Friday, December 21, 2012

How many billions per year will the DSM-5 cost?

This was a really interesting article, because it gives a glimpse of the economic reality of the American medical system.  Among the parties involved - doctors, pharmaceutical companies, lawyers, and patients, there is but one incentive:  do more, prescribe more, treat more.  Whether patients are helped or hurt by these treatments seems to be of minimal concern, and certainly nobody is doing a cost-benefit analysis.  It is as if financial resources were infinite.

Read the comments at the bottom, too.

Wednesday, December 19, 2012

What does Adam Smith think about your medical degree?

This letter was written two years before "The Wealth of Nations", in 1774.

My favorite paragraph:

"A degree can pretend to give security for nothing but the science of the graduate; and even for that it can give but a very slender security. For his good sense and discretion, qualities not discoverable by an academical examination, it can give no security at all. But without these, the presumption which commonly attends science must render it, in the practice of physic, ten times more dangerous than the grossest ignorance, when accompanied, as it sometime is, with some degree of modesty and diffidence."

Tuesday, December 18, 2012

Vegan sandwich!

Who says you need meat and cheese to have a great sandwich?

Spinach, sauteed red peppers (if they are hard they don't fit into the sandwich well), red onion, hummus, avocado, tomato.  And here is the trick - use sprouts like a net to hold it all together.

Very satisfying and balanced..  Carbs from bread and tomato, protein from sprouts and hummus, fat from avocado.

Tuesday, November 27, 2012

Dumb, even by Fox News standards

I thought this was one of the dumbest columns about gender relations that I've ever read:  The "war on men".

Also worth mentioning, since I'm on the subject, is this video:  Fox News called out for Benghazi hype.  A lot of people on Fox News and in the Republican Party (listing those separately was redundant, I know) are pushing conspiracy theories about the Benghazi incident.  The problem is that nobody has a good explanation for why Obama would need to lie about it in the first place.  Why would a terrorist attack in Libya need to be covered up?  How does Obama gain if his ambassador is killed?  Call me crazy, but this omission seems non-trivial to me.  Apparently, motive isn't a necessary component of a conspiracy theory for paranoid people anymore.

Monday, November 19, 2012

Israel's missed opportunity

Two years ago I wrote a (sadly) prescient piece about what I believed was a historic missed opportunity on the part of Israel's leaders: 

"When it comes to Israel and war, there are two questions: one is whether Israel has the right to keep pounding its enemies, and the other is whether it should keep doing so. The first question: Israel certainly has the right to defend itself. No doubt, it feels good to see Israel teach a terrorist group like Hamas a lesson, especially after Hamas provoked the Israeli response. The second question is harder to answer. Israel beat Hamas, but hundreds of innocents died in the process. The international community almost universally condemned Israel. Relations with Turkey in particular melted down to almost nothing. The most important thing to remember is that pounding Hamas did not actually accomplish anything for Israel. Hamas is still in Gaza, it is as radical as ever, and it is still arming. Israel cannot continue to engage in these wars with non-state actors who don't care how many of their own people die so long as they hurt Israel; it's like playing chicken with someone who is suicidal. Weapons and war can only make Israel safe in the short term; the only thing that can make it safe in the long term is compromise, negotiation, and peace."

This has been so tragically predictable.  No nation would or should tolerate rockets being fired at a fifth of its citizens, no matter how poorly aimed.  I don't blame Netanyahu for the last four days; his hand is forced.  The last four years?  That's a different story.  Hamas may be unwilling to negotiate, but Abbas and the PA have been sitting in the West Bank doing nothing.  Imagine if significant progress had been made towards Palestinian statehood there?  The people of Gaza could then look to the West Bank - a peaceful land on the verge of statehood, and contrast that to their own homes - again under Israeli attack after relentless provocation by extremists.  If you want people to reject violence and terrorism, it will be easier if they have an alternative.

Tuesday, August 28, 2012

Medicine and ED docs: should you consult surgery for your demented patient?

As the surgery consult resident, I am frequently called by the emergency department or the medicine teams in the hospital to evaluate patients to see if they will need surgery.  I was recently called about an elderly patient (in his late 80's) with severe advanced dementia and other comorbidities who has no immediate family members.  The medicine physicians wanted to know if the patient would benefit from surgery.

Here is a statement from the Alzheimers Association website:

The research on the efficacy of aggressive treatments and the burden experienced by the person in the advanced stage of Alzheimer’s disease, the Association supports the elimination of hospitalization and aggressive treatments, including cardiopulmonary resuscitation, dialysis and all other invasive technologies, in favor of palliative and comfort care in the person’s residence, whether in the person’s home or in a nursing facility.

To assist individuals and families as they make decisions about end-of-life care, the Association recommends that physicians and other health care providers educate families regarding the choice of burdensome treatments in the advanced stages of dementia versus the choice to provide comfort through palliative and hospice services.

The Association asserts that open and honest communication between health care providers and families as to the person's prognosis as well as the implications for aggressive treatments will assist families in making compassionate choices.

As it turns out, the patient doesn't need surgery.  What if he did?  Should we operate?  Think the fact that I'm writing this right now suggests my own feelings about this particular consult.  The "default setting" in the American medical system is to constantly intervene and "treat" unless we can get someone from the patient's family to tell us not to.  Is it a sign of moral cowardice to fail to stand up to the system, to stand up for the patient? 

Why is it not the default option to restrain ourselves and let the individual's body follow its natural course?

Friday, August 24, 2012

The Economist on Mitt Romney: "nobody knows who this strange man really is."

The liberal media is at it again.  The left-wing Economist newspaper (/sarcasm) has not once, in the last three decades, endorsed an incumbent president for re-election.

2012 is sounding like it could be the first.

"All politicians flip-flop from time to time, but Mr Romney could win an Olympic medal in it."

"Competence is worthless without direction and, frankly, character."

"He has appeared as a fawning PR man, apparently willing to do or say just about anything to get elected."

"Behind all this sits the worrying idea of a man who does not really know his own mind."

"The Romney Programme for Economic Recovery, Growth, and Jobs" is like "Fifty Shades of Grey" without the sex."

"It is a little odd that the number two has a plan and his boss doesn't."

"A business man without a credible plan to fix a problem stops being a credible businessman.  So does a businessman who tells you one thing at breakfast and the opposite at supper."

Tuesday, August 21, 2012

How to lose the future

Taken as a percentage of GDP, investment in research by the United States is at the lowest level in decades.  Other nations such as Finland and Israel, known for their innovative and entrepreneurial economies, spend far more than the United States.  Cuts in research spending won't hurt us now - they will hurt us in a decade or two.  The time lag between benefit and cost makes such cuts a tempting political target. Enter the Ryan plan, which plans to cut "non-defense" research spending to trim our budget.

We're in a tough time economically, and our deficit is absolutely out of control.  If someone was making the case to me that we just can't afford to increase R&D spending until our fiscal future is secure, I don't think I would find that argument unreasonable, although I wouldn't agree with it. What I do find to be unreasonable is the Republican insistence that the military needs to be spared all forms of spending cuts.  It is the epitome of short sighted to cut general research spending in order to maintain our high current levels of military spending.

Mitt Romney plan will cut research spending, but he has promised to increase military spending (for what threat are our current forces insufficient, I wonder).  Barack Obama has stated he will not spare the military from a greater plan to fix our budgetary crisis, but has nevertheless urged increased spending on research and development.  Americans have been given a choice this election.  They can think about the present, or they can think about the future.  The central theme of pretty much every history book I've read ever, is that great national powers which maintain high levels of military spending to the detriment of other areas of the economy quickly cease to be great powers. 

Friday, August 17, 2012

A very good point re: Ryan medicare plan

Josh Barro on Bloomberg reminds us that the Ryan Plan would delay actual reforms to Medicare for 10 years. 
What are the chances that such reform will withstand a decade of partisan demagoguery by opportunist politicians?  Congress has proven time and time again that even when congress passes its own legislation that "forces" spending cuts down the road, the spending cuts don't happen.  Look at the medicare doc fix - every year, congress passes a 1-year funding bill to avoid the cut.  Listen to the howls of politicians about impending mandatory cuts from sequestration.  What are the chances those cuts actually go through?
A similarly lame attempt to "reform" medicare a decade down the road will similarly fail.  There is no shortcut to real reform, but that's what we need to curb health care spending in the long term.  Instead of gimmicks, real reform is going to require serious policy analysis, honest proposals, intelligent cost-benefit analysis, and good-faith compromise.

Saturday, August 11, 2012

Paul Ryan for VP

My biggest concern about a Mitt Romney presidency is that he would end up being a George W. Bush repeat:  expanding defense spending, cutting taxes, while leaving entitlements untouched if we're lucky or larger if not.  After all, if we are going to have big government, we need to pay for it.  The only thing worse than high taxes and big government is low taxes and big government.  In the former case, Americans living in the present are paying for services they receive; in the latter case, Americans in the present are living large while future generations are stuck paying the bills.

Up till now, Romney really wasn't very clear about where he stood on things.  We know for certain that he is a Keynesian, and has expressed that he would hesitate to cut federal spending if the economy was still weak.  He has promised to increase military spending, and to cut taxes.  Without massive cuts to entitlements, the math doesn't even begin to add up.  Paul Ryan as VP shows how Mitt Romney makes the equation work.  It is a relief that Americans will actually have a real choice to make this November.

If I knew that Ryan's strategy to cut spending would actually work, I might be willing to vote for the challengers.  I remain extremely skeptical that the Ryan plan will actually cut health spending rather than merely transfer it.  The problem isn't medicare per say, the problem is the health care system itself.  It is how we deliver care; it is about the incentives to do more that doctors, hospitals, and patients all have, and the consequences if they do less.  Our system only knows how to do more - there is no restraint.  Changing who pays for medicare doesn't change the system itself; in fact, it is more likely to exacerbate the worst tendencies of the system.  In a previous post, I explain why I don't think the Ryan plan will work.

This is what democracy is all about - real choices.  No matter who wins in November, I hope that administration will have some support from congress to enact their proposed agenda.

Thursday, August 09, 2012

Enjoy your right to drive a car, part 3

Three hundred thousand accidents.

Part 1:  why I think it will eventually be illegal for humans to pilot automobiles on public roads, and why we should embrace that future. 

Part 2:  intersections of the future.

I used to think the transition to computer-only driving was at least two decades out.  Now I'm not so sure - it could come much sooner because the technology is moving really quickly.  There are huge economic and safety gains to be had from banning error-prone humans from getting behind the wheel of cars.  Once those gains become apparent, there might be a massive push towards computer-only driven cars.
Considering how dependent on cars many Americans are for transit, the future could be pretty scary from a privacy standpoint.  If a citizen needs to tell the car's computer where to take them, then someone could potentially be tracking where that individual is going at all times.  Other than the government, there are of course other interested parties (spouses?  parents?) that might be keen to check on the car's recent travel history...

Tuesday, August 07, 2012

HCA "controversy" is the butt of a four+ year old internet parody video

There is a video on youtube which is now over four years old which many physicians-in-training find hilarious:
The "news" that physicians in Florida are performing unindicated procedures because they have a financial incentive to do so is not news to anyone in the health care profession.
People respond to incentives.  There are incentives to perform procedures.  Physicians are people.  Follow me?

Monday, June 25, 2012

The China Study

Per recommendation from my mother, I've started to read "The China study".  She and I both have an interest in nutrition and disease so I am excited to read the book and gather new insights - and maybe find a new lifestyle ideal to work towards.  I have only started to read the book, but from what I gather, the author is going to build a case that animal products and specifically animal protein in the Western diet is responsible for many of the common diseases that afflict us, including heart disease, cancer, and obesity. 

As I was reading the first chapter, my mind wandered a bit and I remembered the time I spent in east Africa.  The Maasai people are nomads who live in the Great Rift Valley of Kenya and Tanzania and we had many encounters with them on our trip.  Their economy revolves around cattle - they are nomads because they must find new grazing lands for their herds.  Maasai diet is extremely high protein:  they drink milk from their cows and even harvest cow blood from a small cut in the jugular vein to drink raw.  They will consume meat from goats, sheep, and their cattle if they need to.

From the New England Journal of Medicine, on the Masai Diet, from 1971:

"The Masai of East Africa exhibit some unique biologic characteristics. Despite their customary diet composed of 66 per cent calories as fat, they have persistent low serum cholesterol and beta-lipoprotein levels. Post-mortem examinations provided direct proof of a paucity of atherosclerosis. Metabolic studies revealed that the Masai absorbed large amounts of dietary cholesterol, but also possessed a highly efficient negative feedback control of endogenous cholesterol biosynthesis to compensate for the influx of dietary cholesterol.  The high ratios of phospholipid to cholesterol and bile acid to cholesterol in their gallbladder bile explain the extreme rarity of cholesterol gallstones. All these characteristics may reflect a long-term biologic adaptation of the tribe."

I don't think this refutes anything, it is just food for thought.  For example, it seems plausible to me that relative dietary protein excess could be related to "Western" diseases but if such protein is immediately utilized that might be a different story.  The Maasai eat a lot of animal protein but they are also nomads and spend their days in different ways than your average American and probably make more use of the protein in their diets.  Also, I'm not aware of any good studies of cancer among the Maasai but I will keep looking.

Switching gears.  On page 80 off the book I made a self-serving observation:  there was not a statistically significant link between eggs and blood cholesterol found in the China study.  After some arguments with friends about the relative health risks/benefits of eating eggs, I had previously scoured pubmed for links between egg consumption and blood cholesterol.  After viewing multiple studies, I was able to find no such link - only transient increases in blood cholesterol were reported (immediately after consumption). 

From a scientific perspective I wouldn't be totally shocked if eggs were ultimately shown to be fairly benign dietary additions.  I am about to embark on a path of pure unadulterated, unsupported speculation (as I often do).  If there is something unique about animal protein and animal cholesterol as it relates to cancer, causing tumor progression, I wouldn't be surprised if it ultimately proved to be related to the consumption of signalling molecules & growth factors that feed malignancy.  Consuming "animal protein" essentially is an exercise in consuming the cells of various animal tissues.  Those cells all have membranes that are full of cholesterol molecules and transmembrane signalling proteins.  Those cells will also contain a cytoplasm full of hormones,intracellular signalling molecules, enzymes, signal amplifiers, and the like.

Eggs wouldn't necessarily have those things because eggs aren't tissue.  Its a protoplasm of undifferentiated nutrients that will ultimately be built into differentiating (specializing) cells and tissues.  Raw eggs just represent building blocks for later animal protein.  The animal protein in eggs would lack signalling molecules and hormones.

Anyway, I will be curious to see if there is stronger anti-egg evidence later in the book.

Tuesday, June 12, 2012

Have they learned nothing?

On domestic policy issues, I don't think that Obama and Romney will differ all that much.  Both men will work towards and almost certainly get a grand deficit-controlling bargain that will largely be limited in scope by constraints imposed by the legislative branch.  The Republicans in the house will limit the tax increases, although there will be some.  The Democrats will limit the cuts to entitlements, although they will be hefty in either case because they have to be.
The biggest difference between Romney and Obama, in my mind, is when it comes to foreign policy.  I don't believe that Romney is a war-monger but I do believe that he will be surrounded and supported by "intellectuals" who are.  The Republicans are ITCHING for another war.  They want a strike on Iran, they want intervention in Syria.  Its madness, but it is the truth. 
I don't believe that Romney will initiate these events, but I do believe that those who surround him or those in control of the party will push buttons and initiate events such that the gears of war start turning.  Once the machine starts moving, Romney will go along with it.  Read this for a sobering reminder of why this remains my single biggest concern for the prospects of a Romney presidency:
John Bolton isn't just any foreign policy thinker in the Republican Party.  He is THE foreign policy thinker of the Republican Party. 

Tuesday, June 05, 2012

First, they came for your soft drinks

The hysteria surrounding Mayor Bloomberg's large soft drink ban is fairly ridiculous.  Really, my biggest problem is his approach; a ban on large drinks will be less effective than a hefty tax on soda by the ounce.  Not a ton of people agree with me on this:  Americans seem to think that what starts with a super-sized soft drink ban will logically and inevitably end with a nanny-police state.  This assumes that we have no capacity for restraint or rational governance, which is ridiculous.*

Most people already accept that the government has the right to intervene in some situations.  If a parent gave a child ice cream for dessert every night, we might think the child spoiled.  If a parent fed their obese child ice cream for breakfast, lunch, and dinner, we would be thinking about calling social services.  If a parent was giving their child alcohol or cigarettes, we would definitely call social services.  Many of the loudest voices criticizing mayor Bloomberg also firmly in the anti-drug legalization camp.  If a police state is scary, why are we incarcerating people who smoke marijuana?

Next, consider that while trying to regulate soda slightly infringes on the rights of people who drink soda, being obese and relying on government-provided health care greatly infringes on the economic rights of people who pay taxes.  If we lived in a nation where everyone had to sleep in the bed that they made for themselves, I would be more sympathetic to libertarian extremes.  As it stands, all Americans are guaranteed access to health care in emergent situations and all Americans are guaranteed health care at age 65.  Your right to drink soda and be unhealthy needs to be balanced with my right to be free from overwhelming tax burdens.

It is very important to remember that government is part of the reason we got here in the first place.  There are government subsidies for industrial agriculture, corn, meat, and processed food.  This artificially cheapens the price of the most unhealthy types of food; it is literally the case that the federal government pays Americans to eat at McDonald's (indirectly).  No wonder why we have an obesity crisis!  It is not libertarian or conservative to be a defender of a market so distorted by government influence.

The obesity crisis is getting worse, and health care costs are literally bankrupting the United States.  Are there more ideologically pure ways to fight the obesity crisis than to tax soda?  Possibly; but none are so simple to implement, likely to be effective, and politically realistic.  Smokers consume a lot of health resources, and we all agree that smoking is a bad habit.  Not a ton of people are upset about the fact that we tax cigarettes.  Soda should be similarly considered.

On an aside, from a purely speculative health standpoint, let me also say this:  if you forced me to either drink 3 cokes every day or smoke 10 cigarettes, I am inclined to think that I would be better off smoking the cigarettes.  It would be interesting to read a study that tried to compare the two to see which is worse for health.

* Unless Republicans are in charge

Friday, June 01, 2012

Will democracy survive in Europe?

Given the imminent collapse of the Euro, one blogger posed the question:  "Will democracy survive in Europe?"

I'm not so sure I buy the "locked-in" theory of modern democratic consolidation, which posits that once a nation state becomes democratic, and its culture molds around that political structure, it remains a democracy despite political or economic turmoil.  My personal belief is that historical trends are more a product of trans-national influences that exert changes in the same direction.  It is true that *generally* in the 20th century we've seen a trend towards democracy, but it is also true that the United States and Western Europe have been the wealthiest and most powerful nations in the world throughout that century.  The attraction and the influence of the Western democratic model has been strong for the last 150 years.

Look what happened to nations that were within the gravitational pull of powerful non-democratic states, though.  The eastern European states in the Soviet Union's orbit failed to become democratic until the Soviet Union collapsed.  Some of the Asian states around China (Vietnam, North Korea) have stubbornly failed to transition.  In the case of Hong Kong, we have an example of an economically free zone that has become less politically free with the decline of democratic political influence (Britain) and the rise of non-democratic ones (China).  The transnational influence doesn't rely on the presence of a regional power, either:  look at the brotherhood of thugs that have dominated Arab dictatorships for years.  If Jordan was surrounded by Arab democracies, I suspect King Hussein would not be the autocrat that he is.  Lebanon would not be so unstable.  Iraq's transition would certainly be easier if its neighbors were democracies.

In South America, the trend has been towards democracy over two decades when the only superpower in the world was a democracy, but those gains are tenuous.  What happens when the powerful Western democracies continue to wane in influence?  We're going to find out soon enough.  The author of the blog entry above puts the chance of a non-democracy emerging from a European political collapse into something else at 1 in 50.  Here is my prediction:  the chances are 1 in 3.  Greece is the most likely to go; it has a particularly toxic brew of factors that will make it ripe for dictatorship, something it has a fairly recent experience with anyways (as does Spain, coincidentally or maybe not).  Greece is facing a nearly unprecedented economic collapse.  It has an increasingly powerful historic foe (Turkey) on its doorstep, which will only increase feelings of nationalism and militarism.  I've also read reports of a new sense of animosity towards the Western democracies that it would otherwise be emulating.

The people of every age always think they're at the end of history.  Especially given the nearly unprecedented political instability that the United States has experienced over the last 12 years (as far as dysfunctional government is concerned), I think a little caution is warranted.

Monday, May 28, 2012

More end of life issues

Warning: this nymag article is depressing, but a worthwhile read. What I take away from the piece, as it pertains to health care for the elderly, is that oftentimes less is more.

Imagine how much worse the story gets when the decision makers lack the ability to differentiate between "alive" and "living", or have completely unrealistic beliefs in the ability of modern medicine to cure and reverse disease.

The American medico-legal-industrial complex knows only how to push in one direction: more, more, more. If the system is making the decisions, it will never stop. Patients and families need to always remember they can say no to the doctors.

Wednesday, May 23, 2012

Why America is going bankrupt: Barcelona vs Atlanta

If people are trying to figure out why middle class incomes are stagnant, here is one place to look:Comparing Atlanta and Barcelona 

Would the free market - the driver of efficiency, ever have resulted in such a sprawling mess as Atlanta?  Of course not.  It got that way, like so many other American cities, thanks to government subsidies.  The government builds the roads, the utilities, the power grids.  It fights the wars to secure the oil.  Government regulates that businesses must have abundant parking spots (a subsidy for cars), offers cheap parking on the street for a few quarters; government zones land and centrally plans its use.

Imagine the wasted resources in infrastructure.  The wasted fuel costs.  Time wasted in transit.  What about the redundancy?  Atlanta must need 30 times the gas stations, 30 times the McDonalds.  Atlanta will need more airports, more parks.  I can only imagine the scale of the waste if we could somehow quantify it.  It must be on the order of trillions of dollars.  The US economy is more productive than Europe's, no doubt, but somehow the Europeans manage to maintain equal if not higher standards of living than Americans (maybe not for long thanks to the Euro crisis, but that is incidental).  I would argue that their superior organizational efficiency is a big part of it.

Some are quick to disagree; they point out that Europe is much older so their cities were already built up and became smaller by default.  That is only half true:  after all, most great American cities were well established by the year 1900.  The car didn't really come into its own until a decade or two later.  Make no mistake - America centrally planned this mode of development.  We could reverse this process by putting an end to the subsidies and the government works projects and let the markets or local citizens plan their transit.  Unfortunately, instead of free market solutions, we get 300 billion dollar highway bills for the next 5 years, calls to "drill baby, drill" or to "bomb, bomb Iran".  And that is just from the "pro-free market" political party.

Saturday, May 05, 2012

The Ryan Medicare Plan: increased costs, worse outcomes?

Paul Ryan has a plan for controlling Medicare costs. Instead of a public health insurance plan for everyone over the age of 65, senior citizens would get a voucher to buy private health insurance. The value of the coupon would initially approximate the cost of insuring a senior citizen, but would increase more slowly than health care costs in general. Over the long term, this would create pressure on insurers and providers to increase efficiency, as seniors shop around for cheaper plans. Meanwhile, the US Treasury is absolved of its major unfunded liability.

Many critics have questioned whether or not the private market is actually better at controlling costs than a public plan. They point out that the US spends far more per capita than the other major industrialized nations, most of whom have single payer public plans. Studies that compare cost growth (in the USA) of medicare and private spending can be found to support either argument. My understanding is that over the last two decades, cost growth has been roughly equivalent across the rich world (the US started at a higher spending point back then, which explains our current higher spending level).

Cost growth has been equal, but there are other factors to consider. For example, the United States does a lot of research that the world benefits from, both private and public. The US also has higher rates of obesity and violence, which should increase our costs compared to our peers. In the background of these challenges, keeping cost growth parity with other rich nations could be seen as a sign of the superiority of our system. Yet I can find equally compelling arguments for the single-payer side. Many nations elsewhere have aged more than the US, and older patients should be more expensive to treat. Not to mention, most other rich nations have better public health outcomes than we do; longevity, infant mortality, etc. In summary, it seems to me that there is no obvious answer here. If the private market is better at controlling costs than a single payer, it certainly isn't by much. The assumption that Ryan's plan will save money by shifting to a private insurance market seems tenuous at best.

At any rate, I am convinced that the Ryan Plan will lead to higher costs and worse outcomes, but for other reasons. To come to this conclusion, one has to recognize a flawed assumption and remember a simple fact. The flawed assumption: once the medicare privatization is under way, most seniors will be able and be willing to cover their insurance costs over the value of their coupon. The simple fact: it is illegal to not provide emergent care or to unsafely discharge a patient from a hospital (ie patients who cannot take care of themselves must be sent to a facility of some sort).

Imagine the health insurance market when the Ryan plan goes into effect. I understand there will be a delay in impact since the plan won't apply to anyone over the age of 55, but this is irrelevant to the thought exercise. The health insurance coupons will be worth enough to cover insurance costs on the private market for the healthiest seniors. No problem there. Right from the get-go, the price of insurance for the less healthy seniors will probably be significantly more than the price of a voucher. For those unfortunate seniors with the most significant medical history, the ones with major pre-existing conditions, they will literally be uninsurable at any price.

(This concept, of patients with pre-existing conditions being uninsurable at any price, was illustrated in a recent study by grad student at MIT. The entire point of the concept of 'insurance' is to buy hedge against random events. A customer with a pre-existing condition buying health insurance is like a gambler who brings a loaded die to the craps table. The customer has insider knowledge on their condition which causes the market for insurance to break down. No insurer will cover a patient with a major pre-existing condition for the same reason that casinos don't let players use their own dice.)

We will start to see a rise in the number of uninsured Americans; they will be the sickest ones who are over the age of 65. These uninsured patients will still get treated in emergency rooms and in hospitals, because it is illegal to not do so (and because, well, most of us didn't go to medical school to let people die of treatable diseases on the hospital doorstep). The treatments will probably be more expensive, since the seniors without insurance will lack maintenance checkups and clinic visits. Their lack of insurance will give their medical problems the opportunity to fester and become more significant before they are finally addressed in the emergent setting. Providers still have to make ends meet, so to cover the costs of all of this free care to the uninsured, we'll just raise prices for everyone else (as we currently do). This will drive up the cost of health insurance even further, which will drive even more seniors from the pool of insured Americans.

Ever more Americans will find themselves in the ranks of the uninsured, avoiding routine visits and checkups for their major medical issues because they lack the insurance coverage - until the problems become life threatening, at which point they show up in the ER. To grasp where the problem lies, keep these numbers in mind: 5% of Americans consume 50% of its health care resources. 1% of Americans consume 30% of the resources. These are the patients who show up in the hospital with one foot in the grave, so to speak. They're the ones who spend weeks or more in the ICU, with dozens of tests and surgeries. If and when they recover, they end up at rehab for weeks if they're lucky, or at permanent facilities or nursing homes if they are not. These people will be cared for whether or not they have insurance.

The way to save health care dollars is not to make it unaffordable for patients to be followed and routinely managed, its to get them insurance so they don't show up in the ER after their problems have gotten out of hand. The way to save health resources is also to have patients meet with doctors before hand and discuss their long-term prognoses, what their treatment goals are, under which circumstances do they want medical interventions to be performed, et cetera. This is a whole separate topic but its something that I think about when I see uninsured patients come in and receive months of treatments that, honestly, they probably didn't even want but weren't conscious to tell us to not perform.

When I look at the end game of the Paul Ryan health plan, I can't help but see a death spiral of increasing costs, increasing numbers of uninsured, and worse outcomes. Paradoxically, if there was an individual mandate in place with a ban on discriminating based on pre-existing conditions, this cost spiral might be avoided (although many of the fundamental inefficiencies of the system would still remain to be addressed). I wonder if Paul Ryan realized the ACA might be overturned by the Supreme Court when he wrote this bill? The lack of a mandate makes this plan completely untenable. It is a cheap fix, not real reform, and it won't work.

Thursday, May 03, 2012

Futility of medical treatment.

Want to know why our health care system is so expensive?  Because we do all sorts of things that confer no benefits.  The second to last sentence says it all.  From the NEJM:

"The ethical question therefore shifts to waste avoidance. Even though the concept of medical futility has had a vexed history, this new ethical question is a subcategory of the futility debate. We used to think that the issue of futility arose only when physicians, in keeping with their professional integrity, refused to offer useless treatment even when patients or families demanded it. We now realize that futile interventions may be administered not solely because of patients' demands but also by physicians acting out of habit or financial self-interest or on the basis of flawed evidence. The ethics of waste avoidance is thus in part a component of the ethics of professionalism."

Friday, April 27, 2012

Ayn Rand, Paul Ryan, and conservatives' love for Atlas Shrugged

I read Atlas Shrugged a few years ago, in 2009. It had been recommended to me many times by my late grandfather, and was on my list anyway. I knew the book was considered a pillar of the modern conservative movement. With the Tea Party resurgence the nation was experiencing, I felt it was a perfect time to finally read the book. Of course, I loved the book as an entertaining piece of political fiction. To live in a world of absolutes, of ideological purity, refusal to compromise with liars and corrupt cowards and ultimately triumphing over them; Atlas Shrugged is satisfying.

Ever since reading Atlas Shrugged, there was one particular contradiction that I couldn't get over.  Its been in the back of my mind ever since. I suppose I never really brought it up because I didn't believe my observation would be acknowledged by its objects.  As it turns out, just this week, Paul Ryan, the budgetary guru of the Republican Party, nailed my contradiction square on the head:

“I reject her [Rand's] philosophy,” Ryan says firmly. “It’s an atheist philosophy. It reduces human interactions down to mere contracts and it is antithetical to my worldview. If somebody is going to try to paste a person’s view on epistemology to me, then give me Thomas Aquinas,” who believed that man needs divine help in the pursuit of knowledge. “Don’t give me Ayn Rand,” he says.

Bingo.  There is no question - Atlas Shrugged is, without a doubt, an extremely anti-Christian book. The protagonists don't explicitly declare that they are anti-Christian, but their philosophy is clearly anti-religion. They despise people who operate on anything other than reason, evidence, and logic. The protagonists despise those who lecture about charity, social responsibility, and living and working through others. They openly profess that their sole motivating force is greed and money, which is about as contrary to what Christ taught as anything could be.  Remember how much the protagonists hated Robin Hood?  Yet, who among us remembers Robin Hood to be a dastardly, despicable fellow?  Not me, anyway.

We live in a country where we have a Republican Party that is created somehow through the fusion of pure idolization of free market forces and the pursuit of one's selfish interests with Christian theology that is, in theory anyway, opposed to those things. Now of course, I recognize that part of this is a phenomenon of the whole political process of coalition building. Some Americans are motivated mainly by Christian instincts; the evangelicals who want abortion banned and gay marriage outlawed.  Other Americans are motivated by financial concerns, and want less taxes, less regulation, and smaller government. The two groups agree to form a coalition so they can both get some of what they want.  I get that the former don't have to share the latter's economic views and the latter group isn't necessarily religious.

Still, who could honestly look at today's Republican Party and say a huge percent, if not the outright majority of supporters, are not in fact adherents to both philosophies? Look no further than the Tea Party: radically Christianist, but also economically as Randian as one can claim to be. Its a total contradiction.  Read Atlas Shrugged and pay attention to what John Galt says.  The modern American politician that he describes with hatred more accurately than any other is, in fact, Sarah Palin.  And yet, the Tea Party, the most powerful force in the modern Republican Party, idolizes both Ayn Rand and Sarah Palin.  The two women philosophically despise one another! 

I'm glad Paul Ryan finally put this out there.  One has to wonder, when observing such widespread inconsistencies of has to question whether they are living in the twilight zone, or whether they are actually the one who is crazy and everyone else is sane.  Yep, its not me - it really is the Republican Party.  That's a relief.

Monday, April 02, 2012

Obama's foreign policy: an "astonishing failure", according to Mitt Romney

Mitt Romney called Obama's decision to remove US troops from Iraq "an astonishing failure". Almost a half-year after Barack Obama's reckless withdrawal from Iraq, that nation has descended into chaos and civil war.

Stupid Obama. He should have continued the US occupation for another few years - at least! - and not pulled out until he got permission from "the commanders on the ground".

Sunday, April 01, 2012

Wean yourself from consumerism

Can anyone think of the last time a "thing" made them anything more than transiently happier?

Yea, neither can I. Should be no big secret - buying stuff doesn't make people happier, except maybe in the very short term. Most Americans remain chained to a consumer-driven lifestyle anyway. While buying stuff doesn't make people permanently happier, it can definitely make them *unhappy* when they are in debt, stressed, and suddenly unable to make ends meet.

For anyone who wants a model to follow, this is the guy. I stumbled across his website the other day, and I absolutely love it. Read some of his older posts. He was living easily on $ 7,000 per year. It's an ideal to work towards.

Sunday, March 25, 2012

Are you human?

I ran into banking issues, so I decided to do an online chat. Didn't my helper seem to be just a little...robotic? I decided to test him/her/it.

The test was passed, but was it challenging enough? My thought is that a good test to see whether or not something is human is to probe for a sense of creativity or the ability to be illogical.

I'm still not completely convinced that Maya is human.

Monday, March 12, 2012

Enjoy your right to drive a car, part 2

I wrote a post two years ago where I predict that we will see manual driving of cars in our lifetimes be outlawed. One advantage of automated driving?

"No need to stop at red lights. Automated cars could perfectly time passage such that we travel through intersections seamlessly from all ways without slowing down. This might be a little harrowing at first, I'll admit."

Now you can watch a video representation of that prediction. It's kind of cool.

Sunday, March 11, 2012

America is not stealing the world's doctors

Response to a recent NYT column:

Forget concerns about brain drain; opening international borders to immigration and free movement of individuals is by far the best policy. Its hard for me to believe that dysfunctional nations are better off because their brightest talents are kept captive by political barriers. Certainly, the individuals themselves are worse off.

I happen to think the originating nations benefit in was that aren't appreciated, beyond simple remittances. Well-trained expats around the world can serve as a go-between between the local (originating) economy and the international economy. If anyone is poised to catalyze positive change in troubled nations, it would be these expats, who will be unique in understanding the local economy and the global system.

Another advantage of open borders: dysfunctional nations whose talented citizens consistently emigrate elsewhere have a very strong incentive to reform, do they not? If dysfunctional nations don't have to compete for talent just because it happens to be local, they are less likely to nurture it. Consider if top American researchers started emigrating to China: I bet you that the USA would jack up spending on R&D in response, to keep the talent here.

Ultimately, we should be less concerned with the success or failure of specific nation-states, and focus on what is best for humanity and the world as a whole. Humanity benefits when every individual is able to reach his or her full potential, period. Where that happens is less important than whether it happens. What if Einstein had been born in a nation with few opportunities for science or education? An even more troubling question: how many Einsteins has the world already missed out on?

For further reading, Tyler Cowen wrote this rebuttal to the piece that suggested that recruiting African workers should be a crime.

I guess this is another one for the "I told you so" file.

Maybe I'm jumping the gun. Approximately two years ago, I took stock of the Tea Party Revolution:

"I do not believe political gains made by [false intellectual pretenses] are sustainable. Republicans may have accomplished electoral victory this year but there will be a big question whether or not they accomplish legislative victory; the former is worth nothing without the latter. When you gain political momentum on false pretenses...for example, by lying about Obama and demonizing his intentions, you aren't winning an argument in the minds of the American people, you're just scaring them.

...Conservatives should be less short-sighted. The foundation of a strong conservative movement won't come from cheap sound bytes put forth by idiot news casters on Fox. They'll come from real thinkers who don't need to beat their political adversaries with lies - they can beat them with better ideas and stronger arguments. That was the movement that Buckley and Goldwater supposedly started and it lasted a generation. The movement of intellectual hacks like Palin and Gingrich will last two years. If that."

The conservative resurgence in 2010 was based on a large degree on generating emotional reactions by describing a simplistic view of complicated issues. Simplistic views, by definition, are extreme in that they do not appreciate nuance. This was successful in electoral terms, for sure (its easy to get people to the polls when you convince them that Obama is a radical socialist who is remaking America). It has been a disaster in legislative terms. Many republicans, who were elected as purists, have had no ability to appreciate the complexity of the serious issues this nation has faced. This has made it impossible for them to organize a coherent agenda and come up with bills that are sane enough that they can all agree on, much less get any Democratic support.

The Republican Party has not achieved one significant legislative victory since taking the House. They have not secured not a single compromise that advances their agenda; they have not cut spending a single iota. They have squandered their electoral mandate on useless fights over reproductive rights and settling political scores. To appeal to such a party that has become so detached from reality, their candidates for president are either insane or have had to become so extreme that they may be unelectable in a general (the rest didn't even bother running). Less and less we are hearing talk of the GOP taking the Senate and the White House, and more we are hearing about whether or not they will even hold onto the house.

America has serious issues facing it. This country cannot move forward without two functioning political parties. Until the GOP has members who understand the complex issues we face and are capable of compromise, the political system will remain gridlocked and real conservative change will remain elusive. I have argued before: in the absence of real reform, big government wins by default. The road to a single payer health care system - actual government run health care, will be paved with a lack of compromise.

Monday, March 05, 2012

Fantastic thread on predictions

On Marginal Revolution.

One of my favorite lines, for some reason:

"Kids are always at least one step ahead of their parents where technology is involved. Much in the way that banks are with regard to regulators."

Link here

Friday, March 02, 2012

America is getting punked by congress.

Mitt Romney wrote Obama in 2009 urging him to include an individual mandate??? Wait a minute. I've seen this before. This isn't real. This was a TV show starring Ashton Kutcher. Our government has to be pranking us. In my mind, this is more or less how the conversation went:

"OK guys here's the plan. Everyone just say really crazy things about Obama. At the same time, Mitt, make sure there is zero daylight between you and Obama on all political and social issues. You should routinely criticize the things that you have both done. The only difference between you and Obama is that you should be sure not to relate to people in a human way, and occasionally make comments that perfectly caricature what liberals think about rich people.

Mitt, when you run for president in 2012 the only people who will compete with you should be completely unelectable. I'm thinking we either go with people who would not be out of place in an asylum...Bachmann and Perry, I'm looking at you...or we dig up some has-been politicians from the 90's who left office defeated and in disgrace. Does anyone have Newt or Santorum's number?

Lets come up with plenty of slogans that don't really mean anything and that aren't internally coherent. Sarah, I love your "keep your government off of my medicare" and "death panel" bits, keep them up! While peddling those, we'll bring up issues that we have already argued about and solved in previous decades.

Liberal Americans will feel like they've entered the twilight zone. The narrative will be so convoluted that they won't even know where to begin. Conservative Americans will be found sobbing on the floor in the fetal position with Rush ranting in the background.

Right then, we all run out and yell "you got punked!" Then we pass the "We Sure Got You Good Act" which balances the budget next year, pays off the deficit in 5, includes the Iran peace treaty that we negotiated last year, funds entitlements, lowers taxes, implements effective financial regulation, simplifies the tax code, and expands military spending. Then we can adjourn for the rest of the year since there will be nothing else to do."

Thursday, March 01, 2012

No, employers cannot do whatever they want.

I've seen some attempts to defend the "right" of employers to infringe on the rights of their employees because those employees, after all, can quit and find a new job.

We have in fact already fought this battle, and it is already established that an employer cannot do whatever they want to their employees.

They can't pay women less.  They can't discriminate against minorities.  They cant sexually harass their employees.  They can't force them to work 100 hours per week or force them to go without lunch.

I could go on.  This fight has already been had.  It's unbelievable to me sometimes how much perspective and sense of history Americans can lack when having a political debate.

The end result is Americans completely lose the ability to approach things in a balanced way.  Nobody is going to make priests hand out condoms.  It doesn't follow that employers can do whatever they want.  Sheesh.

Sunday, February 26, 2012

Occupy The Middle Kingdom?

Income inequality isn't only a problem in America. I do believe that China's Gini coefficient (a measure of inequality) recently overtook the US. This will be tolerable to the legions of workers while China experiences the 10% growth that it currently enjoys. With a significant slowdown, it won't be tolerable.

Westerners tend to ascribe virtues of competence and wisdom to the Chinese government. If these leaders were wise, they would be starting to implement political reforms now. That way, pressure release valves are already in place when the system gets dealt a shock. Have they not been watching the news at all over the last year?

Monday, February 13, 2012

Would Republicans be OK with Sharia law being applied to Christians?

Interesting hypothetical:

"Suppose the Muslim owner of a large company that employs Muslims and non- Muslims (or even just Muslims) wants to be exempt from insuring medical stuff except in cases where male employees see male doctors and female employees see female doctors. The owner find it objectionable that 'his money' should pay for anything he finds religiously repugnant, and this is his take on sharia law. Would Republicans have any objection?"

Call me crazy, but something tells me that John Boehner wouldn't exactly be rallying people to support the religious freedom of the Muslim business owner here. Many more hypothetical scenarios here. Again...the real story is that health insurance has no business being tied to employment status. Especially not in the increasingly liquid labor market that we live in. The link causes economic problems, ethical problems, and political problems.

Saturday, February 11, 2012

Lessons from the contraception controversy.

1.  Nice to see the GOP so concerned with Catholic opinion (seriously).  I assume this means they agree that the death penalty should go and that we should extend unemployment benefits.

2.  The real story here is how ridiculous it is that health insurance is tied to our jobs.  Breaking that link will help with cost control, and will enhance labor market fluidity by encouraging riskier moves on the part of workers.  (Health insurance is an anchor keeping talented people at 'safe' jobs instead of going solo, with a new firm, etc.)

3.  Obama is unwise for picking a fight with the Catholic Church.  He thinks Republicans are stubborn?  It took the church 360 years to exonerate Galileo.

4.  Catholics themselves need to be more active participants in their church's theology.  Family planning is smart, not sinful.  It reduces abortions.  It results in healthier families and societies.  Condoms can prevent disease, reducing the health care burden and suffering.  The Catholic Church needs to have a new council to address these issues for the 21st century.  Their flock, but not the government, should be pushing for that.

5.  Mitt Romney enacted similar regulations in Massachusetts as governor.  Enjoy your nominee, Republican Party.  You could have had Jon Huntsman but nope he wasn't crazy enough for you.  Now you get Obama until 2016.

Wednesday, February 08, 2012

Questions for Catholic Bishops re: health insurance coverage

The Bishops believe that Catholic insurance should not cover contraceptives, because they do not want to encourage what they say is sinful behavior.  There are many other situations where the church would be encouraging vice by paying for medical treatment.  I would be curious to know where the church would come down on a few of these issues:

1.  Sexually-transmitted diseases are a consequence of promiscuous sex.  If the church treats such conditions, people do not live with the consequences of sinful behavior.  This is clear moral hazard which will encourage more vice.  However, if left untreated, STDs can be rapidly fatal, hurt unsuspecting spouses in cases of infidelity, cause birth defects and stillbirth of fetuses, and increase the risk of pregnancy.

2.  On one hand, the Gardasil vaccine gives our daughters carte blanche to have lots of promiscuous, unprotected sex.  On the other hand, it is a simple vaccine that prevents cancer.  Its easy to see where the controversy comes from.  Reducing the risk of a behavior will certainly encourage said behavior.

3.  What to do in cases of cervical cancer caused by HPV?  If we treat our daughters every time they develop cancer after having unprotected sex, aren't we just encouraging their sinful behavior?
4.  Gluttony is a grievous sin.  However, bariatric surgical procedures have been shown to be cost effective at increasing the health and quality of life in morbidly obese people.  Should the church be forced to encourage gluttony?

5.  Type II diabetes is, like obesity, very often caused by excess consumption.  Should the church be forced to cover the costs of medications that control the disease, hence promoting sinful behavior?

6.  Many people who smoke will develop lung cancer.  For Catholic insurance to pay for treatment would clearly violate the teachings of the bible; see Corinthians:19-20

"Don’t you realize that your body is the temple of the Holy Spirit, who lives in you and was given to you by God? You do not belong to yourself, for God bought you with a high price. So you must honor God with your body."

7.  If a person develops a parasite or neurocysticercosis after eating Biblically-forbidden pork products, obviously the church would violate their principles if they paid for treatment.

Tuesday, February 07, 2012

Why haven't aliens contacted us?

Some people believe that the lack of outside contact is evidence that complex life does not exist in the universe.  As the idea goes, we know that simple life is easy to create (from our own experience).  Yet, complex life defined as a civilization at or beyond our level apparently does not exist.  If they did, presumably there would be a lot of them, and we would find evidence of them in the frequencies of the cosmos.  So some people believe life is easy to start but hard / impossible to develop beyond a stage where we are, the conclusion being something snuffs out the civilization when it is about our age.  Maybe nuclear weapons are to blame.

There is a tribe deep in the Amazon jungle in Brazil that has never had contact with humans from the outside.  The Brazilian government is actively protecting them from outsiders who are trying to contact them, in fact. If anyone is curious why we haven't been contacted - this is my theory why:  we are the equivalent to the uncontacted Brazilian tribe.  There probably are millions of intelligent civilizations, and maybe even the supreme among them are protecting our planet from outside signals from others who would interfere.  In their mind, we should make our own way.  If we succeed then we can join the league of universal civilizations.  If we destroy ourselves in the interim, then we weren't a worthy species.

I think Bill Watterson's theory is good too: