions for those who stay at recommended weight, don't smoke, and do regular exercise will be accused of "cherry picking" and exploiting inequalities, and you may be sure that the morbidly obese will find lawyers to challenge the practice.

There are insurance companies that offer lower premiums to selected groups, such as current and former military officers; indeed, such companies typically offer rates far below those of the next competitor. Of course they are letting the US government select their eligible clients. In the past, health care insurance companies have used similar means for selecting clients. Group insurance is almost by definition "cherry picking". Should this be continued?

Clearly the best insurance strategy is to have none (thus avoiding premium payments) until you know you are sick, then get insurance from a company that cannot turn you down for pre-existing conditions. Of course companies in that category generally don't last long in a competitive environment. A "public option" that can't go broke because it is subsidized by tax money would have the problem that most employers would prefer to send employees to that than to buy a more costly private policy. The next best strategy, in my judgment, is to belong to a good HMO. Alas, those are scarce; I belong to a very good one, but many are not happy with their HMO and the concept of requiring everyone to belong to one, which at one time was popular among public policy wonks, seems not to be so popular now.

If you can put all that together into a universal plan that we can afford and which would survive lawsuits, you will have done better than the current Congress.

The President promises that you will be able to keep your present plan if you like it; but one does wonder how that can happen if the company giving the insurance has to compete with a publicly subsidized competitor.

I don't have any solutions here beyond asking the obvious question: is everyone entitled to have someone else pay for his/her health care? If so, who is the someone else, and how was that obligation acquired? And on what basis does the entitlement rest?


The problem isn't the lack of health insurance - health insurance itself *is* the problem.

The advent of health insurance has created a false economy in which everyone assumes he's going to get more in benefits than he pays into whatever type of insurance scheme, public or private, he's paying into at any given moment.

Outlawing health insurance would solve the problem quickly; a true market would develop, with the medical equivalents of Wal-Mart, Bloomingdale's, and everything in between springing up. House-calls, compassionate nursing, and other niceties long-departed since the advent of GOSPLAN-type insurance bureaucracies would spring forth yet again; combined with a tax credit (not a break, but a *credit*) for donating monies to charities set up explicitly for the purpose of providing health care for the indigent would largely serve the needs of the poor.

Prices fall, choice expands, the poor are served - everyone wins.

Unless, of course, the object isn't to provide health care at all, but rather to extend the tendrils of government into all aspects of the lives of the proletariat in order to ensure their 'lifestyle choices' minimize the healthcare expenditures of the State. But that couldn't happen in America . . . could it?



Common Unsense

Below are some excerpts from an article on a conference about how to work with NASA. I felt it was more of a cautionary tale about why Govt officials should never be allowed to touch money. I assume parents prepare their children for government jobs by teaching them how to eliminate any shred of common sense from their work.

Still, the excerpts do provide light entertainment.

"Another potential hurdle for entrepreneurs is the government's reliance on contracts that allow it to modify requirements midstream, panel members said. Often, government officials are wary of contracts that set a fixed price for goods or services, according to Muncy. As a result, NASA often conducts research-and-development programs under contracts that pay for the cost of developing a piece of equipment then add a negotiated fee. "That dramatically raises costs and stops investment of private resources to meet government goals," Muncy added. "Conduct a cost-benefit analysis to see if you want to work with the government," he said. "When you get money from someone, there are strings attached. Don't forget to look at the risks and the strings."

Davidian advised entrepreneurs to find the people within government agencies who support their endeavors. "Find your champions within government," he said, adding that those champions can help entrepreneurs succeed.

One champion of private industry is NASA Ames Director Pete Worden, according to the panel members. "He's created a friendly front door for entrepreneurs," Muncy said.

Worden said. "NASA should midwife new industries."

The space agency has not always embraced that role, however. Conference participants cited many cases in which NASA did not support entrepreneurs. Zero Gravity Corp. of Las Vegas, for example, faced stringent requirements for handling combustion experiments aboard the parabolic flights designed to support NASA projects even though no such experiments were contemplated, Davidian said. Another benefit to working with the space agency is that NASA officials will often support risky research and development projects that are unlikely to be funded through other sources, Pittman said."






The dragon in the backyard.


--- Roland Dobbins


Potemkin villages in China erected to fool bureaucrats.


-- Roland Dobbins


Subject: TSA

Dr P;

After spending the week traveling from Los Angeles to New York (Rochester to Chicago, JFK to LAX ) I was struck at the regional differences in post 911 travel at Los Angeles International vs. JFK. At LAX when you check in your bags and proceed to the TSA security checkpoint, you are herded into a roped off queue where TSA agents YELL AT YOU to make sure YOU ARE FOLLOWING PROCEEDURES. As if the LOUDER THEY SPEAK, THE MORE YOU WILL UNDERSTAND THEM.

At JFK with American, the lines were organized, there were color flat screens well in advance telling you what to place in bins, to take off your shoes and place electronics in a separate tub (side note: I travel with way too many electronics) all in all a pleasant experience.

I have traveled through LAX over the years since 911 both domestic and international, and all times find the TSA presence to be disorganized and inefficient. Individual agents can be nice to travelers, but most are, well mean.

Is it intimidation at LAX and kindness at JFK?


I haven't had a particularly unpleasant experience with TSA since Jacksonville, Florida a few years ago. On the other hand, I work at being pleasant about being ordered about. It's a good lesson in humility. I always wonder if they really think they are making us all safer.


'The school system gets about $7,560 in state funds for each enrolled student. Its enrollment target is 83,777, and "any student above that translates into more funding," Wasko said.'


- Roland Dobbins


'I cannot Conceive of the Necessity of becoming a Slave while there remains a Ditch in which one may die free.'


Roland Dobbins

During the Cold War there were also those who said "Better to live on our knees than to die on our feet." Also known as "Better Red than Dead." Die Gedanken sind frei.









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