Health care rationing is good

For a reminder of the big picture issue in health care, former Colorado Gov. Dick Lamm’s Sunday opinion piece in the Denver Post is well worth a look. Lamm has been writing about this issue since the mid-1990s, and federal deficit and spiraling costs have moved events increasingly into his philosophical sights.

The piece argues that we already ration health care (“Your health insurance contract is a rationing document setting terms of coverage”), and that, given the conflicting directions of cost curves and budgetary reality, we have no choice but to face some very difficult decisions. Lamm reminds us that federal health care costs now exceed Social Security costs, and that Medicare and Medicaid tabs amount to more than triple the federal defense budget, with no signs of slowing.

For all the talk of resurgent family medicine, the creation of medical homes, and the use of electronic medical records to avoid redundancy/foolishness in care, the monumental cost of end-of-life care is an issue we can no longer skirt. Health care is ultimately a zero-sum game, with a finite basket of resources already inadequate to cover 51 million insured in this country. Whether by “death panel” or a simple refusal by insurers, public or private, to pour tens of thousands of dollars into services that extend a patient’s life for a month or two, change has to happen, and we should support it.

 

 

Space budgets in the news

Why do space missions go over budget? John Kelly of Florida Today did a solid summary of some of the key issues in his Saturday column, based, it looks like, on a Government Accountability Office report on the same topic. The key points are similar to those I made here based on my experience writing a book about three over-budget missions across about 60 years of the American space enterprise. I wasn’t the first to make these points, either. Kelly’s/the GAO’s key ideas:

  • Project teams are optimistic about their technical abilities
  • NASA lowballs the costs of major missions thinking they’ll get more money if they need it later
  • There’s not enough contingency (rainy-day fund) to cover the inevitable technical hurdles.

Points he doesn’t mention:

  • Smaller missions go way over budget, too. Its just that the overruns aren’t as painful or visible as the James Webb Space Telescope type budget-annihilators.
  • Once a mission gets going, NASA’s appetite for failure dries up, requiring less “aw, it’ll be fine” and more “prove it.”
  • Cost overruns feed contractors and engineers, and while Congresspeople don’t like overruns on the one hand, they do quite like the work coming to their districts.

Elon Musk and Alan Stern had some interesting comments on this whole dynamic in the fifth paragraph of this post, particularly the punishing of on-budget, well-run missions by out-of-control missions.

Pulling the plug on Afghanipakistan

For those who had forgotten, The New Yorker‘s most recent issue has reminded us once again that it is America’s best magazine. You’ve got Anthony Lane visiting Pixar, Malcolm Gladwell revising the revisionist history of Xerox PARC, and a raft of top writers riffing on Pakistan/Afghanistan, among other stories.

You have to read The New Yorker strategically. A thorough treatment each week qualifies as a part-time job. First you hit the comic caption contest in the back. Then the table of contents. Choose articles ruthlessly and ignore all others. Read the opening comment, skip the second story (almost always very NYC-specific and, to those of us in the hinterlands, meaningless). Read Shouts & Murmurs. Fail to do so and, 45 minutes later, you’ll find yourself at the end of a piece about some rising Soho artist whose name you will forget when you close the magazine.

Two pieces in this edition triggered this post. Lawrence Wright’s withering story on Pakistan and Jon Lee Anderson’s “Letter from Khost,” about Afghanistan. Anderson is a phenomenal war writer. In the previous issue, he did a fascinating, and ultimately heartbreaking, piece on the Libyan rebels.

You can’t really read these stories without concluding two things. First, the best we’ll be able to do in Afghanistan is keep it from becoming a terrorist haven again; and  second, that we need to sharply curtail the billions we’re giving to Pakistan’s military-intelligence establishment.

The big fear with doing the latter, which Wright touches upon, is that militant Islamists will topple Pakistan’s government and start lobbing nukes at Western cities. But is this a real risk? Think about it. Terrorists are successful precisely because they’re non-state actors. You can’t find the bastards half the time, much less retaliate. For the Pakistani nuclear arsenal to fall into militant hands, Islamic radicals have to become state actors. Once you’re a state, the rules of statecraft apply, and you have another cold war, which we’re pretty good at.

This ignores the risks of nuclear proliferation. But it’s hard to argue that the current Pakistani state has a firm grip on their warheads anyway. A.Q. Khan has already done huge damage.

Finally, a precondition for a radicalized Pakistan is that the Pakistani public (and military) welcomes/tolerates Islamic radicals’ rise to power. Whatever the Arab Spring means, it hasn’t involved protesters calling for religious rather than dictatorial oppression.

Five bucks well spent

The CU Center for Environmental Journalism forwarded a note with this link this morning, to a Wired.com article about how Al Gore and Push Up Press are aiming to “blow up the book.” As someone who recently wrote a book and then converted it into Kindle and ePub formats, this caught my attention. Push Up Press, founded by two former Apple guys, has created an app for books, as opposed using the Amazon Kindle or ePub formats, which are all HTML (standard web language) based. “Our Choice” is their inaugural product.

It’s amazing what they’ve done with “Our Choice,” Al Gore’s 2009 book. The print version is full of great images and artfully done, and a great place to start if you’re looking for a rundown on renewable energy technologies, biofuels, energy efficiency approaches, political and sociocultural considerations, population and environmental issues and other facts of the climate change mitigation/adaptation puzzle. This app, which I bought for my wife’s (well, mostly my wife’s) iPad and which, for the moment costs, $4.99, brings the graphics to life; lets you click on photos to understand exactly where Shishmaref, Alaska or Guazhou, China are; and has embedded videos as well as animations in which with Gore narrates how wind turbines, geothermal plants, solar concentrators and so on work. This iPad/iPhone/iPod Touch version has also been editorially updated and has tons more pictures than the book (such as of wind turbines in Guazhou, China).

Whether the “Our Choice” app is a model for the future of e-publishing, I don’t know. The book’s topics are visual and topical, and they lend themselves to multimedia. Publishers will have to invest more in their books to make this standard. A novel about an Elizabethan-era romance won’t gain much by it. Reading fiction and narrative nonfiction is ultimately about visualizing scenes in the mind, the ultimate multimedia tool. It must have cost a fortune to create this thing.

It’s also not searchable, at least as far as I can tell, and while the scroll bar at bottom’s pretty useful, there’s no table of contents page that gives a quick overview.

But man, is it worth the five bucks.

To tax or not to tax

President Obama’s remarks on fiscal policy today put forth a few numbers worth committing to memory before the forthcoming, protracted budget debates:

“So here’s the truth.  Around two-thirds of our budget — two-thirds — is spent on Medicare, Medicaid, Social Security, and national security.  Two-thirds.  Programs like unemployment insurance, student loans, veterans’ benefits, and tax credits for working families take up another 20 percent.  What’s left, after interest on the debt, is just 12 percent for everything else.  That’s 12 percent for all of our national priorities — education, clean energy, medical research, transportation, our national parks, food safety, keeping our air and water clean — you name it — all of that accounts for 12 percent of our budget.”

Consider also a very interesting tax calculator from Remapping Debate, a publication that started showing up in my inbox a few weeks ago and as been worth a look pretty consistently. Taxes are currently pretty low, by historical standards (unless you’re talking Gilded Age).

Today I sent $4,000 to the feds and another $1,000 to the state of Colorado. Being taxed doesn’t feel good. I could only afford to put four grand in my retirement account this year. But you grit your teeth and remind yourself: taxes are necessary, because government is necessary. Taxes are quite low in Somalia, I hear, for those who want to give no government a shot. The House Tea Party caucus could do an exchange year. “Morons to Mogadishu,” we’ll call it.

Which brings me to the Republican party writ large. The idea of privatizing Medicare/Medicaid aside (it’s insane — let’s cut costs of a proven program by adding layers of private-sector bureaucracy and diluting purchasing power! At best, it’s cost shifting — rather than via government, seniors and the poor and society as a whole will pay more, just directly to insurers), the particulars of their plan are just cynical. Sure, we must cut. But taxes have to be on the table, too, just like they were for Ronald Reagan, who raised them eleven times. Because Reagan was a leader. A pragmatist.

And so U.S. Rep. Paul Ryan, R-Wisc. and his cadre, in the face of a $14 trillion budget deficit so dire that the government was nearly shut down last week, that the Environmental Protection Agency and Planned Parenthood were to take debilitating cuts, that a fight over the $14.3 billion debt ceiling makes the world wonder what our problem is, proposes to lessen the tax burden on the wealthiest.

Let’s get this straight. You refuse to even consider raising taxes — even when the numbers show that cutting outlays in meaningful ways will make us more vulnerable and hurt our most vulnerable. It’s fighting the budget battle with one hand tied behind your back. Our problems are too serious to play these games.