Health Care: A Parable

The White House, October 4th, 1957

Anonymous staffer #1, rushing into the Oval Office: Mr. President, the Soviets have just launched a satellite!

President Eisenhower: A what?

Anonymous staffer #1: A satellite, a man-made object circling the earth.

President Eisenhower: Like an airplane?

Anonymous staffer #1: No, much, much higher. Above the atmosphere, like the moon.

Presidential adviser #1: My God, how did they do that?

Anonymous staffer #1: They used a rocket to boost it into orbit.

President Eisenhower: If there is a race into space, we seem to be falling behind. Do we have anything similar?

Presidential adviser #1: The Army has the Explorer Program, and the Navy has Project Vanguard. We could rush one of these into full production.

President Eisenhower: Any other suggestions?

Presidential adviser #2: We could copy Sputnik. It's cheaper than making our own design, we know it works, and simply having a satellite would show we are are world-class superpower.

Presidential adviser #3: I hate the idea of just copying the Soviets. How about we copy the Soviet rocket engine, take the body from a German V-2 – since we have plenty of German scientists kicking around – and then copy the fuel from a Chinese rocket?

Presidential adviser #1: The Chinese don't have rockets.

Presidential adviser #3: The ones they shoot fireworks up with. Those are really pretty.

Presidential adviser #2: Will it work?

Scientist #1, clearing throat: Mr. President, we could have teams of scientists and engineers test the various proposals against each other, and then pick the best one. As we gain experience with rocketry and outer space, we can propose and test design suggestions, and then roll out any improvements we discover. With adequate funding, we could land on the moon in a dozen years or so.

Presidential adviser #1: A dozen years? Are you out of your mind? The President will be a decade out of office, and you are looking at six election cycles between now and then. I say we rush Explorer or Vanguard into production.

Presidential adviser #2: Copy Sputnik!

Presidential adviser #3: Copy bits and pieces from other rockets!

President Eisenhower: Well, I'm a lame duck anyway, and don't have any political capital to spend. Let's turn the problem over to Congress.

Scientist #1: Are there any scientists in Congress?

Presidential adviser #1: Lawyers, mostly. But it's not like it's rocket sci – er, they can consult with scientists, and then work out the differences in the various designs in committee.

Scientist #1: You are going to design a rocket with a group of lawyers? I mean, I like the idea of using wind tunnels, but --

Presidential adviser #2: Oh, good point. Better bring on board labor unions, the National Rifle Association, AARP, and the American Bar Association. We will need their votes in the next election.

Presidential adviser #3: And once we have hammered out the differences between Democratic and Republican rocket plans, and brought the various interest groups on board, we will have the best spacecraft ever!

President Eisenhower: Get to it! I want everyone to see what American ingenuity is all about!

***

Sometime in 2050:

Anonymous staffer #5006: Mr. President, we beat Lithuania into orbit!

Anonymous staffer #5007: Making sure that each congressional district and interest group got precisely the same amount of money did the trick!

***

Okay, now I will be serious.

We have something called the scientific method that can tell us what health care proposal is the best for the United States, and 47 million uninsured Americans who would benefit from any sort of health care access. Why not come up with an experiment – along the lines of a much-expanded Rand Health Insurance Experiment (see http://en.wikipedia.org/wiki/RAND_Health_Insurance_Experiment ) – and test the various proposals against each other?

Give each political party and interest group a set amount of time to come up with a universal plan conforming to specific criteria – you could have the Liberal Democratic Plan, the Blue Dog Democratic Plan, the Republican Plan, the Green Plan, the Libertarian Plan, plus plans by AARP, the American Medical Association, the Insurance Lobby, and even the American Bar Association, if you wanted. Throw in copies of the Canadian, French, English, German, Swiss, Japanese, and Singaporean plans, plus any other national plan that seem to be working well and can be applied to the United States.

During the time the designated interest groups are coming up with their “optimal” plans, decide on a standard set of criteria to judge the success or failure of each plan, and an amount of money to spend. At the end of the design period, select plans that conform to the starting criteria (things like universality, funding, and the like). Randomly assign the 47 million uninsured Americans to the plans, and give each plan the equal amount of money and a set time period.

If one plan is clearly worse than the median of all plans during the course of the experiment, remove it and randomly assign the people involved to one of the remaining plans. Continue until the agreed time period has completed, or there is only one plan remaining, and then use the winning plan as the national system. Or you could have an experimental group and a buy-in group, where the experimental group includes the uninsured Americans above, and the buy-in group includes individuals, groups, and companies that wish to access a particular plan with their own funds, which would provide additional data as to what plans are popular with which groups, but wouldn't affect the experiment itself.

There is a far greater chance of finding the best plan using the scientific method than there is using the wishes of the loudest interest group and the most highly-paid lobbyists interacting with a bunch of lawyers and politicians. It would also quiet (though admittedly, not completely silence) the loudest critics, since their pet health care plans would have been shown to be inferior to the winning plan.

And not only would this method provide a means of continuing improvement – since the experiment could be continued with a small group even after the vast majority goes on the universal plan, and improvements rolled out to the nation as a whole – but it would provide valuable information for every other country on the planet. So much so , in fact, that some countries may be interested in contributing scientific proposals and/or funds, in order to share in the rewards of such research. A plan that contributes not only to the welfare of the United States but to mankind as a whole would seem to be a goal worth pursuing.

Just a brief note about tit-for-tat in game theory

Four words:
Cooperate
Retaliate
Negotiate
Forgive

In other words, cooperate as long as the other party does, punish them for any defections, negotiate a return to cooperation, then forgive them for their defection.

/And it's been a half year since I wrote anything in the blog. I really need to A) Post some stuff I've written about balanced senary notation (specifically, the cool truncation/rounding part, including things like prices), B) Post some thoughts on IFNOP/ILOOP Condorcet completion methods (Ignore Fewest Number Of Preferences/Ignore Lowest Order of Preferences), and C) Post some ideas on the Single Tax, and how much cooler it is than the mis-named "Fair Tax." (grin)

Five lessons learned from Iraq

This came to mind from a Fark thread entitled Ten Iraq lessons learned. You won't like them.

1. Only attack other countries who actually attack you first. Massive retaliation is preferable to incorrect pre-emption.
2. Wars should only be fought to protect the people and the Constitution of the United States, not to reshape the politics of the Middle East or other parts of the world.
3. "Allies" share danger, so that both are safer together than they would be apart. If one group shields another at the cost of their own safety -- shifting danger from one group to another, rather than sharing it -- they are more accurately called a patron, benefactor, or protector, and the quote about "entangling alliances" comes into play.
4. People have friends, countries have interests. The interests of the most annoying state in the union come before even the nicest country overseas.
5. If terrorists hate us for our freedoms, taking away our freedoms to fight them is a stupid idea.

Health Saving Accounts -- updated

I updated this in a post on Slate.com, so I thought I'd copy it so I had a record for future reference (and possible inclusion in Fark and Slashdot threads). Here goes:

It seems like most of the plans proposed by the major candidates for President require mandatory enrollment and government-control. Still, it's not necessary to have a super slush fund set up by the federal government to pay for medical treatment -- it's perfectly possible to have universality with mandated private health savings accounts, which not only remove the stranglehold of insurance companies on the process, but the government temptation to redirect funds (e.g. Social Security).

For example, how about the following:

1. Calculate the amount of money a person is likely to require for healthcare throughout his life, factoring in pre-existing conditions and genetic predispositions. Adjust this amount to reward good healthcare decisions (regular exercise, immunizations, annual checkups) and punish bad ones (overeating, smoking, etc). You might also give a break for those who are regular blood donors, or have signed a consent form for organ donation.

2. Figure out how much money a person can afford to set aside for their health savings account, up to some maximum percentage of income. Require at least that amount to be saved (though of course they could save more if desired), until their account matches the actuarial estimate in #1. In addition, front-load the account so that it is fully-funded before the person retires, barring accident or illness. This would be pre-tax, to provide an incentive to those who are saving the most.

3. Have the government calculate a standard fee for a wide range of medical services, and reimburse health care providers up to a set amount based on the drug, procedure, or treatment. A person could opt for a more expensive option, but they would have to pay the difference out of their own pocket, and if they are able to take advantage of a cheaper option, then less would be taken from their account.

4. If there is any shortfall in the account, the state would cover it, but treat it as a loan with interest. If the person's financial situtation improved, they would start paying off the debt, and then return to funding their account.

5. Once an account is fully funded, the owner of it would no longer be subject to automatic withholdings, unless there is a future shortfall. If there is a surplus in the account, a reasonable rate of interest could be paid, and the owner allowed to spend the excess, or transfer it to another account.

6. Parents would be responsible for all healthcare costs for their children until they reach adulthood.

7. If a person dies with an account shortfall, the money to retire the debt would come out of the estate, if possible. If there is a surplus, it will be treated as an asset, and transferred to one's heirs.

8. Since there will probably still be a shortfall over the entire system (since surpluses are fully transferred, but shortfalls after probate are not), a graduated tax rate could be imposed to make it fully solvent.

This system would be universal, and since the state would have a direct say in the maximum payment per procedure from the HSA, there would be a two-prong approach to limiting costs and minimizing fraud -- patients wouldn't want to spend more from their account than necessary, and the state would set a limit for their reimbursement, kind of like insurance companies do nowadays. By making patients fully aware of the costs for treatment, they can make more informed health decisions, turning the system into a means of exploiting the "wisdom of crowds" rather than the "opinions of bureaucrats."

In addition, this plan would reward people who were frugal, and encourage conserving scarce resources without requiring the state to ration care. On a related note, people in the final stages of their lives who have no hope for recovery would be less likely to choose the most expensive, herculean efforts to prolong their suffering, since the cost would be taken from their estate.
Finally, it would also severely curtail the free-rider problem, since a person demanding expensive, unnecessary care would be paying more for the privilege than a thriftier person.

Most arguements against this kind of system are that it's unfair (what could be fairer than paying as much of your own way as you can?), punishes the sick (but treatment is guaranteed, and repayment only necessary if you can afford it), is mean-spirited (okay, it doesn't give freebies to anyone), or is inefficient (but the government would still controll the maximum payment per service, it would simply have a second pair of eyes -- the patient -- trying to minimize the bill as well). Compare to a system where the government puts the money in a big pool, and ladles out coverage as necessary, this has less potential for fraud and abuse, and is probably more in tune with American desire for individuality than most of the "socialized medicine" alternatives.

/I wonder if anyone will bother reading this far? Oh well, it's fun to craft plans like this and see how people respond.

The hunter and the bear

I argue a lot on Fark, and typically, political arguments are of the form "Candidate A doesn't believe in X, so you are an idiot if you vote for him." Of course, this completely ignores who you should vote for. I finally wrote the following:

These threads are a bit like a religious argument between a Mormon and a Muslim. Sure, it's easy for one side to poke holes in the wacky beliefs of the other, but only when their own beliefs aren't subject to the same scrutiny.

Which is probably why a lot of people seem to be against everything and for nothing. There are relatively few arguments like "I believe Ron Paul is mistaken in the role of the Federal government in universal health care, which is why I support John Edwards," while there are plenty saying "Ron Paul is a racist homophobe, and if you vote for him you are an idiot."

There is a joke about two hunting guides walking in a forest. On the other side of the canyon they see a grizzly bear stand up on it hind legs, sniff the wind, then take off running toward them. The first guide looks around the scrubby pines in vain for a tree to climb, while the second grabs a pair of running shoes from his backpack and starts to hurriedly put them on.
"Why are you doing that? You can't outrun a bear!" The first guide exclaims.
"I don't have to outrun the bear," the other replies. "I just have to outrun you."

Likewise, Representative Paul is far from a perfect candidate, but he doesn't have to be perfect, he just has to be better than the others -- as President, not king, or emperor, or whatever, but as a chief executive that must defer in certain matters to the Congress, the Court, the various states, or to the citizens of the United States.

There is plenty of time between now and election day, and there is a very good chance I may change my mind in the interim, either by some policy statement of Paul's, or by another candidate really impressing me, but at this point I don't trust any of the other Republicans to keep us out of unnecessary wars, and I prefer some form of divided government to offset the Congress, rather than a Democratic rubberstamp. With Paul, it would be like divided government no matter which party held Congress, and that situation works for me.

Ron Paul -- spamming or swarming?

I wrote this (as "anonymous") on the Elephant Biz blog, and I thought I'd put it here as well, since it's a brief synopsis of what I think about the accusations that Ron Paul supporters are "spamming" online polls:
***
Are the same people voting in multiple polls? Probably. Are they voting multiple times in the same poll? Probably not -- or at least, not any more than supporters for other candidates. Checking the IP address, using cookies, and validating e-mail addresses would prevent the vast majority of that from happening.

Thus, I don't think "spamming" is the correct word, though "swarming" might be. While it can be annoying for websites that prefer other candidates, it does show how excited some people are about the election. Rather than ban a particular candidate, I think other candidates should differentiate themselves from the pack in order to generate the same excitement -- people tend to root for the underdog, and a person standing for his convictions in the face of widespread opposition is attractive to many. For example, John McCain impressed me with his principled stand against torture, especially since he was the only person on the stage to have endured it (granted, he lost most of that goodwill with his stand on immigration, but that's another subject).

Finally, the Republican Party has to decide whether their platform is a big tent or a pup tent. If they can't defend their views against a person in their own party, how will they fare in the general election? The Iraq issue isn't going to go away between now and Novemeber 2008.
***

For me, "spamming" means a small group of people voting over and over in the same poll, while swarming means a larger group of people who vote in many (most? all?) of the polls they see, but only once per poll. The latter might annoy some people, but it's no more unethical than if Gallup and Pew called the same person on the same subject, and they answered both times. "I'm sorry, I already answered that question for a Gallup poll, so I can't answer it here" seems a little excessive.

My suggestion for other candidates (as mentioned above) is to find an important position where you disagree with the majority of your compatriots, and give a firm, reasoned defense of that position. It will help differentiate you from the rest of the pack, and generate excitement with those who agree with your position. Saying "Me, too!" and "I'd do that -- twice as much!" doesn't give anyone a reason to vote for you over anyone else in the race.

Ron Paul did not say the U.S. invited the 9/11 attacks

I see this pop up on blogs (and even in some newspapers, which one would assume know better), and it's kind of irritating to see a lie repeated over an over, as if it will become the truth.

He said (and I quote):

"Have you ever read the reasons they attacked us? They attack us because we've been over there; we've been bombing Iraq for 10 years. We've been in the Middle East -- I think Reagan was right. We don't understand the irrationality of Middle Eastern politics."

Let me give an analogy. Let's say a little girl is visiting Yellowstone, and she is mauled by a bear. One park ranger insists that bears are inherently evil, and should be hunted down and exterminated.

Another ranger disagrees, saying:

"Have you ever read the reasons bears attack humans? They attack us because people feed them, and they associate humans with food and seek them out. We don't understand that wild animals are not pets."

Is this blaming the child for being attacked? Is this blaming the majority of park visitors, who heed the warning signs to not feed the bears? I would say it does not. Instead, it is giving helpful information about how to avoid future attacks. Much like the warning signs in parks, Paul believes the U.S. would be better off if we follow the Constitution rather than ignoring it.

Of course, not feeding bears and not occupying foreign countries only helps most of the time. Sometimes you have to hunt down a vicious bear and shoot it, and sometimes you have to invade a foreign country to protect your own. It's interesting that Paul actually voted for the invasion of Afghanistan, which indicates that he knows the difference between non-intervention and pacifism.