Me and my colony

It has long seemed self-evident to me but I'm not finding others talking about it so maybe this is unusual enough to write about.

Legally, we're all essentially pregnant, or at least siamese twins. That might need some unpacking.

One of the toughest legal questions around has to do with what to do when there's two inseparable individuals that legally fall into different categories, one guilty of a crime and the other innocent, or at least materially less culpable. Case law is not clear on this because it's such a rare condition that it's never come up in a common law country.

In the case of pregnancy, you have two genetically distinct humans with unequal rights. Sometimes the unborn is given a right to life. Other times no rights are assigned. Other times it's something of a case of chattel where the mother-to-be can kill the infant but nobody else can such as the case where it's a double homicide if a pregnant woman is killed but abortion is legal.

Everybody, however, hosts colonies of creatures on and inside our bodies. These colonies have no rights. In a lot of cases, the colonies are beneficial. Without our gut bacteria, we'd all be in significant digestive distress, very unpleasant distress. Other times, they get annoying, such as the various cold and flu viruses that lay us low periodically. There are mostly social sanctions in place for humans who cooperate in spreading those around and like the case of a worker sneezing into a food tray at a cafeteria there can be legal sanctions in terms of fines and operations shut downs for inadequate hygiene.

The most extreme of these legal sanctions is reserved for our hitch-hiking killers. Typhoid Mary, America's first documented asymptomatic carrier of the typhoid virus was isolated twice over the disease, the first time for three years, the second for the rest of her life. Strangely enough, her first major victim cluster was where I grew up, Mamaroneck, NY. Who knew?

Typhoid Mary was diagnosed with an infection of typhoid in her gallbladder but she refused to have the infected organ removed and without that removal she remained a public health hazard and was isolated until she died because she was so irresponsible after her first release from isolation as to change her name and continue seeking employment as a cook while refusing to wash her hands because, in her mind, she posed no threat.

The law could not force the removal of her infected organ. It could imprison her, and did. That's a very relevant distinction today. There is a difference between me and my colonies of various hitchhikers. I have rights and they don't. When they are not too noxious, they benefit from a sort of penumbra of rights. It's too difficult to separate us and they benefit. But if they are too noxious, if they even might be too noxious, I suffer a diminishment of rights. The penumbra goes the other way.

Which way the penumbra effect goes is a difficult question, one that we will never answer in a proper way so long as we do not explicitly lay out the facts as they are, that with every individual is a non-rights bearing set of organism colonies intimately locked in an embrace with our own biology. This is a legitimately hard question for which we have no final answers at the present, just a competing collection of unhappy feelings at whatever solutions are proposed by our political class, whether the disquiet at the laxity of the CDC or the outrage at the state quarantine orders nobody's entirely happy.

Where is the ACA's Punch Down List?

If the Democratic line on Obamacare/ACA of "Fix Obamacare, don't repeal it" were more than a poll tested platitude, Senators and Congressmen in that party would be coming out with reform bills, essentially punchdown lists, that purportedly fixed the legislation so that the system ran better. We would have a crystal clear idea of what the Democratic members of Congress actually wanted to do to fix this program.

Currently, we don't have such bills in front of the Senate, where Democrats could put one up even if the GOP were being entirely obstructionist. We also don't have any such bills bottled up in committee in the House.

What we do have is a nice media campaign that doesn't actually serve the interest of the american people at all because it's all empty words.

Please Lie Better

You know you're in trouble when your political opponents on a policy are asking you to lie better and quoting Fatal Attraction. The President lied. He said you could keep your plan when forcing the young to subsidize the old with new plans that cost more was at the heart of the political bargain that made Obamacare possible.

Now an un american plan that would somewhat accelerate the disintegration of american medicine with its anti-choice provisions is turning into a fiscally unsustainable train wreck that responsible for profit health care companies have to start putting on their forward guidance to investors. But how many responsible companies will be out there when they have a regulatory gun to their head and an administration that is perfectly willing to demonize and penalize them if they make too much noise about this disaster in the making?

Untreatable Gonorrhea

We may have to revert to the strait laced sexual ways of our forefathers if we lose the ability to treat STDs using antibiotics. According to the CDC we're almost to that point of untreatability with gonorrhea. We are utterly unprepared socially to deal with a world where STDs are once again an untreatable road to sterility, madness and death. The stakes are going up on this problem. It's time to start thinking about what we're going to do in the post antibiotic age.

Incompetent Government Doesn't Measure the Right Metrics for Success

Success for Obamacare is getting the right numbers and the right mix of signups to overcome the number of people who have lost their insurance plan and get new enrollees that make all the pain and expense worthwhile. Get the numbers wrong enough and we're going to have huge losses in the insurance field and a major hole in the Federal budget. An enrollee is someone who successfully navigates their application through the process and pays their first month's premium.

So, do we actually measure the number of people who have gone through the process all the way through to paying for it? Of course we haven't. The government could have included in the law a requirement for the insurance companies to report to HHS when those premiums came in. That could have been a requirement of one of the enabling regulations so that the IRS doesn't inappropriately assess tax penalties. But nobody did it and as a result, we are in a canoe and all we hear is the waterfall because we're wearing a blindfold. By the time we figure out that we're over the falls, it's too late.

HT: Instapundit

The Most Important Obamacare/ACA Metric

Greg Sargent has his political blinders on claiming in the Washington Post that "the most important Obamacare metric of all" is "how many people are gaining hea[l]th care coverage". This is not the most important metric. The most important metric, and real data won't come in for quite some time on this, is whether the ACA health payment regime is sustainable and can maintain our first class medical system, avoiding system collapse.

The most important thing in the health care reform debate is not insurance. It is the delivery of actual care. When you change reimbursements, certain business models stop being profitable. We have no idea how that will play out in marginally sustainable practices and hospitals across the country.

Cost Conscious Health Care

Health Care Policy and Marketplace Review has an interesting article on how few of the uninsured are signing up for the new ACA policies. The bottom line is that the exchanges are offering a deal that meets government requirements but not the requirements of the people signing up. People were promised a dashing charger to take them away to the prince's castle of improved health care and they find themselves being overcharged for a broken down nag that can barely hold itself up much less provide real help.

The fundamental problem is that there are multiple layers of poor pricing practices in health care. Where there are treatment choices, a cost conscious system would start by examining what is the lowest priced treatment that might work in this patient and try that, following up with progressively more expensive treatments until one of them worked. Too often what's actually happening is a doctor with a full panel and a waiting list of patients wanting to see him just prescribes the best treatment that has the highest chance of success. This reduces the number of return trips but also makes treatment much more expensive. The ACA doesn't fix that.

We have the wrong number of doctors due to restrictions on residency slots due to the AMA capturing the residency slot authorizing system. We have the wrong mix of doctors due to poor pricing decisions that have been going on since the 1970s in the Medicare price lists. Our pricing system is unnecessarily opaque due to the AMA holding copyright on the codes needed to document the pricing system. All this combines to create a system that is too expensive and trending the wrong direction on costs. Government insurance with plenty of coverage mandates just makes the problem worse.

Until we fix healthcare pricing things will continue to degenerate. Obamacare is just speeding up a pre-existing condition that has been bleeding the US medical system out for decades.

HT: The Glittering Eye

How Science Dies

Tim Worstall has had enough of contradictory scientific diet advice. I have too. It's a curious fact that people have been misled by bad advice over food and drink intake by the same crowd for decades and for the vast majority of us, this record of bad advice and objectively bad results in the diabetes and obesity epidemics has little effect on our willingness to listen to the next pronouncement from the science crowd over what we should eat and drink.

I don't think that scientists should cease to operate in these areas. I just think that they ought to be a great deal more humble when they are flipping back and forth through the years and decades. But no, confident statements that we should drink no wine are followed by equally confident statements that it's good for you. A more humble approach would allow for diversity of opinion and far weaker guidelines. Past a certain point, people stop listening, stop believing, and stop following scientific advice.

Scientists are squandering their credibility. It really is quite sad and we'll all be the poorer for it.

Lake Wobegon Healthcare Edition

Ezekiel Emanuel, who helped design the Affordable Care Act, thinks healthcare choice is overrated. Instead the problem is that the narrow networks that he helped make possible are not of sufficiently high quality. Some of you are facepalming right now at the vision of a world where all the health networks are above average. I sympathize. For the other 90%, here's a breakdown why this is jaw droppingly irresponsible and stupid.

For a doctor, insurance is a cost, both in time and in money. For each insurer you accept, for each of their plans that you're on, there is a certain amount of overhead that is taken up both in time and money. The rules change. How you report to them changes. It reduces the number of patients you can see (administrative time spent dealing with them) and increases what you need to charge for each procedure (the cost to pay for the extra billing overhead).

The narrow networks of high quality that Emanuel is suggesting we use to cure the problem of lack of patient choice implies that those doctors who are at the peak of their profession and the best in the business would need to belong to a large number of these narrow networks to avoid the creation of second class networks. This would maximize their paperwork and expense while minimizing the medical good they could do. Very few doctors would take that deal. Why should they? At that quality level they could operate entirely on cash and still have a full patient panel.

Emanuel illustrates his article with a woman who was stymied from going to get the second opinion on her cancer diagnosis she wanted. In the end, she went to a different center for a second opinion, a happy ending, says Emanuel. But there is no guarantee that the second opinion is correct, nor that the Houston clinic the patient wanted to go to in the first place would not have arrived at a different answer. But she got a second opinion, the second opinion box got checked off and therefore all is well with the world, according to Emanuel. Insert facepalm here.

Pot Causes Munchies

Just about everybody knows that pot makes you want to eat, except for the Attorney General of the United States. To keep marijuana illegal, he has to official believe that it doesn't. You see if he admits that it does then marijuana has a medical use and does not belong on schedule I, right up there with heroin.

It is not a good thing for the country to have the nation's top law enforcement officer have to officially hold obvious lies and form major policy around those lies but that's where we are with the drug war.

HT: James Taranto

Improving Prison Inc.

What if private prison contracts were structured in a way that they would favor bids by organizations that do mental health institutionalization and prisons both? What if we made treating mentally ill people was slightly more profitable than warehousing them in prisons? This would create an incentive to identify and move people into a mental health treatment situation so that they aren't in and out of very expensive prison slots. The prisons themselves would, as a function of the profit motive, seek to move people into mental health treatment and not allow them to fall through the cracks once their sentence ends.

Is anybody already doing this?

All your health information belongs to us

Federal law requires that when a private corporation is hacked and customer information is stolen, it must notify the victims of the theft. This is a reasonable requirement that lets people rush out and buy identity theft protection and/or keep a close eye out for funny charges showing up on their bills. 

In the case of the federal healthcare exchange, there is no legal requirement to report such breaches. Individuals on the federal exchange are without such protection though most states do have reporting requirements. The issue came up during regulatory comments and HHS apparently declined to support any sort of mandatory reporting rule. They'll let us know when they feel like it. 

To add salt to the wound, HIPAA privacy protections do cover insurance companies and health providers accessing federal government systems but the federal government itself is not obligated to honor those protections. Fancy that. 

HT: National Review

How Socialized Healthcare Systems Actually Fail

Three reports on appalling conditions in the UK's NHS should have everybody thinking second thoughts about socialized medicine. For supporters is the stark reality of how bad care can get in a 1st world country if it is socialized. For opponents the lesson is less obvious, more subtle. It is a political danger. 

Socialized systems do not fail right away. They rot out from the inside over a long period of time. It took a good long time for NHS to achieve its current state of decrepitude. A US collapse will take a good long time too, perhaps 60 years. 

But the collapse started when Medicaid and Medicare shifted incentives in medicine in the mid 1960s. We're at year 50 in the countdown but our half private/half socialized system will not fail in the same manner. The NHS got as bad as it is today with 60 years history of controlling far more of medicine in the UK than Medicare and Medicaid control in the US. 

Certain parts of the system may break very quickly. Others may take decades to be ground down to the poor care levels outlined in those three damning reports. The truly worrying bit is we don't know which bits are on their last legs, waiting for Obamacare to plow them under and which bits will survive, for now. We won't know until systems start to fail. 

Obamacare Scrooged

People signing up for Obamacare are being robbed by the government. This time it's not metaphorically, like when your perfectly satisfactory insurance plan is made illegal and all the compliant plans are more expensive and have worse terms but literally. People are having their accounts debited improperly during the Christmas season. And because it is being done by the government, there is little recourse to sue due to sovereign immunity and, of course, those most injured haven't the money to hire representation anyway. I think Pope Francis calls it 'despoliation of the poor'.

Double debits, wrong day debits, wrong amount debits, these are all standard hazards with any sort of Electronic Funds Transfer (ETF) system. There's nothing particularly new about these issues. It's all part of the back end errors that those dastardly Republicans have been hyperventilating about and Democrats have been pooh poohing for weeks now.

You never know when Tuttle will turn into Buttle in one of these systems. But what's in a name?

Merry Christmas Cross posted: Chicagoboyz

Volunteer fire departments to be forced to provide health insurance?

Healthcare reform could endanger fire protection budgets across the USA. Volunteer firefighters are categorized as employees by the IRS but not employees by other sections of the Federal government. This makes their impact under Obamacare a gray area. A number of fire departments would be pushed into the position of being forced to offer insurance if the volunteers are employees because they would have over 50 employees. Over 1800 fire departments have 50 or more volunteers and would qualify just based on the volunteers they have with hundreds more likely having their employee counts go over 50 due to the addition of volunteers.

The temptation would be strong to cut volunteers or otherwise manipulate head counts in an effort to remove public service organizations who have no way to afford health insurance for people who generally already have insurance from their businesses and employment elsewhere.

Nancy Pelosi said we had to pass the bill to find out what was in it. It seems we're still finding out new consequences. Now fire chiefs all across the country are nervously awaiting a legal ruling from the IRS on whether they are going to have a huge hole blown in their fire protection budgets.

HT: Pajamas Media

Another scary paper gets retracted

This time it's rat tumors from GMO corn that has fallen by the wayside. A small study finding a link has been retracted for being too small to rule out the possibility that the increase in tumors happened by chance in a breed bred to create just such tumors. The researchers plan to sue which is a shame. I'd think that they'd just rerun the study with more rats.

HT: Instapundit

As little as 60% of Obamacare's software is complete

The Obamacare software development death march continues as it becomes clearer and clearer that even the early pessimists had no idea how bad things really were. This reduces confidence we know how bad things are right now. We've been fooled multiple rounds.

You see, to make the Affordable Care Act work, you need a fully functioning "federally facilitated marketplace" as Deputy CIO for CMS, Henry Cho says, and there is lots of software involved, much of it will never be seen by the public except indirectly when the public facing portions fail to give the right data because the back end systems are either not working right or not even built at all.

HT: Mediaite

What's that party? Obamacare Insurance Mod Rejection Edition

On Drudge right now is an early rejection of President Obama's plan to permit insurance companies to retain their noncompliant plans for a year. The State of Washington's Insurance Commissioner took two hours to release a statement rejecting the idea. Nowhere in the piece is a mention of the man's party so for most readers it would be a surprise that he's an Obamacare supporting Democrat. His Wikipedia page notes he had previously served 16 years in the Washington legislature and one term in Congress as a Democrat.

This man took to the pages of the Seattle Times on November 12th to defend insurance cancellations. President Obama made this man look like a fool, just as he's done for a great deal of the rest of the Democratic party. But don't count on the press to highlight the party source of much of the return fire.

Healthcare basics II

There are a lot of areas that I see us lacking consensus or basic factual understanding but nowhere is it worse than in the area of healthcare. This series is a number of short examinations of what healthcare is and how it is currently paid for in the US. Some of the lessons are specific to the US while others are universal.

Healthcare consists of two basic things, figuring out what (if anything is wrong with you) and doing procedures to treat (and possibly cure) what ails you. Procedures, along with medicines and equipment, are what you pay for, and procedure codes are the functional equivalent of UPC codes for consumer goods.

Conceptually, there are two kinds of codes. Codes that are incurred to figure out what is wrong with you, or diagnostic codes, and codes that are incurred to actually treat what is wrong with you, or treatment codes. Both these types of codes are laid out in a procedure code book.

In the US the procedure code book until recently has solely been the Current Procedure Terminology (CPT) which is written and maintained by the American Medical Association (AMA). The author of the code book in this case is highly relevant because, as a private American organization organized as a 501(c)6 tax exempt business league, the AMA may maintain copyright, which it does in this case. The royalty scheme used by the AMA is $14.50 per user, per electronic product and $14.50 per distributed product. No guidance, other than look it up is given by the AMA as to what it considers fair use.

Were the American Petroleum Institute to copyright the terms, unleaded, plus, and super, gasoline pricing would be profoundly affected. The effect on medical pricing is no less profound, or pernicious. Doctors simply do not advertise prices with attached CPT codes so that people can do the ordinary consumer activity of price shopping.

In 2012 the AMA received approximately $80M in CPT royalty payments (royalties and credentialing products were $83.1M). It receives less than half that in dues ($38.7M) out of a total of approximately $273.9M in revenues. Its royalties are 30% of income while dues are less than 15%. Without its CPT royalties, its 2012 positive results of $16.6M would likely be wiped out and replaced by a significant deficit.

Series Index

Healthcare basics I

There are a lot of areas that I see us lacking consensus or basic factual understanding but nowhere is it worse than in the area of healthcare. This series is a number of short examinations of what healthcare is and how it is currently paid for in the US. Some of the lessons are specific to the US while others are universal.

Healthcare consists of two basic things, figuring out what (if anything is wrong with you) and doing procedures to treat (and possibly cure) what ails you. In the US, what is wrong with you is laid out in a code book written by the World Health Organization (WHO) who author the ICD codes. In the US, the National Center for Health Statistics (NCHS) has been licensed by WHO to create a variant with greater detail for clinical use that is identified by a trailing CM on those products.

Currently, the US is transitioning from using the ICD-9-CM code book to the latest update, the ICD-10-CM code book. The ICD-9-CM was frozen as of October 1, 2013 and will no longer be updated. ICD-10-CM is in limited update mode during this transition until October 1, 2015 when it will start regular yearly updates once again. At this point in time your medical provider in the US should either be fully transitioned, or at least transitioning to ICD-10-CM to describe any medical conditions you may have. If they aren't, they are going to start running into payment reductions and refusal of payment issues which may jeopardize their ability to keep their doors open.