Merry Christmas, Happy Holidays and a great New Year for all!

My Christmas wish list to Santa:

• Global energy independence from fossil fuels and nuclear energy over the next 20 years using existing capital, real estate and technologies.  Sounds like a great public works project that would employ a lot of laborers, construction workers and engineers.
• The tech sector should start realizing their job is often to put other people out of jobs.
• National legalization of marijuana: tax and regulate it, and spend the money we spend on criminalizing it on something more useful.  Like Pat Robertson says.
• An end of poverty: a universal basic income equivalent to poverty line income, no strings attached, funded by a combination of a household carbon tax of no more than $100/year and   de-funding organizations helping those in poverty (because no one would techinically qualify anymore).  See reasoned discussions from those flaming commies at Business Insider and Forbes Magazine.

For all of us who's celebration no longer includes family or friends who are no longer with us, may you please find love and hope this season and be consoled that they are not forgotten.

So, what do you think about "Obamacare"?

I got asked this a lot when the Affordable Care Act (a/k/a "Obamacare") got passed, and I'm asked that a lot with the rollout of insurance markets.  I gotta say, my viewpoints on this are complicated.  

For one thing, I have from the beginning been in entire agreement with former Secretary of State Colin Powell that we should have a single-payer health insurance like all the other industrialized countries in the G20.  Yes, that means taxpayer money is spent on providing a basic health insurance from cradle to grave for all US citizens: MediCare for All, if you will. I'd certainly prefer this over a series of "tweaks" that fully involved drug companies and insurance companies in the decision making.  I don't see any of those monied interests allowing a solution that would impact their revenue stream.

Is this a real departure from the status quo? Yes. Why do it?  Because all the other industrialized countries are successfully doing so, with longer life expectancies than the US, lower medical error rates, and at 1/3 of what we pay per capita. (Feel free to see earlier posts for links on these figures.)  I happen to like Germany's system as a model.  The German government provides a basic insurance from birth.  If you want and can afford more extensive insurance, you can buy all you want from the very active and competitive private insurance companies.  If you don't want to, you don't have to but at least you're not a hospitalization or accident away from personal bankruptcy. 

What keeps the insurance companies in line is  that annual increases in premiums of over 6% per annum are not permitted unless the insurance company can prove to the government that it is necessary due to medical costs incurred and not just profit motive. 

What keeps doctors and hospitals in line is that the government routinely does comparison tests head-to-head of medicines, surgeries and devices and then publicizes the results so everyone involved knows what works and what doesn't.

Sounds good to me: I've never heard anyone characterize the German government as being soft-headed or given to wild over-spending.

Otherwise, I have to admit that Covered California (California's insurance website) is pretty impressive.  It runs smoothly and the rates offered look very attractive and the tax credits for individuals or small businesses are generous and not just for the wealthiest or most impoverished but really benefit middle class individuals and businesses with fewer than 25 employees.

I agree with requiring health insurance of all citizens.  Just simple math here: insurance risk pools fail if "healthy" people can opt out but everyone still has to pay if they get sick or hurt.  Arguing that you shouldn't have to carry insurance because you won't get sick is like saying you won't wear seat belts because you've never been in an accident.

On the other hand, my biggest concern with "Obamacare" is its underlying assumption that bigger and more centralized has to be better.  This is my principle objection to other trends in government, services and business.  The ability to shop Amazon from your smartphone and receive your goods two days later at prices lower than in your town is all very well and good (unless you have a small business in your town), but applying this model and philosophy to everything as a default model to every complex system is flawed.

The widespread application of computers, robots and out-sourcing has, in my opinion, resulted in a massive and tacitly accepted exchange of more expensive but higher quality for cheaper and good-enough.  Remember when you could buy a tool or appliance that you'd hand down to your kids?  Bought anything that good lately?

Many aspects of the Affordable Care Act incentivize doctors and hospitals to coalesce into larger more centralized organizations under the assumption that this will reduce costs and improve the quality of medical care.  In my experience, sometimes this helps, and other times it doesn't.

However, to seek to change the great majority of medical care in the US to a smaller number of much larger and centrally controlled organizations is to risk losing its personal qualities.  What do people like about Kaiser?  Everything under one roof: see mid-level, draw blood, pick up medications all in one visit to one place.  What do people not like about Kaiser?  Never see same doctor, doctors rushing to see patients in 8 minutes, hard to get to see specialists.

I happen to believe that the practice of medicine has a deeply and inherently personal quality to it.  It takes time to ask enough questions to arrive at a correct diagnosis.  It takes time to build a trusting, respectful relationship that is mutual between patient and doctor.  I think and see that it does matter that the doctor who sees you in the hospital already knows you well as a patient and as a person.

So, I guess what I think about "Obamacare" is that it is at least a reasoned and good-faith effort to fix something that is really in need of improving.  However, the long term impact is going to make medicine more like corporate businesses: bigger with more "economies of scale" (uck) that will provide medical care in a way that is less expensive, possibly more efficient (depending on how that's defined) but increasingly impersonal and detached.