Repairing a broken America - where the Trump oligarchy is vulnerable

I expect it will be transiently reversed, but the Jan 21, 2025 federal informer program was a historic marker. Nobody will be able to say they did not know.

The key to restoring a liberal democracy to America will be to identify and publicize Trump actions that his voters will find disturbing.  In a Bluesky thread I identified several measures that I think may resonate with non-college white men and women. I don't think Musk's impulsive nazi salute or the passing of liberal democracy or similar outrages will have much traction. I think these topics might. I will update this post as I collect ideas from more informed sources than me.

1. Corruption. I believe corruption has been the downfall of many authoritarian governments even in nations that are much further from a functional democracy than America. Do not tire of pointing out the corruption of Trump and his oligarchs. Do not omit the corruption of Congress (including many Dems) and of the Supreme Court.
2. Eugenics: Trump, Musk, Andreesen et al are true believers in eugenics. They believe that breeding must be encouraged among the cognitive elite. (Don't assume that the oligarchs are simple pigment racists, they will be more or less happy to include any cognitive elite.). They key here is that their eugenics enthusiasms exclude the majority of Trump voters. Most of them would not qualify as breeders.
3. Medicine: I will not be entirely unhappy if RFK leads HHS. If immunization rates fall low enough we will see some outbreaks of truly horrible diseases among (mostly) unvaccinated children. The images will resonate with Trump voters. Mothers in particular may be unhappy.
4. SCOTUS: If America has a future the Roberts Court will be counted among the most corrupt in history. I have a hunch there is a special vulnerability there.
5. Religion: There is a reason church and state were separated hundreds of years ago. America has many religions and many sects. They all compete for funds and followers. They all believe they know the true way, and that their rivals are at least somewhat wrong. There is a strong Catholic component to the Trump regime (esp SCOTUS), that cannot please his Protestant fundamentalist followers. Do not fail to remind Trump's religious fundamentalists that he his oligarchs are all agnostic or atheist.
6. Andreesen's Federal Bitcoin reserve: The use of "taxpayer money" to give Andreesen an exit from his bitcoin holdings will resonate with the Trump base. They do not mind oligarchs, but some will resent this.
7. Crushing support for cognitively disabled children: Andreesen and Trump seem to have a particular dislike for the support of cognitively disabled children. Their language and cuts are particularly cruel. (They apply to cognitively disabled adults as well, but that cohort is less photogenic.) In my experience conservatives are often personally supportive of the cognitively disabled and more sympathetic than many Dem elite. This cruelty should be exposed and shared.
8. Informer programs: The people of East Germany did not care for the STASI. Many of the Trump base will be offended by informer programs. Do not fail to publicize these.

It is two years to the midterms. Our goal is to show the Trump base that they have been cheated and betrayed. Some will vote Dem, many will decide not to vote. The 2026 midterms are the next battle for American democracy.

PS. I created a Perplexity page to gather advice from our AIs.

The Jan 21 2025 Federal OPM informer program is a historic milestone

The Office of Personnel Management (OPM) informer program launched within government on Jan 21 2025. This is a historic milestone.

 [1] “… If you are aware of a change in any contract description or personnel position description since November 5, 2024 to obscure the connection between the contract and DEIA or similar ideologies, please report all facts and circumstances to DEIAtruth@opm.gov within 10 days.”

https://chcoc.gov/sites/default/files/OPM%20Memo%20Initial%20Guidance%20Regarding%20DEIA%20Executive%20Orders.pdf

I think this may come to be seen as a tactical mistake. It is too early to launch informer programs, too early to turn colleagues into STASI style informers. The shape and form of the memo will rouse some. 

I worked for the Veterans Health Administration for six years and received DEI training during the Biden administration during the brief time the staff program ran before internal pushback ended it. I remember (fallible) one of our instructors as a black woman. Almost certainly a veteran. Patient, gentle, cautious -- the sort of person who will have friends and supporters. They will be unhappy.

I would not be surprised if the memo is rescinded and the author reassigned within the Trump administration. As I said - too early. But whether or not it is reversed, the wake up call is clear. Nobody will be able to say they did not know.

I am retired and, to be honest, I have been a bit at loose ends. In an odd way this is the sort of thing I've been waiting for. I'm reaching out locally to set up some in person discussions and networking for peaceful resistance and support.

On DOGE and government efficiency: bad software, bad regulations, underfunded commitments and more

I spent six years as a mid-level (regional) federal bureaucrat in VHA. I'm also a tech and economics geek with 20 years experience at a very large publicly traded corporation and through our children I have extensive experience as a consumer of federal government services. Lastly I don't have to worry about offending employers or colleagues.

All of which is to say that if you want to think about President Musk's government efficiency push these thoughts may be helpful.

1. The Federal government hires a lot of people to work around both software limitations and a rats nest of Congressional mandates and regulations that may have been well intended but are now obsolete and harmful. The mandates and regulations are only added, never removed.
2. Much of the federal government is outsourced to huge consulting firms that benefit from both less awful internal software and freedom from many federal mandates and regulations (famously including many laws constraining law enforcement). They take a large cut for themselves so their net efficiency effect might be positive or negative. If government became more efficient then much of that outsourcing should be reversed -- but that would drastically reduce campaign donations and post-political employment for public servants.
3. Government software quality was pretty good in the 80s and into the 90s. I've seen some good work in past few years, often by a very quiet semi-volunteer SV cohort that was brought in by Obama, survived Trump I, and continued through Biden.
4. The Federal government lives by unfunded mandates and underfunded commitments. Inefficiency in many forms is a major way to reduce spending on those commitments. A more efficient government would employ far fewer people but would spend more money. The net effect might be negative.
5. If software quality were improved, even without removing dysfunctional internal mandates and regulations, large numbers of working class American would lose what are often low paying but secure high benefit jobs. Even as the overall economy has far less to offer the non-academic class than it did even 20 years ago. Inefficient government employment is a model for what we will need to do for most Americans as our AIs develop.
6. The main reason federal software quality is poor is because federal software procurement follows rules set up in the 1980s to reform defense department purchasing and because of mandates designed to support military veterans and historically disadvantaged populations. These rules are incompatible with creating and maintaining complex software.
7. If government switched to modern software platforms there would be a huge expenditure to upgrade IT infrastructure.

That's about all I have. I know there are others who can offer far more detail, but they will usually be unable to speak freely. If you are a journalist I suggest hunting down other retired mid-level federal bureaucrats.

Naturalized and adopted citizens and Medicare/Social Security - the SSN class trap and a likely SSA software process failure

TLDR;

1. If you are a US citizen by naturalization or adoption you should check (call SSA and wait on phone for 1-2 hours) that your SSN is classified as US Citizen. The reclassification of an existing SSN has been an issue for over 40 years. If it is not correctly classified you will run into problems when you start Medicare or Social Security coverage (which can be at different times).
2. I think the rats nest of issues I ran into getting Medicare coverage arose because SSA software automates routine processes but it doesn't cover this problem. AND there isn't an effective process to manage exceptions to the automation rules.

Story

One of the joys of Oldness includes obligatory encounters with overwhelmed government services, not least the Social Security Administration. Recently I fought my way past the usual array of minor bugs and UI issues and browser incompatibilities to register for Medicare 8 weeks before my 65th birthday around May 30 2024.. I believe it was on the first day that I was eligible to start the process online.

That's where it went bad. After completing the application the screen briefly showed a confusing message about needing to submit some sort of additional documents -- but not which documents. I also got an email dated 6/3/24 saying to expect instructions. I waited ... and nothing happened. My online application status indicator stayed at the start of step II.

I checked the online status many times over the following weeks but nothing turned up. I finally phoned SSA and after about 1-2hours of waiting I got someone who started to work the problem. Somewhere during this process my line was disconnected. SSA staff don't have a way to call back or reach anyone who is disconnected.

After a week or two I were getting closer to my birthday and I forced myself to phone again. This time after 1-2 hours I was told to bring my naturalization certificate and state ID to our local SSA office.  I was later told this advice was wrong for my situation -- in fact they needed my passport and state ID. (I suspect two government approved IDs and my naturalization papers and birth certificate might have worked if I didn't have a passport.)

In the aftermath of the CrowdStrike fiasco I waited 3.5 hours in the local SSA office until I finally reached a very pleasant expert who looked at my passport and state ID, explained that my SSN classification was wrong, and passed on the correction to the one person who could process it. Somehow that happened the same day -- so I think she made an extra effort.

The SSN conversion thing is a problem -- two our children were born in Korea and both got caught out by this. SSA being overwhelmed is a problem too -- not everyone can spend hours and hours waiting on the phone or at the SSA office.

But the interesting problem to me is that I only received one of two emails that I was told were supposed to have been sent to me and neither of the two paper letters that were supposed to have been sent. In addition the description of the problem I saw in the original online submission form was incomplete and only showed there. 

I'm sure SSA believes I missed the 2nd email and that I threw out both SSA letters. The latter is especially unlikely; we have two special needs children and Emily does NOT miss SSA letters. It's a life, death, and taxes class thing.

That's what SSA would believe, but I think the letters were never mailed and the 2nd email was never generated. That what's would happen if the business logic in SSA automation didn't have a specific response to the SSN classification problem AND didn't have a good process for "problems not elsewhere classified". That would also explain the incomplete or misleading instructions my second phone rep passed on to me. It might even explain why the first phone rep might have dropped my call (lest she fall infinitely far behind).

I wasted a lot of hours dealing with this, and so did SSA staff. I worked for years with government software so I'm not optimistic this will get fixed; I suspect "edge cases" will be falling off the SSA process for decades to come. But I did write our state representative's office, so maybe the summer student will find a way to pass on the speculative bug report.

The LLM service I will pay for -- call Social Security for me

One of the fun things that happens to Americans as we become redundant to life's requirements is signing up for Medicare. There's a sort-of-useful cobbled together web site to do this. Processing is supposed to take under 30 days, though I've read the federal mandate is 45 days. Perplexity basically says it's heading towards 60 days average.

Anyway, my wee application is well over the 30 day limit. There's no way to contact anyone other than the phone. Which my wife assures me takes at least 45 minutes on hold. (Don't fall for the "call back" and "hold your place in line option" -- my wife tells me they simply don't bother.)

And, yes, the hold music is horrendous. As Emily says: "One of the challenges of getting old is listening to music on hold. No one ever tells us."

So, while I wait on hold I once again think how there's one LLM service I want to pay for. Want.

I want to give my Agent the social security and medicare data it is likely to such; case number, my SSN, my phone, etc.  I want it to call social security using my voice and sit on hold for days, weeks, years until someone accidentally answers. Then it begins the conversation while paging me to swap in .... with a text summary of current discussion and a timer to join in 5.... 4..... 3.... 2.... 1....

Yeah, that would be worth some money.

Update 7/19/2024: I finally got through to be told that requests were mailed to me 6/3 and 7/3 requesting additional information. We are very vigilant about social security correspondence so it's very unlikely they were delivered here. We have seen MN Post Offices lose tracked social security correspondence, presumably due to internal theft.

The IRS "Free Tax" scam and the hilarious reason why Turbo Tax is the only good free solution.

I wrote this for Facebook friends but I keep seeing people praising the "Free Tax" program and dissing Turbo Tax -- without any actual knowledge. So reprinting it here:

We did B's tax returns for 2022 using the IRS "Free Tax" program. This being America is kind of a scam. Sharing this as a guide to the unwary.

We used "TaxAct". She had state income tax forms for MN and CO. At the very end of the process you learn it costs $40 to print each state return. (Be careful when navigating, at first it seemed Federal eFile was not free; if you defer the state returns you just completed then the free option is available.)

MN is supposed to support Free File [1] but even after we removed Colorado from her form TaxAct still wanted $40 to print the state return. So reentering on the paper form.[2]

[1] Free File program are Arkansas, Arizona, Georgia, Idaho, Indiana, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Missouri, Mississippi, Montana, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, Vermont, Virginia and West Virginia, plus the District of Columbia.

[2] If you start at the MN site they don't include TaxAct on their list of FreeFile options. So if one chooses a vendor from MN site you might get a better results.

Hilariously, if you hunt around you can find the free and effective Turbo Tax program for simple returns. It's free because Intuit is in litigation and need to keep it free until that's done. 

United airlines passenger assault: Blame the Feds.

Involuntary bumped seat leading to assault on a United Airlines passenger?

Blame the Department of Transportation (emphases mine):

If you’re involuntarily denied boarding, the Department of Transportation regulates what you’re entitled to. Here are the rules, as published by the DOT …

… If the substitute transportation is scheduled to get you to your destination more than two hours later (four hours internationally), or if the airline does not make any substitute travel arrangements for you, the compensation doubles (400% of your one-way fare, $1350 maximum)….

The US government sets the maximum compensation amount. I suspect that amount was set years ago and hasn’t changed

The article I found this in calls $1,350 “sizable”. No. That is not “sizable". I was almost bumped myself because Delta couldn’t find takers of a similar offer. $1,350 was a reasonable offer in 1990. In our 2017 lives a reasonable offer starts at $5,000. If there has to be a  limit that limit should be around $10,000 — regardless of ticket price.

So, yeah, I hate United as much as most travelers. But this one the Feds own.

Crisis-T: what to do about the delusions and the lies.

I’ve been using “crisis-T” as a tag for our times. I used to think it was a bit melodramatic; that maybe T would somehow veer to the fantasies of Thiel and the like.

Welcome to week two of Crisis-T. A week in which I’ve started monitoring neo-soviet propaganda for clues to what Bannon, Flynn and Putin are thinking (the troika).

Emily and I are still working out how to respond to this. I hope the March for Science happens — I’d join that one way or another. We already subscribe to the NYT, The Atlantic, The New Yorker, and Talking Points — it’s essential to support journalism with hard coin. The 2018 congressional campaign has begun and we will be active (I’ll likely vote in the GOP primaries, more on that later). We’ve done our first of many ACLU and Planned Parenthood donations. Basically we more or less track what Scalzi is doing.

I write and tweet of course, but that’s more therapeutic than useful. It does mean though that I run into some of the issues that real journalists face. Like how to approach the maelstrom of lies and delusions that Bannon and Trump produce. On the one hand presidential speech is a form of action, it can’t be disregarded. On the other hand I’m beginning to worry Bannon is not a conventional idiot. He may have a real talent for strategic propaganda and effective distraction.

I wonder if we should treat the lie-stream like the weather.  Box it on the proverbial page 2 as Bannon-T lies and delusions of the day. Each lie-delusion is then listed with a contrasting statement of testable reality. Then the main pages can focus on even more important problems, like swapping the Joint Chiefs of Staff and Director of National Intelligence for Bannon on the principals committee of the National Security Council.

More as we figure this out …

Update Jan 30, 2017: Jeff Atwood has one of the best action lists I’ve seen.

After Trump: reflections on mass disability in a sleepless night

I’m having trouble sleeping. There are a few boring reasons for that, but the election is not helping. So it’s time to write while sleep-impaired. I’ll try to keep this short, but I’m also going to break it into sections.

Context

My son has a substantial cognitive disability and little prospect of self-sustaining employment. His temperament is different from mine. I am novelty-seeking and instinctively skeptical of authority, he loves routine and structure. I am Vulcan, he is Klingon.

I am elite. He is not. Obama is my ideal President, he declared for Trump (though, interestingly, he chose to abstain in the end). I used to be uneasy around police, he loves K9 cops.

My son’s growth and development has shaped my life and thought for 20 years. He has informed my thinking about mass disability, something I’ve been writing about for 8 years. Because of him I have sympathy even for the Deplorables, angry and lost in a world that doesn’t want them any more.

The Big Picture

I don’t think any period in human history has seen as much cultural change as America 1950-2016. Civil Rights. Feminism. Gay Rights. Atheist Rights. Gender Rights. I have a flexible mind, and I feel a bit awed by all I have had to unlearn and learn. It’s not just America that’s changed of course. I believe that, in addition to ecological collapse and economics, the 9/11 world is a reaction to the education and empowerment of women.

And then there’s the demographic transformation of America. There’s a fertility transition that continues to drop family size; without immigration America’s population would be shrinking.  There’s the rapid aging of the post-war boomers. There’s the transition of the euro-american to minority status.

Now add China. No period of human history has seen anything comparable to the rise of China — if only because it is nation of a billion people. The economic transformation is severe; there is a limit to how quickly economies can adapt.

And, of course, no period of human history has seen an intelligent machine. We live in the AI era. Not the sentient AI era, or at least not so far as I know. But we now have distributed, almost ubiquitous, machine intelligence. Pre-AI technologies have already eliminated much of the work that supported the non-college middle class. The service work that remains pays far less and demands strong emotional control. A control that many men, and some women, don’t have.

The AI era is the era of mass disability. An era when the work that is valued and compensated requires cognitive and emotional skills that perhaps 40% of the US population does not have. No, more college will not help.

Extreme cultural transformation. Demographics. China. The AI era and mass disability. I haven’t even mentioned that pre-AI technologies wiped out traditional media and enabled the growth of Facebook-fueled mass deception alt-media.

We should not be surprised that the wheels have come off the train.

The GOP in 2016

We will lose the consumer protections and financial regulation slowly built over the past 8 years. We will lose Obamacare. The Gender Rights movement will stall.

I’ve seen some talk of the Senate minority slowing this, but we are also going to lose the filibuster.  We are unlikely to win the House or Senate in 2018 — so this will happen.

This will be sad and it will hurt a lot of people, not least Trump supporters.

It may not be as bad as some fear though. ObamaCare was failing. It was a tough political compromise that ran into GOP hellfire; the GOP blocked the post-launch fixes any big legislation needs. It was from the start intensely corporate and bureaucratic, with a misguided focus on analytics and top-down controls. GOP Representatives and Senators are not going to risk the wrath of their constituents, especially the non-college whites who are at risk of losing coverage. There will be a replacement. It will cover fewer people but perhaps it can be built up.

CO2 control seems to be hopeless now, but I’m not so sure about that. Sure, Trump is an idiot, but not everyone in the GOP truly believes that global warming is a good idea. There’s a chance the GOP will make changes that Obama could never get past the GOP.

This was all going to happen with any large GOP victory. Indeed, with his political core of white non-college voters Trump is going to be more cautious that Cruz or Ryan.

Trump: the mass disability conversation

I once wrote a blog post titled "Donald Trump is a sign of a healthy democracy. Really.”. It was really prescient:

… I enjoy seeing the GOP suffer for its (many) sins, and it would be very good for the world if the GOP loses the 2016 presidential election, but Trump won’t cause any lasting political damage. Unless he runs as a third party candidate he’ll have no real impact on the elections.

Hah-hah. Laughs on me.

This part holds up better:

Trump appears to be channeling the most important cohort in the modern world — people who are not going to complete the advanced academic track we call college. Canada has the world’s highest “college” graduation rate at 55.8%, but that number is heavily biased by programs that can resemble the senior year of American High School …

… about 40-50% population of Canadians have an IQ under 100. Most of this group will struggle to complete an academic program even given the strongest work ethic, personal discipline, and external support…

… this cohort, about 40% of the human race, has experienced at least 40 years of declining income and shrinking employment opportunities. We no longer employ millions of clerks to file papers, or harvest crops, or dig ditches, or fill gas tanks or even assemble cars. That work has gone, some to other countries but most to automation. Those jobs aren’t coming back.

The future for about half of all Americans, and all humans, looks grim. When Trump talks to his white audience about immigrants taking jobs and betrayal by the elite he is starting a conversation we need to have.

It doesn’t matter that Trump is a buffoon, or that restricting immigration won’t make any difference. It matters that the conversation is starting. After all, how far do you think anyone would get telling 40% of America that there is no place for them in current order because they’re not “smart” enough?

Yeah, not very far at all.

This is how democracy deals with hard conversations. It begins with yelling and ranting and blowhards. Eventually the conversation mutates. Painful thoughts become less painful. Facts are slowly accepted. Solutions begin to emerge…

I guess we’re having the conversation now. Too bad we didn’t have it four years ago. Obama, my ideal president, missed that one. He wasn’t alone, as recently as 2015 I complained “Both DeLong and Krugman missed the college vs. no-college white middle-age cohort, and I think that’s the important story” (K had a false start in 2012.)

Late in the campaign Obama picked up the theme with work on labor market monopsony and “predistribution”. Some of the Bernie Sanders themes that Clinton adopted, like free community college, were a first step. Overall though my team missed this one. It was a huge miss. They should have been reading Gordon’s Notes …

Trump: white nationalism and patriarchy

Half of college educated white women voters voted for Trump. I can’t quite get my head around that one. That cohort would have given Clinton the election.

Half.

What do we understand that? We need to resurrect anthropology and fuse it with journalism. How? I’ve no idea, but we need a way to explain ourselves to ourselves. A NYT piece made a good start with an interview of some of these women. Rage about the Black Lives Matter movement and critiques of police (prime job for the blue collar) were a factor; as well as susceptibility to Facebook-fueled right wing agitprop. I suspect these women are also relatively comfortable with traditional male-female roles. They want a “strong leader”; maybe they favor “enlightened patriarchy”. (The article had one significant error, it claimed white college-educated women voted for HRC. They did not. If they had we wouldn’t be talking about this.)

The whites are acting like a tribe. It’s different from acting like we own the country. This is shades of old racism mixed with aggrievement, loss, and bitterness. Unfortunately, unlike other tribes, the white tribe votes.

Reagan pioneered the use of white racism to win power. Trump has kicked it up several notches. He has summoned  our demons at just the right wrong time. Now we live with the consequences. Trump isn’t going to beat these demons back, he is much more racist than Reagan was (more than most of us imagined).

On the other hand the GOP is going to get nervous about this. The party is not going to be comfortable with overt white racism. There will be some GOP help with stuffing the Nazis and Klansmen back in the bottle. We will need that help.

The Resistance

In my home town of St Paul Minnesota a mob has been blocking a freeway. That’s dumb team. Stop doing that. We need more leadership. There’s a guy I know who’s going to be out of a job in seven weeks…

Ok, so Obama is probably going to want to take a break. We are going to need someone though. This isn’t just one crazy election. Remember the “Big Picture”. There are huge forces at work, especially the lack of demand for non-elite labor (what I call “mass disability”). If you think we’re in trouble now, imagine what’s going to happen to China in the next few years. (Russia is toast.)

We need to oppose Trump. He’s a twisted wreck. I suspect, however, that he’s going to find a lot of long knives in DC. The GOP leadership are not nice people, and they prefer Pence to Trump (not that Pence is good news).

We need to oppose Trump, but we also need to remember why we have Trump. We need to focus on the big picture - there are solutions. We live in whitewater times; we need to hold onto each other while we try to steer the raft. Because there’s a waterfall ahead …

See also: 

I’ve been writing about this for a bit over 8 years …

KRISTOF: Watching the Jobs Go By - his weakest column in years 2/2004. Very early thoughts in this direction.

Why your daughters should be roofers — not architects 3/2004. Precursor ideas.

On redistribution 6/2004. From an article in The Atlantic: “It is doubtful that in any society with universal suffrage the majority is going to sit on the sidelines and watch, generation after generation, while a handful of investors and corporate managers reap almost all the benefits of technological and economic progress."

The limits of disaster predictions: complex adaptive systems 2/2007. We have survived doom before.

Mass disability and Great Depression 2.0 3/2008. 

"I believe that about 20% of adult Americans aged 25 to 65 are effectively disabled in our current globalized post-industrial economy. I believe this number will rise as our population ages. I believe this is the fundamental problem, along with network effects, driving modern wealth concentration.

Over time the economy will change to develop niches for unused capacity (servant economy?), but the transition need not be comfortable. In the meantime technological shocks, such as ubiquitous robotics, may induce new disruptions to a non-equilibrium economic structure — risking extensive economic breakdown."

Causes of the Great Recession: China, GPSII and RCIIIT. Now for Act III 4/2010

Civilization is stronger than we think: Structural deficits and complex adaptive systems 5/2010. Hope.

Post-industrial employment: adjusting to a new world 5/2010. College is not the answer.

Unemployment and the new American economy - with some fixes. 1/2011 “In a virtualized economy workers with average analytic and social IQ less than 125 are increasingly disabled. Since this average falls with age the rate of disability is rising as the we boomers accumulate entropy …Start applying the lessons learned from providing employment to cognitively impaired adults to the entire US population.” Looking back this is when my thinking about mass disability began to crystallize.

Mass disability goes mainstream: disequilibria and RCIIT 11/2011. I thought we’d have the conversation then, but it didn’t go forward. Unfortunately.

Life in the post-AI world. What’s next? 9/2011

The Post-AI era is also the era of mass disability One of my favorites. 12/2012

Addressing structural underemployment (aka mass disability) 5/2013 Some ideas on solutions. Good ideas by the way.

Donald Trump is a sign of a healthy democracy. Really. 8/2015

Trump explained: Non-college white Americans now have higher middle-aged death rates than black Americans 11/2015 “Both DeLong and Krugman missed the college vs. no-college white middle-age cohort, and I think that’s the important story” 

Trumpism: a transition function to the world of mass disability 8/2016

How does the world look to Trump’s core supporters? 9/2016.

After Trump: information wants to be free, but knowledge is expensive 11/2016. This feels fixable, but it’s a fundamental problem.

What socioeconomic support will look like in 20 years

This is what I think socioeconomic support will look like in 2040 based on cognitive [2] quintiles.

The bottom quintile (0-20%, non-voters) will have supported work environments and direct income subsidies; an improved version of what most [1] wealthy nations do for the 0-5% of adults currently considered cognitively “disabled” [1].

The second quintile (20-40%, Trump base if white) will have subsidized employment (direct or indirect).

The fifth quintile (80-100%) will live much as they do now.

I don’t know what happens to the 3rd and 4th quintile.

- fn -

[1] The US is currently “mainstreaming” the cognitively disabled into relatively unsupported work, a well intentioned and evidence-free project by (my) Team Liberal that is going to end in tears.

[2]  In US male euros (avoid racism/sexism effects) maps to academic achievement which tests learning, social skills, temperament and the like.

Minnesota explained: Rubio, Sanders and the President Gordon agenda.

My home state of Minnesota, most annoyingly, uses caucuses. I attend the Dem variety in the bluest of neighborhoods. They are crowded, disorganized and well meaning. When I ride my bike to caucus cars slam to a stop as though I were a family of 5 on foot. Which is wrong and dangerous, but I appreciate the sentiment.

The Dem caucus is not representative of the Dem voter. You have to be very persistent to fight through traffic and crowds to hit the narrow window for voting. Only the most committed can get there. The caucus system is a bad, bad idea. I think the same is true of the GOP caucuses here.

So the caucus results last night were not too surprising.

The GOP, as usual, went for the extreme right candidates. This year there were three of ‘em - Trump, Rubio and Cruz. Since we have one of the strongest economies in the US, with unemployment under 5% for years, Trump didn’t have his usual vote-of-despair left-behind advantage. So the three extremes ended up with fairly similar numbers, but the anti-Trump movement focused on Rubio and he won.

My team went, as usual, for the more left candidate. Sanders won by 20%, so he might even have won a primary. I voted for HRC, but the MN DFL is effectively to the left of me — which is saying a lot.

I’m backing HRC but, in truth, we need to go down some variation of the Sanders road over the next two decades. We’re going to have to bias the post-AI globalized economy to generate jobs for the non-college — even at the cost of economic efficiency. We have to build more social supports for people who aren’t working, with some kind of rethinking of what we do for disabled workers. We may end up with a non-binary definition of disability, or even some kind of guaranteed income.

We will end up taxing wealth in one form or another and we’ll do a  lot more government redistribution. We should also, and this is not so much Sanders, execute on the old Gore “reinventing government” mission, refactoring regulatory systems. We need to break the accounting, tax and regulatory frameworks the mega-corporations (“neo-Chaebol is a term I like) have built; the foundations of a great stagnation ecosystem wherein new companies are built only for acquisition.

We need to build supports that enable entrepreneurial types to pick business designs off a shelf and implement them. We need to strip benefits from employment completely, and both fix and finish the mission the ACA started — while breaking the corporatization of that great compromise.

Phew. It’s a big mission, but it is doable. We have to do it, or we get President Trump. Or worse. Sooner or later. 

So I don’t feel that bad that Sanders won Minnesota. It’s a good sign for the future. I don’t want him to go up against the GOP though. By the time their attack machine is done with him he’ll be hiding in a stone shelter in the wilderness. HRC’s great strength is she’s lived that machine for decades. Nobody short of Obama can equal that. (And, of course, I would love him to keep his job. Alas, even if our constitution allowed that I think he’s ready for a change.)

See also:

• The AI Age: Siri and Me 12/2011
• Causes of the Great Recession: China, GPSII and RCIIIT. Now for Act III. 4/2010. Holds up pretty well, but I now add a third somewhat related factor of a mega-corp created environment that’s toxic to the startups that historically create employment.
• Amerisclerosis? Why US underemployment (and probably inequality) persists 9/2013. Secular stagnation is the current term.
• Mass disability goes mainstream: disequilibria and RCIIT 11/2011. In the new age there jobs for the high EQ/IQ. Others are not so needed.
• Ants, corporations and the great stagnation 12/2011
• Causes of the crash of ’08 - how much fraud? 2/2009. Good to look back, but I know think these were secondary causes. For example, IT enabled complexity and complexity enabled fraud.
• Civilization is stronger than we think: Structural deficits and complex adaptive systems 5/2010. Trumpism is scary, but it’s also the way the “meta-mind” approaches big hard changes.
• Donald Trump is a sign of a healthy democracy. Really. 8/2015. The problem of the unwanted non-college (“working class”) isn’t going to be solved by more education. Remember, the non-sentient AI revolution will come for you too.
• For American adults are poverty and disability the same thing? 10/2013. I think this is true for white and asian men in America, for others racism also drives poverty. (I mention this at the end of the post but should have had it up front.)

American economy 2015: Ta-Nehisi Coates and Donald Trump lead to the same conclusion.

Donald Trump as the voice of the non-college 50%. TNC on the mass (black) incarceration society - and reparations. Hundreds of colleges produce no earnings boost (but lots of debt).

There is a common thread. America needs 40 million non-college jobs that pay $30 an hour.

That is our 21st century “Manhattan project” class challenge.

Get creative.

Happy accident fraud - Feds move on Aetna and other health insurers with deceptive provider listings

Happy accident frauds are emergent frauds — nobody needs to plan them. Don’t put your Disability Claims office on the fifth floor of a building with a faulty elevator to defraud anyone, just do it for the cheap rent. Then save costs by replacing your customer support staff with an automated call management system.

The insurance industry is great at emergent frauds enabled by complexity and powered by perverse incentives. It’s baked into their business model; any player who doesn’t cheat will go bankrupt.

So it’s not surprising that health insurers competing in public marketplaces have produced inaccurate physician directories. It’s not limited to public ACA style coverage, we get our Minnesota health care through an employer plan, and after we chose Aetna we discovered their oral surgery listings were fictional. They seemed to have many providers available in our area, but all the ones we called said the listing was wrong.

Why pay the costs to maintain an accurate listing when an inaccurate listing gets you customers who can’t actually make claims?

The good news is that the Obama administration is now starting to address the problem. Alas, the fines are likely to be pathetically small, we’ll need class action litigation to really change things or find ways to drive the worst offenders out of business by failure of ‘network adequacy’. (emphases mine, note the related problem of prince concealment in the industry, another part of a fundamentally murky business)

White House Moves to Fix 2 Key Consumer Complaints About Health Care Law - NYTimes.com

The White House is moving to address two of the most common consumer complaints about the sale of health insurance under the Affordable Care Act: that doctor directories are inaccurate, and that patients are hit with unexpected bills for costs not covered by insurance.

Federal health officials said this week that they would require insurers to update and correct “provider directories” at least once a month, with financial penalties for insurers that failed to do so. In addition, they hope to provide an “out-of-pocket cost calculator” to estimate the total annual cost under a given health insurance plan. The calculator would take account of premiums, subsidies, co-payments, deductibles and other out-of-pocket costs, as well as a person’s age and medical needs.

Since insurers began selling coverage through public marketplaces 19 months ago, many consumers and doctors have complained that the physician directories are full of inaccuracies. “These directories are almost out of date as soon as they are printed,” said Kevin J. Counihan, the chief executive of the federal insurance marketplace.

Medicare and Medicaid officials have found similar problems in the directories of insurance companies that manage care for beneficiaries of those programs. In December, federal investigators said that more than a third of doctors listed as participating in Medicaid plans could not be found at the locations listed.

The new standards significantly strengthen an earlier rule, which required insurers to publish directories online and to make paper copies available on request. In the federal exchange, violations are subject to civil penalties of up to $100 a day [ed: 0.000001% of revenue?] for each person adversely affected.

Federal officials said that inaccurate provider directories could be a sign of larger problems. If doctors listed in a directory are not available or are not taking new patients, consumers may not have access to covered services, and the insurers may not meet federal standards for “network adequacy,” the officials said. Consumers must often pay extra when they use doctors outside the network of their health plan, so an inaccurate directory could also lead to higher costs for patients.

… Aetna says that data in its directory is “subject to change at any time.” UnitedHealth tells Medicare beneficiaries, “A doctor listed in the directory when you enroll in a plan may not be available when your benefits become effective.” …

See also:

• Emergence: how entropy and incentives create scams: 2009, Aetna’s FSA management - just make it hard to process a claim
• Mobile phone fraud - The accidental data charge and other scams: 11/2009. A lot of these scams have gone away during the Obama administration, thanks to more competition between carriers and a lot of regulatory action. Government can work.
• Emergence: how entropy and incentives create scams 2/2009.
• Emergent fraud: Anthem and automatic payment denials 9/2010
• Anthem - Putting the Hell in Health Insurance 8/2010
• Health insurance: we’re defeated by a complexity attack 11/2009
• Employment benefit complexity: we are sheep 11/2007
• The hidden insurance problem: they can play the game better than we can 11/2007

Tax refund fraud targets health care workers, exploits big hole in IRS security

I missed this last year, but it’s worth knowing about. The usual suspects are exploiting weak security on tax returns; they steal identities, file returns, get refunds. Often targets physicians for obvious reasons — they tend to have large refunds and physician information is notoriously easy to steal from low security licensing databases.

If it were a corporation with this kinds of security weakness they’d be sued out of existence, but we can’t sue the Feds. 

The IRS is very slowly rolling out a PIN to include with returns to establish (relative) authenticity. There were arrests in late 2013 but this fraud is only going to grow over the next few years unless the security upgrade is accelerated. That would require serious bipartisan political pressure.

Salmon, Picketty, Corporate Persons, Eco-Econ, and why we shouldn't worry

I haven’t read Picketty’s Capital in the Twenty-First Century. I’ll skim it in the library some day, but I’m fine outsourcing that work to DeLong, Krugman and Noah.

I do have opinions of course! I’m good at having opinions.

I believe Picketty is fundamentally correct, and it’s good to see our focus shifting from income inequality to wealth inequality. I think there are many malign social and economic consequences of wealth accumulation, but the greatest threat is likely the damage to democracy. Alas, wealth concentration and corruption of government are self-reinforcing trends. It is wise to give the rich extra votes, lest they overthrow democracy entirely, but fatal to give them all the votes.

What I haven’t seen in the discussions so far is the understanding that the modern oligarch is not necessarily human. Corporations are persons too, and even the Kock Brothers are not quite as wealthy as APPL. Corporations and similar self-sustaining entities have an emergent will of their own; Voters, Corporations and Plutocrats contend for control of avowed democracies [1]. The Rise of the Machine is a pithy phrase for our RCIIT disrupted AI age, but the Corporate entity is a form of emergent machine too.

So when we think of wealth and income inequality, and the driving force of emergent process, we need to remember that while Russia’s oligarchs are (mostly vile) humans, ours are more mixed. That’s not necessarily a bad thing - GOOGL is a better master than David Koch. Consider, for example, the silencing of Felix Salmon:

Today is Felix's last day at Reuters. Here's the link to his mega-million word blog archive (start from the beginning, in March 2009, if you like). Because we're source-agnostic, you can also find some of his best stuff from the Reuters era at Wired, Slate, the Atlantic, News Genius, CJR, the NYT, and NY Mag. There's also Felix TV, his personal site, his Tumblr, his Medium archive, and, of course, the Twitter feed we all aspire to.

Once upon a time, a feudal Baron or Russian oligarch would have violently silenced an annoying critic like Salmon (example: Piketty - no exit). Today’s system simply found him a safe and silent home. I approve of this inhuman efficiency.

So what comes next? Salmon is right that our system of Human Plutocrats and emergent Corporate entities is more or less stable (think - stability of ancient Egypt). I think Krugman is wrong that establishment economics fully describes what’s happening [2]; we still need to develop eco-econ — which is not “ecological economics”. Eco-econ is the study of how economic systems recapitulate biological systems; and how economic parasites evolve and thrive [3]. Eco-econ will give us some ideas on how our current system may evolve.

In any event, I’m not entirely pessimistic. Complex adaptive systems have confounded my past predictions. Greece and the EU should have collapsed, but the center held [4]. In any case, there are bigger disruptions coming [5]. We won’t have to worry about Human plutocrats for very long….

See also

• Princeton Study: U.S. No Longer An Actual Democracy
• Justice Stevens Suggests Solution for ‘Giant Step in the Wrong Direction’
• Economist Receives Rock Star Treatment
• Transcending Complacency on Superintelligent Machines. Hawking, Russell, Tegmark and Wilczek
• The Piketty pessimist | Felix Salmon
• Frustrations of the Heterodox - Krugman

and from my stuff

• Ants, corporations and the great stagnation 12/2011
• Speculation: The corporate ecosystem and American stasis 11/2010
• Corporate growth and the unexpected triumph of central planning 11/2012
• The debt ceiling: Can Goldman Sachs win if the US defaults? 4/2011. 
• Mass disability goes mainstream: disequilibria and RCIIT 11/2011
• The limits of disaster predictions: complex adaptive systems 2/2007
• Fermi Paradox: The solution set is stable 3/2013
• Apologetics: God and the Fermi Paradox 11/2010 (Sort of related :-)
• Sympathy for Economists 8/2013
• The new history is deep history 4/2010. Democracy is but the blink of an eye.

- fn -

[1] I like that 2011 post and the graphic I did then. I’d put “plutocrats” in the upper right these days. The debt ceiling fight of 2011, showed that Corporations and Plutocrats could be smarter than Voters, and the rise of the Tea Party shows that Corporations can be smarter than Voters and Plutocrats. Corporations, and most Plutocrats, are more progressive on sexual orientation and tribal origin than Voters. Corporations have neither gender nor pigment, and they are all tribes of one.

I could write a separate post about why I can’t simply edit the above graphic, but even I find that tech failure too depressing to contemplate.

[2] I don’t think Krugman believes this himself - but he doesn’t yet know how to model his psychohistory framework. He’s still working on the robotics angle.

[3] I just made this up today, but I dimly recall reading that the basic premises of eco-econ have turned up in the literature many times since Darwin described natural selection in biological systems. These days, of course, we apply natural selection to the evolution of the multiverse. Applications to economics are relatively modest.

[4] Perhaps because Corporations and Plutocrats outweighed Voters again — probably better or for worse.

[5] Short version — we are now confident that life-compatible exoplanets are dirt common, so the combination of the Drake Equation (no, it’s not stupid) and the Fermi Paradox means that wandering/curious/communicative civilizations are short-lived. That implies we are short-lived, because we’re like that. The most likely thing to finish us off are our technological heirs.

Valerie Plame Wilson on the NSA, Keith Alexander, and Edward Snowden

Ten years ago Karl Rove, Richard Armitage and Lewis Libby took revenge on a man who'd exposed some of Bush/Cheney's Iraq lies. Their revenge was to blow the operational cover of his wife, Valerie Plame, a CIA covert agent. Scooter Libby was convicted of lying to investigators and sentenced to prison. Bush commuted his sentence.

Yeah, the Bush/Cheney years were like that.

Today I heard Valerie Plame speaking on the NSA, Keith Alexander ... and Edward Snowden. If you have any doubt that Snowden is a heroic figure in American history you should listen to the speech.

Plame's description of Keith Alexander is particularly memorable -- and chilling. There are always people like Alexander lurking in the shadows of American history, waiting for their main chance. Most miss out, but 2001 was a very good year for Alexander. He is now a terribly powerful man, and a much greater threat to American democracy than Bin Laden ever was.

We're all living in his shadow now, and he's not gone yet.

How the US could get a real (big) carbon tax

The Philippines has been hit by a very powerful storm. Thousands are dead and more will die, suffering will be extensive and long lasting. (Yes, poverty matters, but remember Katrina killed 1,500-3,500 and devastated a wealthy country city.)

Science-based thinkers expect a grim outlook for the Philippines. Sea level will rise, storms are likely to be more powerful, this will happen again even if many move away from the current crowded coastal zones.

Which makes this a good time to talk about a Carbon Tax. Not a trifling Carbon Tax, but a 'sell-the-SUV' and 'wear sweaters' and 'upgrade AC to smart adjust' carbon tax. A Carbon Tax that's politically impossible in 2013 China, USA, Australia, Canada or even Germany.

To be sure, a (Big) Carbon Tax (BCT) isn't about raising money for research - the funds would likely be offset by other tax reductions and by subsidies to people most hurt by cost shifts.. It's about keeping Carbon in the ground longer (maybe forever) by making extraction unprofitable, and accelerating transitions to low CO2 technologies (esp. solar, smart tech energy, etc) by making them cost-competitive ten years sooner than expected.

Nice idea, but impossible.

Except ... things change. Warfare happens. India suffers, and declares if it's going down it will take wealth western cities with it. Massive rogue geo-engineering projects have nasty side-effects that lead to more war, more threats.

Maybe a BCT becomes more palatable. Here's how it might happen -- the key is Border Tax Adjustment - "... import fees levied by carbon-taxing countries on goods manufactured in non-carbon-taxing countries...".

So what happens is China, India and Germany commit to a BCT -- for reasons of self-preservation and economic advantage. They tax American goods and services with the Border Tax Adjustment. The US can either suffer this or can add its own Big Carbon Tax -- and put various compensatory tax reductions/subsidies in place. The BTA goes away, the money stays in the US.

Once you have China, India, Germany and the US the rest of the world falls in line.

The Ranbaxy story: why we still can't trust our medications

It isn't just China that struggles with counterfeit and defective medications.

India's Ranbaxy makes much of the generic Lipitor consumed in the US -- and today a Pulitzer prize quality Fortune investigation makes it clear that Ranbaxy is a criminal enterprise.

Ranbaxy has been fined $500 million (no criminal prosecutions) in the US, but most of its crimes took place in weaker nations and during a time when America's regulatory agencies were reeling under GOP attack (emphases mine) ...

Dirty medicine - Fortune Features

.... On May 13, Ranbaxy pleaded guilty to seven federal criminal counts of selling adulterated drugs with intent to defraud, failing to report that its drugs didn't meet specifications, and making intentionally false statements...

...  the sixth-largest generic-drug maker in the country, with more than $1 billion in U.S. sales last year ...

... we simply don't know what we're dealing with," says Dr. Roger Bate, an international pharmaceutical expert. "No one has actually gone into these sites to expose what's going on."...

... Drug applications work on the honor system: The FDA relies on data provided by the companies themselves....

... Ranbaxy took its greatest liberties in markets where regulation was weakest and the risk of discovery was lowest...

... The company manipulated almost every aspect of its manufacturing process to quickly produce impressive-looking data that would bolster its bottom line...

.... directed to substitute cheaper, lower-quality ingredients in place of better ingredients, to manipulate test parameters to accommodate higher impurities, and even to substitute brand-name drugs in lieu of their own generics in bioequivalence tests to produce better results...

.... the majority of products filed in Brazil, Mexico, Middle East, Russia, Romania, Myanmar, Thailand, Vietnam, Malaysia, African Nations, have data submitted which did not exist or data from different products and from different countries...

... drugs for Brazil were particularly troubling. The report showed that of the 163 drug products approved and sold there since 2000, only eight had been fully and accurately tested...

... deceptions greatly accelerated the pace of the company's FDA applications. They were also a grave public-health breach...

... the drugs Ranbaxy was actually selling on the U.S. market were an unknown quantity...

... Thakur knew the [HIV] drugs weren't good. They had high impurities, degraded easily, and would be useless at best in hot, humid conditions. They would be taken by the world's poorest patients in sub-Saharan Africa, who had almost no medical infrastructure and no recourse for complaints. The injustice made him livid...

 ... The inspectors also took and tested samples of Sotret, Ranbaxy's version of the acne drug Accutane, and found that it degraded far in advance of its expiration date....

[In 2006] ... the FDA ... did nothing to stop all the drugs that were already on the market,... .... Ranbaxy got six new approvals....

... September 2008, [the FDA] announced it was restricting the import of 30 drug products made by Ranbaxy (11 of which had been approved after Thakur's first contact with the FDA three years earlier). The agency still did nothing to recall the very same drugs on pharmacy shelves all over America, despite finding that Ranbaxy had committed fraud on a massive scale....

... many of Ranbaxy's senior executives were expected to ... carry suitcases full of brand-name drugs ... former employees suspect that the company used the brand-name drugs as a substitute for its own in testing...

The company is still in business, Tempest and Sigh aren't in prison, and the recent $500 million fine will soon be forgotten. In the meantime, does anyone imagine Ranbaxy is the only fraudulent manufacturer of generic drugs? And will Americans ever wake up?

We're wasting our time GOP scandal-theater, and ignoring the real scandal in front of us.

See also

• Ranbaxy: Looking Under the Rock. In the Pipeline 5/13 
• FDA Fails to Catch Generic Drug Disasters - The People's Pharmacy 5/2013
• FDA Let Drugs Approved on Fraudulent Research Stay on the Market - ProPublica (Cetero Research - 4/2013)
• We really need to panic more - FDA inspection of Chinese drug suppliers 2/2008
• Pet food poison and pithed America 3/2008 -- melamine poisoning
• The case of the curious silence: Counterfeit Heparin killed 62+ 4/2008
• Fraud and global supply chains - unanticipated consequence 5/2007
• Poisoned medicine: Even I am stunned. 5/2007

Update: The People's Pharmacy has five responses I liked, I omitted the one I disliked

1) Country of origin labeling. You should know where your medicine comes from!
2) The name of the manufacturer of your medicine should be on the label.
3) The FDA should release its bioequivalence curves for all generic drugs. These data should not be kept secret, as they currently are.
4) We must demand unannounced inspections in all countries that wish to export pharmaceuticals to the U.S. market.
5) Every foreign drug manufacturing company must be inspected every two years, just as U.S. manufacturers are inspected.

American Healthcare: only the little people pay list

In healthcare, only the uninsured pay list price. They actually pay the crazy amounts that show up on their healthcare bills. Other payers, like insurance companies, pay a steeply discounted amount. Sometimes 70% off.

Pretty outrageous eh?

It's not new though. That's how it worked when I was a country doc in the early 90s and it was old and outrageous then. Now it's getting more attention; but it's not new. The weird thing is that this 'secret' has been in plain view for decades.

That's not the end of the story though. At least when I was in practice, we couldn't do a cash discount. The insurance price was based on list, and if we lowered list the insurance payments would fall. Indeed, our 'customary' charge rating would also fall, and in the bizarro world of healthcare finance what insurers were willing to pay us depended in part on our past charges.

Back then we wrote off many cash charges, but times have changed. For one thing, the Bush GOP made it much harder for regular folk to declare bankruptcy and escape healthcare debt.

So now that this story is getting traction, I wonder if Americans are ready to learn about how Evaluation and Management CPT codes (E&M Coding) destroyed primary care. Hint: "What gets measured gets done" doesn't mean "what is good gets done".

Many Americans still think we have a great healthcare system. It's probably not our only mass delusion.

Electronic health records and payment increases: It's not fraud.

There was a bit of press about an extensive CPI series investigating increases in charges by physicians using electronic health records. I know this domain, and I've been watching for someone to explain what's really happening and why.

Today John Halamka pointed me to what I was looking for. The explanation comes from Don Berwick:

Hospitals grab at least $1 billion in extra fees for emergency room visits | The Center for Public Integrity: 

... Dr. Donald Berwick, the immediate past administrator of the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, said a small portion of the billing increase is likely caused by outright fraud, but in the majority of cases hospitals are legally boosting profits by targeting the vulnerabilities of Medicare’s payment system. “They are learning how to play the game,” Berwick said about the hospitals.... 

... Berwick, the former CMS head, said patients haven’t changed. What’s changed is the aggressiveness of how hospitals bill. “They are smart,” Berwick said. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get.”...

Don't be fooled by his background leading CMS. Berwick has a long record in health reform, and an unimpeachable reputation. He got one year in CMS before the GOP got rid of him. He's telling the truth.

The deeper story goes like this:

• In the 1990s reformers tried to come up with a fair way to reimburse for the work physicians did, particularly 'cognitive' work vs. procedural work. In part they wanted to to equalize the playing field between medicine and surgery. This was a horrendous task even before the AMA got their hands on it.
• By the time the AMA was done a new kind of accounting system was created to track what doctors did. It was called "Evaluation and Management" coding, which looks to the uninitiated like a set of 10 or so "CPT Code" (also AMA controlled).
• This introduction of E&M codes changed medicine -- for the worse. Immediately. I won't bore you with the details, but basically doctors worked to the accounting system instead of focusing on improving patient care. Accounting matters. 
• Four years later proceduralists complained and the E&M codes got much worse. At this point they were almost impossible to understand. There was supposed to be a usability test but it never happened. Somewhat better, but even more complex, codes were stalled in 1999.

After 1999 doctors more or less staggered on with this accounting system. They routinely 'undercoded' to avoid prosecution, but payments for less sophisticated codes rose so it 'worked out'.

During this time, however, electronic record systems grew. It became far easier to capture all the inputs to the coding system. It was also easy to ask a few additional questions and so exploit a loophole in established patient encounters. (Basically you can do a complete exam for a sore toe and do quite well).

EHRs let billing systems, especially hospitals, fully exploit the problems in a fundamentally horrible accounting system.

There's no fraud here. The fix is to eliminate E&M codes.