August 22, 2017

Is Medicaid Helping Fuel the Opioid Crisis?

Probably.

According to Express Scripts, which is a large manager of pharmacy benefit plans including Medicaid, “Medicaid members are 10 times more likely to suffer from addiction and substance abuse than the general population.” Unfortunately Express Scripts doesn’t give a source for this statistic and it doesn’t appear in the full text of their report. This sentence may refer to both drug and alcohol abuse and it doesn’t help us untangle cause and effect.

Some people qualify for Medicaid because substance abuse restricts their income.  Almost 25% of 3.1 million Medicaid subscribers whose records were scrutinized in the Express Scripts study had opioid prescriptions in 2015.   Having Medicaid available to pay for pain killers relieves pain which people might otherwise have suffered. But does having Medicaid available encourage opioid abuse?

In an editorial, The Wall Street Journal  says: “Evidence suggests the program may contribute to the epidemic… Overdose deaths per million residents rose twice as fast in the 29 Medicaid expansion states—those that increased eligibility to 138% from 100% of the poverty line—than in the 21 non-expansion states between 2013 and 2015.”  Their argument comes from a statement Senator Ron Johnson (R-WI) made, which doesn’t appear on his website and for which I can’t find a link.

In the statement Johnson quotes a letter he sent to the Inspector General for the Department of Health and Human Services, which I also can’t find online: “it appears that the program has created a perverse incentive for people to use opioids, sell them for large profits and stay hooked.”

If Johnson is right, this is a huge problem. The incentives are easy to understand. If an addict has anything of value, he’ll sell it to feed his habit (except possibly pills which he can take himself). The copay on legally prescribed opiates is far, far less than their street value. If there were no abuse, it would be truly extraordinary. What matters is whether the abuse is significant and is helping fuel the crisis

The WSJ’s only source for this statistic is “a federal Health and Human Services analysis requested by the Senator”. No link to any such study. No study I can find on Google. Because I think the subject is crucially important, I did some research. Age-adjusted opioid deaths by state for 2013 and 2015 can be found in a report from the Centers for Disease Control. I found a list of states which expanded their Medicaid programs here. Note that my source lists 19 states which didn’t expand eligibility while WSJ says 21. Since they didn’t give their list, I can’t reconcile the difference.

Using these sources, I get the same results as the WSJ. The statistical method is somewhat suspect, however, since it averages results from states with different populations. Population adjusted, deaths from opioids increased “only” 59% faster in expansion states.  Statistically, the fact that this correlation exists both state by state and in the aggregate increases the likelihood that it is more than a coincidence  , and so this is not good news.

Another possible reason to discount the statistic as being evidence of cause and effect is that there are demographic differences between the mostly red states which rejected Medicaid expansion and the mostly blue states which implemented it. WSJ tries to address this by comparing states with similar demographics: “Deaths increased twice as much in New Hampshire (108%) and Maryland (44%)—expansion states—than in Maine (55%) and Virginia (22%). Drug fatalities shot up by 41% in Ohio while climbing 3% in non-expansion Wisconsin.”

Here WSJ is cherry-picking to some extent. Vermont is more like Maine than New Hampshire is and Vermont is an expansion state. There was “only” a 6% increase in opioid-related deaths in Vermont from 2013 to 2015; but I can’t find many such exceptions among similar states. There are states like Vermont which did support Medicaid expansion and had relatively low increases: California (5%), Oregon (11%), Arizona (4%); but these are exceptions. Maine is the “no” state with the highest increase; most of the rest of the “no”s had relatively low increases or, in a few cases, decreases.

It looks like there is a statistical correlation between expanding Medicaid eligibility and increases in opioid related death rates. A statistical correlation does NOT prove cause and effect. There is also a possible explanation for cause and effect: the huge difference between the copay on opioids and their street value coupled with the need of addicts for money.

Only 4.1% of Medicaid’s costs are the direct fulfillment of opioid prescriptions according to The Express Scripts study. However, the indirect costs of addiction to Medicaid must be much higher both since addiction itself needs treatment which must be paid for and because addiction leads to diseases and accidents which must be treated. If Medicaid is fueling addiction, then its costs will keep spiraling up.

The cost of addiction to society is huge and growing. Addiction is devastating both to addicts and to their families.

If expanding Medicaid caused drug-abuse to increase significantly, then base Medicaid is also likely fueling the problem, which is actually a crisis. Although nothing above proves that expanded Medicaid causes increased drug abuse, there is clearly enough reason for urgent study. Since Medicaid administration is a state responsibility (with many federal rules), states – including Vermont – ought to both examine the safeguards against over-prescription and resale and do actual forensic investigation of possible abuse including, of course, doctors and pharmacies. Of course, the feds should be looking as well.

Making sure everybody has access to affordable basic health care is a laudable goal. Avoiding the unintended consequence of damaging public health and safety with misspent healthcare dollars is a necessity.

August 17, 2017

American Tears

My nephew Luke’s maternal grandparents are holocaust survivors. On his paternal side we’re descended from refugees fleeing Eastern European pogroms. Luke’s wife, Sokchea, survived the Cambodian genocide. The events in Charlottesville led Sokchea to write this sad and beautiful letter to their baby daughter.

My innocent girl, in a few years, you will learn humanity's saddest lesson. No matter who you are or what you do, there are people who will hate you. They will say it's because of the color of your skin or where your ancestors came from. But it's just because you are different than them.

On that sad day, your dad and I will hold you and we will explain to you that nothing is wrong with you. You are a little girl who is loved by two very different people who found love by embracing their own differences. You don’t look like mommy, because you are unique. You don’t look like daddy, because you are unique.

You will have people ask you "what are you?" You will even have people call you names just because you look different. You’ll be faced with the gawking pupils of white men who may look at you in disgust. Or worse. And then you'll wonder why there are white women who are doing the same.

I write you this today because I saw something that struck me. Today I saw a sign calling out Jews and condemning immigrants to hell. They’re talking about you. They want to burn your Jewish side and desecrate your Cambodian soul. And I kept wondering, “how can they think that about you?” If only they can see your smile. Feel the gentle snuggle of your hugs in the mornings. Laugh at your baby babbles. Or maybe if they saw how you've learned to fake laugh or cry to get your way, would they still carry those signs and chant hatred? I wish more than anything that I can explain to them that you are not evil. You cry, laugh, and bleed just like them and their children.

But in the end - what I really want for you to know is that you are different. And that that difference is what makes this world worth exploring. Worth enjoying. Worth loving. Because if we were all alike - then we might as well live in front of a mirror. When you finally lose your innocence and begin to learn what makes you different - please remember that difference is what created you.

Stay safe, my love.

August 16, 2017

Whataboutism

Trump, Obama, and Naming Evil

Nothing excuses Donald Trump’s failure to immediately denounce Nazis, KKK members, and white separatists in Charlottesville immediately and by name. Even this slime has a right to march and speak; but they have no right to violence.  Moreover, he should have disowned their claim of allegiance to him even before their march turned violent.

While it is probably true that there were also counter-demonstrators spoiling for a fight, blaming them equally for the death that resulted is like excusing 9/11 because some victims may have been anti-Muslim.

Trump is not excused by his predecessor’s inability to say “radical Islam”; Trump correctly criticized Obama for that so presumably understands the consequence of not being able to say evil’s name. Trump is not excused by those on the left who remain deplorably silent in the wake of violent campus protests against free speech.

Nor is Obama’s failure to lay blame for much terrorism on radical Islamists retroactively excused by Trump’s latest offence. Those who won’t defend free speech are moral cowards or would-be censors no matter what Trump does or doesn’t do. Two wrongs don’t make a right.

According to an article by Jeremy Peters in The New York Times:

“There is also a new political term to describe the circular firing squad in which right and left have blamed the other for the country’s degenerating political debate — ‘whataboutism.’”

“What about” excuses nothing.

As a civil (I wish more civil) society, we suffer from both too little and too much name calling. Nazis, fascists on campus, the current government of Venezuela, racists, and radical Islam need to be called out for what they are. Leaders have a responsibility to speak frankly; they also have a responsibility to let us know how they see the world.

However, not everyone who thinks that immigration cost him his job is xenophobic. Some very good people want to see more gun control; some very good people believe that abortion is murder. All proponents of gay marriage are not agents of the devil; all opponents of gay marriage are not deplorables (HRC was against gay marriage before she was for it). Not everyone who marches with a “Black Lives Matters” banner is a would-be cop killer nor is every policeman who shoots someone of a different race a racist murderer.

David Brooks writes (also in the NYTimes):

“…I’m beginning to think the whole depressing spectacle of this moment — the Trump presidency and beyond — is caused by a breakdown of intellectual virtue, a breakdown in America’s ability to face evidence objectively, to pay due respect to reality, to deal with complex and unpleasant truths. The intellectual virtues may seem elitist, but once a country tolerates dishonesty, incuriosity and intellectual laziness, then everything else falls apart.

“The temptation is simply to blast the neo-Nazis, the alt-right, the Trumpkins and the rest for being bigoted, vicious and hate-filled. And some of that is necessary. The boundaries of common decency have to be defined.

“But throughout history the wiser minds have understood that anger and moral posturing are not a good antidote to rage and fanaticism. Competing vitriols only build on each other.”

There is no question these are hard and scary times. We make them worse both when we refuse to name evil AND when we label everyone we disagree with as being evil. Whataboutism excuses nothing.

August 14, 2017

If We’re All the Same, Who Needs Diversity?

“Diversity in schools and workplaces is crucial,” I remember being told, “because people from different ethnicities, places, economic situations and men and women have different points of view, different ways of looking at a problem.” My experience has been that diversity does bring all these benefits and more. Problems and opportunities are best attacked from diverse points of view.

But I have a question: If we’re all the same, then what does diversity mean? Why would it have any benefits?

An engineer at Google named James Damore wrote a memo on a company forum listing some statistical differences between men and women and giving reasonable although not conclusive sources for the differences he cites. He was supporting his argument that part of the reason there are more male programmers at Google than female is that women statistically may not want this job as often as men do. He’s been fired “for perpetuating stereotypes” even though he conscientiously pointed out that statistical differences between groups cannot and should not be used for judging individuals. It has become impermissible to talk about the differences which are one of the main benefits of diversity!

The Orwellian reality is that “diversity” has become a code word for uniformity of results. Somehow every subset of every profession should have a proportion of men and women, different ethnic groups, and different gender identities which exactly matches the population. I think we Jews are under-represented in the NBA just because statistically we are not very tall and don’t jump as well as certain other ethnic groups.

Like James Damore, I have to acknowledge that stereotypes which arise from some combination of statistical differences and prejudice do often prevent individuals from getting the consideration they deserve for jobs (and country club memberships). Like Damore I think this discrimination is wrong. Even more specifically I know that stereotypes and social pressure discourage some girls from pursuing “scientific” subjects and that these girls and society as a whole both lose by this stereotyping. One of my great pleasures as a grandfather is talking science and math with my granddaughters, both of whom have aptitudes for these subjects.

Even more important, though. I have tried to teach my children and grandchildren that nothing is unthinkable. What if less women than men want to be programmers? What if that’s the truth? We could look at the job and ask why it’s unattractive to many women. If the answer is that there’s a men’s club of programmers who make women uncomfortable, that culture should change.

But if the answer, or part of the answer, is that more (remember, we’re talking statistics) men than women are willing to (or want to) work in a job with minimal social interaction, why shouldn’t that choice be honored for those who make it? I’ve been programming for 57 years. Many of the great programmers I know have borderline Aspergers Syndrome. Many more males are diagnosed with Aspergers (and other autisms) than females. My point, and Damore’s, is that there is a spectrum of statistical differences between genders and so expecting all genders be equally represented in each profession is a dumb goal and leads to reverse discrimination and other dumb decisions.

 Individual choice as well as individual aptitude should determine choice of profession.  Opportunity, of course, must be equal; real results will vary.

Before judging Damore one way or the other, please read his paper. It’s interesting and well written.

Also please see an excellent op-ed in the NYTimes by David Brooks: Sundar Pichai Should Resign as Google’s C.E.O.

August 04, 2017

Hospital Competition Would be a Good Thing

Monday I blogged that ACA (aka the Affordable Care Act aka ObamaCare) is an unworkable political compromise between private health care and government run health care in which insurance companies become rent collectors but add no value. I asked “is it time to just give up the pretense and go to single payer?” – certainly something many on the left believe sincerely would be a good thing.

Reader John McClaughry commented:

“Don't cave in to the socialist "solution" - single payer - just because the fascist "solution" - ACA - fell apart. Replace the unconstitutional individual mandate with income tax based recapture of unpaid medical bills, plus capping the deduction for high priced plans, equalizing tax advantages for individuals, expanding HSAs, allowing catastrophic coverage, breaking up regional health care cartels, removing the efficacy requirement for pharmaceutical patents, allowing insurance purchasing groups, and imposing med mal tort reform. That's for openers.”

John’s suggestion that regional medical cartels be broken up is probably the most important.

A free market usually delivers better product at a decreasing cost over time. That’s even happened with energy despite fears of “peak oil” and it’s certainly happened with computers, telecommunications, and transportation. In order for a free market to work, there has to be competition. We business people don’t willingly lower our prices (and profits); we make reductions so our customers don’t desert us for lower-priced competitors. We don’t plow our money back into R&D just because we love to innovate; we make that investment because we’ll be out of business if a competitor has either a better mousetrap or one that costs less to make.

In much of the country including Vermont competition between hospitals is deliberately suppressed because of the socialist misconception that prices are lowest without the “cost” of over-capacity. Hospitals must get a Certificate of Public Need (CPG) in order to make an investment. They won’t get the CPG if a nearby hospital can demonstrate it already has capacity which will be duplicated. The CPG process assures no competition or pressure to lower cost and prices develops. In theory hospital rates are then regulated to make sure monopolies aren’t exploited. What really happens is that, without fear of competition, hospitals layer on costs such as high pay for doctors and administrators (but not nurses) or overelaborate facilities, which then justify higher prices.

In the competitive world, prices only go down if there is over-capacity. If my competitor and I are running our factories flat out, we won’t reduce prices. But we will add capacity (or someone else will). Pretty soon, as much as we don’t want to, we’re cutting prices to compete. If want to survive, we’re also desperately investing and innovating to distinguish our product and reduce the cost of production. Our customers win.

If there’s competition, some hospitals will fail; that’s a fact. Once airfares became competitive, some airlines failed (and survivors bought their assets at bankruptcy sales). Some of the hospitals which will fail will be “non-profits”. A socialist would say non-profits can offer lower prices because there are no investors demanding a return. Where that’s true, the non-profits will be survivors. If not, they deserve to fail – and should so that more efficient competitors can take their place.

If there’s competition, hospitals will be tempted to cut corners. That’s true and there are expenses we want them to trim. But what about safety? That’s what regulation is for. Airlines can cut costs (and prices) by jamming us in like sardines in the cheap seats; but they can’t put more people on a plane than can be safely evacuated. They can’t skip maintenance. Competitive hospitals will still have to be regulated, just not as much as they are now.

Of course competition is only effective where the consumers care about cost. That’s why McClaughry also suggests HSAs, available catastrophe-only plans, and income tax recapture of unpaid bills.

See also:

A For-Profit Surgical Center is a Good Idea for Vermont

Nice Business To Be In

Freedom, Responsibility, and Preexisting Conditions

Time to Face the Health Care Facts

 

 

August 03, 2017

Arlo by Night

What could be worse than a raccoon in the garden?

First Arlo, my DIY home video camera, discovered a groundhog in Mary's vegetable garden which is being raided faster than leaves can grow. While we were discussing groundhog-elimination strategies, Arlo made another discovery, this one using night vision.

 

In the end the raccoon climbs a ladder-like structure we shouldn't have left there to get to the raspberries.

So what could be worse? It only took a day to find out,

 

That's pretty bad and that was going to be my blog for the day... until a nice lady rear-ended me in traffic. Not my day.

Could be much worse, though. Only bent metal and plastic - and missing raspberries and grapes.

 

July 31, 2017

Nice Business To Be In

You’re in a business where the government requires Americans to buy your product. You’re only allowed to sell the blue-ribbon version of the product; you can’t legally sell an economy version. Many people can’t afford your product at the price you offer it; but that’s not a problem because the government will subsidize their purchase or just compensate you for selling at a “loss”. Competition is all but ruled out by laws which don’t allow a version of your product to be sold across state lines. Industry profits are setting records. What business are you in?

Health insurance, of course.

During last week’s fruitless debate on who pays for health care, Republicans threatened to repeal the individual mandate, the requirement that everybody buy or be offered health insurance. Not surprisingly the health insurance lobbyists were against letting people choose whether or not to buy their product. They pointed out, correctly, that many people wouldn’t buy at the prices they are charging. In Washington scorekeeping, people who choose not to buy insurance are people who will “lose their insurance coverage”.

Even worse, as the lobbyists pointed out, the people who would refuse to buy are young, healthy people who are very profitable. With the most profitable customers gone, rates would have to be even higher for everybody else. Unless Congress raised subsidies even higher, insurance as we’ve known it since the passage of the Affordable Care Act (aka ACA aka ObamaCare) would collapse. It’s hard to be sympathetic toward the insurance companies, which would have been hung in a noose of their own devising – costs going out of control because they can only offer plans no one can afford including coverage for pre-existing and politically expedient conditions and customers being unwilling and/or unable to buy. Strangely anti-corporate Sen. Elizabeth Warren was very concerned about the fate of the insurance companies. She quoted their dire predictions and neglected the attack I would have expected on their profits. Bernie Sanders lost no opportunity to criticize the Republican plan but was, at least in what I’ve read, uncharacteristically silent about profits. Warren and Sanders aren’t good long term allies for the insurance companies, however. They are honest that they want “single payer” health care. If we had that, insurance companies would be out of the loop entirely except perhaps for an opportunity to sell policies providing superior care to people with the money and willingness to buy them.

Although the ACA was passed with no Republican votes (sound familiar?), it was still a compromise between centrist Democrats who knew people wouldn’t like the mandatory coverage and weren’t ready to scrap private insurance and those who looked admiringly at government run and paid healthcare systems in much of the rest of the world.

 ACA has proved to be an unworkable compromise with some of the worst aspects of both public and private health; it’s a disaster financially even though less hospital bills go unpaid by patients. There hasn’t yet been a large-scale study showing improved health outcomes even though people who know their visits will be paid for are going to the doctor more. Costs are spiraling out of control. In my opinion keeping the private insurers in the loop has done nothing but pile on cost and complexity. Private solutions are beneficial when there is competition and a choice of both suppliers and product.  In many markets there are now one or only two providers; products must be gold-plated by government fiat.

Like many benefit programs, this one has proven to be a barbed hook. People are being subsidized by their own tax dollars (with a share subtracted for administration and insurance companies). They have no faith that they’ll be better off personally if cost of the “benefit” is done away with – and some won’t be. Even threatening to repeal the initially-hated personal mandate can’t pass Congress because the ACA (as well as insurance companies) will collapse without it.

So is it time to just give up the pretense and go to single payer? I think that would be a better alternative than trying to maintain the public-private monstrosity called ACA. I would prefer a truly competitive market both for health care insurance and for providing health care (with subsidies for the indigent as we do with food, fuel, and much else). Right now it doesn’t seem we have the political leadership to buck the insurance industry and get us either back to competition or to a government-run (ouch) system with no role for insurers who aren’t providing value.

Just to end on a happier note: Trump has tweeted a threat to make Congresspeople and their staffs buy their own health insurance on the exchanges. The ACA actually requires this but the Obama administration granted a waiver partially based on the fiction that each Congressional office is a small business with less than 50 employees on the average. That which can be waived can be unwaived. Might focus the congressional minds.

 

See also:

What if The Senate Really Debated Healthcare?

Freedom, Responsibility, and Preexisting Conditions

 

July 28, 2017

Arlo Captures Critter

At least on video.

I bought the basic wires-free version of Arlo as an experiment in DIY home security and am trying it in parallel with our traditional system. The first task we gave Arlo was to identify the critter who ransacks Mary's vegetable garden. It's taken awhile but finally Arlo did it. I thought it was rabbits; Mary bet on groundhogs. See the video for the winner

When first installed, Arlo gave lots of false alarms. The alerts can be received on your computer and/or smartphone. Birds were the most frequent cause. So we pointed him at a mass of critter-snack on the ground. Two days later, voila!

Note that you only see the critter leaving. This is because there is a delay between when motion is first sensed and when recording begins. We may have missed the critter a few times because of this so I tried turning up the sensitivity from 80% to 99%. Too many false alarms so had to turn it back down. According to marketing material Arlo Pro (more expensive) responds to motion almost immediately. You can mix and match so I'll probably put a Pro on critter duty and use the old camera for slow people.

 

See also:

Arlo: DIY Home Security

Alexa: The End of a Great Relationship

July 27, 2017

What if The Senate Really Debated Healthcare?

They do have an opportunity.

Thanks to John McCain’s typical bravery, the Senate has taken up the bill passed by the House and IS technically debating healthcare. This debate is a good thing. Who pays for healthcare (which is what this “debate” is actually about) is obviously an important issue. It certainly wasn’t solved for all time by the Democrat’s partisan imposition of ObamaCare; it won’t be solved by rolling the clock back to preObamaCare. Congress is supposed to debate before making policy. The debate is open to both Republicans and Democrats. It’s a slim, slim hope but maybe something good will come from this discussion.

The alternative would be no discussion at all. Many Senators on both sides of the aisle would have preferred no debate because they would have been spared from having to create a record of their votes on amendments. For some reason most of the “resistance” is also against having a debate in the Senate even to the point of vilifying McCain for his vote to allow debate. Frankly, I don’t get it. You’re against an imperial presidency (so am I) but you don’t want the legislature to do the job we elected them to do. Doesn’t compute.

Yes, I’m being a Pollyanna; but there is an opportunity for the actual bipartisan compromise and legislation John McCain pleaded for in his speech. Whether this happens or not is up to both Republicans and Democrats. For example, a Democrat can offer an amendment to the House Bill which solves some of the obvious problems with ObamaCare (like spending being on an unsustainable growth path) while preserving some of its benefits. Republicans might vote for that, especially if the Senate can avoid debating whether it is fixing or replacing ObamaCare and just concentrate on what affects people. A Republican can propose a phasedown of the absurdity of Medicaid with absolutely no limits while providing some funding so the exchanges can function with certainty. Will all Democrats vote against that? I hope not.

If anything passes the Senate, it’s got to go to committee with the House and be accepted there in some form. Tough problem but all House members are up for reelection next year. If a bill passes the House and Senate, it still needs a Presidential signature. I’m the last person to think Trump is predictable; but good chance he’d like to claim a victory (which is NOT a reason NOT to pass a bill).

The reality is that the status quo is not sustainable. Democrats know that the exchanges will simply implode without more funding and that funding isn’t going to happen without Republican votes. Republicans know now (if they didn’t before) that they will be blamed if healthcare funding collapses. Perfection won’t happen; progress can.

July 24, 2017

Even Hateful Speech is Free

The story below appeared on VTDigger:

BURLINGTON — City officials say they discovered racist and anti-semitic graffiti, involving a swastika and epithet, in the bathroom at the Fletcher Free Library.

The graffiti has since been painted over and library staff are working with the Burlington Police Department on the police investigation into the graffiti, according to a news release.

“As library director at the Fletcher Free, I want to reassure our community that such acts will not be tolerated here, as they are not tolerated anywhere in Burlington,” said Mary Danko, library director, in a prepared statement.

“Our support of free speech does not translate into tolerance for hate speech,” she added.

In his own statement included in the news release, Mayor Miro Weinberger said, “Hate speech of any kind in Burlington is unacceptable. It undermines our work to be a welcoming and inclusive community for all, and threatens the diversity that enriches our community.”

This is the comment I posted:

As a Jew, I resent anti-Semitic speech. However, as an American I am appalled that the Library Director and the Mayor are apparently saying that speech can and should be regulated according to its content. The right to free speech in the Constitution is meaningless unless it protects ALL speech. There is no need to protect speech everyone agrees with.

Defacing public property is a crime and should be punished. Graffiti should be removed from public places whether its content is hateful or benign.

Years ago there were flag burnings in Burlington. Many people (including me) thought them obnoxious. But these were rightly protected as exercises of free speech.

A city with many residents who pride themselves on "resistance" should be the last place to allow a government official to say what speech is "acceptable". There is no place in America for regulating speech according to its content.

See also:

Don’t Ban Anti-Semitic Speech

Motives Are for Mysteries

 

July 19, 2017

Debating Net Neutrality Live

Tomorrow, July 20, at noon ET I'll be debating "Net Neutrality" on "Vermont Edition", a Vermont Public Radio Program. Bradley Holt, a developer advocate and senior software engineer with IBM Watson Data Platform, will be defending the 2014 regulations. I'll be explaining why I think they stifle innovation and protect the dominant Internet players like Google and Amazon who lobbied for them. It's a live call in discussion moderated by Jane Lindholm.

Live streaming available at http://digital.vpr.net/online-streams.

More about the show at http://digital.vpr.net/post/net-neutrality-and-you-whats-stake-internet-regulation.

See also:

“Net Neutrality” Protects New Monopolies from Old

Internet Fast Lanes

An Open Letter to My Friends at Google

Don’t Make the Internet Safe for Monopolies

Drug-Addicted Babies

A Repugnant and Maybe Necessary Step

“From 2003 to 2012, the last year for which statistics are available, the number of babies born dependent on drugs grew nearly fivefold in the United States. Opioids are the main culprit, and states like Kentucky are particularly hard-hit: 15 of every 1,000 infants here are born dependent on opioids.” – from an article by Catherine Saint Louis last week in The New York Times.  

This tragedy effects not only the babies and the mothers who often can’t care for them. Neonatal intensive care units are overwhelmed and don’t have enough incubators both for these afflicted children and those born with other severe problems. It seems there is a news story every day in Vermont about the increase in children needing foster care. Should standards for foster families be relaxed to meet the increased need? How many more caseworkers do we need both to monitor more adoptions and to cope with a mushrooming case load of abused children and distressed families? These are just some of the questions which have no good answers but can’t be ignored.

What about prevention? We’ve tried a war on drugs. We lost. Will legalization of drugs decrease abuse? We haven’t finished the experiment but I doubt it.

If we can’t prevent drug abuse, perhaps we have to concentrate just on reducing the number of children born to drug addicted parents (I don’t mean just addicted mothers; I mean addicted fathers – present or absent – as well). Banning sex by addicted people – or even getting them to use condoms - is unlikely to work.

Suppose we offered $1000 no questions asked to anyone between 18 and 45 who is willing to be surgically sterilized. It may well be an offer that addicts can’t resist. Men may well be more inclined to take the offer than women. It probably would reduce the number of addicted babies and babies born to addicted parents six months after it goes into effect.

There is a lot to say against this idea. The money will go for yet more drugs. Some people will recover from their addiction and regret the choice they made when they were less than competent to make a life decision. There will certainly be people who take the $1000 just because they are in desperate need of cash – or to feed an alcohol or gambling addiction.

To some this will sound like the kind of racist eugenics which motivated Margaret Sanger and many other Americans when she founded Planned Parenthood. However, this is not a racist solution; something certainly needs to be done about addicts having addicted babies here in the snow-white parts of Vermont. The drug epidemic does not respect social classes. The decision to be sterilized will be as voluntary as the decision to use drugs; although clearly some people cannot help themselves when drugs are involved.

I find this idea repugnant, frankly; but I’m afraid it may be necessary. My hope is someone has a better idea. I know we must address this ongoing tragedy and will not be able to do so with rose-colored glasses on.

July 14, 2017

“Net Neutrality” Protects New Monopolies from Old

Over the next decade which companies do you think will be better able to exercise monopoly power?

  1. Amazon
  2. AT&T
  3. Comcast
  4. Facebook
  5. Google
  6. Regional phone companies
  7. Verizon

If you’d asked me this question in 2000, I would’ve picked AT&T, Comcast, Verizon, and regional phone companies. They are part of local duopolies for wired infrastructure.  They had a comfortable relationship with the FCC which regulated them nationally and with most of the state regulators. They saw the Internet as potentially disruptive and would’ve preferred to have its potential for innovation slowed by regulation. Amazon and Google (and most of the Internet community of the day) were against FCC regulation of the Internet exactly because that would chill innovation.

The Internet won; the FCC chose only the lightest of regulation. We got innovation; Facebook and Twitter happened; Google and Amazon grew enormously.

And then guess what. In 2014 at the urging of Google, Amazon, and the rest of the Internet establishment, the FCC decided it needed to regulate the Internet after all. In an Orwellian twist, this regulation was given the attractive name of Net Neutrality. Its stated purpose is to protect us from abuses that AT&T, Verizon, Comcast and the like “might” commit.

Are the telcos more powerful than they were in 2000? Of course not; even their landline duopolies are less powerful as more and more last mile access to content is wireless and wireless becomes more and more competitive.

Are Google and Amazon more in need of protection now than they were then? Sounds absurd but they’re the establishment now. They are strong enough so they can’t be toppled by smaller competitors with the same products. The only commercial threat to them – as it always is with dominant players – is disruptive innovation. And what better way to slow innovation than regulation? Note also that regulation is usually favored by those who think they can control the regulators (telcos in 2000; dominant Internet players in 2014).

“Net Neutraility” forbids telcos for charging content providers a premium for “fast lanes”. But Google, Amazon, et al already have private fast lanes and local data centers and data caches so that their content can reach consumers faster than content from anyone else. Conveniently Net Neutrality regs don’t cover the private internet expressways. In fact if you pay Amazon to host your site, you too can have a fast lane. But you can’t buy that fast lane from AT&T ala carte without the hosting because they’re not allowed to sell it.

What if someone were to provide a drone-mesh-based fast lane and charge more the faster you want your content to go? Would that be a threat to us? No. Would it be a threat to Amazon and Google? A little; it might be disruptive. Better, in their minds, to subject that service to the strait jacket of regulation. What if telemedicine requires a guaranteed faster service than the public Internet provides? Does it just have to wait until the whole Internet gets faster to start saving lives? Why shouldn’t AT&T or the drone-based ISP be able to sell the faster service at a premium?

If all the ins-and-outs of the Net Neutrality debate are hard to follow, just ask yourself in 2017 if Google’s search dominance is more of a present danger than AT&T’s eroding monopoly. I’m not for regulating Google or Amazon purely because of their size; but I’m certainly against regulation like so-called Net Neutrality which protects their dominance.

See also:

Internet Fast Lanes

An Open Letter to My Friends at Google

Don’t Make the Internet Safe for Monopolies

July 11, 2017

Freedom, Responsibility, and Preexisting Conditions

We want the freedom to decide whether or not to buy health insurance but we don’t want to take responsibility for the cost of healthcare when we get sick and don’t have insurance. Evidence: Americans hated the individual mandate in Obamacare enough to give Republicans control of Congress in 2010 and we are now insisting that Congress repeal the individual mandate WITHOUT leaving us uncovered for preexisting conditions. No politician of either party nor the President wants to tell us that we’re asking for freedom without responsibility. Not surprisingly there is no replacement for or repair of Obamacare which can meet these conflicting demands.

We don’t expect to be able to buy house insurance when we smell smoke. Banks mandate that we buy insurance before granting a mortgage.

We can’t get driver’s liability insurance after an accident. That’s why there’s a mandate for the protection of people we might hurt to buy liability insurance before we register a car. We don’t have to buy collision insurance for our cars; but we won’t get reimbursed after an accident we caused if we don’t. Fair enough and not buying may be a good economic decision if you can afford to replace your car. We certainly don’t expect to be able to buy insurance to cover a “preexisting” collision.

Just to be clear, I’m NOT talking about the problem of coverage for preexisting conditions if you change jobs and must change insurers or when you first leave your parent’s policy and get your own. As long as you have continued coverage from someone, there’s no actuarial problem in covering these conditions.

Insurance obviously only works if people buy it before they know whether they’ll need it. The premiums of the lucky ones who don’t collect fund the payouts for the unlucky ones who do have a loss (plus the expenses and profits of the insurance company). Obamacare acknowledged this by mandating that everyone buy insurance. This mandate actually makes the question of preexisting conditions moot. If you have to buy insurance, you can’t wait until you get sick to make the purchase. Everyone, healthy or not, is in the pool.

But Obamacare has its own contradictions which are causing its actuarial collapse. The cost of insurance for young people is so high and the penalties for not buying so low and so rarely enforced that young, healthy people are NOT buying. On the other hand, the premiums are kept low for older people (because of a hoped-forl subsidy by the young) so older, sicker people do buy. Insurance companies then pay more in claims than they collect in premiums. They either charge even higher premiums, which cause enrollment to drop further, or leave the insurance exchanges or collect a government subsidy or some combination of the three actions.

We can’t fix or replace Obamacare without facing the contradiction of wanting the freedom not to buy insurance without the responsibility of paying for care when we need it. Here are the options:

  1. Socialize all medical costs. Government pays them all. In essence, however, this amounts to an insurance mandate. We’d all be buying insurance but the cost would be hidden in our tax bills. Bernie Sanders will tell you that the cost will be in the tax bill of “the rich and the cawperations” but I’m afraid that money will also be needed for the free college he’s promised. We have already done this with the large percentage of Americans on Medicaid and, to a lesser extent, with us geezers on Medicare who did pay some (involuntary) premiums.
  2. Keep the individual mandate AND coverage for preexisting conditions and stiffen the penalty for not buying. Politics aside, this could work actuarily if premiums for younger people reflected the actual cost of insuring that age group; but then, of course, the cost to the elderly would go up. This solution is between a political rock and a hard place.
  3. Drop the individual mandate and leave those who choose not to buy insurance responsible for the medical costs they incur. Note that the indigent get “free” insurance in the form of Medicaid so they will not be affected. This does not mean that we leave people who gambled and lost to sicken or die; we can’t do that. Not buying insurance is a financial decision. The consequences of not buying should be financial as well. You get the care you need when you need it; you pay for that care either immediately if you can or over time if you can’t. Liens on assets and garnished salaries are as appropriate for collecting this debt as they are for any other.

The choice is stark: we either give up freedom or accept responsibility.

See also:

Freedom and Responsibility

July 07, 2017

Alexa: The End of a Great Relationship

“Alexa, you’re disappointing me,” I said.

“I’m not sure about that,” replied Alexa, my Amazon Echo.

I once described the device gushingly as a “wonderful listener”. I had great plans to make her the hub of the DIY home security system I’m designing. She used to play whatever music I asked for. She answered questions pretty well.

But the affair is over. Alexa doesn’t play nice with others anymore.

The Home Security Fail

Echo supports a website called IFTTT, which allows even non-nerds to program connections between devices and services. IFTTT is also supported by my home security camera, Arlo. Great, I thought, I can make them work together. There are already IFTTT scripts you can use so that you can tell Alexa to arm or disarm your security system. There are scripts to send email or texts when Arlo sees motion. But I couldn’t find a script to have Alexa tell me when the camera detects motion. “Aha,” I thought, “a product opportunity. I’ll write one.” (I’m retired; I would’ve just made it available free.)

Then I found out why there are no such scripts: Amazon does not support an IFTTT interface which lets you tell Echo to do things, only an interface so Alexa can tell other things what to do. In my experience a willingness to give suggestions but never take any on the part of one party does not lead to a good relationship. This is actually Amazon being selfish. Amazon-provided services, like the one they hope to make replace what’s left of the home telephone, can make Alexa speak up. But Amazon has apparently decided to keep this interface to themselves. They have a right to do that, but they make Alexa a lot less desirable as part of any system if she can’t be made to tell her owners what’s going on.

The Music Spat

“Alexa,” I said on Independence Day, “play ‘Courtesy of the Red, White, and Blue’.” Every 4th since 9/11 Mary and I play this Toby Keith song loudly.

“Here is a sample from ‘Courtesy of the Red, White, and Blue,” said Alexa and proceeded to play a 20 second snippet. Then she asked me if I wanted to sign up for an Amazon Music account.

I remembered that lately she has been picky about just playing music without specifying what service to get the music from. “Alexa, play ‘Courtesy of the Red, White, and Blue’ from my iHeart Radio account.”

“Do you want me to set up a ‘Courtesy of the Red, White, and Blue’ radio station on iHeart Radio?” she asked.

“When I said “no”, she just shut down and played nothing. So I tried again and said “yes”. She started to play music but not the song I asked for. She didn’t respond to some of my profanity.

I told her to play from Pandora. She said my Pandora account wasn’t linked (it used to be). I linked it. “Do you want me to set up a ‘Courtesy of the Red, White, and Blue’ radio station on Pandora?” Still can’t get her to play our song.

This all used to work so I did some research. Turns out that Echo now supports two types of music service linking: music library and radio stations. You can only get specific songs and artists from music libraries. Music libraries supported are only Amazon Music and Spotify paid service. iHeart and Pandora are “station suppliers” when accessed through Echo; they play songs like the ones you requested (in their opinion) but not what you requested.

Sorry, my dear Alexa, that doesn’t work for me. I made a Bluetooth connection between Echo and my droid phone (not as easy as it should be). Played ‘Courtesy of the Red, White, and Blue’ from my Google Music account, and made Alexa a Bluetooth speaker. Finally we heard our song. To be fair, this is very similar to Chromecasting (Google) my Amazon prime video to my TV.  Google doesn’t want to play nice with Amazon any more than vice versa. But it was Alexa I was infatuated with.

Alexa, you’re disappointing me.

See also:

Arlo: DIY Home Security

Alexa – Cover Your Ears

July 03, 2017

Freedom and Responsibility

Once the American Revolution was won, the colonies had the freedom they’d fought for. They also had the responsibility that came with freedom. When things went bad, there were no bossy Brits around to blame. And things did go bad. The Articles of Confederation adopted by the Continental Congress and eventual the colonies were inadequate during the war and a failure after. The current constitution, adopted in 1789, saved the day – but not without a great civil war.

A lesson for Independence Day is that freedom comes with responsibility.

We’re debating whether various drugs should be legalized. I think the answer, as it has been for alcohol, should be “yes”. With the freedom to use drugs comes responsibility (that’s why children, who aren’t responsible, don’t get freedom).  Drug use can’t be a mitigating factor for a crime even if the immediate decision to commit the crime was clouded by drugs. The decision to use drugs (or alcohol) led to the crime. Society has a responsibility to publicize the dangers of drug (or alcohol) use and to provide some help to those who are dependent. But, if society has an unlimited responsibility to those who choose to use, then society must take that choice away. That puts us back where we started with drug use banned. We can’t have freedom to use drugs without personal responsibility for their effects on us and how we deal with others.

We’re debating whether banks should be free from Dodd-Frank constraints. Yes, IMHO but only if they also have the freedom to fail. If there is any possibility of bailouts, then no freedom for banks. Bernie Sanders is right on this: too big to fail is too big to exist.

What about loans that provide the freedom to go to college? Sure. But the recipients have the responsibility to spend the money wisely and to pay it back whether they spent it wisely or not.

Shouldn’t we be free not to have our children vaccinated? No! Because you can’t take responsibility for the consequences either to your own children or to society as a whole, whose herd immunity is diminished by your choice. No freedom without responsibility.

What about freedom not to work at an “unfulfilling” job? Goes with the freedom not to eat assuming there’s some job available, you’re able to work, and there’s a daycare solution.

What about environmental regulation which restricts business? Businesses (I’m a businessman) should be careful what they wish for in this case. If there are no regulations, then you are responsible for harm that you do. Regulation can be a needed protection both against competitors who cut corners and unlimited liability. This is a tradeoff against freedom, one that I think we often need to make.

The glories of freedom should be celebrated on Independence Day. Celebrate responsibly!

June 28, 2017

Planting Cut Flowers

My friend Nancy quoted me a bit of extreme wisdom: “Making policy without studying history is like planting cut flowers.”

Bingo. Much of what passes for policy today is an attempt to get the bouquet and beauty of flowers without any messy work with seeds, roots, and dirt.

Healthcare won’t improve with the top dressing of more and more government subsidy. In fact life expectancy in the US has gone down for the first time since the peak of the AIDS epidemic despite the introduction of Obamacare. The roots of escalating health costs are obesity, opioids, and the fact that we can prolong life greatly if expense is not a consideration.

Businesses look for government grants to bypass the cumbersome business of attracting private investors or leveraging income from early sales.

We want a higher minimum wage without the training or skills which makes workers worth more.

We want everybody to be able to go to college without addressing the root problem that our K-12 system is graduating people who aren’t ready to flower in a post-secondary environment.

For politicians there’s an obvious advantage in planting cut flowers so long as they don’t whither before the next election. It takes a long time to make visible progress from the roots up. It behooves us all to study history.

June 23, 2017

Arlo: DIY Home Security

We already have a traditional home security system; but I’m a nerd so can’t resist the new gadgets. The sandbox for my experiment is Mary’s currently unprotected vegetable garden. Despite a fence, it is subject to immediate attack by critters unknown whenever a leaf pokes above the dirt. Nothing can survive there except weeds (critters don’t eat weeds), grapes, and raspberries. Obviously we need a crittercam to identify the culprit.

I bought Arlo (see picture below) because it’s double wireless: runs on lithium batteries and uses WiFi to talk to its base station. Software nerds try to avoid wires. The camera includes a motion detector so it only records video when it thinks something is going on. Video clips go immediately go the cloud where they’re stored free for seven days with more time available at a premium; the critter won’t be able to destroy anything to cover its video tracess. Arlo supports IFTTT (If This Then That), which lets me program connections with other devices. It comes from Netgear as does my router making me think (correctly) that setup would be easy, Arlo got pretty good reviews on Amazon. I did not do a thorough search of competitive devices – too many of them.

The starter kit comes with one camera and a base station, which can support up to 5 cameras on the free plan. The base station is physically connected to your router with an included Ethernet cable; does mean you must have a port available on your router. You put batteries in the camera and turn it on. You pair it with the base station by holding it close and pushing the pair button on both devices. Easier than Bluetooth. However, this tells us that the camera is communicating directly with the base station by WiFi and is not actually part of the WiFi network managed by your router.  You won’t like this limitation if you have used multiple routers to extend the area of your home WiFi network; the cameras will still all have to be in direct range of the base station and you may need multiple base stations.

You use the Arlo smartphone app (iOS or Android) to set up the camera and then the app is the best way to monitor what’s going on. First I put Arlo on a table in the living room. Every time I walked by, my phone promptly buzzed. The app let me view the latest recording (me shambling by), earlier recordings, or a “live” view – whatever the camera sees now regardless of whether motion has been detected. There is also a browser-based version of the app for use on your computer. If you want it to, Arlo will send you an email when he detects motion. Most intriguing, Arlo triggers IFTTT events; this means IFTTT scripts could be written to do almost anything when motion is detected including setting off an alarm (or perhaps a sprinkler in the garden). Will blog about that when I do it.

Once Arlo passed the living room test, it was time to install him as crittercam. The base is a metal hemisphere which attaches with one screw (even I can do that). There is a magnetic indent in the back of Arlo which gloms onto the hemisphere so you can angle the camera in a good range of directions. We angled him towards a collection of lettuce we’d put out as critter bait.

Arlo (2)

I may have angled Arlo too high. He reported a couple of intrusions but there was never anything to see. I do expect some false alarms; things move outside. Then I went out to take Arlo’s picture for this post. I thought he’d take a video of me taking a picture of him. But he didn’t notice me until I was latching the gate on the way out. I could need an Arlo Pro with advertised better sensitivity, a wider angle lens, and sound; nerds are suckers for upgrades.

Arlome

Haven’t caught the critter yet but it won’t be long.

June 20, 2017

Teach a Person to Fish and…

We all know the Chinese proverb:

“You give a poor man a fish and you feed him for a day. You teach him to fish and you give him an occupation that will feed him for a lifetime.”

Elon Musk, founder of Tesla and SpaceX, thinks that robots will do all the fishing we need so we’ll have to provide free fish daily:

“There will be fewer and fewer jobs that a robot cannot do better. I want to be clear. These are not things I wish will happen; these are things I think probably will happen. And if my assessment is correct and they probably will happen, than[sic] we have to think about what are we going to do about it? I think some kind of universal basic income is going to be necessary…”

Former Labor Secretary Robert Reich agrees:

“…we will get to a point, all our societies, where technology is displacing so many jobs, not just menial jobs but also professional jobs, that we’re going to have to take seriously the notion of a universal basic income.”

I think this is elitist nonsense. “You are useless,” is what Musk and Reich are saying to many people around the world; “but don’t worry; we’ll feed you like the animals in the zoo (so long as you vote the right people into office).” It’s hard to think of any worse solution to the non-existent problem of not enough jobs than a universal dole.

Bernie Sanders, whom Reich supported in the primaries, does believe in jobs. His plan for free college, at its best, would be a form of teaching people to fish. However a degree in political correctness with minors in sloppy thinking and grievance politics doesn’t teach you how to bait a hook… or how to weld or wire circuits or plumb. Of course there are college whose students are taught to fish. Champlain in Burlington, VT (of which Mary is a Board member) teaches not only accounting but also digital forensics. Not surprisingly, almost all its graduates get jobs.

Donald Trump, whom Reich calls a fascist, also believes in jobs; that belief got him elected. IMHO the reason so many people voted for Sanders and Trump is these voters don’t like being told by elites that they are useless. I think Trump is wrong to blame unemployment principally on foreign competition (including illegal immigrants); I think he is absolutely right to support apprenticeship programs as a way to teach fishing and welding and circuits and plumbing.

Apprenticeship is also the best way to learn computer programming, as I know from experience. Two more advantages of apprenticeship as opposed to classroom learning: your teacher is a useful role model because she is practicing what’s she’s teaching and you learn that you can learn a skill. The specific skill may become obsolete; it will certainly change. But, once you know you learned how to catch trout, you will be confident that you can learn to catch tuna.

We know there is no current shortage of skilled jobs, for many of which a college degree is useless. There is no unemployment among commercial truck drivers, welders, plumbers, electricians, dispatchers, etc. etc. Anyone with these skills can find work (although sometimes relocation is necessary).

But what about unskilled jobs? Well, they certainly haven’t disappeared yet; look at the help-wanted ads. Retailers are finding they need to pay more to get workers; always a good sign. One reason why entry-level wages haven’t gone up faster, unfortunately, is that welfare benefits in many states including Vermont go down more quickly than take home pay goes up at salaries near the minimum wage.

Farmers around the country are complaining that Trump has scared away the undocumented workers who used to work at minimum wage (if that) so there’s no way to harvest the crops or milk the cows. I admire the migrant workers and their work ethic. Farm work is hard; legal residents can earn as much or more at McDonalds, which doesn’t hire undocumented workers. Farmers will need to pay more to get people who do have an alternative to take hard farm jobs. That’s a good thing even though food prices will go up some. People won’t stop eating. But there are jobs!

Will these jobs exist tomorrow or will they all be automated away as Musk and Reich seem to think? My friend Andy Kessler writes:

“This is a false premise. All through history, automation has created more jobs than it destroyed. Washboards and wringers were replaced by increasingly inexpensive washing machines, while more women entered the workforce. Automated manufacturing and one-click buying has upended retail, yet throughout the U.S. millions of jobs go unfilled…

“The economics, which they apparently stopped teaching at Harvard, are straightforward: Lowering the cost of goods and services through automation allows capital—financial and human—to attack even harder problems. Wake me up when we run out of problems.”

Milking a cow is done with a machine. Clerks at McDonalds enter orders on computers. Automation makes each human’s contribution worth more, not less. All the jobs will change; some will disappear. New unimagined and better jobs will materialize. I’ve made a living for most of my life from computer programming. The job didn’t exist when I was born.

No one is “useless”. Our affluence lets us help those who need help; we should do that generously. The best help will often be teaching a person to fish.

See also: No Job is Bad

June 15, 2017

Fathers Are Coconut Shells

That’s our role with respect to our daughters; I have two. Father’s Day reminds me of this, but it’s been known since antiquity.

We’re supposed to be very tough, protect the vulnerable young ladies from any and all threats. Locking a girl up in a tower may be a bit extreme; but, if you remember, Rapunzel ended up living happily ever after.

We’re supposed to be very tough (I may have said this already); but we’re also supposed to lose. It wouldn’t be good for the coconut species if the fruit could easily be eaten by rodents; it also wouldn’t be good for the species if the shell were made of plastic. Eventually it has to rot away. It’s our job to lose, but not until the right suitor comes along.

If a young man blanches at the prospect of cleaning the Augean Stable, good riddance to bad rubbish. Do you think he’ll take out thrash? If he won’t fight the Nubian Lion, how’s he gonna deal with the IRS. If he can’t kill a Hydra, think of the crabgrass problem they’ll have. Don’t think he gets welcomed with open arms after he finishes his Herculean labors, either. By definition no one is good enough for a daughter.

His last task is to convince his beloved she wants to be with him even more than she wants to obey her father and then to bravely abscond with her. At that point we do our job and lose. The coconut shell shreds. Hopefully they live happily ever after.

We may even get to play with the grandchildren when our sons-in-law forgive us. They do get very understanding as soon as they have daughters of their own.

BTW, mothers have their own methods for dealing with unworthy daughter-in-law candidates. But they (the mothers) play rough.

Happy Father’s Day.

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