Healthcare - Market Reform

A core problem with the American health care system is that its market is fundamentally flawed. Part of this is due to laws created to provide humanitarian treatment during medical emergencies. In 1986, congress passed the Emergency Medical Treatment and Active Labor Act. Before EMTALA, if you showed up at an emergency room without proof of insurance, you could be turned away. Under this new law, hospitals would be required to provide services no matter the financial status of the patient.

Under EMTALA, there became less of an incentive for people to get insurance since emergency care would always be provided. And since the uninsured will be will be far less likely to pay their bill, someone has to cover these costs which are estimated at 55% of all emergency services. This results in hospitals raising their prices for services, which typically falls on the insured, raising premiums. Thus, you have a perverse incentive for the purchase of health insurance.

A large percentage of the uninsured are young healthy Americans. These individuals would contribute more to insurance revenues rather than costs. Therefore, a possible solution is to require obligatory coverage. By doing so, we expand the risk pool of Americans to lower per capita insurance costs. Since most Americans are now insured, the cost of EMTALA is reduced, which lowers costs across the board. This is a market based approach to the concept of socialized medicine.

There is another positive side effect. Since insurance is mandatory, anyone showing up for treatment without insurance would most like be an undocumented alien. These individuals could be treated and turned over to immigration officials thus easing the loads on ICE. However, it is also likely that illegals would purchase insurance to prevent easy discovery. Either outcome is a net positive for health care.

As a libertarian, the thought of mandated insurance is in exact opposite to my core principles. But the other solution is to turn away people at the hospital that are not insured or don't have an insurance bond. I'm not sure any libertarian could support that ideal.

Healthcare - Cost Benefit Analysis

People complain about HMO's and “drive-by medicine." They say that hospital stays should be longer and more comprehensive. But what happens when the controls are released and the floodgates are open? Let’s say that an indigent mother gives birth to a premature child. We have the medical technology to save the child. But at what cost? $100,000 to $1,000,000 is not uncommon for this type of service today. Perhaps you think it's ok for the taxpayer to foot this bill at this level. But, what happens when it becomes $10,000,000?

We have not come to the point of accepting that actuarial decisions MUST be part of health care. If you have X dollars to spend and there is a request for $1,000,000 in treatment for a single case, it has to be determined how that money is best spent. A bleeding heart liberal would say the insurance companies make too much profit so make them save everyone. But the insurance companies just pass those costs on to the consumers, which is our current problem.

On a related note, will someone please take Sarah Palin moose hunting and not bring her tired ass back? Her idiocy in blabbering about supposed “Death Panels” was the stupidest thing that a conservative could have done. End of life counseling was the one sound fiscally conservative aspect of the heath care reform bill. But no, politics are more important than real reform.

Tough Questions on Healthcare Reform

I was watching Dateline last night when they covered problems people were having getting insurance companies to cover treatment. The show was named "Critical Condition" and it was pretty heartbreaking to watch. The theme of the show was that insurance companies were denying critical treatment for patients. My thinking is there were much bigger issues at play. And these issues didn't have as simple answers as you were led to believe.

The first segment was on Patrick Gannon, who suffered a heart attack at 41. The doctors applied $1,000,000 worth of treatment to the man to save his life over the course of several weeks. The result was a man that required full time care, unable to walk, talk or mange his own life. After paying out all that money, the insurance company opted for a cheaper rehabilitation route that the one that family wanted. The claimed result is that this approach drastically affected Patrick outcome.

Let's remove the emotion. The doctors performed $1M of treatment on a poor outcome that left Patrick in a predicable state and probably wouldn't have knowingly consented to. It destroyed his family financially in the process. To apply that much medical intervention on an infarction, you have to be dealing with little more than a corpse. Someone during this period should have realized that this was going to be a very bad outcome and let him die peacefully. The emotional and financial toll on his family will continue and it's unknown how it will affect his daughter. There isn't a good answer to all this, but I'm really not seeing the insurance company as the bad guy here. I'm surprised they covered as much as they did.

The second was a firefighter named Rick Crusoe with a rare form of cancer. The insurance company balked at an experimental treatment that had a 10%-15% chance of prolonging his life an undetermined length of time. I can't speak specifically to the numbers involved, but they were requesting an authorization of up to $250,000. Would you give up your house for a 15% of helping someone live for a couple of months maybe years? I'm not sure many people would take that bet. Maybe a grieving mother or husband. How many lives could that money save if put to better use like paying for vaccines or other more certain treatment?

For last patient, we have Nataline Sarkisyan who was in need of a liver transplant. It was about $500,000 for a bridge to keep her alive for many months while they continued to treat her leukemia. My reading is that the treatment will probably kill her new liver and she would have to have another later on. They had already authorized a bone marrow transplant that could run up to $700,000. We could be looking at a total of $1.7M and that's assuming she could find the second liver. Again, where is this money best spent?

In summary, I got the following from this report. First, medical costs are too high. This is obvious, but they always will be as long as research is expensive and risky. Therefore, we need to deal with this reality. Second, if you have insurance, you hope that your money isn't being wasted on questionable medical decisions that will increase your costs. However, if it's your loved one, you want them to spend everything they have. This is referred to as The Prisoner's Dilemma. Someone external to the situation needs to make those decisions. Currently, only the insurance companies will do it because it affects their bottom line. And perhaps that's the best way. Honestly with the material presented, I didn't fault them for their decisions.

Third, doctors need to understand long term quality of life issues relating to the decisions that they make. Traumatic Brain Injury or Neurological Impairment with regard to heroic lifesaving measures are life shattering and a poor outcomes can usually be predicted early. Present the facts clearly so families can make sound decisions. But even then, people will override medical advice. And Patrick Gannon may have well been one of those cases.

What is the iPad?

I'm watching all the Apple fanboys buzzing over the new iPad. General consensus seems to be that it's underwhelming, but I think Apple may have found an interesting market niche. It's not a computer and it not a competitor for the netbook segment. It's a media/surf terminal. A little toy you piddle with while you're watching TV to answer questions that pop up like "Who played Lumpy on leave it to beaver?" or "What else was that actor in?". Or perhaps you look up the playoff scores and read your email. Just Plain Old Surfing. New acronym - JPOS (tm)- you heard it here first! :)

A lot of people use their laptops for this type of stuff (me included). But if you don't have a laptop and you find your iPhone or Droid is a little inadequate for regular couch surfing, this would be a better replacement that a $$$ macbook. IMHO, a netbook is a better and more versatile option, but for an Apple person, it isn't as desireable. As for mass market adoption, you might snag some ebook people and perhaps some that find it a sexier alternative to the eeePC. But I don't see another iPod craze on the horizon.

My only question is ergonomics. What does it do to your wrists to balance that thing for a couple of hours? You can't read it if you lay it down. And how do you use the keyboard on your lap? Time will tell.

On the Nature of Human Intelligence

What is the nature of intelligence? Is it just you or the sum of you and any tools you have at your disposal? For the purposes of an IQ test, it would be just the organic part. However, on your job were it really counts, all bets are off. You are allowed any trick in the book to achieve your goal. And in your personal life, you set the rules. I submit that we have already entered the Cyborg age. It may not be exactly what you expected from reading science fiction, but the details are just speed and interface.

The typical techie has some type of wireless Internet access at most times, be it 3G, EVDO or wifi hotspot. With this technology, you are able to access such on-line resources such as Wikipedia, Wolfram Alpha, or the Internet Move Database. If you can access this information at any time and place, doesn't it make it part your smarts? I mean you can get the information, perhaps not with the speed of Marilyn vos Savant. But you could easily wax her tail with the sheer volume of information available. Who played Lumpy on leave it to Beaver? Suck on that, Marilyn. It's given that only part of intelligence is pure recall, but it's an important part. Original and theoretical constructs are key piece of total cranial horsepower. But even each of these are based on a foundation of basic recall.

You could argue based on the premise that we have been in the Cybernetic age since the first written word. But I submit that carrying around the Library of Congress is impractical. It is only the confluence of wireless devices and the Internet that finally makes the total of human knowledge available on demand.

There was a time when students weren't allowed to use calculators during a test. Now its pretty common if not encouraged. And now we are seeing Internet access accepted on tests as well. Thus, the total of the human experience now includes handheld devices.

The biggest threat to Microsoft is Microsoft

I was reading this article on Microsoft having it's revenue eroded because of low cost hardware. The author made some interesting points, but I think there is a bigger issue that Microsoft is facing. While the market is pushing toward lower cost hardware, this trend has been going on for years and isn't the big problem. The elephant in the room resides in your pocket, lets mom know you're safe and comes with nifty ringtones.

Modern PC's are used for a great many tasks and they do them quite well. So well in fact that the only technological advances that we've seen in this area have been incremental. Quicken 2008 looks like 2009 and 2010. We've plateaued, at least for now. Current innovations are in real-time, portable, personal media and communications. PC's aren't the platform and never will be.

Smartphones are the new technological touchstone. They are dynamic, constantly following us on our kinetic lives, connecting us with our loved ones and documenting our adventures. And now they are the interface for the human experience. Witness the smarthone's effect on the Iranian revolution. Apple saw this to some extent and threw fuel on the fire with the iPhone. RIM(Blackberry) is playing catch-up but appears to be hobbled by their devotion to corporate America. Android is a small but growing contender. Microsoft, however, completely blew it. It has had a foothold in smartphones since the Palm days, but couldn't close.

The reason? Microsoft's financial foundation is built upon legacy revenue streams. It is this market that it's afraid to disrupt. And all new technology is fundamentally disruptive. Smartphones could eat into the PC's market if they became too powerful. Why buy Outlook when your email and calendar are in you hand? And who will buy a $300 package for a smartphone they probably got for free? It's not a platform for Microsoft's sales model.

Thus they made the conservative choice and failed to innovate. This is a very serious problem for them as it appears that the consumer market is moving away from the platforms that Windows is geared towards. Windows 7 is a move in the right direction, but the competitors are nipping at its heels. The reality is that Microsoft is being outflanked in nearly all areas, with the possible exception of the Xbox.

What will the future hold? Microsoft has touted that Windows is installed on over 75% of all new netbooks. However, this is considerably less than the 90% dominance that it enjoys on the PC market. If this trend holds, then we will see further market erosion. Firefox has already established itself on 30% of PC's and according to some sources will soon approach 50%. Clearly, Microsoft is losing consumer mindshare. The safe money appears to be on the open source software movement from which Linux, Android, your beloved Tivo and to some degree Apple Mac OS X are built upon.

The Real Green Revolution

I live in an area near one of the last hangouts of an endangered mussel known as the Carolina Heelsplitter. There has been considerable protest over this little critter in the last few years, bring development to a halt and even running a construction company out of business. I'm all for conservation, and don't really have a problem with the protests beyond they fact that they are affecting my ability to get to Taco Bell in a timely manner. But the group is a little fringy IMHO as I know a couple of them and some of their other causes. In particular the rush for renewable energy

I was wondering if those same people were aware of the side effects of the all the renewable technology they are pursuing. It's typically accepted that hydro power is pretty green, but check out this article. It's doesn't even describe the effect on fish migration and spawning which are well documented. We've seen the effect on diverting food crops to ethanol on the world food supply. Oops. That was quickly reversed. Wind affects the migration paths of birds. What happens when these confused avians get lost en mass, can't find mates and begin to decline in numbers? Solar appears to be pretty benign until the change in weather patterns starts affecting crops and food production.

Looks like a green revolution may occur with the green revolution.

The Panty Bomber

With all the outrage over lax security, it is inevitable that we will enact further weird and useless measures to make our flights safe. Military tacticians have stated that in asymmetrical warfare, the defender is always at a disadvantage. We continually spend money to patch up the current crisis, while new attack vectors are already being planned. They started with traditional hijacking involving guns and grenades in the 1970's. Our response was to install metal detectors. Richard Reid, the shoe bomber, got everyone taking off their Nikes. Now the Underbomber has got us scrambling for body scanners.

Where does technology eventually lead us in this cat and mouse game? Let's move forward a few years to the era of the BioBomber. This twisted individual will ingest a cocktail of explosive ingredients. They might be poisonous, but not in the time frame that he is concerned with. Next, immediately before entering security he ingests a primer in a time delay capsule. Once the protective coating is breached, the explosive is triggered. This is the ultimate smartbomb. You are not going to find this dude by searching old ladies and toddlers. Do we intend on endoscoping all passengers? Of course, they could always go old school and set off a bomb vest in the security checkpoint, maybe even in the scanner.

The point is that the TSA is political theater designed to keep the masses feeling comfortable. If we expect to make people truly safe, no-fly lists and body scanners aren't the answer. You are going to have to take proactive measures that get to the root of the problem. People want to blow us up. Why is that? "W" said it was because they were evil. I doubt seriously it's that simple. Afghanistan and Pakistan house part of the problem, but let's not forget about Israel and Palestine. It is a festering wound that is a great source of many of our troubles and a great recruiting tool for Al Qaeda.

Before you flame me for giving them ideas, realize that they have already thought about this. What else are they going to do sitting up in a cave in Waziristan?

Am I the least interesting person in the world?

Seems like everyone on the intertubes is running their own blog, so I decided to jump in. My site at http://www.unconventional-wisdom.org houses a lot of extended essays on various topics relating to politics and technology. However, because of their formal nature, I don't update them more than once or twice a year. There are a lot more thoughts I'm interested in expressing, so I'm going to try a little stream of consciousness posting to see where that leads. No promises. I might well end up being the least interesting person in the world. :)

Stick around and let's see if I can amuse you.