Saturday, December 31, 2011

Growth Comparison: Medicare vs. Private Insurance

This piece in the Times gave me an excuse (and a source) to look at growth rates of normalized per enrollee expenditures for Medicare vs. Private Insurance.  The author uses the data to make a case against competition:
Despite competition and choice in the private insurance system, Medicare spending has grown more slowly than private insurance premiums for comparable coverage for more than 30 years.
 Below is a chart showing the annual change in cost.  At first glance it supports the contention that private insurance on average has higher growth rates.  The actual annualized rates from 1969 - 2009 are 8.2% for Medicare and 9.5% for private insurance.  That makes a big difference over 40 years.

But check out the spike in the late 80's.  Up to that point spending growth tracked fairly closely, the annualized growth rates from 1969 - 1986 are within a tenth of a percentage point.  Then from 1987 to 1991 private insurance becomes a house on fire.  What happened?  The answer is that Congress raided Medicare using the newly enacted PPS reform.  From the Incidental Economist piece:
Aggregate Medicare hospital payment-to-cost ratios fell every year from 1987-1992 because hospital did not restrain costs as quickly as payments were adjusted (Guterman, Ashby, and Greene 1996). As Medicare margins fell, private pay margins grew over this period. The effects of managed care had not yet been fully felt in the commercial market, leaving private purchasers vulnerable to hospitals’ market power...
Hospitals took back from the private insurer market what they lost from inadequate Medicare payments.  Hospitals pushed that as long as they could until employers responded by embracing managed care, initiating the age of HMO's.  Getting back to the growth rates, if private insurance had grown at the same rate as Medicare from 87 to 91 the annualized rate over 40 years drops to 8.7%.  Still half a point higher then Medicare, but a lot closer then Medicare/single payer advocates like to claim.  Especially if you think cost shifting happened in more then just those 5 years. 

More important though is that there is no fiat answer to slowing cost inflation.  From 1969 to 1986 Medicare and private insurers were equally bad at it, competition or its absence was irrelevant.  Once payers started getting tough both systems proved capable of containing costs.  PPS made a huge difference to Medicare, and managed care proved effective in private markets (look at 92 - 97). 

What it comes down to is that for cost control you don't need any particular system, you just need the backbone to stand up to providers.

Wednesday, December 28, 2011

More coverage on implants

in the NY Times.  The part they don't mention is that the cost of settling all this crap will ultimately be born by citizens, either directly by patients facing unreimbursed costs or by health insurance payers who will make everyone in the industry whole through higher prices.  Not only will we pay for direct damages to remove the implants and defragment people, but we'll pay all the legal bills incurred as doctors, hospitals, manufacturers and insurers try to pin blame on each other.  It's too bad no one tested these implants for effectiveness, assuming an average severity of  5K per recipient puts the total liability at 2.5 billion.  That would pay for a lot of effectiveness testing...

Coincidentally AP ran a story on the Patient-Centered Outcomes Research Institute (PCORI), created by the Obama health care reform.  The mission of that organization is exactly that- testing medical effectiveness.  Expect opposition from care providers and whoever will carry water for them.  When they say "death panel", think "hip shredder". 

Development and Taxes

Random statistics:  The property tax payoff for the SE 28th and Burnside condos.  An old greasy spoon Chinese restaurant on the corner of Burnside and 28th was torn down to make way for condos in 2009.  How much value did this create?

I'll use a real simple first order approximation and look at property taxes.  The figures are online at Portlandmaps.com.  The 32 condo units have a 2011 tax totaling $138,997 or an average of $4,344 per unit.  That's about 10% more then the average tax paid by the rest of the non tax-exempt property owners on the block, who actually own land!  To put those numbers in concrete terms, look at the map:

Now you might think there is something wrong with that block, maybe the land use is particularly ill-conceived and atypical.  So I rolled up the taxes on the block south as well.  That block had an even lower average tax, a few points below the Burnside block the condos sit on.  Here is a total view:
So that little sliver of condos pays almost as much in taxes as the rest of the two blocks combined.  To put it another way, the condo development almost doubled the tax revenue coming from the two blocks.

Who benefits from the taxes?  Pretty much everyone.  It is money for schools, the city, the county, and just about every other local municipal agency.  Even the greasy spoon came out better off.  And best of all it was accomplished without coercion, but by just staying out of the way and letting change happen.  Keep that in mind the next time you hear about a development proposal.

Saturday, December 24, 2011

Implants: An object lesson in Ineffectiveness

Via the NY Times, an Australian study shows how newer models of joint prostheses fail at higher rates then older more established models.  The failure rate may not be the worst aspect of the newer style implants.  They also pose risks due to breakdown of the metal rubbing on metal, releasing metallic particles into surrounding tissue.  Resulting inflammation can make replacement surgery "far more complex and can leave some patients with lasting complications."  Some questions:
  • What drove physicians to use the newer implant style over the old one?
  • What disclosure was made to patients about the relative risks?
  • Do we really not keep an implant registry?  Getting information second hand from Australia is the best we can do?

Tuesday, December 20, 2011

Memory and the Future

This piece by Ryan Avent displays a rare sense of humility  in admitting how difficult it is to imagine the future and how our descendants might judge us.  To participate, consider how you think about the past, and in particular the decisions made by our predecessors.  Do you lament or celebrate the widespread adoption of the automobile, or the industrial development that polluted so much of our environment, or...  anything?  The sad truth is we think little about the past at all, the world is what it is and we try to make the best of it.

This is part of what I dislike about preservationism, the idea that we should preserve structures so that future generations can enjoy them.  Who knows what future generations will enjoy or value or need?  Think about BDS shutting down the Green Castle cart pod in part because a neighborhood planning document written in 1987 didn't contemplate food carts.  1987!  That's only 24 years ago, yet I have absolutely no idea, interest, or even desire to know what people back then thought except as a purely historical concern.  How much less compelling would be the ideas and intentions of people from fifty years ago, or a hundred?

Preservation doesn't save the past so much as it foists the present whether people want it or not.   Implicit is the belief that the way things are now is the best that they could ever be, and that any change would necessarily be for the worse.  It is narcissism writ large.

Sunday, December 18, 2011

Medicare and the Development of Rate Setting


Via Incidental Economist and White Coat Notes, I found a pretty good paper on the developments that led to Medicare's Prospective Payment System (PPS) in 1982.  PPS is the price setting mechanism that specifies what price hospitals are paid for the services they render.  Under PPS they get a per diem rate set by the federal government.  Prior to the advent of PPS Medicare just paid cost- hospitals sent in the bill and Medicare paid it.

The paper describes how Medicare from inception was beset with massive price inflation, with expenditures running at 5 times what was expected a mere 8 years after full implementation.  That inflation quickly led to cost control efforts, first with Nixon in 1972.  Though ineffective at controlling prices, that reform enabled state pricing regulation such as Maryland's all payer system.  Coincidentally, they were the first state to seek out pricing regulations and they are the only state that kept them.

Carter took another bite at the apple but whiffed, with hospitals successfully killing his proposal in Congress.  Carter's efforts were not for naught however as the price hospitals paid was a commitment to voluntary cost controls.  The voluntary effort showed modest success for two years, before hospitals fell off the wagon at roughly the same time Reagan came into office.  The outcome of this combination was not what you'd expect.

Republicans had hung their hats with the hospitals against Carter and been made to look like fools.  Their antipathy for government spending overruled their hatred of regulation, with some added incentive that Social Security was bankrupt (and I mean "we don't know where next month's payments will come from" bankrupt).  This led to a monster Social Security reform bill, part of which involved robbing the Medicare trust and paying for it by using PPS to bring costs in line with the balance.  Most legislators didn't even know what a DRG was, to them it was just a Social Security bill.

Some lessons to draw from this:
  • "Single Payer" means absolutely nothing when it comes to reining in prices.  What matters is political consensus and the will to enforce it.
  • Compare how Reagan and Dole reacted to their challenges to say, George W Bush and Tom Delay.  The GOP has fallen a long, long way.
  • That said, cost control reform doesn’t happen without major bipartisan support.  72 and 82 both involved mixed leadership.  Carter's efforts failed in large measure because Republicans made hay by standing with the hospitals.
  • Major reform involves lots of actors with lots of motivations.  Republicans put aside their antipathy to regulation when it allowed them to save money.
  • Successful reform requires provider participation.  They won't come to the table unless you hit them with a really big stick first, one big enough that whatever reform you seek looks like pain relief to them.  TEFRA served this purpose with PPS.
  • All reform is temporary.  Providers will eventually subvert any cost control regime given enough time, as Medicare's current finances demonstrate.
  • Finally, crises really are opportunities.  The Social Security debacle was the backdrop for PPS and it gave everyone more backbone then they would have had otherwise.

Saturday, December 17, 2011

Hospitals are the new Drug Companies


Good:  Regulations aimed at limiting the influence of drug reps over physician behavior has led to lots of unemployed drug reps.

Bad:  Those same drug reps are now being hired by hospitals to influence physician behavior.  Some choice quotes (emphasis mine):

"While hospitals have always tried to woo doctors to refer patients to them, the institutions are growing more direct in their efforts. The hospitals mine data to see which doctors have the most profitable, well-insured patients, and then they assign those doctors to a sales rep. "

"While federal law prohibits hospitals from paying doctors to admit patients, hospitals paying sales people to influence doctors can get the same results [said a critic]."

Remember, market leverage is what allows hospitals to raise prices.  Just one more example of why it is profoundly unwise to pretend medical providers are angels.

Cumings' Korean War

I finished reading Bruce Cumings' Korean War this week.  This book is a thoughtful retrospective on what the Korean War means to Korea and the vast misconceptions that still define the conflict in the American consciousness.  It is not for the faint of heart, Cumings does not shy away from gory detail when he wants to make a point.  His views of North Korea are considerably more sympathetic than pretty much any other American author.  That was in fact why I picked up the book, dissidents may be right or wrong but they're almost always interesting.  I was not disappointed. 

Cumings describes a conflict that anticipates Iraq as much as it does Vietnam.  An ignorant and ill-prepared military occupation quickly followed by guerilla warfare, rampant atrocities against civilians committed by American troops and the Korean forces they empowered, and driving it all an arrogant belief in the inerrancy of American military power.  It is tragic that Korea is our forgotten war, there is a hell of a lot to learn in it.

Thursday, December 15, 2011

Happy Ending in Hollywood

I'm glad Creston Homes found a way around neighborhood opposition to build on the empty lot next to Hollywood Theater.  Success came from giving up early on working with the Design Commission and neighbors.  The article quotes a project manager with the developer (emphasis mine),
“It had a lot to do with the fact that anyone in the neighborhood could file an appeal of any decision (of the design commission), for a small fee,” he said.
Such appeals, [the project manager] noted, could have derailed the project.
The commission’s design review process also could have been longer, he said. And that would have made a huge difference because city building permit fees increased on July 1. Because the team applied before fees increased, [the project manager] estimates that it saved $56,000. The permit for construction was issued Nov. 17.
Anyone can appeal anything for any reason, at low cost.  Even if the appeals are eventually rejected by the Design Commission that can drag out the review process for months.  That by itself is enough to kill projects.  The net result is a regular review track heavily weighted towards preserving the status quo, even when that means keeping an empty lot at an address with a walk score of 92 in an area targeted for major transit infrastructure.  As a city with dreams of growth and density Portland needs to do better.

Tuesday, December 13, 2011

Conflicts of Interest in Medicine

Nothing good comes from thinking of doctors as angels.  That isn't to say that they are bad, just that they put pants on one leg at a time like anyone else.  And when one takes 300K in sponsorship money from a drug company, that means they have a conflict of interest just like it would for anyone else... 

The real lesson here though is that your care is ultimately your own responsibility.  Finding out whether your doctor's financial interests may conflict with your own, and what to do about it, is up to you.

(H/T White Coat Notes)

Monday, December 12, 2011

Republicans and Ineffective Medicine

Incidental Economist noted an interesting story from a few years ago by Shannon Brownlee in the Washington Monthly, it is well worth reading in its entirety.  The gist of it is that there is very little research on the comparative effectiveness of medical treatments.  So when a doctor recommends treatment x, there is a good chance there is no scientific basis for saying that x is a better choice then treatment y.  The consequences of this can be horrific:
For example, surgeons long assumed that a radical mastectomy for breast cancer, removing not just the breast but the underlying chest muscle and the lymph nodes under the arm, was the only way to get every last cancer cell. Then a massive, multimillion-dollar clinical trial launched by the NIH in the 1990s found that lumpectomy with radiation was just as effective, not to mention less traumatic for many women. Many patients and doctors also fervently believed that high-dose chemotherapy was a woman's best hope when she had advanced breast cancer. The brutal regimen was used for twenty years before clinical trials finally demonstrated that it was no more effective than standard, far less punishing doses of chemo. During those twenty years, an estimated 9,000 women were killed not by their cancer, but by the high-dose treatment.
You'll need to read the story to understand all the reasons why we do so little research in comparative effectiveness, but one cause stands out because of its intentional character.  The first Bush administration created an agency that could deal with this problem, the Agency for Health Care Policy and Research (AHCPR).
Democrats and Republicans alike hoped that the AHCPR's research would help rein in costs by giving doctors better direction, and offering payers—especially Medicare—the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed—and refrain from giving them care that could harm them.
Unfortunately, the agency did its job and released a study on back pain in 1994 that was unfavorable to back surgeons.  The surgeons got up in arms and found a champion on capitol hill in the new Speaker of the House, Newt Gingrich.  Although he failed in his goal of eliminating the agency, he succeeded in restricting its mission.  "Now, the AHCPR would merely be a 'clearinghouse' for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover." 

Simply put, Newt worked to keep healthcare stupid.  The consequences of that stupidity are obvious:  rampant price inflation, unaffordable premiums and increasing numbers of uninsured, and oh yeah, a bunch of guys who were rendered impotent and/or incontinent for no good reason.

You might think that this would be an issue given Newt's front-runner status for the Republican Presidential nomination, and in a different world it would be.  But in this world making healthcare stupid isn't exceptional for the Republican party, it is the rule.  Just look at the treatment of Don Berwick, Obama's nominee to head the Centers for Medicare and Medicaid Services.  He served a year under recess appointment before being filibustered out of office by Senate Republicans.  His awful crime?  You guessed it, promoting medical effectiveness. I won't even go into IPAB.

All of this leads to a question:  What is it about ineffective medicine that so appeals to Republicans?

Saturday, December 10, 2011

How the Internet makes the world smaller

While reading comments on a post on one of the health care blogs I noticed someone named Maggie Mahar.  Her comment jumped out as it received a response from the blog author that showed obvious respect.  Later while looking for something to read on my next trip I found this, a big book by Maggie Mahar on health care financing.  Small world...

Thursday, December 8, 2011

Different stick, same horse

Beating the same horse as yesterday, here's a WW story on problems in the Portland rental market.  The elephant in the room is that most of the inner east side is reserved for single family housing.  Planners have sort of acknowledged the incongruity between their density goals and the infrastructure on hand, but the only solution they've posed is granny apartments.  They are nuts if they think that is a solution, if people don't want to live in their mom's basement why would they want to live in some other mom's basement?  And on the owner side if people can afford to buy a single family home in the city why would they take on the infrastructure cost and liability of creating a separate unit in exchange for low end rent?  Even in this puff piece they cite $1,200 per month in rent- exactly the high end niche that is already amply served.

The reality is that if Portland wants to encourage high population density it needs high density housing.  What exists  on much of the inner east side isn't it.

Wednesday, December 7, 2011

Followup on Irvington

The new issue of the Hollywood Star has further reporting on problems between the Irvington Community Association (ICA) and the city over the Historic Preservation District.  The story is worth reading in its entirety, but sadly is not available online as far as I can tell. The gist of it is that there are two issues:
  • The current fee schedule represents a "doubling" of cost per the ICA
  • The ICA is dissatisfied with what actions trigger review and what do not.
No offense, but buyer beware.  By doing what it did the ICA voluntary subjected Irvington to the whims of the city's review process and its expense.  There is no exception in the city code that says review will follow exactly what the ICA wants at exactly the price ICA thinks appropriate.  That point is obvious, and it should have been obvious to everyone involved last year.  But focusing on the ICA misses the real culprit, which is evident in a parallel story about the Buckman neighborhood's pursuit of its own historic register listing.

Per the Buckman story the only way a register listing can be opposed is if a majority of property owners send a notarized letter of opposition.  Read that twice- they aren't saying a majority of people who write in, but an absolute majority of all property owners have to send notarized letters opposing the designation to shut it down.  That burden is so insurmountable that the state doesn't even include the possibility in its process flow chart.  It's a process so slanted to produce an "approval" it would make union organizers blush.

No wonder the Irvington listing passed, there was no way it couldn't.  The process doesn't imply real consent, it is designed to provide a fig leaf of consent while passing the listing.  I'd expect to see something like that in a history of Jim Crow South, not living in the flesh in my state government.

This brings me back to a quote in the original posting on Portland Architecture,
[an architectural historian and Irvington Preservation Committee member] said the Portland currently counts 5,277 buildings either in historic districts or individual landmarks on the National Register – all of which require design review for exterior alternations.
That list could grow substantially in the future. Citizens are either gathering data for potential historic districts in the Buckman neighborhood and are investigating that option in at least two others.  Under  national historic standards, [the historian] said 85 percent of buildings in North and Northeast Portland west of 82nd Avenue could qualify as eligible for historic protection.
Much of inner Southeast Portland is basically of the same vintage, so potentially the entire inner east side could be put off limits to development.  How does that square with the urban growth boundary, which demands urban infill?  How does that square with Oregon's property tax limits, which demand redevelopment in order to sustainably fund city services?  How does that square with the premise that the Portland metro population will double in the next 30 years?  There is a serious disconnect here...

Tuesday, December 6, 2011

What we have here is, a failure to communicate...

Per Incidental Economist, a study on how well parents of overweight children understood their children were overweight...  after being told by a doctor that their children were overweight.
This study couldn’t be simpler. The parents of nearly 5000 children who were over the 85th percentile for BMI were asked if they had been told their child was overweight (they were). Know how many said yes? 22%.
Admissions to med school are ultra competitive, with selection based on MCAT scores, GPA and the like.  What if the people selected by those criteria absolutely suck at communication with the average American?  I see it as just more evidence that we have the wrong people practicing medicine.

Saturday, December 3, 2011

Kitzhaber (vs. Occupy?)

From an address by the governor yesterday to the Oregon Civics Conference (emphasis mine):
That brings me to this whole issue of civic engagement and civic literacy. It is our civic machinery, our structure of government, that gives us the capacity to resolve disputes and work in the interest of the common good. It allows us to achieve our highest aspirations as a society. We take that for granted, but it works only as well as the people who are engaged in it. So that means people have to understand it.
So let me wrap up with a quick story from my own background. I was civically illerate for the first two decades of my life. I was bored to death. I was not interested in politics. I was not interested in government. I was a 21-year-old student, a junior, at Dartmouth College in 1968, when a lot of things were going on — the civil rights movement and the war in Vietnam.
“Martin Luther King was registering black voters in the South, there were sit-ins in restaurants, where they would go into segregated restaurants and sit down at the counter and expect to get arrested. They didn’t oppose the rule of law, but they wanted to highlight a law they felt was unjust. As a result of that, we had the Civil Rights Act, the Voting Rights Act, and ultimately elected Barack Obama president.
In 1969, people were getting drafted to go to Vietnam at the age of 18, but you could not vote until you were 21. So we were essentially being drafted and sent halfway around the world to fight in a war that had murky justifications, at least to us, who had no say in that. Bobby Kennedy was running for president; he was against the war, and he was giving a voice to many voiceless people — the farm workers in California, native Americans on reservations, who were out of the mainstream of American life. That was all going on.
That April (1968), Martin Luther King was assassinated. I can remember right where I was. I was in a physics shop, I remember putting my screwdriver down, listened to the radio and felt profoundly moved. I couldn’t even begin to tell you why. It was just as if the light had gone out. Then when Bobby Kennedy was assassinated on June 6, just after he won the California primary. I think for a lot of people my age, we just decided the country lost something that was a lot more than two individuals. But it was a belief that you could work in the system, work within the structure and change the world and make it better — and we all had a responsibility to do that. That was my moment of political awakening. I ended up doing this for a lot of reasons.
So my message to you is that you really are not powerless. I am speaking more to young people, not to those who teach and guide them. What this country desperately needs is to rebuild a sense of community. There are certain things we have to do together to make us all better. The only tool we have to make that happen is our government structure — and the will of individuals to use that structure. If you drop out, it operates on its own. You are the drivers. Civic literacy gets you there. It is your ticket.

That looks a lot like a rebuttal to the Occupy movement to my eyes:
  •  America has structures for civic engagement but those structures don't run themselves, they are only tools for citizens.
  • The civil rights movement is a demonstration of how to effectively use those tools.  Civil disobediance targeted at specific laws, with the purpose of changing them to create fairer and better laws.  With the tools we have, even the most disadvantaged segments of society can affect radical change.
  • No system is perfect, and sometimes things go bad as when national reform leaders were murdered.  We face a choice in those moments, to carry on the work of building a better society or to abandon it and fall into cynicism and disassociation.
  • Too many people have chosen the latter course in the false belief that it is a means of reform.  It is not.  Our system of governance is the only one we have, and disassociating from that system won't change it.  It just makes the system operate poorly.
Instead of blowing up another park Occupy leaders might want to think about this.

Thursday, December 1, 2011

Bartlett on Gingrich

Bruce Bartlett has a good op-ed in the NY Times on Gingrich's efforts to stupidify congress.  What struck me was the ending line:
It is essential that Congress not cripple what is left of its in-house expertise. Gutting the G.A.O. and abolishing the C.B.O. would be acts of nihilism. Any politician recommending such things is unfit for office.
Acts of nihilism are pretty much all Republicans can manage.  Consider the attempt to default on America's debt, or the intent to revoke health care reform without an alternative solution.  On too many fronts Republican ideas have been proven decisively wrong:  Lassez-faire markets and the wall street debacle, climate change and the increasing frequency of catastrophic weather events, trickle down economics and the most unequal society in living memory, the George W Bush administration...  Rather then acknowledge failure, Republicans resort to wholesale denials of reality and nihilism.  Gingrich isn't exceptional in his need to dumb things down, he is typical of the Republican party.

Finished reading "Broken Branch"


This book wasn't what I wanted.  Too much of it was the authors quoting their own columns in Roll Call.  Ugh…  I came away knowing not much more then I did going in.  Newt Gingrich is responsible for a lot of bad things, the level of centralization within the house has changed over time.

Ok, why did the house trend toward decentralization for most of the 20th century?  Why did incoming Democratic freshmen demand more of a voice, while incoming Republican freshmen gave it up?  Why are congressmen less likely to stay in DC and why in an age of ever-present telecommunication does it matter?  Why does the south seem to dominate national politics through whichever party it leans towards?

Questions for another day (and a different book).

Monday, November 28, 2011

Huh (All Payer Claims Database Edition)

The MA commission reviewing provider pricing regulation came out with recommendations a few weeks ago.  The headline is that this is another step towards pricing regulation, but something else caught my eye.  One of their recommendations was to increase price transparency, and included this (emphasis mine),
Access to the All-Payer Claims Database. DHCFP is currently in the process of developing an All-Payer Claims Database (APCD), pursuant to M.G.L. c. 118G §6.  The Special Commission recommends that the state make the APCD accessible to consumers, purchasers, providers, insurers, and researchers both for standardized queries and in support of research to analyze price variation consistent with the provisions of the Data Release regulations, 114.5 CMR 22.00 et seq. Such disclosure should carefully guard protected health information (PHI), consistent with the Health Insurance Portability and Accountability Act (HIPAA). In addition, the Special Commission recommends including third-party administrators that process claims for self-insuring employers among the entities required to submit claims data to the APCD, consistent with the filing requirements for insurers serving fully-insured employers and individuals, to the extent it is legally feasible to do so.
Back in February I emailed the Office for Oregon Health Policy and Research to see if citizens would have any access to Oregon's all payer data.  The answer was no, due to privacy restrictions.  Maybe I'll forward them a copy of the MA report...

More on the concept that we need different doctors

Via Incidental Economist, more evidence that we'd be better off with different people going into med school.  Some folks did a study comparing graduates from Mount Sinai's non traditional HuMed program with those from the regular med school.  From the abstract:
Purpose: Students compete aggressively as they prepare for the MCAT and fulfill traditional premedical requirements that have uncertain educational value for medical and scientific careers and limit the scope of their liberal arts and biomedical education. This study assessed the medical school performance of humanities and social science majors who omitted organic chemistry, physics, and calculus, and did not take the MCAT.
...
Conclusions: Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.
 Not only was their performance statistically the same, but HuMed grads were more likely to go into cost effective primary care and less likely to do high cost surgical specialties.  That isn't a neutral result, it's a win.

Sunday, November 27, 2011

Irvington Historic District: Buyers Remorse

I guess some people didn't know what they were signing up for when Irvington applied for Historic District status.  Take a look at the fees applicable.  "Minor Projects" like changing the house color or adding exterior lights now costs $1,050, just to pay the city to think about whether or not it will allow the homeowner to proceed.  I can understand why people would be upset, but how did they not know what they were signing up for?  It's not like the city just created the fee schedule, this is what Irvington residents elected to do to themselves

I can laugh now, but I'll be downright pissed if they get the fees reduced and I wind up having to subsidize their nonsense.

Paul Starr Op-Ed

The O linked to a Paul Starr Op-ed today.  A lot of it is a digest of Remedy and Reaction, but with some extra musing about the paring of Obama and Romney:
If former Massachusetts Gov. Mitt Romney and President Obama face off in the 2012 presidential campaign, America will witness the singular spectacle of two candidates getting very little love, and plenty of hate, for the same signature achievement: reforming health care.

Both overcame long odds to pass legislation, Romney in Massachusetts, Obama at the national level. Even the specifics of their reform laws are similar: Both include subsidies for private insurance, the establishment of insurance exchanges and a mandate for individuals to maintain a minimum level of coverage. Each man expected to reap credit for his effort. But neither has gotten political mileage out of it; in fact, both may have lost more ground than they picked up.

In another era, we might be celebrating the remarkable fact that both a Democratic president and a leading Republican challenger arrived at fundamentally the same approach to fixing our health-care system. That is not the America we live in now.
Worth reading.

If you wonder why enactment was delayed until 2014, Starr gave these reasons in R&R:
  • Delaying enactment reduced the CBO cost, which covers the next 10 calendar years
  • The decision to give states the responsibility for creating exchanges meant giving them time to enact legislation
  • IRS said it would be confusing and chaotic tax-wise if programs incepted mid year or inconsistently across states
  • Dems did not want enrollment occurring in Nov 2012 during election.  Medicare Part D blew up in someone's face in 2004(?).

 Starr implied that the real problem was Obama's failure to anticipate right wingers' willingness to turn on their own ideas in order to score political points.  That's what makes the prospect of a race between Obama and Romney so ironic.

Friday, November 25, 2011

Occupy vs voting

There are aspects of the Occupy movement I'm sympathetic to:  The initial focus on the actual Wall Street and the institutions that inhabited it was brilliant.  Just by being there, just by showing that citizens have as much right to Wall Street as Main Street they knocked it's mystique down a peg.  But then everyone decided to Occupy Wall Street, and many decided that New York was too far away and it was easier to occupy whatever was close at hand and would gain attention.  The movement when downhill from there...

That leads to today's post in the Oregonian. I'd read that protest camps tended to rely on caucuses and consensus rather then voting to make decisions, but I didn't know their contempt for voting ran so deep:
"We are demanding that we stop trying to solve problems in a "vote yes, vote no" format. We are making a statement that they cannot and will not be resolved simply by electing a different puppet into the same political structure..."
How do these people reconcile themselves with the history of struggle and sacrifice aimed at extending voting rights?  Do they think that was just a waste of time?  Gaining majority support is hard and uncertain, but without it there is no legitimacy.  Demagoguery is a poor substitute for democracy.

Monday, November 21, 2011

More Pushback from VT Providers

We've seen the "good cop" side of Vermont care providers' response to Single Payer, here comes the "bad cop."  The good doctor gives a litany of ways providers will react to the cost control regime, none of them good.  This kind of reaction is predictable and inevitable, it is why single payer advocates who focus solely on the evils of private insurance are not setting themselves up for success.  But two points are worth bearing in mind:
  • The fact that doctors practicing under the current system are unwilling to practice under a system affordable to the public doesn't mean that reform is unworkable.  It just means that different doctors will be needed.  Med Schools starting at the application stage need to reconsider what it means for someone to be a good candidate to become a doctor.  Why does someone want to practice medicine?  Is it to help people, or to get automatic entry into the top 0.1% of the economy?  Such questions need to be given priority, especially when you consider how trivial admissions processes are (is it relevant in any meaningful sense whether someone got an "A" or a "B" in a weed-out OChem class?)
  • Despite all the threats and complaints, the reality is that doctors in countries with single payer plans tend to be happier with their work then doctors now in the U.S. Again, see the point that maybe we need different people with different priorities and motivations practicing medicine.

Saturday, November 19, 2011

Why the "industry" means more then insurers

When Oregon considered creating its Health Insurance Exchange, there were two key issues of dispute.
  • Would the exchange be an "active purchaser", with the ability to exclude carriers even though they met federal qualifications?
  • How many board members could be from the "health care industry," where that was broadly construed to mean insurers and providers.
 In discussions of the latter issue, it was routine to see questions about why doctors should be excluded or to simply construe "industry" as meaning insurers.  Implied was that providers were disinterested parties not at all concerned about money.  Here is a headline that puts such thinking in its place:

AMA opposes ‘active purchaser’ model for exchanges

H/T Incidental Economist

Irreconcilable Differences on the Right

From Kaiser, on why South Carolina isn’t trying to build an exchange:
[South Carolina’s Director of Health and Human Services] argues that the main function of the exchanges is to deliver the federal subsidies. That, according to Keck and other members of the subcommittee he chairs, "is solely a federal concern in which the state has no compelling interest."
From WSJ, claiming federal exchanges can’t offer subsidies:
ObamaCare authorizes premium assistance in state-run exchanges (Section 1311) but not federal ones (Section 1321). In other words, states that refuse to create an exchange can block much of ObamaCare's spending and practically force Congress to reopen the law for revisions.
Who’s lying?  Also notice the extortion angle in the WSJ piece- rewrite the health care law or Tea Party states will go to court to deny themselves exchange subsidies.  Wow, that will keep people up at night.

Monday, November 14, 2011

Ratemaking vs. Negotiating in Vermont

Doctors in Vermont have apparently picked up on the concept that they will be providing most of the savings under Single Payer.  Unsurprisingly, they're forming bargaining units to "inform the process."

Here is a philosophical question:  Does it make sense to pay doctor groups differentially based on how effectively they negotiate?  Should the Vermont Medical Society get paid more then HealthFirst because of the skill of their lobbyist?

That question points out a politically incorrect truth.  The process of establishing provider payments isn't really a negotiation at all, it is an exercise in rate setting by the state.  That rates will likely be influenced by "negotiators" does not contravene this, it will just indicate a clumsy and poorly thought out ratemaking process.

Saturday, November 12, 2011

POW: Alex Steffen

LSE hosted Alex Steffen for a discussion of where the world in general and cities in particular are going.  I thought the most interesting take was the concept that what will save us is better data.  He talks about how everything from how we drive (mileage meters) to how we use power or water will eventually automatically record data and then give us information- how do we do compared to average?  How are we doing compared to yesterday or the year before?  To me it is a profound example of tech making what was once arbitrary and irrelevant into something specific and purposeful- changing how we use the gas and break pedal to be more efficient, connecting actions with consequences.

There is a downside though, in that the process of converting data into knowledge is not value free.  Someone has to determine what the average is and how it should be calculated, someone determines the scales on which we judge ourselves.  For example with utilities is the relevant average per household or per person?  For vehicles should they be judged by class (hatchbacks separate from SUV’s) or all together?  Those questions establish norms for society, but because of their “back room” nature it is unlikely people will be aware of them or the values embodied in their selection.  It’s analogous to what insurers do in developing classification plans, except that if people don’t like the way an insurer classifies them it’s easy enough to find a different insurer.  Not so with society…

Wednesday, November 9, 2011

Notes from Vermont

The Vermont Legislative Joint Fiscal Office released a report estimating the savings made possible by Single Payer. They estimate it will save between 0.8 and 3.5 billion between 2014 and 2019. To put those numbers in perspective, at the high end it would save more in six years on a per person basis then the much ballyhooed “super committee” is trying to cut in ten.

There’s also plenty of grist to back up my suspicions that people who advocate for Single Payer don’t really know what they’re talking about. The most common narrative advocating Single Payer runs along the line of “If we just get rid of the insurers, there will be tons of money and everyone will be happy.” Helpfully, Vermont breaks out their savings into some detail:

The low estimate shows about a third of savings coming from admin including both the payer (insurance) and provider (doctor) sides. More then half the savings come from clinical reform, which addresses how much doctors get paid, in what manner (capitation vs. fee for service), and improvements to public health and reduced utilization. The location of the "fat" is even more apparent in the high estimate:

So if Single Payer works the way people want it to, more then 75% of savings come from medical reform, not admin. And unsurprisingly, this is really hard. The paper discusses some of the issues confronted just to construct credible estimates. For example,
Each of these [payment reforms] has its own set of difficulties. For example, what is the right price to pay for a medical service? Is it the amount it costs to produce? Is it the amount at which an adequate provider supply is available? Is it the amount someone without insurance would be willing to pay for it (and who – Bill Gates or someone working at a minimum wage job)? Finally, is it the amount we as a society can afford to pay?
Implementing Single Payer involves all kinds of questions about what care should be delivered and what should be paid for it. In my view to answer those questions is to sell the program. How likely are people to buy into single payer if they don't know what they are getting? Instead advocates rely on a false narrative that reinforces a mythical conception of cost-free healthcare, one that ensures that even if the public does buy into single payer they will be unwilling to accept the compromises necessary for it to actually work.

Thursday, November 3, 2011

Remedy and Reaction

I finished reading Paul Starr’s Remedy and Reaction.  This is an extraordinarily readable discussion of health insurance.  The book is worth getting for the first chapter alone, which summarizes reform efforts from the progressive era through Carter with enough detail to articulate why programs like Medicare succeeded versus the many others that failed. 

Starr then devotes chapter length treatments to the Clinton and Obama plans, describing why the Clinton plan ran off the rails and how Obama was determined to avoid the same fate.  I couldn’t help but walk away with much more respect for both men for their efforts.

Highly Recommended!

Monday, October 31, 2011

Pushback on rates

This is interesting.  A large health insurer is suing Maine for setting rates below what would be required for a "a fair and reasonable return."  The margins in question are

  • 2009 3%
  • 2010 0.5%
  • 2011 1%

For context, Oregon (cited in the article) set rates at negative returns, specifically saying they wanted to take insurer surplus and give it to consumers.

This kind of “taking” looks fair if you don’t think about it.  After all, why shouldn’t consumers benefit if insurers have excess capital?  The problem in a nutshell is that the excess capital wasn’t paid in by the same people who would be getting it out.  People who are policy holders in 2011 are not necessarily the same people who were policy holders in prior years when the surplus was built up.  Even more so, there are differences in product mix.  If an insurer is making “fat” profits off large group customers, what is the moral reasoning behind taking that money and giving it to small group or individual customers?  It subsidizes small business at the expense of large, or even worse subsidizes employers that don’t offer insurance by taking from those that do.  Anthem leaves this to section III-A-3 in their brief, but to me it’s their best argument.

I hope the Anthem suit fails because regulators should have maximum flexibility to respond to market place needs.  But at the same time the concept of “taking” deserves much more public scrutiny, and for that I’m glad the suit was filed.  Scheduled for oral arguments 11/8/2011.

Saturday, October 29, 2011

Women and the City

One of the angles I don’t see covered enough in public discussions of urban living is gender.  For instance, the desirability of standing alone in the dark at a bus or train station may change markedly depending on who you ask.  I’d expect that to filter down to residential choices, that women faced with income constraints would be more likely to move out until they found affordable housing rather then stay in and accept the trade-off in neighborhood quality.

Here in a roundabout way is empirical evidence.  The MTO study didn’t show the educational effects for children its authors were looking for, but it did find significant health benefits for women who moved out of high poverty neighborhoods to those with low poverty.  In essence better neighborhoods are healthier neighborhoods for women in a way that doesn’t apply to men.

Worth considering for a region like Portland with specific goals for densification and urbanization.

Friday, October 21, 2011

Blue Shirts Unwanted

"You're probably used to seeing TSA's signature blue uniforms at the airport…"  When I see the signature blue uniforms an announcement goes off in my head.

"Attention! You are now entering a liberty-free zone. What you once understood to be inalienable rights are void. So long as you are here your rights are the equivalent to what they'd be if we lost World War II. Thank you and have a good day."

The prospect of seeing signature blue uniforms more often and in places other then airports is both depressing and unsurprising.

Sunday, October 16, 2011

Hospital Pricing Regulation: A History (as of 1997)

I came across an extremely readable short history of state level hospital pricing regulation.  I highly recommend it for getting a broad overview of what was going on in the 70’s, and why it stopped. 

The short version is that prices were gamed, particularly by urban and teaching hospitals.  It created a situation where everyone, from the insurers to businesses to unions to the states themselves decided they could negotiate lower prices than the official rates.

The author notes the influence of politics on deregulation but suggests it was mostly symbolic, providing a rallying point for existing interests.  I think that gives short shrift to the power of ideology.  It’s a reverse Lake Woebegone effect- its mathematically impossible for everyone to negotiate costs below average, but everyone in the 80’s suddenly became convinced that’s what they could do.  Whatever you call it, the Reagan ethos had an effect.

It’s kind of funny, you wouldn’t guess from the paper’s tone that 14 years later HMO would be a 4 letter word.  The paper is actually a sort-of defense of regulation.  From the conclusion:

…viewed by the standards of the era in which they were created, and seen in the context of the tools that were available and usable at that time, mandatory hospital rate-setting programs were able to leave an overall legacy of effective intervention. In future years, when the shape and effects of the emerging system are more clear, we may yet come to a greater appreciation of the challenges and accomplishments of this health policy epoch.

I wonder if the author expected we’d be taking another look at this.

Saturday, October 15, 2011

History and Heart

I thought this column on learning from history was trivial, is it possible to engage analytically with the world without referencing history?  To do otherwise is an exercise in mythmaking or religion.  But he ends with a provocative question:  America came out of the Great Depression stronger and more unified, but does anyone think that will happen this time?

Friday, October 14, 2011

Book Review: Ghosts of Cannae

I finished reading Ghosts of Cannae. Very readable and enjoyable military history of the Second Punic War. Hannibal invaded Italy with enormous success, winning devastating tactical victories at Trasimene and Cannae. But he never translated those victories into strategic success, Rome stood undeterred. In a sense Hannibal was outclassed. Rome was not ruled by any warlord or Greek despot willing to make peace based on a rational calculation of interest. Instead it was already an empire with unmatched manpower and a Senate determined to win at all costs. If that meant sacking their own major cities like Capua then so be it.

Capua is instructive. They accepted Hannibal's offer to break off from Rome on the condition that they didn't need to contribute soldiers. That left Hannibal with the liability of protecting the city but no additional assets to do the job. An impossible situation, one quickly exploited by Rome. Hannibal couldn't win by being a mere warlord, he needed to make the conflict with Rome into a civil war instead of just a foreign invasion. That meant giving dissident latins something to fight for, they needed an ideology or an idea that was worth dying for. Hannibal couldn't just break up Rome, he needed to create an alternative. Instead, Rome created a new Hannibal in the form of Scipio Africanus and the rest is history.

The book references a provocative thesis I hadn't seen before: That the Republic fell because Rome couldn't meet its military challenges without powerful and charismatic generals, and that this was Hannibal's ultimate legacy. This seems a bit off- Rome did quite well isolating and marginalizing Hannibal without a superstar. The only way Scipio is necessary is if you think Rome would have run out of willing soldiers, and there's nothing to support that. How different would things be if Publius Scipio died at Cannae!

Saturday, October 8, 2011

Auto Enrollment vs. Mandates

The Incidental Economist looks at the Republican version of health care reform.  One interesting concept picked out is the idea of auto-enrollment:

Mechanisms include “ERs, submission of state tax forms, workplaces, and state dept of motor vehicles offices, such as when people renew their drivers license.”  Presumably by using these to boost enrollment other incentives such as the mandate/tax penalty would be unnecessary.

Two thoughts: 

  • What a whopper of hypocrisy to protest the mandate as unconstitutional because “the government can’t force you to buy something”, then propose something like this.  Here, the DMV or IRS is actually buying it for you without your consent.
  • Is there anything stopping a less coercive measure at the state level to supplement the mandate?  Make it as easy and mainstream to sign up for the exchange as it is to register to vote.

Friday, October 7, 2011

Good Quote from Robert Gates

Speaking at the National Constitution Center, he says,

I have worked for eight presidents, and I have known many politicians of both parties over nearly five decades, and I never met one who had a monopoly on revealed truth.

At a time when our country faces deep economic and other challenges at home and a world that just keeps getting more complex and more dangerous, those who think that they alone have the right answers, those who demonize those who think differently, and those who refuse to listen and take other points of view into account—these leaders, in my view, are a danger to the American people and to the future of our republic.

Worth remembering.

Thursday, September 29, 2011

Development Matters

ECONorthwest recently released a report on the long term financial challenges facing municipalities commissioned by the League of Oregon Cities.  The headlines are about benefit costs, and how their growth is far out of line with growth in government wages and property tax revenue.  But the report touches on something I don’t often see mentioned, the connection between development and property tax revenue.

From the intro discussing property taxes (emphasis mine):

Even though property taxes are not directly tied to personal income, it makes sense that the two go hand in hand. As a city experiences growth in population, and as its residents see their incomes grow, they drive demand for new housing and new businesses. This new construction fuels growth in assessed value, and in property taxes.

If measures 5 and 50 are a problem because they limit growth in property taxes, development is a salve that eases the problem.  And note that location matters:

Cities will also experience unequal property tax growth. Cities able to capture new residents and employment growth will experience more property tax growth, whereas cities unable to attract residents and jobs will experience personnel costs that far exceed any growth in property tax revenue.

If it’s easier to develop in Washington County then that’s where development will go, and so will the property tax revenue. 

This is why I get ticked when I see people blithely trying to kill development projects or redlining whole neighborhoods, as if there weren’t a cost to their actions.  Forestalling such development leaves the city and its residents poorer.  Some buildings are worth paying that cost in order to save and some are not.  But an honest discussion of costs and benefits is impossible when you miss one entire side of the equation.

Thursday, September 22, 2011

PPS looking grim

Conservatives rail against social security, warning young people not to assume it will be viable when they retire. I feel that way when I look at PPS. Increasingly I think it won't be able to provide an acceptable level of education to my kids. It doesn't mean private school but it does mean I'll treat it like a tool, one of many needed to get the job done.

I wonder how many other parents feel that way?  I wonder what we could do on our own if we put our heads together?

Saturday, September 17, 2011

Hospital Concentration vs. Insurer Concentration

 

Here is a very good post on the Incidental Economist discussing the leverage effects on pricing.  The author  posits a “sweet spot” in the middle, ie too much concentration on either the insurer side or the provider side will raise prices.

Something missed:  Regulation.  There is a well established regulatory authority to review insurer pricing and ensure monopoly benefits are passed on to consumers.  The regulatory task actually gets easier and more efficient as the number of insurers drops, and when you take it to the extreme you wind up in Vermont with single payer.  In contrast there is no established regulatory authority over hospital pricing, that’s still the wild wild west.

That suggests the “sweet spot” curve needs to be tweaked…

Friday, September 9, 2011

Hardware vs. Software

The NY Times ran a story this week questioning the value of technology in the classroom.  They cite in particular a showcase district in Arizona that has been pouring money into tech without creating any observable benefit in test scores. 

To me that story highlights a key point:  The “software”, that is the teaching practices and processes that rely on tech are critical to effective utilization.  As one teacher puts it in their signature file,

“It’s not the stuff that counts — it’s what you do with it that matters.”

The conclusion to draw from that isn’t that tech doesn’t matter, it’s that you need to do more then just buy stuff.  You need to think about how to use it, and adapt as you gather experience. 

Flashback:  The Social Life of Information makes the same point about business processes.

Monday, September 5, 2011

Provider Pricing Regulation takes another step closer to reality

in Massachusetts.  The fate of this proposal deserves as much attention as Vermont’s single payer plan.  Both depend on much greater scrutiny and regulation of health care pricing.

Saturday, August 27, 2011

POW: Delete

LSE hosted Viktor Mayer-Schönberger for a podcast discussion of his book, Delete: The Virtue of Forgetting in the Digital Age.  I’m a big fan of technology and its ability to shift information through space and time.  Mayer-Schönberger describes significant downsides to this ability, and how it conflicts with human cognitive function. 

Forgetting isn’t just loss, it is a curating process in which the necessary is separated from that which we don’t want or don’t need to carry forward. Forgetting defines and creates us as much as it destroys.  By putting so much of ourselves online we lose control over that process, the cloud forgets nothing.  Alternatively we could become luddites and withdraw from technology, but who would want to do that?  Mayer-Schönberger suggests an alternative solution:  building the ability to forget into cloud systems and making their function a little more human.

Interesting stuff.

Thursday, August 18, 2011

A better Groupon

WW has an article on the frustrations and problems of contracting with Groupon. It got me thinking.  How to do it better?

For starters, I’d use a different middleman.  Groupon reaches an audience that self selects for cheap eats.  Why not reach out to alternative local communities- for instance blog readers?  There are all kinds of local interest blogs like Blue Oregon, Portland Transport, Bog Blog, etc.  Why not reach out to them? 

Offer a theme night, with customers claiming “the Blog” sent them getting an x% discount.  The blog gets a reasonable kickback for promotion and generating traffic, the restaurant gets control over how much and when a discount is offered so disruption to existing clients is minimal, and blog fans get to show their support for their favorite bloggers while also getting a discounted meal and (depending on the venue) an opportunity to socialize with fellow fans.  If a particular audience proves a poor fit then they’re gone after one night and you never see them again.  If an audience fits in and does well then invite them back once in a while  What’s not to like?.

Sunday, August 7, 2011

S&P Downgrade

S&P is getting a lot of flak for the downgrade, with suggestions that because they ignored a big math error they were really just playing politics. That criticism misses the point. The downgrade isn’t a consequence of any mathematical formula, it’s a judgment on the behavior of congress (and especially the Tea Party) in last week’s debt ceiling debate. The U.S. very nearly defaulted. The whole purpose of ratings is to warn ahead of time of such an outcome. A post on Actuarial Opinions said it best:

Are you really surprised? AAA debt is supposed to be the ultimate sleep insurance. You park your money there and don’t have to ever worry about it. You don’t have to think about it. It is completely, unquestionably safe. If you didn’t feel that way last weekend, you agree with S&P.

Saturday, August 6, 2011

Recommended reading for the Tea Party

  Barbara Tuchman defines folly as “the pursuit of policy contrary to the self-interest of the constituency or state involved”.  It is hard to think of a more appropriate word to describe the recent behavior of Republicans and the Tea Party.

During the debate over the debt limit the Tea Party openly courted default and rejected compromise.  After the settlement the Republican senate leader described the crisis as a “template” for the future.  The consequences of this course were predictable and predicted.

So now that we’ve had our first downgrade which explicitly cites the inability of congress to compromise and its unwillingness to raise taxes, will the Tea Party change its tune?  Nope.  Keep on dancing, fools.

Thursday, August 4, 2011

What if…

There is a lot of feel good talk about how well the recent state legislative session went, with big agreements on health care, education and the budget.  I’ve had a fear in the back of my mind though:  What if the economy slows down in the second half of 2011, and state revenue fails to meet forecast?  That looks increasingly likely.

The question highlights how bipartisanship was possible largely because of an implicit (who knows, maybe explicit) agreement not to pursue fee or tax increases.  I don’t see how that arrangement survives if the economy does a double dip.  The line between us and Minnesota may not be as wide as we think…

Kudos to DCBS

DCBS gets some much deserved credit for its robust health insurance rate review process.  There are a lot of things DCBS can improve on, but it’s important to recognize they do a lot of things right as well.

Saturday, July 23, 2011

An interesting micro debate

on how progressively health care costs should be spread.  This story (especially the comments) presents a debate within one of the major public employee unions over how to bear health care costs.  One option was for everyone to pay a fixed percentage of their insurance premium, the other option was for everyone to pay a percentage of income.  Obviously, the first option would hit lower paid employees harder as they’d have to pay a higher percent of income, while the second option was more progressive.

Here is what they decided.

Book Review: Taney vs. Lincoln

I picked this up as a continuation of supreme court/federal history from the Marbury vs. Madison book. This wasn't as interesting. Cliff Sloan's history was a story of exploration and settlement as the court (and Washington DC) found their place in America. This is a story of their decline into irrelevance as they fought a futile campaign to preserve slavery in America. The Dred Scott decision was discarded in the north as soon as it was issued, the Prize cases were important not to America but to the British, and at the start of the war the Federal Government couldn’t even count on the loyalty of surrounding territory in Maryland.  The real action in this period happens not in DC but in the nation at large: fighting in Kansas, a revolt against the fugitive slave law in Wisconsin, the south's secession first from the Democratic Party and then from the nation.

Lincoln’s office was a product of the fighting in the country at large, and it is misleading to pose him and Taney in parallel. Their conflict was no more a match between equals then a speeding train hitting a car stalled on the tracks.

Saturday, July 9, 2011

Effective Columning

Reading Lister’s column on Hales got me thinking. What good is it to trash a candidate 10 months before the primary, where the field isn’t even clear yet? Lister lambasts Hales for leaving office midterm 9 years ago, but what will he do if the general comes down to Hales vs Cogen (who would be abandoning the county chairmanship midterm to run…)? Point is, it’s too early to bust on candidates.

So what is a columnist to do? Why not promote the issues that they think this election should be about. Lister mentions the police and firefighters disability fund for instance, only to use it as a mudball. Why not devote a column to telling people what the fund is and what the actuarial projections imply. You don’t need to solve it, just put it out there and try to make people care about it. It seems like a much more effective way to influence the discourse then trying to direct votes that won’t be cast for a long time.

Friday, July 8, 2011

POW: John Mearsheimer

John Mearsheimer led a discussion promoting his new book, courtesy of the Cato Institute. He discusses why leaders lie, fib, prevaricate and otherwise answer other then truthfully. He describes how lying tends to correlate with trust: Governments lie to their own citizens much more then they lie to each other, and democratic governments lie more often then non-democratic ones. Lying over wars of choice gets particular attention, with contrasting views of Bush and FDR (crafty enough that he didn’t need to lie).

Interesting and timely material.

Tuesday, July 5, 2011

POW: Michael Scheuer

Michael Scheuer makes for an interesting lecture, even in a post Bin Laden world.  He provides a sharp critique of the American war on terrorism and the “they hate us for our freedoms” meme that I usually only see from Glenn Greenwald.  I’m a sucker for grumpy old folks pounding the table about how everyone is wrong, especially when there’s some truth to what they’re saying.

Monday, July 4, 2011

More head scratching on Hollywood Theater

I travel up and down Sandy a lot, so I routinely go past the Hollywood Theater. I still can’t get over the concept that they think they’re better off with an empty garbage strewn lot for a neighbor rather then an apartment building targeted at young, single, bike/transit oriented people. But I’ll put aside the economics, it isn’t my theater after all. Considering only the aesthetic question of whether an apartment building would “infringe” on the theater’s image, I still think they’re nuts.

Below is a series of pictures from the southwest (the theater sits on a street running diagonal, from the southwest to the northeast). And I’ll assume no one would suggest the proposed building interferes with the view from the northeast, since from that angle the theater is in front.

First I’ll set the floor. The theater is barely visible from either side of Sandy at 3900. On the west side a traffic island with trees almost totally obscures the theater, if you zoom and look closely you can see the billboard.

From the east side, the only portion of the theater visible is the top of the facade tower.

Moving up toward 40th street, the theater comes in to view on the west side. You can also see how much is happening to obscure the view. Trees and street signs everywhere.
Over on the east side of Sandy, the sidewalk is shifted to allow a turning lane. No part of the theater is visible.

On the west side, it's only when you get to 40th that you can see the view and imagine it being adversely affected by the apartments.
Note that on the East side there is no impact on the view at 40th, the facade is almost totally obscured by trees.

Finally, moving on to 41st the west side facade view becomes clear as you'd move past the apartment building.
On the east side you begin getting a view impact once you clear the trees, roughly midway between 40th and 41st.


So to recap, there is no impact to the view anywhere except between 40th and 41st. On the west side the lower half of that block is affected, on the east side it's the upper half. Round up and call it one square block. What is that worth? Then consider the view we have now:


Why is this even a discussion?

Saturday, July 2, 2011

Online Education

I was impressed with this article in Harvard Magazine covering online education.  It ties together a number of threads:  Disruptive innovation, the unsustainable increases in tuition, the potential impact of dynamic programming tailor learning to the individual.  Best line:

When America’s traditional universities arose, knowledge was scarce, which meant that research and teaching had to be coupled tightly. That is no longer the case.

Even sharper is this analysis of the structural problems with traditional universities:

Examining the traditional universities through the lens of innovation, we see that a muddled business model is causing the industry’s ruinous cost increases...  A typical state university today, for example, is the equivalent of a three-way merger of the consulting firm McKinsey—focused on diagnosing and solving unstructured problems; the manufacturing operations of Whirlpool—which uses established processes to add value to things that are incomplete or broken; and Northwestern Mutual Life Insurance Company—in which participants exchange things to derive value: fundamentally different and incompatible business models all housed within the same organization.

Good stuff!

Saturday, June 25, 2011

Mass AG: Time to regulate Provider Pricing

I think provider pricing regulation is both inevitable and necessary to controlling growth in health care costs.  Step by step, Massachusetts is reaching the same conclusion.  Per Incidental Economist, here is state Attorney General putting the idea out in the annual cost analysis (emphasis mine):

The competitive benefits of tiered or limited network products, however, are unlikely to counteract, on their own, the historic price disparities that threaten many health care providers. During this time of market transition, we recommend temporary statutory restrictions on how much prices may vary for comparable services. Statutory restrictions should only be used as a stop-gap to the extent necessary to moderate price distortions until the corrective effects of tiered and limited network products can improve market function. We are not recommending a return to rate setting for hospitals and physician groups. Instead, we recommend a competitive market-based approach balanced with limited government intervention to foster effective market function.

The AG can call it what she likes, she’s not fooling anyone.  Whether it’s single payer like Vermont or mandate based private insurance like Mass, all roads lead to regulating provider pricing.  All roads, that is, that work.