Star Ford

Essays on lots of things since 1989.

On healthcare, disentangled


The current debate in Congress on healthcare is so hyperbolic and disingenuous that I felt it was time to actually pull out the threads and uncrumple the ball and lay it all out.

I will talk about the moral dimension, then the financial dimension, then the health dimension.

The moral dimension is simply this question: do we help each other through sickness and in health, or do we take the opposite extreme of every man for himself (women be damned)? Or do we take some middle road? Throughout most of my life, the moral choice made in the US was that middle and upper class people help each other out as a group, while we helped the working poor to a lower standard, and we essentially let the underclass die. Our sense of shame prodded us to ease the brutality of that death sentence somewhat by setting up a safety net. While that safety net was significant (medicaid, medicare, emergency services for the uninsured, for example), its moral foundation was that “we” treated “them” as inherently lower and less deserving. For generations health was never considered a right, and the debates focused on to what extent the recipients of “our” generosity were worth the expense.

The ACA fundamentally challenged that moral stance by declaring that we should take care of all of us to a more reasonable minimum standard, and it set in motion a trend towards more universal insurance coverage.

The current debate is completely hostile to that moral advance of the ACA, and I think racism and class superiority is a driving force. Some of the people who hate the ACA really want an underclass to exist, they enjoy winning, and nothing stimulates their competitive brain receptors like seeing the underclass waste away while they sip drinks by the poolside. They realize the ACA threatens to bring in more equality, so in retaliation, they ramp up their attack with an agitated fury and logical vacuum that can only be explained by the fear of the loss of their position in society. That is the moral failure in today’s debate, and it is driven by psychological forces that people experience when they lead narrow unexamined lives.

The financial dimension is a bit complex but important. Many people misinterpret the incentives of the four parties to each transaction, so I will lay them out:

  • Patients want to avoid doctors when we are well, but we also want the power to buy health-related services at only the level we need when we need it, no more and no less. It is important to see that there is not an infinite demand for services; thus patients are not the driving force behind cost escalation. But we want to be able to spend millions of dollars if needed, thus some kind of risk pooling is in our interest. It is not very relevant to us as patients whether costs are pooled by a public instrument or a private one. Like all consumer choices, we will minimize our personal costs and if insurance is not required or favorable, we will not buy it.
  • Providers (doctors, hospitals, etc) are private entities with the inventive to maximize income. Like anyone selling anything, they will do whatever it takes to make more sales – upselling, advertising, monopolistic practices, and lobbying. While the individuals involved in that system usually want to care for people at a personal level (they chose to go into that line of work), their corporate structures have the incentive to care less and charge more.

The first two of the three parties – buyers and sellers – operate just like with any other kind of financial transaction, but with healthcare, there are third and fourth parties.

  • Insurers and underwriters are private or governmental or non-profit organizations that provide the pooling of risk, taking a cut of the sales. Their incentive is to pay less out and charge more, but they operate in a market and under regulation, so they must stay within acceptable limits to stay in business. The important function of insurers is to determine what is an acceptable expense – more on that below. Many people on both sides incorrectly blame insurers for cost escalation and other problems, but insurers actually have the incentive to lower costs, so they are just a distraction from the central problems.
  • Courts are the final party involved in the money side of things, because ultimately they rule on insurance claims, if patients appeal, and thus courts ensure the insurers are following their own rules.

Costs can only be kept “correct” (not artificially low or high) if there are market forces at play, and the root reason why health costs have gone up in the last decades is that the market forces are not strong enough. Markets must have buyer choice and seller choice to be true markets, but in the US consumers cannot effectively shop around for health-related prices, so there is too little choice. Insurers commonly make deals with providers that cap prices on each procedure (more proof that insurers are on our side), but they are not allowed to cap the number and kind of procedures done.

Countries with more efficient health delivery systems (that is, all other countries) achieve that because they do fewer procedures, do them more efficiently, do not spend as much on marketing, and do not pay the doctors and CEOs outlandish salaries. Their cost savings are not achieved by pooling (insuring) differently.

The ACA changed the way the parties collude to set costs in some important ways, but it did not change the basic set of incentives. The main changes were that insurers were required to spend 85% of revenues on health costs, and they no longer could deny coverage (thus their whole business model became simpler, and they downsized). So under ACA, insurers are a less important variable in the cost equation than before.

There is an important link between the moral and financial dimensions, which is the question: what do we do if someone is not insured and they get sick and need help? They were not paying their share into the risk pool to help others, so when they need help, do we help anyway? (The same question is asked in the Little Red Hen story.) Or do we let them get insurance when they need it? Ultraconservatives say no, if they failed to think ahead, we should let them die. They are right on purely economic grounds for the same reason that if you sustain a loss of property that was not insured, you are out of luck; no one will pay you back the value of your loss. But it is clearly barbarian for us to live like that. If we really pause to consider this, we can only come to the conclusion that if we do not want to be barbaric, we need to require people to be in the risk pool. That is, either we have a public pool that automatically covers everyone, or else we require them to be in a private insurance pool. It does not make moral sense to have the “choice” to be uninsured.

The ACA was a compromise plan that favored the private pools to appease conservatives, and one of its failures was that the penalty for not being in a pool was too small; thus its adoption rate has been gradual.

The second financial dimension concerns the role of health spending as a tool of wealth distribution and equality. (I was talking about spending on health itself above, and now switching to issues of taxes and credits.)

Pre-ACA, health spending wasn’t tied in any rational way to income equality, so those expenses, being relatively equal across economic tiers, was a “regressive” type of expense; that is, one whose percentagewise impact on the poor is greater than that on the rich.

One of the most important effects of the ACA was in how it changed the distribution of wealth generally. It shifted the tax burden and entitlements on a gigantic sector of the economy such that wealthier people were paying a much larger chunk of the cost of health services for all of us, and many more people were getting those services at little or no cost. If you’re into active public management of poverty (as I am), this form of progressive taxation was a good start. Two or three more programs of that magnitide (such as in housing, food, or transport) would have made the US more like the compassionate socialist European states.

The condensed version of the way ACA was affordable is that Medicaid was theoretically expanded to include more people, and additionally, if you graduated out of Medicaid (by earning too much to qualify), then you still would qualify for credits towards premiums. Thus there was little or no gap which had existed previously. (One of the persistent failures of US social programs is that they often have a cutoff, so people have an incentive to stay poor to remain eligible.) As income goes up between around 30 to around 90,000 per year, the credits phase out.

The current agenda is being set by the uberrich, who seem to always want more money, so the brunt of their health reform proposals are to reverse the ACA taxes and entitlements. They say the ACA is broken and use terms like “choice”, but all of that is lies and distractions, and their actual motive is that they do not want to pay the taxes, along with the racist/classist motives as noted above. They propose reducing Medicaid and eliminating income-based help on premiums. Not only is the entire dimension of the health system as a tool of equality being chopped, it is even proposed to be reversed by creating a credits that the wealthy qualify for.

The health dimension includes the questions of what gets done for patients, who decides what gets done, and whether it is effective. Amidst all the noise about choice and rising premiums, these questions are not making the news. The current debate is completely missing the much larger factors of what the money gets spent on. We should be debating the finer points of who gets to decide whether to do each procedure and how much they can charge for it. Or we should be implementing more market forces to keep those prices under control. One of the ways to shift incentives is to pay for outcomes rather than procedures, so insurers only pay after the patient is treated successfully, instead of paying simply because something was done to them.

One of the big principles missed by conservatives is that people will not make good decisions about insurance in an unregulated market. Generally speaking we will under-insure ourselves if given too much choice. We might choose a plan with a 1 M$ lifetime cap, because that seems like a lot, but then need 2 M$ to survive cancer, and having made that choice when we were not thinking we might get cancer, we end up dying because of it. Or we might choose a plan that does not cover some drug that we never heard of, and then end up needing that particular drug.

We also do not know what procedures we need if we do not happen to have medical training. But on the other hand we cannot let doctors decide everything, or they would simply order every known test for every patient and drive prices up forever.

So the question of what gets done ultimately has to be a community decision – made either publicly or by insurers backed by courts. It does not make sense to make those decisions as individuals or as providers. The conservative’s notion that “doctors and patients” will decide on everything on a case-by-case basis is naive and does not contain costs. The ACA took a rational approach to that question by making those choices nationally, and putting into law specifically what had to be covered for everyone.

What do we do next? There are a lot of ways to rationally pay for healthcare costs. Here is the super-consolidated list of points that would need to be decided:

  • Who sets prices – There has to be a market force limiting the ability of providers to set runaway prices. (This point is rarely mentioned in debates, but assumed to be the role of insurers.)
  • Who decides what procedure is done – There has to be a market force limiting the ability of providers to do unnecessary procedures. (This point is rarely mentioned in debates, but should be central.)
  • What choice of doctors will you have – If insurers are allowed to control prices, they have to limit choice of providers as a way to do it. If you want to be able to go to any doctor and they can charge whatever they want, then there is no way to control runaway prices. (Republicans pretend to favor choice but have no plan that makes sense; Democrats pretend to favor choice but actually favor insurer price controls.)
  • Self-pay versus risk pooling – Only the 1%s could afford to pay full medical costs without pooling their risk, so all the rest of us need to pool risk. However, some chunk of the middle/upper income people could pay for a fairly large portion of typical medical costs if they accumulated money in health savings accounts (HSA), thus partially being their own insurer. (Everyone is assuming the combination of insurance and HSAs as far as I can tell, but Republicans want to expand the use of HSAs.)
  • Who gets included – Let’s assume that our goal is to care for everyone equally, and leave no one out. So the baseline assumption is that everyone is in a cost sharing pool of some kind. (Democrats generally favor this; Republicans generally opposed.)
  • Mandated coverage – This is really another word for who gets included; it may sound draconian to say “mandated” but it is how every other country does it. (Democrats generally favor; Republicans generally opposed but without any rational alternative.)
  • Penalty for not being covered – Pre-ACA, the penalty for not being covered was that once you developed a condition, you could not get covered for it at all, or only after a long wait. Thus in some cases the penalty was your life. Starting with the ACA, the penalty shifted to a simper tax payment. Another alternative is paying higher premiums after a coverage lapse. Another alternative is to automatically include everyone, avoiding the question of enforcing a penalty. If there is a choice in coverage, there logically has to be a penalty for opting out; otherwise the insurance market would collapse. A lot of people do not get this, but it is the main thing we need to get if we insist on using the insurance model for health costs. (Democrats generally favor the tax penalty or universal automatic coverage; Republicans favor a penalty through higher premiums.)
  • Change in coverage – Risk pools inherently require people to pay into them as a group when they are not sick, and by the same token, you would need to pay for the level of insurance that you might eventually need, before you need it. The strategy of buying minimal insurance while healthy and then switching to better insurance when you get sick undermines the whole concept of risk pooling. The ACA dealt with this problem by limiting the period of enrollment in a plan to the calendar year, which was not sufficient, since it would be economically favorable to wait out the year and then switch, for those who develop a chronic, expensive condition. Other solutions are automatic universal coverage, higher premiums (as above), and longer enrollment periods such as 3-5 years. (Democrats favor the ineffective one-year period and do not seem to have a solution; Republicans favor higher premiums.)
  • How the risk pools are grouped – There has to be a way to decide who is in a pool together, if there are going to be multiple separate pools. One way is to have the whole country in one pool. Another way is by employer. Another way is by insurer. Pre-ACA, continuously insured people were in pools by employer or by insurer if covered individually, while those who could not get insurance in the market either were in the medicaid pool or public high-risk pools. With the ACA, this mostly did not change but the ACA “exchange” established separate pools with a more transparent market. (Democrats favor a universal pool or the ACA compromise; Republicans appear to favor the tiered pre-ACA pool system.)
  • Who underwrites the shared risk pools – This is the question of insurance backing, and currently includes government, quasi-government public insurance companies, non profit and for-profit backers. (Everyone appears to be sidestepping this and is OK with the current slate of complex options.)
  • Who pays premiums – This is the question of whether consumers pay directly, through an employer, or via taxes. Pre-ACA, taxes paid for most of medicaid, most people with private insurance paid through an employer, and some paid directly. ACA did not overhaul that system, but it added a major tax credit component, such that insurers could collect part of the premiums monthly from the government and part from the consumers. (Democrats favor the current complex system or universal “single payer” via taxes; Republicans appear to favor the pre-ACA system.)
  • How is poverty handled – This is the question of how and if the health system trends towards more or less income equality. As I said above, the ACA had a system of credits and overall expansion of low-income support. (Democrats favor the current ACA system; Republicans favor a regressive taxation/credit system instead which makes it impossible to fully include the poor in the whole healthcare system, leading to countless deaths.)


Given the huge range of ways to do things, here is what I would do. My first choice would be single payer via taxes, automatic universal inclusion, and essentially removing the insurance component. The market forces would be created by publicly setting rates for outcomes, allowing providers to compete by minimizing the procedures necessary to achieve the outcomes.

Given that my first choice is a political non-starter, my second choice would be to keep ACA with these few changes: (1) improve the ability of insurers to negotiate prices and procedures, (2) shift to fees based on outcomes, (3) increase tax penalty for non-coverage, (4) lengthen the enrollment period to 2 years, and (4) phase out employer-sponsored plans.

Conclusion: There are complex choices to make, there is no one obvious best answer, and Republicans (mostly) are clouding the issues through a steady stream of lies to the point where meaningful real debate is possible.


(edited 3/11 to add more on medicaid and poverty)

Leave a comment »

On being myself, and other animal traps

This collection of pieces forms a whole essay, but only loosely. I’m trying to find the principles behind being (a) engaged, happy, moving versus being (b) alienated, traumatized, stuck, at least for me. Each piece is a bite out of that puzzle.

1. Being “myself” is a trap


Image description: Comic panel – person says “Just be yourself”, “Not like that”.

I’ve really tried to follow the advice to be myself, but it feels unreal. Any attempt to be Something counteracts my natural tendency to avoid fixing on that thing, even if that thing is “myself”. Not-being, or the absence of attempts to be, could leave more room for me as an animal to use my built-in facilities to meet my needs. Any conscious attempt to “be” could get in the way of my nature and make me stuck. Trying to be forces identity to be made into static words. I could say to myself, “well I should just accept that I’m an introverted autistic lesbian” (or whatever string of adjectives feels like an “identity”), so I should just “be” that openly. I could even be overtly proud of it and do things like make a blog with that string of adjectives as the subtitle, thus claiming that particular identity. But those are just very partial and inaccurate words, and by following them, I’m trying to become a dead concept from my mind, rather than be all of me, always unfolding.

The cartoon feels like the advice I’ve gotten all my life.

2. Being someone else is a trap too

Some parts of the therapy industry, especially the autism part of it, are based on the notion of becoming a better person by being indistinguishable: that is, by copying, conforming, and not being at all “yourself”. This idea is also prevalent in how we treat lower and middle class children generally, from the moment of conception through school. There are “developmental milestones” that everyone is supposed to meet. If the weight gain in pregnancy isn’t “right” (meaning average) then it’s “wrong”. It’s wrong even if that weight gain is right for that particular baby. Then you’re “behind” if you can’t read when you’re six, and so on and so on. The more wrong you are, the greater is the pressure to become normal. Read the rest of this entry »

Leave a comment »

“Leveling up” as a societal design pattern

Americans are not used to living in a well-ordered nation. Stemming from the federal system, the history of the wild west, and the longstanding tension between individual and community needs, we tend to complicate things and then believe that they must be complicated. In France by contrast the country is divided into 18 regions, which are neatly subdivided into departments, which are further subdivided into communes. Each level delegates down to the next, and there’s not a lot of overlap in powers or in geography. For example you wouldn’t find a department that spans multiple regions, and all the schools and other organizational systems are more aligned with the departments and communes. But in the US it is typical to have overlapping jurisdictions, such as a school district or a water authority spanning parts of multiple municipalities. The districting of congress, the state legislature, the post office, schools, churches, and businesses rarely fall on the same lines.

The situation results in a feeling of being unitless, by which I mean not having a known basic unit of organization. If we want to solve a neighborhood problem, who are “we”? – what are the boundaries that define the people who can solve the problem, and what authority do we have to solve it? There’s often no clear answer because of widespread unitlessness.

I’ve argued before for jurisdictional alignment (19 years ago!) so in this paper I’ll take up the related but more elusive concept of “leveling up.” Leveling up is defining the relationship between a function of society at one level and its subordinate level, particularly defining the escalation of problem resolution upwards and delegation of authority downwards.

Here are 6 areas of organization with a discussion of leveling up for each one.

1. Justice vs legislation

Under democratic rule of law, an established pattern is that legislation deals in universals and justice deals in individuals. The leveling-up concept related to this is that individual cases need to be judged by a larger body (at a higher level) than that which made the law in question. For example if a town council decides to let students out of school for a religious holiday, but a particular family who doesn’t observe the holiday contests the decision, the trial should be held at the county or state level, not by peers at the same level as the town council. This is because human nature prevents us from being impartial regarding decisions about people immediately around us.

Laws made at extremely small local levels tend to be prejudicial concerning individual people even if names are omitted. For example “the village will permit tractors to use route 509” might really mean that Sam Jones can drive their particular tractor; alternately a law banning tractors might really be a way for people to get back at the nasty things Sam has done. A local judgment of whether the law is just turns into a contest of who is on Sam’s side; this is a basic failure of rule of law when done all at the same level. But a judgment at the state level would look at tractors in general, not just at Sam. Likewise, cities and states are more likely to enact racist laws even if they omit names of groups as a way to divert attention from the racist aspect. It’s more difficult to do that nationally. Human nature allows us to be impartial with strangers. The larger the unit is, the more people rulings apply to, and the more impartial the rulings tend to be.

2. Wild and human habitat

North America has a range of human density running from extremely sparse such as remote Alaska where people are incidental to the natural habitat, all the way up to big cities where nature is incidental to, and more completely under the control of people. In the latter extreme, land is first completely denuded of nearly all life, then a nature-substitute is designed and installed by professionals. There’s a continuous range of expression of that relationship between the extremes, including towns, suburbs, and vast areas of “managed” land, in which there’s a balance, and often a gradual increase in human control over time.

I’m not arguing against the extremes; despite being a nature lover, I concede that in big cities it can make sense to install a nature look-alike atop and between the areas of pavement.

In my mind the problems are more with the middle range. The first problem is the presumption that all land by default is “ours” with the exception of defined regions of “protected” land. So in the American mental model of land, there are dots (foreground) of “nature” on a background of human-managed land. In some cases the dots are connected by wildlife corridors, but many are not. We need to reverse that concept so that the “dots” are human settlements on a background of all other habitat. This is not by itself an argument for less overall developed land, but rather for a pattern of organization that condenses our development into the “dots” and leaves the rest of it in an interconnected continuous mesh of habitat for all other species.

The diagram below shows an abstract representation of green dots on a developed background (left) versus development dots on a green background (right).


The second problem with the middle density range is how much of it there is. Some people say the suburbs are the best of both worlds – country and city – but in other ways they are the worst of both: they lack the efficiency we get from the compactness of cities and also lack any true escape into nature. By sharpening the edges of the dots and making them more compact, then it’s possible to get the best of both worlds and use less land for human settlements overall. Furthermore if the edges of the settlements are highly reticulated, not simple squares or circles, then a great majority of people can be close to real nature, not stuck in vast suburbs.

Agriculture as the largest land use would do the same thing, only the dots are bigger. Fences would have to be discrete shapes enclosing pasture or human activity, not connected continuously to other fences as is the pattern now. Fences could no longer be used to “fence out”; they would only “fence in”.

(Of course I get this is just an ideal of the distant future, but it’s worth thinking about.)

There’s a couple ways this “dots on background” idea is a kind of leveling-up proposal. First, it sets the earth as the higher authority and puts all of our levels below that. Second, it creates place (dispels unitlessness) and consequently creates natural jurisdictions, which then lend themselves to orderly subdivision.

3. Transportation land

The land devoted to transportation is vast – more than half of all urban land. That includes roads, airports, parking, and rail-yards. The roads we use are classified by level – a state road, a county road, and so on, although often it doesn’t matter or it is not always apparent why the classification is made. There’s a lot of complexity and absurdity in the system. For example a road with lots of houses and businesses on it could be a state route and be slow and mainly serve local residents, while some other municipal road might be faster and mostly serve long distance travel; the jurisdictions that make decisions might not represent the main users. Roads can be reclassified, and organization can be rigidly imposed over a history that doesn’t fit.

One of the knottiest problems that ensues with all this is when an individual resident, say a family with children, seeks protection from their previously peaceful road becoming a dangerously fast highway with noisy trucks. It’s impossible to serve both needs well – the legitimate needs of residents, and the legitimate needs for travel in the broader region. It might be counterproductive to everyone to balance the needs through compromise. For example, trucks limited to 40 mph instead of 60 doesn’t really address the family’s concerns, and it slows travel for everyone.

Leveling up to the rescue! We define a continent-wide lattice of superhighway corridors, airports, train lines, etc, and move that land ownership and all its decision-making to the national level. This is a tiny fraction of all land, but it is nationally significant. This land is built above or below the ground level where it crosses between human settlements, so that the background of natural habitat is not dissected. Then, we can decide as a country how to manage that land and its systems to work across the country, without primary regard to local needs. (There’s plenty of other land for local needs.) I get how this is expensive and certain people lose out, and that we have to seize property to make this happen, but ultimately I think it makes more sense because the level of government that is designated to solve a problem has the authority and resources to solve it.

The same concept applies then to the remaining state land: states make a more fine grained lattice of state owned corridors and leave the reminder to the lower levels.

Funding does not need to be collected at higher levels and re-granted to lower levels; each level can manage its own fees and taxation itself by whatever method makes sense to that jurisdiction.

4. Transportation systems

Following from the leveling of transportation land and funding, we can then imagine how transport systems can evolve more rationally without jurisdictional gridlock.

Here’s a technology picture that makes more sense than what we are doing now:

  • At the national level we acquire very straight corridors, and create supersonic evacuated-tube transport to supplement highway and air travel and freight. The federal level rids itself of regionally significant infrastructure, focusing only on long-distance travel. The cost savings and added focus allows us to shift towards renewable-powered high efficiency tube transport and away from the more dangerous and polluting modes. Because of the high speed, all of the systems are isolated from people – none of them would permit bicycles or pedestrian crossings.
  • States acquire a lattice of corridors of statewide significance, including much of the crumbling infrastructure that is deemed not nationally significant. States seize and release land over time as needed to create straighter routes between major population centers, and as with the national system, they focus on regional-speed travel such as maglev and other automated networks to supplement highways. Over time travel shifts greatly towards the safer, efficient modes.
  • Major cities do the same thing at a city scale. For example they acquire and release land such that the city owns a grid of arterials over time, so it can plan and execute efficient city wide travel on bus and surface transit, automated networks, and suitably restricted roads. (By restricted I mean they wouldn’t allow arbitrary number of left turns or connections with local roads, and may not permit pedestrians, or would have signalized pedestrian crossings.)
  • Neighborhoods, towns and boroughs then control the remainder or the developed land, and can focus on slow transport that serves all destinations. This is a very different problem than transport at the higher levels, and deserves creative solutions that fit just that level. For example, the entire local circulation system could consist of 5-foot wide one-way paths limited to 20 mph, so that neighborhood vehicles, electric taxis, bikes and pedestrians can safely share the surface.

The proposal is to think and design for distinct levels rather than a mix or balance; we don’t invest in widening a certain local road just because more people are using it for commuting; instead we route traffic through the corridors that have been designed for regional travel.

There have been many concepts for cities of the future, that generally depict the ground level to be greened up and free of congestion, pollution, utility poles and so on. The main problem with them is that we have already invested trillions in infrastructure, and many of those concepts rely on rebuilding everything from scratch. In reality, creating safe and sustainable transport systems is more urgent than the 100-year lifetime of buildings, so we need approaches that gradually improve what we have towards those greened-up visions. The leveling-up concept provides that mechanism: neighborhoods won’t have to consider speed and distance in their decisions, and the higher levels won’t have to consider access and pedestrians in their decisions. Eliminating the impossible task of balancing unbalancable needs opens up creativity to solve those levels separately and better.

There is also the market aspect to thinking about these transport systems. If the jurisdiction owning the corridors can set up a market for private providers to compete in the traditionally-public modes, then we can take advantage of innovation in those modes like we’ve been able to do with cars. For example, a neighborhood electric robo-taxi can consist of a fleet from multiple competing providers.

5. Utilities and infrastructure

Physical distribution of pipes and wires to millions of endpoints and the connecting grid is a system that parallels the transport network, and would also benefit from some leveling-up concepts.

The reason we have the utility model for some businesses (which is a regulated public-private hybrid business type) is because of the root problem that market competition cannot be effective when it comes to endpoint-oriented infrastructure. It is not reasonable for a variety of gas companies to run a separate network of pipes to every house in order to have consumer choice. Without consumer choice there can be no market, hence the problem.

Leveling-up solves the market problem like this: there are large scale providers of gas, electricity, and data, providing distribution from the global level down to a neighborhood interface. The neighborhood interface is where the private and public sides of the system connect. Neighborhoods provide local connectivity from each endpoint to the interface. While there is just one public network inside the neighborhood, there are one or more privately controlled grids at the higher levels.

This model preserves both market advantage and democratic control in two ways:

  • The regional and national utilities compete for consumer business, and they can reach all consumers without having to build duplicate endpoint networks.
  • Builders of local networks compete for the business of setting up and managing the local networks. Because there are thousands or millions of neighborhoods, they form a consumer pool which allows for market competition.

This radically simple system also applies to shipping: different long distance carriers don’t need to drive separate trucks into each neighborhood; packages transfer at the neighborhood interface, and the neighborhood manages the local distribution. Trash collection is a parallel problem that can be handled the same way as shipping.

6. Everything else

I have a tendency to want to engineer everything according to my extremely egalitarian views, but at the same time I find most renderings of future green cities to be eerie, and have an overly sterile regularity. Here’s an example rendering of a city concept that may have lots of great points, but it doesn’t feel like real people could live there.


I think some people approach the problem of improving human settlements with an assumption that it will be centrally planned like Soviet apartment towers, and that is what gives it the eerily unreal flavor. I’m more interested in freedom, diversity, and small democratic units, which would yield a future that can’t be rendered in a picture like this because the places would be all different from each other.

Everything else besides the way we use and connect space is important too – that is, policing, education, health, taxation, and so on. But if feels like if the physical organization and transportation aspects were first, other forms of organization could follow more easily. All those things could be run on the level at which they make the most sense – so things like education would not need to be absurdly centralized. Those things would become easier to improve because the units would be clearer and the power to accomplish things would rest cleanly within the unit.

As a final topic, why should we care about any of this when there may be more pressing concerns? I feel like it is important to care about all of these:

  • The concrete topics on a progressive agenda like deforestation, climate change, poverty, crime, and equality (to name a few), and..
  • ..The power structures and power holders that block or promote those agenda topics, and..
  • ..The principles of organization that give rise to the power structures.

Leveling up is one of the principles that, if in practice, would power different power structures than we have today. The structures we have today partly block the human-centered political agenda in America, which is why we have so much worse performance than other countries in things like literacy, health, crime and energy use, despite being wealthy and partially democratic. I don’t think the bad performance is because we’re different than other people culturally; it’s because we organize in a way that twists democracy, and the fragmented federal system of overlapping jurisdictions gets leveraged by minority power holders to overpower majority values.

So that’s why we need to care about it.

Leave a comment »

North Gulch Mystery

“North Gulch Mystery” is a role playing mystery game for exactly eight players. It should take 1 or 2 hours. All you need is some envelopes and scissors and the printout of the game sheets.

North Gulch Mystery game sheets (PDF)

Leave a comment »

How Trump can be a better candidate

It’s election season in 2016. Of course we are all aware that Trump is a dangerous narcissist, but remember that Clinton is also imperfect. It sometimes is hard to tell which of two candidates is better when neither is ideal. So I made this diagram to explain how Trump could be the choice of so many Americans.


The diagram shows how I imagine America rates men and women from absolute virtue at the top to absolute evil on the bottom. It clearly shows Trump at a slightly more venerable position than Clinton. What other evidence do you need?

Kidding aside, I think that even if there was a scale of virtue like this, the lowest women category exists in the minds of some men only – there is no one actually in that box. This is a depiction of the worst slice of our slut-shaming misogynist culture.

If women didn’t have the vote, Trump would win in a landslide; but even scarier is that millions of women are voting for him – a majority in many states. The only way I can understand that is that millions of women see the world the way the diagram is shown, with women having greater innate sin. If anyone thinks we don’t need feminism any more, consider the internalized misogyny of those millions, and all the forces that are keeping up this social-values map alive in the national consciousness.

Drawing the diagram and writing “slutty” was hard for me to do, and I feel dirty, and exposed to fire from all sides. I’m pushing past that and posting it anyway because I think it is part of the value system in America and it does help explain why the election is going as it is. In fact I think it’s an essential ingredient to understanding what is going on.

I’ve never seen weirder and more massive mental programming than what is going on now. Maybe the scale of the calamity shocks us into mindless compliance somehow. I can’t even find words to express the sadness of the loss of heart, the loss of dialog, sanity, and reason. I feel there is a gigantic shift in perspective happening that is so great that we are no longer even standing on the ground. But that’s just a tiny bit of what I’m feeling about it; I have no way to say more. I pray that others can find words to say the thing more fully, and that the people hurting from the shaming will find ease and vision somehow, to pull ourselves back to grounded reality.

1 Comment »

Legal arguments on birth

When does life begin? At conception, or nine weeks thereafter? When the baby is born? Or maybe after it gets its first master’s degree? Or never? Personally I think it’s never. Life reorganizes; it does not begin.

I saw a nun praying outside Planned Parenthood the other day. My urge was to pray with her, not against her. Instead of wondering what her thoughts were, or what she was for or against, I felt the power of her upholding that life which does not begin. It felt like there were not two opposing sides at that moment; her energy felt unifying.

1. Abortion

I grew up with the semantically twisted stance that killing babies before birth was not really “killing”. But when my heart softened about “abortion” (a sanitized word), I admitted it was killing, and I couldn’t be “pro-death”. Instead I wanted to uphold mother and child, to protect and strengthen all of us. When we sit to feel and consider abortion in the abstract, we need to honor the strengths and mourn the losses of the mothers. We should not be stuffing down the feelings of loss simply because we hold a political view of choice. Politics has a way of making abstract ethics central and extreme, and suppressing mercy for each individual circumstance. We should use the word “killing” because that is honest, but using that word doesn’t make it a blanket wrong. Read the rest of this entry »

Leave a comment »


Olivia Lipkin appreciates pie the way a fish appreciates water. The enigmatic explorer does not usually meet with journalists, but something I said on the morning of the interview must have given her an opening, or maybe it was the August breeze that stills the heart with its reassurance that the most oppressive part of summer is over, and that the day will be long enough for all things. We sat on the shaded veranda of town’s only cafe, her berry-stained white blouse fluttering as she revealed, always close to tears, her story.

Star: So, tell me about your last pie.

Olivia: Oh I can still taste it now! I hardly know how to describe it except to say it was magic. It brought me face to face with the essence, as if time stopped and I melted with the first bite into a dream. You know when you’re full of doubt and then you taste pie and everything settles? You go to this special place, your whole world self-organizes, then you come out in peace. That was that pie.

S: Wow, what kind of pie was it?

O: It was the kind that holds all of summer, and speaks quietly but reveals adventures if you listen carefully. It was not a simple pie, quite complex actually.

S: But I mean what was in it?

O: There was a certain panic or maybe heartbreak from the experience making it, but love of course, full of love. Sorry I think I’m going to cry thinking about it. I can’t even believe it’s gone. I ate it all!

S: You certainly loved that pie. But, was it a cherry pie or what?

O: No, blackberries! There’s a patch I had known about and last month I couldn’t wait any longer and I just needed to go pick them.

S: Tell me about how you made the pie.

O: Well, I got all my gear together and made the trip. There I was, facing these thorns all alone – millions of thorns. I started around the edges, tentative at first. All that was going just fine, but I felt this intense calling.

S: Not to go inside?

O: Yes, I had to.

S: What equipment did you use?

O: I had brought my bowl, but I didn’t think to bring food and water, can you imagine? Luckily as a girl I used to devour survival literature, so I remembered to bring rice.

S: Rice?

O: Yes, I put the grains of rice in a line so I could find my way out. I had picked almost the whole bowl full, and was getting deeper and deeper in. There were thorns everywhere and I just remember things started swirling and I couldn’t distinguish berry juice from blood. I was actually inside the beast! – the beast that intoxicated me, and I couldn’t find my way out.

S: Oh no! What about the trail of rice?

O: I guess Gretel’s technique was not actually so effective now that I think of it. No one heard my cries of pain, and I thought I was going to die there. But on the third day I had a startling epiphany that would ultimately save my life: I could eat the blackberries themselves in order to survive.

S: Good thinking!

O: That definitely gave me strength. What probably kept me going the most though was the love of that future pie that was already being conceived through this harrowing experience. And I never gave up hope that there would be uncharted waterways that would make rescue by boat possible.

S: Did you get rescued in the end?

O: No I just kept going, being stabbed endlessly from all directions, wishing I had remembered to bring shoes, and finally when I was close to giving up, I saw light.

S: A testament to perseverance. How long was the journey?

O: It’s anyone’s guess – but I’ll always insist it was at least 18 feet.

S: And now that you have recovered, do you have more adventures planned?

O: Not til the pie calls me. I’m just the servant.


Leave a comment »

a bit about autism for crisis line volunteers

(This paper concerns crisis lines, such as suicide hotlines, rape crisis lines and so on. I’m volunteering for such a line now.)

Autistic people are not woven into the fabric of families and social groups like other people are; our way is to be independent instead of enmeshed – and this point is close to the very definition of autism. Unfortunately for us, that extreme independence can make supportive relationships out of reach, and even push us out of society to the point of being friendless or homeless. Thus, while autism accounts for only about 1% of the whole population, among callers to crisis lines the rate may be a lot higher. Crisis line staff can benefit from identifying autistic traits and some helpful ways to communicate.

Perhaps the easiest way to detect autistic tendencies in a call is when they seem unusually literal. If you ask “are you sad?” they may just say “yes” – only the literal answer to the question without accepting the implied invitation to say more. If you ask “May I ask you a couple questions?” and proceed to ask one question, then later in the call, they may still expect you to ask the second question (because they interpreted that you had exactly two questions). If you ask “How did you sleep?” they may interpret the question to be about the technique rather than about the quality of sleep, and they might answer literally: “I just got into bed and waited.” Or they might say they don’t understand the question, because they interpret the question to be literal and precise, when it might have actually been just a general way to keep the conversation going.

Autistic people have the same range of feelings and the same needs for love and connection and safety as everyone else, but our communication is different. Communication is interpreted more according to strict dictionary definitions of words, and the adage that 80% of communication is nonverbal may not be true for that kind of caller.

One way to be effective is to realize that your tone of voice may not communicate much, and their apparent tone can be misleading. If they are calmly stating “I am angry”, believe the words and not the misleading tone. An autistic caller may always use the same tone and not modulate it for different feelings as other people do. Try to find specific words to convey meaning and don’t assume they get much from your tone.

You can ask open-ended questions, but to communicate that your question is open ended, be literal and don’t rely on softening phrases or anything vague. If asking “What about your relationship?” elicits confusion, try saying “Describe the good and bad aspects of your relationship”. An autistic caller might understand “What are all of your feelings about that?” better than “How is that for you?” If asking “Were you ok after the fight?” results in a one-word answer, try requesting that they tell the whole story of recovering from the fight.

Autistic problems can be specific. If a caller says “I didn’t get to finish a Minecraft construction project before class”, you might wonder if Minecraft is a misplaced target or a symbol for some hidden, deeper problem. But there may be less focus on relationships and the seemingly trivial issue of Minecraft could be the literal problem. The person might be using a tool like that to help structure their thinking and memory, and someone prevented them from using it. Although the problems are diverse, one common thread in the problems reported by autistic people is the lack of agency (control over our time and environment). Our drive is to be independent, but when other people control our money, our belongings, or time, that can be the crisis.


Leave a comment »

On collaboration

Things that make collaboration hard

Collaboration is hard. In all my efforts to work in volunteer groups in the past, so-called “collaboration” has felt like slowly wading through mud with people who don’t seem to be proposing anything specific, but they also don’t like or understand my ideas, and we’re doing something that isn’t really aligned with what I want to do, while everyone seems to overreact to very minor issues, and my patience wears thin.

In most of my attempts in the general (nondisabled) world, one or more of the following happens:

  • Someone decides “there is conflict” and we need “healing” before we can do anything. I never have any idea what they mean and I sense it is usually a delay tactic. I feel like we all always need healing, but it can never be complete.
  • We get people who want to study the situation forever and others who want it to be done immediately, with not much flexibility between the two groups. In one youth coalition I was in, the young people were really good at springboarding off each other’s inspiration and they wanted to decide things in rapid fire, while the older people seemed to miss that level of communication completely and they wouldn’t agree to anything. The young people had a sense of now, and not of the distant future, while the older people were only concerned with the distant future and could not do anything now. (Since at any moment, it’s always now, I guess they never did anything.)
  • Half the people who show up have the main objective of just using the meeting time to socialize or get attention, or they have no intention to do anything. Therefore, the longer it drags out, the better. Others want the meetings to be a short as possible.
  • Certain people who are used to having more than their share of social power intentionally try to foil democracy, so they’ll agree to democratizing procedures reluctantly, but then skirt them. Others try to make things equalizing and transparent, and that difference in interests tends to make discussions about internal procedures rather than about what the group is doing.
  • Someone will declare that before we can do one thing, we must do another thing. For example, before we can decide what to write in a letter, we need to decide what are objectives are. Or, before we can determine our objectives, we have to write the letter. There is no way to satisfy everyone’s sense of the proper sequence of events.

Parts of collaboration

I think there has to be room for three kinds of activity in “collaboration”:

1. contemplation – brainstorming, venting, listening, and anything unstructured – This takes the most time.

2. business – structured processes for deciding on actions

3. taking action

Any attempt at collaboration probably needs all three of these in some balance.

Autistic collaboration

I think it could take more patience to herd autistics than other people, or even to decide to collaborate. Some day maybe I’ll write an ethnography of our subculture, but for now, here are some unstructured points that maybe it could help to be aware of:

  • Autistic people tend to get triggered; most of us have some level of PTSD, and have extreme responses to situations that seem innocuous to others. So in a group, it’s reasonable to assume that at all times, someone may be getting triggered by something.
  • We’ve often been excluded, so we can get bitter and bring associated baggage to groups.
  • When the topic of collaboration is autism or disability, the fight for power over the conversation often becomes fiercely directed against autistic people. Groups that deal with other topics (transportation, environment, etc) might be more accessible, whereas groups that deal with disability could be more likely to turn us into tokens or “others”.
  • We may not have as much experience with collaborating effectively as others. If being in a group as an equal is very new to me, I might not know how to stay on topic, for example. I might not be aware of what is meant by the various words used to organize, like agendas, minutes, and petitions.
  • We tend to build up our own mental universe of “obvious” truths, which is not as shared with others as we think, and then we’re amazed that other people are so “dumb” because they don’t know what we know, or didn’t read our 10 page essay on the subject.
  • We tend towards “if this is not exactly 100% in line with what I’m trying to do, then I’m outa here”.
  • We sometimes assume that others are acting as a bloc when they are not, or that they are all followers of a certain leader. So if I put forth an idea and the leader is opposed to it, I might assume that everyone is acting as a bloc and they are all opposed to it. That’s discouraging.
  • Most of the people trying to organize autistic people are not themselves autistic at all, or they are a socially effective subtype that is not very representative of the rest of us. So even in groups that are supposedly for us and by us, we might still be excluded.
  • We have issues pretty often with energy level and commitments. I might offer to do some of the needed work, but then life could take a turn and I might not be able to do what I said.

I don’t have any answers, but I’m pretty sure effective autistic (or inclusive) collaboration would look different from effective allistic (or exclusive) collaboration.

1 Comment »

The trait square

Here is a little therapeutic trick you can do with a piece of paper, whenever you think badly of yourself. First you name your “bad” trait and write it in square #1 of a figure like the one pictured here.traitsquare_conceptThe four steps going around counterclockwise are:

  • Write the “bad” trait in square 1
  • Write the opposite of that bad trait in square 2. This should be a good trait.
  • Write the negative restatement of that in square 3. This should be the same trait as in square 2, only the extreme or negative form of it.
  • Write the opposite of that negative in square 4.

You should end up with a positive restatement of what you wrote in square 1.

Here’s a simple example:
traitsquare_ex1To walk through this one, my negative trait might be “lazy”. So I think of the opposite – what would the person most unlike me be? So I write “energetic”. But that trait could also be seen in a negative light, if one is too energetic, so I write “hyper/manic”. Then I think of what the opposite of that bad trait is, and I write “relaxed”. That reveals that I could choose to see myself as relaxed rather than lazy.


You can also get more descriptive about your issues. Here’s one about me that shows some of my associations:

traitsquare_ex2In this case I used “she” as my fictitious opposite, and I think if I were my oopposite, I’d be in danger of being proud or manipulative. Your associations might be different so your opposite might be something else. Ultimately the restatement of my “bad” trait does not deny it (I might still be ugly), but it shows things that I might also be because I’m not the opposite – humble or genuine.

Seeing “humble” come up like this doesn’t feel quite right so I might go do another one using “pride” as the starting bad trait.

Some people practice direct contradiction as a therapeutic technique. For example if I believed or feared I might be ugly, I would say (out loud) “I’m beautiful”. That’s a powerful technique, but it can be so contradictory that some people cannot say the contradiction out loud. The trait square is different. It does not contractict or deny the original negative thought; it only reframes it. It widens the trait you are looking at to include a more balanced view of positive and negative aspects of that trait.



1 Comment »