Hey Republicans: If you want to cut ObamaCare, try wellness programs

Few people will have noticed new rules around corporate "health-contingent wellness programs" (emphases mine):

Administration Defines Benefits Under Health Law - NYTimes.com

... The rules also give employers new freedom to reward employees who participate in workplace wellness programs intended to help them lower blood pressure, lose weight or reduce cholesterol levels. The maximum permissible reward would be increased to 30 percent of the cost of coverage, from the current 20 percent.

The rules would further increase the maximum reward to 50 percent for wellness programs intended to prevent or reduce tobacco use.

Rewards could amount to several thousand dollars a year, officials said, because total premiums in employer-sponsored health plans now average more than $5,600 a year for individual coverage and nearly $16,000 for family coverage...

The Hill's Healthwatch has more details. It is remarkable that CNBC can have a general freakout about an increase in marginal federal tax rates for persons earning over $250,000 a year, but say nothing about a program that costs middle-class workers $2,000-$3,000 a year.

Let us take a moment to contemplate this curious silence.

Yes, I said costs, because the money for these programs has to come from somewhere. In this case it comes out of take home pay - either as a direct benefit cost or as a reduction in future income. In some cases the money might come out of ACA mandated health insurance premium rebates ...

Health Insurance Refunds May Stall in Employers’ Hands - NYTimes.com

... while some employers are returning the money directly in paychecks, or planning “premium holidays” that increase take-home pay, others are weighing different options, benefits consultants said, like reducing next year’s premium, or spending the refund on so-called wellness programs that reward workers who lose weight or quit smoking.

Yeah, that's a bad sign.

In theory the money we're losing now might be offset by reduced healthcare costs over time, which might in theory reduce insurance costs and maybe one day the lost income might trickle back down again.

*cough*

Right. That's not going to happen.

It is also possible that, regardless of impact on health care costs, and after considerable administrative overhead is deducted, these programs will make some workers healthier than they might otherwise be. In that sense they might be considered a form of social transfer; all employees pay for improved health habits for some employees.

That wouldn't be so bad - if we knew the programs worked. But we don't know that; these programs were launched with very little research. What little I could find showed some surprises ....

New Research Shows That Prevention Is Key To Reducing Health Care Costs For All Employees, Even Those With Chronic Conditions - New York Times

... while a reduction in employee health risks leads to immediate cost savings, the accumulation of additional health risks soon leads to substantially higher medical and pharmacy costs...

I don't know why corporations are so keen on these programs, but I suspect there are sound business reasons. They may not be obvious; I'm reminded that Walmart liked defined contribution plans because they discriminated against unhealthy (and costly) spouses. I have read that some states offer tax credits for the programs, and I assume that the $2,000 a year or so I'm paying for our corporate program is treated as a tax deductible health care benefit.

Which brings me to the GOP. They're looking to cut money from the ACA. Why not do something useful and ask about corporate wellness programs?

Right. I bet this is one of those things that made it into the ACA as a sop to the GOP...

See also:

• Gordon's Notes: The Walmart healthcare memo: You DO need to read the original 11/2005
• Wellness Tax Credit (a curious unlaunched astroturf site)
• Workplace wellness - Wikipedia, the free encyclopedia
• Corporate Wellness Programs | American Institute for Preventive Medicine

Why are Google and Facebook ads so crappy?

In our world billions of dollars are spent trying to get us to read and click ads.

Billions.

So why are the ads so crappy? Google, which knows more about me than my mother, offered me these two next to my Gmail:

Master of Science Nursing
Earn a CCNE Accredited Masters in Nursing Online - Norwich University...

Overstock iPads 2: $43.20
Today Only: Get 32GB iPads for $43. 1 Per Customer. Limited Quantities...

A probably fake diploma program (or it's Norwich in the UK?!) and a con. Either Google thinks I'm an easy mark (demented already?), or it doesn't really know me after all.

Facebook is no better.

Really, spammers do better. After all, I'm marginally more likely to pay for genital enhancement than to send money to a con man. (I can imagine, for example, developing a brain tumor that might radically change my personality.)

It's not that I'm opposed to viewing ads. I pay $20 a year so that, in part, I can read the ads in Silent Sports.

Let me repeat that one. I actually turn over cold cash to read ads. I'm not the only one. Once upon I would, on occasion, buy a giant monthly phonebook sized slab of newsprint called "Computer Shopper" so I could read the friggin' ads.

I don't read or click Google or Facebook ads. Not because of an ideological objection -- but because they're worthless.

So where are all those billions going? Why doesn't Google or Facebook ask me what ads I'd like to see?

Why am I the only person who seems to notice this? Is it really just me?

There's something very strange going on here.

Keystone XL, carbon sequestration, and the tax in the closet

The Keystone Pipeline XL (Keystone Expansion) is a part of  a multi-billion dollar project to "transport synthetic crude oil and diluted bitumen from the Athabasca Oil Sands in northeastern Alberta, Canada to refineries in Illinois and Oklahoma, and further to the U.S. Gulf Coast".

There is debate about the project, but the media coverage is hard to follow. That's because there is an "elephant in the room". (see - unspoken).

The elephant is carbon. If we taxed CO2 to offset the externalities of global climate change the Keystone XL would not be built and the existing Keystone pipeline would be dismantled. Of course if we had a Carbon tax the price of energy would rise about 10%, though that would be offset by the increasingly low costs of solar power.

It's easy to see why the media is missing the Keystone XL story. Without a Carbon Tax, or the regulatory equivalent, the Keystone XL makes business sense. A Carbon Tax, however, is a wee bit unpopular. It's easier for XL opponents to talk about other environmental impacts such as oil spills, water contamination and the like.

Of course once Keystone XL is built, instituting a carbon cost would mean dismantling a suddenly irrational multi-billion dollar investment. So maybe we should be talking about the real issue now.

It's a similar story with coal plant carbon sequestration. To the surprise of nobody whose paying attention, it's not happening. Shareholders would fire the CEO of a corporation that invested in carbon sequestration without either a carbon tax or the regulatory equivalent.

There's more than one elephant in this (too small) room. The other is Peak Oil, defined as the beginning of the end of the good stuff. It's gotten lost in the so-far-lesser depression, but our fracking and Keystone investments are consistent with Gwynne Dyer's 2008 prediction. We are now post-peak-oil.

Does it all make more sense now?

Yeah, I thought so.

There's a twist to this story though.

Is a Carbon Tax really all that unpopular? Governments need money to provide services an aging and increasing disabled population needs. There's no happy way to increase taxes. Compared to the alternatives, a Carbon Tax may not be as unpopular as we imagine. Maybe that's why nobody is talking about it. When politicians are forced to deal with big problems, they prefer to keep the real solutions behind closed doors.

Roots of the irrational in American politics: pre-dementia and religion

I've written recently about the role of religion in the reasoning of the GOP base. This is an elephant in the room; pundits will discuss the role of American's exceptional fundamentalism in the context of abortion politics, but not in the context of debt politics. The mainstream media is missing an important ingredient in our political paralysis.

There's another elephant out there, and it will grow over the next ten years. The average American voter will become increasingly demented. Demented people rarely vote of course, but most dementia is the end stage of a very long process. Before a voter is disabled, they will lose the ability to process information, recall all but the most recent events, and adjust their beliefs based on evidence. They will, in other words, become less rational.

How big a factor is this?

We can make some estimates by starting with the end-stage state of clinical demential ...

Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study

... The prevalence of dementia among individuals aged 71 and older was 13.9%, comprising about 3.4 million individuals in the USA in 2002. The corresponding values for AD were 9.7% and 2.4 million individuals. Dementia prevalence increased with age, from 5.0% of those aged 71–79 years to 37.4% of those aged 90 and older...

... The elderly population (those aged 65 years or older) in the USA is expected to double from approximately 35 million today to more than 70 million by 2030...

Of course these numbers are only a start. What we really want are numbers expressed in percentages of voters, and we want the average disease duration from judgment impairment to disability. Personally I suspect that's about 20 years, but the best data I could find was on a relatively rare and aggressive form of early dementia ...

Pre-dementia clinical stages in presenilin 1 E280A... [Lancet Neurol. 2011] - PubMed result

... Pre-dementia cognitive impairment was defined by a score 2 SD away from normal values in objective cognitive tests, and was subdivided as follows: asymptomatic pre-MCI was defined by an absence of memory complaints and no effect on activities of daily living; symptomatic pre-MCI was defined by a score on the subjective memory complaints checklist higher than the mean and no effect on activities of daily living; and MCI was defined by a score on the subjective memory complaints checklist higher than the mean, with no effect on basic activities of daily living and little or no effect on complex daily activities. De

... Median age at onset was 35 years (95% CI 30-36) for asymptomatic pre-MCI, 38 years (37-40) for symptomatic pre-MCI, 44 years (43-45) for MCI, and 49 years (49-50) for dementia. The median age at death was 59 years (95% CI 58-61). The median time of progression from asymptomatic to symptomatic pre-MCI was 4 years (95% CI 2-8), from symptomatic pre-MCI to MCI was 6 years (4-7), from MCI to dementia was 5 years (4-6), and from dementia to death was 10 years (9-12). The cognitive profile was predominantly amnestic and was associated with multiple domains. Affected domains showed variability in initial stages, with some transient recovery in symptomatic pre-MCI followed by continuous decline.

In this disorder asymptomatic pre-MCI started at age 35, and disability (dementia) at age 50. So the aggressive form has a 15 year course. I would expect less aggressive forms have a longer course, so I'll go with 20 years.

So by these very rough guesstimates about 15% of 50 year old voters will be impacted by "asymptomatic pre-MCI", an early form of cognitive disorder that will impact their judgment. That prevalence will go up with age. Since GOP voters are much older than Dem voters, this, like religious fundamentalism, will be concentrated in the GOP base and it will strongly impact GOP politics.

If you don't understand the two factors of religious fundamentalism and pre-dementia cognitive impairment you will have a hard time understanding the future of the GOP.

Get your international transpant with MedToGo

It occurred to me that a custom Google news section would help me track the worldwide retail organ business.

The results were more impressive than I'd expected.

Here's one ...

Desperate Americans Buy Kidneys From Peru Poor in Fatal Trade - Bloomberg

... Medical tourism company MedToGo LLC, based in Tempe, Arizona, says it will offer kidney transplants in Mexico and Costa Rica for about $50,000, a fifth of the cost in the U.S...

MedToGo has an agreeable web site. Owned and operated by US physicians, who are facilitating trafficking in the organs of the poor. I wonder; are there any state licensing board issues?

The organ trade is one of those curious stories that get little press attention.

Update 5/19/11: MedToGo's CEO wrote to object to the way they were portrayed in the Bloomberg article. They say they provide access to transplants performed in Mexico to Americans and Canadians, but only with American and Canadian donors. I am curious how that can be done, since I am sure they are bypassing North American transplant boards. They also say they do not pay donors, but they do not say the donors are unpaid. Based on MedToGo's response I've modified my post title and content as above.

See also:

• Organlegging Neuromancer style – China’s liver trade 5/10
• Enlightenment 2.0 and a Hong Kong student post on the Chinese organ trade (5/07)
• Niven scores: The organ trade grows (4/06)

Epsilon breach: the iStealer and CyberGate mystery

A marketing (legal spam) firm was hacked and a bunch of our "private" (hah!) information was stolen. We can now expect more personalized phishing attacks (yawn). We might see more identity theft, but I've read that the identity reseller market has collapsed -- perhaps because there was too much cheating going on. (This is why civilization can win -- crooks can't trust each other).

Yawn. Another day, another semi-legal enterprise hacked. it's a boring story [1], not nearly as interesting as the far more sensitive, and far less discussed, RSA hack.

The story is boring, but there's a curious angle. The attack was prosaic ...

Epsilon breach used four-month-old attack - Security - Technology - News - iTnews.com.au

...The link in the body of the email took the user to a page that downloaded three malware programs – one that disables anti-virus software, another (iStealer) that is a Trojan keylogger to steal passwords, and a third (CyberGate) which offers hackers remote administration of the infected machine....

But the curious angle is how the attack trio are described: iStealer, CyberGate and an anonymous tool for disabling system defenses. I can't find out anything about them!

A google search on iStealer turns up lots of hits -- but they're obviously from shady sites I wouldn't visit without a VM constrained self-destructing browser. The only Wikipedia hits are on Russian language pages. In fact, as of today, this blog post is probably going to be the only legit result in many searches! (Sorry, I don't know anything.)

Why this curious silence?

[1] The firm is called Epsilon -- a silly name right out of a Bond flick. I think that's why this got so much attention.

Why you will live in an iOS world

Five years ago, just before Microsoft Vista was released, our household CIO made a strategic decision. We would move to OS X.

It wasn't a hard decision. The cost of supporting both XP and OS X was too high, XP's security, debugging and maintenance issues were intractable, and OS X had a much more interesting software marketplace. Moving to OS X would dramatically reduce our cost of ownership, which was primarily the CIO's opportunity cost. Time spent managing XP meant less time spent on my health and on family joys and obligations. [6]

It worked beautifully. One of my best strategic decisions. Yes, I curse Apple with the best of them, but I know the alternatives. I'm not going anywhere.

Except I am going somewhere. I will fade. So will you, though there's a bit more hope for the under-30 crowd. We might be able to slow the natural deterioration of the human brain (aka "Alzheimer's" and its relatives [4]) by 2030. It's too late for the boomers though, and probably too late for Gen X.

Sure, I'm still the silverback of the geek tribe. I may have lost a step, but between experience and Google I still crush the tough ones with a single blow.

Not for long though. I give myself ten years at most. I won't be able to manage something like OS X version 20, and I don't want to be reliant on my geek inheritor - son #2.

We will need to simplify. In particular, we'll need to simplify our tech infrastructure (and our finances [1] and online identities [7] too).

So our next migration will be to iOS - a closed, curated, hard target, simpler world.

You'll be going there too -- even if you're not fading (yet). The weight of the Boomers [2] will shift the market to Apple's iOS and its emerging equivalents. Equivalents like ChromeOS, now turning into iOS for desktop device with its own App Store [5].

I still have a few years of OS X left, including, if all goes well, the 11" MacBook Air I've been studying. The household CIO's job, however, is to think strategically. Our future household acquisitions will shift more and more to iOS devices, possibly starting with iPad 2.0 (2011) [3].

I expect by 2018 we'll be living in largely iOS-equivalent world, and so will you.

-- footnotes

[1] I miss Quicken 1996 -- before Intuit went to the DarkSeid.
[2] The 2016 remake of Logan's Run will be a smash hit. 
[3] I bought iPad 1.0 for my 80yo mother -- same reasons.
[4] 1989 was when the National Institutes of Health needed to launch a "Manhattan Project" style dementia-management program. I wasn't the only person to say this at the time. 
[5] If their first netbook device doesn't come in under $150 with batteries Google is in deep trouble. Android is not an iOS-equivalent, it's a lot more like XP. 
[6] Pogue's 10 year tech retrospective is a beautiful summary of the costs of making the wrong household tech decisions. He misses the key point though. The real costs are not the purchase costs, or the immense amount of failed invention, or the landfill costs -- it's the opportunity costs of all the time lost to tech churn. I've a hunch this opportunity cost is important to understanding what happened to the world economy between 1994 and 2010. That's another post though!
[7] Digital identities proliferate like weeds. Do you know where all your identities are?

Healthcare quality 101

There are superb French (and other) pastries all around the island of Montreal, but Minneapolis St. Paul pastries peak at mediocre. The Twin Cities are richer than Montreal, but money can't buy everything. In health care terms we'd call this a kind of variability.

The pastry variation is cultural. Minnesotans don't love the chocolate, flour and licquer pastries I grew up with, so there's no competitive market in my favorite food.

There's cultural variation in health care quality too. The best description of the causes of this variation, better than any prior academic publication, appeared in a 2009 New Yorker essay by Atul Gawande.

There's a different kind of variation that Gawande doesn't talk about. It's the difference between "Cicely" Alasaka and Rochester Minnesota.

Rochester is the home of the Mayo Clinic. It's the champion of conventional health care delivery.  The combination of a small city and an international service business generates enough revenue to support a full range of health care technologies and care givers. There's a culture of process monitoring and improvement that kicks it up a level above most referral centers.

Cicely is a mythical rural community. It's the archetype for communities with small populations that can only support a limited range of local health care delivery. At its best this will involve a reasonable number of family physicians, PAs and nurses and a smaller number of specialists. There may be only 1-2 pediatricians,  maybe some hospitalists, 1 orthopedic surgeon, 2-3 general surgeons, and so on. There's unlikely to be a colorectal surgeon. There's probably 1-2 obstetricians, but obstetrical epidural anesthesia may be hard to get.

Care in this mythical Cicely, the care experienced by 17% of Americans, is different from care in Rochester.

In some ways Cicely is better. Primary care physicians are experienced. Care communication is much better than in large centers. Reputations are known, and they matter. Patients don't get missed or lost as easily. Most of us don't want to die, but we particularly don't want to die miserably. If I'm ready to die, I'd rather be in Cicely than at the Mayo.

In other ways Rochester is better. Cicely is probably not the best place for a child with Cystic Fibrosis. When there's only 1-2 specialists in a community that needs at least one, choice may be limited. Many procedures aren't available, or shouldn't be available, outside of specialty centers. Health care will often involve travel to a place like Mayo (back in the day I liked Marshfield Clinic -- almost as good as Mayo, and a lot closer).

It's good to understand that there are different kinds of health care variability. The pastry-kind of variation is fixable. The Mayo model, or a cheaper variant that's 80% as good, could be applied elsewhere (it's not the water). Other kinds of variability are much more persistent; they're driven by local market size more than culture. Cicely will never be a good place to have a glioma removed; though it's the place I'd want for care of an untreatable glioma.

The obvious is shouted, the interesting is whispered

Perhaps it was always this way, and it is only with time that I see it.

Or perhaps our media is less interesting, more controlled, than it once was.

The obvious is shouted a thousand times an hour. The interesting is whispered in closed doors.

This morning, for example, I wrote ...

Gordon's Notes: The iPhone iAd framework and parental controls

... iOS devices (iPhone, iPod Touch, iPad) come with parental controls. Android OS, interestingly, does not ...

...  iOS comes with FairPlay DRM (digital rights management), Android OS lacks a DRM standard. Even Gruber, a giant of fan blogs, does not seem to get this. FairPlay is worth billions to the iOS App market...

This is a small thing, in a technical domain, but it is not hard to discover. It is not a matter of opinion. Any reasonable person who thinks about it for a moment will agree - yes, the way FairPlay DRM manages iOS apps is extraordinarily important to Apple's revenue stream.

Yet this goes unspoken. Unspoken, that is, in the media. I am sure it is discussed at Google and Apple.

I've written before about dogs that don't bark in the night. These silences speak volumes. In my blog I now tag them as unspoken.

Why are some important and obvious things unspoken?

Sometimes it is because people with power understand, often wisely, that the less said the better. China's rare earth embargo is an example.

Sometimes it is because some things aren't obvious until they are spoken. Not just spoken in an eccentric blog with an unusual readership, but spoken in a bigger platform. These silences end in time.

Most often though, I think it is because most struggles are bipolar, and neither of the two parties wants to introduce a meme that might disturb both. Perhaps, as happens in American politics, there is something both parties agree should happen, but one party wishes to maintain an illusion of total opposition. Perhaps the unspoken fact might introduce a disruptive third position, and both parties prefer the enemy they know.

These days, when I write in this blog, I try to write about things are not spoken. My Reader Share, and its secondary (inferior) twitter stream, are for interesting things that are shouted.

The iPhone iAd framework and parental controls

iOS devices (iPhone, iPod Touch, iPad) come with parental controls. Android OS, interestingly, does not. This is rarely discussed [1].

Parental controls should be important to parents with children who, by age or disability, are particularly vulnerable to exploitation and injury. They are, of course, also important for cultural reasons.

Even though Apple's iOS includes parental controls, they are very weak. Disabling Safari does not disable embedded browsers, and many, many applications embed WebKit browsers. It is not hard, for example, to navigate from the NYT's iPhone App to Google's image search.

The worst offenders use Google's AdMob/AdSense/Mobile Ads platform. That platform, unsurprisingly, uses WebKit. A product that uses Google's Ad Platform breaks iOS Parental Controls.

Apple has an ad platform too. It's called iAd. It's not based on WebKit, it's an Objective C (Cocoa) framework. This morning I viewed the Tron iAd featured on the New York Times iPhone app. The Ad was ... impressive.

Clearly Apple's iAds have a high barrier to entry. Perhaps not as high as a television or major print advertisement, but much higher than traditional web advertising. The one I saw was essentially an application. iAds will need to scope their material to the parental control rating of the container application.

The Tron Ad did not have an obvious WebKit escape. Whether one exists or not, it is clear that iAds can achieve their goals within a fully constrained environment. Apple's iAds are Parental Control friendly, Google's Mobile Ads are not. If Apple were to enable a Parental Controls block for embedded browsers, they'd break Google's Ad Platform on iOS devices. Children are an important advertising target. This should be interesting.

[1] Another unmentionable is that iOS comes with FairPlay DRM (digital rights management), Android OS lacks a DRM standard. Even Gruber, a giant of fan blogs, does not seem to get this. FairPlay is worth billions to the iOS App market.

Oddly silent dogs: The digital TV conversion

Canada still hasn't converted, but the US went to all digital TV on June 12, 2009.

We were supposed to convert in Feb 2009, but the switchover was delayed to allow more consumers to buy D/A converters or digital TVs. My family stayed with rabbit ears; they work better with our subsidized D/A boxes than with old school analog broadcasts. It is true, however, that nobody here watches TV on a TV any more. (The kids see their cartoons streamed to the laptop during their earned computer time, we also stream Netflix to iMac or Wii or we try to watch Netflix's frequently defective DVDs).

Which brings me to something noteworthy. The dog didn't bark. I expected some screaming by on June 13th -- didn't happen. Nothing happened. Cheapskates like us bought subsidized converters, others bought new TVs, cable subscribers weren't affected anyway. As best as I can tell, everyone who wanted a subsidized converter got one.

Most of the analog frequencies were sold off for vast sums (dwarfing the A/D converter subsidies), but a critical component has been made a public good with potentially enormous implications.

This was a huge change in American life, and it was created and executed by government. The six month switchover delay and extra converter subsidies happened under the Obama administration, but this was a long transition that started in Clinton years and went through Bush II.

A longterm, bipartisan, massive technological transition entirely driven and controlled by the Federal government -- that worked.

Nobody talks about it.

Isn't that a bit weird?

The missing Google solution: no file sharing

I make fairly frequent use of Google Page Creator (still a "lab" product), Google Documents, and, indeed, most of what Google produces including their photo sharing service. I even have 3 or 4 (it's easy to lose count) Google app domains including our family domain. I've been a Google fan since the first few weeks they had a web presence, back when everyone else I knew was still using Alta Vista (yes, it still exists).

Yeah, I 'm a fan. Google is awesome, the paradigmatic (hey, it's a good word) 21st century company. If they ever open an R&D office in the Twin Cities I'll send in my resume -- just so I can say I tried. There are some things, however, that Google has steered clear of. It's this kind of omission, the "dog that didn't bark in the night"omission, that catches my attention.

Google doesn't provide a quality service for uploading files to share on the web. Yahoo xdrive doesn't either. The old webdav services I used to use, that did provide URL (http port 80) access have faded away.

Sure, Google Pages ("lab" supposedly, but it's part of the free Google Apps service) lets you upload a file, but it doesn't scale. You can't rename a file once its been uploaded, there's no metadata save name and size, there's no real browser -- it's such a barebones solution that it underscores how reluctant they are to provide a web accessible file store.

Look at Google Apps Premier edition. Sure there's no presentation software, but that's on the way. More intriguingly, there's no file server.

So why won't Google, or xdrive, provide a file server solution with a web accessible addresses? It can't simply be fear of copyright violation -- Google owns YouTube! I wish someone better connected than I am would notice this and track it down a bit ...