On the Supreme Court's Ruling in Dobbs

The headline today in legal matters will surely be that Roe v. Wade (1973) has been overruled, but the problem goes further. The reasoning employed by the Supreme Court in Dobbs v. Jackson Women's Health Organization (2022) undermined the reasoning employed in Lawrence v. Texas (2003) under which Bowers v. Hardwick (1986) was overruled to end anti-sodomy statutes, which is the same line of reasoning ultimately used to prevent states from banning same-sex marriage (e.g., that the State had no legitimate interest to protect), and in fact the same line of reasoning used by the Supreme Court to strike down laws criminalizing birth control.

We have not seen the end of this.

JAMA: Legal Weed Reduces Painkiller ODs?

And now, for something completely different.

New research in JAMA Internal Medicine (formerly Archives of Internal Medicine) finds a 24.8% reduction in annual opiate overdose mortality in states that allow physicians to prescribe cannabis for pain.  The nontrivial improvement in so concrete a metric as mortality represents an interesting fact in the discussion of cannabis regulation.  The association of prescription availability of cannabis with the mortality reduction strengthened over time.

Healthcare Shopping Lunacy

After my disastrous bait-and-switch experience at healthcare.gov, I finally (after more than four months and several hours of on-the-phone troubleshooting) get confirmation the plan that didn't include my kids' pediatrician (despite the pre-enrollment search that listed all the docs I cared about) was cancelled.  Then L's coverage terminates, and we are in the market again.  My existing insurer can't add L to my plan because its employees can't figure out who to transfer me to in order to get a quote, until they finally transfer me to someone whose incompetence (I shudder to think his abuse is intentional, but it certainly could be) prevents him from obtaining from me the information needed to provide me a quote.  He interrupts me over and over; I hang up and try back for someone else in his department, but he answers again and is no more helpful the next time, either.  So, bye-bye Aetna.  This is how you lose healthy insureds.  That's why I'm on a private exchange looking for health coverage.  The private exchange is pleasant in that I could get a human to walk me though it and answer questions and email me documents about the various coverages available.  It looks pretty good.

I enter detailed information about everyone I want covered in order to get plan cost information, and when I click to "apply" for the plan … I'm required to enter it all over again. 

I do. 

Then, I get a page that informs me I haven't applied until I've made a medical application. 

Guess what?  I get to re-enter all the information, yet again.

I click to add a spouse, and the webform demands I answer whether this spouse is married.  I mean, really.

Then I get this:

The Affordable Care Act (ACA) requires us to be reasonably assured that you and each member on this policy have coverage for pediatric dental services that are essential health benefits. The Affordable Care Act requires these benefits even if there is no one on the policy who is eligible for these services.

The government's own web site makes crystal clear that this is a lie: there's no obligation to purchase dental coverage, only an obligation to make it available – and no tax imposed on persons without dental coverage.  After doing some math based on expected dental costs, I conclude I'm better off putting premium dollars in a health savings account.  But the "medical application" requires one to claim to have dental coverage, or purchase it for over $40/month/person.  Just crazy.  The law doesn't require the coverage, but the idiots who coded the site do.

This just goes on and on.

Beam me up, Scotty.  There's little sign of intelligent life in the insurance industry.

High-Compliance Exercise program

The world's largest woman revealed that the secret to her loss of a hundred pounds in the last year was an exercise program to which she was able to remain committed all year long. Her ex-husband, apparently extremely attracted to her shape, reunited with her – enabling her to "sexercise" 6-7 times per day. She says each encounter burns 500 Calories, which means her program burns 3000-3500 Calories per day beyond those involved in her ordinary activities.

Of his amorous efforts, she summarized: “He took charge as I couldn’t move much, but he was so attentive.”

Of course, the government will not be supporting fitness programs based on this finding despite the high-compliance nature of the exercise program. After all, this is the country where the Surgeon General was forced to resign for advocating masturbation as a way to survive adolescence free from pregnancy or STDs. Goodness knows we can't have an outcome like that.

Game Console Loss Leaders As Medical Subsidy?

CNN reports that British researchers have discovered a medical use for XBox hardware. Simulating cardiac behaviors historically requires sophisticated computer systems whose cost can be prohibitive for some institutions. However, thanks to the triple threat of competitive design, mass production, and deliberate pricing below cost, the high-end game console seems poised for use in medical research.

The question: can Microsoft charge enough for medical imaging software to make up its per-unit loss on non-gaming sales of its loss-leader hardware, or will Microsoft subsidize medical research in Britain and the world?

For Microsoft's sake (I have some friends who own shares) I hope this doesn't become a major market ....

Student Bus Hijacking Resolved Bloodlessly

Disarmed by a fit football player, a fourteen-year-old girl was taken into custody without apparent injury to anyone after she drew a .380 semi-automatic to threaten bus-riding students whom she accused of teasing and bullying her. Video is available.

Bullying and teasing are both cruel, and also often overlooked or discounted. Some observe it's ironic that its victims are more likely to be caught retaliating than initial aggressors are for their instigating behavior (about which, The Onion has a take). Obviously, wielding firearms on a school bus is neither ideal nor likely to achieve effective bullying reduction: for would-be vigilantes there is worse bullying in incarcerated populations, and for those facing "justice" the message is surely lost behind the medium. However, it's possible that sober adults should exercise a bit of responsibility rather than abdicate solutions to the imaginations of outraged teens whose self-worth lays in ruins due to years of steady abuse.

Bullying and its sequelae are not a uniquely American problem. It likely derives from fundamental dynamics of social organizations, as it has analogs in other species that live in social groups, such as baboons. Fighting bullying is likely akin to creating an ideal government: it works against the instincts of many who would be subject to the rules but prefer to avoid their application. It's a problem that requires real study and not simply armchair quarterbacking by self-proclaimed experts. Imagine the improvement in the quality of life -- and worldview -- of future generations if we get a handle on bullying among youth.

Paid Transplants A Reality in America

If reports that 1500-2000 paid-for kidney "donations" occur in the U.S. annually, payment for organs is an undeniable reality in America.

Given the history in America of the effect of banning commerce in things for which definite demand exists, one wonders whether lawmakers will have the courage to develop policy based on the balance of interests rather than the political expedience of pushing puritanical proclamations on the public -- claiming that moral reasons exist to tell people they do not own their own bodies and cannot choose as they like what to do with them that does not harm third parties.

Nuts Atttribute COBRA to Obama

I was surprised to read that Obama, who took office just last month, was to be credited with the passage of COBRA (the Consolidated Omnibus Budget Reconciliation Act, which among other things modified the Employee Retirement Income Security Act of 1974 to permit employees to obtain continuation of employee beenfit plans after losing eligibility as employees -- in other words, people who quit or were fired could keep employment-based health coverage for in most cases up to 18 months), which is an Act signed into law by Ronald Regan in 1986.

The author apparently is rather behind the times in health policy matters. The news is that continuation benefits under COBRA (for which employees are permitted to be charged up to 104% of the employers' actual cost to run the plans) will now qualify for a 35% federal subsidy (so they pay about two thirds of the unsubsidized cost), provided the employees aren't too well off.

The article also claims CHIP as a feather in the new President's cap. The State CHildren's Health Insurance Program, enacted in 1997, is a state-federal program designed to help families with kids who don't qualify for Medicaid coverage to obtain subsidized health insurance. In Texas, one of the significant barriers to enrollment under CHIP is that the federal government doesn't allow CHIP participation by anyone who can qualify for Medicaid (which would also provide coverage), so in order to qualify for CHIP one must first perform all the steps needed to enable the state to determine Medicaid qualification (else, the federales won't match the state's CHIP expenditures, even up to the matching funds cap). Assuming that prospective participants are properly educated that making more than a few thousand bucks per year isn't actually a disqualifier, but that the forms are just part of a federal hazing ritual, one still has a daunting stack of forms to fill out. This might not seem like a big deal, but to the extremely-busy two-job-working-poor this program should be helping, this kind of hazing ritual is a substantial barrier to entry. Additionalls, many people look at the forms, realize the economic thresholds inquired about are well below their incomes, and give up because they believe they cannot qualify. I'm not sure what amendment to CHIP may have been part of the recent stimulus package, but I'm wagering it's an increase in the federal match cap.

Pouring money into coverage schemes will have the effect of making coverage easier to obtain for the people who can afford their share of the price tag (two thirds of the cost of an employee benefit plan can be steep, depending on the plan), but it does nothing to the structural elements of the health care system that cause the U.S. to outspend every other nation in per-capita health costs. Contrary to the apparent claims of the Obama health policy team, the secret is neither tort caps or the supposed inefficiency of paper records. The most substantial and pervasive cost has to do with the fact that federal law has for decades prevented states from creating universal coverage through mechanisms that would eliminate health risk segmentation by third-party payors and ensure uniform minimum standards. By contrast, federal law has made health coverage a kind of "wild west" in which third party payors with even fairly tenouous connections to employee benefit plans enjoy a "get out of jail free card" in connection with their health coverage decisions. Thus, neither patients, physicians, nor hospitals know what's covered and it takes an entire army of dedicated full-time employees to call, punch through hold queues, and make a case for coverage of a whole host of things that are so obviously necessary or routine that such costly pre-treatment routines do nothing except add 50% to the cost of care.

This transactional friction is attributable directly to federal law, which has prevented state-by-state solutions -- notably in Hawaii and Oregon, but also elsewhere -- that would have helped teach the country how to obtain quality results for a good price under American-tolerable market conditions and without sacrificing expected quality. For someone in the federal government to claim interest in solving this problem with more federal law is the height of D.C. hypocrisy.

It is also utterly unsurprising.

'Cello Scrotum': British Medical Journal Giggles About Being Hoaxed

The British Medical Journal, hoaxed thirty years ago by a female physician (and now member of the House of Lords) who thought 'guitarist's nipple' was funny, has announced that its prior report describing 'cello scrotum' is bunk.  Apparently the hoaxer saw 'cello scrotum' referred to as an actual malady and realized it wasn't obvious to non-cello players that it was a load of hooey.

Thank goodness.  Now, I can take up the bass.

Media as Norm-Setting Tool

After reading at The Onion about using mainstream media to desensitize Americans to brutality, you can read at CNN about using television to indoctrinate children to become impregnated as a teen.

The first may be a bit of a joke ... almost ... but the second is quite real.

Just like kids who learn how to lie on television (and don't realize how transparent they are at it, how bad, and how easily caught) and learn it wrong, naïve kids without perspective on normal relationships apparently learn from shows like Sex and the City and Friends that it's normal to play musical beds, and that you end up with a ginormous New York home worth a fortune if you do. Something for parents to think about when they decide to let the television substitute as a bargain-priced baby sitter. Maybe the price is higher than they reckon.

Obama Baffled By Health Policy Debate

President Obama unfortuntately doesn't get it.

He recently claimed that a statement from a McCain health policy adviser, indicating that members of employee benefit plans with health coverage through their employer group would not abandon coverage as a result of the tax plan McCain urges, somehow proved that McCain's plan was a disaster. In the last debate, Obama claimed that McCain's plan was a disaster because it would drive people out of employment-based coverage. Obama: make up your mind. The punch line is that Obama's old claim, that McCain's plan would drive people out of employer-sponsored plans, was supposed to be a disaster because it would create risk segmentation as young healthy people bought coverage with McCain's tax credit. Risk segmentation exists now due to the coverage-selectivity of insurers, and their longstanding practice of setting up can't-opt-out health plans to capture cheap risks in the form of employably healthy workers. Driving up the cost of employer-based coverage by siphoning off good risks would actually decrease the problem of poorly-regulated employer-based coverage; people buying coverage in the open market get genuine insurance instead of the watered-down "rights" conferred under plans governed exclusively by the Employee Retirement Income Security Act. Regulated insurers offer superior rights and better risk distribution. Obama's own health care advisors, interviewed on television, made plain months ago that employment-based coverage was a drag, and that Obama's plan included it only because of inertia. Obama's more recent claims that there's a reason to want employment-based coverage to continue in perpetuity are so farr off the mark that it would make a genuine policy architect weep.

Oh, well. Obama, when he speaks, is apparently no different in substance from any other politician whose lips are moving.

And like most Americans, President Obama is bad at math:

And once you're out on your own with this $5,000 credit, Sen. McCain, for the first time, is going to be taxing the health care benefits that you have from your employer.

And this is your plan, John. For the first time in history, you will be taxing people's health care benefits.

By the way, the average policy costs about $12,000. So if you've got $5,000 and it's going to cost you $12,000, that's a loss for you.

-- Barak Obama, Oct. 15 debate (transcript)

In the hands of a person in the 30% marginal tax rate, a $5,000 credit would be as large as all the tax paid on the last $16,666.67 of income, if it were all taxed at the highest rate. In the hands of a person in the 15% income tax bracket, it would be equivalent to all the tax paid on $33,333.33 -- but of course one can't make $33,333.33 within the 15% tax bracket. Obama's claim that a $5000 tax credit won't put people in a satisfactory position if their health benefits are taxed -- that is, a financial position at least as good as before the change in tax status -- is absolutely false. There is no family at any income level that would suffer from a $5,000 tax credit in exchange for taxability of health benefits, even if the price of health coverage were as high as Obama insists.

The benefit of taxing health benefits is that employers' health expenses become more transparent, and price competition becomes possible. Cherry-picking by the insurers backing plans becomes easier to detect. Substandard plans become easier to detect. Employees have a stronger reason to seek better-priced coverage, because they know the costs and can do the math. Employees have better leverage to negotiate on wages because the illusion of valuable untaxed non-cash benefits is evaporated by transparency caused by taxation.

The tax credit proposed by McCain has a valuable purpose: to level the field of competition between the old, terrible employment-based health coverage system that so long has been subsidized by the federal government through advantageous tax status, and the older system of insurance that works just fine (e.g., for automobiles, homes, and lives) because its regulation hasn't been supplanted by a cloudy haze of federal law that provides aggrieved beneficiaries no useful remedy. Let's face it: the reason the insurers who work for employee benefit plans are working to prevent universal coverage under state law because it would result in clear rights, and prevent the windfall they currently receive with ambiguous plan terms they are free (under federal law) to interpret in their own favor (which is not allowed under state law). McCain's tax-and-credit plan would allow fair price competition, loosen the death-grip of employment-based coverage, enable citizens to buy health coverage with their tax dollars instead of their post-tax earnings, and set the state for state-by-state universal coverage just like we have for drivers -- without making the health care system a one-payor federal health care monopsony as proposed by some.

President Obama just doesn't get it.

Risk Segmentation In The Health Care Market

The Jaded Consumer hopes to outline a few salient health care finance issues in a series of issue-focused posts. There may be many solutions to some issues, and the Jaded Consumer does not pretend to offer ideal solutions. However, a policy piece finding fault with the status quo should offer proposed interventions, or it is a mere gripe session. Other nations, with different national predilections, would doubtless steer a different course likely to be recommended here. However, The Jaded Consumer intends offering practical solutions that might be accepted in the United States.

This first article addresses risk segmentation as a barrier to affordable universal coverage. Universal coverage is not addressed as a right, though there are states in which legislatures sought to make it a right before encountering federal barriers to achieving the goals of their constituents. Universal coverage for health risks is addressed here as a national aspiration.

The barrier raised by risk segmentation is escalating marginal cost. The idea is something like this:
0) The risk of health care expenses is distributed unequally across the population
(This point is a huge deal and is numbered zero as a sort of emphasis.)
1) Most easy-to-cover people get covered easily through private funding. (This is in part a result of the tax-advantaged status of employee benefit plan contributions under statutes designed to enshrine compensation practices dating from the time of World War II wage freezes, when non-cash benefits seemed to employers a plausible way to compete for scarce labor. Today, anyone sufficiently healthy and socially stable enough to hold down a permanent full-time job is advantaged in accessing externally subsidized health care. The subsidy isn't, as often thought, the subsidy of employers -- they will never pay more than they can afford for labor -- but the subsidy of the federal government, which has chosen to push people into employee benefit plans by electing to tax this form of compensation at zero percent.)
2) People who argue most forcefully that they need coverage, and those whom advocacy groups most urge should be covered, are drawn overwhelmingly from a subset of the population far from the left tail of the health care expense curve; these people are, on the whole, less likely to be cheap risks to cover. (Think about impoverished, permanently disabled Medicaid enrollees and the elderly, who are already in high-cost federally-supported safety net systems precisely because the risks posed by these persons has led to government intervention.)
3) Uncovered and safety-net populations experience increasing concentrations of high-risk individuals. This one takes a little explanation, and is critical to the problem of incremental establishment of universal coverage. The cherry-picking of "good" risks by for-profit coverage schemes (like mandatory coverage participation at some level for young full-time employees who've never been ill a day in their working lives) cause the population of already-covered people to have a lower cost of coverage than the groups described by (2) above, making the "high expense" of covering those easy-to-cover people seem to be chump change by comparison to the cost to cover the concentrated risks in the remaining population. As the cost of coverage increases, the benefit of the tax breaks in (1) will push more people into available private schemes because of the amplified after-tax cost advantage, despite legal uncertainty regarding enforceability of rights under employee benefit plans (compared to non-employment-related insurance coverage).

How Insurance Works

You don't hope to crash your car.

However, for only a few hundred bucks, you can get months of protection (by a licensed insurer, regulated by the state for its solvency in the face of its insurance obligations) against the risk that you cause a wreck that crumples someone else's fender -- protection that includes sending someone to inspect the claimed damage, haggling on the phone or by mail with the other driver about the cost of his repairs, and even defending you against his law suit -- hiring lawyers, conducting depositions, running a trial -- if he doesn't like what your insurance company is telling him about the value of his rusting jalopy.

All things considered, this coverage is a deal.

As it happens, you don't have a choice about this coverage; every state in the Union has a vehicular financial responsibility law, and when last I checked forty-eight of them specifically required insurance as the way this financial responsibility must be demonstrated. In order to evade this coverage, there are people who work all kinds of scams -- paying one month on a six-month policy and then ceasing payment, printing false insurance cards, you name it -- but if you want to renew your driver's license and keep your car registered so you're not pulled over and ticketed every week, you either have the coverage or you work very hard to evade the requirement. The reason this coverage is so cheap is part of the secret of how insurance works, and why it works so well when the covered population is (almost) the whole population at risk. Only scam artists escape the pool; all the responsible people like yourself are in the covered pool, and are sharing the cost of the risk. The legal minimum insurance is cheap not because law suits aren't costly and not because people don't get into wrecks in this country and because there aren't tens of thousands killed every year on U.S. roads and many more injured -- the insurance is cheap instead because the burden of all this cost is allocated across an enormous pool of covered risks. (Okay; it's also cheap because the legal minimum caps out at a cost well below the cost of a human life. Most fender-benders aren't million-dollar claims. The outlier risks are left where they started, in the hands of individual motorists, because the many state legislatures creating the mandatory coverage laws have reached a compromise between the premium-paying public and the premium-hungry insurers, and have drawn a line where the mandate ceases, and private choice to obtain more coverage steps in. Tweaking local coverage requirements isn't rare.) In short, since the whole population contributes to mandatory coverage, the per-member burden is comparatively modest.

The coverage you elect, the one that protects you against the risk of someone totaling your car and fleeing into the night, is more expensive. It's above the point the mandatory coverage, above the point risks are spread population-wide, that risks are concentrated among a subset of willing buyers -- and this is the point at which it starts to become expensive. If you don't owe a bank money secured by a car (banks require more-than-minimum insurance to protect their loans' collateral), and you aren't frightened by these risks (fearful people often overinsure, to the delight of insurers), then you need not pay for them. You can opt out of the extra coverage.

Adverse Selection and The Problem Of Personal Choice
Insurers like to talk about moral hazard -- the tendency of the insured to conduct themselves so as to experience losses at a greater rate or severity than the non-insured -- and they like to allege that the world is full of insurance fraud. The world is as equally full of insurers trying to shirk their contract obligations in the face of loss. It's probably a wash, each side diligently working to cheat the other.

The real reason insurers hate the individual coverage market is adverse selection.

Adverse selection is the reason that when insurers price a lifetime annuity (a bet the covered life will last forever) and life insurance (a bet the covered life will end tomorrow), they don't use the same mortality tables. When you shop for an annuity, insurers use a mortality table that assumes you are healthy and going to live an awfully long time. When you shop for life insurance, they use a table that assumes you are hiding anything that can't be picked up on their screening tests, and will drop dead without a great deal of provocation. In short, the insurers assume when you shop for insurance that you know you need the coverage.

While some folks can be convinced by an insurance agent to buy anything, there are others who are particularly keen to get life insurance because they know all their near relatives died young, or they just learned they have a lethal illness and have been approached by a viatical settlement buyer, or the like. Prospective insureds who fear losses can be in a much better position than an insurer to appreciate the risks facing them. In this world -- where paper medical records can lay unnoticed by searching insurers, where billing codes are manipulated to ensure payment rather than accuracy -- insurers fear the information gap in underwriting important risks like health (which can quickly run into six or seven figures on a bad risk) is stacked against them. In a market in which members can opt out of sharing the population's risk, insurers fear the worst and charge accordingly.

Mandatory Coverage Is Coverage For Insurers
This is why full-time employees "get" health coverage in most companies whether they like it or not. Without the choice to opt out, employees are powerless to exercise adverse selection, and insurers can rest easier, unworried that new applicants are seeking coverage to run a scam; they are seeking coverage because they want a job. People with genuine work qualifications are probably less likely to be running a scam than the general population, besides. Moreover, insuring a whole pool of covered risks is a more attractive enterprise; there's little wonder insurers who deal with employee benefit plans structure their offerings so as to yield this result.

With very few employers failing to insure health risks at some level, and none to my knowledge processing claims directly, it's clear that the preference of insurers in structuring their offerings directly drives benefit plan coverage decisions. Insurers don't want to have to insure loners who turn up begging for coverage (what does he know that we don't?), but they are happy to write policies on whole populations who can't say "no" when their employers are looking for a way to pay valuable compensation that isn't subject to employer taxes.

Covering The Uninsured
So let's look at a common solution: we'll take the people who we're worried about -- the uncovered folks we want to stop choking emergency departments to death by allowing neglect of primary care to mature into a succession of expensive minor emergencies, the chronically ill who don't seem to qualify for stingy government programs, and so on -- and we'll cover them all in a special program to stem the tide of uninsurance. Because this population is selected for its high costs, coverage of it will be through the roof.

Think about it: if these people's claims weren't breaking local hospitals' ER budgets and didn't swamp county hospitals' funding and weren't killing everyone with an inclination to provide charity care, nobody would be clamoring for their coverage. If the claims weren't significant, the whole problem would be written off as not-a-big-deal. The county would cover it, or teaching hospitals, or charities. But that's the problem: the cost of this care dwarfs the resources people want to use to address it.

Covering these folks will cost a fortune.

Enter the High Risk Pool
The idea of creating government-established high-risk pools and offering group coverage to everyone in the pool surely sounds like a great idea at first: it's group coverage and not individual coverage; everyone in the group must paricipate; there should be a group discount -- right?

Ha, ha.

Americans like to think you get a deal buying products in bulk, but this is insurance, not a sack of yams. You get a discount by spreading risk, sure. But a high-risk pool isn't a place risk is spread: it's a place risk is concentrated. Insurers don't want any part of it at typical prices. Unless the premium is so high that there's a safe bet on the large concentration of risks, all bets are off. Insurers required to play this game would sooner leave the market. (Mind you, you don't need zillions of insurers to have a competitive market; two or three are enough, if there is no price collusion.)

The usual fix for this is to have government subsidize the high-risk pool. This, in effect, is the very thing the pool was to avoid: soaking the public fisc with the cost of the uncovered care. Taxpayers don't want to do this, since they are themselves (ask them) already paying for their own care. The only folks they see covered by a scheme like this are folks who don't have a job and don't pay taxes. Not exactly an easy sell, is it?

The Newest High-Risk Pool Proposal
President Obama -- I say President Obama because it's sure he will win, so why bother dreaming up silly terms like "hopeful" and "prospective" to term what's already a fait accompli? -- will urge a payroll tax to cover the cost of covering everyone not already covered by an employer plan. He spells it out right here. (In it he also spells out some funny things like how he'll save money for the health care system with tort reform, which is ironic considering the biggest estimates ever calculated for the annual financial cost attributable to malpractice claims and so-called "defensive medicine" don't amount to a tenth of a percent of the national health care budget. This, from a man who has claimed earmarks aren't a material expense!)

President Obama's plan expressly exempts from the payroll tax any employer already providing "adequate" coverage. This means that every employee will have a choice: whether it is cheaper to pay the payroll tax, or to maintain the existing plan. In other words, covered populations that are cheaper than the payroll tax will be able to avoid shouldering any of the risk-shifting associated with the incremental coverage. Once the price of the new plan is known -- that is, once the employer tax is spelled out in a statute -- employers will have even greater incentive to game their benefit plans for tax purposes. Employers with young, healthy populations will pay insurers to keep them out of the employer tax, and employers with older or less healthy populations will cheer, throw their health plan out the window, tell employees they have joined the new federal program created by Congress, and save all those extra health care dollars. After all, the payroll tax will be a tax-free benefit and fully deductible, it'll just be cheaper.

This market behavior will ensure that only populations that cost more than the payroll tax are in the federal risk pool. By spelling out the alternative in a statute, the payroll tax will enable insurers to conduct their ordinary cherry-picking operations even more effectively. Employers will be beseiged by cut-rate plans offering to "cover" for less than the cost of the payroll tax mostly-healthy populations with plans designed to scrape through the payroll-exemption language in the post-Obama tax code.

Spreading Risk For Real
To spread the risk of the whole population -- including the population of covered lives cherry-picked by insurers from an applicable risk pool -- it is necessary to tax not payroll but premiums. A premium tax of the sort states ordinarily collect on insurance premiums can be used to conduct risk allocation by funding the overpayments caused by the risk pool. A premium tax ensures that insurers price all their products -- to any market segment -- so as to cover the demands of the high-risk pool. The premium tax structure can thus be designed to make cherry-picking futile, ensuring more coverage and less coverage-avoidance.

Federal Health Services Funding Monopsony? Not The Cure!
In the law of the sale of goods, every state in the Union has the same substantive law. (Louisiana does not have common law, so the Uniform Commercial Code Article 2 language that depends on the existence of the common law cannot be used there; however, a local analog containing the same substance has been enacted to achieve the same result with different words.) Congress didn't need to create federal law on the sale of goods; the utility of uniform law was itself enough to inspire coordination and uniformity. State-law insurance insolvency statutes are the same way: federal law does not govern them (due to the McCarran-Ferguson Act), but there is nevertheless uniform law nationwide. Automotice drivers' responsibility has worked the same way. The argument that federal law is needed to create uniformity is a canard.

Federal law is in fact the major obstacle to universal care in this country, and has been so since the late 1970s when employers used federal law to enjoin a payroll tax funding Hawaii's health plan. Oregon had a radically different plan -- one with distinct and innovative cost-containment measures from which the nation could have learned valuable lessons for health plan design -- but the lessons brave Oregon would have taught us have been lost to federal preemption. Tentative movements of other states toward universal coverage have been slowed by the lack of freedom to experiment in this regulatory arena.

Experimenting on a state-by-state basis to provide data points on coverage features that are effective -- and which are ineffective -- is not a strength a single federal plan can possibly offer America. Once in place, the plan will be pulled about not by data or the lessons of neighbors' differing lessons, but by pure politics. Health care providers who have been terrorized by their powerlessness before federal payors and their ruthless watchdog agents' hungry zeal to threaten fee recoupment will understand immediately why a federal monopsony in health care finance is a danger to the field. Hospitals and physicians familiar with federal funding games will understand why giving the federal government an even larger fraction of the covered population will work against health care workers and their desire to provide quality care.

The worst obstacle to the development and innovation in health care policy in the last thirty years has been federal law preventing state experimentation in funding policy, plan enforcement, and quality assurance. The last thing America needs for the improvement of health care policy is more involvement by Congress. A new federal uninsurance pool funded by an opt-out payroll tax will accelerate risk segmentation, escalate the cost-shifting of the cost of health coverage onto government, and will prevent local efforts to innovate -- as Oregon heroically tried to do before it was stabbed in the throat for its efforts -- in ways that will result in genuine efficiency gains.

Houston Getting Power

This week, about a quarter of Houstonians are still without power -- but more are getting power restored daily. Trucks from Pennsylvania and Connecticut have been spotted, and the estimate that ten thousand imported repair workers are in town is probably accurate. One power company, Entergy, boasts that all its Houston-area subscribers are back in power.

The M.D. Anderson Cancer Center offers an example of how this weather-related disaster can wreak havoc on institutions with no material physical losses. Anderson didn't lose power, both because it has generator backup and because the backup wasn't needed: the Texas Medical Center is supplied with power by buried cables, which weren't hit by falling trees. Centerpoint has some 14,500 steel transmission towers, and zero of them were destroyed. The power losses appear to have been caused almost exclusively by lines and connections being severed by falling trees. One wonders how much economic loss might be saved in the future by an investment in increased underground cabling.

Houston hasn't got a hotel shortage, but perhaps a third of the rooms are unavailable due to damage or simple absence of power. With FEMA having bought up all the remaining unoccupied hotel rooms, people coming to Houston for business have a hard time obtaining accommodations. Since a third of M.D. Anderson's patients are out-of-towners -- all of them paying customers, as opposed to storm-turfed nonpayers -- the institution has taken a substantial economic hit.

The problem of storm-turfed nonpayers (non-paying patients "turfed" to Anderson by institutions closing shop for the storm) is vexing because they aren't Texans qualified for coverage under state indigency programs (else their care would not be uncompensated), but are people that other branches of the University of Texas Health Science Center (coughGalveston'sUTMBcough) thought they'd treat on taxpayers' nickel, for fun, despite that they flew into town from other states or countries in order to pose as broke needy locals and are scamming them for free services. Yes, people fly into Houston from Iran and similar places for cancer treatment, and try to avoid paying a nickel for it. No, Texas legislators didn't think they'd opened a worldwide free medical clinic when they funded the University of Texas system during the last legislative cycle.

Some nitwit administrators don't know how to pronounce "no" or "fraud" and just let these folks walk all over them. Maybe they think pissing away taxpayers' money on people who not only don't qualify for indigent care but aren't even Texas or even U.S. taxpayers is somehow a worthy cause. My subtle take is this: being scammed isn't a virtue, and letting people scam you out of resources you are safeguarding for the public is lazy and corrupt.

Sometimes, it's people driving across the Texas border and pretending to be an American cousin to get coverage, and sometimes it's folks flying their known-sick relatives from other continents to the Texas Medical Center to foist them on local hospitals in the hope of winning the medical lottery. I hear someone in the distance crowing about universal health care, and the need for it, as if we should be happy to suffer this indignity. (Nevermind the only reason we now lack it is federal obstruction of state regulation to create universal coverage; let's hear the plea for federal single-payor care and try not to puke.) Even under a universal health care system as exists in Hawaii, Germany, Canada, or the UK you can't just fly into town and demand outrageously expensive treatments for the serious diseases you know you've got. The public feeling of entitlement to health care really creates problems in a place like the M.D. Anderson Cancer Center, where treatments for serious illness routinely cost six and seven figures to provide. The volume of patients at Anderson are quite a bit higher on a daily basis than the emergency rooms that are forced to give uncompensated care to folks who roll in on ambulances, so the losses mount faster. Suddenly absorbing unfunded fraudulent care cases from other branches of the U.T. system (because their administrators don't bother to do the work needed to weed them out) is a serious blow atop the sudden loss of so much regular paying work.

But back to the original point: Houston's power and infrastructure are getting back into shape. Folks with actual physical damage to their power connection to their homes are having the most trouble getting re-connected. I continue to encounter intersections whose traffic signals are dead or flashing, if not laying in the median in pieces.

The Mayor stated that the driveability of Houston roads was mostly restored by citizens responding to his call to take chainsaws and axes to felled trees blockading streets, and was mostly remedied in the first forty-eight hours following the storm. The existence of civil order in Houston appears to have been key to the relatively swift restoration of infrastructure to usability. The existence of a curfew order may have been useful to prevent property crimes, but the number of citations for curfew violation seems to support my thesis regarding the order: it was designed to amplify a show of force by police units, and not to be directly enforced. I strongly suspect selective application on the basis of subjective factors, but I anticipate that officers trained to avoid appearing to conduct profiling "needed" the curfew order as cover for what amounted to a profiling-based enforcement policy.

The intentional use of a curfew order as cover for arbitrary or oppressive enforcement would be very concerning. However, I suspect the order was intended not to support invidious discrimination but to provide cover for hard-to-quantify suspicions regarding vehicles and persons believed by officers not to appear engaged in innocent behavior. The intent of the persons creating the curfew -- that is, if they didn't intend it to be applied uniformly but only selectively against persons bearing undescribed characteristics that would lead police to want to stop and search them -- is a matter that deserves some thought in respect to legality and constitutionality, but that's not this post.

The Bolivar Peninsula appears to have been largely converted into a wasteland, and I expect in time the death toll from the storm will be revised upward as known or suspected non-evacuees are presumed dead.

The Effectiveness of Preparedness

On Thursday, when hurricane Ike was thought likely to make landfall in Texas as a class three or stronger, its predicted impact included a Galveston Island storm surge of twenty feet or more. The National Weather Service issued a strongly-worded warning for coastal areas of Texas, and urged evacuation.

A storm similar to Ike's predicted power had hit Galveston square-on before, in 1900. During that storm, locals did not evacuate but had actually gathered on the beach to observe the waves. The only non-marine egress from the island at the time was "the longest wagon bridge in the United States" and there was no manmade storm surge barrier on the island. Six thousand are known to have died in Galveston's storm of 1900, and the complete count of the dead is thought likely between eight and twelve thousand. Thousands more were injured, and approximately ten thousand left homeless.

According to the United States Census of 1900, the population of the United States stood just under 76 million inhabitants. The loss of eight thousand (the number offered by the National Oceanic and Atmospheric Administration) amounts to about one hundredth of one percent of the national population. During the census year ended in May, 1900, the annual death count was about a million and a half, suggesting that the loss of 8,000 souls contributed about a half a percent the then-current all-causes annual death toll. On the other hand, understanding the scale of the disaster may be aided by considering that the Texas death toll in the 1900 census was less than one hundred thousand, and that the population of Galveston was less than twenty thousand. (Today, the population is sixty thousand.) If you are nearby, it looks terrible indeed.

The construction of fifteen-foot storm barriers against the encroaching ocean contributed to Galveston's improved outcome when it later faced a similar storm surge:

In 1915, a storm of similar strength and track to the 1900 hurricane struck Galveston. The 1915 storm brought a 12 foot (4 m) storm surge which tested the new seawall. Although 275 people lost their lives in the 1915 storm, this was a great reduction from the thousands that died in 1900.
from Economist's View

Today, storm surveillance and still-developing emergency-response strategies have enabled the hurricane death count to be controlled to a mere four. Granted, uncooperative non-evacuees peppered emergency numbers all night with futile pleas for evacuation, and more might have been killed on Galveston had the storm surge hit those choosing to remain with the predicted twenty-foot-plus surge rather than the surge that materialized. However, people who choose to ignore a plea for evacuation like this take their lives in their own hands. It's not the same as breaking into a junkyard to taunt hunger-maddened dogs while wearing a cat costume to win a home video competition, but it's not far behind. The four and a half million without electricity will eventually get power restored, including the sixty thousand on Galveston.

Unlike freak acts of nature that might or might not strike, known sources of human-caused risk create an evergreen source of mortality, morbidity, and property damage. For example, accidental drownings in recreational environments aren't a result of the weather or unavoidable astronomic phenomenon such as meteor strikes, and they routinely kill thousands of Americans annually. The Centers for Disease Control and Prevention -- the "Prevention" was added to the CDC's name recently enough that the agency is still called the CDC -- has a special page devoted to drowning risk. Accidental drowning in recreational environments is such a significant cause of death that -- despite widespread laws requiring home pools to be fenced, swimming training programs, and laws ensuring boater access to life vests -- recreational drownings eclipsed terrorist attacks as a leading cause of mortality even in the year of the high-water mark of terrorist attack fatalities in the United States. One wonders how much worse drownings could be, but for the effort to control its toll.

One way to illuminate the effectiveness of preparedness is to look at the progress the United States has demonstrated against another manmade mortality risk: driving-related fatality. During the 1980s, the approximately-fifty-thousand annual death toll from driving-related incidents in the United States challenged the country's cumulative death toll of the entire Vietnam war. Despite increasing numbers of drivers and increasing numbers of miles driven, efforts to control risk -- including interventions like mandatory seat belt laws, education on driving risk, and the implementation of widespread designated driver promotion programs -- have decreased the absolute number of annual deaths. The rate has plummeted even more. (It turns out that alcohol is a nontrivial contributor to drowning fatality risk, too.)

Risk-control interventions significantly impact materializing losses. The question is whether the results are worth their human and financial cost. In the case of avoided drownings and avoided road deaths, it's easy and politically non-controversial to conclude that prevention is money well-spent.

The question is how to develop a policy analysis framework with the power to address situations in which political views heavily color viewpoints.

Why We See FUD At Election Time

I recently wrote on FUD as a de-marketing technique aimed at confusing comprehension and
preventing customer conviction (a late stage of positive marketing response). By engineering a micro-environment characterized by Fear, Uncertainty, and Doubt, marketers prevent potential customers from committing themselves through action (entering long-term service contracts, creating valuable content in proprietary file formats ... or mailing in an absentee ballot) to a competitor's offering. My examples involved the tech industry, and included the technique of vaporware. (Incidentally, you can search"vaporware" at Wired to find the annual Vaporware Awards, an entertaining read. Vaporware is the announcement of a non-existent product for upcoming release -- especially an announcement full of ambitious features that put existing alternatives to shame -- when there's no hope the announced product will make the release date ... vaporware is at its best when there's no product at all, and no-one working to build it. The purpose of vaporware is FUD: it seeks to convince would-be buyers of competing products that the existing alternative is about to be rendered obsolete by something that will, in fact, not be brought to market within the useful life of the existing alternative. Wired's list isn't all true vaporware, some of it is just entertaining entries of highly-anticipated products, like games or tech accessories, that just took forever to get off the ground.)

Now, think about candidates' marketing right around election time. Every plausible voter will know the names and party-affiliation of the likely victors. Naming your opponent in a primary election, in which name recognition goes a long way toward victory, doesn't raise the same risk in the general election. Awareness of the marketers' candidates and their opponents isn't really in question by the time one is able to cast a ballot for an office as high-profile as the President of the United States.

Comprehension isn't really a deep part of American buzzword political marketing; the folks who think they want comprehension will be reading about the candidates, or their positions on the issues that they personally believe to be game-critical issues. On the other hand, maybe they'll be asking their opinion leaders about those issues, and the candidates, because they don't value deep comprehension and will accept conclusions secondhand from people they trust. Generally, deep understanding of candidates' positions and their implications and likely results doesn't come from candidates' stump speeches. The best you can expect from candidates' marketing is comprehension of the candidates sound-bite on the topic, for or against gay marriage, abortion rights, nuclear power, domestic petroleum drilling in various hot-button locations, firearms policy, etc. Comprehending these "positions" puts voters in a mind to believe they can tell whether a candidate "believes as I do" or "doesn't believe as I do."

But the easy sells are already done. The remainder is a bunch of folks too unexcited to be certain they will vote, or unconvinced by what they've heard even though they are likely to fill out a ballot

The only game in town is thus the fight for conviction. The problem is that the folks who respond to a candidate's claims have probably already been convinced, and the ones who by election-time remain undecided are just not readily moved by the things that create conviction in the parties' main camps.

On the other hand, people do often vote for the lesser of two evils, and it's not hard to imagine ways to make opponents worry about the risks posed by an opposing candidate. Negative campaigning and blatant fact-free FUD appears for the cold and logical reason that it is effective in preventing opposing votes, because it interferes with opponents' conviction-building exercise, and it can create wanted votes if it leads to lesser-of-evils votes for the candidate spinning out the FUD.

Just so nobody misses it, I expect both candidates to lay big whoppers on us this election season. I expect both to pretend that they have well-reasoned strategies to address socially and logistically complex issues involving trillions of dollars, like those raised by the employment-based health coverage system operating in the United States, when each has equal likelihood (zero) of fixing from the Oval Office the problems the next Congress and President will inherit, changed only for the worse, from Jimmy Carter. Jimmy Carter signed the Employee Retirement Income Security Act of 1974 and stuck American health coverage where we now find it, without the benefit of state-level health coverage innovation repeatedly thwarted by federal law. We'd have fixed this years ago but for Congress' disinterest in fixing the problem, and it's ironic to hear officials, who are trying to leave Congress for a position that cannot pass legislation, promise to correct problems originating in badly-worded or merely misapplied Federal law from the Presidential Mansion. McCain and Obama are basically trying to sell you a fake Good News page in advance. This would be an example of Vaporware in action, and vaporware is always good FUD.

I expect both candidates to make wild claims about their likely future achievements and about the risks posed by their opponents. It'll be FUD at its best, from vaporware to specious bug reports.

Bring popcorn.

Kinky Sex Better Than You Thought

Unlike vanilla slavers whose genuine coercion ruins lives and attracts the well-warranted attention of law enforcement, consensual BSDM practitioners appear better adjusted than 'normals'.

So, is it time you hit the sex shop?

Fighting to Bleed: Medical Comment Fetches Comments

M.D.O.D. is an entertaining blog providing important education on valuable medical terms of art, and happens to include an emergency medicine doc's top-ten-style rant on why he's leaving emergency medicine. I commented in response to reason #5, which featured a misprioritizing supervisor's misdirected disciplinary behavior, inspired not by observed wrongdoing on the part of the victim but by the supervisor's own fear of personal consequences for shoddy work. My comment got a few of its own comments, and I thought I'd repost the comment here:

It's amazing what people will do to jeopardize care when they are afraid of liability. Folks think liability is a big problem in the U.S., and I'm willing to hear a case made about it, but I was surprised as can be to discover it was lethally dangerous in Honduras.

I traveled with a volunteer surgical team to perform operations on an impoverished and underserved community in the middle of noplace. While there, we had a patient whose kidney wasn't possible to save. There wasn't an ill part that could be removed; the whole thing was scar tissue, and it had grown in size several times and encroached upon and melded with numerous other structures in the area.

Including the ascending vena cava.

Needless to say, the operation ran long, and was bloodier than hoped. I kept an eye on the patient's face, and she was getting scarily pale.

The hospital didn't have a blood bank.

We went around the room trying to ascertain whether we had among us any plausible donors -- without the ability to test for pathogens, we didn't dare recruit locals -- and it turned out that as an O+, I was the only person in the room whose blood would not kill the B+ patient.

This is where the liability got crazy. The physician with the contract to attend the hospital -- a local Honduranian -- instructed the lab tech not to give me a blood bag. Without the blood bag, my mission to donate a unit of blood was in jeopardy.

After a while arguing -- they claimed the risk involved in not-exactly-type-matched blood was dangerous, and I explained that since they weren't planning to test for minor antigens anyway, it didn't matter, and that without the transfusion she was certainly going to die, which made the theoretical risk she might die due to a fatal mismatch among minor antigens a fairly good bet by comparison.

About this time they decided they didn't speak English any more. So I let into them with my broken Spanish. And, let me tell you, my Spanish was pretty broken. The upshot was that their behavior would kill the patient, and that whatever I was proposing, therefore, had only the possibility of helping.

However, it was more important to the physician contracted to the hospital that he keep his job by avoiding the appearance of having contributed to killing the patient. If the patient died under an American knife, he was blameless. If he allowed a donation using his blood bag and the donation's complications were implicated in the immediate cause of her death, then he could face trouble, and he feared for his position.

And they weren't offering any known clean B+.

Eventually, the tech took a blood bag out of a drawer, placed it on the table behind her counter without giving it to me, and took a break. I understood it was my responsibility to steal the blood bag without permission.

Then I donated into the blood bag, carried it to the OR, and passed out while I watched it given.

Turns out dehydration and blood donation don't mix.

My take-home lesson came in several parts. One, drink lots of fluids in the hot dry mountains of Honduras in the summer. Two, the U.S. isn't the only place folks do silly things for fear of liability. Three, the local nurses will make fun of you in Spanish if you are seen passing out, and they will make jokes about whether the patient will be doomed to pass out after getting your weak-assed gringo blood. But three is OK: they know you kept her alive long enough for the next three donors to get back from a supplies run in the next town, and that without you the poor girl would have died and her husband would have been left alone, so the nurses are smiling at you as they giggle when you pass.

I've worked a bit in the medical field (broadly defined; my activity at times involved psych patients, at times involved pharmaceutical research, and at times involved transplant tissue collection). I presently regard myself as an interested observer but a nonparticipant. That is, I try to stay well enough that I don't need to risk myself near physicians or hospitals, which as everyone knows are strongly associated with sickness and death.

Strange Crime

You knew that to try to kill a human and fail was a crime. Did you know it was a crime to try to raise the dead and fail? In Russia, the crime is apparently fraud. That'll show 'em!

More seriously, the fact that the accused could be convicted of eleven separate incidents in which he induced people to part with money in exchange for his efforts to effect supernatural cures says something about the ease with which one can find people who are really gullible. As the great philosopher Barnum is alleged to have elucidated, there's one born every minute.

And what do you figure fruitless expenses do to the cost of health care?

Easily confused and misdirected people aren't solely confined to the victims of crime: There are some nitwit perpetrators, too.

A would-be thief in Japan didn't want to believe his knife-point mugging victim was out of cash, so a quick-thinking housewife lulled him into a false sense of security by offering him tea and got him set monologuing about his life. In The Incredibles, we learn from Pixar's keen students of human moves that once the villain is monologuing, you have an opportunity to escape. For example, fill him with tea 'till he visits the john and flee, or else offer to nip down to the store to buy cookies on credit -- cookies go so well with tea, don't you think -- and make an emergency call. Maybe duck out of the room to change that baby's diaper, and just not return without a police escort.

Alas, she just cracked and gave the thief ¥10000 (over $90) and let him escape. She could so have just apologized for not having the money to help him, and thank him for letting her pour him some tea, and she would have gotten off Scott-free. Tokyo cops are still looking for him.

Trading With The Enemy

CNN seems to imply that allowing Americans to sell cigarettes, brassieres and bull semen to folks suffering under the Islamofascist regime in power in Iran since the Carter era is evidence of political hypocrisy.

I beg to differ.

As mercantilist competition of earlier centuries illustrates, trade is tantamount to war. In this enlightened era in which we like to preach free trade, we have anything but free trade. When the Soviets were still the major bogeyman for Americans, the US' staunch anti-Communist allies in Japan were so wary of US as a threat to domestic rice producers that it seized (purportedly on grounds of national security) the few kilos of specimens an American exhibitor had brought to a Toyko trade show. You know, several little clear boxes with labels like "long grain" and "for sushi" or the like. If buyers knew rice grew in Texas for a few bucks a pound, they might not want to pay through the nose for the produce of Japanese farmers that, to maintain price competitiveness, was protected with an 800% import tariff.

Yes, 800%.

The United States maintains import tariffs, too. The question isn't whether the US will protect domestic producers, but which producers and in what percentage. A look at the tariff on sugar, for example, shows that not only do we tax it strangely (for example, Congress levies a greater tariff against an import of cane sugar than it does against beet sugar), but there's a lot of energy being spent figuring out what sugar tariffs do to its price over time. Carl Hiaasen's excellent Florida-set fiction includes some hilarious hijinx caused by sugar barons and their lobbying efforts; I wouldn't recommend the movie, but read the book. The things domestic lobbies accomplish ....

Who is allowed to bring what into a national market and at what price is a big deal to people in the market, and to people trying to sell into the market. Trade isn't an academic matter. There are some financial heavy-hitters who regard dependence on foreign-produced commodities as a serious threat (Pickens views petroleum imports for energy as such an albatross that he's investing in alternative energy.)

So CNN has figured out that over the last eight years, America's biggest export to Iran is addictive poisons for recreational use. When last I heard, Iran was the enemy. (UPDATE: one of this cycle's remaining U.S. presidential candidates gets this joke, though he probably lost political correctness points for spelling it out while the camera was rolling.) Iran's current regime had been so cast since overrunning the US embassy in Tehran in 1979 (even if the invasion was unconnected with the government, the new government's later conditioning of captives' release on political accommodations by the United States unequivocally ratified and endorsed the action), then subsequently parading the corpses of US servicemen who died in an ill-coordinated interdepartmental rescue mission. Jimmy Carter's museum web site paints these events in a slightly different light that I present, and I link it in the interest of equal time. Some of Iran's attacks have been pretty clever. However, Iran's Islamofascist government has not merely confined its attacks to other tyrannical regimes, but have targeted the interests of democratically-aligned targets. Doubt that Iran's agents work to undermine neighboring democracies is quenched by Iranian reprisals for thwarting its agents and admissions by co-workers. One would be unsurprised to learn that, despite official positions on the matter, efforts against various Iranian efforts have resulted in some activity that resulted in chasing Iranian agents home to Iran.

Of course, the US position is that it is against the government in power in Tehran, not against the people whose efforts to oust them have been thwarted by systematic efforts to ensure only Islamic fundamentalists have any chance of appearing on the ballot. For example, U.S. Secretary of State Rice has discussed opening a bureau in Tehran modeled after the one in Cuba, for cultural contacts and processing visas but not for diplomatic contacts. This would be immediately attributable to a propaganda effort, except that no U.S. administration has had a competent propaganda campaign since Truman threatened to continue using atomic bombs to end the capacity of Japan to wage war, after he'd dropped the last one he could order dropped. The probable intent of a new bureau in Tehran is to process visas for dissedents and businessmen whom the US would like to encourage in the view that the US is a great place to do business and to give talks about how life sucks under what passes among Islamist tyrants for an Islamic caliphate.

If the Japanese want to suck down Marlboros -- or if Americans can work out how to market them successfully, there will always be some folks who think addictions are about supply and not demand -- at the same time as they fight tooth and nail to beat Americans in the marketplace, let them. When I say tooth and nail, I mean the Japanese government made sure the most modern production mechanisms were affordable and that container ships the US were cheap to build by providing capital to Japanese industrialists at reduced interest rates, on the backs of Japanese taxpayers whose national debt per capita swelled far past Americans' own crazily-mounting Cold War debt. Life in Japan was so stressful one could buy insurance against, and get paid benefits for insured losses from, death due to overstress due to overwork. The Japanese even have a one-word name for this risk: karoshi. Hundreds of claims are paid each year for karoshi. That's not claims made, that's claims proven.

And still, Japanese somehow live longer than nearly anyone else. So on those smokes: no harm, no foul, right?

Americans rail against dollars for petroterror, or how SUVs fuel terrorism, or the like, so they should be entitled to smirk when they hear about some distant tyranny sucking down cigarettes, bull semen, and anything else Americans can produce at will. Assuming Americans have some dog in the fight, sales are bullets in an economic war and should be withheld only for cause.

If Iranians want to buy American bull semen, how does this harm Americans? There's even a propaganda angle in there, if Iranians need to order out to America for quality semen.

Crazy Place To Send People

A woman involuntarily admitted to a New York psychiatric hospital was allowed to sit in a waiting area until she died -- and then another hour -- until she was given some attempted (futile) treatment.

The facility is being sued over the event, a fact that is all the more likely to receive sympathy after the hospital falsely recorded that the deceased woman was waiting quietly, taking trips to the bathroom, and otherwise seeming to enjoy normal use of the waiting area for more than forty minutes after films show she in fact had collapsed on the floor.

The state of mental health in the United States seems pretty bad. If we can't identify dead people in the waiting area of a psych ward, how will we identify mentally ill people suffering in the general population?

There may not be a lot of public interest in mental health, but untreated mental health is costly in lost productivity and consumed services (just because the services aren't sought for a mental health condition doesn't mean they're not sought for traumas, comorbid conditions, etc.).