Friday, November 01, 2013


Of all the drawbacks of an excessive regulatory, bureaucratic state, perhaps the most significant is that all of the necessary mandates and prohibitions eventually mkes the government adverse to the citizenry.

Friday, October 11, 2013

Restorative forces

There is a corollary to yesterday's post on stability. When a stable system is perturbed, forces inherent in the system act to return it to equilibrium. In political systems, these forces are popular reactions against reform. Political systems differ from physical ones, in that the public responses are often delayed as a result of public perception, remoteness of experience, or initial misperception of the scope and purpose of the reform. The forces seeking equilibrium are present and relentless however, and eventually overcome the transient and artificial dispruptions imposed by authorities. This is why dictatorships fall, or stagnate, and why socialist utopias eventually encounter crises between promises and realities.

Thursday, October 10, 2013


An essential characteristic of a stable system is the tendency to return to a state of equilibrium after being disturbed by some influence. This is true not only of physical systems but biological and political ones as well. The baseline or ground state is an inherent property of the system, and determines the response to perturbation.

Societies are highly complex and heterogeneous systems that, if they are to be stable, will have defined baselines in terms of institutions, economics, and social values. It is of course possible for these to evolve over time, but this evolution tends to be a response to environment and a constellation of circumstances rather than a discrete influence. When reformers and idealists seek to alter these fundamental characteristics of a society they often succeed in achieving only a transient and artificial change that cannot persist without the threat and use of force. Such enterprises, even if they initially have popular approval, eventually collapse under the strain of human nature.

It is difficult, almost to the point of impossibility, to "fundamentally change" a society through legislation or political machination. The natural tendency is for politics to eventually reflect the underlying values of the society, rather than to shape them. The fact is it is not possible for politicians of any type, whether they be tyrants, democratically elected legislators and executives, or appointed functionaries to prescribe what people want or what people value.

The forces necessary to fundamentally change a society, that is to change the baseline or ground state at which a society functions in the absence of force or duress, ultimately derive from people's experience and subjective interests. The instincts and subjective experiences that influence how people interact with each other are much more robust and enduring than political policies or ideological ambition.

Wednesday, October 09, 2013

A technological paradox

An article published in the medical literature in 2011 documented a significant increase in the number of pulmonary emboli that were diagnosed since the introduction of sensitive tests for them. The mortality associated with that condition, however, did not improve significantly over the trends that had existed prior to the adoption of more sensitive diagnostic methods. The number of complications associated with therapy of pulmonary embolism did increase in the same manner as the number of diagnoses. The implication of this is that the introduction of sensitive diagnostic technology led to a dramatic increase in the number of cases diagnosed, but that that increase did not have a significant impact on patient outcomes. Pulmonary embolism began to be overdiagnosed, and some patients experienced significant complications from therapy that previously would have been unnecessary.

This circumstance is not limited to pulmonary embolism, nor to a small number of similar conditions. Diagnostic technology has advanced to the point that resolution of diagnostic studies has out-paced our ability to interpret them. We are finding more minute and unanticipated anomalies for which we do not know the significance. As a result, physicians are making diagnoses, often based on incidental findings, and providing treatments where they would not have only a few years ago. The benefits and risks associated with making these diagnoses and treating these patients is unclear. In the case of pulmonary embolism, increase diagnostic sensitivity clearly carries the risk of overdiagnosis, providing treatment where none is required, and causing unnecessary complications.

The tendency to overdiagnosed and over treat arises not only from technological advancement. Fear of litigation, patient expectation, and the proliferation of protocols and algorithms also influences medical decision-making in the direction of more frequent and less efficacious treatment. Paradoxically, while diagnostic technology enables greater detail of unclear significance, the use of protocols and algorithms homogenizes diagnostic data and disregards other clinical information of significance to a particular patient.

These factors contribute to an undesirable praxis in American medicine. The desire to provide diagnostic certainty when there actually is none, to medicalize everyday difficulties and consider them as diseases leads to such excesses as overprescribing antidepressants and stimulant medications, a proliferation of unnecessary procedures for treatment of ill-defined "syndromes," and an explosion in the number of patients claiming disabilities of one type or another. A peculiarity of American medicine is that many diseases and medical conditions are associated with their own interest groups. Diseases have lobbies. It is an undeniable and likely inescapable fact of American medicine that some interests benefit from overdiagnosis and overtreatment, and those interests are active in perpetuating what is fundamentally bad medicine.

This is only one of an innumerable number of factors for which the affordable care act provides no answer.

Tuesday, October 08, 2013

Government healthcare

With all of the angst accompanying the roll out of the Affordable Care Act, the foibles, the unintended consequences, the unanticipated costs; it may be instructive to review the findings of a previous investigation into government run healthcare. These were the findings of a Senat Committee on Indian Affairs investigation into the operation of the Indian Health Service in the Aberdeen Area in 2010:

Among the investigation’s major findings:
• Chronic mismanagement, lack of employee accountability and financial integrity;

• Several service units experienced substantial and recurring diversions of reduced
health care services, due to lack of qualified providers or funds;

• Five IHS hospitals in the Aberdeen Area are at risk of losing their accreditation or
certification from the Centers for Medicare and Medicaid Services (CMS);

• Several facilities have been cited as having health care providers on staff who
lacked proper licensing or credentialing;

• Key senior staff positions remained vacant for long periods of time, contributing to
the lack of proper management;

• Employees with a record of misconduct or poor performance being transferred to
different health facilities within the Indian health system;

• Pharmaceutical audits of narcotics and other controlled substances are not
regularly performed, and three service units within the region have a history of
missing or stolen narcotics.   Source:

Morbid curiosity

There is perhaps an intuitive sense that human life is protected by the odds. It seems reasonable that the risk of cataclysm is sufficiently small to have enabled human beings to thrive for millennia, and expect to do so for many more. Most commonly perceived threats are associated with vanishingly small likelihood of occurrence. A worldwide extinction such as that which befell the dinosaurs is likely rare enough to have been considered a one off. This perception applies to most conventional threats, such as a catastrophic asteroid impact or nuclear calamity. The odds, simply, appear he to be in our favor.

It may however be the case that there are mortal threats lurking in far more likely scenarios. To take one such example, it is reasonable to assume that there is at least one, and likely several amino acid sequences that would code for a pathogen that would be devastating to human life. Imagine, for example if the human immunodeficiency virus had a genetic makeup that would allow it to be passed by casual contact, or to be transmitted with the ease of the common cold. It is possible to conjecture the existence of such a genome and wonder how likely random mutation is to produce it. Is such a peril thirty base pairs away? ten thousand? A million? It is also possible to consider that such a fateful genetic sequence might be the result of human manipulation.

This is not to imply that human beings are necessarily doomed, or that a biological catastrophe will wipe out the species. It is to suggest however that it might not be unreasonable to wonder what the true odds of disaster are, and when luck might run out.

Monday, October 07, 2013

Thursday, October 03, 2013

The limited competence of public institutions

One thing that you learn from coaching or watching football is that not everyone can do everything well. Certain players can do certain things well that other players cannot do at all. The same applies to entire teams. You also learn that not everyone who does something well does so indefinitely. Players age, skills fade, and times change. Likewise, even though someone may do something very well there is always the possibility that someone will come along and do it better. These principles apply not only to sporting contests but in civic life. No one institution does everything better than the others. Institutions that do something well initially may get progressively worse at it as time goes on. Institutions may be so hampered by bureaucracy that they are unable to adapt to changing conditions, or they may assume responsibilities for which they are wholly unsuited.

These principles weigh against the progressive notion that the government should be relied upon for nearly all important endeavors. The fact is that there are some things that charities, and private enterprise do much better than public institutions. There are also things that public institutions may have initially done well that they have increasing difficulty doing competently. There are things that may best be done by government initially that private enterprise, or dedicated nonprofit organizations eventually do better.

The list of things that require public institutions because private or charitable institutions tried and failed is vanishingly short. There are of course some things which, on the whole, are proper objects of public enterprise; these include such things as law-enforcement, management of roads and thoroughfares, and providing fire protection services. Other areas in which public institutions to have a role, but which benefit from the participation of other entities include such things as managing hospitals and education. Scientific research likewise benefits from not being reliant on a single source of support, and undertakings such as space exploration are areas in which public institutions have been largely left behind.

The fallacy that, unless the government does something, it will not get done, or alternatively, that unless the government does something it will not be done well, is detrimental to both progress and to civic life in general. Governments and public institutions are inherently bureaucratic and hence inherently limited. There is no reason for a free and thriving society to inflict such limitations upon itself without good cause.

Friday, September 27, 2013


President Obama has indicated, in discussions regrding the debt ceilling that "America pays its debts." The fallacy of this appeal lies in the fact that, if you are borrowing money to pay off your debts, you are not paying off your debts, you are just shifting them around.

Thursday, September 26, 2013

The end of Islamism

I An interesting biological phenomenon is that simple organisms such as bacteria, viruses, and fungi are capable of wreaking havoc on more complex and highly developed beings. This is not surprising, as entropy favors destruction and decay. It is always easier to destroy than to build. This concept applies not only to biological organisms but to societies and cultures as well.

The destinies of civilizations are not always in the direction of greater advancements. There is no guarantee that the future is limited to greater artistic, intellectual and humanitarian achievement. The triumphs of civilization are often fragile and barbarism is always a threat.

GK Chesterton observed that barbarism does not always describe only those cultures that are insufficiently advanced in civilization, but also describes those that, having advanced, become hostile and threatening toward it. The source of this contempt and enmity for values and traditioms that oppose, for example terrorism, genocide, and religious persecution vary from time to time and place to place. The most prominent doctrine that now opposes liberal values is that of radical Islam. The stated goal of this movement is to establish worldwide sharia law and dominance of political Islam. The ideological springboard for this regressive and destructive movement is not based in religious piety but in an emotional, supremacist fantasy.

There in fact will never be a worldwide caliphate. There are many reasons for this which include:

1.) Sharia law results in relatively weak political systems, that are not well suited to the complexities and rapid change of modernity.

2.) The present worldwide Islamic terrorist movement is not capable of achieving and maintaining power, as terrorism itself is unstable..

3.) The strategy of attempting to establish demographic dominance by emigration to Western countries fosters an atmosphere of dependence and insularity that is inherently unstable.

4.) While religion has provided an organizing framework for many cultures and societies, there is a limit to the influence of any particular religious doctrine in pluralistic societies. Human beings are simply not religious enough to accede to religious dominance in all areas of life.

5.) If political Islam were capable of creating and maintaining desirable cultures and societies, the net immigration would be from Western societies to Muslim ones rather than the other way around.

6.) Chauvinism is a poor basis for a system of government.

7.) There's a reason why Ataturk ditched the agonal Caliphate about eighty years ago. The present campaign to reestablish political Islam through terrorism, wanton violence, demographic hegemony and narcissistic complaint is a doomed effort to reinvigorate a failed idea.  

8.) The more establsihed that Islamism becomes, the more susceptible it is to the barbaric instincts that inhere in human nature. It will become the target, rather than the aggressor.  

9.) Threatening to behead those who "insult" you or cause you offense is a hallmark of weakness; any doctrine that cannot accommodate ridicule cannot accommodate reality.

Tuesday, September 24, 2013

Common sense gun legislation

Advocates of gun control legislation frequently feel the need to burnish their proposals with the adjective "common sense." Thus, appeal is often made to public support for "common sense gun control legislation." One of the first requirements of common sense legislation is that it accomplish its intended purpose. "Gun control" legislation that does not control guns, or more specifically, does not reduce criminal gun violence does not legitimately bear the appellation "common sense."

Cosmetic legislation that serves only as an emotional bromide can legitimately be called neither common sense nor gun control. Gun violence is first and foremost violence, and it is the pathologies that predispose certain individuals to violence that are at the heart of the crisis. Seung Hui-Cho, Eric Harris, James Holmes, Anders Breivik, Jared Lee Loughner, and Aaron Alexis all perpetrated mass shoootings of strangers, and all had previously been referred for psychiatric evaluation. What is equally troubling, is that all were relatively intelligent and capable of intricate planning. It is inobvious how magazine capacity limits or ammunition surcharges, or outlawing firearms with flash suppressors would have thwarted disturbed but cunning minds. It is quite likely that they would outsmart the most heartfelt of firearm restrictions. It is also worth noting that Anders Breivik killed eight people with a bomb, and that James Holmes rigged his apartment with incendiary devices. The essence of a mass murderer is a malignant motive and will. The weapon to be used is secondary.

Whether or not some idea qualifies as "common sense" depends upon context. If a community were suddenly gripped by a violent crime wave, in which the authorities could do little more than show up after the fact, it might certainly be "common sense" that the citizenry be armed in its own defense.

The people who insists on retaining the right to own firearms for their own personal use do not thereby condone the actions of psychotic murderers; they do not provide the impetus to slaughter by mentally unstable, but quite resourceful miscreants. They do not excuse the acts of madmen; the people who focus on the weapon rather than the act do. The people who support the Second Amendment do not condone the lawless gunfire in gun control venues such as Chicago or Washington DC. They do not assume moral culpability for refusing to play along with the deluded fantasy that "common sense" gun control legislation is anything of the sort.

Monday, September 09, 2013

The Dissolution of Obama

I have previously noted the difference between power, authority and influence. After more than 4 1/2 years it is apparent that Pres. Obama retains all of his presidential authority, but possesses significantly diminished power and vanishingly little influence.

The President's deteriorating stature has not so much to do with dominating events or cruel fate as it does the inherent limitations of the man. These limitations were not so much revealed by this financial crisis or turmoil in the Middle East as they were ignored by a media and publicenamored with a vaporous abstraction. The fact that Obama was president of the Harvard Law Review, yet produced no significant legal scholarship should have at least suggested caution in evaluating Obama as a man of substance. His habit of voting "present" when the public did not support his individual ideology, his vacillation regarding gay marriage, his pathological avoidance of responsibility for the scandals and corruption that pervades the administration, as well as the complementary usurping of credit for good fortune or the sacrifice of others all bespeak a defect, avoid of character hidden in an illusion.

It has become obvious that many of Obama's most desirable qualities are not personal characteristics that inhere in him, but are rather romantic yearnings that the public and media have projected onto him. His lack of influence is seen in the rebuff of his efforts to have Chicago host the Olympics, his absence of leadership in the various political upheavals in Iran, Libya, Egypt and Syria, his inability to advance a gun control agenda, and the disarray accompanying implementation of the Affordable Care Act. These deficiencies are all the more remarkable when one considers that the first two years of Obama's presidency included large majorities in both houses of Congress, and a historically compliant media.

There is no denying that the economy has underperformed, that race relations have endured several affronts to which he was a party, that American diplomacy has become more amateurish and ineffective, and that America has become a tepid ally and a timid adversary. Those who continue to defend him, complaining about what he "inherited," or the intransigence of political opposition, or the complexity of modern politics are simply in denial. His greatest "accomplishments" are both unpopular and unfinished; his failures cannot be undone by media spin, finger-pointing, or whining.

It would be tempting to attribute all of Obama's shortcomings to hubris, or lack of seriousness, or ideological blindness. The reality however is not so simple. Obama's strengths and virtues have always been an abstraction, a semi-conscious daydream in which imagined virtues were given parity with unforgiving reality. Obama actually believed that the thoughts in his Cairo speech were original and that peace in the Middle East eluded the world because he had not yet expressed those thoughts. He believed he could impose "fair" economic regulations without adversely affecting economic activity. He thought he could make the oceans recede. He thought he could reason with despots whose ambitions dismissed reason. He thought he could morally bully those who had no reason to recognize his moral authority.

The dissolution of Obama is not a tragedy nor a lamentable example of unfulfilled promise. It is simply the natural consequence of people looking at a man and seeing what they want to see, rather than what is actually there.

Wednesday, August 21, 2013

Drone on

Several questions come readily to mind regarding the use of drones in the war on terror: is the intelligence used to identify targets valid? Does the use of drones entail an unacceptably high risk of killing innocent bystanders? Is the use of targeted drone strikes effective in bringing about a successful conclusion to the war on terror?

The answers to these questions, and to a plethora of others just like them, are difficult to ascertain from readily available information, and do not even begin to address the deeper and perhaps more important questions regarding the legality and morality of such tactics. It is not at all clear that terrorist organizations respond predictably to threats of death, or that their operational effectiveness is irreversibly degraded by serial assassinations of their leadership. Israel has eliminated multiple senior leaders of Hamas, yet the terror threat posed by that organization persists. Discussion of these issues certainly is beyond the scope of a simple blog post, but there is one point that should not be neglected in the hubbub.

Terrorism is, after all, a tactic of demoralization. Whether blowing up spectators at the Boston Marathon with a couple of pressure cookers, or obliterating an Al Qaeda commander with a hellfire missile has the greater effect on the opponent's morale depends not so much on the operational details, but upon the opponent's state of mind. The crucial point is this: the West is losing confidence in its institutions and the terrorists are not, and this fact is wholly independent of the violence that either side uses. The West is losing confidence in its institutions, not because they are being attacked by the Muslim world, but because they are being attacked from within. Liberal values such as freedom of speech, the dignity of human life and equality before the law are not succumbing to an alien invasion, they are being disparaged and degraded by self loathing elites, cynical opportunists, and anti-human nihilism.

Being able to incinerate a jihadist in the Hindu Kush or Yemeni desert is simply going through the motions of fighting a war on terror. The fact is that a terror war cannot be lost without the consent of the losing side. A terror war is won when resolve, rather than fighting ability, is overcome. One's resolve to defend something tends to flag when he does not value the thing being defended.

The lethal enemies in the clash between Western civilization and the Islamic world are not the bomb makers, or hijackers, or psychotic morons that celebrate the death of innocent children. The lethal agent is the one who, given the benefit of Western-style freedom, is disdainful of human dignity and who nurses an irrational resentment of the freedom of others.

Sunday, August 18, 2013


The concept of "narrative" is prominent in political discourse. This describes the effort to manipulate public perception to accept an underlying doctrine or theory as valid. Some common contemporary narratives include those that portray Tea Party as backward racists, Global warming empiricists as superstitious and malign conspirators, and those that oppose gay marriage as "hateful." If the proponents of a particular narrative do not find the facts sufficiently compelling, they create their own, such as showing up at an immigration rally pretending to be the opposition and holding an embarrasing sign, or editing audio and video recordings to create false impressions.

The concept of narratives has a deep, if not honorable past. There was a common narrative in twentieth century Europe regarding the relationship between Jews and money. Red baiters promoted a narrative regarding the ubiquitous infiltration of American institutions by communists. The Jim Crow south played on the narrative of the predatory black putting the virtue of white women at risk, and being used to justify and even brag about lynching.

The narratives of the past and those currently used to attack critcs of the president, silence global warming discussion, advocate for amnesty, and any number of insular political interests have one thing in common: they are all base bigotry. A narrative is simply a prejudice sent to college, and adorned with sham virtue.

Saturday, June 01, 2013

The use of force

There are many interventions in medicine that are life-saving when used acutely but detrimental when applied chronically. Steroids produce highly desirable results when used for brief periods in such conditions as asthma or rheumatoid arthritis. When used for extended periods they cause abnormalities in bone and skin, psychiatric disturbances, weight gain and cataracts. Antibiotics are useful for acute infection but when used long-term do more harm than good. Surgery is often necessary in an acute, discrete crisis but is impractical as a continuing intervention. The underlying principle is that certain actions and interventions that are indispensable in confronting dire, but focused emergencies do not function as well when used as indefinite strategies.

The same principle that applies to medical therapy of human illness has an analog regarding the use of force in civic life. The use of force, and particularly armed force, is often indispensable and necessary in the management of discrete crises, such as violent criminal behavior and hostile military confrontations. The use of force is much less efficacious, and in fact detrimental when used as a governing principle for day-to-day life. This is true not only for actual armed incidents such as SWAT team actions or law enforcement raids, but also for the coercive legislation that serve as the rationales for such actions. Bans and prohibitions, mandates and imperatives, while perhaps necessary to transient exigencies are detrimental and corrupting when relied upon for social order.

A society cannot succeed, progress or even survive when daily life occurs under the shadow of government coercion. Dictatorships and tyrannies have limited lives because the inevitable result of rigid force is destruction and decay. Societies thrive as a measure of the character of their members rather than the force of their rulers. The transient efficacy of force is not dependent upon the rationale for its use. Force and coercion can be employed for malevolent as well as benevolent purposes. They can be used to suppress virtue as well as vice. The indiscriminate use of force tends to become a substitute for reasoned policy and the consensus that results from civil discourse. Bans and mandates are the tools of the impatient, incompetent, misguided and corrupt.

Once force is employed as the basis of a particular policy, especially when such is contrary to popular sentiment, it creates a self-perpetuating cycle of increasingly intrusive and coercive interventions that eventually become unsustainable. The bonds that exist between members of a thriving society are not bonds of submission. The use of force and its antecedents are malignancies in the body politic, consuming more and more of civic life and corroding the societies that host them. If society that requires the use of force and government intrusion for survival is doomed regardless.

Sunday, April 21, 2013


The practical consequences of the Administrative State are limited not only by legal and constitutional considerations, but by less arbitrary ones as well. Bureaucracies quite simply, and as a general rule, get worse the longer they exist. This is because they are subject to corrupting incentives that cannot be changed by “law”:

- Everyone likes things that make their jobs easier; give bureaucrats discretion and they will use it to make their jobs easier, even if it frustrates the purposes of those jobs in the first place.

- Turf guarding. Bureaucracies have survival instincts, and these affect their operation. Give bureaucracies discretion and they will expand as a matter of self-preservation and self-perpetuation, regardless of the public benefit or detriment.

- Insularity. Stuff a bureaucrat into a life tenure and his or her world gradually shrinks to the limits of the bureaucratic fiefdom. The external becomes the extraneous, and bureaucracies become unmoored from the common interest.

- Loss of proportion. Bureaucracies breed petty tyrants, for whom authority becomes a substitute for common sense.

-Risk aversion. Bureaucracies become more and more intolerant of risk as they age, to the point that obscuring responsibility, dodging accountability and suppressing any activity that may require a tough decision eventually become the guiding principles.

These influences arise from common psychology, rather than any particular ideology or political philosophy. All “administrative states” eventually become inefficient, sclerotic, senseless, abusive and obsolete. The more authority that is delegated to them, the faster they become so.

Saturday, April 20, 2013

Common thread

Psychologists, criminologists, historians and those who are simply curious will expend a great deal of effort trying to find a common threat that links the perpetrators of spectacle crimes. Surely, there must be some relatively simple and indeed common element that connects Eric Harris, Seung-Hui Cho, Anders Brevik, Mohammed Atta, James Holmes, Adam Lanza, Jared Loughner and Tamerlan Tzarnaev; and indeed there is. Some of these were psychotic, some ideological, some reigious fanatics. There is a great deal of heterogeneity in the motives, and cognitive processing of these individuals, but there is one thing common to them all: fantasy. Each of theme had a fantastic notion of how his crime related to some goal, with such relationship reinforced not by rational analysis but by emotional compulsion.

It is assumed that each had a pathological lack of empathy, and this is true, but one of the things that fantasy provides is a mechianism that makes empathy unnecessary. Movie villains and video game characters can be killed wantonly without moral qualm because they are acknowledged to be only part of a fantasy. this mechanism also works the other way, however. Not only can reality be projected onto fantasy, but real people can be perceived as the characters in a fantastic episode, in which everything; the motive, the outcome, the emotional satisfaction, is ultimately a figment of imagination.

Social media

The biggest benefit to the emergence of social media is not that it will help keep people more informed, but that it should make them more skeptical.

Tuesday, January 08, 2013

Efficiency and rationing

What will happen if the government institutes universal coverage, while trying to contain costs? The system will become more efficient, but not in the way the government intends. Take for example ear nose and throat specialists. Right now, such pracitce involves ear tubes, tonsillectomies, thyroid surgery, neck dissections to remove tumors, sinus surgery and more specialized procedures involving the inner ear, trachea and larynx. Much of the ear tubes and tonsillectomies are performed on pediatric patients, and involve a disproportionate number of medicaid recipients. If you give everyone coverage and begin to limit reimbursement for particular services, say for example, ear tubes, otolaryngologists will respond by making their pracitces more efficient; not more efficient in terms of performing more procedures in a given amount of time, but more efficient in terms of concentrating their time in other procedures. If a physician can get the same reimbursement for doing two hours worth of sinus surgery that he does for three hours worth of ear tubes, that physician will eventually focus on the former procedures and do less and less of the latter. He will focus his marketing efforts and networking to the more lucrative procedure, leaving the less remunerative surgeries to less senior surgeons or less established practices. Micro-specialization will occur, with the result that the less remunerative procedures will experience longer wait times, and less choice of qualified physicians. This has already happened to some extent in neurology, where physicians discovered that their time was much better compensated doing nerve conduction studies in thier offices than in doing inpatinet consultations. As a result, many hospitals had no emergency department coverage for neuroly patients. Pulmonary specialists also gravitate to bronchoscopy or sleep specialties at the expense of intensive care unit coverage.

This phenomenon is also observable in the growth of boutique practices, where physicians decide that it is better to get reasonable compensation for reasonable services than to get paid a little more for a lot more effort.

If the government provides universal coverage with price controls, it will not discourage unnecessary or inefficient care, it will discourage access to time-intensive and poorly-reimbursed care. The incentives will be such that costs will be saved, not by discouraging patients from seeking care, but in discouraging doctors from providing it.

Cost effectiveness

Here's a quick question for those who advocate a government role in cost effectiveness research: Is it cost effective to treat aspiration pneumonia? The answer, of course, is yes. Or no. Well, yes and no.

If a forty year old trauma patient aspirates immediately after urgent surgery, then yes, it is relatively inexpensive and efficacious to treat with a short course of antibiotics. On the other hand, if the patient is a 74 year old stroke patient with recurrent aspiration, end stage renal disease, and prostate cancer, treating his most recent pulmonary event will prolong the course of dialysis, potentially involve future stays in the ICU on a ventilator, gastrosomy tube, etc., all for the expected benefit of the patient being kept alive so he can die of something more horrible. It is easier to see that treatment might not be cost effective if we consider the patient to have widely metastatic prostate cancer.

If we take this last patient and start removing, one by one, the co-morbidities that make treating aspiration pneumonia such an expensive proposition, at what point do arrive at the objective cut-off that treating him is cost-effective? It is the fact that identifying such a cut-off seems reasonable that is problematic, because it implies that whatever body decides cost-effectiveness will eventually be forced to decide on case-by-case bases. This is the achilles heel of all high minded healthcare system reformers, and all of those overly academic types that worship at the altar of "evidence based medicine." The practice of medicine is founded on the doctor-patient relationship, not the doctor-population relationship or the doctor-health board relationship, or the doctor-utopian social justice fantasist relationship.

It should be axiomatic that a doctor not give a patient medicine to treat the anxiety of a family member. The principle at work is that the provision or withholding of a therapeutic intervention should not be for the benefit of third parties. Similarly, we should not conclude that an intervention is not cost-effective for a particular patient, merely because some egghead has decided that it is not cost effective for a heterogeneous population.

Population studies and statistical models and various and sundry other such are useful for identifying general principles that a competent physician may incorporate into the treatment decision that he makes for his specific patient. They are not reasonable bases upon which to dictate those same decisions from a remote authority for whom that patient is just a data point.

Typical and atypical healthcare

The more socialized healtchare systems of western Europe ("European medicine") do some things very well. So does Cuban medicine, and Honduran medicine, Chinese medicine, etc. Kaiser does some things very well, as does the VA. But none of these systems do everything well, and all of thses systems, including the European ones benefit from America’s willingness to take the risks necessary to advance medical science for the benefit of all.

If you look at the medical system of the Europeans, and Cubans, etc. you will notice that they do a good job of providing a particular type of medical services. So does Kaiser and the V.A., and if you were an astute reformer, you would immediately perceive both a rational approach to reform, and immediately spot the problems with current healthcare reform legislation.

All reform begins with a simple task: classifying aspects of the thing to be reformed into groups according to their beneficial and non-beneficial attributes. Now we can do this with healthcare in any number of ways; trauma and non-trauma, catastrophic and non-catastrophic, preventive and acute, experimental and non-experimental, pre-existing and not, publicly financed and private pay, etc. Whether or not reform is successful depends crucially on which distinctions are selected as the bases of reform. When it comes to talking about cost savings, the classifications degenerate into rationing on the basis of condition (like the Oregon medicaid system) on the basis of who the patient is (e.g. Obama’s reference to patients who are better off taking pain pills), or on some homogenized metric of efficacy (comparative research panels.) Each of these approaches requires a trade-off at the expense of liberty and values of individuals, and this is the reason why “Obamacare” is unpopular, and actually antithetical to the purpose of healthcare.

A more reasonable approach is to realize that there is a natural discriminant in healthcare services: typical and atypical care. Typical care is that which you receive for uncomplicated pnuemonia, coronary artery disease, diabetes, etc. It includes preventive care and management of chronic diseases. Atypical care is everyting else: ICU stays for complicated pnuemonia, costs for defensive medicine, experimental care, elective surgery, the more exotic imaging techniques, care for extremely premature babies, etc.

Europe and China and Cuba (and Kaiser and the VA) do very well with typical care for a very straightforward reason: typical care is relatively inexpensive. If so inclined a national formulary could consist only of drugs that Target provides for $4 a month. Furthermore, the vast majority of people could get by with only typical care. It would suck for some people if we didn’t provide for end of life ICU care, or organ transplants or reconstructive surgery, but these would affect a comparatively small portion of the population. If you reformed healthcare to only provide for typical care, the cost effectiveness would sky-rocket, at the expense of course of those for whom typical care is not good enough.

Over time, things that start out as atypical become accepted and routine (and cheaper) and naturally become typical type of care. Laparoscopic surgery, statin drugs, PET scans, Herceptin, and so forth. Subsidizing atypical care eventually benefits everyone because it advances the state of the art. Admittedly, there is a huge amount of waste in the atypical category, including defensive medicine, futile care and needlessly expensive interventions where cheaper ones would suffice. We Americans put up with this for a number of reasons: 1.) because as mentioned, it advances the state of the art for everyone, 2.) because we have adopted a societal ethic that we will not discriminate on the basis of health, and 3.) that we will not intrude on the patient’s determination of what an acceptable quality of life or benefit of therapy is. Note that ineffective or inefficient therapies would not be accepted as “typical,” or if that is already the case, be replaced by better therapies that start out as atypical.

 An astute reformer would begin by assuring access to “typical care.” This is in fact the only thing that the European model has done, with very little downside, because those nutty Americans are traditionally disposed to uderwriting the benefits of care that others regard as atypical. If you were so inclined you could reform American healthcare to cover “typical” care and let people contract individually for “atypical care” and get the best of both worlds.

Of course what Congress has done is to do the opposite. An insurance mandate is an artifice by which atypical care is treated as typical. It imports the inefficiencies of providing extraordinary and costly care into a market designed for cost effective and predictable care. It imposes the inflationalry pressures of private third party payers on a portion of the system that should be actuarily sound, and necessitates the replacement of discarded efficiencies with explicit rationing. Worse, it shoehorns providers into a system where the mandated inefficiencies will be addressed by preferentially treating those who are less ill, (which not surprisingly is more cost effective than treating very ill people) thus discriminating against those who receive adequate care now, and would receive such care in Cuba, China etc.

You are correct when you note “if you increase Medicare payments with no thought about the effectiveness of what you are buying your country will go bankrupt even faster.” This is exactly what “Obamacare” does. It divorces payment for medical services from a rational allocation based on the expected risks, benefits and costs. It stifles innovation because it falsely treats newer and promising therapies as typical care before experience and ingenuity have enhanced their effectiveness, and efficiency. In short, no one, including Europe, could afford it if everyone’s healthcare system were like Europe’s. And our tradition of liberty and personal autonomy wouldn’t take well to it either.

Thursday, January 03, 2013

Predictability and economy

One concept that runs throughout Mr. Greve's post is that of predictability. Predictability is the reason why we have written laws, constitutions, contracts, stare decisis, etc. etc. Predictability is essential to the rational expectation that the future can be made better than the present. This same idea forms the basis of credit, and ultimately, of capitalism. It is much easier to have faith in the future if we have some reason, beyond hope, to expect that it will contain something worth striving for.

 Predictability is also central to an unalterable truth. The economy is healthy so long as enough people expect the future to be better than the present. It is an uncomfortable fact, to the point that it can scarcely be spoken, that the value of something is only an opinion. Tulip bulbs, and Facebook stock are ultimately only worth what people think they are worth, and this is largely dependent on what people think they will be worth in the future. Debt is the same way. We can go on borrowing forever if someone will lend us money forever. However, the price of tulips, and corporate stock, and debt and equity markets collapse upon a fairly uniform occurrence. It is not necessarily when debt-to-revenue ratios reach a certain level, or when short term bond yields bear some relation to those of long term instruments. Bubbles burst, systems collapse and economies tank when enough people realize that they are going to get screwed. The predictability that makes economic growth possible is that which makes risk of being screwed something measurable and manageable. Right now our political class is destroying predictability with abandon.

We are all going to get screwed.