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.

Expedia caveat emptor

Expedia sounds Latin, really, so I thought I’d match it up with some other Latin words so I could share some insights, as a disgruntled customer, more widely than Expedia might prefer.

Expedia, the travel web site, is to thank for my unplanned overnight stay in Kansas City, which is, checking Google Maps on my phone, not in Kansas at all. Who allowed this?

I blame Expedia.

It’s raining here, and windy, and while there are no tornadoes nearby (the only place in the Midwest not being torn to shreds in a vortex of some sort, it seems), the weather is not good. My legs were in fact soaked as my 15-year-old Japanese super-fold-up umbrella (actually bought in Japan!) buckled under soaked and shoving gusts en route to Ruby Tuesdays a couple hundred yards away, and on the way back. I held the umbrella literally horizontally. My knees are still drying as I type this.

So. I spent three days in Washington D.C. at Compliance Week 2011 at the Mayflower Hotel. This is a wonderful hotel, far too expensive and nice, normally, to allow me past the extraordinarily heavy, I think brass, doors. But Compliance Week was paying for it, and I was in fact authorized to enter. I had a nametag hanging from a Compliance Week laniard, complete with my name on it. Todd Neff, Compliance Week Contributor, it said. And it’s true.

Freelancers live schizophrenic lives, make no mistake. Last week, I wrote about abiraterone/Zytiga; on the plane back from Washington D.C. to Denver, where I jointly own a home with my wife and where my daughters and puggle now sleep, I looked over my notes for a sample chapter involving a mountain of municipal solid waste; today I moderated a panel during which three amazing board directors talked way over my head, at the Mayflower Hotel, in Washington D.C.

I learned, in the seventh floor elevator lobby of the Mayflower Hotel, that Franklin Delano Roosevelt composed his inaugural address, and the “Only thing we have to fear is fear itself,” line, right down the hall from my room (He was in a room, though. Not in the hall). The band Living Colour first made the quote famous in their 1989 hit, “Cult of Personality.”

So Expedia. Having moderated/introduced 9 panels in 2.5 days at Compliance Week 2011, I presently have a rather honed notion of risk/risk management, and I am, or was, angry with Expedia because they deceived me into buying an airline ticket dripping with risk without letting me know. So, in effect, compared to other possible flights (and DEN-DCA is not an obscure route, lots of options) it was extremely risky. So it should have been priced extremely inexpensively, or I should have understood the risk I was taking so I could avoid it assiduously. Neither was the case, so I didn’t, So Expedia ripped me off.

Let me explain.

My flight was scheduled to leave Washington National at 4:40 p.m. and arrive at 6:25 p.m. A Frontier flight. Then from Kansas City, which Google maps tells me is in fact in Missouri (who would have thought? I mean, what a great idea. Next, I’ll bet, they’ll name a city in Indiana “Michigan City”), I’d take a 7:47p flight to Denver. That flight, turns out, was on United Airlines.

Now, I booked this whole thing based on schedule. Compliance Week 2011 ends at noon, and there’s a bit of a flight desert in the early afternoon, so it made sense, or seemed to. And while I wanted not to saddle Compliance Week with a huge flight tab, they were paying. So I booked the flight. It was a $565 dollar flight, all told. So expensive. And, thanks to Expedia, super risky.

How? Well, it was delayed. Not long–20 minutes out of the gate. Then for what seemed like inordinate time on the tarmac, in our Embraer 190, a plane made in Brazil. Embraer’s chief compliance officer had spoken at a panel I had introduced just the day before (the Dairy Farmers of America rep who hogged the armrest between us was all stoked about it, until he fell asleep and started infringing upon the foot space also). So we got in at about 7:30p.

This is a tight connection if the gates are next to each other. I disembark apace and the gate agent says, oh, United? They’re in Terminal A. Look for the red bus.

Red bus?

She may as well have said, “It’s in Topeka, which is actually in Kansas,” because even though the bus showed up reasonably quickly, it was way too late. United, the guy tells me as he shuts down the counter, doesn’t fly to Denver again until Friday.

It is now, as I write this, for the next four minutes, still Wednesday.

Try Frontier again, the guy suggests. And maybe Expedia. So back on the Red Bus, around (Kansas City’s airport is arrayed in a three-terminal circle, as if someone had started building a supercollider and given up and settled for a sprawled airport instead) back to Frontier. I am, the entire time, on hold with Expedia. Fuming at the Frontier counter, though it’s not their fault in the least. A 20-minute delay is not bad, really, given DCA and weather etc etc. Need to talk to the supervisor. Still on hold with Expedia. The recorded CEO talks to me about how important I am. “I’m Leaving on a Jet Plane,” the song, plays. Smiling voice overs. I want to kill Expedia.

The Frontier guy goes out of his way to be nice. But it’s not good. Amazingly, there’s not a lot of flights in and out of Kansas City, despite the presence here, among other things, of the Kansas City Chiefs. And 8 p.m. in Kansas City, looking at the monopane departures flatscreen, is like 11 p.m. in a major airport. There’s nothing else for the night.

After probably 20 minutes, Expedia answers the phone, absorbs my snarling abuse, the least of which they deserve, and says they’ll call back.

Frontier forges ahead. Fifteen minutes of code-entering and indecipherable phone-calling later, they’ve got me on standby on a nine-something flight tomorrow morning. Everything else is completely booked up, they explain. And is a smoking room OK? At the Drury Inn?

Sure, I say, and I mean it. I am beginning to emerge from the anger/denial phase into something well shy of acceptance. But first I have to take the Red Bus back around to United, because my checked bag is over there. Maybe.

It is. The United Lost Bags lady calls to someone whose office is, in my imagination, deep underground, and they fire up the carousel for the express purpose of coughing up my leaden roller bag. And then the Drury shuttle picks me up, and here I sit in a room in which the relatively light ashen scent tells me that not a few nonsmoking marooned travelers have come before. The hallway smoke is worse. And I braved the rain to Ruby Tuesdays and had two very tall Blue Moon seasonal weizen beers and a half rack of ribs and watched both NBA and NHL playoff games (in part) and ended up in spirited sports-related conversations with three sales guys (two riding mower salesmen, one medical device salesman) and a bartender-woman whose father owns a rink. In Kansas City, not Kansas, nine hundred fifty miles from home. Because — because! — Expedia sold me a flight that should never have been sold. And I won’t forget it, and neither should you.

Expedia caveat emptor!


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.

Elon Musk, Alan Stern and the future of space

Elon Musk and Alan Stern teamed up for a public event sponsored by University of Colorado’s Laboratory for Atmospheric and Space Physics (LASP) 10 days ago (April 29). With the caveat that I’m not as versed in New Space as I am “old space” (what do you call the space program as we know it today?), it was a pretty enlightening show. If you’ve got two hours to spare, it’s online here.

Very quick bios: Musk is CTO and CEO of SpaceX (as well as CEO of Tesla Motors and chairman of SolarCity); Stern founded and led the Southwest Research Institute office in Boulder, Colo., during which time he finally sold NASA on a mission to Pluto, which he now leads (New Horizons). He then led NASA’s Science Mission Directorate (~$5 billion annual budget) for a couple of years, and now consults widely as he leads New Horizons and prepares to take scientific payloads on commercial suborbital missions (via Xcor and Virgin Galactic).


In addition to being at the the top of their business and scientific fields, both are top-drawer communicators. I took a lot of notes.

One of the most interesting bits was from the Q&A, when someone asked how commercial space outfits like SpaceX can manage to launch satellites (or, in the future, people) for a third the price of existing players. (I wrote a bit on the topic of space budgets, focusing on satellites and instruments, here).

Musk said part of it is a lack of choice for government buyers, who are forced to work with a handful of cost-plus contractors. “They will underbid the project, then once they’re in they will raise the prices to the maximum amount, just short what would bring about program cancellation.” Stern elaborated that the incentive of such programs is to add people to them. That costs money and makes communications worse, which leads to problems, which they then hire still more people to fix. “It’s a bad closed-loop feedback,” Stern said. “and the government system likes more jobs, even though it doesn’t say so explicitly — more jobs particularly in the zip codes of people on the approriations committee.”

Because of the lack of appetite for cancellations, money is then pillaged from good-performing projects to shore up ones that are over budget, providing yet another bad feedback. In sum, he said, “They’re all pumping the system towards something disastrous happening.” In contrast, Stern said, private commercial companies are largely led by people with training in the Internet or elsewhere. “And now they’re porting all that over to aerospace and it is the rise of the mammals against the dinosaurs,” he said.

The rest in bullets (Stern, then Musk).

From Stern’s talk:

  • If the distance from the Earth to the moon were a 100-yard football field, the space shuttle (and space station) orbits at the equivalent of 2 inches from the goal line.
  • The space shuttle program has cost us about $200 billion; the International Space Station $100 billion.
  • “Really we have had, for 40 years since the era of Apollo, a very politically driven, centrally managed, really Soviet style approach to space flight.”
  • SpaceX conceived, designed and flew the first Falcon rocket for less money than was spent on the launch tower for the (cancelled) Ares I test firing.
  • The entry of players like SpaceX, Blue Origin, Armadillo Aerospace, Xcor, and Virgin Galactic offer, for the first time, the potential of multiple competitors to carry people into space (in the U.S., it has always been a single option — Mercury, Gemini, Apollo, the shuttle program). Stern said he expects four separate suborbital lines to reach markets in the next two years.
  • Paying $250,000 for a scientist to carry an instrument into space on Virgin Galactic’s Space Ship Two might seem steep, but it’s a deal compared to the $2.5 million needed to loft an instrument on a Black Brandt sounding rocket, the next-cheapest option. Stern called it “an access revolution, where spaceflight goes from rare to routine,” and likened it to the transition from big, expensive centralized mainframes to PCs. In terms of aviation history, commercial space is today where commercial aviation was in the 1920s, Stern said. “I think this is the beginning of a real revolution,” Stern said. “This is the best time to be alive in space exploration.

From Musk’s talk: (Musk, for the record, had just flown in, and his jazzy SpaceX videos, e-mailed prior, for some reason couldn’t be coaxed to work. So he went a capella. Where Stern is straight-talking, go-getting American in his delivery, Musk’s South African background lends a British sensibility; soft spoken; very wry wit also).

  • The lessons of history, Musk said, are important in setting one’s own priorities, or that of a business. Looking back, the less important stuff falls away. Musk is talking big, big picture here, citing the emergence of single-celled life, the evolution of creatures with differentiated cells, and the transition of life from oceans to land being “important.” Where does SpaceX come in? He views life becoming multiplanetary as a similarly important moment — perhaps more important than the oceans-to-land transition, “because you have to travel hundreds of millions of miles across irradiated space to do it.” Musk says he’s happy to take payloads to the moon, but he’s most interested in Mars. “Mars is a real planet. There’s water almost everywhere, the red is iron oxide.” To get there, launch costs need to be at most $100 a pound, he believes (they’re at $1,000 a pound now).
  • “That’s why I’m into space. To advance the technology of space travel and set us on a path to make that happen.”
  • As far as what we should spend on going multiplanetary, Musk said maybe a quarter of a percent on GDP per year — less than what we spend on health care, but more than we spend on lipstick.
  • Despite his leading Solar City and running a rocket company, Musk is dismissive the idea of space based solar power. “If anybody should be interested in it, it should be me,” Musk said. “But it totally doesn’t work.” The sun’s intensity in orbit is only about double that on a good spot on Earth, and you’d need to orbit equipment to convert photons to electrons and beam it down via microwave radiation, and then convert back to electrons on the ground. “Even if launch costs were free and you could teleport the equipment to Earth orbit–which would be awesome–it still doesn’t work. So we shouldn’t be thinking about it.”
  • The Falcon Heavy, which SpaceX recently announced, can lift 53 metric tons orbit, more than a Boeing 737 with passenger, luggage, fully loaded with fuel. “That’s double the capacity of the space shuttle, the Delta 4 heavy or any other rocket on Earth.” First flight is slated for 2013, he said.
  • The dream of truly inexpensive access to space depends on the creation of what Musk described as “a fully and rapidly reusable” orbit-class rocket. That is, the rocket becomes like the jet plane or the bicycle, which you don’t write off each time you ride it. If it can be done, one can amortize capital costs across “tens of thousands of trips,” making those costs “quite small.” So if a Falcon 9 launch costs $50 million and could fly 1,000 times, you’ve got a capital cost of $50,000 per flight, Musk said, plus propellant (propellant for a Falcon 9 costs about $150,000, equivalent of loading up a Boeing 757, he said).
  • SpaceX hopes to unveil something by the end of this year, Musk said. “But it’s quite tricky, because Earth’s gravity is quite strong.” No rocket has ever carried even 4 percent of its weight to orbit (I’ve described space-bound payloads as the equivalents cats in sedans). Usually it’s 2-3 percent of the total rocket-plus-payload weight that ends up in orbit, Musk explained. And if the rocket’s rapidly reusable, you’ll need to add reentry shielding on the upper stage, hardware for a deorbit burn, final velocity attenuation. . . “In all prior attempts, you come up with negative results. You get negative payload to orbit. Not very helpful,” Musk said.