I know obscenity when I see it...

...and this post crosses the line. Talk about your gratuitous, disturbing content.

20TH CENTURY HISTORY MUST BE A SECOND SEMESTER CLASS AT DOWLING CATHOLIC

One of the selling points of Catholic schools is the way they are free to promote religious values. Dowling Catholic High School has found an interesting way to do this: by incorporating symbols of mass murder and athiesm into a marching band routine. The Des Moines Register reports:

Red flags of the former Union of Soviet Socialist Republics will be on display Friday when Dowling Catholic High School's marching band performs during halftime of the school's football game against Mason City

Well, it's nice that they can let bygones be bygones:

KIEV, Ukraine (AP) The bodies of 190 people were discovered at a monastery in western Ukraine that was used by the Soviet secret police after World War II, investigators said Thursday.

The remains including those of 70 children, some less than 1 year old were discovered by monks restoring a Greek Catholic monastery in Zhovkva, 340 miles west of the capital, Kiev, said Mykhailo Pavlyshyn, a leader of a team of experts investigating the burial site.

In fact millions of Catholics were murdered under the Soviet flag - many starved to death as a matter of policy - and thousands of churches destroyed or defiled. This was part of the great historical experiment documented in The Black Book of Communism:

The breakdown of the number of deaths given in the Black Book is as follows: 20 million in the Soviet Union, 65 million in the People's Republic of China, 1 million in Vietnam, 2 million in North Korea, 2 million in Cambodia, 1 million in the Communist states of Eastern Europe, 150,000 in Latin America, 1.7 million in Africa, 1.5 million in Afghanistan and 10,000 deaths "resulting from actions of the international communist movement and communist parties not in power."

Back to the Des Moines Register article:

The use of flags from the now-defunct communist empire is aesthetic, not political, said Steve Holland, Dowling band director.

Well, that's just so aesthetic. Here's a suggestion for the next home game: a routine where the flag girls charge the field to "Ride of the Valkyries" wearing brown military uniforms and carrying Nazi flags. Or maybe Klan robes and burning crosses to the theme of "Deliverance". Remember, it's just aesthetic, not political.

The Banana Republic of Polk County

Starting and running a small business is hard. There's a lot more to it than just selling something people want to buy. You have to pay and keep good employees and figure out how to get rid of bad ones without getting sued. You have to comply with nightmarishly complex tax laws. And it seems like everytime you need to do anything new, you need to get a permit from the city or the county.

What would you say if same county that holds the power to destroy your business by inspecting you to death or dragging its feet on a needed permit has decided to go into business as your competitor?

You could say, "Welcome to Polk County, Iowa."

DES MOINES MAKES A $1.9 MILLION EQUITY INVESTMENT IN A GLORIFIED SPORTS BAR

A company called inPlay wants to set up an "entertainment center" in the old General Growth building off Second Avenue in downtown Des Moines. They have an unusual equity partner. From the September 12 Des Moines Register:

To make the inPlay project work financially, City Councilman Chris Coleman said, the city and county came up with an unusual incentive package that would work as follows:

- Polk County would make an interest-free loan of $1,875,000 to the city, and the city would make a grant of that amount to Nelson Development for the inPlay project.

- The city would repay the loan in 10 annual installments of $187,500, using new property tax revenue from the project to make the payments.

The most unusual part of the agreement is a profit-sharing plan.

"When inPlay's percentage rent reaches a predetermined amount, the county, city and Nelson will split every dollar above that amount equally," according to the proposal presented Monday night. "Exact details of this structure will be clearly identified in the final loan documents," which will be presented later, the proposal said.

What a great deal. The city and county combine to give a business almost $2 million to compete with every other recreational business in Polk County. Meanwhile Larry Smithson, the Hunter family, the Coppolas and all of the other entrepreneurs who spent years hustling and scraping to keep downtown Des Moines from dying entirely now find the same government that can shut them down by pulling their liquor licenses is now going into business against them. If you think the government would never abuse its power like that, remember how Archie Brooks crudely threatened ZZZ Records with condemnation so that the developers favored by the city could take its building. The rest of the city council and county board may have better manners than the Civic Thug, but don't count on them having better souls.

HOW THE CITY TREATS LESS-FAVORED BUSINESSES

A story in the Des Moines Business Record gives a taste of how the county treats the businesses that it doesn't buy into:

Schaffer's owner Kari Smith would have to sell a lot of $3 cups of coffee at the café she wants to include in her new store to cover an expense created by a recent ordinance change in Greater Des Moines.

Recently, Smith learned that she is required to install a large grease catcher that could cost up to $75,000 for the 20-seat café at the building she plans to share with Boesen the Florist in the West Glen Town Center.

It's a cost she hadn't anticipated, and one that may cause her and her partners to change their plans.

Downtown a new coffee chain, Amici, is getting ready to open an espresso bar in the old Midland Building:

Greg Tornberg, president of Mille Miglia Caffe LLC, which owns the Amici locations, said his company is waiting to hear back from the WRA if the coffeehouse falls under the classification of a food service establishment and would be required to comply with the ordinance. He estimates that the cost to install the underground unit at the new store would be over $50,000.

Tornberg is hopeful that Amici will be excluded from the ordinance because the coffeehouses only prepare beverages, not food. The baked goods sold at Amici are bought from an outside vendor and baked offsite.

Bill Stowe, the bureaucrat in charge of the grease-trap police, doesn't sound eager to help:

"From our experience, a food service establishment can quickly expand from being just a coffee shop to a larger grease producer by adding items like croissants, sandwiches and French fries," Stowe said. "This is our method to be proactive with preventing sewerage overflows while meeting the EPA's requirements for keeping grease and contaminants out of the water."

If a bureaucrat can be this difficult just by being his usual official self, imagine how much fun he could be if he was one of your competitors.

The best that can come out of this deal is that existing businesses are paying taxes to lure and subsidize their competitors. If the government decides to squeeze its new competitors, things could get far worse.

Anytime a government looks ready to dump money into a business, two simple rules should apply:

1. If the business were sound, it could line up private equity and debt financing.

2. If it's not a sound business, the government shouldn't pour our tax money down the rathole.

But in the Banana Republic of Polk County, your government may soon be your competitor, too.

'We can't let them stop the music.'

I was working in Bettendorf five years ago today. I had scheduled my annual trip to the client, which typically took three days, around a concert in Iowa City by Bela Fleck and the Flecktones. I planned to head to the show - a one hour drive - after finishing the day's work at the client office.

It was a gorgeous day, and I was listening to the NPR news on the five-minute drive from the motel to the client office. Nothing out of the ordinary. When I reach the client office, though, I'm told "Did you hear two airplanes crashed into the World Trade Center?"

Puzzled, I asked "How could two airplanes hit the World Trade Center?" I didn't get it. One airplane - a freak accident. Two?

My client is a very smart man. He was the first I heard to suspect Al Queda. When Flight 93 crashed, he correctly suspected that the passengers took the plane down. We watched the towers collapse on his little office black and white TV. He shooed everyone out and got us back to work. Might as well; even in the top floor of the tallest building in Bettendorf, the terrorists probably weren't after us.



That left the concert. At the end of the day I called the University of Iowa ticket office, and they said the show was still a go. I had a half tank of gasoline, which was handy, because there were panic lines at the gas stations -- I thought it was moronic, because the hijackers didn't bring down any oil refineries or anything. I also thought the gas operators who raised their prices to $5 a gallon were doing the right thing - it was a way to slap some sense into the panic buyers - but the politicians cried "price gouging."

It was a great concert. I think I was the only male in the crowd with both short hair and no beard or mustache. I was probably the only accountant, too. The band started with one of their best songs, "Big Country," which now always says September 11 to me. During the concert Bela Fleck, whose family lives in lower Manhattan, said his family was all right. The Flecktones bassist, Victor Wooten, has his birthday on September 11 (happy birthday, Victor!). The band rocked, but I was strangely agitated and couldn't relax. The music was great, but I was preoccupied trying to sort out the days events and my mind kept drifting away from the music.

A year or two afterwards, Bela was touring with another great bassist, Edgar Meyer, doing a classical tour. They did a little seminar thingie during the day before the concert, and I had a chance to chat with Bela. I asked him about the September 11 show, and he said that they weren't sure whether they should play. Then Victor Wooten settled the issue when he said "We can't let them stop the music!"


That works as a battle cry, for me. The Islamists of September 11 were of the same ilk as those in Afghanistan, who literally stopped the music. They still want to. They've been trying since at least 1993. They're still at it and they'll keep at it. Nothing but our death, their death or our conversion to their death cult will satisfy them.

We can't let them stop the music.

Experiencing Oatmeal

The newspaper this morning came wrapped in one of those plastic bag that has ads and a free sample. It promised more than I think it is likely to deliver.



I thought it was appropriate, though, in that it enclosed the Des Moines Register, itself an oatmeal experience, in its own way.

I think this ad slogan also sums up the election for me. I know that voting is supposed to be a civic duty and all, but I'm really not happy with the selection. The partisans do their best to get us excited, but it's still just another oatmeal experience.

Governor: Culver v. Nussle

Iowa is one of the least dynamic states in the country. We have the same structure for delivering government services that we had 100 years ago. We have high taxes, 99 county sheriffs, 99 county attorneys, 99 little self-preserving political machines dedicated to keeping 99 sets of public employees employed. Our leaders attempt to grow the economy by taking money from our current businesses and using it to lure and subsidize their competition. And what do our leaders want to do?

Chet Culver wants to raid the public employee pension fund to lure and subsidize competition for existing businesses.

Jim Nussle wants us to grow and burn corn.

It's as if we're doomed to choose between Terry Branstad and Tom Vilsack forever.

The only reason Chet even gets on the ballot is because his father used to be Senator - and one of the most self-righteous and bombastic ones ever, on a level with Ted Kennedy. Oh, and because the Iowans voting in the Democratic primary decided he was the "electible" candidate, with the same keen insight that gave them the same idea about John Kerry.



And to think they could have had Ed Fallon. What were they thinking?

Nussle is running because it's his turn. That's how it seems to work with Iowa Republicans. Doug Gross had his turn last time, and Lightfoot had his turn before. I suppose Latham or somebody like that gets the next try.

I will vote for Nussle mostly because he's not Chet. He's shrewd and unlikely to really screw up anything. He's also unlikely to do anything worthwhile.

Come to think of it, comparing this choice to oatmeal isn't right. I actually like oatmeal.

Always cite this insightful site

Brent is impatient for a new post. The postman provided this:



That's what I like about blogging; you can fix embarrassing typos. Unless, of course, they really think people will be incited by Chuck Grassley. That's sort of like being whipped to a frenzy by a bowl of Cream of Wheat.

Iowa Pork!

Congressional appropriations bills have more pork that the Iowa State Fair. Here is a link to Iowa "earmarks" in the pending "Labor, Health and Human Services" appropriations bill. No doubt all of the spending reflects urgent national priorities, including:

$250,000: Des Moines - Blank Park Zoo for exhibits, programming and equipment.

Compared to Earthpork, maybe that's a bargain...

$250,000: Des Moines - Des Moines Area Community College, for training dislocated workers, and for career exploration and preparation for high school and community college students.

$250,000? That won't pay a single jobs training executive for one year!

$200,000: Cedar Falls - University of Northern Iowa to expand the National Institute of Technology for Inclusive Education We Build Communication Access Through Technology (WeBCATT) program

The acronym WeBCATT is worth $200,000 by itself!

$100,000: Des Moines - Community Kollel, for K-12 education programs

Who says pork can't be kosher??

$80,000:Cedar Rapids - National Czech & Slovak Museum & Library for upgrade of permanent collection.

Mmmm. Koloches!

Chet Culver spotted with Cliff Barnes

Gubernatorial Candidate Chet Culver was photographed with famous oilman Cliff Barnes (via State 29). Can we assume that J.R. is in the Nussle camp?

Don't let the door hit ya!

Archie Brooks resigned today from the Des Moines city council(hat tip: the Political Madman). Better 13 years too late than never.

From the Des Moines Register's copyrighted story:

Des Moines Mayor Frank Cownie said Brooks did the right thing.

"Nobody wants to be a detractor of the good things he has done," Cownie said. "It was his decision and something I'm sure he thought long and hard about. I think in his mind, he's doing the right thing. I think his decision is appropriate."

Archie has made many notable contributions to the community - from forgetting about whether he had ever dated Ramona Cunningham to forgetting about whether he had approved colossal bonuses to her to forgetting about trying to smear whistleblowers. And who can forget his threatening small east-side businesses to clear the way for well-connected interests economic development?

But the highlight of his career in public service will always be turning off the city's emergency radio system during the disastrous 1993 floods in a snit over being ordered to close the building where he worked. Yes, Mayor Cownie, let's remember all of the good things. What a guy.

Why don't you post more, Joe?

Good question.

For starters, I can't find my copy of "Crisis of Abundance," which is very embarrassing, so I'm reluctant to show my face here. I finished it while waiting for this parade, and then I had to run to the end of the parade route in the rain to rescue some wet marchers. Somehow I lost track of it in the madness and have yet to find it.

Second, I only post if I have something to say. If it's tax or Iowa, and it bothers me, I might post. Or not.

Third, I post elsewhere. I have my work blog and my picture blog so my Mom in Illinois can see lots of pictures of the boys, etc. Also I have posting rights at Chequer-Board for when something in Iowa needs wider notice.

Finally, a poster at a favorite infrequently-updated blog puts it well:

Look, it's not that I don't pay attention to the news. But frankly, I can't see any reason why anybody else should care about my opinion on world or national events. Anything I'd be inclined to say I'm sure has already been said, better than I could say it, somewhere else. Adding value, people. I've already got all the captive audience I need here at home, people I can harangue in person, and even tell to go to their room if they disagree with me.

There are a lot of smart bloggers out there. If I have something to get off my chest that is otherwise neglected - say, the stupid Clive traffic-light cameras - I'll say it. Most of the time, though, somebody else has already said it for me.

Absent due to absent-mindedness

No, I haven't abandoned the "Crisis of Abundance" series. I had just misplaced the book. You may wonder how I could do such a thing. Well, it's a little book, and I had put it where I put my bills and magazines until I sort through them, and then I sat down to pay my bills this weekend, and there it was. Vacation looms, so I will be finishing it up.

If you are looking for something to read meanwhile, I have two recommendations.

1. Kyle has an excellent post this morning, a cri de coeur about the lack of anything to vote for this fall in Iowa. While I quibble with some details of his post (some economic downturn, eh?), he lays out what I see as the real problem for his party - what do they want to actually do?

The money quote:

I'm infuriated by Democrats who spend more time on the stump talking about their opponent's failings than their own strengths. Maybe 8 years ago we could have made an argument that running as non-Republicans might win an election. By now, we should be pretty sure that's not going to work.

While Kyle is talking about his own party, the state Republican organization has a lot of the same problems. The Nussle program, as far as I can tell, is to make Iowa the Saudi Arabia of cornfuel. Yeah, that'll work, sure.

Meanwhile we have about 85 counties more than we need, a shriveling rural population, a government built for the 19th century, an insane income tax system - and nobody even mentions them. Yet it's hard to see how Iowa will achieve any kind of dynamism until somebody tackles these things.

2. The Wall Street Journal has a front page story today telling the story of Hao Wu, the imprisoned Chinese blogger-filmmaker whose face is featured on this home page to the left. I think the link only works for WSJ online subscribers, but it's worth paying 75 cents at the newsstand to read this.

He affects people here the same way

"In D.C., Vilsack stresses 'ordinary people'"

-headline on page 1 story in today's Des Moines Register.

LAZY SUNDAY 'CRISIS OF ABUNDANCE' POST

Yes, I'm still reading Crisis of Abundance, Arnold Kling's smart little book on health care economics. I should be posting more, and I apologize to the (almost certainly hypothetical) readers that have been eagerly awaiting my next post. Today - chapters 3 and 4

DOLLARS AND DECISIONS

Health care economics are all about deciding how best to spend the limited pool of dollars available. This may seem obvious when you think about it, but many people probably don't. It's easy if you look at in extreme terms. For example, lets assume we have a billion dollars to spend. What if we could use it to save one life through an incredibly expensive but 100% effective medical treatment? What if that person was already 80 years old? What if we could instead spend the money ensuring sanitary drinking water for an entire developing country, saving thousands of lives that would otherwise be lost through cholera or dysentery? From this viewpoint, you'd almost certainly decide to let the one guy die and save the thousands.

In real life the decisions are a lot closer, and sometimes the answers aren't at all clear. These are the problems Dr. Kling engages in chapter 3 of Crisis of Abundance. He makes five "key points" at the start of this brief chapter and fills them in.

What I get out of the chapter:

• A lot of health care spending isn't clearly necessary or unnecessary; it instead falls into a gray area.
  

• In a perfect world, we could look at a given medical procedure and measure the probability it will help, and value of the benefit if it does work, against the cost of the treatment. In the real world, we can only know the costs for sure; few treatments are 100% effective, and the value of the benefit of the treatment, even if it were 100% effective, is often at best a rough guess.

All of this is complicated by the availability of different diagnostic procedures and treatments with different possibilities of success. The "best" diagnostic tool might be only 10% more effective than the next best, but it may cost 3 times as much. It's not so important if it's a difference between a $10 procedure and a $30 procedure, especially for a serious ailment, but it can make a big difference when you have a $5000 procedure.

Given these difficulties, it's not surprising that different doctors and patients come to different conclusions. Even for Medicare, which is fully paid for out of taxes, the results vary widely by regions. One statistic jumps out of chapter 3"

The proportion of patients seeing 10 or more physicians in the last six months of life ranges from a low of 17 percent to a high of 58 percent."

I don't think it means we have widespread random malpractice in the treatment of dying patients. It does mean that a lot of capable doctors and concerned patients are groping in the dark for answers.

NO PERFECT HEALTH CARE SYSTEM

What, then, should a health care system look like? Chapter four begins to look at this. No system can be perfect. He starts the chapter as follows (highlights are mine):

Any health care system must reflect a compromise of preferences. We cannot have a health care that is both accessible and affordable while insulating consumers from the cost.

It's a point that should be obvious to grown ups, but is often lost in the health care debates. You can can't have whatever you want whenever you want it for free. So we have to sacrifice some combination of accessibility, affordability, or cost. Which go over the side?

accessibility. In a world where we ditch accessibility, says Dr. Kling,

The solution would be to have government set a budget that limits the supply of health care services. Bureaucrats would set health care priorities. Inevitably, some consumers would be denied treatments that they seek.

Affordability. Maybe we could decide we want the best heath care possible, screw the cost. Is that a good idea? At some point it seems you run out of money.

Insulation. Here Dr. Kling hits an area that is one of my pet ideas: if "somebody else" is buying, you'll spend more. The lottery winner just walked in and is buying drinks for the house? You put down your bar scotch and order the Glenlivet.

The conclusion? Dr. Kling puts says that "insulation" goes over the side:

For an economist, it makes sense to sacrifice the principle of insulation to promote unfettered access and affordability. The principle of access unfettered by bureaucratic intrusion is consistent with consumer choice, free trade, and other concepts that economists hold dear. The principle of affordability also has an obvious economic appeal. However, the principle of insulation has little or no economic justification. In fact, I think that the task for economists, and for Chapter 5 of this book, is to explain the high cost and dubious benefits of catering to the principle of insulation.

So on to chapter 5 in the next post.

Previous Crisis of Abundance posts (6!):

Expat comments on Crisis of Abundance Posts.
Premium medicine in action
C of A: "Three Health Care Narratives"
Crisis of Abundance: "Premium Medicine"
May 20, 2006
May 16, 2006

Hit me harder

"Civic leaders" are pushing an additional 1 cent sales tax for Polk, Dallas and Warren counties, according to the Des Moines Register:

Shoppers in Polk, Dallas and Warren counties would pay an extra penny per dollar on most things they buy as part of a plan by civic leaders to build more recreation trails and boost metro-area cultural attractions.

Supporters say a sales-tax increase to 7 percent would also give communities a new source of money to pay for law enforcement, libraries, street repairs and other services. That, they say, would result in lower property taxes.

Counties and cities have been asked to outline in writing how they would spend the money.

They'll need to convince folks that they are spending the money they have already wisely. I wonder if these folks will help with the campaign:


Ramona Cunningham and Senator Harkin at the dedication of CIETC Tom Harkin Learning Center.



Former CIETC Director, current Des Moines city councilman and self-proclaimed "rubber stamp" Tom Vlassis


Former CIETC Chairman and Des Moines City Council Member Archie Brooks

Legislators attempt to muster a Kelo-veto override session

Can the legislature reverse the veto of the eminent domain reform bill? It looks like they're going to try:

Republicans in the state legislature want to attempt to over-ride Democrat Governor Tom Vilsack's veto of a bill that would have limited city and county powers to seize private property for economic development projects.

House Speaker Christopher Rants, a Republican from Sioux City, is sending certified letters to all 100 members of the House, asking for their signature in support of such a move. "We understand that private property rights are one of the bedrock principles involved in the founding of this country," Rants says.

But while a big majority of the legislature's Democrats voted for the bill, they may not have the spine to stand up to their lame-duck leader:

But the effort is likely to fall short because Democratic leaders in the legislature say while a special session is "inevitable," they want to sit down and craft a new bill addressing some of the governor's concerns.

A primary victory tomorrow for Ed Fallon, a vocal supporter of the bill, would stiffen many a mushy spine. With no race for governor in the Republican primary, maybe some GOP property-rights fans will cross over for the day.

Expat comments on Crisis of Abundance Posts

I have finished chapters 3 and 4 of "Crisis of Abundance"; I will be preparing a post soon. Meanwhile, I will share comments from a reader who has experience with both the U.S. and U.K. health care systems and who has perceptive observations, which I am sharing with her permission. My reader is an old friend from college days who moved sometime ago to rural Scotland, and who renewed contact with me via stumbling on my work blog. The internet is a great thing. Her comments:

The topic of health care really gives food for thought. The US healthcare system is probably the one largest reason I will not be returning to the US to live. Not out of protest, but because I know how hard it will be to get insurance. We’re all still healthy, but the premiums, even for healthy people are crippling.

When I lived in Iowa City and was working at a small law firm, they couldn’t offer my health insurance. There were just two lawyers and the business couldn’t handle the burden. I had to get private health insurance for myself and the two boys. When I looked into it, I discovered that the premium each month for one adult and two healthy boys was larger than the rent on my house. I tried with higher deductibles, but the bottom line was, I couldn’t afford it. I was just an office worker and a single mother. With no child support coming from their father, it was all I could do to keep the rent paid, utilities, car insurance, food and clothing. There were times when the phone was off because the cash just wouldn’t stretch. I could have packed in the job. Then I would have had help with rent and state medical cover but that wasn’t my style. The point is, I am sure there are more working poor who are in the same boat. People who need to work but whose employers are small businesspeople.

Granted, I am not as dirt poor as I was 15 years ago but from what I gather, the situation isn’t improving. I’m just looking for some sort of solution in Crisis of Abundance. Yes, it’s terrible that doctors won’t just treat illnesses. They feel they must refer up the ladder either because they are afraid of being sued OR they know that they will make more money by referring to a more expensive specialist. Are specialists getting annoyed by all these referrals or do they just line up the patients and watch the cash roll in?

Over here in the UK, the GP (general practitioner) or family doctor is the work horse of the National Health Service – NHS. They see the bulk of the pathology that comes in to the NHS. They will treat the problem then and there to the best of their ability. They have diabetic and asthma clinics a couple times a week to care for the patients with chronic and specific problems. At these clinics, practice nurses will be aiding in the bulk of the work. If there is a patient who requires more treatment than is provided by the local GP run health centre, either because the problem has gone beyond their capability OR the health problem has become more acute it is then that the patient is referred on to the hospital where the specialists practice their arts.

In my job as a pharmaceutical salesperson, I speak to GPs every day. I also speak to the hospital specialists. I know that most GPs will prefer to treat at the primary level. Specialists hate to get spurious referrals they feel it wastes their time when they get a patient through there door, referred from GP who really should have treated the patient himself. But for the most part, everybody gets taken care of. From my perspective as a former US resident, I think the system is brilliant. Naturally there are holes and problems as with all human run systems. Slick US style diagnostics are kept for the large teaching hospitals and centres in large cities. Shame for us folk out in the sticks but we’ll get to see them if our conditions warrant shipping us in to town.

I am reading your current thread with great interest and hope that in the end you will be throwing a ray of hope on the situation. If I ever move back to the US, I don’t want to be panicked about health care.

My correspondent notes a U.K. medical culture that seems to disfavor U.S.-style "premium care. I believe Mr. Kling would say it's just such cultural differences that make it impossible to transplant Britain's NHS over here. In a recent post on his blog, though, he suggests that it would be good for one state to try a single-payer system as a laboratory test of how single-payer might work in the U.S. medical culture:

Right now, single-payer represents a "grass is greener" model, where advocates are free to tell us how wonderful everything is in Canada, the UK, France, or wherever. I want to see a state in the United States implement it, with our culture and our technology. Then we can talk about how the system really works, instead of people's fantasies about how it works.

Any takers?

Previous Crisis of Abundance posts:

Premium medicine in action
C of A: "Three Health Care Narratives"
Crisis of Abundance: "Premium Medicine"

May 20, 2006
May 16, 2006

Archie Brooks still has a friend

He has trouble remembering whether he's dated the executive director of the agency whose board he chaired and whose salary he set, or how often, and for how long. He turned off the city emergency radio tower during the catastrophic 1993 floods in a petulant fit. He can't remember writing memos trying to stifle the CIETC whistleblowers.

Through it all, Des Moines city councilman Archie Brooks still has kept one friend: Governor Vilsack, who will veto the new emininent domain restrictions passed overwhelmingly (Senate 43-6 and the Iowa House 89-5) by the Iowa legislature. And Archie will be cool with that, given his past:

City Councilman Archie Brooks said he will propose action within the next month to move forward with eminent domain proceedings.

He said the $450,000 offer is far more than what the city will give Hamilton. The properties are valued at $206,000, up almost $70,000 since 2001, according to county records.

"We're not asking him to do anything else than what others have already done," Brooks said. "We're not going to let this die. We've got people standing in line to buy those buildings over there."

Yes, we can't take away the right of responsible guys like Archie to sieze property from the unworthy in favor of the worthy. How can we possibly have economic development without superior intellects like Archie directing the process? And it fits perfectly with the Vilsack (and Blouin) economic development philosophy of taxing existing businesses to lure and subsidize their competitors.

More here.

Premium medicine in action

The thesis of Arnold Kling's Crisis of Abundance is that America's taste for "premium medicine" is the key to the rise in health-care costs. When I started reading the book, I laid out my own guesses as to the cause. One of them was a tendency to demand the latest, most expensive technology for health care. A Wall Street Journal story today ($link) shows these theories work together.

The story says that demand is so strong for the newest mammography technology, digital screening, that some patients are foregoing the old-fashioned kind even when digital is unavailable:

Interest is growing in the digital version of the breast-cancer screening test, driven in part by a study last fall in the New England Journal of Medicine that said digital was better for some women. The findings quickly became a marketing tool for makers of digital-mammography machines and hospitals that have them. Sales of the machines have been rising, with one major manufacturer citing digital equipment as the driving force behind record second-quarter revenue.

But some hospitals and doctors are concerned that the advantages of digital are being overestimated and may be causing women to delay getting a mammogram until digital machines arrive in their area. Still only about 11% of the 8,800 U.S. mammography facilities are estimated to have digital.

The story says:

The advice from doctors: Don't wait, especially if you are in one of the groups for whom digital has no demonstrated advantages. The study found that digital was better at detecting cancer only for premenopausal women, those under 50 years old, or those who have dense breasts. The majority of women who get mammograms are over 50, and looking at the 40,000 women in the study as a whole, the new technology was found to be no better than film overall.

Crisis of Abundance says

"An important characteristic of premium medicine is that many procedures have a low probability of affecting the outcome. In fact, often the procedures do not even affect the treatment plan."

Digital mammography seems an apt illustration of this point. It is more effective for only a minority of patients, and the treatment for a cancer discovered digitally doesn't differ from that discovered on film. Yet as it is the latest technology, and in short supply, the digital technology will cost more. It's an illustration of "premium medicine" that could have come right out of C of A. And, as C of A notes, spending on imaging services is growing twice as fast as health spending as a whole.

Maybe somebody will disprove the premium medicine explanation for high health costs, but it sure seems to me to explain a lot.

C of A: "Three Health Care Narratives"

Arnold Kling's "Crisis of Abundance" reads much faster than I am blogging it. Books continue to have a few clear advantage over newer technologies - portability and no bootup time. I read most of the second chapter during a half-hour piano lesson (the 2nd-graders, not mine). But setting my thoughts down on computer - that's harder to squeeze in.

Mr. Kling's first chapter talks about "premium medicine," the expensive tendency to use more specialists and more technology in healthcare. The second chapter stacks up the "premium medicine" theory of the rise of health care against what he considers the two other prominent explanations:

-a failure of private health insurance, and
-price gouging.

It's sad that anybody would take the idea of "price gouging" seriously anymore, but there it is. I won't spend any time on Mr. Kling's concise debunking of that nonsense.

The theory that private health insurance doesn't work is a more serious possibility. Mr. Kling summarizes it:

This narrative suggests that the main reason there are people without health insurance is that the risk pool has broken down. People who believe that they are healthy will opt out of insurance. People who are particularly sick will be rejected by insurance companies."

The theory of insurance failure does make sense, unlike the price-gouging narrative. As insurance companies exist to make money, why wouldn't they try to eliminate high-risk customers?

C of A addresses this by looking at data. The U.S. really has two parallel health insurance systems: private insurance for those under 65 and Medicare for the old folks. If private health insurance was the cause of high health costs, one would expect that health costs for Medicare receipients would reflect this, adjusted for the age of the receipient base. Mr. Kling concludes that Medicare doesn't work any better than private insurance at keeping costs down. He supports this by comparing U.S. costs and practices with countries with national heath insurance for all ages.

This makes sense, but it glosses over some issues with private insurance - it can be difficult to buy outside of a group, and there is adverse selection caused by healthy young people who save money by going without. I think regulations that prevent a free national market for health insurance are largely responsible for the problems of buying individual policies, but I am at a loss as to how to deal with those who voluntarily go uninsured. Is it a widespread problem? Does it really affect insurance prices? And how many people who say they "can't" get insurance really mean they "can't" get it at the price that they want to pay?

Handy C of A statistic:

As a line item of our national health care accounts, health insurane administration accounts for about 1 percent of GDP, out of total health care spending of 15 percent of GDP.

Crisis of Abundance: "Premium Medicine"

As a fitting sideline of my glamorous and thrill-filled life as a tax accountant, I am blogging my reading of "Crisis of Abundance," Arnold Kling's new book on health care economics.

Mr. Kling identifies "premium medicine" as the culprit for the continuing increase in healthcare costs. "Premium" medicine describes the routine use of high-tech diagnostic tools and specialists in everyday health care. While the book lays out statistics on this, it hit home best for me when he explained it in terms of one patient's odyssey in dealing with an eye inflammation. He discusses how the "Quixote's" inflammation would have probably been treated 30 years ago:

In this case, the patient might have been sent home with an antibiotic and perhaps a prescription for Prednisone, a steroid used to reduce inflammation. There would have been nothing else to do. In 1975, computerized medical imaging technology was new and exotic, with limited applications.

In contrast, in 2005, over the course of a few days Quixote was given a computed tomography scan, referred to a specialist, sent to a different hospital, referred to a specialty clinic, seen by a battery of specialists there, and given yet another CT scan. Ultimately, however, she was sent home, as she might have been 30 years ago, with an antibiotic, Prednisone, and no firm diagnosis.

I hadn't given much thought to this aspect of health costs - the way that even relatively routine health problems are made more expensive by the application of specialists and technology. I had always thought that was more of an issue for emergencies and life-threatening illnesses. Doctors aren't cheap to start with, and specialists probably tend to cost more. Add two CT scans, "a battery of specialists," a second hospital and a special clinic, and you've got one expensive eye inflammation.

It's an interesting problem. This shows that the application of expertise and technology doesn't necessarily change the treatment or the result. Yet in some cases it does - the MRI for the backache patient that identifies an unsuspected cancer in time, for example. I look forward to seeing what suggestions. Mr. Kling has for this.

Prior bookblogging of Crisis of Abundance:

May 20, 2006
May 16, 2006