Every year after my birthday, I try to reassess my life. I write down this reassessment so I can read it. I’ve found my memory slants things in my favor and only by writing down my thoughts can I later be sure of exactly what I was thinking at the time. So this post is primarily for me, put out publicly for anyone who might be interested. In essence, I’m reintroducing myself to myself. If you want to get to know me again, this would be a good thing for you to read, if you don’t there won’t be much you haven’t heard already.
I spent most of my life with what you might call a divided self. To some people, I was a good and serious Christian, to others I was a very liberal Christian, to myself I could be either of those two, but there was also a private life hidden from both my serious Christian friends and my nominally Christian friends. There were two parts to this private life as well: there was young man that desired nothing but the satiation of the flesh, and finally caught in the tension of all of this and man who truly hated his very life, and struggled constantly to avoid physical self harm and deep feelings of worthlessness. I was deeply ashamed that I, a Christian felt that way and struggled as much to keep people from finding out how I felt like trash as I did to overcome those feelings.
It made for a complicated life. I thought my parents were the greatest parents on earth and I loved them. At the same time, sometimes I hated them so much it was purely my fear of the punishment of God for disobeying them that kept me at home much past my 16th birthday. If I was going to choose one word to describe my young adult and adult years it would “confused”. I was never sure who was the real me: the serious Christian, the liberal Christian, the sex freak, or person who was prevented from suicide purely because whenever he put a gun to his head he saw his family around his hospital bed as he was in a vegetative state, clucking their tongues and saying “Couldn’t even get that right, could you?”
I was always on the look out for someone who had the answer of how to live the Christian life. I wanted to truly be a Christian more than anything on earth. Adolescent angst turned into adult depression. Frequently, I would wake up before my alarm went off and stare at the ceiling trying to will myself into facing another day of failing to be the man I was supposed to be. Usually I could. Sometimes I could not, and it cost me more then one job.
This would lead me to join a radical Pentecostal group who claimed to have a corner on knowing God. Some would call the group cult-like, and perhaps it was but, in the end it was good for me. For the first time in my life I was honest with people about the feelings I had about myself and others. There was an enormous rush to being that intimate with people emotionally. The feeling, though sexless, is not entirely unlike the feeling of being courted. (I’ve talked to a few cult survivors who say this remains a feature of their live that they now miss.) When the novelty of those wonderful feeling wore off however, I was largely the same person. This became an increasing source of frustration. Further, the church talked a very radical, revolutionary game, but when I started to ask hard questions about when this so called revolution would start, I was ostracized.
A pivotal moment in all of this, was falling in love with my wife’s best friend. Of course, being 24 and her being 22, part of these love feelings including an intense and acute desire to make love to her. Which at first, made me hate myself more then I knew was possible. It would hardly seem that this could work for good? But it did. Through long conversations with my wife about my feelings, we came to the conclusion that it wasn’t feelings that were wrong but the actions you took with them. That being the case, I just ignored the sex drive and enjoyed loving someone. Always I had seen my desire for sex with a woman I was not married to as sick and twisted, and myself as perverse for having such feelings. Now, I accepted those feelings and enjoyed them but chose not to act on them. This was the beginning of a life of much less self hatred.
This new life of believing that I was worthy of love changed what I expected from a church. I now wanted to be treated as a peer. This didn’t sit well with the somewhat cult-like church we went to. The last straw was when I quit my job (to avoid temptation, long story) and no one would help us. Further, I was reading the Bible as a whole document looking for the whole story rather then reading individual passages to see what I could make it say. Our church wasn’t even close.
We had moved to the inner city to be closer to the people we were supposed to be saving. I sat on the stoop listening to the gun fire and the sirens. I realized that every stupid thing I had ever done was because I thought someone besides me would take care of me, yet here I was unemployed in the projects of Kansas City. I had a high enough ACT score to get into MIT and I was waiting tables and living three doors down from a crack house.
I decided I would start taking care of myself, and that such a thing would glorify God. I also still wanted to help people in the inner city, and it looked to me (after 2 years of hearing about transformation that I never saw) that hard working people getting money into the crappy schools would go a lot farther then prayer meetings.
I joined the Air Force (same pay as the other branches but least chance of getting shot and most time at home). I joined a very sincere Christian who had reached one simple conclusion: If one was going to consistent with ALL of scripture instead of just the parts they liked, then God was a radically different person then most people thought.
It’s unfortunate in many ways that I deconverted after joining, because I think a lot of people have the idea the military experience is what made me an atheist. Not at all. I joined, as I said, primarily to make enough money to make a difference. I came into the military a Christian. It was not the Air Force life that deconverted me but careful study of Scripture and the history of the early church.
That study lead me to believe that one of three things must be true (1.) There is no God. (2.) There is a God but he actively hides from those who seek him (3.) There is a God and I personally can see no evidence because he doesn’t want me to. In any of those three cases, this life on earth is the highpoint of my existence as I am either bound toward nothing or hell.
Logic says to believe the idea which requires the least invention to work. I could invent a God that cannot be found with the scientific method, or say there is no God. I chose no God. I prayed a final prayer, “Lord if you are real, I came to this conclusion with the brain you gave me and the best facts I could get. If you are real and I am wrong, then please keep my daughter and don’t hold my sin against her. I’m going to be true to myself and admit I don’t see you.”
After this, everything got better. (A subject I have blogged on extensively.) I didn’t ache inside because I wasn’t failing anymore. I stopped pretending I was a Christian, so now I had one kind of friends: the kind that liked me for me. Three months later, I woke up and was getting ready for work. I felt strange and it took me some reflection to realize why: I couldn’t remember the last time I woke up so depressed that I couldn’t go to work.
I didn’t immediately “come out” as an atheist. In my life I have been many things and what I am really excited about today is not something that will necessarily have great meaning to me in 6 months or a year or 5 years. I quietly worked out things. One of the things I really struggled with was the meaning of life in the absence of God. Christianity is a pre-packaged world view, the paradigm equivalent of a Lunchable. Atheism is merely a theology. Eventually, two things would move me. The first was existentialism. Sadly, since most existentialists are big philosophy geeks, existentialism has a huge image problem. Existentialism does not say that life is meaningless (that would be nihilism), on the contrary existentialism says life can have great purpose: the purpose you give to it.
This helped me understand some of the great confusions of my life. What meaning did my relationships have? The meaning I chose to give them. Guilt I had carried over an ex-fiance for years melted away. But what of the indifferent universe that I now believed I lived in? Well, when I spoke of this to the very wise Doctor Karen Stollznow, she said, Israel, rocks and trees may be indifferent, but we as humans are generally surrounded by human beings who are as authentic parts of this universe as the sun or the earth. Because people can make the choice to care, the universe is not indifferent.
During this period (around this time last year) I began to really hate my parents. I was profoundly bitter with Christianity and I blamed my parents for raising me in it. That was stupid. We’ve talked since and worked it out largely. Though not bitter, I remain slightly miffed at Christianity. I’m 29 years old and it has only been the last few years that I have had a normal sexual relationship. I’ve been in a sexual relationship since I was 22, however it wasn’t normal or healthy until fairly recently as atheism and existentialism helped me come to healthy view about myself. Sex is not very important to some people and incredibly important to others. I am the latter, and it irritates me that I spent the first 25 years of my life when unhealthy, ineffective thoughts and actions regarding sex because of Christianity.
A note here, when I say “Christianity” I am not referring to a code of ethics based on the Gospels, but the unique expression of American, politically conservative protestantism as I understood it. I have talked to many people since deconverting that managed to believe psychologically healthy things as well as Christianity. They managed to believe everything I do, yet do so with a paradoxical belief largely at odds with scripture. More power to them, I’m not mad at them anymore either. (For awhile I was jealous of their ability to keep all the pleasant trapping of Christianity without the madness, but I’ve come to accept that they can do it and I can’t)
This is largely the complete story of how I got to where I am. Next post I will tell you myself (and you all) where here is.
The purpose of market is to provide a place for the producer and consumer to form voluntary contracts. The market has no intrinsic morals and only one rule: the best deal. The producer makes supply, the consumer makes demand. Between them, and the competition of various producers to provide for various consumers, this constant desire for the best deal drives price ever downward. It rewards the most efficient producer and the most efficient consumer alike. It’s almost a kind of magic.
Market failure doesn’t refer to a total break down of the buying and selling but a break down of the magic, of the automatic best deal for everyone. It’s not discrete point, but direction the market can go. The opposite direction leads to the perfect market. It too is not a destination but a direction, the ideal by which markets are judged.
A perfect market consists of a few key principals, describing the market as a game it looks like this: (1.) Rationality of all players in the game. (2.) No hidden costs to any move. (3.) Enough players that no single one can steer the game by their behavior. (4.) something all the players want to play with [demand] (5.) Freedom to play or not play at any point (6.) No barriers to entering or leaving the game (7.) No barriers to any player about information on any other player.
How does the medical industry fail these criteria?
Rationality of all players in the game
(1.)Well, first of all, the medical consumers are highly irrational. Short term fun at the expense of long term health is not rational, yet 80% of heat disease alone is preventable. Throw in smoking, obesity, diabetes, etc, and the single greatest killer is short sightedness. In a perfect world, doctors would serve as check on this irrationality, but the fact is, doctors are over-treating (which gets people killed) because of their fear of litigation. The consumer is crazy and so is the producer.
No hidden costs to any move
(2.)The whole field is full of hidden costs. From regulations you never heard of to taxes you can’t imagine, the medical field is a minefield of hidden costs.
Enough players that no single one can steer the game by their behavior
(3.) Well, about half of the cost is payed for by one player (gov-care), and up to 70% of the remaining half is payed for by one company per area. Normally, this would be called oligopoly, but honestly, its worse than that. Because the first half is the government, its more like a oligopoly on the second half and monopoly on the first. Under normal circumstances, even if a player owns 50% of the total market, that player can rarely take away your organization’s legal right to exist, or place members of your organization under arrest. The government has what is known as a monopoly on force. Monopoly represents a market distortion. Force, on the other hand, represents the nonexistence of market. The foundation of market is people forming contracts of their free will, ie, without threat of force.
Something all the players want to play with [demand]
(4.) Demand, we’ve got. Sort of. The fact is, while doctors may not be the paragons of reason we hope, the producer side (as is typical in other industries) is better at being rational then the consumer side. If nothing else, it’s better organized. The consumer demand is health, not care. But doctors have no economic incentive to pursue health. They have need to produce care. So there is break down between the needs of the consumer and the ability of the producer to meet that need. Note, I am not saying there is a conspiracy by doctors to keep people sick. Doctors are like most people: there’s a few true saints, a few evil bastards, and lot of pretty ethical folk. But the fact is, we must relay on doctors’ moral incentive and not their economic incentive to provide us with health. Systems work better when the two incentives are the same.
Freedom to play or not play at any point
(5.) This one absolutely does not apply. Playing in this case means the freedom to form or not form voluntary contracts. If the consumer doesn’t enter the market he suffers or dies. At the same time, if the producers do not enter the market many suffer or die. Further, hospitals must provide emergency care to everyone, regardless of ability to pay. On the insurance side, insurers must provide insurance to at a loss to certain high risk people. They must by law.
No barriers to entering or leaving the game
(6.) Well, the barriers to entering the game are enormous. Lets say we want to start a tiny private practice, with very limited services. First, the price of becoming a MD is between $175K and $200K. Then, the first year cost for 1600 square foot commercial space, a receptionist and tech who makes no benefits is about $250K. So, minimum startup cost is right around half a million dollars. Nor can hospitals simply exit the market, they provide a community service and without them people will suffer and die. Insurance is the most heavily regulated industry in the US, so even if cash on hand was not a problem the regulations would be, but in any case, and insurance company must have the cash on hand to pay out all claims if they were all called at once. The startup costs for an insurance company are in the tens of millions.
No barriers to any player about information on any other player
(7.) This is the worst. Insurance companies use hundred page contracts written legalese on purpose, to hide the information the consumer needs to know. At the same time, insurance fraud is a huge expense, because people aren’t honest with the companies either. If people are totally honest with doctors, their premium could go up. Conversely, if doctors are honest about risks with patients, the patients will simply go to another doctor who paints a rosier picture. Again, the moral incentive is diametrically opposed to the economic one.
All in all, it’s a wonder health care is as cheap as it is. Again, I’ve hit over 1000 words, so I will post my solution(?) later. Thanks for reading all, feel free to weigh in on any of this.
Ok, so last blog, I looked at the insurance companies. Basically, there is large room for improvement, but I didn’t find the huge smoking gun of “THE WHOLE THING SUCKS BECAUSE OF THE INSURANCE COMPANIES” I thought I would. In fact, ultimately, premiums are high because hospital care (which premiums insure) are high.
A hospital is a business, even when it is a non-profit. If cash out exceeds cash in, like all other businesses, it fails. Right now, hospital costs are higher then they have ever been, so we would think that hospitals are making money hand over fist. Actually, not at all.
Over the last 10 years the average profit margin (the amount of economic surplus) has increased. It’s gone from (ready for this)… 4.9 to 5.2%. An oft quoted stat is that many of the most profitable hospitals are making a 20.1% profit margin. It’s true. Some of the most profitable hospitals are putting a 20% mark up on certain procedures. It’s to cover the 15% loss they take on the other ones, leaving an end of the year balance of…5%.
Why are they taking a 15% loss? Well, because Medicare, Medicaid, SCHPs, (all the gov-care) doesn’t pay the full cost. Note, this isn’t saying gov-care doesn’t pay the full charge. Think of it this way. A procedure costs the hospital $100. They bill $120 for a twenty percent markup. Private insurance pays $120. Gov-care pays whatever it can afford, usually around $85. A 15% loss means 15% below cost, but about 43% below the price.
The reason for this is the program is never given enough money to pay all the expenses it incurs. If the program was supposed to pay for 100 procedures at $1 each, and there are 140 procedures, then all the hospitals get $0.71 instead of a dollar.
Further, remember that gov-care is only about 1/3 of the number of patients, 2/3rds are private insurance, so how does the hospital not make a killing, taking 15% loss on 1/3 and getting 20% gain on 2/3rds? Because the 1/3 of people on gov-care are the most expensive patients. Despite the fact they make up only 33% of the hospital population, they make up 50% of the expenses.
Hospitals can refuse gov-care patients so why don’t they? If taking a patient on medicare meant you were going to loss 15% of the cost of care, why would hospitals take them in? Because of the Emergency Medical Treatment Act of 1986, which means, “regardless of citizenship, legal status or ability to pay” any patient who needs emergency care must receive it.
Hospitals loss on average, about $84 per emergency room patient. Emergency rooms account for about 20% of the total cost of running a hospital. So, why have one? Because 1/7 patients who visits the ER will have a highly profitable inpatient transfer. The best way hospitals can get the profitable 2/3rds of insurance payers into inpatient surgery is through the ER doors.
What about people who don’t have insurance, and don’t qualify for gov-care and simply refuse to pay? They are very small part of hospital losses, about 3% on average.
So if, 97% of the hospital customers are paying, and half the cost is at a 15% loss, and half is at 20% profit, that doesn’t really explain why health care is so expensive. I mean, yes all the responsible people are effectively paying a 20% sales tax to the hospital to cover the portion of socialized medicine that the their income tax didn’t pay. But, 20% sales tax does not 200% overcharging make. (The cost US health care exceeds the cost of better health in many other industrialized democracies.) So what gives?
The most expensive thing in the hospital is labor. If we are serious about reducing the cost of health care, we have two very basic options. One is make labor cheaper, the other is use less of it.
What about cheaper labor? The most expensive section of hospital is ICU and 80% of the cost of ICU is labor. ICU nurses make about 46k a year. I’ve often mentioned France in this study. Nurses in France make half of what American ones do, and health care is cheaper.
As to reducing the number of hours nurses have to spend with patients, let me rip this long section from this article.
For example, if you are a Medicare recipient and you have a heart attack in a region where doctors practice less aggressive care, like Salt Lake City, your care will cost Medicare about $23,500 over the course of a year. But if you have your heart attack in a place like Los Angeles, the bill will be closer to $30,000.
The wide gulf in spending between the two cities is not because of different prices. Sure, everything costs a bit more in Los Angeles, including nurses’ salaries and the laundering of hospital linens, but not enough to account for the extra amount Medicare pays for a heart attack. The reason the same patient’s care costs more there than in Salt Lake City is that doctors and hospitals in Los Angeles tend to give their patients more tests, procedures, and surgeries, and their patients tend to spend more days in the hospital.
But here’s the important part. All that extra care in L.A. doesn’t lead to better outcomes. As it turns out, heart attack patients who receive the most care actually die at slightly higher rates than those who receive less care.
So, um, why are we doing this to our selves? Again, same article:
Why? Because doctors believe patients will be less likely to go to a lawyer if they think the doctor did everything possible—even when doing so doesn’t help the patient or causes harm…
The article puts forward the idea 50% of medical procedures are basically done to make people feel better rather than be better. That is to say, nearly half of all procedures done have no backing in reality which suggest they are necessary. At least one large portion of the problem is that lack of skepticism and respect for the scientific method exhibited by American medical consumers.
Tune in next time, when I tie the this blog and the last one together to create a cohesive solution.
I wish I could buy an Ubuntu car.
Now, there are people out there working on what they call an open source car, but I’m not super impressed with any of them yet. Further, it think their basic premise is flawed, or frankly, stupid.
Open source is a response to closed source. Had closed source not started it all, open source would not have had a reason to exist. Let’s look at the cause of open source, Microsoft.
Microsoft wrote DOS. DOS lets people talk to the computer, but DOS is still pretty obtuse. Microsoft makes a bunch of pretty pictures than normal people can use, and those pictures can talk to the DOS to talk to the computer. That’s windows. Windows was really popular, and computer code is easy to reproduce. Microsoft, like all good companies was interesting in making profit for its owners so it took steps to make it hard to sell and reproduce the code that many thousands of Microsoft programmers had worked very hard on and need to be paid for.
Linux was created as a substitute for DOS, not for windows. Essentially a guy named Linus re-wrote a old operating system for mainframes (Unix) into a new operating system for PCs. He did it because he thought computers were a force of capital G Good in the world, and he didn’t want Microsoft’s bottom line to get in the way of people being able to use computers.
Later, just as Microsoft developed a graphic user interface for DOS, a graphic interface would be developed for Linux. If fact many would be developed, the most popular is called Ubuntu.
Ubuntu is the most popular because it is, for all practical purposes, NOT Linux. Though Linus’s original code is buried in Ubuntu, it has been improved by thousands of highly skilled programmers working tens of thousands of hours. Further, Ubuntu contains a whole bundle of pre-packed goodies that make it a functional windows replacement. Those goodies were all developed by yet more thousands of programmers working tens of thousands of hours.
Despite the fact that Ubuntu was developed for free, it was not developed by amuteures. It was developed by some of the best programmers in the world over a period of years, and in some parts of the source code, decades. (The original Unix kernal was written in 1969.)
What the programmers did was what you cannot do. They did the very hardest parts, the most esoteric parts that take the greatest level of technical proficiency.
Finally, Ubuntu has a tremendous support network. Wikis and forums which explain each step in plain detail. If you can’t handle that, often in the forums, there are links to blogs which will explain tiny steps in stupefying detail.
One of the unique things about being human is that we cannot do anything that we can’t conceptualize. The amount of sugar is something is really hard to visualize. Even if you say something like “Contains 18 tablespoons of sugar per serving” it doesn’t necessarily help me. I have no idea what a pile of 18 tablespoons sugar looks like, or what 8 oz looks like in different glasses. Useless, I say.
So, her is my proposal for a rating system for the sugar in drinks. The standard will be Mussleman’s apple juice. It’s a plain old, everyman’s sort of apple juice. The sugar level of this standard apple juice will be 1.0. Then all other drinks will be rated by that standard.
Cranberry juice .2
Orange juice 1.1
Starbucks Frappuccino 2.9