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)

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Deep Accessibility

This paper explores five levels of accessibility, extending the familiar notion of wheelchair access to the sensory and cognitive levels of accessibility. It is slanted towards autism-related accessibility, but the framework could be generalized and adapted to other kinds of people. The levels to be described are:

  1. movement
  2. sense
  3. architecture
  4. communication
  5. agency

Basically, I am looking at what makes the difference between a place or event that a lot of different kinds of people can go to and get what they need effectively, versus one that is impossible to get to, threatening, confusing, or in other ways unavailable. Autistic people avoid lots of kinds of places for a variety of reasons, but using this accessibility framework, I hope to make it easier to talk about specifically why they avoid those places, by giving vocabulary to why those places are not accessible, and to make it easier to make those places accessible.

Before I get into the levels, I need to define some abstract things, starting with this graphic explanation of inclusion versus accommodation.

Inclusion

incidence

This chart shows a bunch of people clustered on the left (without a disability), and progressively fewer people who are more disabled or at least more divergent. The three categories are those who are systematically included (the largest group; the one the system was made for), the group that is not included by design but can be individually accommodated by some adaptation, and those who are excluded. Read the rest of this entry »

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­Cost of disability

­This essay discusses the way we pay for autism, from a marxist perspective. It goes into economic reasons that certain people are disabled from participation in the economy, some models of redistribution of money, the kinds of incentives that affect behavior in each of those models, the complexities of insurance as a redistribution model, and what to do about it. I’m starting with economics background to frame disability. Even though it is probably too long and thick, I hope you will read it and discover a completely different take on costs of disability than the conventional wisdom.

1. Efficiency and exclusion from the workforce

The very rich and very poor live off the work of others, as do the old and young, all those whose work is undoing the work of others, and all those who are disabled in the quest for employment. Various wealth redistribution systems exist to maintain the imbalances, and those systems constitute the livelihood of the majority; actual economic productivity is relatively uncommon. For every one person doing economically productive work like growing food, installing windows, or teaching children, there are several operating within the economy, but just doing paperwork or fighting over money and attention, the result of which meets no actual human needs. The more efficiently industrial production is accomplished, the more inefficiency we create on purpose to soak up the excess time. So far, we are seeing advanced capitalism playing out as Marx predicted.

There was a time when we could not afford to exclude people from the workforce: people who were too weak to plow fields were still needed for other things, and generally speaking, if you could not do one thing, you could probably do something else. There was no retirement and no adolescence. With gains in efficiency, however, we can now afford to be idle; or looked at another way, we can now afford to exclude the old and young from the workforce. As efficiency marches on, we are not using the gains to better meet the needs of everyone; in fact we just become more competitive and we concentrate the wealth more, creating a large chronic underclass with no means to provide for their own needs.

Advanced capitalism therefore has two opposing effects: increasing efficiency, which tends to exclude an ever greater portion of people from the workforce; and increasing inefficiency which tends to concentrate wealth. Both opposites operate together. For example, in the food production chain, the actual farming, transport and delivery of food becomes more labor efficient over time, and the resulting wealth is distributed in the sense that the people doing that work are all getting paid and the consumer is getting a necessary product for less money over time. But there is also a growing workforce in the areas of food patents, genetic engineering, marketing and legal sectors, who are all working exclusively for the owners of the food production chain in order to increase the owner’s advantage and increase their assets, and has no benefit to others.

Adolescence and retirement were invented concepts at one time, which served the progress of capitalism by ejecting people who were no longer needed for industrial and agricultural production, and at the same time, creating a dependent class with a redistribution system around them. We now have vast budgets for schooling and social security, and whole sectors of the economy dedicated to wealth redistributing and otherwise providing for the young and old, who either may not work or cannot compete against a narrowing class of employable people. I’m not making the case that the old way is better than the new way, or vice versa, but just that a class of people have become recipients who were once contributors.

This historical pattern has not stopped with age-exclusion; capitalism demands that we continually invent new categories of exclusion, expand the pool of people who are non-productive beneficiaries, and build a distribution system for these new categories. I’m looking at disability in this context: a class of non-worker with a distribution system surrounding it to allocate money to that class. Disability is a lot of things, but this essay is only about disability in that particular economic sense.

2. Why am I writing this?­

As an autistic person, I’m focusing mainly on the redistribution system we are building today to support the neurologically disabled – including autism, so-called attention deficits and other conditions of the mind that affect interpersonal relations. This dependent class is currently undergoing rapid expansion. This affects me greatly where I am in the economy. In the 20 years I’ve been in the workforce, a lot changed. I was not considered autistic before, under the older definition of autism. Earlier in my career my particular style of social communication was a disability, but not so major, in the sense that people would willingly pay me to do things in the information technology sphere. However, over the course of two decades, autism has expanded to engulf me: the definition changed to include people like me, and at the same time, I’ve been less able to compete in the market. As I write, I’m moving into more dependence on government programs for the disabled. It is important to see this not as any change in my objective value or ability to contribute, since I have actually become more skilled over time. It is rather a change in the economy: a new criterion is being used to filter out people from productive roles. Terms like “autism” probably stay roughly synchronized over time with the set of people who have fallen out of economic favor.

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On Measurement

The empathy test

Here’s a report on some “research” that “measures” the amount of empathy people have:

Looking at their test questions, it becomes immediately clear that the test is a composite of several different things. All together, these things are labeled “empathy” and the implication is that the more of it you have, the better. Before I get into why this does not qualify as research, I’ll elaborate about their test.

Here are four of the questions from the empathy test:

  • I can easily tell if someone wants to enter a conversation.
  • I can pick up if someone says one thing but means another.
  • I am quick to spot when someone is feeling awkward or uncomfortable.
  • I can sense if I’m intruding, even if the other person doesn’t tell me.

These four questions apparently measure the ability to read what someone else is thinking or feeling, or what their motivation is. Now, here is a set of different questions, which are apparently designed to measure the extent to which a person internalizes the emotions of others:

  • I tend to get emotionally involved with a friend’s problems.
  • It upsets me to see an animal in pain.

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Getting rid of the Box – comments to DOT

Comments to RITA docket 2009-0005-0001

In addition to research on technology, case studies, and detail strategies and metrics, there also must be some more macroscopic study on waste and stagnation. There have been many attempts to describe the elements of efficient and safe macro urban designs, such as TOD, on-demand transit, integration with bike/pedestrian, coordinated land use, and so on, yet as the decades pass, we are still building primarily auto-exclusive zone-segregated places, driving more and more, and not even coming close to meeting the stated federal goals.

Clearly the way planning is carried out at the federal and state levels cements this technology and policy stagnation. Nearly all studies are scoped, meaning they define what is to be studied – a truism in government, but not a necessity. The scoping creates the box that one is to think inside of. In order to unblock the process, one must think outside the box, and to do that, one must not have a box – that is, no scoping.

Study is needed on how to remove the scoping box from government struture and let flow the natural creativity that is harnessed by the private sector, in order to make it possible to meet any of the goals. This study should include advice on the next congressional transportation authorization.

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Freedom of Information – Act 2

(letter to elected representatives)

Please introduce legislation to expand the Freedom of Information Act to a new level. The original act made transparency the rule, and secrecy the exception, in theory. But the act allows the executive branch to keep something secret just by stating a reason why they don’t want to release it, and it also gives them the ability to be noncompliant with no repercussions.

 

What is needed now is an act that directs the executive branch to operate publicly at all times, and puts the burden on Congress to determine if something should be kept secret. The order needs to be court-enforceable. The new act needs to distinguish between (1) releasing hidden information, and (2) operating in a transparent way in the first place. Transparency in operations means every piece of correspondence, email, expenditure, and audio notes from meetings is published on the web at the moment it is created. Nothing would ever be “unveiled” (a common word used in government reporting), because nothing would have been veiled in the first place.

 

What led me to this conclusion was my recent review of the WTC building 7 report from NIST, and the public comments on the report. The NIST report may or may not be plausible, and I’m not asking for a new investigation. A new investigation under the same rules of conduct would have the same result. It is useless to pretend that the government – any government – can produce an “unbiased” consensus opinion from closely guarded evidence. It is not even necessary for the government to have any interpretation of how the building was destroyed. Instead, the government simply needs to release all evidence and let the media and citizens who have an interest draw their own conclusions. The government seized footage and other evidence, and prevented media access in all the 9/11 sites, and that fact alone is sufficient grounds to disregard any government findings. The simplest and most common explanation for keeping a secret is to protect the guilty, as you may remember from childhood.

 

Under the current system allowing the executive to keep secrets at will, we have little protection from this type of terrorist activity. There are many other buildings like WTC7, and currently building owners and local safety inspectors have no new information that will keep these buildings safe. Whoever brought down WTC7 could bring down hundreds of other buildings, perhaps all in the same day.

 

If 9/11 were to happen under an expanded Freedom of Information Act, taxpayer money would go towards obtaining copies of all footage, publishing it, sending debris and all physical evidence to universities around the county and other institutions, who could collaboratively get to the bottom of it much more quickly and accurately than government can. Naturally this would be more chaotic and many false conclusions would be circulated, but that is part of democracy. Having access to just one official story is not part of democracy.

 

You may or may not believe that office fires can make steel brittle. I don’t know – I’m not a structural engineer either. But a full transparency rule is not just about terrorist investigations – it would improve outcomes on health, transportation, energy policy, and everything else. This is one important step towards keeping expanded executive powers in check and sustaining our democracy.

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Libertarian Socialist

Two main lines of thought today are libertarian and socialist. They are sometimes thought to be opposites, but actually are compatible. Libertarians believe that the free market is the best way to allocate labor and stimulate efficiency. Socialists believe we should work cooperatively and fairly, rather than allow an owning class to exploit a working class, and that a limitation on the concentration of economic power is the best way to allocate labor towards human needs.

The truth of the libertarian view can be seen easily in certain highly competitive and rapidly changing markets such as electronics, where it is fairly obvious that free competition benefits the consumer. On the other hand, highly regulated sectors like health care and public transportation do not experience a truly free market and as a result, they are stuck with rising costs and stagnating quality. In these sectors, the incentive to improve the product does not rest with those who have the power to do it – a libertarian view of that situation.

The socialist view is backed by reality in the sense that countries with the most protection against concentrated wealth have the least poverty and a high standard of living.

Those who ally with socialist thought might trust free markets in the original sense (farmers selling their wares in a marketplace), but mistrust them when they become dominated by a small number of large interests, which is also known as capitalism. Those who ally with libertarian thought might trust the general idea of protection from exploitation, but mistrust the notion that economic fairness can be legislated. Thus, both sides have a basic compatibility with the other philosophy, but mistrust the other side taken to an extreme.

A blend of these two lines of thought is what is needed today. That blend can be summarized by the rule that the public – through government – should referee the economy, but not play in the economy. To referee means to make sure the playing field is level, so a free market can thrive, and ensure it does not get dominated by monopolies. It also means the government should not be handling trillions of dollars, because you can’t both play in the game and be the referee.

Health care is a timely example of a sector that can be corrected by the combined “libertarian socialist” thinking. As aspect of the debate is whether the government should be a gigantic economic player in health care or not. One side says yes because medical decisions should not be driven by profit, and public control would give everyone equal access, and supposedly take money out of the equation. The other side says no because the free market is theoretically better at providing the best service at the lowest cost, and it keeps each person in charge of their own life, free from centralized control and possible corruption. If we think instead in terms of refereeing the economy, not participating in it, then there are many ways to create a free market system with distributed control, and also ensure fair access. Public policy would deal with transparency, fairness, truth in labeling, and upholding contracts, rather that deciding who gets paid for what. The rule that “if you insure anyone, you must insure everyone” is an example of the government playing referee – not being in the insurance business itself, but setting the groundrules for those who play. That rule helps us achieve our egalitarian objective while also remaining competitive.

As with health care, in so many other areas of the economy, the single word “referee” can help us determine the best way for the government to be involved.

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Health care: my experience of waste

(letter to the editor)

On a recent trip to a hospital, we waited and waited – and waited – for stitches. And watched as they threw out hundreds of dollars worth of supplies, and went through unneeded procedures. It was the night of “wait and waste”. My daughter didn’t need an X-ray or any other equipment. All she needed was a clean needle and thread!

If she had needed a stucco repair, she could have gotten bids, and the suppier who could do the best work the most efficiently would be rewarded, to everyone’s benefit. But instead, she needed a cut sewn up, so the supplier who could think of the most procedures to do got the biggest reward.

I hope that Senators Bingaman and Udall will work to create the kind of market competition that rewards quality and efficiency, while also ensuring everyone can get treatment. A public option that pays for results rather than for procedures appears to be a reasonable way to achieve this.

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A parable explaining how to think about budget shortfalls

Some years ago a group of pioneers arrived from various directions, and decided to settle some miles North of here. By chance, the group had a great variety of gifts. Some were teachers, some were builders, some farmers, and some healers. Consequently the children could all read, ate well, and slept in warm beds with beautiful woven blankets. The elders said, when the village was new, they must attend to the most important things first – having food and shelter enough for the winter. Being so industrious, they soon accomplished the basic needs of life, and turned to higher forms of employment such as tending to rows of flowers along the public promenade, and building a theater. For these pursuits, each family contributed according to a wonderful formula devised by the village economist. And as it happens in other villages, their society became gradually more complex and specialized, and most people turned to the more advanced trades such as acting, finance, and law. Late in his life, after working for years in his home, the village economist completed a study of the conditions of the time, emerged, walked into the common house, and heaved onto the great table two great volumes of his work. These were the two remaining options, he said. At that time neither the public officers nor their staff took notice, as they were in full time meetings concerning the village budget. It had been determined that there was a growing backlog of needs, and not nearly enough revenue to cover those needs. At each meeting, the villagers thought of more needs that they wished to have provided, and these were added to a great list. When it was finally decided to consult the economist’s work, he had already died, and his chart of annual economic indicators along with the rest of his life’s work was no longer legible because it had been buried in snow that came in through a hole in the rotting roof of the common house. All that was known about the two remaining options was that one option was to reduce public services, which was impossible because so many people were not working and depended on them. The other option was for each working family to contribute more, and that was also impossible because they were already working long hours at cross purposes, and didn’t have enough extra to give. With no other options, the villagers sat on old crates and watched each other die one by one, either by starvation or disease, while their houses rotted and the fields went to weeds. There was nothing else they could do: the economy had ruined their good fortune.

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Three simple steps to fix government with frameworks

Most legislation should be done as frameworks rather than specifics. Examples of framework legislation include the ADA, the NEPA, and the various -TEA transportation bills. In those cases, Congress sets forth goals and procedures, not specific allocations. In many cases, compliance is local, and can be court-reviewed.

Nearly everything complex – financial, environmental, health, and so on – can be developed into a framework. The framework has goals (health, climate stabilization, peace, etc) and allows for numerous alternatives to be proposed, a procedure for evaluating alternatives against the goals, and finally (in some cases) further legislative action to choose the alternatives to fund after the executive has done all the detail work.

The requirement to approach lawmaking as frameworks can be codified as law and should itself be open to court review. Several other aspects would need to be worked out to make it solid, such as elimination of riders.

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1. Executive power is too strong, and leads to abuses.

2. Government by nature is not creative. The legislative branch by nature lacks visionary coherence. This proposal works around that natural limitation, by preventing the consideration of an idea in isolation. It forces the question of “why” we want to do X, and what other ways are available to do it, and why would be choose one way vs. another way. That is the essence of creativity as it works in the private sector.

3. Making the last step (selection of an alternative) legislative ensures that the power remains distributed democratically.

4. Major public decisions should be determined by the legislative branch, not by “public participation” in the executive. The idea of “public involvement / participation” is anti-democratic in the sense that government should be by the people 100% through representation, not a thing that people can be partly involved with. When we beg only for participation, we’ve given up ownership and democracy is lost.

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