Healthcare Politics

The other day several friends and I were having a discussion about a number of things, and the issue of health insurance came up. One friend said that one of the problems with the Affordable Care Act was that it made people pay for coverages they didn’t need. And he’s absolutely right… and totally wrong.

The entire point of insurance is to spread the risk among a large number of people and over time. If people were allowed to buy insurance only after they needed it, then there wouldn’t be any insurance, because the insurers would be broke. For better or worse, that was the reason why insurers refused to cover “pre-existing conditions,” or would only do so with a far higher premium, unless the insured had already been covered by the same insurer prior to the discovery of that condition [and some insurers wouldn’t even do that], which often tied people to a given job or resulted in huge problems when they were laid off or had to switch jobs because an employer went out of business. No matter what one thinks about the Affordable Care Act, it is a plan based, if less than optimally, on commercial insurance, and that means that the costs of health care have to be covered by premiums. Those premiums also cover the high salaries and profits of the insurance companies, and the trade-off between the ACA and a single-payer, government-backed system is whether the “efficiencies” [about which I have certain doubts] of the private sector outweigh the costs of a profit-making enterprise enough to make the cost to the insured lower than would be the case in a government-backed single-payer system.

The second problem of understanding is simply that the principal problem underlying the insurance costs is and will continue to be the rising cost of health care in the United States. So long as those costs rise, so will the costs to anyone who is insured, and if there are large numbers of uninsured people who need health care, those costs will be added to the costs of the insured, either through higher premiums and/or greater co-pays because, at present, the vast majority of hospitals are required to treat people who need care, whether or not those individuals can afford it or not.

The third problem is that no country in the world, even the United States, has the resources to provide the ultimate in high-tech health care to every single individual in the country. There isn’t enough funding, enough medical personnel, and enough equipment to do that. So, like it or not, health care is effectively rationed. The “traditional” way of doing that in the United States has been through the market system. If you have enough insurance and money, and enough intelligence to deploy the insurance and money effectively, you can generally get the best health care. If you don’t, you get less, and in some cases, you effectively get nothing. In countries with government-mandated systems, most people get coverage for what the system determines is “equitable” for everyone, although, in some of those countries, if you have great resources, again, you can get better care.

All the political rhetoric about health insurance boils down to how society will pay for the rising health care costs of those who either cannot afford it or choose not to afford it, and how this impacts each person. In our extended family, my wife and I have ended up paying more and more out of pocket every year as the insurance costs, deductibles, and co-pays go up, but we have relatives who work long hours who now have better coverage for less.

But there isn’t a “magic” answer. Health care costs. It’s that simple, and all the political rhetoric in the world won’t change that. That political rhetoric is merely “code” for saying who should pay more.

The Unacknowledged Costs of Lawyers

In Shakespeare’s King Henry VI (part 2) Dick the Butcher declares, “Let’s kill all the lawyers,” a statement which, in the context of the play, is actually one in support of lawyers, but if Shakespeare were living today, I’m not so certain that Dick and Jack Cade wouldn’t be supporting the lawyers [since Cade’s purpose was to undermine the rule of law], given not only the damage they’ve wreaked on U.S. society with the excesses of tort claims, but also the unseen and unacknowledged damages that have been incurred at almost all levels of society as a result of the efforts of businesses, governmental entities, and other organizations to avoid litigation.

Trial lawyers continue to insist that medical tort claims lawsuits are necessary to remove bad doctors, while ignoring the facts that very few such claims ever lead to a doctor being removed from practice and that the abundance of medical malpractice lawsuits has increased the cost of malpractice insurance astronomically in some specialties, even for those doctors who’ve never had a claim against them. An associated problem is the fact that doctors often ask for more diagnostic tests than medically necessary, just so that they can claim that they haven’t overlooked any possibility and to bolster themselves against malpractice claims. As a result, healthcare costs increase. Everyone focuses on the issue of costs to the victims of bad medicine, but there’s been no real consideration of the costs to the rest of the profession or the increase in costs for healthcare insurance, and for those purchasing it.

While this is the most public example of the costs of attorneys, it’s far from the only one.

Post-tenure review is now becoming more and more widespread at universities, despite the fact that a very small percentage of tenured faculty actually abuse their position or fail to meet their obligations, yet the post-tenure review documentation required at regular intervals takes goodly amount of time to prepare. It also takes a fair amount of time for the committees to review it, and yet very few faculty members are found wanting and dismissed. So why can’t universities employ a process asking suspect faculty to submit such paperwork, rather than spending all the time and effort to review all tenured faculty? Because the lawyers fear lawsuits alleging discrimination, and the post-tenure review process insulates the university from the claim of discrimination. But a faculty member dismissed by either process can still protest and file a lawsuit. In effect, post-tenure review does little to weed out tenured faculty who aren’t cutting it. What it does do is increase the paperwork burden on the rest of the tenured faculty, because the documentation required is extensive, while making the job of a few university lawyers and administrators easier.

Another area where lawyers engage in costly litigation is in “patent trolling,” where lawyers essentially practice a form of legal shakedown by making “patent infringement” claims on productive companies, often on the flimsiest of cases. All too often, the companies being sued simple settle, because the time and effort to fight such claims would be even greater than the settlement costs. A recent study pegged the unnecessary costs of patent trolling at nearly $30 billion annually in direct costs and more than $80 billion in indirect costs.

The same sort of process occurs in business, in everything from warranties, privacy policies, personnel policies, you name it. Legal documentation is expanding everywhere. Why? Because organizations are trying to minimize the chances of costly litigation. Why do they need to go to such extremes? Because other lawyers are looking to fatten their finances through litigation or the threat of litigation. This is incredibly obvious, yet, with the exception of malpractice claims, I’ve never seen even an estimate of the national cost added to business, education, and life in general by litigation and the threat of litigation. And, of course, Congress refused even to consider limiting malpractice tort claims under the Affordable Care Act, possibly because trial lawyers contribute considerable sums to congressional campaigns.

I’m not against lawyers, and there are more than a few in my family, but I’m certainly against litigation and legal processes that don’t improve matters and whose costs continue to spiral.

Indirect Warfare, Direct Consequences?

For some time, I’ve wondered why on earth the Russians were committing so much in the way of military force in Syria, ostensibly in support of the government of Bashar al Assad. What do they gain by that? Especially given the ethnic fragmentation and conflicts that aren’t going to be resolved by more bombs and deaths, and which may in fact be increased by such measures? Then, there’s another question. Why is Vladimir Putin so intent on building up the Russian military at a time when Russia seems to face uncertain economic times, if not economic chaos?

In Syria the Russians have provided all manner of “aid,”including close air support; attack helicopters on the battlefield; high-precision strikes with missiles like the short-range Iskander; artillery support; special forces backup; intelligence; targeting; electronic warfare and even mine clearance. Although some of the top attack aircraft were recently flown back to Russia, attack helicopters that are less susceptible to the sandstorms that blow this time of year replaced them. A recent CNN report revealed that, in addition to first-line jet aircraft and helicopters, the Russians have also deployed modern main battle tanks, armored personnel carriers and surface-to-air missile systems, not to mention a satellite-based missile guidance system.

On May 10th, Putin himself stated, “Since the start of the operation, Aerospace Forces planes have flown more than 10,000 combat missions against international terrorist facilities on the territory of the Syrian Arab Republic, have conducted a large number of strikes on the territory and have engaged over 30,000 targets, including more than 200 facilities for extracting oil and refining oil and crude oil feedstock.”

Putin also noted that the conflict in Syria brought out certain problems with new Russian weapons and systems, problems which he indicated will be soon addressed. It’s almost as if the Russian Syrian initiative was as much to field test new weapons and systems as to tell the world that Russia is back on the world stage with a totally revamped military structure and posture.

At the same time, Russian attacks continue to destroy civilian targets, ostensibly in pursuit of ISIS, but in practical terms, every attack creates more refugees, and the war in Syria has created roughly five million refugees to date. In addition to the more than a million Syrian refugees already in Europe, three million have fled to Turkey, a country with already contentious social and ethnic confrontations that the flood of refugees can only exacerbate. Lebanon, a country of 4.5 million people, also with a divided cultural and ethnic society, hosts over a million.

Barriers against the flood of refugees are going up all over Europe, either mental or physical ones, at a time when much of Europe faces economic difficulties, as well as where a significant number of nations have shown an overall unwillingness to markedly expand military capabilities. Add to that the fact that the United States military is already over-extended, and a majority of Americans are tired of overseas military operations that seem to offer little hope of resolution and only more American casualties.

What, indeed, could Vladimir Putin be thinking?


The local university has implemented a new course/faculty evaluation plan. A significant number of faculty members hate it because it requires far more time and demands all too often quantification of the qualitative and the unquantifiable, and it also requires using the same parameters for describing learning outcomes for all the various disciplines. The result is that either professors must oversimplify or only evaluate those aspects of their courses that can be described and measured by the accepted parameters. The reason for the adoption of the new evaluation system was to provide “hard data” for use by university administrators to prove to accrediting bodies and to the state legislature that the university is successful in educating students, in short, to make the administrators’ jobs easier and to present “data” that the legislators can understand at a glance. Or in other words, the lower-paid faculty must spend even more time on administrivia in order to better enable higher-paid administrators to justify their jobs. Put another way, to shift work to others while essentially requiring a process that will present oversimplified and often misleading results.

Furthermore, professors can be downgraded for having “too many learning objectives,” even if the nature of the course requires a number of disparate learning objectives. Of course, the easy way is simply to come up with generic learning objectives, but that results in poor data… and good data doesn’t fit the “mold” in all too many cases.

Add to that student evaluations, in which 18-22 year olds attempt to evaluate what they “need” from professors who have spent at least a decade learning and applying their expertise. Such evaluations often require even more time and effort on the part of the professors to rebut the often erroneous judgments of inexperienced students. More to the point, study after study has shown that the most consistent result of student evaluations is not improvement in education, but grade inflation, and that means that not only do ever more intrusive student evaluations put more burden on faculty and fail to improve education, but they do so in an effort by administrators primarily to make universities more “student friendly” and marketable.

This sort of work-shifting permeates society today.

Take another cost-shifting measure – the decision by major U.S. airlines, except Southwest, to charge fees for checked luggage. While this has increased revenue for those airlines, it’s also increased costs for TSA, which has to hire more employees to screen the vastly increased number of carry-on bags, as well as increasing security screening delays at U.S. airports. This cost-shifting creates costs for the taxpayers who fund TSA and delays for passengers.

Then, too, as I’ve mentioned before, the proliferation of email requests for status reports in organizations and businesses results in employees spending a greater and greater share of their workday answering such requests rather than doing actual work. It may make their supervisors’ tasks easier, but it’s a drag on productivity, which isn’t all that high these days anyway, and it’s resulted in longer workdays for employees.

Every time that I take an airline flight, buy an electronic book, stay in a hotel, purchase an appliance or piece of furniture, no matter how small, or even buy groceries, I’m asked or prompted to fill out a survey – and if there’s something wrong, I’m supposed to suggest how the seller or vendor could do their job better. Isn’t that their job? Yet we’ve been sold a bill of goods that the seller is just asking for our opinion because our opinion counts, when it’s both as marketing tool and a way to obtain data on a lower-cost basis.

Walmart and other retailers get in on the cost-shifting movement by setting up self-check-out lanes, resulting in fewer cashiers. More than once at stores, I’ve ended up doing self-check-out, even when a cashier could so it faster, because the lines at the cashiers were so long.

Yet another form of cost-shifting is practiced by governments, either state, local, of federal, when they offer “tax breaks” to businesses for various purposes. Those tax breaks may indeed create jobs and the like, but seldom do they cover the foregone tax revenues, which means that the “new jobs” are at least partly subsidized by the old taxpayers.

Yes, indeed, cost-shifting, another example of the capitalistic great American economy… and yet I see almost no one who’s willing to call it for what it is, an additional cost on taxpayers and consumers.

Piracy on Another Front?

As most of my readers know, I’m not exactly fond of electronic piracy of my books, or of anyone’s books, and I’m certainly not the only author or editor who feels that way. While much of the publicly expressed concern over piracy has focused on fiction and music, there’s an even more problematical aspect of piracy – that of scientific journals and papers.

The battle over electronic piracy of scientific papers and journal articles has become a huge issue since the founding of Sci-Hub by Alexandra Elbakyan in 2011. According to Science magazine, in the six months from October 2015 through the end of March 2016, 28 million documents were downloaded from Sci-Hub, with the greatest number of downloads going to China (4.4 million), India (2.6 million), and India (3.4 million).

The problem is simple. Legal access to the majority of scientific journals and papers costs money, and especially for scholars in the developing worlds, or scholars at educational institutions without the funds to obtain wide access, the cost of keeping up with developments in their fields becomes prohibitively expensive and enormously time consuming. Obtaining just the permissions for the papers a U.S. university linguistics researcher needed took over a year. An Indian scholar discovered that to legally obtain copies of papers to stay current in his field every year would cost five times his annual living expenses.

At present, as calculated by Science, Sci-Hub’s downloads represent only about five percent of the total number of science documents downloaded in the world every year… but those numbers are growing, fueled by the increasing need of scientists and other professions to follow current scientific developments and by the fact that a huge number of those professionals who need access for their professions have either limited legal access, no legal access except by paying out of their own pockets, or the time required to use other legal ways of obtaining access.

No matter what anyone says, useful information doesn’t come cheaply. I’m not a scientist, but as a science fiction writer I need to stay current. I did a quick checklist of the science periodicals that I take and read – and my annual “information” costs come close to $2,000, and I’m talking only about periodicals and science books that represent a small fraction of the documentation a full-time scientist or researcher needs to know.

That’s one side of the problem. The other side is one that very few consumers/users of fiction, music, or scientific documents seem able to grasp – the cost of assembling, editing, copywriting, and overall production of these documents is far, far, greater than the final cost of physical production. Another difficulty is that recent studies have shown that too many science papers haven’t been properly peer-reviewed and vetted and their results can’t be replicated. That also takes not only money, but a structure that’s not supported by piracy or by an information disseminator such as Sci-Hub.

Add to that the fact that most researchers and scientists aren’t paid much, if anything, for having their work published, and those who profit most from scientific publishing are companies like Elsevier, not either the researchers or the users/readers of those documents

According to Marcia McNutt, the editor-in-chief of Science, “Today, digital publishing is just as expensive as print for a state-of-the-art Web design that incorporates multimedia, is responsive to desktops, tablets, and smartphones, and maintains access to back content.”

All of which means we have a problem that’s going to get worse. If piracy of scientific documents follows the path of fiction, what happens to all the checks on falsified or sloppy research…or who is rightfully credited with what…or who gets paid for coming up with an innovation. These areas are already problems, and I don’t see the world of increasing intellectual piracy solving them.

Now…the world isn’t going to stop if fiction writers don’t get paid and all “creative” writing becomes essentially a hobby because not enough readers want to pay the real cost of production, or if classical music dwindles to nothing, or if art reproductions return all artists to a semi-starving situation. But the piracy and distribution of scientific documents is, to me, a different situation.

It could be that I’m totally wrong… but… if I’m not…?