Sympathy for the devil: Anything good in RyanCare?

One year ago, against enormous resistance, Barack Obama and his allies muscled RomneyCare, aka the Patient Protection and Affordable Care Act, into law. It will come into full effect by 2014 assuming the GOP doesn't get complete control of Congress in 2012 (even if they do, the ACA will survive albeit with much less coverage for the poor and disabled).

The ACA was very much a political compromise. A Democratic controlled Congress was barely able to pass a GOP designed health care reform bill against hysterical GOP opposition.

Nobody is happy with RomneyCare, though I believe it was the best that could be done in for our time. A lot of palms had to be greased to get it through (I suspect the AMA was paid off with a CPT deal).

These days the GOP is talking a lot about RyanCare, which has some remarkable resemblances to RomneyCare. Sadly, like RomneyCare, and unlike McCain's half-hearted proposals, both plans keep health care insurance tightly coupled to employment.

The differences between RyanCare and RomneyCare are predictable. The ACA provides support for the poor and the weak and protects people with disabilities and illnesses. RyanCare does not ...

Consensus and Conflict in Health System Reform — The Republican Budget Plan and the ACA | NEJM Health Policy and Reform

...  The Republican plan offers additional (often inadequate) assistance only to very poor elderly and disabled persons, and to very-low-income pregnant women and families with children. The ACA, by contrast, offers assistance to uninsured Americans with incomes as high as 400% of the poverty level.

Second, the plans differ in the protection they afford against health-status–based discrimination. The Republican Roadmap assures guaranteed issue, requires risk adjustment among insurers, and offers high-risk pools, but the ACA prohibits insurers from varying coverage or premiums on the basis of health status and bans preexisting-condition exclusions altogether...

Like RomneyCare, RyanCare puts healthcare firmly into a large corporate framework. This isn't surprising, large corporations have robust control of their ecosystem. This isn't to my tastes.

There are three poles of service provision in the US - diverse market, corporate, and government. My preference for service provision is "diverse market" - small business, large business all with active competition. My second choice, and it's rather a distant second, is governmental provision. My last choice, far behind the other two, is provision of goods and services strictly through large minimally competitive corporate entities. Both RomneyCare/ACA and RyanCare drive all healthcare provision towards large minimally competitive corporation. There's more regulation in the ACA, and less regulation in RyanCare. In the case of Verizon/AT&T/Goldman Sachs like corporate entities lack of regulation is not a feature.

Overall RyanCare is, in some ways, an improvement on healthcare of 2008. It's a huge step backwards from the ACA. There's only one aspect of it for which I have some mild sympathy ...

... vouchers limit federal expenditures by shifting the risk of inflation in health care costs to the states, Medicare beneficiaries, and ordinary Americans ...

Vouchers are not necessarily evil. There are some voucher plans worth considering ...

A Comprehensive Cure: Universal Health Care Vouchers - Emanuel and Fuchs - Brookings Institution

... The Universal Healthcare Voucher System (UHV) achieves universal health coverage by entitling all Americans to a standard package of benefits comparable to that received by federal employees. Enrollment and renewal are guaranteed regardless of health status, as is the individual's right to buy additional services beyond the standard benefits with aftertax dollars. Health plans would receive a risk-adjusted payment based on their enrollment. UHV is funded entirely by a dedicated value-added tax (VAT) with the rate set by Congress. A VAT of approximately 10 to 12 percent would insure all Americans under age 65 at a cost no greater than current public and private health care expenditures.

UHV offers true universality, individual choice, effective cost control, and competition based on quality of care and service. To foster accountability and efficient administration, the voucher system creates a National Health Board and twelve regional boards with a governance structure and reporting requirements similar to the Federal Reserve system. ... UHV is relatively simple compared with other reforms that have similar objectives. Most importantly, it is congruent with basic American values: equality of opportunity and freedom to pursue personal goals.

Ezekiel Emanuel's UHV system looks now like a cross between RomneyCare and RyanCare. It would have been intensely disruptive, it is not necessarily corporate friendly and it would have severed health care coverage from employment. In a world where the GOP had not gone insane, and where corporations were less powerful, the UHV might have been a compromise solution.

Disruption is what we need, and markets can be good at that. Governments, and especially large corporations are much better at stasis. The ACA is much better than RyanCare, but the disruption it promises will be mediated by large, powerful, senator-owning corporations. That's not going to go well.

Generation gap: Bin Laden and the Chatterbox cafe

After seeing The King's Speech at the local discount theater, I'm showing Emily 'Triumph of The Will' on my iPhone over beer and hard cider at the Chatterbox Cafe. Leni Riefenstahl, that monster of Will, did love clouds.

We'd just gotten to Hitler's drive along the rows of adoring blond women and children when our waitress says bin Laden is on TV.

It's the run up to Obama's speech ...

We watch the speech - alone. The Chatterbox is pretty busy, lots of 20 somethings. The Karaoke bar is particularly rowdy. One young woman comes over, she is mildly interested. The staff are curious too, but busy. That's about it though. We're the only ones to watch the speech.

They are young. They have grown up with the Forever Wars. As adults, they've mostly known the Great Recession.

They don't remember the way we do. For them it's all very far away, and not all that interesting. They don't remember the world we lost, a much better world than the one we have now ...

Malice, incompetence, and happy accidents

Napoleon said "Never ascribe to malice that which is adequately explained by incompetence."
That is true, but incomplete.

I would say as well "Never ascribe to incompetence that which is adequately explained by the happy accident of emergent malice."

Update 5/4/11: Dilbert 2011-05-04 says it all in 3 panels.

The undiscovered world is all around us

Wonderful essay about the 2002 discovery of a new insect order (the Mantophasmatodea). In a few years they went from unrecognized fossil specimens to being seen almost everywhere ...

Rob Dunn blogging for Sci Am: Man discovers a new life-form at a South African truck stop:

... What was required to discover the Mantaphasmatodes, whether the species on top of the Massif or the species at the truck stop, was the realization that no one else knew what they were. Once that realization was made, discovering them was both easier and more interesting. Until then, the Mantaphasmatodes, like much of life, seemed (wrongly) likely to be known by some expert in a university somewhere. Yet they were not known, just as most of life is not known.

It was only recently that it was discovered that mice sing to each other. It was not so very long ago that it was discovered that clouds are filled with bacteria. What else remains to be known? Nearly everything....

After reading the essay, I recommend a visit to the Brandberg Massif via Google Maps/Earth. Be sure to turn on the photos and wikipedia layers.

Peak Oil: One of my better predictions

In May of 2007, as oil prices rose, I drew a line along a graph of gasoline prices ...

Gordon's Notes: Gasoline prices: refining or secular trend - the 11 year chart

I was wondering the other day, how much gasoline costs in Europe. It's about $3.40 a gallon in the Twin Cities, and over $5.00 a gallon in Canada, but what about in France or Germany? Have gas prices reached the "magic" $7.00 a gallon mark? I'd long imagined that was a price point that would change consumer choices about where to work and live, and what to drive....

Is the effect entirely due to refining capacity, as some suppose? If so, wouldn't the effect differ between the US and Europe?

... If we accept the trend then French gasoline will be $13.50 @ 2013 and $27 @ 2019. I wonder how close this is to the "tipping point" where the ROI on petroleum storage starts to become persuasive.

Without adjusting for income in any way, it's noteworthy that US gasoline is now as expensive as French gasoline @ 2001 and French gasoline today is nearing the "magic" $7/gallon mark....

It was remarkable that despite very different tax systems, prices rose in parallel.

In 2007 the GOP's explanation for rising prices was inadequate refining capacity. That might have contributed, but it was clearly a minor effect. The Left's explanation was evil speculators; but in this case any speculators would be our friends (even if they are producers who keep oil in the ground).

By July of 2007 I figured that once gasoline hit $5 a gallon it would begin to change what Americans did. I based that on the Canadian example. I estimated that would happen in 2011. By August of 2008 I made my Peak Oil call. The means I expected demand of light sweet crude would exceed supply until oil hit around $200 a barrel and resource substitution really kicked in (meaning we bake the planet with high CO2 fuels).

Then the roof fell in. In the teeth of the Great Recession oil prices retreated to June 2007 levels. They fell back about 1 year.

The Great Recession grinds on (screw the technical definition, feels like a recession to us). Even so, gas prices in MSP are back to almost $4/gallon. By August we may make my $5/gallon prediction.

After the summer season gas prices will fall. If China's bubble bursts in 2012 and their Great Recession begins our gas prices will fall probably bounce around $4/gallon for a year or so. Otherwise gas prices will head for $8-10/gallon in the US by @ 2017.

This is a good time to be investing in energy efficient high speed rail, public transit systems, and bicycle lanes. We'd be rethinking a lot of our assumptions. I am confident Minnesota's GOP controlled legislature will do the right thing.

Yeah, I'm joking.

More today from Ezra Klein ...

If only speculation explained gas prices - Ezra Klein - The Washington Post

... James Hamilton, an energy economist at UC San Diego, has studied not only the current oil prices, but the 2007-2008 run-up, in great detail...

.. If you read Hamilton’s detailed paper (pdf) on that period — no one can accuse him on not looking seriously at the numbers — you’ll hear about two major forces in the oil market, both of which are scarier, in the long-run, than speculators. On the supply side, Saudi Arabia. On the demand side, China. And caught between them, the global economy, and our wallets.

Traditionally, Hamilton says, Saudi Arabia, the world’s largest producer of oil, would smooth out spikes in demand. But around 2007, Saudi Arabia stopped. They left oil in the ground, assuming they could sell it for more later...

But that was 2007-2008. Is Saudi Arabia part of the story now? It appears so. Not only did they slash production in March, but they’re freaking everybody out by offering accounts of their production volume that don’t make any sense.

On the demand side, China — and other developing nations, but mostly China — is the 800-pound gorilla in the room. “China was a net exporter of petroleum up through 1992, and its imports were still only 800,000 barrels a day in 1998,” writes Hamilton. “By 2007, however, China’s net petroleum imports were estimated to be 3.7 mbd, making it the world’s third-largest importer and a dominant factor in world markets.”...

Patel - the Value of Nothing

Pickings were slim at the airport today. There were the usual Friedman/Tipping Point style books, but I'd rather read the dictionary than another of those. Raj Patel's "The Value of Nothing", an examination of externalities from a neo-Marxist perspective, looked at least novel.

I got something out of the book. I now know that while I'm a filthie commie Rationalist by GOP standards, I'm a long way from people like Klein, Patel, and others of the Hard Left. We have substantial agreement on ends, but their means read like a recipe for flail. Not coincidentally I feel the same way about Marx - sympathy for the ends, no value to the means.

I also found an unattributed quote in the 2009 book, inserted as though Patel wrote it ...

There are two novels that can transform a bookish fourteen year old's life: The Lord of the Rings and Atlas Shrugged. One is a childish daydream that can lead to an emotionally stunted, socially crippled adulthood in which large chunks of the day are spent inventing ways to make real life more like a fantasy novel. The other is a book about orcs.

In March 2009 John Rogers, in his blog Kung Fu Monkey, [1] wrote:

There are two novels that can change a bookish fourteen-year old's life: The Lord of the Rings and Atlas Shrugged. One is a childish fantasy that often engenders a lifelong obsession with its unbelievable heroes, leading to an emotionally stunted, socially crippled adulthood, unable to deal with the real world. The other, of course, involves orcs.

I hope this is a mistake, but although it's been noted elsewhere the error has never been corrected.

Reading Patel, I'm reminded that the Hard Left shares some of my thoughts on emergent corporate entities. I will claim a significant distinction however. Patel and his kin see these emergent entities as rapacious and destructive. I see them as powerful but simple minded, with interests that usually align with civilization and sometimes even with "the weak". They are humungous beasts that walk the "realer than real" world of Finance, but they are not predators. They are coopetitors with humans -- and there's a chance that we can steer them ...

Update and [1]: When I first wrote this I was puzzled by attributions to John Rogers, when Kung Fu Monkey was the only source I could find. John Rogers contributes to KFM and wrote the original quote. So it should be attributed to John. Thanks to an Anonymous comment for the clarification. I really should have figured this out on my own!

Update 4/28/11: Good news on the citation. Patel noted the mistake a year ago and posted on it. Thanks Nick for the comment.

Rework reviewed

I wanted to like Rework by Fried and Hannson, but I feel like I overpaid.

To say it's a short book is an understatement. This is pretty much it:

• Simplicity is the only winning formula.
• Don't hire until quality falls.
• A successful private company can get by with very few employees by outsourcing utility functions (details on this may be in their other book)
• Meetings are bad, but distributed teams need to get together every three months or so. Evidently whatever those teams do together is not "meeting". Whatever "meeting" is.
• True productivity works with a balanced 45-50 hour week -- but when you're doing a startup you should sacrifice sleep and keep your day job.
• You can make money by reselling the detritus of corporate activity, like this book.
• Cash flow is king, be positive early.
• Build enough to sell, then build what you need to keep selling.
• Customers can't tell you what they need.
• Don't fear customers graduating from your services (but I wager they don't make it easy for customers to migrate their data).
• Don't surrender ownership early -- wait until you're a proven company.
• Only hire talented writers - regardless of the position

The book isn't worthless. About two thirds of it feels right, which is better than the average business book. On the other hand, I don't buy average business books.

I'd recommend a pass on this one. Do pick it up at the library or a used book store. $8 would be a fair price.

Montreal and Minneapolis: Unremarked differences

I grew up in Canada, but most of my adult life has been spent in the US. I'm more American than Canadian, but I keep in touch with the old country.

Moving back and forth between Minneapolis-St Paul (MSP) and Montreal (YUL) so many things are similar that the differences can come as a surprise. Some of the smaller differences are most interesting.

Of course there are the differences we all know about, such as the two Ms: "Medicare" [1] and the Metric system. Both came in during my childhood. For a poor kid in Quebec in Medicare was a flaming miracle. These two are obvious and large differences [4], but I doubt either would pass in today's Canada. I wonder if Canada and the US were more different forty years ago.

Montreal is poorer overall, but only relatively - it's obviously a wealthy region. Although inequality seems to be growing, it's still far less skewed than the land of the GOP. Education in particular is much less of a local responsibility. Public schools and buildings are spartan everywhere in Montreal, but luxurious in MSP's wealthier suburbs. Overall Montreal's non-historic structures are more minimalistic, more built to budget than similar places in MSP. Concentrations of poverty are also less severe than in MSP [3].

Montreal's automotive infrastructure is abysmal. Despite the astounding collapse of a major bridge [2], MSP's roadways are much better. There's now a desperate traffic paralyzing catch-up roadway rebuilding in Montreal so it's fortunate that Montreal has a vastly better public transit system than MSP. On the other hand MSP is now extending its light rail transit system. The two are converging.

Other smaller similarities and differences are perhaps more interesting. [4] Both Montreal and MSP have very extensive bicycle trail systems that have expanded over the past ten years. In last year's rankings Montreal was rated #1 in North American and Minneapolis was #2 (take that Portland!). That's despite climates that are wintery (MSP) and miserable (Montreal) [5].

Accessibility is a very big difference. MSP is largely accessible; most of the city can be navigated in a wheelchair and most of the restaurants and private businesses are accessible. That's not a local virtue, it's a legacy of the astounding American Disabilities Act of 1990. Montreal is almost completely inaccessible. It's an vast gap to MSP's advantage, and seems little remarked on in Montreal. You don't want to have physical disability in Montreal.

It's not just physical disabilities that are a problem in Montreal. I have a good understanding of the 'special needs' experience in MSP and some knowledge of how Montreal performs. I guesstimate MSP is about twenty to thirty years ahead of Montreal in its care of cognitive disability in school age children. I see convergence here too however. Montreal seems to be improving, and Minnesota is regressing. Still, like physical disabilities, MSP is curiously ahead of Montreal in the management of cognitive disabilities.

Both cities have good and bad restaurants, but only Montreal has pastries. Sure, MSP has places that sell excellent bread (including baguettes) but you can't buy a pastry in MSP.

Ok, I admit, there are places in MSP that claim to sell "pastries", but the best of them are weak sugary things that would disgrace a Montreal strip mall. The Bagel-gap isn't quite as wide, but it's still there. These are puzzling market failures.

The case of the Aero bar is even stranger. My daughter loves these mundane chocolate bars, but they are sold only in Canada. There has never been a serious modern attempt to sell them into the US market. Strange.

There's one last curious distinction that is personally annoying. In MSP most cafes and libraries have open public WiFi access. Even many McDonald's have it. The entire city of Minneapolis has a WiFi network (though it's not free). In Montreal I have a hard time finding any access at all; even Starbucks charges for access here. I suspected liability or regulatory differences, but that doesn't seem to explain the difference. I wonder now if it's because of the monopolistic Canadian telecom industry, and if open WiFi will disappear in the US as our market consolidates.

Will these gaps close over the next 30 years? I suspect so. The US will, very slowly, go metric in many ways, though perhaps not in temperature. Aero bars will surely come to MSP before I die, though pastries may take longer. The Bagel gap will close, already MSP does well with bread. The US and Canadian health care systems will probably converge on some messy compromise. Open WiFi will disappear everywhere. Montreal will have to do something about accessibility as its population ages. Both cities will become more cosmopolitan, less pale, more multilingual.

The worlds will continue to converge.

[1] How'd the US system for care of the elderly get the same name as Canada's universal coverage? Some time I'll have to research the etymology.
[2] After all the investigations it looks like the primary cause was a manufacturing error. 
[3] By US standards MSP is relatively enlightened, which means by Nordic standards MSP is the first circle of Hell.
[4] Languages differ of course. Montreal is predominantly French with a lot of English (still), MSP is predominantly English with a growing Spanish segment. Both cities look very pale to me, but MSP is a shade less melanin-deficient. Montreal is historically Catholic and now largely indifferent, St. Paul is historically Catholic (and French) and still somewhat religious. Minneapolis is historically Lutheran, now indifferent. Both are river cities, Montreal has the St. Lawrence, MSP the Mississippi. Both were French/English meeting places.
[5] Montreal has the worst climate of any city outside of maybe Moscow. It's not the cold, it's the frequent freeze/thaw cycles, the endless cloud, the slush ... Yech. Growing up in Montreal is why I think MSP's climate is wonderful, which appalls my native colleagues.
[7] Open WiFi nets are a favorite haunt of traders in illegal pornography.

The debt ceiling test and why index funds are probably evil

We're coming up on one of the great natural experiments of our time. If I and my fellow travelers are right about how the American world works, then either the US debt ceiling will be raised or Goldman Sachs will make a vast (even by their standards) amount of money. If the debt ceiling is not raised, and GS doesn't make another fortune, then I'm wrong about how the supreme court blessed power of emergent corporate entities.

I think I'm right though, so, unless Goldman Sachs has bet big on US debt interest rates rising, the US debt ceiling will be raised.

There's not a lot of comfort in being right though. Being right means that another brief experiment in representative democracy [1] is drawing to a close; voters, even crazy tea party voters, just aren't all that important.

Corporate entities are important though, and not all corporate entities are equal. Exxon has different interests from Apple. Philip Morris and Google are not the same. Privately held corporations can own Senators just like the public, but they can be quite idiosyncratic.

Since all corporations are not equal, all of us are not completely powerless. Those who still have savings can choose which corporations to feed. Some, like Exxon, will oppose a CO2 tax. Others, like Google, will be relatively neutral. Some, like Goldman Sachs, are largely parasitic. Others, like Apple or Subaru, produce useful products. Combining the limited power of voting with the limited power of stock ownership we may be able to keep civilization together long enough for our children to deal with it.

There's a problem though. The problem is that most smart non-uber-wealthy investors [1] put their money in Bogle's proletarian invention - the index fund. That doesn't give us any "vote" on which corporations grow, and which don't.

In the world of corporate rule, index funds neuter our limited influence. We need a new variety of socially conscious investing, a basket of corporations that are mostly compatible with human civilization.

Anyone know of a set to start with?

See also:

• Why you should vote for the Tea Party’s coven in the century of the fruitbat
• Why do corporations (firms) exist?
• Self sustaining entities: corporations and the Spanish Inquisition
• Troubled capitalism: The corporate entity
• Is the GOP truly a pawn of corporations and the wealthy? We'll find out soon.
• Understanding the elections - what's really changed
• The debt ceiling: Can Goldman Sachs win if the US defaults?

[1] The uber-wealthy have access to information we don't have, and they shouldn't have.

The twenty minute HIT bicycle routine

High intensity interval training (HIT) is a popular fix for people with more drive than time ...

What’s the Best Exercise? - Gretchen Reynolds - NYTimes 4/17/11

... High-intensity interval training, or H.I.T. as it’s familiarly known among physiologists, is essentially all-interval exercise. As studied in Gibala’s lab, it involves grunting through a series of short, strenuous intervals on specialized stationary bicycles, known as Wingate ergometers. In his first experiments, riders completed 30 seconds of cycling at the highest intensity the riders could stand. After resting for four minutes, the volunteers repeated the interval several times, for a total of two to three minutes of extremely intense exercise...

The approach seems promising, since most of us have minimal time to exercise each week. Gibala last month published a new study of H.I.T., requiring only a stationary bicycle and some degree of grit. In this modified version, you sprint for 60 seconds at a pace that feels unpleasant but sustainable, followed by 60 seconds of pedaling easily, then another 60-second sprint and recovery, 10 times in all. ‘There’s no particular reason why’ H.I.T. shouldn’t be adaptable to almost any sport, Gibala said, as long as you adequately push yourself."

The NYT likes Dr Gibala, his prior study was featured in a 'Well' blog post of June 2009. The regime sounds a bit faddish, but I do like the idea of a solid workout over 20 minutes (10 minutes out, 10 minutes back). It is well suited to inline skating, bicycling and nordic skiing.

I can see doing this kind of HIT once a week in addition to my other exercise routines. The 'River road' near our home would be perfect for this - few stop signs, limited traffic. I'll look for find a cheap timer I can tape on my handlebars. It's also pretty easy to convert this to indoor (still have a vintage Nordic Track!) when the weather is bad.

Twin Cities bicycling clubs

I did my first TCBC ride in 12 years tonight. The kids are getting old enough I can take a Dad Night every few weeks; soon they'll be strong enough to join me on these kinds of rides. (I do summer Minnesota Inline Skate Club skates with my middle son, but I often tow him. Harder to do on a bike unless I buy a tandem -- which I'm considering.)

TCBC has the most rides in the metro area, especially the B/C rides I like. (It will be a while before I'm a B rider again; their B rides get pretty fast.) It's not the only recreational club [2] though. Aside from the outre Black Label Bike Club (no local site, that would be inappropriate) there is the Hiawatha Bicycling Club [1], the "Easy Riders" (I've seen them, but can't find a web site), the fitness/performance oriented Ride and Glide [3], The Twin Cities Bicycling Meetup and Twin Cities Social Cycling (meetup).

TCBC is by far the largest and oldest of the recreational road cycling clubs, the other may come and go.

[1] Lower key, often lower pace - but possibly in retirement. Their Javascript heavy web site doesn't appear to work in modern browsers; I wonder if was done using an old version of FrontPage.
[2] There are at least a half-dozen racing clubs, probably twice that.
[3] They do pacelines. I think TCBC only does pacelines on A and some B rides.

Care of special needs adults in post-employment America

The Dow is doing very well, though some expect that to change shortly. For most Americans, however, the Great Recession grinds on. The percent of employed adult Americans (employment-population ratio) is now back to where it was in 1976, when most women weren't in the workforce. The annual incomes of the bottom 90% of US families has been flat since 1973.

Against this, we see about 50 million Americans with a disability and 24 million with a severe disability. Looking forward, barring US adoption of Canada's brilliant solution, intractable American demographics means fewer workers supporting more disabled persons -- even as those workers are faced with decreasing employment options and stagnant or falling wages.

So it's not surprising that societal care for the weak is being withdrawn ...

When Children With Autism Become Adults - Goehner 4/13/11 - NYTimes

... As the explosion of children who were found to have autism in the 1990s begins to transition from the school to the adult system, experts caution about the coming wave.

“We estimate there are going to be half a million children with autism in the next 10 years who will become adults,” said Peter Bell, executive vice president for programs and services of the advocacy group Autism Speaks.

Services for adults with autism exist, but unlike school services, they are not mandated, and there are fewer of them. Combined with shrinking government budgets, the challenges are daunting.

“We are facing a crisis of money and work force,” said Nancy Thaler, executive director of the National Association of State Directors of Developmental Disabilities Services. “The cohort of people who will need services — including aging baby boomers — is growing much faster than the cohort of working-age adults that provide care.”

To help parents navigate this difficult journey, in January Autism Speaks introduced a free Transition Tool Kit for parents and their adolescent children with autism. The kit includes information about such critical issues as community life, housing, employment and developing self-advocacy skills...

... Many young adults with autism have transitioned into large residential systems, whether group homes or institutions, offering round-the-clock services. But waiting lists can be long. And increasingly, in an effort to stem costs, states are moving away from the group home model into family-based care, a trend that started about 10 years ago.

... Nationwide, 59 percent of people who receive autism services are living with their families, according to Mr. Lakin.

Living with one’s family may not always be best for a person with autism. Nor is it what many families, who assume their grown child will move into a group home, for example, envision for their future. But options are limited, and given the high demand for out-of-home residential services, Mr. Lakin said, “families really need to think about a longer and more central involvement in their adult child’s life than they have in the past.”

The good news is that many states are providing more support for people with autism who live with their families. They are also giving families greater flexibility and control over budgets with so-called consumer-controlled services, which reimburse families that hire friends or relatives, rather than outside caregivers, for regular care.

Connecticut and Arizona, for example, pay for care provided by family members, a growing trend. Other states, like Pennsylvania, have programs in which contracts are issued for people with autism to live with other families. And Vermont and New Hampshire pioneered a model of providing funding directly to families.

Some families have pooled their own money and entered into cooperatives with other families, a challenge that can take years...

.. Among the most powerful advocates are siblings of those with developmental disabilities. “Sibs have always played a really important role; we just haven’t identified them as sibs,” Mr. Lakin said. “We’ve identified them as agency leaders and social workers occupationally. But the real impulse of their work is that they were a sibling.”

Don Meyer, the founder and director of the Sibling Support Project and the creator of Sibshops, a network of programs for young siblings of children with special needs, said: “Parents need to share their plans for their special-needs child with their typically developing kids. After Mom and Dad are no longer there, it is likely it will be the brothers and sisters who will ensure their sibling leads a dignified life, living and working in the community.”...

It doesn't require a lot of imagination to predict how this will turn out. Among other things, we should expect a return to orphanages (esp. for special needs children) and the return of longterm institutions for the destitute disabled.

This might be a good time to consider the Canadian Solution for immigration. Maybe we should even take a look at where America's trillions are going. Just saying.

The Golden Age: November 9, 1989 to September 1, 2001

In our home it's a short hop from planning a bathroom remodeling to the history of uncertainty in medieval and modern eras to the shadow of The Last American Golden Age, an era when the world felt predictable and the future was bright.

When was that golden age? It wasn't, Emily and I decided, exactly the 1990s. It began with the fall of the Berlin Wall on November 9th, 1989. It ended, of course, on September 11, 2001. So the Golden Age for modern America lasted almost 12 years.

Future historians won't agree. They'll say it's all too neat. Falling walls and towers bookmarking a millennial decade -- it's a cliche.

The cliche doesn't stop there. The seeds of the whitewater world, the Net and the rise of the China and India, world were planted then. Seeds of doom planted even at the peak of power?! Come on. Nobody would write that story.

But that's what happened. Reality doesn't worry about cliche.

Update 4/18/11: I had a typo in the title. Fixed.

Thoughts after two days of a primary care conference

I haven't seen a patient in 10 years, but I like to keep in some contact with my first career. So I've spent the last two days at the MAFP Spring Refresher. It's inexpensive and local and the lectures are comparable to most such conferences.

Mostly I enjoyed the presentations, but I'm not going to write about those. Instead of commenting on the "new" discoveries, I'll comment on the static and the transitory.

What's static is the manner of presentation. In the past 30 years we've gone from transparencies to (yech) PowerPoint, but the basic format of medical lecturing is unchanged. The most interesting material is only spoken, not written. We get lists of symptoms (near pointless) instead of typical and atypical presentations. We don't hear enough about common mistakes. We rarely get frequency or prevalence data or diagnostic sensitivity, specificity or positive predictive value. Even experienced clinicians don't describe natural history of the conditions they know. We see lists of moldy textbook treatments that the speaker would never actually lose herself. Specialists don't tell us what makes a good referral. We get nearly worthless PDFs (that we can't copy/paste), only one speaker (the best) provided a handout of key points.

Thirty years -- and we've made no real progress in something as fundamental as person-present education.  Since improvements are so obvious (see above) this is a curious form of market failure.

What's transitory is medical practice. Medical progress is almost as static as medical education, but I was struck today by the effervescence of medical fashion. Perhaps it's a side-effect of a field that now changes slowly, but several speakers spoke of national care guidelines that seem to reverse direction every two years. I think of daily and monthly changes to medical practice as being like the weather in Minnesota - frequent storms that rage and thunder -- then pass slowly away. Against that is the climate of slow change and true progress, but that now takes a decade to see ...

Text Spam: Phone company text messaging must die

I don't like paying $20/month for our AT&T unlimited texting family plan. After all, it costs AT&T next to nothing to provide SMS services.

I pay because the current IM alternatives don't work. That leaves texting as the polite alternative to the unscheduled phone call. I pay because what I get is worth more than the money I pay.

Or, rather, it was worth more. It's worth less all the time, because I'm getting more text spam like these 595-959 Welcome to Sears/Kmart Shop Your Way Rewards Text Alrts (yeah, "Alrts") ...

Unlike "full number" text spam, AT&T won't accept reports for these...

Instead, AT&T markets "short code" text message services. They charge spammers to spam us, and, I assume, they charge us to receive the spam. Talk about a win-win!

You could try completing the FTC's spam report form for wireless phones, but as of today it's not designed for text message reporting. It's as though the FTC got caught in a time warp @ 2002.

This is only going to get worse. There are now two phone companies in America, and they hate us almost as much as we hate them. They hate us so much they'll drive us to abandon their most profitable service.

We need an alternative to phone company controlled text messages. We need a messaging service that includes spam filtering -- and that doesn't make us sitting ducks for low grade spam. Blackberry did this years ago; maybe when RIM dies in 2013 either Apple or Google will buy their texting service -- and give us something worth paying for. Maybe California will ban text spam and end our spam as a side-effect. Maybe all of the above.

There's an opening here. Help me out Apple, Google, and California!