Obligatory Rapture Day post

I'm sorry. It's union rules. I have to say something.

First, because I'm a certified killjoy, I'd like to see someone advising families on how to counsel the unraptured. I'm not joking. Really. Imagine the shock for people who took this seriously. I thought that number was about zero, but after reading the NYT today there must be at least a dozen of them.

Secondly, the unrapture will be blamed on Barack Obama. God's no-show will be proof that Obama has driven him away. This is my easiest prediction ever.

iPod touch wheel - 9 years and an eternity ago

My daughter brought my first iPod to me - the 2002 Touch wheel iPod. It wasn't responding to her touch.

It sits in a cradle, the battery died many years ago. It works as well as ever, the 30GB drive serving music to a local stereo. I sync it every six months or so, when I remember. Toggling the lock switch took care of the problem.

That's not what I'm writing about though.

I'm writing about the shock of holding it. It feels enormous, strange and crude. It feels like a relic from ancient history, it feels older than a VCR, as old a phonograph.

It's just nine years old.

Heck of a decade for Apple.

Conversations - From emotional confrontation to dialog

I'm back from a two day corporate class on VitalSmarts Crucial Conversations (see also: Amazon reviews of the book). I'm going to summarize here what was new to me, and what I'm going to do differently in my personal and corporate life. This is how I process new material, please feel free to skip this post if this material isn't your tea cup.

I'm not going to review or recap the original book by Paterson et al. I skimmed the book and I wasn't impressed. I was, however, pleased with the VitalSmarts "Participant Toolkit", with their educational materials, and with our instructor.

I'm also not going to recapitulate the course. This is a summary of my personal interpretation and transformation of the course material including my own experience and readings. I particularly recommend the complementary book Bidell's Three Steps to Yes. In some respects this post may contradict the course work, in others it extends the material.

Before I begin, I can't resist some cultural context. It's impossible to read this book, with its model of "silence" and "violence" as two styles of aggressive conversation, without thinking of "female" and "male". Among other things, this material can be read as a guide to communication in a multi-gender corporate hierarchy. There are limits to this interpretation of course. Like many geeks of either gender my "style" score was silence/violence balanced, with a bias to "silence". (Important note: "violence" in this context is verbal - sarcasm (attack), verbal control, and verbal labeling. It's an interesting choice of label.)

The concept of a "crucial" conversation is novel and meaningful. There are three ingredients, but one is particularly critical. The first two ingredients are high stakes and conflict. The third and most critical ingredient is (negative) emotion. The primary focus and value of the "Crucial Conversation" (CC) methodology is managing the emotional component of important conversations. The goal is to transform a high-emotion interaction to a low emotion "dialog".

A CC, therefore, is not a good thing (I think the course materials are confused about this). The "good thing" is a productive and positive dialogue. A "CC" is, at best, a means to getting to dialogue. At worst, it's the result of a botched interaction, and a means to get things back on track.

The first goal of the training is to be able to recognize when a Conversation goes Crucial (think Plutonium going Critical). The most important response, at that point, is to give up on the topic of conversation and focus on managing the emotional component. That's a big idea for me. Especially on a phone conference I've planned, I'll miss or disregard the emotional component and try to power through my original agenda.

Speaking of a phones, this is where the course is partly obsolete. It was written for the 1990s world of person-to-person communication. In the post-Great Recession world our corporate interactions are by telephone conference. No, not telepresence or videoconference -- 1970s style teleconference. Person-to-person emotion management is hard enough, but after years of being beaten and pummeled I can just about manage it. Managing emotions on a multi-person half-the-team-is-muted conference call takes things to a whole 'nother level.

So how can we modify the approach of the course to a setting where emotions can rise fast on a teleconference with people we may see every few years? The approach I'm going to test goes like this:

1. Identify signs of emotional intensity. Conspicuous silence or tone of voice are the best remote cues. I can monitor my own responses, such as rapid heart rate, sweating or increasingly slow speech -- but those are late arrivals. I think an early sign of emotional content, for me, is narrowing of my eyes. I'm training myself to detect that and even to forcibly relax my eye muscles.
2. Manage the immediate emotion. This may mean using techniques that CC considers dysfunctional -- such as avoiding and withdrawing. The goal is to get out of the call without an escalation.
3. Schedule a managed one-on-one "CC" -- by phone usually (alas). (Telepresence is better, and with advance planning may be available). Scheduling the one-on-one "CC" gives time to work on the "path" script of Fact definition, scripted Story, and Ask questions. The goal of the scheduled "criticality" is to get through emotion and back to "dialogue".

The training and course materials don't discriminate between a "planned" and "emergent" CC. That's a big distinction. It's the difference between running up hill and running through a mine field. Given where I am now, my personal goals are to recognize an "emergent" CC, calm it as much as possible (abandon agenda, get out of Dodge alive), and then plan a managed CC.

My outline of a managed CC borrows from CC and Bidell. It starts with a planning phase that's largely Bidell ...

1. What is my goal for me and others? What is the true goal of the other person -- even though they may not know it themselves? (In Bidell's world, it's usually personal success in one form or another. That seems to work.)
2. What is it I want to avoid?
3. How can I achieve #1 and avoid #2?

Knowing the other person's true goal, and how that can be achieved, is the key to both Bidell's "Persuasion" and to creating CC's "shared purpose". That "shared purpose" may be to achieve success for the other person, even if their original conversation goal is not met. In Bidell's terms, find a way for my "Prospect" to "Win" -- while making the sale.

CC next focuses on the "do/don't" statement as a way to express my conversational goals. "I do want to get paid, I don't expect to get paid this week." It's not a bad place to start, but I can see how it might need modification.

The next phase in this structured high-emotion conversation is Fact/Story -- avoiding the dreaded "why" (the other banned word is "but"). Fact is supposed to be an enumeration of verifiable statements that will considered "true" by all participants. The Story comes next -- it's where the emotion and opinions come in. The Story is the statement of personal impressions, carefully refactored to avoid "violence" (sarcasm, control, labeling, etc), to avoid identifying a villain or a victim, and to avoid expressing helplessness.

For me, both the Facts and "the Story" are best written out beforehand and practiced aloud.

The Facts and Story are to be presented in an "tentative" and "testing" fashion (What have I left out? Does this sound right? What are your thoughts/feelings?).

The Story is followed by the "Ask". The goal here is to encourage the "Prospect" (Bidell's term) to follow a similar "Path" by asking framing questions and using classic conversational strategies such as  mirroring (I hear you say you're good, but as I imagine your face I think it's .... ok, so this doesn't work so well over the phone) and "paraphrasing".

At that point, if all (miraculously) has gone relatively well, the "Crucial Conversation" is done, and the action conversation (decisions, dialog, discussion) begins.

Or so the theory has it.

I'll be testing that out.

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)

Yakima fails a crucial test: treating customers well

I've bought four Yakima Steelhead bike mounts over the past decade; all through REI.

All four have broken plastic locking tabs. It's not a rare problem ...

Yakima Steelhead Bike Mount Reviews:

... the red plastic locking tabs are complete junk. I have six of these racks and three are broken, three I don't dare remove from the crossbars as they are about to fail. Yakima support will gladly send me replacements for a mere $54 per rack .... [Yakima's] choice of such a cheap plastic and unwillingness to replace at a reasonable cost has me shopping for Thule...

and

Amazon.com: Anonymous' review of Yakima Steelhead Fork Mount Rooftop Bicycl...

... I had Steelheads many years ago and when I needed a rack for my new car I decided to get another set.... Over time, exposure to the sun has caused the red plastic levers to crumble to pieces, and Yakima Customer Service told me that I would have to buy an entire replacement head which is about half the cost of a new mount. ... Luckily, it can be fixed with a stainless worm screw hose clamp threaded through the slot and around the head to keep the halves together. It doesn't look as nice but it's probably stronger than the original design. It would get 5 stars if Yakima provided service parts for the heads...

The plastic degrades in sunlight.

I'm going to take all four to REI and see if they can get more out of Yakima than their customers can.

Yakima has failed two major tests.

One is that they have known for years that they have a flawed design -- but they haven't fixed it. A second is that they have not offered a low cost replacement program, or a trade-in program to a fixed design.

I expect that from low cost brands, but Yakima is a premium brand. I expect more from them.

Buy Thule instead.

Update 5/26/11: Yakima failed, but REI reminded me why I carry an REI VISA card, and why I've been a member since we made fire from rocks. I paid $100 each for the two racks REI has purchase records for. Turns out I bought the "new" ones in 2003, which is as far back as their electronic purchase database goes. If I can find receipts for the old ones they'll pay for those as well. Considering the age of the racks it would be greedy to claim for all four.

REI rules.

Reliability and the Cloud - Redundancy required

Hardly anyone noticed, but yet another Google cloud service failed this week. There was understandably more attention to Amazon's recent service failure (2008 too). These aren't a surprise, I've had my share of complaints with Google's cloud services.

Despite all of the problems with Cloud services, of which the most serious is Cloud provider bankruptcy, Amazon and Google are relatively reliable. In my corporate workplace, the average worker loses 2-5 days of work each year due to machine upgrades, backup failures and hardware failures. Cloud services aren't quite that bad, but corporate IT is a low standard. Cloud services aren't good enough.

The answer to Cloud reliability, is redundancy. The designers of the late 20th century American space shuttle knew this well ...

... The shuttle uses five identical redundant IBM 32-bit general purpose computers (GPCs), model AP-101, constituting a type of embedded system. Four computers run specialized software called the Primary Avionics Software System (PASS). A fifth backup computer runs separate software called the Backup Flight System (BFS). Collectively they are called the Data Processing System (DPS)....

The design goal of the shuttle's DPS is fail-operational/fail-safe reliability. After a single failure, the shuttle can still continue the mission. After two failures, it can still land safely.

The four general-purpose computers operate essentially in lockstep, checking each other. If one computer fails, the three functioning computers "vote" it out of the system...

The Backup Flight System (BFS) is separately developed software running on the fifth computer, used only if the entire four-computer primary system fails. The BFS was created because although the four primary computers are hardware redundant, they all run the same software, so a generic software problem could crash all of them ...

It's not hard to do the math. A series of 5 procedures each with 90% reliability has a 40% chance of failure (1-0.9^5). A different system with 5 systems of similar reliability run in parallel has a 0.001% (.1^5) chance of failure.

In Cloud terms similar redundancy can come from multiple service providers, with the ability to switchover. File requests, for example, could be alternately routed to both Amazon S3 and to a corporate owned server. Reliability comes from two very different systems with uncorrelated failure probabilities [1][2].

This switchover requirements requires Cloud services to be dumb utilities - or to support some kind of local cache. To safely use Google Docs, for example, there has to be some way to fail over to a local device, perhaps by synchronizing files to a local store. Similarly, to use a Cloud blogging service one would want control of the domain name, and blog software that published to two services simultaneously. In the event of failure, the domain name could be redirected to the redundant server.

None of this is new. Back in the days when Cloud services were called "Application Service Providers" (ASP) I went through the same reasoning process with our web-based Electronic Health Record. I'm sure there were very similar discussions in the 1970's era of 'dumb terminals'. These things take time.

We'll know they Cloud is maturing when failover strategies become ubiquitous. Of course by then we'll call the Cloud something else ...

[1] Of course then the switch fails. There are always failure points, the trick is to apply redundancy to those that are least reliable, or where redundancy is most cost-effective. The Shuttle, infamously, couldn't survive a failure on launch of its solid fuel system.
[2] From a security perspective, two systems like this are two sources of security failure. Multiple systems increase reliability, but decrease security.

American torture dishonored us, but we can honor those who said No.

We have been doubly shamed over the past ten years. Once by our embrace of torture, a second time by our inability to prosecute.

We can't undo our past, but there are some things we can do. Even if, as Tracy Lightcap tells us, "Bush's C-in-C order of 13 November 2001 and the subsequent OLC memos (effectively DOJ opinions) make it virtually impossible to prosecute those involved in acts of torture..." we can still establish a truth commission to document what was done.

Even before a truth commission, however, we can begin with a small step ...

Honoring Those Who Said No to Torture - NYTimes.com
Jameel Jaffer is a deputy legal director at the American Civil Liberties Union. Larry Siems is the director of the Freedom to Write program at the PEN American Center

ON January 2004, Spec. Joseph M. Darby, a 24-year-old Army reservist in Iraq, discovered a set of photographs showing other members of his company torturing prisoners at the Abu Ghraib prison. The discovery anguished him, and he struggled over how to respond. “I had the choice between what I knew was morally right, and my loyalty to other soldiers,” he recalled later. “I couldn’t have it both ways.”

So he copied the photographs onto a CD, sealed it in an envelope, and delivered the envelope and an anonymous letter to the Army’s Criminal Investigation Command. Three months later — seven years ago today — the photographs were published. Specialist Darby soon found himself the target of death threats, but he had no regrets. Testifying at a pretrial hearing for a fellow soldier, he said that the abuse “violated everything I personally believed in and all I’d been taught about the rules of war.”

He was not alone. Throughout the military, and throughout the government, brave men and women reported abuse, challenged interrogation directives that permitted abuse, and refused to participate in an interrogation and detention program that they believed to be unwise, unlawful and immoral. The Bush administration’s most senior officials expressly approved the torture of prisoners, but there was dissent in every agency, and at every level.

There are many things the Obama administration could do to repair some of the damage done by the last administration, but among the simplest and most urgent is this: It could recognize and honor the public servants who rejected torture...

It's the very least we should do. We can start at the local level, then the state level, then the federal.

Does anyone know of an "honor role" of those who said No?

Separated at birth: alternative medicine and climate change denial

As a colleague and I corresponded about my support for the scientific consensus on CO2 driven climate change, I realized I was replaying fifteen year old conversations about the alternatives to science-based medicine. Homeopathy consumers have a lot in common with cosmic ray climate enthusiasts.

One common thread is a skepticism about the value science, and particularly the value of the scientific establishment.

Some believe that science simply doesn't apply. "Healing fields", they say, cannot be detected by science; indeed scientific analysis may destroy them. Herbal remedies are safe because Nature loves us. Yahweh promised us the Earth, so it's impossible for us to render it (transiently) inhospitable.

This version of anti-science is uninteresting. These arguments can't be refuted for the same reasons that we can't disprove the existence of unicorns and leprechauns.  There's no measure for resolving disagreements; these are theological disputes.

Another form of argument grants that the scientific method is effective, but claims that the scientific establishment is corrupt and untrustworthy. This is more interesting because it's at least partly true. Over the past twenty years we've learned about the effects of publication bias, particularly when corporations with strong financial interests (ex: Pharma) control the publication of research results. We've seen some spectacular scientific frauds, and we've seen a trend to "me too" research that gets safe grants but produces small results. During the Bush years, we saw loyalists suppress scientific results their bosses disliked.

Alas, there's no evidence the amateurs are reliable; most seem driven by the same passions that power crank cosmologists. Even if they were angels, furthermore, by their nature these amateurs bypass scientific evaluation and challenge. They cannot be judged because they're not in the game.

Sure, the scientific program is imperfect, but, when it comes to understanding the world, there are no alternatives. The process of iterating on internally consistent models that make testable predictions, and revising those models when predictions fail, has transformed human history. It is the only guide we have to developing better medicines, understanding the universe, or predicting the consequences of CO2 accumulation.

The denialists do have a point, even if they don't fully recognize it. We can and should improve the machinery of science. Requirements to publish data obtained through public investments, registries of studies to ensure negative and unfavorable results are published,  and (more challenging) reforms to grant programs and academic tenure are some of the improvements seen over the past decade.

Science tells us Homeopathy's effects are mediated by belief, not molecules. Science tells us that CO2 accumulation will change the earth's climate; and that these changes will be extremely disruptive for a crowded planet with fixed borders.

Maybe in ten years science will tell us that solar cycles are more important for our 21st century climate than CO2 accumulation. Maybe science will tell us that spinal manipulations do change the immune system. Maybe, but probably not.

Update 5/14/11: I've rewritten parts of the first few paragraphs.

What if Blogger died and nobody noticed?

For the first time in quite a while, Blogger died hard ...

Blogger Buzz: Blogger is back

... during scheduled maintenance work Wednesday night, we experienced some data corruption that impacted Blogger’s behavior. Since then, bloggers and readers may have experienced a variety of anomalies including intermittent outages, disappearing posts, and arriving at unintended blogs or error pages. A small subset of Blogger users (we estimate 0.16%) may have encountered additional problems specific to their accounts. Yesterday we returned Blogger to a pre-maintenance state and placed the service in read-only mode while we worked on restoring all content: that’s why you haven’t been able to publish.  We rolled back to a version of Blogger as of Wednesday May 11th, so your posts since then were temporarily removed. Those are the posts that we’re in the progress of restoring...

Blogger was down for over 20 hours. When it came up some of my draft posts were missing, but they are back now.

During the outage Blogger was slow to update status.blogger.com, but, they were pretty good at posting updates to Twitter.  It's a significant failure, but every company gets those. The failure by itself isn't that interesting.

What's more interesting is how little notice the outage got in the blogs I read. Blogger died, and aside from Blogger users tweeting furiously, nobody seemed to notice.

Google Chromebook - disappointing, but a glimmer of hope

Google's long, long delayed "Chromebook" is out.

... Google Launches Chromebooks with Samsung and Acer: Tech News and Analysis

Acer’s Chromebook will start at $349, and Samsung’s model will be priced $429 for its WiFi model and $499 for a model with 3G connectivity...

A price of $150 would be interesting. $100 without batteries would be exciting. $350 and up is just sad. My prognostication rep just took a big hit.

This is more interesting ...

Google Chrome Blog: A new kind of computer: Chromebook

... we’re also announcing Chromebooks for Business and Education. This service from Google includes Chromebooks and a cloud management console to remotely administer and manage users, devices, applications and policies. Also included is enterprise-level support, device warranties and replacements as well as regular hardware refreshes. Monthly subscriptions will start at $28/user for businesses and $20/user for schools.

Completely outsourcing all IT services, including hardware support, isn't pathetic -- especially for public schools. So there's a glimmer of hope for the ChromeOS, but I bet the Parental Controls will be a disaster.

See also:

• The $80 ultra-portable - in unexpected form (9/10)
• Computing for the rest of us: The iPad and the ChromeBook (1/10)
• The $125 Barbie B-Smart Netbook of 2011 (1/09)
• Squeezed 2009: Netbooks, Android and Microsoft

Florida's emergent solution to medicine's failure - high mortality assisted care

Florida's years of GOP misrule have produced libertarian innovations in the care of the aged ...

Investigation Finds Dozens Of Questionable Deaths In Florida Assisted Care : NPR

... A year-long investigation by The Miami Herald and WLRN has turned up at least 70 questionable deaths in Florida assisted living facilities over the last decade. Herald investigative reporter Mike Sallah reads a list of deaths culled from thousands of state documents ...

... We found deaths resulting from residents being deprived of their medication, and from residents being over-medicated. The cases stretched from Miami to the Florida Panhandle. Questionable deaths occurred in both 100-bed facilities and 6-bed facilities. And in almost all 70 cases, there were few or no consequences for caretakers. Florida, once a national leader in policing assisted living facilities, has fallen behind in enforcement, our investigation shows ....

High mortality assisted care facilities are an emergent solution to a failure of modern medicine -- our bodies now outlive our brains. It's even cheaper than railing-free cruise ships [1].

For my own longterm care, I'm looking for a lock-free facility built on a 600 foot cliff with a view. Emily and I call this "a room with a view".

[1] My cruise ships would only accept advanced reservations for and by people with fully intact judgment. Until, that is, we went public and had trouble meeting analyst expectations ...

What Barack said to Paul

"Thanks for coming Professor Krugman. I appreciate the disguise; you make a convincing janitor."

"No problem Mr. President.  I don't understand the secrecy though. Everyone knows I'm a critic, why all the mystery?"

"Well Paul, if this were the usual consultation, there'd be no need for deniability. This is different. What I'm going to tell you now can never be repeated. In fact, nobody will be able to show you were ever here. All records of this visit have been removed."

"Well, I'm all ears. What's up?"

"I think you need to know the truth. Sure, you know I've been using you. You know the GOP hates you Paul; if you don't like me that helps with [censored] "independents".

Don't look so shocked Paul. You need to hear this.

The truth is that I think you're right. Yeah, sure, you're an academic, but you're closer to the mark than anyone else."

"But ... but... then why don't you push for more deficit funding? Why leave Bernanke to twist in the wind?"

"Well Paul, have you looked at Congress lately? They're worse than dull, they're delusional. It's not just them, the voters are even worse. Have you seen many think I was born in Kenya, or who think Osama died ten years ago, or who don't believe CO2 has anything to do with climate?

Truth is Paul, we're not smart enough for neo-Keynsian economics. We won't save a surplus, and we won't spend against a deficit. We're just not that smart. Come on Paul, admit it. You must see it too."

"I ... I ... I always wanted to believe, to believe people were better ... if only I could show them ... I ... *sob* ..."

"There, there Paul. Don't feel so bad. It's just the way it is. At least you don't have to get elected.

I've got to go now. I need to stop the GOP from destroying the world economy, we've got a hit squad closing on Zawahiri, and I need to ask Hawaii to release a notarized copy of my birth certificate ..."

Pay for performance: the problem with 3rd grade reading incentives

With physicians, world destroying CEOs, Texas teachers and every salesman since the dawn of commerce, Goodhart's Law says you get the behaviors you measure and incent.

Turns out the same thing is true of 9yo girls.

My daughter's 3rd grade class has an "advanced reading" program. Each book read earns points; the "harder" the book, the more the points. This means that weak readers get discouraged fast. Keen competitors though, can wrack up the points.

That includes my girl. She's reading day and night to beat the 5th and 6th grade girls.

Problem is, she doesn't need to practice reading. Math yes, soccer sure, playing with her friends is fine too -- but we done got 'nuff readin.

Incentive programs always have perverse consequences.

Cancer in whales, dinosaurs and birds

Whales have amazing defenses against cancer. It's one reason they're able to get so big...

... Caulin and Maley argue that when animals evolve to larger sizes, they must evolve a better way to fight against cancer. It’s possible that a blue whale simply has a souped-up version of our own defenses. We have proteins that monitor our cells for over-eager growth, for example; they can kill or zombify cells that on the road to cancer...

Caulin and Maley suggest that nature has carried out this experiment as well. We have one copy of a gatekeeper gene called TP53, for example. Elephants–which are at a greater risk for cancer–have a dozen copies of the same gene.

.... Scientists could look at closely related species that span a big range of sizes, searching for telling differences in their cancer defences. Whales and dolphins would be a good pick, since blue whales are 2,000 times bigger than the petite Commerson’s dolpin.

But such an undertaking would have to overcome a lot of inertia in the world of cancer research. Cancer biologists don’t look to big animals as models to study–which is one reason there’s not a single fully-sequenced genome of a whale or a dolphin for scientists to look at...

Maybe scientists don't need to look at whales. Dinosaurs were big for a long, long time. Sure, they're pretty small now, but maybe they kept some of the cancer defenses that let them grow big. We just need to study cancer in small but long-lived dinosaurs, like parrots. Maybe we'll find relics of the defenses T-Rex had, and find a way to use those ...

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.