Archive for November 2013

Will Doctors Treat All These New Medicaid Patients?

Long lines in waiting rooms of hospital emergency rooms are often misinterpreted as solely due to demand from the uninsured.  Certainly some of the people are there because they have no insurance and they know hospitals have to provide them care.  But many of the people in that waiting room do have insurance through Medicare.  But they cannot find a doctor who will treat them at Medicare's combination of low reimbursement rates and onerous paperwork requirements.

JD Tuccille has more

Five minutes with using supply and demand curves and the most basic lessons of microeconomics would have predicted this.  In fact I did, about a year ago.


Courts Have Become the Temple of Junk Science

If the Left is really as passionate as they say they are about taking on people and institutions who are anti-science, then they should be dedicating themselves to rethinking the current tort system.  Toyota may be facing $5 billion in settlements due to a defect that government reports and independent studies say is not there.

And recall NHTSA's performance during the furor almost four years ago over alleged runaway Toyotas. Its then-overseer, Transportation Secretary Ray LaHood, happily participated in congressional hearings designed to flog for the benefit of trial lawyers the idea of a hidden bug in Toyota's electronic throttle control.

When the agency much more quietly came out with a report a year later debunking the idea of an electronic defect, notice how little good it did Toyota. The car maker still found it necessary to cough up $1.2 billion to satisfy owners who claimed their cars lost value in the media frenzy over a non-defect. Toyota has also seen the tide turning against it lately as it resists a deluge of accident claims.

At first, opposing lawyers were hesitant to emphasize an invisible defect that government research suggested didn't exist. That was a tactical error on their part. In an Oklahoma trial last month involving an 82-year-old woman driver, jurors awarded $3 million in compensatory damages and were ready to assign punitive damages in a complaint focused on a hypothetical bug when Toyota abruptly settled on undisclosed terms.

In another closely-watched trial set to begin in California in March, an 83-year-old female driver (who has since died from unrelated causes) testified in a deposition that she stepped on the brake instead of the gas. The judge has already ruled that if the jury decides to believe her testimony, it is entitled to infer the existence of a defect that nobody can find.

These cases, out of some 300 pending, were chosen for a reason. Study after study, including one last year by the University of North Carolina Highway Safety Research Center, finds that elderly female drivers are inordinately prone to "pedal misapplication." If Toyota can't prevail in these cases, the company might be wise to run up the white flag and seek a global settlement that some estimate at upwards of $5 billion—quite a sum for a non-defect.

Your Tax Dollars at Work

An anonymous quote from an employee at the Federal Mediation and Conciliation Service

"Let me give you the honest truth: A lot of FMCS employees don't do a hell of a lot, including myself. Personally, the reason that I've stayed is that I just don't feel like working that hard, plus the location on K Street is great, plus we all have these oversized offices with windows, plus management doesn't seem to care if we stay out at lunch a long time. Can you blame me?"

This is actually the least of the problems in the agency -- fraud appears to be rampant.  The Washington Examiner has a five part series.

KlearGear Sucks

I don't have a lot to add about this story.  A company called KlearGear trying to fine customers for writing a bad review about it (based on some BS prior restraint on criticism buried in their terms and conditions) and then hounding the customers' credit rating through debt collection agencies.  But I am all for the Streisand effect bringing karmic retribution to such folks, so here is my contribution to Google.

By the way, I found their current header warning to be odd:


Anyone ever heard of a "business hour" before?  Since most customers would not really freak at a 48 hour or 2-day order processing time, anyone want to bet that this means 6 business days (6x8 hours) or over a week, but is meant to fool folks into thinking only two days?  I would ask them directly but there is no way to send them an email without registering first as a customer.  Since by registering, I apparently cede my ability to ever criticize them, I won't be able to write them for clarification.

Our business gets mostly positive reviews, but we get bad ones from time to time.  Every bad review is both a pain in the butt (as they hang around forever on the Internet) but also an opportunity for me to learn and identify problems in the business.  On a couple of occasions I have identified personnel problems through online reviews that let me fix a real problem before something much worse happened.

Update:  The bottom of their home page says "As seen on ABC's Good Morning America".  Yup.  LOL


Obamacare Fail Reminder

Almost three years ago, I wrote over 5000 words on problems with Obamacare in three parts (part 1: information, part 2: incentives, part 3: rent-seeking.  Since then I have discussed how Obamacare is forcing the retail service sector into a part-time work model, how my policy was dropped, how the real price increases are coming next year, and how millions of dropped corporate policies will soon follow.

Not one single word was about the web site.

We haven't even gotten to the point where the real problems of Obamacare will manifest themselves.  While the backlash may be very real right now, we are still in the  pre-season.

The Public Rail Spending Game

Kevin Drum has a very good, succinct description of how the rail (light rail, high speed rail, commuter rail) spending game works, in the context of California High Speed Rail (HSR)

As near as I can tell, the HSR authority's plan all along has been to simply ignore the law and spend the bond money on a few initial miles of track. Once that was done, no one would ever have the guts to halt the project because it would already have $9 billion sunk into it. So one way or another, the legislature would keep it on a funding drip.

It's a time-tested strategy, and it might have worked if not for a meddling judge.

Here is a great example of this from Chicago, where all they could afford at first was a single station.

I applaud Drum for opposing this boondoggle, but if he really understands this so well, I wonder why he seldom demonstrates any skepticism about other rail and mass transit projects.

Rail projects, particularly light rail projects that are being constructed or proposed in nearly every major city, are a classic example of a nominally Progressive policy that ends up hurting all the people Progressives want to help.

Bus-based mass transit is an intelligent way to help lower income people have more urban mobility.  Buses are relatively cheap and they are supremely flexible (ie they can switch routes easily).  Such urban bus systems, which like any government run function often have their problems and scandals, never-the-less can be reasonably held up as a Progressive victory.

But middle and upper class people, for whatever reason, don't like buses.  But they do like trains.  And so cities, under middle class pressure, have shifted their mass transit investment to trains.  The problem is that trains are horrendously expensive.    The first 20-mile leg of Phoenix light rail cost over $1.4 billion, which amounts to about $70,000 per daily round-trip rider.  Trains are also inflexible.  You can't shift routes and you can't sell them-- they have to follow fixed routes, which tend to match middle class commuting routes.

Because the trains are so expensive to operate, cities that adopt them quickly start cutting back on bus service to feed money to the rail beast.  As a result, even transit poster-boy cities like Portland have seen the ridership share of mass transit fall, for the simple reason that rail greatly increases the cost per rider and there is not an infinite amount of money available to transit.


It's All About Control

I can't think of any justification for the FDA's shutdown of 23andme's genetic testing service except one of pure control.  It is yet another case where you and I are not smart enough or sophisticated enough to be trusted with information about our own bodies.  Because we might use the information in some way with which Maya Shankar might not agree.

Let me be clear, I am not offended by all regulation of genetic tests. Indeed, genetic tests are already regulated. To be precise, the labs that perform genetic tests are regulated by the Clinical Laboratory Improvement Amendments (CLIA) as overseen by the CMS (here is an excellent primer). The CLIA requires all labs, including the labs used by 23andMe, to be inspected for quality control, record keeping and the qualifications of their personnel. The goal is to ensure that the tests are accurate, reliable, timely, confidential and not risky to patients. I am not offended when the goal of regulation is to help consumers buy the product that they have contracted to buy.

What the FDA wants to do is categorically different. The FDA wants to regulate genetic tests as a high-riskmedical device that cannot be sold until and unless the FDA permits it be sold.

Moreover, the FDA wants to judge not the analytic validity of the tests, whether the tests accurately read the genetic code as the firms promise (already regulated under the CLIA) but the clinical validity, whether particular identified alleles are causal for conditions or disease. The latter requirement is the death-knell for the products because of the expense and time it takes to prove specific genes are causal for diseases. Moreover, it means that firms like 23andMe will not be able to tell consumers about their own DNA but instead will only be allowed to offer a peek at the sections of code that the FDA has deemed it ok for consumers to see.

Alternatively, firms may be allowed to sequence a consumer’s genetic code and even report it to them but they will not be allowed to tell consumers what the letters mean. Here is why I think the FDA’s actions are unconstitutional. Reading an individual’s code is safe and effective. Interpreting the code and communicating opinions about it may or may not be safe–just like all communication–but it falls squarely under the First Amendment.

I know that libertarians want to kill the FDA altogether.  That is never going to happen.  But what might be more realistic is to shift their governing law from validating that medical treatments are safe and effective to just safe.

Brad Warbiany has more, including real life examples of how 23andme's service has been useful to his family.

Health Care Lost Opportunities

One of the real frustrations I have with Obamacare is that I believe we were on the cusp of a revolution in health care costs and payment systems, which the PPACA will likely kill.  As more and more of us adopted high-deductible health insurance plans, there was an increasing transparency in pricing, and new delivery models were emerging to serve this consumer-based, non-third-party payer health niche.

I think this even more as I read about the CMS revising its future health care cost inflation numbers to take into account a flattening of medical price inflation that has been occurring over the last few years.  The Left has hilariously claimed credit for this cost reduction via some kind of time-travelling effect of not-yet-implemented PPACA measures.  But Charles Blahous reads the CMS report more carefully and finds that the PPACA has nothing to do with these inflation reductions, and in fact is if anything slowing the cost reduction progress.

The obvious point that leaps out from this graph is that the chief CMS actuary found that the ACA would increase national health expenditures through 2016. Not content to let the tables speak for themselves on this point, CMS was explicit in the text of its memorandum that the ACA increased the near-term cost projections:

“The estimated effects of the PPACA on overall national health expenditures (NHE) are shown in table 5. In aggregate, we estimate that for calendar years 2010 through 2019, NHE would increase by $311 billion or 0.9 percent, over the updated baseline projection that was released on June 29, 2009. Year by year, the relative increases are largest in 2016, when the coverage expansions would be fully phased in…The increase in total NHE is estimated to occur primarily as a net result of the substantial expansions in coverage under the PPACA…”

...CMS is now projecting slower health care expenditure growth than they were in 2009 and 2010. CMS’s current projection of 2016 health spending totaling 18.4% of GDP is 1 percentage point lower than its June 2009 estimate (19.4%) and 0.9 points lower than its February 2009 estimate (19.3%).

Why did CMS lower its estimates of future health spending? It wasn’t because of the ACA. We know this for a fact because CMS has released a memorandum detailing the reasons for changes in their ten-year outlook since April 2010. Here are the factors CMS cited, and the percentage of the improvement each was responsible for:

1) Medicare/Medicaid/other programs “unrelated to the ACA” (50.7% of improvement).

2) Other factors “unrelated to the ACA” (26.1%).

3) Updated data on historical spending growth (21.8%).

4) Updated macroeconomic assumptions (6.1%).

Now, that adds up to 104.7% of the total improvement. The reason these four factors add to more than 100% is that a fifth factor, the “impact of the ACA,” worked against the improvement. Per CMS, adjusting the April 2010 projections for the subsequent impact of the ACA shows it further increasing spending over ten years (equal to and opposite from 4.7% of the total change).

Republicans Often Trash Property Rights As Well

It appears that Arizonans are all for property rights until a Goodwill store tries to open in their neighborhood.  And then not so much.  A group led in part by my former Republican Congressman John Shaddegg believes that their "right" to determine how other people's property is used were trampled by allowing a local strip mall to rent a large vacant store space to a legitimate business.



Basically, these residents live in a small prosperous neighborhood called Moon Valley surrounded by less prosperous areas.  There are apparently not enough residents in this neighborhood to support the upscale commercial boutiques they would like to see, so their preference is that this poor landlord leave his property vacant rather than rent it to a business that might cause these folks to encounter a poor person on the street.  I am sure these folks would say they have no problems with poor (likely mostly Hispanic) folks per se, but not in their neighborhood!  (By the way, in this town we have the nicest Goodwill stores I have ever seen -- my daughter loves to shop for funky stuff there).

I don't think I am being too hard on them.  Here is one letter to the Mayor's office from a resident:

What does this mean? Quite simply, we now have a mega store/WAREHOUSE in Moon Valley. Goodwill has closed all the surrounding stores to create a "funnel" effect whereby all the surrounding neighborhoods will flock to Moon Valley for a deal. And, they are now free to import as many goods as they like from anywhere they choose to fill up their new mega store and bring loyal Goodwill shoppers to Moon Valley by the droves.

I sat in the parking lot of the Shaw Butte Plaza today and was so saddened. I thought, "We are such a wonderful, unique, special neighborhood, why would you do this to us? Was furthering your political career worth it?" Because, make no mistake, you have sold us out.

I guess all that brown skin walking around is going to destroy her little bit of specialness.  Tough.

We have the same thing going on in our neighborhood.  The country club on whose golf course many of the houses in my area are located was recently revamped.  It was redesigned into a links-style course that is very unusual in the Phoenix market.  I actually thought this was a pretty smart move -- when there are something like 200 golf courses in the area, it makes sense to try to be unique.

Well, most everyone in the neighborhood thinks it is ugly -- I don't live on the course but I actually kind of like it.  But the sort of shaggy, wild look they adopted for it is not at all what Arizonans are used to.  I will confess they did some things that seem crazy to me, like removing all the trees, but my general reaction has been, well, its their land.   My neighbors do not share my insouciance however, and have freaked, writing letters and threatening lawsuits.   Everyone wants property rights for themselves but veto power over what all their neighbors do with their property.

Disclosure:  I grew up in Houston, so zoning is foreign to me.

Of Course The Health Insurers are Behind Obamacare. Its The Greatest Bit of Cronyism Ever.

Kevin Drum thinks it is an insight to his readers that the insurance companies are a source of support for President Obama in keeping Obamacare alive.  And perhaps it is a surprise.  After all, most of the anti-insurance company rhetoric was for the progressives, who are always fired up for any endeavor they think will punish a private corporation.

The rest of us understand that of course the health insurance industry is all for Obamacare. For them, this is the greatest bit of crony legislation in history. For all the Administration rhetoric, essentially the US government has required that every citizen buy their product, and subsidizes many of these purchases with taxpayer money. Corporatism is rampant nowadays, a bipartisan affliction, but ethanol is that only other industry I can think of that has been granted this ultimate crony grail of subsidies combined with a requirement to purchase  (though maybe ethanol wins because, at least for cellulosic ethanol, there is actually a mandate to purchase a product that does not even exist).

ACLU's Distaste for Commerce

Walter Olson writes (emphasis added)

Elane Photography LLC v. Vanessa Willock is the case in which an Albuquerque, NM woman has (thus farsuccessfully) sued husband-and-wife photographers under New Mexico’s “public accommodations” discrimination law for their reluctance to shoot photos of her commitment ceremony to a female partner. One of the most dismaying elements of the case is that the American Civil Liberties Union has taken the anti-liberty side. Adam Liptak in the NYT:

I asked Louise Melling, a lawyer at the American Civil Liberties Union, which has a distinguished history of championing free speech, how the group had evaluated the case.

Ms. Melling said the evaluation had required difficult choices. Photography is expression protected by the Constitution, she said, and Ms. [Elane] Huguenin acted from “heartfelt convictions.”

But the equal treatment of gay couples is more important than the free speech rights of commercial photographers, she said, explaining why the A.C.L.U. filed a brief in the New Mexico Supreme Court supporting the couple.

Earlier, Olson made the useful point that large organizations like the ACLU are not monolithic -- they have internal conflicts on issues like this.  But based on my interactions with the ACLU, I believe the key word is in bold:  "commercial".   For many at the ACLU, the fact that an activity is commercial or for money voids or cancels out any rights one has.  Property rights or rights exercised in the conduct of commerce tend to always come last (if at all) at the ACLU.  Which is why I donate every year to the IJ, the organization the ACLU should have been if they had not been founded by Stalinists.  Update:  That is unfair.  It's like criticizing someone because of what his father did or believed.  Many organizations move beyond their original founder's legacy.  But it is never-the-less undeniable that -- at best -- the ACLU has no interest in property rights or commercial freedoms.

Republican Web Folks Still Suck

Somehow I managed to get on the NRCC email list.  I don't generally mind these things, as I am on several lists from both parties and it is kind of interesting to see what marketing come-ons they are using at any particular moment.

But the NRCC has been spamming the hell out of me.  This in and of itself I think shows a lack of understanding about the medium.  You lose effectiveness really fast if you send, say, five emails in five minutes, which is what I just received.  Worse, though, is that there is no opt-out link in the email.  Who in this day and age is dumb enough to send out even quasi-legitimate marketing material and not include an opt-out?  Morons.  I am one of the those people who actually can and do write rules to sort my email box, so I can take care of the problem, but this is just bush league.  If you are a GOP member, I would not be fooled by your parties happy talk that it is closing the gap on digital communications with the Dems.  I see no such evidence.

During my brief foray into politics Chairing Equal Marriage Arizona, we were trying to message from the center right on the gay marriage issue.  We found out, to our dismay, this is not at all a comfortable approach for established gay rights organizations (to say the least), but we thought it an intelligent and necessary approach to win on the issue in a red state.  Anyway, one thing we found quickly is that there is no bullpen out there of talented web people on the Right, at least in Arizona.   They are all on the Left.  If I were a member of the GOP and actually cared about their fate, I would sure be looking for a way to fix this, perhaps with some sort of internship program to start developing a bench.

I'm Feeling Pretty Good About These Remarks on Inauguration Day 2009

I caught a lot of grief on inauguration day 2009 for questioning the general feeling that some new era was beginning.  Most of you may have repressed the memory at this point of what that day was like, but even normally intelligent, well-grounded people were going a bit goo goo that day.  

I am feeling pretty good about the remarks I made that day.  Here is part of what I wrote.

I am not enough of a historian to speak for much more than the last thirty years, but the popularity of non-incumbent political candidates has typically been proportional to 1) their personal charisma and 2) our lack of knowlege of their exact proposals....Folks are excited about Obama because, in essence, they don't know what he stands for, and thus can read into him anything they want.  Not since the breathless coverage of Geraldo Rivera opening Al Capone's vault has there been so much attention to something where we had no idea of what was inside.  My bet is that the result with Obama will be the same as with the vault.

There is some sort of weird mass self-hypnosis going on, made even odder by the fact that a lot of people seem to know they are hypnotized, at least at some level.  I keep getting shushed as I make fun of friends' cult behavior watching the proceedings today, as if by jiggling someone's elbow too hard I might break the spell.  Never have I seen, in my lifetime, so much emotion invested in a politician we know nothing about.   I guess I am just missing some gene that makes the rest of humanity receptive to this kind of stuff, but just for a minute snap your fingers in front of your face and say "do I really expect a fundamentally different approach from a politician who won his spurs in .... Chicago?  Do I really think the ultimate political outsider is going to be the guy who bested everyone at their own game in the Chicago political machine?"

Well, the spell will probably take a while to break in the press, if it ever does -- Time Magazine is currently considering whether it would be possible to put Obama on the cover of all 52 issues this year -- but thoughtful people already on day 1 should have evidence that things are the same as they ever were, just with better PR.

And I wrote this about the candidate I actually preferred over the Republican alternative McCain. Which explains why it has been ages since I have voted for anything but the Libertarian candidate for President.  The last election was actually a pleasant surprise, as I was able to cast a vote for Gary Johnson, who I was able to vote for not just as a protest vote but as someone I actually would love to see as President.

When Did the Senate Hit Peak Dysfunctionalality?

Kevin Drum argues that the Senate currently could not get any more dysfunctional, so unprecedented changes in the cloture rules by simply majority vote were justified.

But to my mind the peak of recent Senate dysfunctionality was when it passed the PPACA.  It passed a rushed piece of legislation 2000 pages long full of holes and errors that no one had even read.   When bribes (e.g. in Louisiana, Nebraska) were openly being offered to holdout Democratic Senators to gain their vote.

To this day, even Democratic supporters are expressing surprise at what they voted for.  Most of its key provisions (employer mandates, restrictions on individual policies) have turned out to be unenforceable.  While the Obama Administration has done plenty to screw up the exchanges, the problems began in the legislation itself that did not actually fund or specify a home for the web site development.  And because of implementation delays, we have not even gotten to the point where we can see the real problems with the law that many of us expected.

The Dems said that the filibuster made the Senate dysfunctional.  If the PPACA is what results from a "functional" Senate, I will take dysfunctional.

Did Anyone See the Movie Interstate 60? Because This Story Reminds Me of That Movie

No, it's never going to win an award for art direction or acting, but one of my favorite movies is Interstate 60.  In part because almost no one has heard of it and it is fun to be part of the cult in a cult classic.  But at its heart it is really a pretty good movie on the various meanings of freedom -- or more accurately, on the varous ways in which people can enslave themselves.

The movie is essentially a series of vignettes -- short little stories -- connected by a guy on the road on a quest.  One of those involved Kurt Russell as the sheriff in a small town.  For those who saw the movie (and if you have not, go find it on Netflix), doesn't this remind you a lot of the Kurt Russell town Banton?

At nine o'clock in the morning in a garden shed behind a house in Amsterdam, a handful of alcoholics are getting ready to clean the surrounding streets, beer and cigarette in hand.

For a day's work, the men receive 10 euros (around $13), a half-packet of rolling tobacco and, most importantly, five cans of beer: two to start the day, two at lunch and one for after work.

Filibuster Rolled Back

Well, the Senate voted to effectively end the filibuster (or I presume to end the need for 60 votes for cloture) with respect to votes on Presidential nominations that require Senate approval.

As a libertarian, I am generally a big fan of the filibuster rules.  Anything that can slow the relentless march of more and more legislation is a good thing.

That said, I have always been uncomfortable with the filibuster rules as applied to basic Senatorial tasks, particularly the need to approve Presidential appointees.  I think that the Senate reasonably owes the President a timely vote on nominations, so I think from a good government standpoint, this makes sense.

And that being said, the problem is the incredibly extra-Constitutional powers that have been given to certain administrative functions.  I can't argue with filling judge positions in a timely manner, or getting a new Secretary of State hired, but some of the Administrative agencies have acquired to themselves such crazy, unchecked, arbitrary power that the only way to dial them back at all is to try to keep them unfilled.  The filibuster was really the last check available to the minority party on agencies run wild.

So I have mixed feelings.  The Republicans overplayed their hand on some nominations that probably don't matter much while Democrats have convinced themselves that they are never going to lose the White House again so this is one expansion of majority power that will never benefit the Republicans.

@kdrum Missing the Point. Doctors May Control the Cartel, but Government Gives it Power.

The other day, Kevin Drum wrote a post wondering why we had so few doctors per capital in the United States and observing, reasonably, that this might be one reason to explain why physician compensation rates were higher here than in other countries.

He and Matt Yglesisus argued that this smaller number of doctors and higher compensation rates were due to a physician-operated cartel.  This is a proposition I and most libertarians would agree with.  In fact I, and many others apparently, wrote to him saying yes there is a cartel, but ironically it owed its existence to government interventionism in the economy and health care.  In a true free market, such a cartel would only have value so long as it added value to consumers.

Drum seems to have missed the point.  In this post, he reacts to themany commenters who said that government power was at the heart of the cartel by saying no, it's not the government because doctors control the nuts and bolts decisions of the cartel.  Look!  Doctors are in all the key positions in the key organizations that control the cartel!

Well, no sh*t.  Of course they are.   Just as lawyers occupy all the key slots in the ABA.  But neither the ABA nor these doctors cartels would have nearly the power that they have if it were not for government laws that give them that power (e.g. giving the ABA and AMA monopoly power over licensing and school credentialing).  I had never heard of the RUC before, which apparently controls internship slots, but its ability to exercise this control seems pretty tied to the billions in government money of which it controls the distribution.

Let's get out of medicine for a second.  I am sure Best Buy wishes it had some mechanism to control new entrants into its business.  Theoretically (and it may have even done this) it could form the Association of Bricks and Mortar Electronics Retailers (ABMER).  It could even stake a position that it did not think consumers should shop at upstarts who are not ABMER members.  Take that Amazon!  Of course, without any particular value proposition to do so, consumers are likely to ignore the ABMER and go buy at anyway.

Such cartel schemes are tried all the time, and generally fail (the one exception I wonder about is the Visa/Mastercard consortium, but that is for another post).  Anyway, the only way the ABMER would really work is if some sort of government licensing law were passed that required anyone selling consumer electronics to be ABMER members.  And my guess is that the ABMER might not invite to join.  All of a sudden, Amazon is out of the electronics business.  Or maybe it just gets forced to deliver all its product through Best Buy stores, for a fee of course.

Crazy stupid, huh?  The government would never write licensing laws to protect a small group of incumbent retailers, right?  Well, tell that to Elon Musk.  Tesla has been trying for years to bring its cars to consumers in innovative ways, but have time and again run up against state auto dealership laws that effectively force all cars to be sold through the state dealer cartel.  Or you can talk to California wine growers, who have tried for years to sell directly to consumers in other states but get forced into selling through the state liquor wholesaler cartels.

All these cartels are controlled and manned by the industry, but they are enforced -- they are given their teeth -- by the government.

Here are a few off-the-top-of-my-head examples of cartel actions in the medical field admittedly initiated and supported and administered by doctors, that are enforced by state and federal law:

  • Certificate of need laws prevent hospitals from expanding or adding new equipment without government permission.  The boards in this process are usually stacked with the most powerful local hospitals, who use the law to prevent competition and keep prices high.  This is a great example where Drum could say that the decisions are essentially being made by hospitals.  Yes they are, but they only have the power to do so because the government that grants them this licensing power over competitive capacity.  Without this government backing, new hospitals would just laugh at them.
  • Government licensing laws let the AMA effectively write the criteria for licencing doctors, which are kept really stringent to keep the supply low.  Even if I wanted to only put in stitches all day to busted up kids, I would still have to go through 8 years of medical school and residency. Drum and Yglesias focus on the the number of medical schools and residencies.  I do not know if these are an issue or not.  But what clearly is an issue is the fact that one has to endure 8 expensive years or more just to be able to hand out birth control or stitch up a skinned knee.
  • Government licensing laws help doctors fight a constant rearguard action against nurse practitioners and other less expensively trained folks who could easily do half or more of what doctors do today.
  • The FDA and prescription drug law not only helps pharma companies keep profits up, but also increases business to doctors as people have to have a prescription for certain drugs they could easily buy on their own (e.g birth control pills, antibiotics).
  • The government limits immigration and thus labor mobility, reducing the ability of doctors from other countries to move here.

I am sure there are more.

There is no denying that in the middle of every industry cartel are insiders who are maneuvering to increase the rents of the incumbent players.  In fact, I am sure that every industry has participants who dream about getting off the competitive treadmill and creating a nice industry cartel, and would be the first to sign up.  But none of these dreams are ever going to happen unless they are enabled by the coercive power of government.

Of course, the consistent answer is, well, we just have the wrong guys running things.  If we had the right guys, it would work great.  But this kind of co-option always happens.   Look at taxis and liquor license holders and the entire banking sector.  Five years ago I would bet that progressives thought they finally had that right guy in the administration.  And look what has happened.  Banking cronyism is as strong as ever.  Obama's signature health legislation is full of crony giveaways.  In 6 months the health insurers are going to be running the entire PPACA infrastructure to their own benefit.

update:  This post is verging on the "is cronyism capitalism's fault" argument.  Rather than go into that again, it is here.

Update #2:  Related

Arkansas orthodontist Ben Burris was hauled in front of the state dental board in September after dentists in northeast Arkansas complained that he was offering dental cleanings to the general public in his Braces by Burris orthodontics clinics. The price for dental cleanings was $98 for an adult and $68 for a child, which Burris has said is about half of what dentists in northeast Arkansas typically charge.

Burris said most of the patients who need cleanings don’t have a dentist, but are checked by one of the three orthodontists in his clinic. Also, Burris said he offered the service because it was good for his business and good for the public. Some of his competitors “have gone absolutely ballistic” over the price and complained to the board, Burris said.

MP: Of course, the Arkansas dental cartel has no basis to complain directly about the low prices for dental cleaning at Braces by Burris clinics, so they are instead complaining that the clinic’s low-cost teeth cleaning services violate the states Dental Practice Act, which prohibits orthodontists and other specialists from practicing “outside their specialty.”

Note Who Gets Exempted From This Regulation

The Feds are going to require seat belts on buses:

Beginning in November 2016, all new motorcoaches and some other large buses must be equipped by manufacturers with three-point lap-shoulder belts, the National Highway Traffic Safety Administration said.

Ahh, but there is an exemption

The rule doesn’t apply to school buses or city transit buses.

What do these two exempted categories have in common:  They mostly belong to governments (public schools or public transit agencies).  So the government comes up with an expensive new regulation, but exempts itself from it, applying it to only private operators (who own a minority of buses in the country).


I am registered at a LOT of sites - blogs, hosting accounts, stores, message boards, etc.  A few years ago I started using the Lastpass Chrome add-in to track and remember all these passwords.

One problem though: like most people I was using the same few passwords over and over.  I had fixed, mostly, the most egregious mistakes, such as using the same password for low-trust sites like bulletin boards as for critical sites like banks.  But Lastpass showed me was that I still had a lot of password duplication.

The Adobe security breach finally got me off my butt.  My user name and password were among those that Adobe lost (which was particularly irritating because Adobe was one of those software companies that demanded a registration even when one should not have been necessary).  There was nothing at Adobe of mine they could screw up -- the registration was obviously to try to sell me more stuff but I never bought anything.  But there were possibly other sites using the same password they could screw up.

So I began a mission to change my passwords to 12-digit randomly generated strings of letters and numbers.  Having Fastpass helped a ton, as I would never have remembered all the sites with which I had registrations.  There were hundreds.

This was a real slog, a task so boring it was equaled only by the month when I ripped all my CD's to my hard drive and surpassed only by the 3 months when I ripped all my DVD's to hard drives.  The problem was that every web site was essentially a little portal-like adventure puzzle, trying to figure out where the hell the options for password change could be found.  I challenge those of you who have registered at to sign a survey to find the place to change your password.  At JetBlue, there is no such option in the user accounts -- you have to log off and click "forgot my password" at the logon screen and then click on the option to reset the password, but the reset email never shows up.  At two or three sites I had to email the site web manager to send me a link to the password change page.

Anyway, it's finally done now.  There are a couple of sites I use from my iPad for which I had to create unique memorable passwords because iOS does not have very good support mechanisms for such services as Lastpass, though as Chrome for iOS gets better, I expect that to make the problem easier to manage.  I had forgotten how many of these passwords (Netflix, Hulu, Amazon, etc.) were plugged into things like my Roku.  It was irritating with the crappy remote to enter these random strings of characters as new passwords.

Of course security of the Lastpass account becomes a problem.  I guess I have to trust them.  My password for them is unique and never has been used anywhere else and contains no real English words.  I use 2-step verification at all times to log into it, so hopefully I am moderately well-protected.

Confused About Argument by Anecdote

Politicians frequently argue by anecdote.  I don't generally find this compelling -- after all, one can find an anecdote about just about anything among 300 million people.

But for those who do believe that an anecdote proves their case -- doesn't a reversal of fortune within that anecdote then disprove their case?  How can a particular person's experience be entirely generalizable, and then suddenly not be so when the facts change?

Back in October, Sanford had written a letter to the White House to share her good news. The 48-year-old single mother of a teenage son diagnosed with ADHD had just purchased what she considered to be affordable insurance on the Washington state exchange....

Her heartfelt letter made it to the President's hands and then into his October 21 speech.

"'I was crying the other day when I signed up. So much stress lifted.'" Obama said, reading from Sanford's letter.

The president said Sanford's story was proof, despite the technical problems with the website, that the Affordable Care Act was working....

But then, after Obama mentioned her story, Sanford started having problems. Sanford said she received another letter informing her the Washington state health exchange had miscalculated her eligibility for a tax credit.

In other words, her monthly insurance bill had shot up from $198 a month (she had initially said $169 a month to the White House but she switched plans) to $280 a month for the same "gold" plan offered by the state exchange....

Last week, Sanford received another letter from the Washington state exchange, stating there had been another problem, a "system error" that resulted in some "applicants to qualify for higher than allowed health insurance premium tax credits."...

The result was a higher quote, which Sanford said was for $390 per month for a "silver" plan with a higher deductible. Still too expensive

A cheaper "bronze" plan, Sanford said, came in at $324 per month, but also with a high deductible - also not in her budget.

Then another letter from the state exchange with even worse news.

"Your household has been determined eligible for a Federal Tax Credit of $0.00 to help cover the cost of your monthly health insurance premium payments," the latest letter said.

Another Problem With Community Rating

Hospitals are required to treat everyone who shows up at the door, which results in a substantial amount of uncompensated care that hospitals must spread into their rate structure for other patients (and which also gives the lie to the syllogism that being uninsured means one does not have access to health care).

Supposedly, the PPACA was going to eliminate all these costs.  Actually, it does not eliminate these costs, it just changes who subsidizes them.  Currently, other hospital patients (and their insurers) subsidize this care.  In the PPACA medicaid expansion, some of this subsidy would shift to taxpayers  (whether the actual amount of costs subsidized would go up or down depends on your assumptions as to whether the Feds or the hospitals are better at managing them).

But hospitals think they might have found a third approach.  By law, insurance companies cannot legally turn down any applicants, particularly through the exchanges, based on their health condition.  So why not have the hospital (or its non-profit Foundation) buy policies for its perennially most expensive uncompensated patients?

US hospitals are exploring ways to buy “Obamacare” insurance plans for their sickest and poorest patients as they strain under the weight of tens of billions of dollars in uncompensated costs from the uninsured.

...The controversy is another reminder of the complexity of the US healthcare system, where hospitals are forced to pay about $40bn a year in so-called “uncompensated care”. People who are not insured go to emergency rooms because they cannot legally be turned away, and often hospitals bear the brunt of the costs.

“Hospitals are considering it,” says Mindy Hatton, general counsel of the American Hospital Association, the hospital lobby group. “Hospitals shouldn’t be on the front lines delivering preventive care that patients should be receiving in a clinic or doctor’s office. That doesn’t make sense for anyone.”

This is insurance companies' worst nightmare, of course.  It would not take very much of this sort of thing to trash the whole insurance market.

The Administration response to all this has been typical of its behavior through the whole PPACA implementation.  In general their approach to all new problems has been to:

  1. Make it clear that it hadn't really thought very deeply or completely about important implementation issues
  2. Make snap implementation decisions to tactically deal with one problem only to find they had created new problems
  3. When everything gets really messy, claim broad dictat-by-press-release powers it is not clear the law actually gives them

In this case, the Administration was faced with questions from Representative Jim McDermott.  He asked if exchange-sold health plans were considered Federal Qualified Health Plans (QHP) under the law.  If so, he pointed out that several of the things the Administration had discussed (e.g. allowing insurers to offer monetary inducements to customers who maintained good health habits) could be illegal under anti-kickback provisions.

As usual, it was pretty clear the Administration had no answer.  Or more accurately, had five different answers from five different people and agencies.  Kathleen Sebelius wrote back to McDermott that no, exchange sold plans were not QHP's and so the anti-kickback law did not apply.  This tactically solved McDermott's issue.  But it created large new issues, since it is the anti-kickback law that would have prevented hospitals from buying exchange plans for their most expensive patients.  If exchange plans are not QHP's, then hospitals considered that buying such plans was now legal.

All Sebelius has been able to do to temporarily quiet this mess has been to claim vague and unlimited powers to regulate virtually any behavior related to the exchanges.  Like Obama, she believes her press releases have force of law.  But in fact, even if she does have the claimed regulatory power, she actually has to go through a rules-writing process before any such rules can take effect.   These are structured, drawn out affairs with long delays for public comment.  This is the type of thing she needed to be doing 18 months ago.

The One Thing Politicians Do Really Well... get elected.  That's it.  It's the only thing they have to do well, really, to have their jobs.  Name one other thing President Obama is good at?

Here are Obama's polling numbers over the last couple of years (approve is black, disapprove is red).  Note the fair to middling muddled approval rating for most of the period.  The numbers never crack 50 ... EXCEPT for the days leading up to the last Presidential election, and then he managed put in place a full court press to get his popularity up just high enough and just long enough to get elected.


Moore's Law on Steroids: World Computing Power for One Type of Calculation is Doubling Every Three Weeks

Over at Forbes, I wrote this week about Bitcoin mining.  But don't be immediately put off.  This is not yet another article by a crazed libertarian and Cryptonomicon fan on the miracle effects of digital currencies.  Instead, I look at the crazy economics and absurdly steep capacity and technology curves of Bitcoin mining.  An excerpt:

Let’t take an example, and consider the Cointerra TerraMiner IV, a 2TH/sec machine priced at about $6000 which if purchased today would be delivered sometime in February, or about 3 months from now.  At current difficulties and exchange rates, such a machine would pay back its purchase price in less than a week, producing over $25,000 a month in Bitcoins.

A no-brainer, right?  But Bitcoin mining difficulty has been going up of late by a factor of 10 every 3 months.  Based on a mining difficulty ten times greater than today and current exchange rates, we could expect instead to be making at delivery something more like $575 a week.   Three months later we would be making a tenth of that.  If we factor in the costs of electricity, this machine will never cover its costs at current Bitcoin exchange rates.

I do not think I have ever seen a business technology obsoleted so quickly.  Essentially, the next generation of mining processors will be virtually obsoleted between the time of its sale and its delivery 3 months later.  Every three months one has to reduce his production costs by a factor of 10, in a business where cost reduction basically means throwing out all one’s existing capital assets and buying expensive new stuff.

LOL, Going to See a Lot of These

Got this from some Republican group (the "virtue" of being a libertarian is that I get bipartisan spam).

Tim Bishop = ObamaCare 

Bishop Has Been a Co-Conspirator in the Disaster That is ObamaCare; It’s Time for Him to Apologize For This Colossal and Expensive Mistake 

WASHINGTON – Today, in a rambling press conference, President Obama admitted he “fumbled” the ObamaCare rollout. And the president even warned of more problems to come.

Tim Bishop has been a vocal ObamaCare supporter from the beginning—voting for the bill in 2010 and giving the president a blank check on ObamaCare time and time again. Now that the law is becoming more of a disaster every day, Bishop needs to answer for the higher premiums and canceled plans facing families in his district.

Didn't even know who this dude was until I checked (US Representative from NY, apparently).  I expect to see a lot of this.  At least for now.  Things can change quickly.  After all, just 30 days ago the Republicans were supposedly on the ropes from self-inflicted wounds vis a vis the shutdown.  Now, no one even remembers it.

WOW! Incredible Contradiction in October Exchange "Enrollment" Report

I have not seen anyone notice this yet, but perhaps it is just because I have obsessed over the pathetically bad Commonwealth Fund survey whose findings were demolished by the numbers in the October report (here and here).  Well, it turns out, the October report actually proudly highlights the Commonwealth Funds report,  and quotes this line from the Commonwealth Fund in Appendix D:

Of those who have visited the Marketplace, 21 percent enrolled in a plan.

WTF are you doing including this survey finding in a report that essentially makes a laughing stock of this very finding?  Let's review what numbers we have in the October report:

  • From our chart here, the people covered by a "clicked" plan (sorry, but that is their circumlocution, not mine) were 106,185  (note this is generous because it is not actual enrollments, which will be less)
  • From the same chart, the people who were found eligible for Medicaid were 396, 261 (note this is generous as this is not actual enrollments, which will be less).
  • Finally, from the same source are total web visitors times 1.78  family members per visitor (to make our ratio apples to apples) of 47,840,217.  See here for further explanation of why this calculation is necessary

This gives us a percentage of web visitors of 1% that managed to do something kindof sortof close to enrollment.

This demonstrates just how insane the 21% figure is from the deeply flawed Commonwealth study.  So why in the hell is the Obama Administration quoting it as authoritative in their report?  Do they think anyone is dumb enough to use the 21% figure instead of the 1% figure?  Is this just providing ammunition to political hacks who want to spin the story in Obama's favor?  Did the Administration or possibly OFA actually pay for that study?

The only effect including that 21% number has on me is to say that Obama likely has a bigger problem -- If 21% of visitors THINK they enrolled and less than 1% actually did so, aren't a lot of people in for a rude shock?