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Thursday, July 20, 2017

The Presidential Oaf of Office

     Article II, Section 1:
...Before he enter on the execution of his office, he shall take the following oath or affirmation:--"I do solemnly swear (or affirm) that I will faithfully execute the office of President of the United States, and will to the best of my ability, preserve, protect and defend the Constitution of the United States."
     Article II, Section 3:
...he shall take care that the laws be faithfully executed...
 My thoughts on Facebook earlier today:
When you become U.S. President, you swear/affirm the Oath set forth in Article II, Section 1 of the Constitution to "faithfully execute the Office of the President" and to "preserve, protect, and defend the Constitution." What you are bound to "execute" is also set forth in Section 3: "he shall take care that the laws be faithfully executed." 

Today I read two articles detailing Trump's explicit statements and his administration's overt actions aimed at deliberately sabotaging the LAW that is still "Obamacare" (whatever your opinion of it) to help make sure it "fails," irrespective of how many citizens get hurt in the process.
"Team Trump Used Obamacare Money to Run PR Effort Against It"
"Trump’s Clueless Abdication of Presidential Responsibility"

To me, that should be impreachable right there -- willful contravention of his Oath of Office, with regard to a law directly and substantively impacting nearly 20% of the U.S. economy and nearly every life in the nation. This is not about dissing or subverting some tiny Capitol Park Police Dog Leash law.
Yeah, I know..."wish in one hand..." "tu quoque" (they all do it).


President Trump just gave the New York Times a bizarre, on-the-record, audio-recorded interview (the one during which he threw his Attorney General under the bus, insulted the FBI, and threatened Special Prosecutor Mueller). From the health care segment of the 7,500 word transcript:
TRUMP: Hi fellas, how you doing?
BAKER: Good. Good. How was your lunch [with Republican senators]?
TRUMP: It was good. We are very close. It’s a tough — you know, health care. Look, Hillary Clinton worked eight years in the White House with her husband as president and having majorities and couldn’t get it done. Smart people, tough people — couldn’t get it done. Obama worked so hard. They had 60 in the Senate. They had big majorities and had the White House. I mean, ended up giving away the state of Nebraska. They owned the state of Nebraska. Right. Gave it away. Their best senator did one of the greatest deals in the history of politics. What happened to him?
But I think we are going to do O.K. I think we are going to see. I mean, one of my ideas was repeal. But I certainly rather would get repeal and replace, because the next last thing I want to do is start working tomorrow morning on replace. And it is time. It is tough. It’s a very narrow path, winding this way. You think you have it, and then you lose four on the other side because you gave. It is a brutal process. And it was for Democrats, in all fairness. I mean, you think of Hillary Clinton, and you look, she went eight years — very capable — went eight years as the first lady, and could not get health care. So this is not an easy crack. The one thing I’ll say about myself, so, Obama was in there for eight years and got Obamacare. Hillary Clinton was in there eight years and they never got Hillarycare, whatever they called it at the time. I am not in here six months, and they’ll say, “Trump hasn’t fulfilled his agenda.” I say to myself, wait a minute, I’m only here a very short period of time compared to Obama. How long did it take to get Obamacare?

BAKER: March, March 2010.
TRUMP: So he was there for more than a year.
HABERMAN: Fourteen months.
TRUMP: And I’m here less than six months, so, ah, you know. Something to think about.
BAKER: We wrote the same stories, though, in August of 2009. “Obama can’t get it.”
SCHMIDT: It died several times.
HABERMAN: Several times.
TRUMP: Well, it was a tough one. That was a very tough one.
BAKER: He lost that election [the 2010 midterms].
TRUMP: Nothing changes. Nothing changes. Once you get something for pre-existing conditions, etc., etc. Once you get something, it’s awfully tough to take it away.
HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.
TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.
HABERMAN: Am I wrong in thinking — I’ve talked to you a bunch of times about this over the last couple years, but you are generally of the view that people should have health care, right? I mean, I think that you come at it from the view of …
TRUMP: Yes, yes. [garbled]
TRUMP: So I told them today, I don’t want to do that. I want to either get it done or not get it done. If we don’t get it done, we are going to watch Obamacare go down the tubes, and we’ll blame the Democrats. And at some point, they are going to come and say, “You’ve got to help us.”

BAKER: Did the senators want to try again?
TRUMP: I think so. We had a great meeting. Was I late?
TRUMP: It was a great meeting. We had 51 show up, other than John.
BAKER: Senator McCain.
TRUMP: That’s a lot. Normally when they call for a meeting, you have like 20.
HABERMAN: How about the last one in June? Do you guys remember how many came?
TRUMP: Ah, 49. It was actually 48, but John McCain was there. But I guess we had 51 today, so that counts. That shows the spirit.
BAKER: Who is the key guy?
TRUMP: Well, they are all key. The problem is we have 52 votes. Don’t forget, you look at Obama, he had 60. That’s a big difference. So, we have 52 votes. Now, I guess we lose Susan Collins. I guess we lose Rand Paul. Then we can’t lose any votes. That is a very tough standard. Statistically, you want to bet on that all day long. With that being said, I think we had a great meeting. I think we had a great meeting.
HABERMAN: Where does it go from here, do you think?
TRUMP: Well, I say, let’s not vote on repeal. Let’s just vote on this. So first, they vote on the vote. And that happens sometime Friday?
HABERMAN: Next week.
TRUMP: Or Monday? Monday. And then they’ll vote on this, and we’ll see. We have some meetings scheduled today. I think we have six people who are really sort of O.K. They are all good people. We don’t have bad people. I know the bad people. Believe me, do I know bad people.
And we have a very good group of people, and I think they want to get there. So we’ll see what happens. But it’s tough.

SCHMIDT: How’s [Mitch] McConnell to work with?
TRUMP: I like him. I mean, he’s good. He’s good. It’s been a tough process for him.
HABERMAN: He’s taken on some water.
TRUMP: Yeah. It’s been a tough process for him. This health care is a tough deal. I said it from the beginning. No. 1, you know, a lot of the papers were saying — actually, these guys couldn’t believe it, how much I know about it. I know a lot about health care. [garbled] This is a very tough time for him, in a sense, because of the importance. And I believe we get there.
This is a very tough time for them, in a sense, because of the importance. And I believe that it’s [garbled], that makes it a lot easier. It’s a mess. One of the things you get out of this, you get major tax cuts, and reform. And if you add what the people are going to save in the middle income brackets, if you add that to what they’re saving with health care, this is like a windfall for the country, for the people. So, I don’t know, I thought it was a great meeting. I bet the number’s — I bet the real number’s four. But let’s say six or eight. And everyone’s [garbled], so statistically, that’s a little dangerous, right?

BAKER: Pretty tight.
TRUMP: I hope we don’t have any grandstanders. I don’t think we do.
TRUMP: I think it will be pretty bad for them if they did. I don’t think we have any — I think it would be very bad for — I think this is something the people want. They’ve been promised it...
Okeee-dokeee, then. Mr. Dunning-Kruger.
A new interview reveals Trump’s ignorance to be surprisingly wide-ranging
He doesn’t know what he doesn’t know.

Nobody knows everything, and certainly nobody who’s ever sat in the Oval Office has entered with a complete mastery of all the varied issues that land on the desk of the president of the United States.

But reading the transcript of Donald Trump’s recent interview with three New York Times reporters, two things stand out. One is the sheer range of subjects that Trump does not understand correctly — from French urban planning to health insurance to Russian military history to where Baltimore is to domestic policy in the 1990s to his own regulatory initiatives. The other is that Trump is determined, across the board, to simply bluff and bluster through rather than admitting to any uncertainty or gaps in his knowledge.

It’s an approach that’s certainly commonplace among Trump’s cohort of rich Manhattanites. People who’ve spent years surrounded by flatterers and lackeys eager to get their hands on their money tend to come away with an inflated sense of their own domains of competence. But precisely because the demands of the presidency are so unimaginably vast, it’s a frightening attribute in a chief executive.

The complete interview is a little bit hard to parse, since Trump keeps ducking off the record and the transcript interrupts. But it really is worth taking in the whole thing — the scope is breathtaking.

Trump doesn’t seem to know what health insurance is
Health care policy is very complicated, but most Americans have at least some passing familiarity with how health insurance works because most of us have health insurance.
Trump himself, meanwhile, has spent years as a top executive at a business that provides health insurance to its employees. So you would think that even if he were completely ignorant of every single topic of public policy, he would at least be aware that to provide a person with health insurance is expensive. It is, after all, an expense that his businesses incur…
Noted in my prior post,
"You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy." - Donald Trump, Oct 2016 Florida campaign rally.

The most powerful man on earth.

From my November 9th, 2016 post, What will the 45th President do about health care?

"We have to come up, and we can come up with many different plans. In fact, plans you don't even know about will be devised because we're going to come up with plans, -- health care plans -- that will be so good. And so much less expensive both for the country and for the people. And so much better.” 

- Donald Trump, September 14th, 2016 on the Dr. Oz show


From The New Yorker:

John Cassidy
Donald Trump’s Addled and Ominous Interview with the Times 

It is often said, and with ample reason, that much of what Donald Trump says isn’t worth a jot. As Tony Schwartz, Trump’s ghostwriter, noted last year, “lying is second nature to him.” When he isn’t telling outright whoppers, he exaggerates things outrageously, and his utterances often bear little resemblance from one day to the next. On Tuesday, he said that Republicans should let Obamacare crash and burn. On Wednesday, he said that he wanted to see it replaced.

But, whereas Trump’s statements often fail to withstand inspection when examined individually, analyzing a group of them together can sometimes provide valuable insights into his mind-set, which, at this time, appears to be even more addled than usual. The interview that Trump gave on Wednesday to three reporters from the Times offers us that opportunity...
I don't find any of this the slightest bit amusing, given the significant major policy issues our nation needs to be forthrightly addressing. Like, duh, health care?


Again, from The New Yorker, excellent, this from Amy Davidson Sorkin, spot-on:
...The Republican leadership’s argument of last resort, when whipping votes, has been that the Party has to do something dramatic about Obamacare simply because, for the past seven years, it has said that it would. That is an explanation of a quagmire, not a call to arms...

...McConnell has said that he will delay the Senate’s August recess, if necessary, to try for another vote on something: repeal, replace, or a thrown-together bill to be named later; his zigzagging mirrors that of the President. If this attempt fails, the backup plan seems to be to turn the matter over to the executive branch and let it commit whatever acts of regulatory, budgetary, and administrative vandalism it can, to break the system bit by bit. For example, it could withhold crucial cost-sharing subsidies, or decline to defend Obamacare against various lawsuits that its opponents, including the House Republicans, have brought against it...
Yep. Jus' sayin'. Taking care "that the laws be faithfully executed" -- what a quaint notion.

More to come...OafTrumpcare

Tuesday, July 18, 2017

Senate GOP ObamaCare Repeal bill goes "poof"

a.k.a. "Trumpcare," though The Donald is "not going to take ownership."

John Irvine at THCB:

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation.  As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising…

So much for Article II, Section I of the Constitution and owning the faithful execution of the  laws. The ACA remains the law.

"You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy." - Donald Trump, Oct 2016 Florida campaign rally.
See my old post (2009) "Public Optional."


Dr. Adrian Gropper posted an interesting comment at THCB under the foregoing post:
The substantive changes that are about to happen in US healthcare will be driven by technology (artificial intelligence, telemedicine, blockchain identity, longitudinal health records), not politics.

Our institutions have little choice but to pretend they are still in control of their traditional roles. Congress may be the most obvious example today, but insurers, employers, and hospitals are also lost in the ether. None of these institutions is pitching a solution.

To stabilize healthcare in the face of massive technological change start with the tech, not the incumbents.
Well, one hopes, anyway. I guess we'll see.

Interesting observations from Bob Cesca -
At some point, congressional Republicans will entirely abandon President Donald Trump. How do we know this? If you look closely, you’ll notice that it’s already happening. One by one, Republicans on the Hill are growing tired of Trump’s poorly-informed, lazy, self-centered lack of leadership, and it’s a safe bet that more than a few members are wondering whether the 2018 midterms will turn out better without Trump dragging them down.

Whether this precipitates a Barry Goldwater Watergate moment in which Republican leadership hikes down the block to insist upon Trump’s resignation remains to be seen, but what’s immediately observable is that the Trump coalition is rapidly vaporizing, leaving the chief executive with fewer and fewer influential defenders in Congress. The rapid, awkward demise of Trumpcare and the president’s confounding reaction in the aftermath might’ve been the last straw in an already ungainly relationship between both ends of Pennsylvania Avenue.

Frankly, if I were Senate Majority Leader Mitch McConnell or Speaker Paul Ryan, I’d strongly consider cutting bait with Trump given the way he has repeatedly set them up to fail while doing little to exercise any kind of meager leadership. Without a substantive ally in the White House, it becomes less likely they’ll continue to tolerate and backstop his uneducated, rookie gibberish and social media outbursts, embarrassing the party and tainting it with the stink of his failed administration. How much longer will they continue to tolerate Trump playing honk-honk-goes-the-truck and tweeting on the john while they spend valuable political capital on legislation he barely understands and, despite his marketing acumen, has repeatedly fumbled?

The failure of Trumpcare was partly about the president’s lack of even a basic, entry-level sense of how a bill becomes a law. It was also partly about Trump’s running-on-fumes political capital. The whole concept of repealing and replacing Obamacare with the snap of his short fingers merely set up Trump and Congress to fail. Not only is it nearly impossible for conservatives to create a affordable, universal health care program, but it was never going to get done within a few short months, much less “on day one.” Since Congress was unable to match a lofty goal established by a political amateur, Trump set them up to fail…

I just wanna sing...

I wrote and recorded that five years ago after SCOTUS upheld the Constitutionality of the ACA.

Links to some relevant prior KHIT posts:
House Calls, STAT!
Paying for Health Care
An American Sickness
Rationing by 'Price.'
There are more. That's enough for now. And, oh, yeah, review "Making the world a better place."


"Nice little Senate seat ya got there. Be a shame if something bad happened to it."


What a difference four years makes, 'eh? 


GOP Arizona Senator John McCain has been diagnosed with a glioblastoma brain tumor. Hate to hear that. Blogged about those here.

More to come...OafTrumpcare

Saturday, July 15, 2017

"Making the world a better place?"

First, from my fav, the insanely over-the-top, (painfully and scatalogically) hilarious Silicon Valley HBO.

After watching that entire 4-season series (many episodes numerous times), I still now have doubts I can continue to cover Health IT sector events with a straight face.

I saw a WaPo article this week comprising an interview with 32 yr old prominent Bay Area techie Sam Altman (President of Y Combinator).
Why this Silicon Valley magnate is funding a new wave of political candidates

Still reeling from Donald Trump’s election, a prominent technologist is taking a page from powerful donors the Koch brothers, who remade state politics by recruiting and funding a new generation of GOP candidates.

Sam Altman, president of the Silicon Valley start-up incubator Y Combinator, announced Wednesday that he would spend from his personal fortune to enlist candidates who want to run for statewide office in California on a platform of “technology, economic fairness, and maintaining personal liberty.” The next races will be in 2018.

Altman, whose fund has helped launch companies such as Dropbox and Airbnb, is part of a wave of tech elites who are now looking to extend their influence beyond Silicon Valley into the wider political spectrum. Many of Altman’s contemporaries, including Mark Zuckerberg, saw Trump’s victory as a wake-up call, pushing them further into politics. Zuckerberg and Altman have gone on listening tours this year with the goal of hearing from Trump voters and people outside the Silicon Valley bubble…

A tech dude with both a brain and a heart. "Still reeling from Donald Trump's election..." Me too, bro'.

Promptly went to his site "The United Slate."
I want to find and support a slate of candidates for the 2018 California elections. I think the current political process is not surfacing the best possible candidates, and our government is suffering for it. I want to help candidates who believe in creating prosperity through technology, economic fairness, and maintaining personal liberty.

Today, we have massive wealth inequality, little economic growth, a system that works for people born lucky, and a cost of living that is spiraling out of control. Most young people think their lives will be worse than their parents’ lives, which should set off alarm bells for us all.

Most people’s lives are not what they pictured—they feel like they have great potential that is being wasted.

We are in the middle of a massive technological shift—the automation revolution will be as big as the agricultural revolution or the industrial revolution. We need to figure out a new social contract, and to ensure that everyone benefits from the coming changes.

We need to get back to a functioning government. If the process can work again, we have a chance to solve our biggest problems.

Our government is in the way of this vision—it rigs the system in favor of a small number of special interests and campaign donors at the cost of everyone else. In the process, our government has gotten us into an unsustainable financial bubble and has given up on fiscal responsibility itself. California is on a trajectory to go bankrupt.

We can have a better world—we can have affordable housing, free health care, a great education system, economic security, and a healthy planet. We can also have opportunity, fulfilling work, and a voice in the future for everyone. It won’t be easy, but it’s also not impossible—we need new candidates who understand the future.

I think California is the right place to start this—we’re the 6th largest economy in the world, and we have a long history of leading this country. We can lead the way here…

I am a product of our time—I got a computer when I was eight years old, and technology has been my obsession and career ever since. I understand its potential for both good and bad. I am simultaneously nervous and excited about the world we are creating, and I’d like to live in the best version we can build…

My heart is on the left, but I’m a pragmatist. I want to use technology to generate a lot of prosperity, and use some of it to pay for programs to make life better for everyone. There is a massive technological shift coming to society, and we can either benefit from it or be hurt by it.

I was one of the last children of the American Century. I’m not quite ready to let it go. If we don’t take action now, the US will be surpassed as the world superpower. I’d like to get back to the values that made our country the envy of the world. I still believe in American exceptionalism, and even with Trump in the White House, my proudest identity of all is being American…

Three Principles

These are three principles I strongly believe in.

  1. Prosperity from technology
  2. Economic fairness
  3. Personal liberty
1. Prosperity from technology

Creating prosperity is how everyone’s lives get better every year.

Most real economic growth comes from technological progress. The US government has turned its back on this basic law of economics, and no longer provides funding for our best and brightest to build a better future. Instead, we’ve built an increasingly financialized economy, and steal from our future with debt. We are getting beaten by other countries.

Obviously, technology cannot solve everything, and getting policy right is more important than just getting the technology right…

2. Economic fairness

The economic growth we generate must be shared by all Americans. We can’t stand for a society in which all of the gains (or more recently, more than all of the gains—life has gotten worse for a lot of people) from progress accrue to a small number of individuals.

I’ve benefited from our current system in a way that would have been nearly impossible for a poor person born just a few miles from where I grew up, where it feels like a different country. The two most important gifts I got in life were the love of my parents and a great education—a great education should be a right for every child.

I believe that economic justice is social justice, and that we will not have true justice until all Americans, regardless of their background or how they look, have equal economic opportunity…

3. Personal liberty

Freedom is the bedrock of America. We must preserve and defend the freedom to choose who we are, what we want to be, what we do with our bodies, how we want to express ourselves, and maintain our privacy in the face of technology. The authoritarian streak currently running through the country is deeply troubling to me.

These are my 3 core principles, but a lot of people probably agree with them. Here are 10 more specific policy proposals I’d like to see candidates enact.

Ten Policy Goals

Here are 10 policy goals I’d like to see candidates work towards enacting.

  1. Lower the cost of living, especially housing
  2. Move to a Medicare-for-all system over time by gradually reducing the age of eligibility
  3. Set a target of 90% clean energy in the country by 2050
  4. World-class education
  5. We need to reform our tax system
  6. Shift 10% of our $600 billion annual defense budget to the research and development of future technologies
  7. Fair trade and fair jobs
  8. Expand the social safety net
  9. A fair government
  10. World-class infrastructure
"Move to a Medicare-for-all system." See down in my prior post.

I signed up to contribute however I can. We shall see. There's no time to waste. In Valley VC-speak, we have a "short runway."

Go to Sam's United Slate site, read all of it. Consider participating.
I forwarded it on to my wife. Told her she should consider running. "Right. In my spare time." "But, baby, 'Women Leaders' and all that.You are a Leader." (She most certainly is.)
Doubt that I'm gonna get any traction there. We got a continuing, indeterminate full plate anyway these days.
Also recommend you read the book "Four Futures."

I've cited it on this blog before. See, e.g., "What might Artificial Intelligence bring to humanity."

My concern regarding our sociopolitical trajectory toward a "Quadrant IV" remains.

The nice thing I see in Sam's idea is that he doesn't conflate "personal liberty" with the sophomoric (albeit broadly tech-cohort fashionable) "Libertarianism" -- the latter of which gets you dystopian, untenable stuff like Uber.

As I reflect on Sam Altman's foregoing humane, reasoned "United Slate" proffer, I am reminded of Facebook CEO Mark Zuckerberg's (HR Dept cringeworthy) assertion that "young people are just smarter." Regarding the tech elites among them, I can't disagree -- as to the "intellectual" aspect, anyway. Whether their aggregate relative distribution of prosocial "moral intelligence" is better than that of us "elders," well, I don't know at this point. In any event, this younger demographic is going to have to live a lot longer with the consequences of our sociopolitical shortcomings than people like me. So, it's entirely appropriate that they take a good whack at politics and leadership.


Interesting Salon article:
A vote for moral technology: Updating Reinhold Niebuhr to the age of Donald Trump
The great theologian's understanding of irony and hubris can help us figure out what happened, and where we go next

It’s the incongruities that perplex and provoke so many of us. The ideal versus the real. It’s hard to look at the imposing U.S. Capitol, all that strong, gleaming marble, and realize at the same time how the nation’s elected representatives have failed at their primary job: improving the lives of those who elected them. We have learned that “those who elected them” doesn’t even mean what the Constitution intended. Disgusting negative ads elected them. Money elected them. A minority of the eligible population voted – inertia reelected them. Politicians are professional fundraisers who principally target “swing voters.” This is who we are now.

Our idealized democracy is obviously not even close to a perfect system for obtaining the wisest deliberator as president. The inordinately long, obscenely costly campaign process, imitating nothing so much as a repetitive TV miniseries, is, effectively, a register of party loyalty, not a measure of the viability of one or another policy direction. With all the talent that exists in the United States – the scientists, engineers, artists, givers, problem-solvers – look what we have now: an inarticulate man of limited imagination, who worships himself and appears to care about nothing and no one else, and least of all the truth. He convinced 63 million people to vote for him.

We – the millions of us who voted a different way – feel corrupted by his undeserved presence in our lives, his repetitive bad behavior, his pettiness, his petulance, his arrogance. Our values have been betrayed, and we are all somehow, in some way, complicit. We didn’t do enough to help voters see through him. We allowed democracy to become a business in the hands of public relations firms, pollsters, financiers and advertisers. And tweets. Sad!...
Well, resonates with Sam's United Slate vision, no?

All of which resonates with George Lakoff's "Don't Think of an Elephant."

From the Amazon blurb:
Ten years after writing the definitive, international bestselling book on political debate and messaging, George Lakoff returns with new strategies about how to frame today’s essential issues.

Called the “father of framing” by The New York Times, Lakoff explains how framing is about ideas—ideas that come before policy, ideas that make sense of facts, ideas that are proactive not reactive, positive not negative, ideas that need to be communicated out loud every day in public.

The ALL NEW Don’t Think of an Elephant! picks up where the original book left off—delving deeper into how framing works, how framing has evolved in the past decade, how to speak to people who harbor elements of both progressive and conservative worldviews, how to counter propaganda and slogans, and more.

In this updated and expanded edition, Lakoff, urges progressives to go beyond the typical laundry list of facts, policies, and programs and present a clear moral vision to the country—one that is traditionally American and can become a guidepost for developing compassionate, effective policy that upholds citizens’ well-being and freedom.
Sam, you can count me in. Who's with me? Time's a wastin'. "Short runway."


How about a bit of music? One of my Swedish friends hipped me to this cat, Henrik Hansson (Swede by birth, lives in Japan). Listen to the lyrics.

Got no time for second-guessing,
Got no time for lookin’ back,
Don’t need anybody’s blessing,
Ain’t like all those fools
Playin’ by the rules.

When the night is over
He won’t realize
Who is real and who is in disguise.
He just plays along,
Don't know right from wrong...
'eh? Anyone come to mind via the lyrics?

More to come...

Friday, July 14, 2017

Okeee-Dokeee, then...

One simply has to give thanks that we have such a calm, civil, rational, seasoned, detail-oriented, eloquently articulate leader at the helm of the ship of state during these stormy times.

Wednesday, July 12, 2017

Webinar on Natural Language Processing in health care

On my calendar today. Saw this on Facebook and signed up.

Company link

Over the past ten years, we have seen a wave of EMR implementations and quality reporting initiatives which have sought out those discrete, reportable data elements which can be used for clinical analytics. However, many more crucial pieces of information that we would like to use for analytics are trapped in radiology reports, clinician notes and other free text fields. A few examples illustrate the point. Ejection fraction data for heart failure patients is embedded in diagnostic test reports and physician notes. A cancer diagnosis resides in the problem list, but the stage and tumor size is often found only in the pathology report. Even in quality reporting used by payers, dozens of data elements are only found in notes. As a result, most health systems employ clinical chart abstractors and nurses to manually hunt through this free text content for critical pieces of information required for reporting on clinical performance.

Today, advancements in technology have made it possible to develop accurate, faster, more scalable alternatives to a manual chart extraction process, and in this webinar, we will review the core capabilities of the software that is used to search text along with the key natural language processing (NLP) techniques that allow teams to effectively analyze the free text found in clinical systems.
Interesting. I recently finished a full cardiology workup comprised of EKG's, a treadmill stress test, and a lengthy cardiac ultrasound px. The diagnostic meat of the ultrasound in particular was all contained in the lengthy text narrative "impression" write-up.

See my prior riffs on NLP here and here.

I've now completed a good bit of background study spanning some of these topics -- AI-related stuff involving Machine Learning, Deep Learning, Natural Language Generation (NLG), Natural Language Understanding (NLU, the far more difficult area), Linguistics generally, and Computational Linguistics specifically.

Based on my readings thus far, my answer to the question "might NLP/AI applications be used to accurately analytically parse the logic in textual arguments?" is "rather unlikely at this point, at least with respect to arguments of significant heft and complexity" (see, e.g., my 1994 "Single Payer proposal" deconstruction). Perhaps some braniac scholar in Computional Linguistics could take it on as a doctoral investigation, but I think the difficulties are too daunting for any relatively quick commercial turnaround of the concept -- given that market interest in such an application might be rather narrow. Moreover, I envision the type of random inaccuracies that dogged the earlier releases of Google Translate.

I could be wrong.

BTW: Some useful contextual background going to "textual analysis NLP in Health IT" is in my prior post "Are structured data the enemy of health care quality?"

Time well-spent (only an hour, including Q&A), though I did have a bit of an "old wine in new bottles" reaction (with a dash of "Gartner Hype Cycle"). Teasing out quantitative (or mixed "semi-quantitative") "data" from unstructured chart narratives/documents is not exactly a new idea, as I've noted before (e.g., it was a topic in the 2005-2008 DOQ-IT Meaningful Use precursor era) -- notwithstanding that the search engines/query tools (as we ought expect) are getting much better. The presenters noted that this emerging "text analytics/NLP" methodology still requires multidisciplinary SME (Subject Matter Expertise) -- e.g., clinicians, informaticists, and "data architects." We're not at the point of just hitting 'Enter' and let the AI do everything for us all the way to dx and/or prognosis derivation or aggregate reportage. This type of process remains more heuristic than algorithmic. Adroit (iterative and recursive) Boolean searching is at once science and art, not yet fully AI mechanistic. Among my takeaways was that they were describing a "computer-assisted, episodically SME human intermediated process." All well and good, but a bit of a stretch to fully call it "AI NLP."
One favorable reality, though, is that "text" is pretty much just text (e.g., mostly ASCII collating std). Consequently, some of the barriers that dog "interoperability" (the "interoperababble" of my "metadata heterogeneity" snark) are of lesser concern. The other favorable thing is the relative narrow range of formatting of clinical "narrative" discourse relative to that of general language communication.
Notably, among deployable clinical experts, they alluded to the utility of "nurse abstractors" for the "data validation" phase. I found that interesting. Back during my first Medicare QIO tenure (1993-1995, called "PROs" back then), we routinely sent teams of laptop-lugging nurse abstracters out to hospitals to collect clinical data for drill-down projects indicated by our UB-82 Claims Forms data analytics (pdf).
Nice downloadable 24-slide deck available to today's webinar registrants. Marked "© 2017 Private and Confidential" on every slide, so I'll refrain from showing anything here.
One slide I will show,

Click to enlarge. I'd love to go to that. Back during the DOQ-IT era, we'd go to the "TEPR" Conference in SLC every year ("Toward an Electronic Patient Record").

Also perhaps of topical relevance (albeit sometimes a bit tangential?), from a current read of mine, going to the salient elements of accurate medical diagnostics:

For all of the sophisticated diagnostic tools of modern medicine, the conversation between doctor and patient remains the primary diagnostic tool. Even in the fields that are visually based, such as dermatology, or procedurally based, such as surgery, the patient’s verbal description of the problem and the doctor’s questions about it are critical to an accurate diagnosis.

In some ways this seems almost anachronistic, given how advanced so much of our technology is now. Science-fiction movies predicted that medical diagnosis would be achieved by running a handheld machine over the patient’s body. And indeed much diagnosis is made with MRIs, PET scans, and advanced CT technology. Yet the simple verbal exchange between patient and doctor remains the cornerstone of medical diagnosis. The story the patient tells the doctor constitutes the primary data that guide diagnosis, clinical decision-making, and treatment.

However, the story the patient tells and the story the doctor hears are often not the same thing. The story Mr. Amadou was telling me and the story I was hearing were not identical. There were so many layers of emotion, frustration, logistics, and desperation, that it was almost as if we were in two different conversations entirely.

It is a common complaint of patients. They feel their doctors don’t really listen, don’t hear what they are trying to say. Many patients leave their medical encounters disappointed and frustrated. But beyond being merely dissatisfied, many patients leave misdiagnosed or improperly treated.

Doctors are equally frustrated with the difficulties of piecing together a patient’s story, especially for those with complex and inscrutable symptoms. As medicine grows more complicated, with illnesses more multifold and complex, the gap between what patients say and what doctors hear—and vice versa—grows more significant...

Ofri, Danielle. What Patients Say, What Doctors Hear (Kindle Locations 98-112). Beacon Press. Kindle Edition.]

We typically think of communication as the words exchanged when doctors and patients are seated across from one another at a desk during the “history” part of the visit. True, this is the bulk of communication and certainly the bulk of what communications researchers focus on, but over the years I’ve come to appreciate that a good deal of communication and connection arises during the physical exam. When I mention this observation, many people—both doctors and patients—are unconvinced. Who wants to chitchat after disrobing and having your body probed by a relative stranger in a room that feels like a meat locker? Who has time, anyway, for a real physical exam when there is so much to document in that electronic medical record and so little time?

So yes, there’s less and less physical examination these days. Visits are shorter and competing issues wrench away precious minutes. The ease and temptation of CTs and MRIs, the constant fear of lawsuits, and—let’s face it—the atrophy of our skills push doctors toward ordering more tests at the expense of a true physical exam. Often, the exam boils down to a halfhearted plop of the stethoscope on the fully clothed patient. I have been equally guilty of rushing through a pro forma physical exam when the pressure is on. And, in any case, the exam primarily serves as an adjunct to confirm or rule out a diagnosis that was ascertained in the history.

Doctors typically don’t like to talk about their truncation of the physical because it stirs an awkward mix of guilt and longing within us. We recall wistfully our rounds as students, when our bow-tied and starched-coated attendings unhurriedly probed every fingernail, meticulously percussed the cardiac contours, palpated the epitrochlear lymph nodes. We feel we are remiss with our current patients, that we are skimping on what has always been the sine qua non of the doctor-patient connection.

A decade ago people were predicting the permanent demise of the physical exam. Luckily there’s been a resurgence of interest in the physical because it can obviate the need for many expensive tests.

In the past few years I’ve observed that the physical exam has taken on an important role again, though as a slightly different medical tool. Now that the computer is front and center in almost every doctor-patient encounter, doctors spend the bulk of the visit staring at a screen. Not only are our eyes yanked away from the patient, but our attention is fragmented by the disjointed and niggling nature of the typical computer interface. It’s no wonder patients feel ignored by their doctors.

But then the doctor and patient move to the exam table and everything changes. This is often the first moment that we can talk directly, without the impediment of technology...
[ibid, Kindle Locations 446-466]

There were only small tangential studies about how much doctors recall of the information they read in medical journals (embarrassingly little) or how well they remember clinical information from a fictionalized case study (full-fledged doctors do better than medical students), but nothing with real patients.

There is one real-life experiment regarding physician memory that happens, unfortunately, a little too regularly. Electronic medical records have been revolutionary in many respects—a patient’s chart can no longer be adrift in the cardiology clinic and a crucial X-ray can’t be languishing in a surgeon’s back pocket. However, by dint of being computerized, such information is susceptible to the same glitches as every other bit of computerized material. In the middle of writing your Tolstoy-worthy note about a patient with sixteen illnesses, the computer freezes, or the program crashes, or you inadvertently hit “escape” or “delete” at an inopportune moment, and all of your carefully wrought observations evaporate into the ether.

At least once a day, it seems, a medical student or intern will turn up, ashen-faced, stammering with incomprehensibility about the note they just lost, about all their efforts that just went up in smoke. Even the old hands at the hospital, who’ve learned the electronic landmines in trial-by-fire experience, are not immune. Recently I’d been writing a particularly complicated note about a patient with multiple chronic illnesses who was on more than a dozen medications and had numerous lab values out of whack, when I was interrupted by a phone call about an abnormal X-ray for a different patient. I had to open that patient’s chart to untangle that issue. After sorting through that second patient’s medical history and what to do about the X-ray, I went to close the second chart so I wouldn’t commit the cardinal sin of mixing up two charts.

It took only a fraction of a second. Before I’d even released my finger from the mouse, I realized I’d closed the wrong tab. I kept my finger depressed on the mouse as long as I could, hoping that I could will that brief gesture into reverse, that I could telepathically conjure the information back onto the screen. When my irrational hopes could be sustained no longer and the boulder of despair had fully dropped anchor into my deepest bowels, I released my finger in agonizing slow motion.

I remained in vigorous denial for as long as I could, but finally my brain was forced to articulate what I already knew in my heart: I’d just lost everything. (And if you thought our vaunted electronic medical-record system would have something practical like auto save to prevent such a mess, dream on!)

I’d lost all the information I’d taken down while the patient was in the room. I’d lost all the analysis I’d been writing after she’d left the room. (She was a new patient, so I’d done an extensive background history.) I’d lost all of the details of her prior medical evaluations. I’d lost my entire train of thought about her because I’d been forced to delve into another patient’s medical history...
[ibid, Kindle Locations 2004-2027]

When I talk to the students and interns whom I’ve coached through similar electronic meltdowns, they have comparable experiences. The HPI and social history are the quickest to reformulate; other details can be sketchier. When I think about this from a literary perspective, the reason is obvious. The HPI is a story—there is a plot with twists and turns, challenges and conflicts. Stories are always easier to remember than lists of facts. And the social history is what writing teachers refer to as “fleshing out the character.” Without the social history, the patient is just a stock character. A thirty-two-year-old woman with abdominal pain is as much a stock character in medicine as the tragic hero or the Southern belle or the wise old man are stock characters in fiction. These are stick figures until the writer fleshes them out to become Orpheus, Blanche DuBois, or Albus Dumbledore. They are now three-dimensional and realistic human beings who lodge themselves in our memories. And while the social history in the medical interview doesn’t allow us the hundreds of pages that Tennessee Williams or J. K. Rowling can luxuriate in, it does permit us to get a fuller sense of our patients and some context of their lives. I may have forgotten what this patient’s diastolic blood pressure was, but I could never forget the pained expression on her face when she spoke of how her job made her miss reading bedtime stories to her daughter each night and how she wasn’t confident that the babysitter was reliably reading those stories to her daughter, who so needed the extra enrichment... [ibid, Kindle Locations 2054-2065]
Stay tuned.


The company's pitch video:

Nicely done. As is this one, below:



They've published the webinar to YouTube. No warning notice of it being "private," so, here it is.



My July issue of Science Magazine just arrived in the snailmail.

Numerous articles on AI applications across a breadth of scientific disciplines.
AI, people, and society
Eric Horvitz

n an essay about his science fiction, Isaac Asimov reflected that “it became very common…to picture robots as dangerous devices that invariably destroyed their creators.” He rejected this view and formulated the “laws of robotics,” aimed at ensuring the safety and benevolence of robotic systems. Asimov's stories about the relationship between people and robots were only a few years old when the phrase “artificial intelligence” (AI) was used for the first time in a 1955 proposal for a study on using computers to “…solve kinds of problems now reserved for humans.” Over the half-century since that study, AI has matured into subdisciplines that have yielded a constellation of methods that enable perception, learning, reasoning, and natural language understanding.

Growing exuberance about AI has come in the wake of surprising jumps in the accuracy of machine pattern recognition using methods referred to as “deep learning.” The advances have put new capabilities in the hands of consumers, including speech-to-speech translation and semi-autonomous driving. Yet, many hard challenges persist—and AI scientists remain mystified by numerous capabilities of human intellect.

Excitement about AI has been tempered by concerns about potential downsides. Some fear the rise of superintelligences and the loss of control of AI systems, echoing themes from age-old stories. Others have focused on nearer-term issues, highlighting potential adverse outcomes. For example, data-fueled classifiers used to guide high-stakes decisions in health care and criminal justice may be influenced by biases buried deep in data sets, leading to unfair and inaccurate inferences. Other imminent concerns include legal and ethical issues regarding decisions made by autonomous systems, difficulties with explaining inferences, threats to civil liberties through new forms of surveillance, precision manipulation aimed at persuasion, criminal uses of AI, destabilizing influences in military applications, and the potential to displace workers from jobs and to amplify inequities in wealth…
Yeah. I've had recurrent runs at some of these topics of concern. See, e.g., here , here, and here.

Nice, brief core AI glossary in the issue.
Defining the terms of artificial intelligence 
Just what do people mean by artificial intelligence (AI)? The term has never had clear boundaries. When it was introduced at a seminal 1956 workshop at Dartmouth College, it was taken broadly to mean making a machine behave in ways that would be called intelligent if seen in a human. An important recent advance in AI has been machine learning, which shows up in technologies from spellcheck to self-driving cars and is often carried out by computer systems called neural networks. Any discussion of AI is likely to include other terms as well.

ALGORITHM A set of step-by-step instructions. Computer algorithms can be simple (if it's 3 p.m., send a reminder) or complex (identify pedestrians).

BACKPROPAGATION The way many neural nets learn. They find the difference between their output and the desired output, then adjust the calculations in reverse order of execution.

BLACK BOX A description of some deep learning systems. They take an input and provide an output, but the calculations that occur in between are not easy for humans to interpret.

DEEP LEARNING How a neural network with multiple layers becomes sensitive to progressively more abstract patterns. In parsing a photo, layers might respond first to edges, then paws, then dogs.

EXPERT SYSTEM A form of AI that attempts to replicate a human's expertise in an area, such as medical diagnosis. It combines a knowledge base with a set of hand-coded rules for applying that knowledge. Machine-learning techniques are increasingly replacing hand coding.

GENERATIVE ADVERSARIAL NETWORKS A pair of jointly trained neural networks that generates realistic new data and improves through competition. One net creates new examples (fake Picassos, say) as the other tries to detect the fakes.

MACHINE LEARNING The use of algorithms that find patterns in data without explicit instruction. A system might learn how to associate features of inputs such as images with outputs such as labels.

NATURAL LANGUAGE PROCESSING A computer's attempt to “understand” spoken or written language. It must parse vocabulary, grammar, and intent, and allow for variation in language use. The process often involves machine learning.

NEURAL NETWORK A highly abstracted and simplified model of the human brain used in machine learning. A set of units receives pieces of an input (pixels in a photo, say), performs simple computations on them, and passes them on to the next layer of units. The final layer represents the answer.

NEUROMORPHIC CHIP A computer chip designed to act as a neural network. It can be analog, digital, or a combination. PERCEPTRON An early type of neural network, developed in the 1950s. It received great hype but was then shown to have limitations, suppressing interest in neural nets for years.

REINFORCEMENT LEARNING A type of machine learning in which the algorithm learns by acting toward an abstract goal, such as “earn a high video game score” or “manage a factory efficiently.” During training, each effort is evaluated based on its contribution toward the goal.

STRONG AI AI that is as smart and well-rounded as a human. Some say it's impossible. Current AI is weak, or narrow. It can play chess or drive but not both, and lacks common sense.

SUPERVISED LEARNING A type of machine learning in which the algorithm compares its outputs with the correct outputs during training. In unsupervised learning, the algorithm merely looks for patterns in a set of data.
TENSORFLOW A collection of software tools developed by Google for use in deep learning. It is open source, meaning anyone can use or improve it. Similar projects include Torch and Theano.

TRANSFER LEARNING A technique in machine learning in which an algorithm learns to perform one task, such as recognizing cars, and builds on that knowledge when learning a different but related task, such as recognizing cats.

TURING TEST A test of AI's ability to pass as human. In Alan Turing's original conception, an AI would be judged by its ability to converse through written text.
Notable to me is that the word "HEURISTIC" is not included. Human (brain "wetware") perception/cognition is way more inductive/heuristic than deductive/algorithmic.

apropos, another new read in my stash:


One of my Facebook friends, a physician, is pumping this every day.


The United States is the only country in the developed world that does not guarantee access to basic health care for residents. Countries that guarantee health care as a human right do so through a “single-payer” system, which replaces the thousands of for-profit health insurance companies with a public, universal plan.

Does that sound impossible to win in the United States? It already exists – for seniors! Medicare is a public, universal plan that provides basic health coverage to those age 65 and older. Medicare costs less than private health insurance, provides better financial security, and is preferred by patients (Davis, 2012). Single-payer health care is often referred to as “Expanded & Improved Medicare for All.”

Under the single-payer legislation in Congress (H.R. 676):

  • Everyone would receive comprehensive healthcare coverage under single-payer;
  • Care would be based on need, not on ability to pay;
  • Employers would no longer be responsible for health care costs and coverage decisions.
Single-payer would reduce costs by 24%, saving $829 billion in the first year by cutting administrative waste and allowing negotiation of prescription drugs (Friedman, 2013); and

Single-payer would create savings for 95% of the population. Only the top 5% would pay slightly more. (Friedman, 2013)
 Recall I did my first grad school paper on the Single Payer proposal in 1994 (pdf).

See also, "Physicians for a National Health Program."

Much of my prior post is of relevance here.

Also apropos, a great post now up at THCB:
The Most Important Questions About the GOP’s Health Plan Go Beyond Insurance and Deficits

Ending healthcare for those who need it will not make them or their problems disappear. On the contrary, the GOP plan will shatter American families and the economy. Nothing magical happens if we stop caring for the elderly, the ones who need vaccinations, the small infections that can be treated for $2 worth of antibiotics, the uncontrolled diabetics, and those with contagious diseases who clean our schools’ offices and homes. They don’t just get healthy.

As George Orwell said in Down and Out in Paris and London, “the more one pays for food, the more sweat and spittle one is obliged to eat with it.” Cutting care only exacerbates illnesses, infection, disability, the effects of age and the costs to society. The burdens continue or increase but the cost is shifted to American families, businesses, and states.

Fifteen years ago, one of the authors showed that lost productivity from workers caring for Alzheimer’s patients cost US businesses over $60 billion a year. Employee-caregivers, usually at the peak of their responsibilities and corporate experience, quit, prematurely retired, were constantly distracted, or engaged in presentism (e.g., at work but focused on mom burning down the house). Business cost were incurred by the need to replace workers, extra training of replacement workers, and increased pressure on other workers to cover for caregivers. The more expensive the employee, the longer and more costly the search and the longer the time to get them up to speed. But that study examined just a miniscule number of patients and workers compared to the tens of millions of people affected by the proposed GOP bill. As noted, it’s not only those needing care, but our society and our families that must deal with the elderly, ill, disabled, under and uninsured, children not receiving even ordinary care, people not being screened for preventable illness, and countless others.

Extrapolating from Koppel’s tiny study to the US population and businesses reveals the GOP bill will cost the nation trillions of dollars in losses and extra costs. It will devastate state budgets, and explains why GOP governors are among those leading the resistance…
Read all of it.


'Access to broadband “is, or soon will become, a social determinant of health.”

What? From "How AI could exacerbate existing health disparities."

More to come...

Sunday, July 9, 2017

House Calls, STAT!

Just up at THCB:
Should Doctors and Nurses Be Patient Activists?

…Like most doctors and nurses, I try to keep the outside world firmly outside the exam room. I don’t talk about politics, religion, money, or sports. I don’t even gripe about the mayor. Most medical professonals avoid political activism for the same reason. But could that reticence be harmful to our patients?

I grappled with this over the past few weeks, as the House passed its American Health Care Act and then the Senate put forth its Better Care Reconciliation Act. As one detail after another was revealed, I began to worry about my patients. The cuts to Medicaid would do real damage to them. I had a number of fragile patients in mind who could die if their care was disrupted.

What would I do, I asked myself, if I started to notice a dangerous side effect of a medication that my patients were taking. The answer, of course, is easy. And it wouldn’t even be a question; it would be an obligation. If I see a threat to my patients’ health, it’s in my job description to speak up.

The ACHA and BCRA suddenly seemed like the same thing—a threat to my patients’ health. Yes, I value political neutrality, but this no longer seemed like politics to me. It was a medical threat…

If I suspect that one of my patients is suffering abuse at home, I am obligated—in fact, legally mandated—to speak up.  If I suspect that my patients’ health will be harmed by legislation, I believe we are equally obligated to speak up…

I’ve thought long and hard about whether this violates my commitment to political neutrality with my patients and I’ve concluded that it does not. I do not discuss these efforts with my patients, and I continue to keep the exam room as neutral as possible. When patients bring up politics—which they do frequently these days—I steer the conversation back to their medical issues because that is my job as their doctor. When I leave the hospital, I start calling Senators about BCRA because that is also my job as their doctor.

Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients. It’s a medical emergency, and medical professionals need to behave as such.
I have cited the eloquent and empathic Dr. Ofri many times on this blog. See, e.g., here, here, and here.

Dr. Ofri's new book:

"Despite modern medicine’s infatuation with high-tech gadgetry, the single most powerful diagnostic tool is the doctor-patient conversation, which can uncover the lion’s share of illnesses. However, what patients say and what doctors hear are often two vastly different things.

Patients, anxious to convey their symptoms, feel an urgency to “make their case” to their doctors. Doctors, under pressure to be efficient, multitask while patients speak and often miss the key elements. Add in stereotypes, unconscious bias, conflicting agendas, and fear of lawsuits and the risk of misdiagnosis and medical errors multiplies dangerously..."
 Not read it yet. Into the never-ending queue it goes.

In her THCB post, she alludes to the #HouseCallsCampaign.

Every day, we medical professionals advocate on behalf of our patients.

Right now, millions of our patients stand to lose their health insurance if the Senate passes their healthcare bill. This would be disastrous for their health.

When a new drug comes on the market, we ask ourselves whether it would harm our patients before prescribing it. We need to think the same way about healthcare legislation.
If you think that the proposed legislation could harm your patients, join doctors, nurses and medical caregivers across the country who are calling the Senate. (We’ve named this the HouseCalls Campaign even though it’s the Senate that needs our medical opinion right now!)

As we all know, advocating for patients is as much a part of medical care as the medical care itself. It  takes only a few minutes to make a call.

"Right now it is estimated that 20,000 Americans will die each year because of the loss of insurance coverage and Medicaid from BCRA. To me, that’s a clear medical threat to our patients."

I don't think you'd have to look far these days to find a Republican who might allude to it as "culling the herd" if he thought he was speaking off the record. We seem to be rather firmly in the hard-hearted political nadir grip of the "Persecutor" phase of the "Rescuer - Victim - Persecutor Triangle."

The other day I saw an estimate of the U.S. medically uninsured rising to a total of 49 million or so in a decade should the GOP BRCA bill pass and become law. I did a quick Excel sheet.

Assume a blended annual compounding health care cost increase of 5% (current 1.9% "core" inflation plus general cost health sector increases above and beyond the inflation rate).

The latest per capita estimate per the NHE is ~$10,500. By 2021 the annual cost of just the uninsureds (assuming a total of 38M by then) approaches that of the entire U.S. Defense Budget. By 2026, assuming 49M uninsureds, the yearly price tag rises to about $800 billion --- with a "B."
And, yes, I know that this scenario further assumes that the per capita health care burden of the uninsureds is roughly reflective of the aggregate average (and, it's not much of a stretch to make the case that this overwhelmingly poorer demographic is and will be more costly). That's why you spreadsheet this stuff, to play with the various parameter estimates.
These costs (whatever their precise out-years magnitude) will get paid for one way or another.

Or, maybe not. We could just "cull the herd." Hey, I know! -- Rand Paul could introduce a bill to Repeal the EMTALA. And, "Rationing by 'Price'." (As in "priced out.")

Once again, I tout Elisabeth Ronsethal's excellent book "An American Sickness." See also my review of "ObamaCare is a Great Mess."

Make some House Calls.



"Yes, I fully appreciate the sentiments here and I believe doctors, like all other individuals, should be politically active. The health care legislation issue may feel more like an Ebola, but is it really? And isn’t this a bit late to the political “saving lives” game?

Without further ceremony, and please forgive me, but where were all concerned physicians during the last few decades when American workers had to watch their wages deteriorate to the point of having to rely on Medicaid and all sorts of other charity just to survive? Where were all the doctors when successive administrations traded away the U.S. middle class at the behest of global corporations and deranged activist billionaires?

Where were the doctors when our education system turned into third world crap, our inner cities collapsed and entire generations of boys and men of a certain color got carted away to prison? Where were the doctors when wars were/are fought for imaginary excuses and when the goddamn “resistance” is beating the drums of war with the largest nuclear power out there?

Where were the doctors when tech companies pushed their sick and addictive products on millions of children, who are wasting their lives powering the tech exploitation machine? And recommending optimal “screen times” doesn’t count. Speaking of addiction, where were the doctors when America plunged into an opioid addiction and mortuaries in small towns began to overflow with victims?

So my question is why now? Why is health insurance different than the other horrific events where your patients were/are literally being killed, not just estimated to maybe be killed in 2037?

Perhaps if I would have seen doctors marching against poverty, worker exploitation, slave-labor importation, environmental destruction, and such, this newfound political activism would not look so peculiar. And maybe, just maybe, if doctors started marching against those patient-killing evils decades ago, we wouldn’t have to march today.

Other than that, excellent article, as usual."
Yikes. From Donald Trump's Bolshevik in Chief. I have no way to know whether she's a seasoned front-line veteran of the Occupy Social Justice barricades or just another affluent First Chairborne Division Keyboard Commando.

Doctors and Nurses Need to Treat BCRA as a Medical Emergency
This isn’t about politics, it’s about health.
By Danielle Ofri 

Illness is not something most healthy people think about regularly. And they shouldn’t. Although as a physician I want to help my patients make smart choices to preserve their healthy state, I also don’t want to deny them the blissful innocence that comes with taking good health for granted.

However, just as the disability community coined the term “temporarily able” to refer to those without disabilities, the reality is that those of us who are healthy are only “temporarily healthy.”

A random encounter with an unprotected partner or a nasty stomach bug or the Second Avenue bus could bring anyone at any age into contact with the health care system. Just getting older and acquiring hypertension or arthritis can do it. And then suddenly you learn. You learn what your insurance does or does not cover. Or you learn what it means to get sick without insurance. You learn that you are not invincible.
For Americans who are still temporarily healthy, the politics of health care can feel distant. The details of the House and Senate’s health care bills can feel arcane and overly partisan...

Most senators have only a passing knowledge of what actually transpires when people make medical decisions. It is the people in the clinical trenches—nurses, doctors, physician assistants, med students—who know. These are the people who understand what happens when patients lose access to medical care. These are the people who will care for those 20,000 ill-fated patients—not in primary care clinics but in emergency rooms, ICUs, and morgues...
BTW, Michael Millenson posted the best comment under the THCB post that gave rise to this one of mine:
"Doctors always believe that the alarms they raise about any action by federal or state government, insurers, employers, health plans, hospitals, other medical specialties, other doctors in the same specialty who aren’t as smart/competent/ethical as they are and anything else related to health care are actions undertaken altruistically out of concern for patients.

As a result, some doctors warn that a single payer system, a la Canada, will kill patients, while other doctors warn just as sincerely that failing to adopt such as system will kill patients. While other doctors, of course, have every other opinion in between.

Because so many doctors, like Danielle Ofri, are eloquent writers, I believe all of them all at once all of the time."
With ‘shame on you’ chants and harsh tweets, nurses union pushes single-payer bill

To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, New Jersey-ish.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly…

Things are getting increasingly heated.


In addition to the 11th Annual Health 2.0 Conference (link at the top right of this blog), this should be on your calendar.

Registration link here
In the last 10+ years, Precision Medicine has seen a multitude of advances in the areas of diagnostics, computing, and consumer tools. The ongoing quest to better understand disease predisposition and prevention through genomic and environmental factors is key to increasing the quality and length of life. The Technology for Precision Health Summit, this coming October, will explore and showcase specific technology that tackles these issues and more.

Speaking of human health writ large, I give you a frightening, depressing article:

The Uninhabitable Earth
Famine, economic collapse, a sun that cooks us: What climate change could wreak — sooner than you think.
By David Wallace-Wells 

I. ‘Doomsday’

Peering beyond scientific reticence.

It is, I promise, worse than you think. If your anxiety about global warming is dominated by fears of sea-level rise, you are barely scratching the surface of what terrors are possible, even within the lifetime of a teenager today. And yet the swelling seas — and the cities they will drown — have so dominated the picture of global warming, and so overwhelmed our capacity for climate panic, that they have occluded our perception of other threats, many much closer at hand. Rising oceans are bad, in fact very bad; but fleeing the coastline will not be enough.

Indeed, absent a significant adjustment to how billions of humans conduct their lives, parts of the Earth will likely become close to uninhabitable, and other parts horrifically inhospitable, as soon as the end of this century...

IV. Climate Plagues

What happens when the bubonic ice melts?

Rock, in the right spot, is a record of planetary history, eras as long as millions of years flattened by the forces of geological time into strata with amplitudes of just inches, or just an inch, or even less. Ice works that way, too, as a climate ledger, but it is also frozen history, some of which can be reanimated when unfrozen. There are now, trapped in Arctic ice, diseases that have not circulated in the air for millions of years — in some cases, since before humans were around to encounter them. Which means our immune systems would have no idea how to fight back when those prehistoric plagues emerge from the ice.

The Arctic also stores terrifying bugs from more recent times. In Alaska, already, researchers have discovered remnants of the 1918 flu that infected as many as 500 million and killed as many as 100 million — about 5 percent of the world’s population and almost six times as many as had died in the world war for which the pandemic served as a kind of gruesome capstone. As the BBC reported in May, scientists suspect smallpox and the bubonic plague are trapped in Siberian ice, too — an abridged history of devastating human sickness, left out like egg salad in the Arctic sun.

Experts caution that many of these organisms won’t actually survive the thaw and point to the fastidious lab conditions under which they have already reanimated several of them — the 32,000-year-old “extremophile” bacteria revived in 2005, an 8 million-year-old bug brought back to life in 2007, the 3.5 million–year–old one a Russian scientist self-injected just out of curiosity — to suggest that those are necessary conditions for the return of such ancient plagues. But already last year, a boy was killed and 20 others infected by anthrax released when retreating permafrost exposed the frozen carcass of a reindeer killed by the bacteria at least 75 years earlier; 2,000 present-day reindeer were infected, too, carrying and spreading the disease beyond the tundra.

What concerns epidemiologists more than ancient diseases are existing scourges relocated, rewired, or even re-evolved by warming. The first effect is geographical. Before the early-modern period, when adventuring sailboats accelerated the mixing of peoples and their bugs, human provinciality was a guard against pandemic. Today, even with globalization and the enormous intermingling of human populations, our ecosystems are mostly stable, and this functions as another limit, but global warming will scramble those ecosystems and help disease trespass those limits as surely as Cort├ęs did. You don’t worry much about dengue or malaria if you are living in Maine or France. But as the tropics creep northward and mosquitoes migrate with them, you will. You didn’t much worry about Zika a couple of years ago, either.

As it happens, Zika may also be a good model of the second worrying effect — disease mutation. One reason you hadn’t heard about Zika until recently is that it had been trapped in Uganda; another is that it did not, until recently, appear to cause birth defects. Scientists still don’t entirely understand what happened, or what they missed. But there are things we do know for sure about how climate affects some diseases: Malaria, for instance, thrives in hotter regions not just because the mosquitoes that carry it do, too, but because for every degree increase in temperature, the parasite reproduces ten times faster. Which is one reason that the World Bank estimates that by 2050, 5.2 billion people will be reckoning with it...
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