Amish Healthcare

Megan McArdle wrote a while back on healthcare problems and solutions.  This past article
describes how the Amish handle their health care.  While they accept modern medicine, they're exempt from Obamacare and the community self-insures, apparently effectively.

Shame on Tom Davis: the Cost of Being Wrong

I sometimes contact my representative and senators, but not often.  Never did before I retired.  I think the first time I did was to write Tom Davis, the Republican who was then my representative, supporting the idea of authorizing needle exchanges, perhaps in DC, perhaps nationally.  This was in the late 90's, when AIDS was still a terror. Congress had banned funding for needle exchanges and for research on needle exchanges.

Davis was a moderate Republican, who'd work across party lines, though shortly after I think he became chair of the Republican Congressional Campaign committee.  He later retired at a relatively early age.  He's well respected for his knowledge of politics and has often been interviewed on TV on various issues.   All in all, he was the sort of Republican who might have supported needle exchange.

But he didn't. He wrote back with an explanation of why he couldn't support the proposal.

It's now close to 20 years after my letter.  Congress, controlled by Republicans, has just removed the ban on funding needle exchange programs (see this fivethirtyeight post).  There's no telling how many lives were cost by the decision not to research exchanges.

Three Times Greece or Poland

No, that's not good.  The US maternal mortality rate is three times that of Greece or Poland, according to this piece.

It's All Downhill from Here: Pillminders

If I have any young readers, I hope by the time you're old someone will have innovated pillminders away.

Maybe a 3-D printer which can produce any known medicine, with the output passed through a permanently installed port in one's arm, with the timing under control of the embedded personal health minder (the great grandchild of the Apple Watch)?

The older readers will know what inspired this: first you have to take an aspirin a day. Not hard to remember, particularly when one's mind is at 98 percent capacity.  Then the doc adds a prescription pill for circulation problems.  By the time the third pill is added for blood pressure, one's mind is at 90 percent and going more quickly.  So it's time to invest in a pill-minder, perhaps a 7 day jobbie so you only have to fill it once a week.

The next step is a couple more pills, one of which has to be taken twice a day, not once. And now the mind is really losing it.

Maybe what I need is a blogminder--something to remind me what I was writing about when I started the post?

Drone Registration and Obama's Immigration Actions and Guns

Today's papers (I think, but I'm playing catchup with my reading after a short trip) say that the FAA is planning to implement a registration system for drones by the end of the year.   There's also a piece about the court battle over Obama's immigration actions.  Why do I link the two?

Because I think both cases involve a bureaucrat's favorite piece of legislation--the Administrative Procedure Act.

As I understand it, Obama is being sued by Texas because he didn't follow the public rulemaking provisions of the Act.  Texas argues that the state is harmed by Obama's actions, meaning that he (ICE actually) should have gone through proposed rulemaking, allowing the public to comment on the actions.  There's a prediction the court fight may drag out through the rest of Obama's term in office.  (If they had gone with proposed rulemaking, the administration's lawyers probably figured it would have taken a couple years to complete anyway.)

If the FAA actually gets their registration system, both software and system design and requirements, up and running by Christmas, in time to catch all the drones being given for Christmas, they will have done well.  But why aren't they required to go proposed rulemaking under APA?

My guess is the FAA's argument in fact, if not formally, is that no one will have the balls nor the legal basis for suing over APA procedure.  They might say that the registration system will be so easy and not burdensome that there's no adverse burden to the public.  What I suspect they'll really mean is that the drone industry wants certainty so they can forge ahead, so no company will sue.  The industry will do better by having known standards than a 2-year court fight over process.


Now from the private citizen's standpoint, I could argue that my freedom is impaired by any federal regulation of guns drones. I could even argue owning and operating a drone is vital to the citizen's oversight of the federal government and my rights will be violated by this hasty rush to regulation.

I could argue that, but I don't.  I wish the FAA good luck with their software project.

Healthcare Behind the Scenes

Politico has a piece describing problems in the overall healthcare.gov system, mostly in the backend linking the signup process with the insurance companies, and extending into handling payments and change of life events.

Sounds a bit familiar from the good old days of the System/36.  One of the enduring lessons I learned was that for everything, whether it's a building or a software system, highways or ships, everything requires maintenance.  What that means for new systems, like healthcare.gov, is that you may implement and release a set of processes while planning to come along later with additional features.  But once you have the first release out, your time gets absorbed in the maintenance of those features, and the schedule for releasing version 2.0 slides.  And the sliding means that the jury-rigs to cover the gap grow and grow, and the problems of transitioning from the jury-rigged current system to the version 2.0 system, once available, also grow.

The NUCC--a Great Discovery for a Lover of Bureaucracy

Who knew there was a NUCC in our world? 

What, you may ask, is a NUCC?

It's the National Uniform Claim Committee, the proud sponsor of 1500_Claim, which is one of the government's most popular publications.

Essentially it tries to standard healthcare claims. As they say:

"The NUCC replaced the Uniform Claim Form Task Force, which was co-chaired by the AMA and CMS and resulted in the development of the 1500 Claim Form, a single paper claim form for use by all third-party payers. With the transition of the medical community to electronic data interchange and the proliferation of data element definitions among various payers, it became essential that an organization be established to maintain uniformity and standardization in these areas. The NUCC is responsible for maintaining the integrity of the data sets and physical layout of the hard copy 1500 Claim Form.

From the provider viewpoint, non-uniform data elements have caused significant frustration, claims billing and processing delays, and rejections. From the payer viewpoint, claims that are not in the required format may be resubmitted several times before they can be processed. The result is a very labor-intensive and costly business practice for providers and payers.

Through an iterative process, the NUCC used existing implementation guides, data dictionaries and results from ongoing standardization efforts within the health care industry to consolidate the many current data sets into one set.  The NUCC continues to work to optimize, as necessary, coordination of implementation within the health care industry, working with ASC X12N as required, to resolve data maintenance and standards problems that arise from the NUCC's work.

Victory Lap: Ebola

Buried somewhere in the comments on Ann Althouse's blog is a bet/promise I made.  It was to the effect that if there were more people dying in the US from Ebola than the number of victories the Washington Skins won in the 2014 season, I'd do my shopping on Amazon through Ann's blog.

At that time the numbers stood at: Americans dead of Ebola--zero, others dead of Ebola dying in the US--one, Skins victories--three.  The final score for 2014 was 0, 1, 4.

I have to admit I didn't have the courage of my convictions or I would have offered a straight bet to all comers, but I can at least claim I was right and all the people who panicked were wrong.

Modern Health Care: Dentistry

I know I've been lucky with my teeth, very few problems, certainly mainly less than I deserved considering the care I've given them.

I hate dentists.  When and where I grew up, one went to the dentist only when there was a big problem.  I think I went once in my teens.  Then came the Army and I had 2-3 small cavities filled. There was one trip to a dentist in my 40's, ruined by a young know-it-all hygenist who lectured me on tooth care. Sometimes I'm humble, but not that humble.

Finally in my 60's I finally had a crisis--bad wisdom tooth which had to come out.  After that I started seeing a dentist every 6 months.  He was my ideal dentist: had no hygenist, did his own cleaning, silent, we exchanged no more than a couple sentences each visit.   He retired, right when my other wisdom tooth started acting up.  After a couple years I finally arranged to see a new dentist.  On the morning of my appointment, half the wisdom tooth fell out.

I was impressed by my dentist's setup--the x-rays were displayed on a tablet computer, as was each procedure with its (high) cost. Though I didn't like the switch from taking a sip of water to rinse one's mouth to having a suction tube setup.  Anyhow, I got a referral to a specialist for the wisdom tooth, which I used this morning.  My dentist's office was able to email the xrays to the specialist's office, so they were able to extract what was left of the tooth without a prior appointment; total elapsed time maybe 40 minutes from the time I walked in the door.  That's impressive.  Perhaps less impressive is the multiplication of jobs in the field of dentistry, but that's looking a gift horse in the mouth.

Our Great Democratic ex-President

Jimmy Carter and his center have, with others, almost eradicated guinea worm.

Note that education and clean water were the keys.

The VA's Problems: a Failure of Imagination?

Much in the press about the problems with the VA.  I wonder though whether the problem wasn't at bottom a failure of imagination.  What do I mean?

Create a simplistic model of the VA--call it a bathtub.

Flowing into the VA are two flows: one is the flow of old veterans turning to the VA for support.  Now we know, I assume, pretty well the demographics of this group: how many WWII vets, how many Cold War vets, how many Iraq I vets, etc.  and the rates at which each group contacts the VA and the rate at which they are approved for care.  Once approved, I assume we also know averages of how often a vet in a specific age group needs treatment/to see a doctor.  Overall, as this group ages they're probably contacting the VA more and needing treatment more, so the potential workload is increasing.  They're also dying more, so that decreases the workload.

The second flow is of course the post 9/11 vets who need care immediately as they transition from service to civilian status.  I assume that's a bit more unpredictable, and the burden on the VA for treatment is greater, because the treatment of a 22-year old with PTSD is more difficult than a 72-year old suffering from aging.


So you have two flows of demands.  How big is the bathtub receiving the flows and how big the drain?  I assume we know how many medical professionals are employed and how many vets they can give various types of treatment to. 

Now if the flows in are bigger than the flows out, the bathtub is going to fill up and at some point it's going to overflow.  If they're exactly equal then the delay in appointments is going to represent the lag time in getting the resources to respond to the flows.  If the drain is bigger than the inflow, the appointment delay is going to represent just local conditions.  (Change the bathtub to a supermarket check out line system--sometimes lines will backup briefly just because.)

Now if you have metrics covering these items you should be able to validate your appointment time statistics by looking at the rates at which people are contacting the VA (i.e., if the rate of 72-year old vets contacting the VA drops from 2000 to 2010).  If the rates drop, that means people are giving up on the VA and going private or not getting care at all.  If the rates are pretty constant, then your stats on waiting for appointments should be goo.

  I suspect what happened with the VA is they were measuring people coming in the door, without the imagination to consider the whole universe of potential VA patients. That's my take, anyway, probably wrong.

[Updated--a Vox primer on VA care.]

Weird Sentence of the Day--Obamacare

From Wonkblog on Obamacare:

""The fact that they have about 2 million enrolled is not that far off from 3.3 million."

Sorry--in my math 2 million is a tad over 60 percent of 3.3, which in my dictionary is "pretty far off" from 3.3.

(I think I know what he was trying to say, but he didn't say it.

Failure To Launch [Website] Successfully

New guidelines for treating people at risk for heart attack or stroke released today.  That's a subject near and dear to my head and heart, so naturally I went to the new calculator website  
to see how I rated.  Oops--apparently they've a problem (too much traffic perhaps). 

ACA IT and Testing

I can't resist the temptation to comment on the healthcare software process.  (BTW, here's a link to their blog.)

They've taken hits for not fully testing, which I can agree with.  On the other hand, remembering the test process we had for System/36 software, I can only imagine the problems they would have had. If my imagination is right, they had these choices for beginning to end testing:

• use live data--i.e., have all the 20-something IT types try to sign up for health insurance for real using their software.  That has some obvious problems, particularly when you have to cover 36 state exchanges. 
• create test data.  The problem here is while you can create applicants, you need to have SS numbers which meet the SSA criteria, and/or you need to create credit histories over at Experian, then you need to tack on test data for those SSN's with IRS, etc. 
• use a subset of live data for test data.  That's what we used to do--get a copy of a counties files in and modify the data to create test conditions. That's very problematic, both from a security standpoint and from a Privacy Act standpoint. And  our FSA system was simple compared to the sort of system ACA requires.

Software Problems

There seem to be many experts who are diagnosing the problems with the ACA online system.  I'm not going to join their ranks--I'm no expert.  I expect only those on the inside, and only some of those, know really what has gone wrong and how hard or easy it will be to fix.

The one thing I will say (immediately contradicting the paragraph above) is that they shouldn't have changed the design to put establishing an account first, instead of putting it at the end.  The problem seems likely to have been the change.  It apparently was too late in the day to make it; they should have kept on with the general design they started with.  That raises the question of whether they had buy-in on the system design from everyone, by which I mean Tavenner, Sebelius, OMB, and the President, well in advance.  

The closest I've ever come to this sort of problem was the 1983 payment-in-kind program, in which the Reagan administration strongarmed the lawyers into a tricky device to swap CCC-owned grain for acreage reductions, a program which I remember as being slapped together in about 2 weeks (though memory is probably fallible).  The Secretary had the Under Secretary ramrodding the implementation, because it was a high risk endeavor, and he had regular (daily?) meetings with the peons who were doing the scutwork. 

Healthcare and the Amish

Always fascinated by the Amish, who are exempted from ACA (Obamacare) because they were exempted from Social Security way back in the last century, as this article describes.

The article doesn't mention the Amish occasionally being medical tourists--i.e., traveling to Mexico for some operations, something about which I've read in the last couple years.

Ezra Klein Differs on ACA Software

Kevin Drum and Ezra Klein are notably more damning of the Obama administrations healthcare exchange software than I have been.  This from Klein:

'But the Obama administration did itself -- and the millions of people who wanted to explore signing up -- a terrible disservice by building a Web site that, four days into launch, is still unusable for most Americans. They knew that the only way to quiet the law's critics was to implement it effectively. And building a working e-commerce Web site is not an impossible task, even with the added challenges of getting various government data services to talk to each other. Instead, the Obama administration gave critics arguing that the law isn't ready for primetime more ammunition for their case.

Obama's Open Government Fail--on Obamacare

I just love to tweak IT types and goo-goo types about openness, and occasionally I like to tweak my liberal friends.  In that spirit, let me quote this from the NYTimes post on activity on the healthcare exchanges:

"It is unclear what the [healthcare] exchanges meant in citing heavy volume; most did not provide numbers, or even return phone calls in the first hours of operation. It is also unclear to what degree problems with the Web sites were due to the kind of technical hurdles that supporters of the program had warned about and that opponents had predicted would demonstrate its unwieldiness."

 Too bad HHS didn't require each exchange website to post their count of unique visitors.

More seriously, I expect the dust to settle and the glitches to get resolved (mostly) in the next few days or weeks, just as Medicare Part D did back in the Bush days.

The Difference a Few Miles Makes

Really, though, it's not where you live, it's the composition of the neighbors in the hood;  it's the difference of a bunch of dollars and/or education.  I'm talking about the latest health stats, as presented in this county by county map.  Here's a post on Herndon Patch about the study.


Fairfax County, where I live, had a male life expectancy of 75.6 in 1985. Prince William, just south of here, had 71.3.  DC had a life expectancy of 64.3.  Over 25 years things changed.  DC improved by 9.4, Fairfax 6.1, Prince William 7.4.  Loudoun county, just to the west of Fairfax, and DC were the two jurisdictions which stand out as having the greatest increase.  Why--Loudoun has gone from mostly rural to rich suburbia in the 25 years; DC has changed its demographics almost as drastically--picking up a lot of yuppies and dinks (as we used to call them) and seeing lower income blacks move out.  DC has also cut its homicide rate drastically.


It's an interesting map to play with.  What's happening in Kentucky?  The bluegrass state has seen a statewide increase in physical activity in the last 10 years, it really stands out on the national map.  I don't think Mrs. Obama has been there more than other states. More seriously, there doesn't seem to be a correlation, at least by eyeball, between changes in physical activity and changes in hypertension or obesity, and Kentucky was very low on activity in 2001, so there may be something odd with the data, not reality.  And using just eyeballs, it looks as if the crime wave documented in the TV series "Justified" has some basis in reality?

Healthcare in France--Free Vacations in the Sun?

Dirk Beauregarde has a vitamin D deficiency, which leads to this:

In France we have a massive welfare bill, mainly due to our free, universal, cradle to grave health care system – it is quite common for the public Heath system to send the sick, the lame, the stressed and the depressed, away for long term cures by the sea or in the mountains why cant they send a low level vitamin D teacher to Corsica for a couple of weeks.