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Mail 585 September 24 - 30, 2009

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Highlights this week:

Some health care views
Letter from England
Burnham: The Machiavellians
on the costs of French health care
China, Solar Power, and investment controls
Some new views on health care
Brain Drain?
Health care and primary physicians
Health Care in Uganda: what if you aren't a wealthy nation?
SAT scores and No Child Left Behind
The US Debt Clock
The Dragon's Egg deployed
Notes on DRM and ebooks
Old fashioned health care vs. insurance
Health care reform as a jobs program

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Monday August 24, 2009

Hi Jerry,

I reject implicitly that anyone is entitled to healthcare, because it has to be paid for, which means I have to pay for it. Charity is charity, and should be distributed through individuals voluntarily, not through taxes at the point of a gun. Much like the 'mandatory' volunteer hours now required to graduate from high-school, a label doesn't change the fact that enforced labor, or the confiscation of the products of labor is morally wrong.

Why should Colorado, the thinnest state in the Union, subsidize Mississippi, the fattest, for their unhealthy lifestyle? That's a somewhat rhetorical question: National Healthcare will exactly allow that regulation to take place (well, perhaps not if there's an ethnic component to it, but I digress). If someone wants to eat themselves to death, that's not my problem, nor should it be. That's a fundamental philosophical difference between socialists/liberals and conservatives/libertarians.

So what's my answer? Simple, make health insurance, insurance again. Here's the simple, easy, quick steps:

1) Transfer the tax deduction for health insurance premiums from businesses to individuals. Result: Decouple insurance from employment. Optional: Raise the tax deduction on medical expenses to 50% (versus your actual tax rate) to make it more progressive and gain moderate Democrat support.

2) Limit pre-existing conditions to a 3 year exclusion. Anything that's been inactive for 3 years doesn't count. Again, make it like car insurance (tickets fall off after 3 years). Yes, that means that folks with chronic conditions will pay more for insurance. But this is a country of equal creation, not equal outcome. And see #6 below.

3) Eliminate government mandates from what insurance policies must include. When I was 29, I tried to purchase a $5000 annual deductible, fee-for-service, major medical plan. That was illegal under Colorado law. The policy I ended up buying cost me $2-3K /year more than the high-deductible version available in other states. Which leads to....

4) Allow insurance to be purchased across state lines (helps with #3, and creates more competition). Let me choose what coverage to buy.

5) Eliminate the HMO and $5 copay concept. Return to annual deductibles. If it costs $60-70 to see your doc, then you're not going to go in for every little thing. If you have to pay $20-40 for a prescription, then you won't take antibiotics for viral infections. Some numbers: If there's 150 million people in the country, and everyone had to pay the first $1000 themselves, that's $100-150 billion in annual savings to insurance payments, which would *dramatically* reduce the cost of insurance, since many folks spend under that total amount annually on healthcare. Optional: Ban television and radio advertising for drugs (reduces demand for unnecessary medications).

6) Create a special 50% tax deduction (versus your actual tax rate) on donations to accredited funds that pay for healthcare for those who truly can't (not won't, or choose not to) afford it. Make charity voluntary again. Ideally those funds would be managed through local churches.

7) Tort reform. Reduce medical costs by reducing litigation costs - especially for drugs. Cap pain-and-suffering damages (no limit on actual damages). Eliminate punitive damages, or better yet, have 100% of them paid into the funds in #6, with no attorney fees allowed. Restrict the portion of proceeds from class-action lawsuits that go to the attorneys to 20% of actual damages awarded. Institute loser pays.

8) If people don't want insurance, then they don't have to buy it. Universal coverage is a smokescreen to extract money from the young and healthy (who often don't buy insurance). I'd argue though, that if the above points are enacted, a major medical policy ($10-20K deduction) would be so cheap that most folks would buy one to insure against those very rare major events.

So the solution is simple: Competition. Individual Responsibility. Charity.

Regards,

Doug

Jerry,

Some musings on health care. Not sure where to go with these, but...

1. Employer-paid health care currently serves two purposes: it provides current health care cost, and it acts as a term insurance for catastrophic health care expenses during the term of employment. One of the biggest issues with the current system is the term nature of employer-provided catastrophic care insurance. This is, a course, a consequence of FDR's depression - level interferences with the economy. But the key point here is that I think the solution may rest in recognizing that the employer-paid system is a variation of term insurance and approach private-sector health care reform on that basis.

2. As with Social Security, Medicare is viewed by the millions of workers who have contributed as an investment in a long-term health insurance program, payable after age 65. Unfortunately, the government has NOT invested it or managed it as an insurance program, but as a recompense for current expenditures. The greatest concern that millions of retirees have with the HR 3200 version of the "health care reform" or "health insurance reform" is that it will eliminate that perspective of Medicare as long-term health insurance and cost them the level of medical coverage they have come to expect.

3. In one of your comments you noted that "saving money in the last six months of life" means that once that decision is made, it is assured that the period in question will be the last six months of life. The relevant metric which should be uncovered and discussed is thus: How long do most individuals with chronic illnesses live AFTER the first time they reach the point of, "without treatment, you only have six months to live" given access to start of the art, top-line treatment? Based on my own, anecdotal evidence, there are millions of individuals, probably a vast majority, who today survive for years to decades past the point of that first brush with death. Under the British system, the anecdotal evidence offered by the opponents of the Administration / Congressional proposals suggests that only a negligible fraction survive that first brush with death. That is the difference that needs to be quantified.

4. Regarding coverage of pre-existing conditions, under a free-market system it can be mandated to provide coverage when moving from coverage under a term health insurance program to a new term health insurance program.

5. As you know, I have some weight issues (OK, "morbidly obese is an understatement" covers the situation adequately), with consequent complications. I don't know that I would have been scared into taking better care of myself if I didn't have employer-covered health payments and had to bear the health expenses, but it certainly would have been a positive, market-based motivator (particularly when my prescriptions reached $225 per month for diabetes and blood pressure medicine, not counting other conditions which may or may not be related). But my out-of-pocket expenses for those medications are effectively zero under my current health care plan (net of short-term cash flow from copayments and recompensation programs). But conversely, if my employer paid me directly what they current pay in health insurance costs and I covered by own expenses out of pocket with 100% deduction for medical expenses, and carried a private catastrophic care policy at about a third of that rate, I'd likely still come out ahead...

6. One inequity I see in the current system is that health insurance companies pay negotiated reduced rates -- while forcing increased overhead -- on doctors, and Medicare and Medicaid are even worse (increased overhead and decreasing compensation levels). I don't think it's fair that the no-overhead cash customer is required to pay more. But that's the way it is...

7. And as regards the current Administration, the companies that are backing them on health care (such as GE) anticipate large federal contracts for medical records reform (and GE is using its media arms NBC and MSNBC to promote health care reform, a clear conflict of interest).

Some thoughts on what I would see for the future.

1. Medicare is a contract with a two generations of Americans to pay after-retirement medical expenses. The Government cannot change that contract in good faith. (Of course, the current Administration has brought the same bad faith to our foreign relations, so...)

2. "Free market competition is better than regulation." Thanks to Wayne Rogers, who just said that in those words on Fox News while I'm typing. Someone else on Fox a little while ago pointed out that Medicine remains one of our big export markets, and health care reform would undoubtedly make that go away as well.

3. Transportable catastrophic-care health insurance, both term and life -- is a necessity. Individuals should be able to own insurance and deduct the cost of insurance and of medical care without discount -- the inequity that companies can deduct health care expenses at 100% while their employees have a massive deduction first is unacceptable.

4. Some records reform is essential. Government control of a lifetime of medical records for all citizens isn't. Record maintenance should be in the care of the primary care physician with safe backups managed locally and regionally, perhaps with government subsidy but without a centralized national repository, and under password control by the primary care physician.

5. Claims reform; a universal claims form would greatly simplify paperwork.

6. The government should subsidize various forms of indigent medical care -- free clinics, tax refunds for private physicians, etc. But persons receiving such care must be required to sign a pauper's oath which among other things prohibits voting for some period while receiving government subsidy.

That's probably grist enough for the mill for now, and I have other errands ("and miles to go..."

Anon

=========

Letter from England

This week: education and the decision to release the Lockerbie Bomber.

Education

Like so many other aspects of UK culture, the educational system just happened. It currently consists of six parts: primary education, secondary education, sixth form, university, masters programmes, and doctoral programmes. Primary and secondary education are similar to what people are used to in America, ending at age 16 with GCSEs (final

exams) in a multitude of subjects. Students planning to go on to university enter a sixth form programme, consisting of two years of specialising in two or three subjects. Their exam marks in those subjects are called 'A-levels' and determine whether and where they are accepted into a university course. (The public and grammar schools have always gamed this system, and dominate entry into the good universities more than would be expected based on the raw talent and hard work of their students.) A university course is usually taught in

*one* subject--none of this nonsense about electives or breadth requirements--by *subject specialists*--again none of this nonsense about interdisciplinary studies--and leads to a final year project that has a great deal of influence on the degree classification (first, upper second, lower second, or third). In the sciences and technical subjects, most projects seem now to be 'library projects', where the student researches and writes up a problem, very much like a traditional humanities project. The reason for this may be that the lab facilities are so expensive, and the legal restrictions on access and ethical approval are so onerous that many universities find they cannot afford anything more. The degree is then given a classification--sometimes only weakly related to the student's actual performance--that is commonly used in hiring and promotion decisions.

Until recent years, the masters was the professional degree and the doctorate the university teaching credential, but with the Bologna Accord, a two-year masters is supposed to be the preliminary to a three-year doctorate. This has not happened in the UK--a UK masters is currently a slightly-more-than-a-year course with a taught element and a project. (I suspect it brings the student up to the level of a graduating US/Canadian college senior.) The doctorate is a three-year research degree that *may* be preceded with a masters degree. Students prefer to go directly into doctoral studies without doing a masters, so, considering everything, your average UK lecturer may have the equivalent of a strong US/Canadian masters, having been exposed to less teaching than a graduating US/Canadian senior.

University teaching seems to be affected by this--undergraduates appear to regress developmentally during their three years at university. They enter ready to take control of their education and graduate having lost initiative and educational maturity. (This may be because they have more choice and better teaching in the sixth form college than in university.)

Why does it work this way? We're talking about UK domestic power base realities here. UK politicians are amateurs who have been described as having difficulty managing a whelk stall, so their leadership style involves keeping people off-balance, back-office deals, and fixes, with a focus on short-term solutions and immediate gratification.

Ministers make twice as much as MPs, so they have a vested interest in not rocking the boat, and many Prime Ministers keep them from developing any expertise, having them move around every year or so.

Labour appears to view university education as a middle-class jobs programme. Hence this week's stories: Students now realising places are tight <http://tinyurl.com/l7u5jy> <http://tinyurl.com/lk3drv> <http://tinyurl.com/nozspt >. It ended up with 147,000 students--almost all from state schools-- in competition for 24,000 places.

"Compassionate release" for Megrahi, the Lockerbie Bomber.

The consensus in the press is that the release was driven by diplomatic expediency and oil interests. There is also a suspicion of a coverup. <http://tinyurl.com/kwgp5h> <http://tinyurl.com/n6mpcr> <http://tinyurl.com/klhheq >

Harry Erwin, PhD

"Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety." (Benjamin Franklin, 1755)

UK Rebuttals to Defence of the NHS

There were some intelligent rebuttals to last weeks defence of the NHS: <http://tinyurl.com/lf2r6c> <http://tinyurl.com/mnfggn> <http://tinyurl.com/n3yqwu >

Problems with Labour management of the Ministry of Defence. <http://tinyurl.com/n3cp2z > <http://tinyurl.com/lcylyr>

Oxford downgrading private pupils to ensure at least a few state pupils are accepted. <http://tinyurl.com/n55f3w>

Science tsar criticises GCSEs for failing to stretch pupils. <http://tinyurl.com/kuykvd >

Children's care crisis triggered by vetting process <http://tinyurl.com/n9cyqc >

-- "If they do that with marks and grades, should they be trusted with experimental data?" Harry Erwin, PhD

============

End of life care -

My mother died three years ago. This week is the anniversary of the first surgery done at the Oregon University Hospital in Portland. My mother realized soon after that she would just be delaying the inevitable at the cost of a lot of pain and chose to have no more surgery. Instead of one or two difficult years she rapidly passed into the final stages of her cancer. Her children knew before the surgery that her kind of cancer had terrible numbers. Basically, she needed to be diagnosed before she ever had a symptom to have a hope of effective treatment.

We had to fight to get what we felt was appropriate palliative care. This in a state that would have allowed her to take a lethal dose of drugs had she enough time to jump through the hoops. Knowing my mother, she would not have made that choice, though.

6 months earlier my friend's grandmother, who raised her, died slowly of kidney failure. She would not have qualified for a transplant and chose not to prolong things with an increasingly ineffective dialysis treatment.

For this email I want to focus only on two of the many grists for my mill that year.

1. Both women got to choose.

2. Both realized that there was only painful prolonging, no healing, in further treatment.

3. Both had difficult experiences with end of life care. My friend was able to manage in-home hospice with visits a couple times a week from nurses. But she could manage all the physical needs and keep her grandmother reasonably comfortable.

My mother was not conscious enough, nor had a good swallow reflex to take pain pills but we were still severely pressured to take her out of the hospital. (My father's insurance coverages were enough to pay all the bills without him having to pay at all. An unusual situation but best possible.)

Just moving her in the bed caused her hideous pain, we were NOT moving her from hospital to hospice or home. We had to present a very solid front and chase away people who would move her in her last week to take tests that would tell nothing we didn't already know...that she would die within a few days. (Some of those tests not taken were on the bill.) We were not taking a bed needed by another, There were a several empty rooms on the cancer floor.

Still we had to fight off those wanting to send her to what looked like a warehouse to die in. Minimal care and unable to rescind the choice.

We don't regret keeping her in hospital. We were grateful that the insurance was good enough to have the choice.

After seeing the horror stories that "house" elderly and infirm people who don't have the money to buy better, I fear for the helpless even if they accept that their age and/or sickness shouldn't be treated. They DO need to be treated with dignity and given care appropriate to their situation.

Who decides? What can they, (we,) expect?

A case study, not uncommon.

Health care and insurance

Jerry,

One point that never seems to get made is that *everyone* in the US can get free health care. Just show up at an emergency room. Bingo - free health care. And its that simple if you're poor.

The real issue is the working uninsured middle class. We'll give them health care, but we'll also take their assets in return. I knew a coworker that needed a bone marrow transplant, a $250,000+ procedure 10 years ago. He didn't have any insurance or money and Stanford Hospital did it for no further charge after he'd sold his $3000 worth of possessions and gave them the money.

I don't know what you do with the people who would rather spend $400 a month making payments on their BMW lease than on health insurance. That seems to be a big part of the problem.

What you do is require them to pay premiums or tax them. The real question is do all pay the same premiums? Do we give a discount for not being morbidly obese? Do we charge extra for smokers? Drinkers? Do your premiums go up when you get a DUI?

Universal Health care

Hi Jerry,

I still wonder if creating a federal option: co-op, expanded Medicare, a VA like system anyone can buy into, will actually increase the overall consumption and cost of health care.

I'm sure that there will be individual cases (and many of them) where someone will demand care that they might not otherwise have gotten.

Yet somehow, virtually ALL of the other industrialized nations have managed to provide one form or another of universal care, while spending far LESS of their GDP on that care. And as has been repeatedly mentioned, they also seem to get far more for their money: lower infant mortality, longer average life, etc.

If they are rationing care (and logically they must somewhat), they have arrived at a formula that their population accepts.

Is our society somehow so different we can't do the same?

best wishes, Jim

The question is, how well are the others doing? Of the lot, I have heard more positive endorsements of the French system than any other. Perhaps it ought to be studied. But we still have a fundamental question: why does one person have an obligation to pay for the healthcare of some other person? That is, the "right" to have one's health care paid for is actually an obligation on someone else to pay the taxes or increased premiums or fees or whatever one chooses to call them. How does that obligation come about? Is each of us obliged to pay for the health care of illegal aliens (for we certainly are in that we pay for emergency rooms). These are hard questions and seldom answered.

Health Care Decision Making or Decision Making of any kind for that matter.

Jerry,

It would seem obvious that in a Free Society it is the responsibility of each Citizen to take responsibility for making the decision regarding his own life and his exit therefrom.

Responsibility, there's the rub! Our Government nannies have spent a great deal of time and effort removing that responsibility from us. We are no longer responsible for the consequences of our actions and we must be protected against ourselves at all costs!

If we want to avoid having some Government "Death Panel" making our end of life decisions for us we must first take back responsibility for the consequences of our actions!

Bob Holmes

===========

Dear Dr. Pournelle,

I love the Chaos Manor. I have been in the United States for 3 years now, as a Ph.D student in economics at George Mason and in strategic studies at Johns Hopkins. I would love to become a citizen but I can't join the military or such without a green card. It seems only marrying will allow it.

I grew up in the highly regulated, prosperous, (traditionally) homogeneous society of The Netherlands and discovered classical liberalism at an early age. I believed the cultural core of individual responsibility and constitutional liberty was still strong in the US, so I came over here. I believe eventually it will not the argument for wealth that will be the strongest argument for liberty, but freedom from the all-encompassing government bureaucrats and regulators micromanaging our lives and deaths, turning us into coddled cogs in a giant politically-correct machine. I've been there, and the US was a blizzard of fresh air for me. Imagine that; I live in DC and have hardly been to the countryside. Unfortunately, I believe it will be only a small group that will prefer independence from government despite it making them materially worse off (there will hardly any profitable free market left).

I found Burnham's Machiavellians online here http://committeeofpublicsafety.files.
wordpress.com/2009/05/themachiavellians.pdf , and a blogpost about it here: http://committeeofpublicsafety.wordpress.com/
2009/05/01/the-machiavellians-principle-i/

Best regards,

Ralph

Thanks. Fair warning, it's a big file and takes a long time to download.

=============

French Health Care

Dear Dr. Pournelle,

In Monday's Mail you responded "Of the lot, I have heard more positive endorsements of the French system than any other. Perhaps it ought to be studied." They may in fact have the best system by current standards but it is system that is 12 to 14 billion dollars in debt every year. (source: http://www.cbsnews.com/stories/
2008/10/26/sunday/main4546041.shtml )

The population of France in 2008 was approximately 64 million persons. The population of The United States of America in 2008 was approximately 304 million persons. If we adopted the French system would we also be adopting a debt of 50-60 billion dollars per year just on health care? Would we be able run a health care system for less than the cost of the French system? Bear in mind, French doctors are paid a tiny fraction of their U.S. counterpart's income. Also, the French have the highest tax burden in Europe (43.3% of GDP) and still the health care system runs a deficit.

Just a few talking points for the Health Care debate.

-J.R. in CT

================d

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CURRENT VIEW Monday

This week:

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Tuesday, August 25, 2009

China solar

Jerry: China continues to play the long game, while the US fixates on the 'fad du jour'. The US is becoming (has become?) a client state.

http://www.nytimes.com/2009/08/25/
business/energy-environment/25solar.html?em

Chris C

The principal criticism of capitalism and a market economy is that the quarterly profit report is more important than any kind of long term investment strategy. Socialism is said to be the remedy for that. Sometimes perhaps it is, but the Soviet Five Year Plans did not confirm that hypothesis. On the other hand, government are the only institutions that are supposed to be concerned about our grandchildren. The balance between government control of investments for long term consequences and private control by those who can be sued over fiduciary responsibility is a subject not often discussed. Liberals are generally certain that government bureaucracies should have a larger role. Libertarians are convinced that government always screws things up and everything ought to be left to the market.

Examples of the failure of the market are all around us today; examples of its success are the comparison of the West to the USSR over the lifetime of the USSR, or East to West Germany. Some people could profit from increased solar power; but my friend Ed Begley Jr. is only now saving as much from his solar installation as he would be getting from the interest on what it cost to install it. The Chinese have better investment information than I do. They have a powerful incentive to keep the economy booming: the Chinese regime is no longer ideologically Communist, and most closely resembles state capitalist Fascism as anything else. They have not always made the right bets.

On the subject of government planning:

deflighted

For your further amusement:

"John Pojman, a chemistry professor at Louisiana State University, is looking forward to quick progress [on private space flights] on his research into fluid dynamics - specifically, how fluids of different densities mix under various conditions. Years ago, Pojman was in line to have one of his experiments flown on the space station. "We passed our scientific review, we were in design mode, and then after the Columbia [disintegrated in 2003], we were 'deflighted,'" he recalled. NASA's managers eventually jury-rigged an experiment that involved injecting a squirt of Russian honey into water recovered from the station's urine collection system. Pojman said it took 900 e-mails and numerous teleconferences over the course of six months to work out the details. "The astronauts were great, but that was a lot of trouble for something that I think should have been easier to get approval for," he said."

http://cosmiclog.msnbc.msn.com/archive/2009/08/21/2042881.aspx

Which, perhaps, brings us to the subject of government control of health care:

============

Subject: The Atlantic Healthcare article.

http://www.theatlantic.com/doc/200909/health-care

David Goldhill's article in the Atlantic is one of the thoughtful proposals on healthcare I have read lately. I've clipped a few key bits below.

Brian R.

Definitely worth reading; I have to read it in more detail. As a general principle I am in favor of universal high deductible catastrophic insurance, but I am not equipped to determine the costs with any accuracy. Predictions of cost seem to be dependent on the inclinations of the predictor. Those in favor of a plan seem addicted to low cost predictions.

[Later: I am inclined to agree with Brian, this is one of the best articles I have ever read on the subject.]

Re. "End of life expense"

Dear Jerry:

At the time of my retirement I had spent a total of 21 years in the Health Care Industry - nineteen of those years as the Accountant and Chief Fiscal Officer of a 176 bed Skilled Nursing Facility. A couple points that someone else may have touched upon:

1) Medicare Part A no longer reimburses expense per se, but rather is now a fee for service program. The program sets a dollar amount that they are willing to pay for a procedure or particular diagnosis and that is it. It does not matter what it actually costs a facility or a physician to provide the service, all they will ever recoup is the amount arbitrarily set by the program.

2) Both Medicare and Medicaid employ something called "The lower of cost or charges." In essence what this says is if you do not charge the the full cost of providing a medical product or service, the program will only pay the amount you billed. Sounds reasonable, but here is how it works in real life.

If a hospital or nursing home buys a catheterization kit, it costs less than $2.00 (It was $1.14 at the time I retired and I assume it has gone up since.) In this example, the maximum that Medicare would pay is the $2.00 cost. But if the very same company that willingly sells kits to hospitals for $2.00 instead bills Medicare Part B directly and provides the kit to the facility "free of charge," the manufacturer can bill the program a "retail price" in the neighborhood of $15.00, collect 80% of that amount from Medicare and technically bill the patient or his insurance for the remaining 20%. Folks might like to keep this in mind the next time they see an advertisement for "Diabetic supplies delivered directly to your door," or one of those electric wheelchairs. ...By the way, it is all perfectly legal. When I gave my Congressman the actual figures a few years back, he wrote to HEW and was promptly put in his place by one of the most condescending letters I have ever seen. Proving one more time that it does not pay to threaten someone's rice bowl.

Very truly yours,

Paul Bloom

Cost controls are never safe from system gamers. The market tends to correct those, but bureaucracies grow them, alas.

Health care and insurance

Jerry,

One point that never seems to get made is that *everyone* in the US can get free health care. Just show up at an emergency room. Bingo - free health care. And its that simple if you're poor.

I don't know what you do with the people who would rather spend $400 a month making payments on their BMW lease than on health insurance. That seems to be a big part of the problem.

health care

Hello Jerry,

"The second major question is whether everyone is entitled to equal health care: that is, should the wealthy be prohibited from buying something that others can't afford."

That is what we have in Canada. Believe me, you don't want that. Up here it is illegal to pay with your after tax dollars for a procedure that will ease pain and suffering. That includes things like MRIs, PET scans orthopedic surgery (which has a wait list of around 9 months, if you are lucky) and so on. It is illegal for doctors, nurses and other professionals to provide these services to Canadians unless it is paid for by the government. However it is perfectly legal for them to take money for these services if it is for Americans who come north. The money to open an operating room or a diagnostic machine is quite welcome at a border hospital just south of Vancouver. Neat eh?

We must keep in mind what illegal means. It means that the state can incarcerate you or seize your possessions (fines) if you do what they don't want you to do. That is the big stick and it is not to taken lightly.

I could go on..

Cheers,

Peter

The problem is that equality demands restrictions on what the rich can do. Why should you be able to get a bypass while I have to wait? Etc.

The Democrat's Health Care Perfect Storm

Jerry,

Democratic problem with Health Care Reform is that the party overall has devoted more than 30 years of effort into making single-payer a reality in terms of study, think-tanks, candidate development, etc.

I.e., the Democratic party overall simply cannot back away single payer, however much individual candidates, even most of them, might want to.

I saw early signs of this when then Sec of Defense Les Aspin went to hire Democratic party affiliated staffers and policy wonks in 1992 for the Clinton Defense Department.

Aspin found an utter lack of young, smart, & flexible minds to fill those positions. He was left hiring Carter Administration re-treads, and his House committee staffers, for those slots because all the best Democratic Party minds had gone into health care issue related think tanks or policy positions during the 12 years of Reagan-Bush41.

The last of the real hawkish Democrats went down in the 1982-1984 Nuclear Freeze movement. After that, they all either retired; became defense contractor lobbyists & retired; or became Republicans. Sen. Sam Nunn's vote on the 1991 Gulf War killed the last of that senior policymaker rear guard in the Democratic Party and Aspin's hiring effort gave them their retirement pensions.

The Democrats have invested too much into single-payer for them to abandon it. This is a party self-identification issue.

In terms of political effects, though, it's their tar baby. They can't let go of it and will keep pushing it long after it is politically hopeless. Plus their continued pushing of it will remind senior voters with money that the Democrats threaten the seniors' survival interests.

It looks like a perfect storm, politically, because the people who the Democrats have infuriated with the threat of single payer healthcare destroying private medical insurance have both money and options.

They have had good private insurance medical care their whole lives *and* they also have the resources to sue private insurers for cause and win.

They can't do that with the Federal government. For them, government universal healthcare represents a clear and present danger to their survival and their quality of life.

IMO, the politics of this plays out as follows:

1) The people (Leftists & Democrats) who want single payer want to see it kill private medical insurance inside their political life time AKA less than 10 years. They know if they don't get it right now, they never will.

2) Because of #1, the people who want single payer have succeeded in making this a survival issue for a lot of elderly people with disposable income (primarily Boomers) who now think being politically active is the only option they have to survive for the next 10-15 years.

3) Because of #2, there will be a lot of conservative political entrepreneurs who will be primarily Republican (They don't face Democratic pro-single payer primary voters) tapping that mass of people outside either the Republican or Democratic partisan machines to get elected or push causes important to these people.

4) As a result of #3, right wing populism will have a decade and a half of party independent seven figure plus funding for issues and candidates everywhere that caters to the interests of these newly activated political networks.

The point to watch here is that the fuss is originating outside the GOP, and particularly among people who previously had not been politically active. This presents an opportunity for some of the younger GOP elected officials to get in front of the wave here, put into words what is in the hearts and minds of the newly politically aware/active, and ride it into the White House.

The Left will never get past this, IMO. The Democrats will, but that will take at least a generation, and possibly two generations, at which point the country's demographics will have changed so much as to possibly defuse the issue, i.e., after all the Boomers die.

High marginal tax rates, high property taxes and government health care competing with private health insurance are going to be these newly active political activists boogiemen.

It is difficult to imagine a better wedge issue to divide the Democratic party from elderly voters.

It will be interesting to see which wing of the Democratic Party survives this fight. Thanks. Clinton, once single payer health care was off the table, became a New Democrat and governed on the platform he ran under, winning a second term even during a Republican resurgence.

=========

U.S. companies detaching from the U.S.

http://slashdot.org/story/09/08/22/
1825208/IBM-Other-Multinationals-
Detaching-From-the-US?from=rss

I do not like this one - IBM and other big U.S. companies are moving their research centers to other countries. It really is a simple matter. Governments in other countries aren't telling the companies how to run their companies. The companies can hire PhD's from anywhere in the world and set them at a desk in Canada or India. They cannot do that in the U.S. because the U.S. won't grant the person a visa. Some people - including the current American President - call these moves "greedy." Imagine, the company doing what will make money. Imagine, the company bringing together the best minds from across the globe into a research center (that is less often in the U.S. and more often somewhere else). Are these foreign PhDs taking jobs away from Americans? Are these foreign PhDs adding jobs to America? Someone has to cut the grass and maintain the air conditioner at the research center and sell houses and cars to people who work there. America is experiencing a brain drain. Much of it due to well meaning but misguided people in our government.

-- Dwayne Phillips - - -

We're from the government and we are here to help you.

==========

Regarding Ebooks

Just one thought to consider....

For myself, and I suspect a good many others, the forays into sci-fi novels was greatly enhanced during the (impressionable) years ranging from high school to just out of college by trips to used book stores. Let's face it -- when you're young, money is typically in short supply.

What will the ebook version of a used book store be like?

Karl

A very good question, and one I had not thought of. Eric Flint of Baen has the view that ebooks sell books. He has evidence. The question is how long that will last: or will people get out of the habit of reading printed books? And I just don't know.

============

the issues of a primary care doctor

http://www.cnn.com/2009/HEALTH/
08/25/harris.primary.care.doctor/index.html

.brian

-- Brian Bilbrey

"I don't like country music, but I don't mean to denigrate those who do. And, for the people who like country music, denigrate means 'put down'." -- Bob Newhart

The long term solution might be free medical school for qualified persons who want to become primary care physicians. That wouldn't be as costly as many things proposed and has the great merit of increasing supply.

Many who might want to become family doctors wouldn't want to do so if it meant an enormous lifetime debt as well as many years of study.

===========

Nursing Homes and mental health institutions

Jerry,

Still on the subject of Health Care�although I know you are winding it down. It occurs to me that nursing homes are going to be a big factor for those unable to care for themselves. Those that can afford the more expensive homes currently have a better life, whether it is waning years or they are in some way an invalid. There�s a whole can of worms that are opened here for the haves and have nots�I suspect Hollywood and Government elite will have the finest care, while the rest of us take what�s left.

Another issue is mental health. The US has pretty good care, and for those that can�t normally be in society, there are facilities that can at least maintain a semblance of life, though not the best. My wife worked in an Alzheimer�s care unit for several years�she�s a very compassionate person, but I visited one day and still have problems thinking of it. My mother�s life ended with Alzheimer�s, and I thank the Lord there were people to care for her, because I could not.

I�m also reminded of trips I took to third world countries that had very limited mental health care. Uganda is one I think of the most. There was a man who would walk through the middle of rush hour traffic every day (rush hour traffic in Kampala can�t be described, it must be experienced�it is absolute madness) dancing and yelling�.he�d been doing it long enough that everyone pretty much ignored him�but clearly his safety and all those around him was at risk, and he needed some place to be helped. There were no facilities such as we have here, and no money to pay for them.

Uganda has a national health care system�and I was deeply involved in facets of it deploying computer systems throughout their hospitals and clinics. Not only was care limited, but most people came from outlying villages, sometimes taking days to get there, waited to see a doctor sometimes for days, and then were prescribed medications that the pharmacy probably didn�t have, meaning they had to go out on the black market for them. I was in the pharmacy in the largest hospital, the National Medical Center in Kampala, which saw hundreds of patients every day�.the pharmacist had about 30 bottles of pills and elixirs he could dispense�so typical he gave each patient one or two pills or a spoon of something, and they had to come back the next day. Or�they could go to another wing of the same hospital, pay for their care and the drugs, and walk out with them.

I remember walking through the pre-natal care section�seeing about 300 women on benches waiting to see the doctor. Each time someone was let in, they slid down one on the backless hard benches, giving an effect like a caterpillar. Where the benches overflowed, women were sitting on blankets along the walls and out the doors.

People in the hospital are not provided linen or food�family members must bring them. Every day the grassy area around the hospital is covered with drying sheets and clothing with family members sitting next to them�they will have burners out cooking food and just sit there quietly or visit with neighbors.

God help us if we ever end up like that.

Tracy Walters, CISSP

God forbid; but will He? Is civilization safe? It never has been.

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Wednesday, August 26, 2009

What Happens When the Electronic Copy Is the Product

I suspect that Cory Doctorow and Eric Flint are right for the moment. Obscurity probably is a much bigger challenge for most authors than piracy, but it seems to me that part of that argument is based on the notion that the electronic copy isn't the "real" product. The "real" product is a physical book. The electronic edition promotes sales of the dead-tree edition. The Kindle seems to herald the beginning of an era in which the electronic copy actually is the actual product.

Flint mentions that it is quite difficult for most authors to find pirated versions of their own work online and that when found, the quality tends to be poor. On the other hand, he advocates making non-DRM electronic copies available. Surely the availability of these would solve the quality problem for the pirates.

With paper books, if a person recommends a book to a friend and then lends him his own copy, he doesn't have it any more until he gets it back. This wouldn't be the case if his recommendation were accompanied by a non-DRM copy of an e-book.

I do find DRM frustrating, and I would very much like to see a world in which we can buy electronic editions of books without worrying about DRM, but I'm not sure how practical this desire is.

In the music world, MP3 players have already caused us to turn the corner where the "real" product is the electronic edition. Plenty of people do share music files though I do agree with Mr. Flint that not every copy could possibly represent a lost sale, since such sharers surely copy far more music than they ever would or could buy.

Some bands seem to have adopted a strategy that the "real" product is the live concert and electronic editions of their music are for promotion. This can make sense. Dave Carroll's "United Breaks Guitars" has been viewed five million times. I can't help but think that this has helped promote his band, an excellent return on the loss of one guitar.

I don't see how the concert model works for "groups" that are really just one guy and a well-equipped studio. Surely authors are much closer to this case. J.K. Rowling may be able to pack theaters to give readings, but she is the exception and not the rule.

-- Mike Johns

=============

SAT Scores Fall as Gap Widens; Asians Gain,

Jerry

High-school students' performance last year on the SAT college-entrance exam fell slightly, and the score gap generally widened between lower-performing minority groups and white and Asian-American students:

http://online.wsj.com/article/
SB125121641858657345.html

"The combined scores are the lowest this decade and reflect stalled performance over the past three years. The reading scores are the worst since 1994."

"This is a nearly unrelenting tale of woe and disappointment."

"You can't look at these results and say that NCLB has been an enormous success," says Jack Jennings, president of the Center on Education Policy, a nonpartisan research organization in Washington. "The bottom line is the country is changing dramatically. Unless minority kids are educated better, we are going to be in trouble because pretty soon they are going to be the majority."

Hmmm. Y'know, there was an experiment in China where they taught kids Pinyin rather than traditional characters. Pinyin is the spelling out of Chinese words in "Roman" letters. Essentially, they compared phonics with learning characters, which is essentially how they teach reading here now. Of course, the Chinese kids who were being taught Pinyin learned to read much earlier than the kids learning characters.

How is that relevant to the SAT's? I believe that kids who find it harder to read new words - a trivial skill for phonics-taught kids but not for public school kids - will have a harder time with college prep material. And when you look at the graphs in the story, you see a visible trail of the fall in reading.

So the results are hardly surprising. Said Chester E. Finn Jr., president of the Thomas B. Fordham Institute, a Washington, D.C., think tank: "If there's any good news here, I can't find it." Indeed.

The modern professors of education have set learning back 2000 years with their "whole word" methods. If you want your child to read, teach phonics. Mrs. Pournelle's program does that. I would wager that every child of anyone who reads this site can learn to read before the end of first grade.

============

Impartial Journalism & Rewriting History

From the LA Times Chamber of Commerce science trial article -- "Environmentalists say the chamber's strategy is an attempt to sow political discord by challenging settled science -- and note that in the famed 1925 Scopes trial, which pitted lawyers Clarence Darrow and William Jennings Bryan in a courtroom battle over a Tennessee science teacher accused of teaching evolution illegally, the scientists won in the end."

John Scopes and Clarence Darrow lost. The judge imposed a fine of $100, the minimum fine under the Butler Act. The judge and jury ruled based on the law (Butler Act).

Upon appeal, the Tennessee Supreme Court found the Butler Act to be constitutional, BUT it set aside the conviction because of a legal technicality having to do with the size of the fine the trial judge imposed (under the state constitution Tennessee judges could not levy fines above $50... was he hoping to be overturned?). A (sensible) justice recommended that the "bizarre case" not be pursued, and it was dropped by the prosecution.

Most might say now that the law was unjust, wrong headed, and unconstitutional, and in fact it was repealed in 1967. It and other similar state laws came to be more or less dead letters anyway with the expansion of Federalism in education... state control of curricula being usurped by Washington.

But the "scientists" didn't win in the end. The Law won, even though the defense tried to put the Butler Act on trial rather than John Scopes. The jury did not choose to nullify.

Mr. Tankersley of the LA Times seems to be making up history to suit his own agenda, else he is writing authoritatively from ignorance. The proposed USCoC trial would have to be specifically about the science underlying the law (EPA rules, regulations, et cetera). They miss the point that 'The Law' need not have factual underpinnings. I personally think it would be great if it did, but it doesn't work that way.

Greg Hemsath

Arthur Kantrowitz spent a good part of his life trying to establish an actual science court. He had in mind cases like the Dow Corning case, but the general idea was to try cases involving actual science before "peers", with scientific rules of evidence. He never got this taken very seriously.

It is an important concept. At the moment we have juries without qualifications, while the persuasiveness of expert witnesses is far more important than their actual knowledge: and since the experts are brought in by contestants, some viewpoints are never expressed, and the conclusions of the experts are pretty well known in advance.

When it comes to laws based supposedly on science and scientific conclusions it's worse. I doubt there are more than a handful of Congresscritters or Senators who have any concept of Bayesian analysis. Few would know what critical evidence might validate scientific models. Most are susceptible to lobbyists. Meanwhile, among the scientific experts, more and more are dependent on grants which are conferred by "peer review". The result is the odd notion of consensus on Human Caused Global Warming: the modelers are certain they see it, while the data gatherers are not so sure. Evidence known by everyone is ignored (most people to this day believe in retreating glaciers, and few seem to have thought through the implications on Arctic ice in the simple fact that there were dairy farms in Greenland and vineyards in Vinland AKA Nova Scotia (as well as in Scotland proper). There is no proper examination of evidence using the rules of science; climate science has become advocacy (in which one presents one's own case) rather than science (in which one must account for all the data, not just selected data).

It may be that Nature has taken a hand in this:

If my count is correct, the current spotless streak is at 47 days. Solar activity is at some of the lowest levels ever recorded. http://www.solarcycle24.com/

The evidence may become too powerful to be ignored.

==========

The Birthplace of Political Correctness

http://bighollywood.breitbart.com
/bwhittle/2009/08/26/the-narrative/

Julie

Transcript of the Whittle lecture. Thanks

==============

Jerry,

As usual with PJTV, this piece ends with a sermon to the choir, however, it puts a lot of what you have been saying about education into a pretty tight video.

http://www.pjtv.com/video/
Sonja_Schmidt%27s_Left_Exposed/
America%27s_Culture_of_Blame%3
A_Scapegoating_and_Explaining_Away
_Failure/2315/

Phil

=========

Ted Kenedy

Jerry,

As usual, your saying, led me to:

http://en.wikipedia.org/wiki/Chilon_of_Sparta

Which was very worthwhile.

Phil

===========

What Happens When the Electronic Copy Is the Product

In partial response to Mike Johns.

"Flint mentions that it is quite difficult for most authors to find pirated versions of their own work online and that when found, the quality tends to be poor. On the other hand, he advocates making non-DRM electronic copies available. Surely the availability of these would solve the quality problem for the pirates.

I do find DRM frustrating, and I would very much like to see a world in which we can buy electronic editions of books without worrying about DRM, but I'm not sure how practical this desire is."

Its unclear from this whether or not Mr. Johns is aware that Baen already sells all its books without any DRM.

Part of what Eric Flint discussed regarding the future of writing is that there will always, in his opinion, be a need for a middle man. Someone to sort through all the dross to find the good stuff. Its been a while since I've read his Prime Palavar essays but from what I recall he felt that even if the financial paradigm changes(He was doubtful of this happening.) the need for people to do the drudge work of finding good material to read will remain. So the opportunity for both writers and publishers or publisher equivalents to make money will continue.

A H

I said much of this in A Step Farther Out (published in the 1970's by Ace when Jim Baen was editor).

For a PDF copy of A Step Farther Out:

Regarding Ebooks

Just one thought to consider....

What will the ebook version of a used book store be like?

Karl

===========

A peek inside the numbers of the hospital endorsement

http://hotair.com/archives/2009/08/25/
a-peek-inside-the-numbers-of-the-
hospital-endorsement/

"But some experts wonder at the price of that political support. Alain Enthoven, a health economist at Stanford University, noted that $155 billion was only about 1.5 percent of total hospital revenue over 10 years � even before taking into account the new, larger amount of money that hospitals can expect if more people have insurance. Wait � the money they will give back only amounts to 1.5% of their revenue? That would make the $171 billion they receive for reimbursements about 1.7% of their projected revenue. What happened to the vast costs that the uninsured create specifically for hospitals as a result of their inability to pay? Even at the more modest projections of the number of uninsured (14 million), they comprise at least 4% of the population. Their portion of revenues (unrealized) at hospitals doesn�t even amount to their representation in the population as a whole. Reformers want us to overhaul a system that works for most Americans, which satisfies most Americans, in order to account for an unrealized 1.7% of hospital revenues. That�s absurd."

The numbers left out of the debate are often more interesting than those repeated ad nauseum.

Graves

Free emergency room care

Jerry,

In the recent health care discussion, several correspondents have made statements like this: "One point that never seems to get made is that *everyone* in the US can get free health care. Just show up at an emergency room. Bingo - free health care. And its that simple if you're poor. "

Really? So if I have a weird growth in my head, I just pop into the local emergency room, and after a long wait, they will zap my head with hard X-rays? And if I have a badly worn, arthritic knee, I can just pop in any time and get a knee joint replacement? Or having Aortic Stenosis, and needing a new valve, I can go to the emergency room and have it replaced? And if I need chemo for cancer treatments, I can just swing by the emergency room every six weeks and get a dose of whatever I need?

In the US, poor people can get some level of emergency treatment for acute conditions for free by showing up at a hospital. But I suspect that this does not represent the majority of health care spending. Comprehensive ongoing treatment for chronic conditions is a very big component of health care spending, and that generally will not be provided in an emergency room setting, no matter how long you are willing to wait.

CP, Connecticut

Primary Care Doctors

In the UK, primary care doctors (GPs) have 5 years of university training, followed by internship and residency. It's sort of off- putting when you use specialist terminology--I'm an auditory neuroscientist--and get a blank stare or misunderstanding.

-- Beware Outside Context Problems

--Harry Erwin, PhD

=========

Cloud rolls

Dr Pournelle

I have never seen clouds like this before. http://antwrp.gsfc.nasa.gov/apod/astropix.html Interesting.

Live long and prosper

h lynn keith

Please see below for proper link.

============

Seeking web security, exploit operators prefer Firefox

Some believe Internet Explorer isn�t at the top of the hit list anymore..

Original URL:
http://www.theregister.co.uk/
2009/08/21/exploit_operator_browsers/

Seeking web security, exploit operators prefer Firefox

Opera comes second

By Dan Goodin in San Francisco

Posted in Anti-Virus, 21st August 2009 00:03 GMT

Criminals running websites that push drive-by exploits overwhelmingly prefer the Firefox browser, according to a researcher who spent the past three months surveilling their browsing habits.

Mozilla's Firefox was used by 46 per cent of the exploit kit operators who were tracked in the study, according to Paul Royal, principal researcher at Purewire, a company that protects customers against malicious websites. One third of the Firefox users browsed using a 3.0 version, while 13 per cent had upgraded to the most recent 3.5 version.

Interestingly, Opera, which by some measures http://www.w3schools.com/
browsers/browsers_stats.asp has only a 2 per cent market share, ranked second among the kit operators, with 26 per cent.

Tracy Walters, CISSP

===========w

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Thursday, August 27, 2009

Private clinics in Canada -

Hi Jerry -

As a Canadian, I find the health care debate interesting, particularly the letters regarding the pros and cons of a Canadian style system. A key thing to remember is that there is no one Canadian national health care system - the Canada Health Act sets out limitations and rules, but the actual systems are run provincially, and there are differences. Such as private MRI clinics - the following quote from http://www.canada.com/
story_print.html?id=aaf6d
061-7672-4020-ab79-987
a7e01f2c1&sponsor= is an example:

"Six provinces have privately owned clinics, but only four -- B.C., Alberta, Nova Scotia and Quebec -- have clinics that accept private payments."

There is a caveat, though:

"Under the Canada Health Act and provincial statutes, patients are not supposed to pay for medically necessary services unless a third-party insurer such as Blue Cross or WorkSafeBC pays on their behalf. But most patient-pays scans are done under the radar."

So if its not medically necessary, you're free to pay for it. Or convince your third-party insurer to pay for it. One I looked at, http://www.canmagnetic.com, prominently lists their rates on their website. They push the personal injury legal angle, but its clear they do lots of other work. So while saying that private, user-pays medical services are "illegal" here is true in the most general sense, there are grey areas. http://www.findprivateclinics.ca is a useful resource that lists dozens of private clinics and services of all sorts.

And while the government-administered medical plan provides emergency and core, medically necessary services, third-party insurance is almost a must if you want, amongst other things: a private or even semi-private hospital room when not medically necessary, dental care as a teen or adult, vision care, most sorts of alternative health care, or any portion of your prescriptions covered (Here in BC, "Fair PharmaCare" pays 70% of the cost after you meet the deductible, which is 2-3% of your net income. But that still leaves a fair bit of ground that makes third party insurance very worthwhile). It can also, by paying for scans in privately run clinics, bypass some wait times (if you can convince them to pay for it).

In any event, it should be clear that a) the Canadian system is not entirely uniform, b) it is actually a mix of public and a smaller private portion, paid for by a mix of taxes (and nominal medical plan premiums), third-party insurers, and (admittedly small, at least legally) amount of private payment, and c) in some ways (critical and urgent care) it often works fairly well, and others (wait times) not so well.

I have no real idea if any variation would work in our neighbour to the south - but I suspect not without some serious reworking.

Cheers, Monty

============

Phonics vs. Hieroglyphics

We have granted the high ground to the professors of education far too long. The so-called <i>whole word</i> method of reading sounds oh-so-up-to-date and benign, but in reality is nothing less than teaching hieroglyphics.

Whenever possible, this fact should be pointed out, using that big, scary word; undercut the high ground. At all times remind the public that in the world of hieroglyphics, only the elite learned to read because they could remember more characters (and started memorizing them earlier in life).

Make it a meme: phonics or hieroglyphics!

Julie Woodman

==========

Data from Charles Murray's next book

The data behind this might be old political demography news to you, but all I could say when I saw the data graphed was, wow!

<http://blog.american.com/?p=4259>

Cheers, Tyler

===========

DC Schools

"One presumes that both parties intend the results obtained [by the DC public school system] since neither party makes any attempt to do anything about it."

Dear Dr. Pournelle:

For once, the Republicans were on the right side of this issue: they authorized and funded a limited school voucher program in the District, which was apparently vastly oversubscribed (I read at one time there were ten applicants for each voucher). I beleive the inception of this effort goes back to when your friend Mr. Gingrich was still Speaker, and it was supported by Eleanor Homes Norton, the "non-voting delegate" for DC, as well as the then-mayor, Anthony Williams (both, I assume it unnecessary to explain, black).

The funding was something pretty pitiful, like $50 million a year. Needless to say this was one of the few things there apparently wasn't room for in the $800 billion "stimulus" bill or the equally egregious $1.7 trillion 2009 budget. So things have reverted to the status quo ante, alas.

Very respectfully, David G.D. Hecht

Actually I recall when Newt told my son (then a Congressional staffer) to work on this one, and when it came through, small but we thought it would grow. But Newt left the Speaker post and no one else seemed to care.

===========

On teachers

Dear Dr. Pournelle:

I found the following article on a link from the INSTAPUNDIT website:

http://www.newyorker.com/reporting/
2009/08/31/090831fa_fact_brill?currentPage=all

I thought it might be of interest to you. Best wishes on your continued good health.

Regards, Tim Scott

We have similar stories in Los Angeles. Nothing can be done. It is the way the United States works now.

============

Debt Clock...

US Debt chart - shows the debt, divided by individual, unfunded liabilities for various entitlement and bailout programs, and other stuff. Changes in real time. Don't know the validity of the computer program used but seems useful when trying to understand the financial implications of adding large unfunded or underfunded entitlements into the mix.

http://www.usdebtclock.org/

Charles Brumbelow

===========

Jerry, the link in the "Cloud Rolls" message from Lynn Keith on Wednesday's mail is to the "current" APOD picture. The picture referred to is here: http://antwrp.gsfc.nasa.gov/apod/ap090824.html

Really bizarre clouds.

--Gary Pavek

=============w

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Friday, August 28, 2009

I have appointments all day, so this will be short shrift to some very interesting letters; they are worth reading without comment.

An sample of the British health care system

I hope this isn't what we're in for. A ruptured appendix after it had been removed. Then a secondary infection from the second surgery. Lost his job because his boss didn't believe him. Talk about getting kicked while down. Oh well, at least he has health care.

http://www.dailymail.co.uk/news/
article-1208970/
Man-collapses-ruptured-appendix--
weeks-NHS-doctors-took-out.html

Regards

Jim Brandvold

One can come up with horror stories from any country, of course, but this one is pretty scary.

============

Dear Dr. Pournelle,

Regarding the Atlantic Monthly article by David Goldhill; I agree with many of the premises forwarded by Mr. Goldhill, especially the disconnect between consumer and payer for medical services and the active interference by government and insurers in medical decision making. If people had a direct cost associated with the choices they make, I think we would see a huge change in the decisions made on utilization (given the ability to put 'transparency', get catastrophic insurance, and get congress and the administration to make the tax changes necessary to make 'self-pay' medical system more effective). I think that people would actually follow the Kaiser-like approach to care and put prevention and chronic disease management forward and try to avoid the costly 'repairs' for complications. If we can see that TANSTAAFL applies just as much to paying for medical treatment as for lunch, maybe we will make some meaningful steps to get out of the quagmire.

What I find in error is his assumption that the people talking about 'Health Care Reform' have an interest in improving health care. As I mentioned in a previous letter I have major questions about the motivation of the reformers given that they have not made any meaningful efforts to fix the systems they already control (and there are numerous counter examples of the government intervention making it worse), and that they demonize anyone who questions their approach to 'reform'. President Obama tries one scapegoat (for example, greedy doctors who perform too many tonsillectomies), and when that gains no traction he moves on to greedy insurance companies, ad nauseum.

Secondly, I can't figure out how his approach would deal with a problem such as the one you faced last year. Even assuming that rationalizing costs by having true costs and competition for providing services reduces costs by 50 or 60%, the care you had would still have cost enough to reach a reasonable standard for catastrophic care. Now, who would have to decide that you can precede with your care, since the neurosurgeon and oncologist couldn't give you much more of a diagnosis than 'you got a lump in your head'?

Third, I don't mind subsidizing some of the health care of others (we all do so now), and I certainly would not mind doing it under a more effective system than the Frankenstein's Monster we have now. But if I have to put money into someone elses health savings account because they can't afford it, shouldn't I (or society as a whole) get some say in how those people live there lives...such as no tobacco use, no pregnancies until they can afford to care for their children, etc. I really don't like thinking about government making these decisions, but I also want to see everyone have some responsibility to make good choices for themselves or I want a way to limit my responsibility for them. Maybe paying through charities would be more appropriate than tax dollars.

Also about 'free' care in the Emergency Department: EMTALA is a federal law that says that anyone who presents to a hospital with an emergency medical condition (one that threatens life, limb or permanent disability if not treated immediately) or in active labor must be stabilized before any financial information can be requested, let alone any payments. A medical screening exam (MSE) must be performed and any unstable conditions must be treated. If the first hospital does not have the ability to treat the condition they can call another hospital that does have the capability and transfer the patient. Interestingly, there is no geographical limit on this. Theoretically, a hospital in Guam can call a hospital in Maine and the hospital in Maine cannot refuse transfer. After an MSE is done and the patient is either stable or no emergency condition exists, the hospital can then ask for payment before further testing or treatment is performed, and the hospital and doctors are still able to bill for tests/treatments performed until then. Practically, people without insurance get stabilized and maybe some treatment to carry them through the next 1-7 days, but the rate of being paid for this care is generally abysmal (at least at my hospital).

Finally, the discussion about 'end of life counseling' is at best a distractor and more likely a dishonest foil used by both sides in the argument of 'reform'. This is a very important part of care for anyone with chronic, life threatening conditons or anyone over 70 (75, 80?). One thing that will make taking care of your parents or spouse even worse is to have to decide what types of care to give in the midst of life-threatening conditions. Preferably, this has been done by people and their families and then with their primary care doctors so that everyone is as clear as possible about a patient's wishes. Then there should be legal documents such as a living will, medical power of attorney and advanced directives. I think that the Republican's painting this discussion as "death panels" is very prejudicial to these discussions, and is not very appropriate to the true purpose for these choices. At the same time, the Democrats are also not very honest about the fact that rationing of care is going to happen (and already does) and that some of the goals that drive these 'end of life' choices are to try to limit expensive care in the last year of life. But again, goverment is way down on my list of people I want making these decisions (see Terry Schiavo).

Unfortunately, although I agree that you have presented a lot of the important facts in the debate, I don't think we can let it drop. The people who are pushing this 'debate' are not going to quit simply because the American public has made it clear we are not interested in this 'reform' plan. We are too stupid to know what is best for us, and I can easily see Nancy Pelosi and Harry Reid, not to mention Mr. Obama, deciding what is best for us.

Now if you could just get Mamelukes out....

Thanks,

Doug Lewis, MD

Dr. Pournelle,

After reading the Atlantic article, I have to say that I agree with his assessment of the problems with our system, if not his solution. There are currently no real market forces working on health care. Doctors have every incentive to make their services as expensive as possible, and no incentive to cut costs. The more they charge, the more money goes into their pockets or practices. Many doctors pay little to nothing for care themselves; professional courtesy between colleagues means they often receive services we pay thousands for at little or no cost. But enough of that.

I do agree that most people only need catastrophic insurance. However, a $50,000 limit is a bit absurd at today's prices. Unfortunately I'm a prime example of this. I'm 25, married, and have a high deductible plan with an HSA which I've been paying into for the past 3 years. Statistically I should have between five and ten thousand dollars in that HSA, more than enough to cover my $5000 yearly deductible. Unfortunately I fall far to the left of the bell curve here. Within the first year of my having said insurance I was in a car accident. I required roughly $10,000 worth of treatment and surgery for my broken collarbone. I believe between my deductible and insurance about $8,000 of that was actually paid out. I would certainly consider this situation to be a "catastrophe." Within the past few weeks I've been diagnosed with and had a procedure for kidney stones, and a subsequent ER visit due to complications. I've yet to see the final bill, but I'll be stunned if it comes in at less than $30,000. I'll likely need another procedure for a remaining stone within the following months. I expect that will cost at least another $10,000. None of these costs are real of course. It didn't cost anyone but me a thousand dollars to give me a CT and inject me with iodine. The doctors and nurses won't actually collect most of that. But again, these were unexpected and fairly "catastrophic." Perhaps if the true costs, closer to what it actually costs to pay for the doctors/nurses at hourly rates, the drug costs, costs of new beddings, etc. were what I was charged $50,000 would make sense. As it is, my HSA is essentially at 0 and I've had to take out a medical credit card (0% interest for 18 months, graciously) to pay for the rest of my deductible. My catastrophic insurance will cover the rest. My HSA won't actually begin accruing again until that medical credit card is paid off. This is all with only a $5000 deductible. If it was ten times that it would take me 10 or 15 years to pay off, and that would be 15 years I'm not contributing to an HSA. Presumably any other medical costs which came along in that time frame which were under $50,0000 would only add to that number?

High deductible plans encourage market forces. I shop around for diagnostic procedures. I ask for generic drugs if at all possible. Etc. Tax free HSAs are a good incentive to save. But, if one doesn't put into the HSA, that's their choice, and they will live with the consequences. Many of my co-workers are like this, and some have had cases where they've paid the deductible with cash or check. My insurance plan also covers bi-annual dental cleanings and annual physical exams; necessary, valuable preventative care. Any plan which seeks to reduce future costs must have some encouragement for preventative care. I like my insurance plan. It's affordable and encourages smart consuming. The market forces drop off a bit after the deductible is met, but usually they don't kick in at midnight when you're doubled over in pain regardless. For those of us on the left hand of the bell curve they are more difficult, because we're going to hit that deductible every year, potentially very early on in the year. It can be hard to get a running start. But other insurance schemes, with low copays and opaque pricing kick the people in the middle and to the right of the bell curve at the gain of the people on the left. Isn't that backwards?

Government plans always seems to try to cover the left hand of the bell curve, and end up expanding it dramatically. Perhaps by focusing on the majority and having hard to trigger special cases for the left hand side we can begin to shrink it instead.

Thanks,

Ryan Brown

At some point there needs to be some attention to personal responsibility. Insurance is usually intended to cover the unpredictable. The consequences of some practices and habits are not unpredictable.

=========

Infant mortality

I know I already sent you an email on this health care subject, but this backs up what I stated, and is from Investors Business Daily:

Official World Health Organization statistics show the U.S. lagging behind France in infant mortality rates � 6.7 per 1,000 live births vs. 3.8 for France. Halderman notes that in the U.S., any infant born that shows any sign of life for any length of time is considered a live birth. In France � in fact, in most of the European Union � any baby born before 26 weeks' gestation is not considered alive and therefore doesn't "count" in reported infant mortality rates.

link http://www.ibdeditorials.com/IBD
Articles.aspx?id=336178343967257

Harold Hamblet

===========

Doctor Pournelle,

According to:

http://www.bostonherald.com/news/
us_politics/view/20090824official_
white_house_sets_up_interrogation_unit/

"Nonetheless, the spokesman added, Obama believes the attorney general should be fully independent from the White House and he has full faith in Holder to make the decision on whether to reopen several such cases with an eye toward possible criminal prosecution. "He ultimately is going to make the decisions," Burton said of Holder.

CIA Director Leon Panetta said in an e-mail message to agency employees Monday that he intends "to stand up for those officers who did what their country asked and who followed the legal guidance they were given. That is the president�s position, too," he said."

(Notice that the Panetta statement parses to "We'll go to the wall to protect anyone who doesn't need protection, and Devil take the hindmost"?)

So one of the savviest and canniest politicians in recent American history (Obama), presumably acting in concert with that other pair of most canny and savvy etc (the Clinton's) is giving complete freedom to his Attorney General to engage in a witch hunt, presumably ending in a show trial media circus that will provide enough talking point tinder to ignite a political firestorm of Dantesque proportions? Right. And the political advantage gained by this? That the "choir" of hard core Obama supporters will continue to say "amen"?

It has "Poison Pill" written all over it.

If Obama really IS this beholden to his hard left base, it's nothing but good news for Republican candidates in 2012. Failing a rapid "Move To The Center" akin to Bill Clinton's after the failure of "Hilary-Care" and the 1994 "Contract With America" Republican landslide, things may fall apart rapidly for Obama.

The inner contradictions of his governing coalition between Clinton-style New Democratic and the Howard Dean style hard left wing of the party will surface, and we'll begin to see cracks in their veneer of solidarity. The first major fissure might well be a Hilary Clinton resignation in spring.or early summer of 2010. Should there be a number of vulnerable Democratic House seats that fall, and if Hilary Clinton were free to campaign for those Democratic candidates, she would collect a goodly number of political IOU's.

IOU's that could be used against a crippled Obama in a 2012 primary challenge.

Petronius

===========

Single molecule's stunning image By Jason Palmer

<http://news.bbc.co.uk/2/hi/science/nature/8225491.stm>

<snip>

The detailed chemical structure of a single molecule has been imaged for the first time, say researchers.

The physical shape of single carbon nanotubes has been outlined before, using similar techniques - but the new method even shows up chemical bonds.

</snip>

This is an amazing feat. One that I never thought to ever see. A picture of actual chemical bonds! Who could have imagined it possible?

Braxton S. Cook

DARPA at Phase 3 on solar powered surveillance strato-ship

I missed this one back in April�interesting technology and probably cheaper to deploy than a space-based platform.

DARPA at Phase 3 on solar powered surveillance strato-ship

$400m robot radar dirigible to stay up for 1 year+

By Lewis Page

Posted in Science, 28th April 2009 10:15 GMT

The famed Pentagon Q-branch boffinry hothouse, DARPA, has unveiled another ambitious plan to further US military-technical dominance. It has given $400m to American weapons globocorp Lockheed to develop a solar-powered robot radar airship, able to lurk in the stratosphere for a year at a time, potentially tracking individual people walking about on the ground across areas 1200km wide.

Full story:

http://www.theregister.co.uk/
2009/04/28/darpa_isis_phase_3/

Tracy Walters, CISSP

EE 'Doc' Smith blasters on the way,

Jerry

EE 'Doc' Smith-style blasters are approaching weaponization:

http://www.theregister.co.uk/
2009/08/26/ionatron_still_going/

"The technology in question is a fairly old idea: that of using a laser beam to create a plasma "tunnel" or "channel" through the atmosphere which would be more conductive than ordinary air. This would allow a powerful electric spark discharge - an artificial lightning bolt - to be directed onto a target with some precision."

Yup. Skylark of Space. The Lensmen. Boom zap.

===========

A bit of irony you couldn't make up.

Dr. Pournelle --

From the Daily Mail:

"Weather supercomputer used to predict climate change is one of Britain's worst polluters"

<http://www.dailymail.co.uk/
sciencetech/article-1209430/
Weather-supercomputer-used-
predict-climate-change-
Britains-worst-polluters.html>

"The Met Office has caused a storm of controversy after it was revealed their �30million supercomputer designed to predict climate change is one of Britain's worst polluters."

" ... the Met Office's HQ has now been named as one of the worst buildings in Britain for pollution - responsible for more than 12,000 tonnes of carbon dioxide a year.

It says 75 per cent of its carbon footprint is produced by the super computer meaning the machine is officially one of the country's least green machines."

"The IBM machine has a peak performance of 1 'Petaflop' - 1,000 billion calculations per second - which it will not reach until 2011.

It is the second time the Met Office has been criticised this year - after the machine famously helped predict a "BBQ summer" which turned out to be another wash-out."

"Friends of the Earth spokesman Maurice Spurway said: 'Life is full of ironies and I think this is one of those situations.' "

The last statement says it all.

Pieter

'Since vast efforts and billions of dollars have been invested in huge computer climate models the scientific organizations are forced to defend the usefulness of the models.'

<http://www.americanthinker.com/
2009/08/global_warming_blues.html>

-- Roland Dobbins

Connections among solar cycle, stratosphere and ocean discovered

Well, I'm completely gob-smacked. Apparently there is a connection between the Pacific Ocean, the sun and the atmosphere (which lies between them) on our weather.

http://www.eurekalert.org/
pub_releases/2009-08/nsf-cas082709.php

And this time their models are agreeing with observations.

--Gary Pavek

=========

"Report on the General Education Requirements..."

Walter William's Aug. 26th column http://townhall.com/columnists/WalterEWilliams/2009/08/26/what_will_they_learn

ACTA conducted research to see whether 100 major institutions require seven key subjects: English composition, literature, foreign language, U.S. government or history, economics, mathematics and science. What ACTA found was found was alarming, reporting that "Even as our students need broad-based skills and knowledge to succeed in the global marketplace, our colleges and universities are failing to deliver. Topics like U.S. government or history, literature, mathematics, and economics have become mere options on far too many campuses. Not surprisingly, students are graduating with great gaps in their knowledge -- and employers are noticing."

ACTA says that "paying a lot doesn't get you a lot." Generally, the higher the tuition, the less likely there are rigorous general education requirements. Average tuition and fees at the 11 schools that require no subjects is $37,700; however, average tuition at the five schools that require six subjects is $5,400. Average tuition fees at the top national universities and liberal arts colleges are $35,000 (average grade is "F").

Well worth reading, especially if one were getting ready to start paying for college.

Chuck Stillings

The more money injected into public education, the more is spent, and the higher the price goes. This seems a law of nature now. I can recall when fewer got into colleges, but state colleges were free.

==========

How to Maneuver in a Space Suit Using the Apollo Number,

Jerry

Current space suits, which are essentially balloons, make running more efficient than walking:

http://www.wired.com/wiredscience/2009/08/spacesuits/

How interesting that no one seems to be working on mesh-style spacesuits.

The lobbyists have been effective in keeping NASA from doing effective space suit research. Our present suits are not useful for most space work, everyone knows that, and nothing will be done. It is part of the military industrial complex. No Administrator will fight that battle. Hamilton Standard's PR people even tried to pressure McGraw Hill to fire me as a columnist because I wrote a critical column about the out of date computer in their space suit. McGraw Hill resisted, but it was an interesting experience.

I wonder if the CPU in the current suits has been revised this Millennium?

=============w

TOP

CURRENT VIEW Friday

This week:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

TOP

Saturday, August 29, 2009

I took the day off for errands and the Writers of the Future Awards

TOP

CURRENT VIEW Saturday

This week:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

TOP

Sunday, August 30, 2009

Gone to his reward.

http://www.latimes.com/news/obituaries/
la-me-sergei-mikhalkov29-2009aug29,0,3291923.story

-- Roland Dobbins

===========

'The Russian navy embarked on its first major operation since the end of the Cold War, rushing three battleships and one frigate to find the _Arctic Sea_.'

<http://www.atimes.com/atimes/
Central_Asia/KH26Ag01.html>

-- Roland Dobbins

============

Op-Ed Contributor - �Peak Oil� Is a Waste of Energy - NYTimes.com

http://www.nytimes.com/2009/08/25/opinion/25lynch.html?pagewanted=1

A nicely written attack on peak oil theory,
Tim.

Peak oil is a recurring phenomenon. How much reserve is it worth looking for? At what prices and with what drilling restrictions? And then there's Teddy Gold

==========

'Or Mr. Obama could decide that now is the moment to kick-start the nascent commercial space business.'

<http://www.nytimes.com/2009/08/25/science/space/25nasa.html>

--- Roland Dobbins

He certainly could. Prizes would do it. And not add to debt, either.

Jerry

Aluminum-ice, or ALICE, is a fuel that could be made on the moon or Mars:

http://www.theregister.co.uk/
2009/08/24/nasa_alice_test/

Maybe the moon could be a way station after all.

==============

Oral History Interviews at the Niels Bohr Library & Archives http://www.aip.org/history/nbl/oralhistory.html

Housed at the American Institute of Physics, the Niels Bohr Library & Archives is a very useful place for historians of science and others with an interest in the lives and personalities of modern scientists. Here, visitors will find their rather unique collection of oral history interviews. They happen to have more than a thousand, and this site contains transcriptions of several hundred of these interviews, along with a selection of audio clips. The subjects covered in these interviews are rather diverse, and they include conversations about laser science, science education, solid state physics, and science institutions. Visitors can click on to the voice clips to hear such notable personages as Felix Bock, H.R. Crane, and Werner Heisenberg talk about their work. Moving on, visitors can click on the "Read Oral History Transcripts Online" section to browse an alphabetical list of scientists. Finally, visitors can click on the feedback form to ask questions of staff members at the Library.

Jane Neff Rollins, MSPH

============

Grade Inflation

A few stories on the A-level system in the UK. The first two about grade inflation: <http://tinyurl.com/mvjz6j> <http://tinyurl.com/ mlw7t4> . Shortfall in funding university places <http://tinyurl.com/n6z7dw > .

Between a rock and a hard place <http://tinyurl.com/lexxe2> -- Labour runs out of money.

-- Harry Erwin

===========

Citizen and taxpayer role reversal

I was struck by the seeming role reversal of today's situation compared to the novels and stories you wrote in the 1970's and early 80's. In your novels, the disenfranchised "Citizens" were housed in welfare islands while a small oligarchy of "Taxpayers" ran the nation.

Today, while there is still perhaps a small oligarchy running things, they have created a brownshirt army of "citizens" to enforce their will on the increasingly reluctant taxpayers through such activist groups as MoveOn, A.C.O.R.N, and public service unions, aided and abetted by the MSM. Sadly, most of your other messages about power and responsibility are just as true today as they were when the stories first came out.

We can only hope that the exodus to space still happens to allow American culture and civilization to grow and thrive away from the bureaucrats and oligarchs who feed off the taxpayer (although I suspect one of the reasons that the space program has been crippled for so long is at some level, they do understand this would provide a means for productive taxpayers to escape).

Keep preaching the message of "A Step Farther Out", since that seems to be the only practical counter program out there.

Best wishes

Arthur Majoor

Indeed. I have to say I had not thought we would go to service employees unions so heavily and thus deliver the country to permit raj. I saw a bumper sticker the other day. "Make welfare as hard to get as a building permit."

==============

Shades of Footfall

Dear Jerry,

I recently saw these images from the Cassini Saturn probe and could not help but think of the early chapters of Footfall:

http://www.habitablezone.com/
space/messages/558506.html

I for one won't do any early negotiating. :^)

Regards,

Larry

===================

Original URL: http://www.theregister.co.uk/2009/08/20/
dragons_egg_land_warrior_to_the_stan/

'Dragon's Egg' hurlable weeble-cams for US digi-troopers

Land Warrior back, too. UK still working on Wheels 2.0

By Lewis Page

Posted in Science, 20th August 2009 11:01 GMT

US forces have become the latest to adopt a throwable camera system, intended to let combat troops see inside rooms, around corners and so on without exposing themselves to danger. Israeli forces have also used such equipment: the UK's MoD, by contrast, has chosen to fund British firms to develop a homegrown alternative.

The US system is known as "Dragon's Egg", and like most of its kind it's about the size of a cricket ball and is intended to be lobbed through doors, windows, around corners etc. by close-combat troops. The AP reports <http://hosted.ap.org/dynamic/stories/
A/AS_AFGHAN_WIRED_WAR?SITE=DCS
AS&SECTION=HOME&TEMPLATE=
DEFAULT&CTIME=2009-08-18-03-15-35> that it's now going into the field with the US 5th Stryker Brigade Combat team*, who are also equipped with "Land Warrior" digi-soldier gear.

According to Octatron Inc, makers of the Dragon Egg:

The patented Dragon Egg� System is the original, throwable, wireless camera. Self-righting, rugged, and compact, the Dragon Egg� can be thrown through windows, over walls, or lowered from rooftops to provide instant surveillance. Using four separate cameras, each Dragon Egg� provides 360� of simultaneous video coverage with no need to pan or tilt, which ensures continuous surveillance. The transmitted video can be viewed on multiple receivers.

One trooper in each platoon** carries weeble-esque Dragon Eggs. Team leaders and above also have Land Warrior, with satnav, text minikeyboard and flip-down video monocle showing battle maps and the like.

Land Warrior went to war in Iraq with an infantry unit in 2007/08, and has changed significantly from its original configuration: the jury remains out as to whether the US Army will embrace it or not. Some form of digi-soldier gear at some point would seem inevitable, however, with many different programmes just in America working towards similar goals.

Tracy Walters, CISSP

=============

Original URL: http://www.theregister.co.uk/
2009/08/19/24th_air_force_activated/

US military cyber force activated

Operation Screaming Fist is go

By Lewis Page

Posted in Government, 19th August 2009 09:51 GMT

The US air force held an activation ceremony in Texas yesterday for its new cyberspace combat unit, the 24th Air Force, which will "provide combat-ready forces trained and equipped to conduct sustained cyber operations".

The 24th will be commanded by former Minuteman missile and satellite-jamming specialist Major-General Richard Webber. Under his command are two cyber "wings", the 688th Information Operations Wing and the 67th Network Warfare Wing, plus combat communications units.

According to Air Force Space Command, under which the new cyber force comes, the 688th will be "exploring, developing, applying and transitioning counter information technology, strategy, tactics and data to control the information battle space". The unit was formerly known as the Air Force Information Operations Center, and will continue to function as an "information operations centre of excellence".

The 67th, by contrast, seems to be a more offensive unit. It will "execute computer network exploitation and attack" as required, and when not doing that will conduct "electronic systems security assessments" for US military units and facilities.

When fully manned up, the combined wings plus supporting units and the 24th AF headquarters are expected to number several thousand personnel, many of whom will be from new specialist career paths in cyber warfare. Space command public affairs describes <http://www.afspc.af.mil/news/
story.asp?id=123163827> the 24th as "a battle-ready, responsive and forward-thinking team of America's best".

The new netwar force will be headquartered at Lackland airbase in Texas, with some personnel dispersed to bases in Oklahoma and Georgia. The US Army and Navy are also in the process of setting up cyberwar units, and there is to be a tri-service cyber command too - co-located with the NSA (another Defense Department tentacle) at Fort Meade.

Tracy Walters, CISSP

===========

In Response to A H

"Its unclear from this whether or not Mr. Johns is aware that Baen already sells all its books without any DRM.

Indeed, I was aware of this. I applaud them, and also note from a brief sampling of the catalog that they seem to have escaped the notion that the e-book edition should cost more than the paperback edition, when it has to have cost less to produce. I hope the enterprise does well.

I was under the impression that these e-editions are still a small fraction of sales, not because of piracy, but because most people don't read electronic editions. At this stage in the game, the paper version is still the "real" product. My misgivings about the practicality of DRM-free content are about the future. What will be the impact of DRM-free copies when nearly all books are electronic? Is the "information wants to be free" meme as strong in twenty-somethings as it appears from my vantage point? Perhaps people won't bother with piracy if the prices are low enough.

I think a more relevant example may be that Amazon sells DRM-free music in a market where many users do buy the electronic edition. Many of the people who buy the CD edition download the content to MP3 players anyway; the difference is largely one of convenience, price, and permanence. I don't know how this may be affecting music sales.

As for the need for editors, and the useful role of publishers as gatekeepers, I don't disagree. I didn't mean to suggest otherwise.

Mike Johns

All we have now is speculation. It's a matter of importance, but I for one don't know where we are going. It seems reasonable that something like a Kindle will become as ubiquitous as the cell phone one day. It may be the cell phone.

============

old fashioned health care

Hello Dr. Pournelle:

Once upon a time, Americans had absolute freedom in regards to their health care. This included the freedom to sometimes make some pretty poor choices, as with the purchase of patent medicines. Still, it was freedom, and better to make the occasional wrong choice on your own, than to have less than optimum choices constantly made for you, to serve the interests of the decision makers. Things have changed noticeably in my lifetime � and not for the better.

Back in the day of my long ago childhood (I am now 52), there was still a relatively free market in health care. Because of this, health care had to be affordable, and had to be responsive to the needs of the customer � there was no other way for health care providers to stay in business. My mother loves to tell stories about my birth, and her hospital stay. She had no insurance; but that was not considered some kind of crises back then � few people had insurance, it was considered quite the luxury, and yet no one moaned that they were deprived of medical care, because no one was.

If you needed a doctor, you paid for one just as you would pay for the services of any other professional. If you needed tests, you paid for those and for a hospital stay if it was required. Because this was still a market driven system, you could actually afford to do this. This was not a hardship, any more than having to pay for food, rent, heat, electricity or clothing was a hardship. You needed goods and services, and you paid for them. This is why people worked to earn money, and so provided goods and services in return. This is how the free market and free exchange is supposed to work. If you could not afford to pay, you went on charity, though individual pride prevented people from doing this unless they had to.

As with food, clothing, housing, and consumer goods, some people could afford more and better health care than others, because they were willing or able to pay more for it. Again, this is why you worked to earn money, and were encouraged to improve your lot in life. If you needed more, you could work harder, or learn skills to make yourself more valuable, or simply work more often. You did what you had to, and what you were capable of. Today this is referred to as making one�s self more productive. Back then it was simply said that you were getting ahead, improving yourself, or making yourself a better life. This individual incentive also added to the wealth and progress of the nation as a whole. More money got you more choices, and better quality. Making yourself more productive made the country stronger and wealthier as a whole. So the deal worked out for everyone. How hard will people work when there is no more chance of getting ahead?

Some doctors charged extra for house calls; but you could get them if you were willing to pay the fee. It was not much. I remember the doctor coming to our house several times, and we were not what you would call wealthy. Our doctor tended to schedule house calls in the afternoons, and office visits in the morning. If I recall, it was around $25 - $30 for an office visit, back then, something like $100 in today�s money. This was not insignificant; but it was also not outrageous. When my mom had me, it cost her a bit over $100, the number she gives is $115, probably equal to about $400 - $500 in today�s money. It was a week�s pay, or perhaps a bit more, for the average worker. Doctors and hospitals allowed you to pay off your obligation in weekly payments.

Before the passage of Durham-Humphrey (1951) required prescriptions for many of the more useful drugs, you could go down to the local pharmacy, tell the pharmacist what was wrong, and he would offer a drug, or perhaps advise you to see your doctor � this is what a pharmacist was licensed and trained to do. Pharmacists were actually health care providers, rather than glorified clerks, back in those days. A pharmacist is still required to go to pharmacy school, and learn all about drugs, and take a sort of a mini course in medicine, though there seems little point in it these days. This also explains a large part of the demise of the local drug store. With druggists becoming clerks, rather than trusted medical advisors, the business is now totally cost driven, rather than service or quality driven.

The vast majority of doctor visits end with a prescription. One way to significantly reduce medical costs would be to give us our full service druggists back, so that for minor illnesses or incidents, we could simply go down to the corner druggist. This is how things are handled in Mexico, and presumably in some other places as well. Of course, this won�t happen. It is not in the interests of the FDA, AMA, large chain drug stores, or medical insurance companies to give us more freedom of choice or lower costs, and it is never in the interest of the government to lay down a regulatory power once it has been acquired. The law, as it stands, does not permit an allegedly free adult, to get medicine from a trained and licensed pharmacist, without the permission of a doctor.

The other big problem is that even a doctor can not treat you, past a certain level, without permission from insurance companies. When I was a boy, and certainly in the youth of my parents, a doctor was a trained professional, who worked for a living. You paid him, and he provided a highly skilled service. The entire transaction, as well as the level of service, was between you and the doctor. You were the patient; but you were also the customer � the doctor worked for you, because you paid him. Today, the doctor works for the insurance company, because this is who pays him.

Today, health care is subsidized - and thus run - by insurance companies. The health care industry now has three administrators for every doctor, on average. It is the function of the insurance companies to pay these people, make a profit, and grow larger. Though it would be unfair to say that they have no interest in providing quality health care, this is clearly not their primary concern. As in any business, insurance companies prosper by maximizing income, and reducing costs. Reducing costs means reducing services, and denying treatment whenever possible. They have various ways of doing this, including the imposition of point systems on doctors, and the almost automatic denial of claims for special treatment or services.

The insurance subsidy of the medical industry tends to remove all incentives to keep costs down. It is proposed that we further subsidize it, and make it virtually unaccountable, by putting it under complete government control. This will add yet another layer of administrators, adding to the overhead costs, and will remove whatever inhibitions are left on cost containment. It will also, to an even greater degree make dependants of us, turning us into beggars and make us beholding to those who provide the services we have already paid for, through taxes and premiums.

The most recent statistics that I heard, admittedly a few years old, revealed that illegal immigrants cost health care 24 billion dollars a year. Doubtless, the numbers are higher today � possibly much higher. It is difficult to know the full effect of the invasion. It is not just a matter of dealing with millions of people who use medical resources and do not pay for them. There is also the problem of the reintroduction of diseases from the third world, which had long ago been wiped out here.

A look at the past seems to indicate that we do not really have any health care issues at all. Our health care system is the best and most advanced in the world. No one is turned away, and anything that can be cured or fixed, can be cured or fixed here. What we may have are health care funding issues. A look back points the finger at centralization, both by government programs, and by large insurance companies. This centralization removes the free market from health care, with subsequent problems for consumers.

So, what does the President propose, to restructure health care, presuming that it should be a function of government to do so? Is it a curb on illegal immigration, resurrection of the old time druggist, or a way to reduce the dominance of insurance companies and government programs on the health care system? Certainly not! Such steps might moderate, or even solve many of the health care issues we have. Instead, a totally organized, centralized health care system is proposed. This will take us further down the same path that has caused our many present health care issues.

It is never the intent of big government types to solve problems. The goal is always to find a way to manage these problems eternally, and keep them alive. You see this pretty vividly in our big government approaches to poverty, crime, public housing, and education. None of these issues have disappeared � all are being carefully managed. Still, this is a whole new arena. In the past, the government was able to do many things; but unless you committed murder or some other serious crime, it was unable to actually kill you � at least directly. Putting the medical system under government control will confer that power. It will also be yet another curtailment of the free market system.

Nationalization is, of course, the end of the free market, and signals the imposition of government controls. This includes the rationing that everyone is so worried about. The fallacy of rationing is that it assumes finite and irreplaceable resources. In general, this idea concurs with the beliefs of the greens and environmentalists, as well as most of the other left leaning groups. I sometimes wonder if this belief is not more of a preference than a belief. For those who wish to control others, finite resources make the job much easier.

The free market implies the belief that resources are not finite, in any meaningful way � that if someone is willing or able to pay, someone else will be willing to do the work. So it is always possible, even desirable, to make more of whatever it is. It assumes that the economy is driven by human potential, and that we can decide and create our own level of resources, by how hard we work, and how talented we are willing and able to make ourselves. It is the antithesis of rationing in that it makes the assumption that we can always provide resources up to the level of demand, rather than having to curtail demand down to the level of present resources. This is another way of saying that it is a belief in the idea of progress and advancement.

Were passage of the health care bill to occur, Medicare, would probably a pretty good indicator of things to come. My mother is in her seventies, and is on Medicare. It is a real pain to get anything paid for, even treatments recommended by her doctor were fought and initially refused by Medicare. I have heard similar complaints from people who are on the state subsidized Cobra plan. In addition, there are doctors that will not take her, because of reimbursement limits, and the volume of paperwork required to make a claim. Now admittedly, in a nationalized health system, a doctor would not have these kinds of choices; but a talented individual could always decide not to be a doctor, or not to be a certain kind of doctor (Perhaps these talented individuals will decide to become lawyers instead). In both cases, the results are the same � the unavailability of certain types of care, and a reduction in the equality of the care received. What a contrast to what health care once was.

Neal

I paid for my first children by saving money for the doctor and the hospital. I didn't expect someone else to pay that for me. It was a predictable expense...

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Democratic Health Care Plans & "The Terri Schiavo Effect"

Jerry,

The real objective of the Democratic health care plans is to nationalize the vast existing private health care oversight industry (insurance, etc.) and make them all public employees. Public employees who will then contribute money to the Democratic Party the way public education employees do.

Note the consistent increase in non-teaching staff (mostly administrators) relative to teachers in school systems is due to the ever-increasing paperwork requirements which add nothing to instructional value. With the administrators/non-teaching staff servicing left-wing causes in which they believe, and knowing that generous political donations to Democratic election groups keep their pay raises and promotions in an ever-increasing bureaucracy coming.

I.e., the Democrats intend to turn the existing huge, but as-yet mostly private, health bureaucracy into another part of the Democratic Party�s public employee client base.

A public employee client base paid for by constant reductions in actual health care, just as the public education budget is increasingly devoured by administrative overhead.

This is what happened with Britain�s NHS. It is now a 1.3 million person British jobs program that has a payroll so large � bigger than the Chinese Army or the entire uniformed active duty American military � it can no longer deliver real medicine to those in need.

The demographic problem for Obama is that the Boomers have seen what has happened to the American public schools and understand that a single payer system means that they get rationed out of their current Medicare benefits.

Now add on top of that major problem the "Terri Schiavo <http://www.bing.com/search?q=Terri+Schiavo&FORM=SSRE> Effect" of the Government intervening in family medical decisions.

The Republican Party started tubing in 2005 with their moderate and libertarian wings when they catered to their Social Conservative extremists by intervening in the family end of life dispute over Terri Schiavo.

Obama's single-payer ideologs are now doing the same thing with the entire WW2 and Boomer generations as the latter are dying and the boomers are feeling their own encroaching mortality.

The government inserting itself into American family's end of life decisions is the new 3rd rail of American politics and the Leftist Democrats around Obama are doing a slow goose step march on top of it.

Trent

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