Cause Of Death: Misprocessing of Medicaid Benefits

Nine year Zumante Lucero, pictured above, had asthma that he could treat with a drug called Advair that he has a prescription for and was entitled to as part of the Medicaid benefits for which he was eligible.

The Denver County Department of Human Services was in charge of handling his application and despite strenuous efforts by his mother to get the county to tell Walgreens that he was eligible to have the medicine, they instead incorrectly told Walgreens that he wasn't even though they had told Zumate's mother (correctly) that Zumante was eligible to have Medicaid pay for his medicines. Zumante couldn't afford the drugs over the several months that Denver's computer system told Walgreens that Zumante didn't have coverage when he actually did, despite Zumante's mother's efforts, and as a result, Zumante's asthma killed him in July of 2009.

"The city fixed Zumante's eligibility status to pay for his funeral." Swell job guys.

The State of Colorado has faced litigation for years over this computer system which it requires counties to use (if I recall correctly, this problem dates back to Governor Owens and neither Governor Ritter nor Governor Hickenlooper have yet been able to solve it), but the Medicaid benefits processing system that was purchased for millions of dollars by the State from a big name private contractor didn't work and never has worked. Judges have ordered the State to take action, but it didn't fix the problem, either by fixing the computer or by finding a work around that worked. This was something that was entirely foreseeable and had been predicted for years before it happened.

Zumante died as much because certain named bureaucrats (and no doubt other unnamed bureaucrats and government computer contractors) screwed up and denied him a few hundred bucks worth of medicine that the law said he was entitled to have and that the Denver County Department of Human Services knew he was entitled to have but didn't extent themselves to clear up despite the life threatening nature of this boy's conditions in the absence of his medicine.

I'm not even going to begin to think about the legal issues involved. Suffice it to say that the when some judge writes an opinion resolving this case a long time from now, if the case is not settled, that the statement of facts will less than a page long and the analysis of the procedural history and the law will be lengthy. Governmental liability in tort is an arcane subject at the best of times in the simplest of cases.

But there is no good reason that kids should be dying in Denver, Colorado when we have the drugs to treat it, the means to pay for the treatment, the legislative will to provide coverage, and an involved parent trying to obtain care by contacting the government officials and pharmacists in charge of making it happen. Moreover, any department whose bureaucratic screw ups can be a matter of life and death that serves people who are, by definition, poor and in practice, almost always not the most sophisticated in cutting through red tape, rarely politically connected and rarely able to afford lawyers, needs to have someone out there with the power and ability to fix problems promptly who is looking out for the program's beneficiaries.

This is not a program where it is reasonable to assume that the beneficiaries or those acting on their behalf will be able to navigate the system and correct governmental screw ups on their own.

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U.S. Health Insurance Reimbursement Paperwork Expensive

U.S. physicians spend nearly $61,000 more than their Canadian counterparts each year on administrative expenses related to health insurance. . . . The study, published in the August issue of the journal Health Affairs, found that per-physician costs in the U.S. averaged $82,975 annually, while Ontario-based physicians averaged $22,205 -- primarily because Canada's single-payer health care system is simpler.

Canadian physicians follow a single set of rules, but U.S. doctors grapple with different sets of regulations, procedures and forms mandated by each health insurance plan or payer. The bureaucratic burden falls heavily on U.S. nurses and medical practice staff, who spend 20.6 hours per physician per week on administrative duties; their Canadian counterparts spend only 2.5 hours. . . . "It's the nurse time and the clerical time, rather than physician time, that's different." . . . The result is an additional $27 billion spent every year in the U.S. when compared to the costs incurred by physicians in Canada.

From here.

The justification for the heavy bureaucratic burden and rules in the U.S. is "to keep health care costs down" but, there is little evidence tht they actually work as intended to do so (the U.S. has the highest health care costs in the world for less than the best care in the world and a bad cost trendline compared to the rest of the world that is long standing).

There are parts of the system, like U.S. government run single payer for the elderly health care system called Medicare and the Veteran's Administration Hospital systems (also run by the U.S. government), that are quite efficient in terms of administrative costs and cost control and outcomes relative to the private health insurance managed part of the market. But, the nation chose not to do that in the most recent round of health care reform out of an ideological commitment to the private sector provision of this insurance function, contrary to the empirical evidence that government insurance is more efficient and better at cost control and produces better outcomes than a private insurance company managed system in the area of health care.

It is also important to mention what the Canadian system is and is not. Health care providers in Canada, by and large, are not government employees (unlike the British health care system). They have their own businesses just like American health care providers do. But, Canadian private sector health care providers fill out insurance forms for one health insurance company run as a government agency, rather than many private sector health insurance companies.

Canadians have decided that it is important to let the private sector handle the very personal business of deciding who will provide you with health care but that the far less personal business (which most Americans have no choice in anyway) of deciding who will process the health insurance claims to decide if they will be paid is not very important ideologically or practically, given the huge cost savings this approach provides and the better cost controls that it facilitates.

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Three Hots, A Cot, Medical Care and Safety

One of the foundational ideas of criminal justice is that the threat of incarceration discourages crime because it is worse to be in prison than to not be in prison. For most Americans, this is an accurate statement. For many young black men in the United States, this is a closer call.

Using data from the U.S. Bureau of Justice Statistics and Census Bureau, I estimate death rates of working-age prisoners and nonprisoners by sex and race. Incarceration was more detrimental to females in comparison to their male counterparts in the period covered by this study. White male prisoners had higher death rates than white males who were not in prison. Black male prisoners, however, consistently exhibited lower death rates than black male nonprisoners did. Additionally, the findings indicate that while the relative difference in mortality levels of white and black males was quite high outside of prison, it essentially disappeared in prison. Notably, removing deaths caused by firearms and motor vehicles in the nonprison population accounted for some of the mortality differential between black prisoners and nonprisoners. The death rates of the other groups analyzed suggest that prison is an unhealthy environment; yet, prison appears to be a healthier place than the typical environment of the nonincarcerated black male population. These findings suggest that firearms and motor vehicle accidents do not sufficiently explain the higher death rates of black males, and they indicate that a lack of basic healthcare may be implicated in the death rates of black males not incarcerated.

From Evelyn J. Patterson, "Incarcerating Death: Mortality in U.S. State Correctional Facilities, 1985–1998," Demography, Volume 47, Number 3, August 2010, E-ISSN: 1533-7790 Print ISSN: 0070-3370, DOI: 10.1353/dem.0.0123.

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Deinstitutionalization Legacy Persists

According to Pete Earley, former Washington Post intelligence journalist and author of "Crazy: A Father's Search Through America's Mental Health Madness" (2006) the United States has made a little dramatic but little noticed change in the way it handles mental health issues from a medical model to a criminal justice orientation:

In 1955, about 560,000 Americans were being treated in state mental hospitals. Based on population growth since then, you would expect more than 930,000 people in such hospitals today. There are only 55,000. Nearly 300,000 are imprisoned. Another half-million are on probation.

The largest public mental-health facility in the U.S.? The Los Angeles County Jail, home to 3,000 mentally ill inmates.

A dramatic shift towards the deinstitutionalization of those with mental health conditions in the 1980s from being the developed nation with the highest institutionalization rate for mental health conditions in the world, to the lowest, afforded some more freedom, but rather than producing a reinvestment of funds previously used for a public sector mental health care into community based programs led to a massive disinvestment in public sector funded mental health care that ended up funnelling many people who had trouble functioning in the absence of that care or family support, into the criminal justice system. Now, it can be hard to find services for anyone but the most affluent, even for bureaucratically savvy middle class families.

The trend is ongoing, with Colorado having seen many of its psychiatric hospital beds taken out of service over the last few years in the face of their high cost, and declining funding support since these programs receive less federal support or budget process protections than programs that have been preserved and often lack of visible constituency.

Earley cites conditions like schizophrenia and bipolar disorder, rather than psychopathy, as driving the trend. Some criminologists, such as Bernard Harcourt, have identified the size of the total institutionalized population as an important driver of crime rates, despite the mystery that the demographics of mental health institutions are very different from those of prisons (particularly in the number of women institutionalized). Early's identification of the large number of people with mental health conditions who are on probation or in jails, rather than prisons also helps to shed light on this demographic mystery; many people who would formerly have been institutionalized in mental health institutions are now in the criminal justice system, but only through probation or jail rather than prison, while many other individuals convicted of crimes are now more likely to be incarcerated in prison than in the past as criminal sentences have grown stiffer.

The brief excerpt in the linked story doesn't shed light on the question of how the United States experience compares to our peers in the developed world. It isn't clear, for example, if Europe and Japan have deinstitutionalized (or never institutionalized) their individuals with mental health conditions to the same extent as the United States, and if so, what the consequences of doing so have been there. The mental health institutionalization rates are indeed higher in Europe compared to a rate of about 25 per 100,000 in the United States (down from a peak in the 1950s of over 600 per 100,000), although they are declining in Europe from past levels:

Among countries in the European Union, the highest rate regarding the number of beds in psychiatric hospitals per 100,000 inhabitants in 2000 was in the Netherlands, which had a rate of 188.5. Other highs were posted in Belgium (161.6), Switzerland (119.9), France (113), and Finland (102.9). The average for the 25 European Union countries in 2000 was 90.1, down from 115.5 in 1993.

Japan's mental health institutionalization rate of 282 per 100,000 is the highest in the world, something particularly notable because the overall prevalence of mental health conditions in Japan is below the developed world average.

It is also worth pointing out that even if the residential mental health institution population were similar now to what it was in 1955, that it would still only be a tiny percentage of the population that receives or needs mental health care. For example, 60% of the population experiences depression, anxiety disorders, alcohol dependence and/or marijuana dependence by age 32. About 11% of adults in Colorado have experienced significant psychological distress (other than substance abuse issues) within the last year. Schizophrenia has a prevalence rate of about 1% in the general population, in contrast, and is about 80% genetic, and the prevalence rate and genetic component of bipolar disorder are on the same order of magnitude, but is more common and less strongly genetic.

The link between mental health issues and criminal justice involvement tends to be a "mental health plus" relationship. In one recent study, for example:

Mental illness alone is not a meaningful predictor of future violent acts, but is very significant when accompanied by a history of violence and substance abuse.

There were 3,089 people deemed to have severe mental illness—schizophrenia, bipolar disorder and major depression—but no history of either violence or substance abuse. They reported very few violent acts, about 50, between interviews.

But when mental illness was combined with a history of violence and a history of substance abuse, as in about 1,600 people, the risk of future violence increased by a factor of 10.

As the same linked post notes, relying on Colorado Department of Corrections date, in Colorado, "Moderate to severe substance abuse is a problem for 82.0% of male and 82.4% of female inmates. Moderate to severe mental health problems exist for 27.8% of male and 34.2% of female inmates."

Mental health problems are also much more likely to lead to serious criminal justice system involvement for individuals who are high school dropouts or have high school diplomas or GEDs but no college degree of any kind.

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Physiological Test Predicts Effectiveness of Talk Therapy For Depression

[A] quick, inexpensive, and easy to administer physiological measure, pupil dilation in response to emotional words, not only reflects activity in brain regions involved in depression and treatment response but can predict which patients are likely to respond to cognitive therapy[.]. . . activity in the brain's cortical emotion regulatory systems is strongly related to pupil size when people are viewing emotion-laden words . . . It is because of this relationship between eye and brain that pupil measurements predict the response to cognitive therapy."

Cognitive therapy is a type of psychotherapy designed to help individuals overcome difficulties by modifying negative or irrational thoughts and behavior, which, in turn, can improve mood and reduce stress. It is usually completed in weekly sessions, with 10-20 sessions being effective for most individuals who benefit.

From here, citing Greg J. Siegle, Stuart R. Steinhauer, Edward S. Friedman, Wesley S. Thompson, Michael E. Thase. "Remission Prognosis for Cognitive Therapy for Recurrent Depression Using the Pupil: Utility and Neural Correlates." Biological Psychiatry, 2011; 69 (8): 726 DOI: 10.1016/j.biopsych.2010.12.041.

The abstact of the paper provides more details:

Although up to 60% of people with major depressive disorder respond to cognitive therapy (CT) in controlled trials, clinicians do not routinely use standardized assessments to inform which patients should receive this treatment. Inexpensive, noninvasive prognostic indicators could aid in matching patients with appropriate treatments. Pupillary response to emotional information is an excellent candidate, reflecting limbic reactivity and executive control. This study examined 1) whether pretreatment assessment of pupillary responses to negative information were associated with remission in CT and 2) their associated brain mechanisms.

We examined whether pretreatment pupillary responses to emotional stimuli were prognostic for remission in an inception cohort of 32 unipolar depressed adults to 16 to 20 sessions of CT. Twenty patients were then assessed on the same task using functional magnetic resonance imaging. Pupillary responses were assessed in 51 never-depressed controls for reference.

Remission was associated with either low initial severity or the combination of higher initial severity and low sustained pupillary responses to negative words (87% correct classification of remitters and nonremitters, 93% sensitivity, 80% specificity; 88% correct classification of high-severity participants, p < .01, 90% sensitivity, 92% specificity). Increased pupillary responses were associated with increased activity in dorsolateral prefrontal regions associated with executive control and emotion regulation. For patients with higher severity, disruptions of executive control mechanisms responsible for initiating emotion regulation, which are indexed by low sustained pupil responses and targeted in therapy, may be key to remitting in this intervention. These mechanisms can be measured using inexpensive noninvasive psychophysiological assessments.

The small study obviously needs to be replicated in a larger sample before being used on a widespread basis, but the 88% rate at which this simple test determines if high severity depressed patients will respond to cognitive therapy, compared to a 60% response rate in the absence of screening, is a major improvement for a technique that requires no investment in drugs or equipment and only minimal additional training for mental health practitioners. This test could spare more than half of severely clinically depressed individuals time and misery trying cognitive therapy that is unlikely to be effective for them, allowing them to use alternative therapies like drug treatments that are likely to be more effective for them immediately, while allowing about half of severely clinically depressed individuals to receive cognitive therapy, knowing that it has a very high probability of being successful, and avoiding the need for them to undergo a psychiatric drug treatment regime that is unnecessary for their recovery. The fact that the benefit is statistically significant at the 99% level in this small study also makes a study calculated to replicate this result look like a promising good investment.

Given that clinical unipolar depression is one of the most common mental health conditions, and is by far the most common one that is not typically congenital, which makes it disproportionately likely to be a condition dealt with by a primary care physician as opposed to a specialist mental health care professional, this kind of advance has particularly great practical relevance. Also, since unipolar depression is so common, the cost savings to the health care system of a diagnostic tool for determining what kind of treatment will be most effective could be an evidence based medicine technique that could make a material dent in the overall cost of mental health care.

Since this is a diagnostic approach, rather than a drug or device, it also doesn't need a long and costly approval process from the Food and Drug Administration. Funding of a simple large scale replication of this study which could be completed in a year or two, would be enough to include this diagnostic technique as part of the standard by the book treatment regime for unipolar depression nationally. Of course, since this isn't an approach would have a biotech company backing it, this kind of study almost necessarily would need to be funded by the public sector, for example, through a National Institute of Mental Health (NIHM) grant.

The real value of treatment effectiveness prediction tools as a means to improve the quality of patient care while reducing health care costs, a field which is coming into its own as a subfield of psychiatry and psychology, also suggests another funding possibility. Health insurance companies have historically viewed themselves primarily as financial institutions and as institutions through which patients can collectively bargain for provider health care pricing. But, the health insurance industry might be well advised to develop and fund a non-profit research foundation to develop treatment effectiveness prediction tools that do not have drug companies or medical equipment makers to fund them, as a way to promote health enhancing quality control.

The benefits of this little study aren't just practical in an immediate sense either. This is some of the hardest empirical evidence yet that there are medically relevant subtypes of unipolar depression in existence, with some indication of what the underlying neurological basis of that subtyping might involve. One of the deep issues in psychiatric classification of mental health conditions, for which the DSM-IV is the current industry standard, is that diagnosis of psychiatric conditions is almost entirely based upon non-physiological symptoms. It is entirely possible that some common DSM-IV conditions are really a cluster of separate conditions with similar symptoms but different causes (and hence different courses of treatment that are likely to be effective), and that other common DSM-IV conditions currently viewed are in fact merely distinctive syndromes that arrives when separate co-morbid conditions are present.

For example, this study shows that there are at least two types of unipolar depression, one of which is talk therapy responsive and one of which is not. This very likely indicates that the causes of the two types of unipolar depression are different. If this insight in incorporated into prior research on the causes of unipolar depression, the sometimes muddy and contradictory theories about what causes unipolar depression and how it can best be addressed might be clarified. One leading theory regarding the cause of unipolar depression conceptualizes it as a situation where prolonged stress and anxiety cause the body's normal responses to stress to shut down and try the new strategy of becoming depressed to deal with the situation. This might be a primary causal mechanism in one but not the other of subtypes of unipolar depression. If so, somewhat muddy data linking this cause to depression might become much more definitive with regard to the relevant subtype of depression, while clearing the decks for a search for one or more alternative causal mechanisms for the other subtype of depression.

Another possibility is that the pupil dilation response to emotion laden words may be a congenital element of a person's personality that is present even in the absence of unipolar depression. If this is the case, this trait might be one of many that is routinely tested for in children or young adults along with traits like blood type. Children with the trait might be at higher risk for the cognitive therapy responsive subtype of depression. Similarly, medical records could indicate which children are at risk for non-responsiveness to cognitive therapy as a treatment for unipolar depression. Since the physiological test for this trait is quite objective and easy to administer on a mass basis, it might also be possible to see if this trait corrolates with other mental health conditions, particularly those which are often co-morbid with unipolar depression (a co-mordidity pattern that might be more stark when restricted to a particularly subtype of depression), and to determine if it has a hereditary component. Patterns of co-morbidities associated with a particular subtype of unipolar depression might shed insight into the causal mechanism of a variety of mental health conditions which in turn might shed light on the kind of treatment regimes that are likely to be effective for those co-morbid mental health conditions.

Indeed, it might even be possible to provide these children or young adults, on a prophylactic basis, the kind of cognitive training that people with unipolar depression receive after they are diagnosed to help these individuals deal with situations that could lead to clinical depression before they happen.

There is no obvious reason that the benefits of cognitive behavioral therapy, which boils down to teaching people habits of thinking and mental tools for coping with certain kinds of problematic cognitive habits or tendencies, in general, can't be almost as effective when administered in advance as they are when administered as therapy after the fact. It might be possible to put together a set of empirically validated cognitive behavioral therapy regimes into a comprehensive set of coping skills that could be transmitted on a mass basis in a manner not unlike the model by which we instruct people in first aid, CPR, rescue breathing, the use of abdominal thrusts to respond to choking incidents, the proper way to respond to house fires, tornados and tsunamis, or suicide and bullying prevention programs. People who experience cognitive behavioral therapy responsive conditions anyway may benefit for refresher instruction and may be able to make more sense of what these therapies involve when they actually have the conditions that they are designed to alleviate, but it isn't unreasonable to think that this kind of public health preparedness model could materially reduce the overall incidence and impact of many common mental health conditions, some of which are subclinical or would otherwise never be diagnosed as such.

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Deconstructing the Concept of Health Care And Options For Dealing With It

The convention of lumping all of the issues that fit under the rubric of health care is necessarily somewhat arbitrary. As we look to improve ways to control costs and find better ways to finance care, which is a never ending process despite the passage of the Affordable Health Care Act, which makes major reforms, it is worth examining ways to break the overall field of health care into parts, and to see if there are things that we commonly don't define as health care that are appropriate to address with the same tools.

Group health insurance plans and Medicare define health care quite broadly, but exclude certain procedures and treatments commonly deemed to be cosmetic or recreational or fitness related; long term care in nursing homes or with home health care services; and sometimes abortion. Medicaid often includes a broader definition that includes, for example, nursing home care.

Individual health insurance plans, out of concerns about moral hazard in the purchase of health insurance, have narrower definitions of covered health care. Routine services are often covered by a deductible on the theory that the tax advantage that applies to group health care plans creating an incentive to include as much as possible in the plan coverage scope for tax reasons does not apply in individual plans of employees who are not self-employed where risk management and price negotiation with providers, but not tax minimization is the goal.

Individual health insurance plans also usually exclude, or include only at prohibitively expensive rider rates (far more than this kind of care contributes to the whole in group health insurance plans) types of health care for which moral hazards exist because patients can know that they will need coverage in advance and buy it only if they need it. These conditions include pregnancy related care, mental health coverage, and coverage for pre-existing conditions (mitigated by a variety of devices to allow pre-existing condition coverage where moral hazard risks are not as serious, such as quasi-group COBRA continuation coverage).

Pregnancy is very expensive to insure against in individual health insurance plans because it is highly controllable by the insured, even though the lifetime costs of pregnancy related care frequently don't vary much from one woman to the next.

Mental health coverage has been further divided into categories that look more or less medical (biologically based conditions). There is dispute over whether some treatment regimes such as non-allopathic medical approaches (such as chiropractic, aromatherapy, herbal remedies, psychological therapy, acupuncture, personal training, and massage therapy remedies) are really health care in the sense intended, and over whether treatments such as fertility treatments are genuinely necessary as opposed to recreational.

Long term care coverage is an example of a very expensive, high probability event, with moderate risks regarding duration and costs, that is further complicated by the fact that long term care typically covers not only medical-like expenses but also non-medical-like expenses such as rent and food costs for the resident. Similarly, loss of income due to disability, or the disabilities presumptively inferred from old age called retirement, are typically handled separately from medical care.

We make distinctions between "emergency care" which everyone who comes to an emergency room is entitled to regardless of ability to pay, at least until stabilized, and other kinds of medical care.

We have different financing regimes for dental care, vision care, work related injuries (worker's compensation or the equivalent), non-work related accidental injuries (tort remedies and casualty insurance), health care for foster children, health care for Medicaid v. non-Medicaid patients, health care for the uninsured who can and cannot pay in cash, health care for certain veterans, out-of-pocket and insurance paid care, over the counter and prescription treatments, and so on.

Within the area of Medicaid covered health care, there are two groups of beneficiaries whose care is very expensive: older people who need nursing home care, and people with disabilities, and another, poor people who are not disabled or old served by the minority of providers willing to accept new Medicaid patients for below market rate reimbursements, for whom it is very inexpensive to provide health care.

A large share of all people covered by health insurance or governmental health care programs are entitled to that coverage not in their own right, but by virtue of their status of dependents of someone else. Medicare is one of the few programs that does not cover the entire family (although individual policies and CHIP enrollment in Medicaid for children only in a family are another).

The Affordable Care Act has made several strategic choices, which made political sense at the moment, but may not be the best long term solutions. One is to focus on a scope of care similar to bare bones group health insurance plans. Group plans are encouraged. Individual plans are made more like group plans through prohibitions on pre-existing condition denials, through mandatory coverage, and through expanded scope of coverage, in order to address moral hazard issues. The scope of Medicaid is expanded to include the near poor. And, tax credits and incentives ease the ability to pay problem for both group and individual plans.

There are other ways that the task could have been divided.

We could have chosen to deliver some or all health care services to children (and even college students) through educational institutions. Most school districts have school nurses and psychologists already, administer a few routine screening tests, provide health education (mostly, but not entirely sex education and illegal drug use propaganda), and refer children who seemed to be in need of medical attention but are denied it to social services authority. But, it wouldn't have been hard to establish a system of comprehensive, single payer health care for children through the school system. This would prevent the current system from suffering strain from the fact that large families do not fully bear the cost of their own care in many cases (particularly with more generous employers), and would in some ways reinforce the notion of connecting health care to one's place of employment - extending the idea to school aged children.

Colorado until recently, and some other states, have experimented with no fault automobile accident medical coverage, in which care for automobile accident injuries are financed through the injured person's car insurance, with particularly severe cases to be settled via subrogation actions by the insurer who pays for the care. There have been proposals to make such no fault coverage universal and finance it with a gas tax or other excise tax that functions as a "pay at the pump" user's fee. Worker's compensation, in theory, at least, covers work related injuries and diseases without regard to fault.

With a universal health care system, it would be possible to remove health care payments from the domain of automobile insurance, casualty insurance, tort judgments and worker's compensation entirely, by making health insurance the primarily responsible party for all health care, with legal responsibility for medical expenses related to fault in accidents or on the job injuries or diseases limited to subrogation actions. This would take a great many personal injury cases outside the tort law system entirely, and narrow dramatically the scope of the issues presented in these cases. Even more dramatically, we could decide that compensation for lost income due to disabilities that arise from injuries or diseases (or perhaps otherwise) ought to be entirely the province of insurance or social safety net programs, rather than the courts, perhaps via a more robust version of Social Security, or mandatory comprehensive disability insurance, in lieu of separate regimes for work related injuries, general tort cases, sick leave policies, and cases covered partially by private disability insurance policies and social security. Subrogation cases could allocate fault in cases where it was necessary to provide the proper incentives not to engage in negligent conduct (although in a society where everyone is adequately insured, this is harder to justify, particularly for small cases where the burden of the risk faced by different insurance companies can be expected to average out over time). In a regime like this one, only "pain and suffering" and dignitary injuries would be left to litigate.

Less radically, health insurance companies would process all health care claims, regardless of the nature of the injury, and then would be reimbursed by casualty insurance companies, with their actual costs entitled to presumptive validity. Tort lawsuits might establish liability for medical costs, but simply order the insurer for the tortfeasor to pay those costs as they come due, avoiding litigation involving expert witnesses over the validity of medical costs incurred and the estimated future medical costs involved in a personal injury case. Casualty insurers and health insurers could resolve medical expense disputes in individual cases through intercorporate arbitration.

We could have had a single payer system for some conditions, perhaps mental health care, or pregnancy care, or congenitally disabled people whose high cost of care is a certainty at the outset, that are hard to deal with through individual insurance due to moral hazard issues, while utilizing the Affordable Health Care Act insurance regime approach only for more ordinary cases. Mental health care or pregnancy care could be quite affordable to provide via a single payer system since they are a small part of the total national health care expense.  Failure to provide adequate mental health and/or pregnancy care has immense externalities for the rest of society as well, so perhaps these need to be redefined as public health issues.

We could have medical care in all trauma cases handled by one program or insurance regime, and handle non-trauma causes in another regime.  The public interest in universal trauma care is greater than the public interest in many kinds of universal non-trauma care.
Pregnancy care could be insured not through employers, but on a basis similar to universal life insurance or long term care policies, with premiums made over a lifetime or many years, to cover a lifetime of coverage. Rather than expiring for want of premium payments, these policies could create non-dischargable debts, a bit like student loans, which insurers could collect with bad debt figured into their pricing. Alternately, we could have a system of guaranteed pregnancy care loans that is directly analogous to the student loan regime, allowing births to be paid for over the course of a decade or two, rather than all at once, and could focus on transparency in pricing as a way to control costs in this area.

Guaranteed medical care loans also make sense as a back stop to a regime with catastrophic coverage in which not all patients have funds in a health savings account or otherwise sufficient to pay their current out of pocket costs.

We could distinguish between catastrophic care, which might be handled by a government program or secondary tier of insurers (a bit like umbrella insurance), and ordinary health care which would de-emphasize risk sharing and emphasized price negotiating and cash flow management. The greater ability of patients to pay for non-catastrophic care would make more ordinary market-like arrangements such as those seen in the area of dental health, seem more workable.

If coupled with a system of guaranteed medical loans, non-catastrophic care could be optional, and only catastrophic care would have to be universal either because it is mandatory in some form, or is a tax financed government program. The downside of making this a mandatory form of insurance, is that compliance can be difficult to secure for a program that actually makes insurance payments to the people who pay the bills only very infrequently, while accounting for something on the order of half of the cost of health insurance. But, catastrophic care on an umbrella insurance model would have very low administrative costs relative to premiums, and relatively few of the really controversial insurance coverage issues involve catastrophic care cases. This could give a government program a fairly large economic role in health care without having much of a day to day administrative role in it that people would fear would interfere with doctor-patient relationships.

Medicare and Medicaid are currently mostly programs that pay providers directly on a fee for service basis, but could be organized to pay for a menu of health insurance options, or to pay providers on capitation or similar basis. The Ryan plan that would provide mere flat dollar vouchers to buy health insurance would be problematic standing alone, but if there was a core set of coverages that could be purchased with the voucher without additional expenses from a vendor of last resort who was required to provide it, this would not be worrisome.

It would be possible to structure health care claim processing a bit like the way we structure credit card progressing today, where cooperatives like Mastercard and Visa process claims and adjudicate billing disputes, but the loans are extended by member banks that set interest rates, set credit limits, and establish their own reward programs. The vast majority of health insurers could be united in a small number of cooperatives, which would receive claims from providers and process them in a standardized process, set provider compensation rates for member providers, and leave the actual health insurers with only a few key terms like copay amounts or deductibles being set by the actual health insurer which would bear the financial cost of claims processed for its insureds, but would not actually administer those claims. This could produce many market efficiencies even if the claim processing cooperative had no formal monopoly.

Of course, to some extent, this is the easy part of the equation. Once you have universal health insurance coverage, it is a relatively bloodless affair to reshuffle the expense from one pocket to another in the interests of more efficient administration and more sensible cost distribution that is consistent with ability to pay. The really hard part of the issue is figuring out which scenario is not going to be to reduce just administrative and marketing costs to a minimum, giving health care consumers the best value for their money. This is the low hanging fruit, which shouldn't be that hard to realize.

The truly hard part of the health care reform question, which still remains largely unanswered, is who is both willing and able to effectively negotiate lower compensation rates for providers that will translate into lower compensation for doctors, nurses, pharmacists, drug companies, medical equipment makers, hospital administrators, and so on. The deepest problem with the American health care system is that the people who are currently making these decisions, with other people's money, are leaving American providers much better compensated than those anywhere else in the world by a large margin, for the same or less or inferior work. And, very few people in the policy world are entirely clear on what precise flaws in the provider rate system is most to blame. Notably, the truly iconic seats of medical excellence in the United States, like Mayo and Bethesda, are not the ones with the most highly paid providers.

Even in a perfect world with high levels of transparency, the sick and the injured are simply not in a good position to bargain for lower provider costs at the time of treatment as one would with many goods and services. They need intermediaries to handle this for them. But, how do we get the intermediaries (who might be civil servants or insurance company bureaucrats that we have never met) the clout that they need visa-a-vis medical providers who we know and love and the incentive to do their job well?

READ MORE - Deconstructing the Concept of Health Care And Options For Dealing With It

Elements Of Ideal World

Charles Stross has bemoaned at his excellent blog the shortage of writers of utopian, as opposed to dytopian science fiction. There aren't enough people envisioning a positive visions of a good society of the future. I'll take a stab at some pieces of what that should look like today.

Health Care

* Health care billing is invisible to the patient who presents an insurance card, pays a co-pay that is easily determined and known in advance, and never hears about the financial part of the transaction again. The behind the scenes billing process would be highly automated, provide appropriate incentives to health care providers, resistant to fraud and inexpensive.

* A larger share of health care services would be provided by reasonably autonomous health care professionals less expensive and less comprehensively trained, but still carefully technically trained, on a par in expertise and compensation with nurse practioners, physician's assistants, EMTs, and midwives.

* The health care system, somehow or other, would provide universal coverage regardless of ability to pay, and everyone who worked a full working life would be in a pension system that would assure them a tolerable standard of living that was not deeply less generous than the one they enjoyed while they were working.

* A comprehensive, evidence based set of lifestyle recommendations for a healthy life would be easy to understand, easy to access, annotated with the genuine impacts of not following them and their evidentiary basis, and widely followed.

* A comprehensive, easy to access, evidence based authoritative catalog of ineffective treatment for medical conditions would be available as a persausive tool, and false marketing of ineffective treatments with medical claims would be regulated.

* A standard part of the labor and delivery package for every child will be a full genome and biomarker analysis that would become a part of that child's medical file for life and would be available on a privacy protected basis for medical researchers, and would be digested automatically for parents in a way that flagged issues and traits relevant to the child's future mental and physical health care, and educational and parenting needs.

* Cavities would be dramatically reduced by a "vaccine" administered to children around the same time as other childhood vaccines.

* Effective vaccines would be available and widely administered for all significantly harmful viral illnesses.

* Effective treatments to end the causes of injuries and diseases like Type II diabetes, cancer, chronic fatigue syndrome, spinal injuries, and autoimmune disorders (like M.S. and Lupus) would exist and provide relatively inexpensive mostly outpatient treatment.

* Birth control would be near universal for those not ideologically opposed to it from puberty onward, in place until an affirmative decision to have a child was made, capable of being ended without negative long term effects, and not disruptive of normal hormonal balances.

* Effective permanent correction of nearsightedness would be widely available and have an extremely low failure rate.

Mental Health

* Mental health care would be easy to access even by impaired people, would be provided on a categorical basis without regular eligibility evaluation to people diagnosed with conditions that are generally life long (while also having the capacity to address acute and temporary issues), would employ mostly professionals with less comprehensive education and compensation than M.D. trained psychiatrists but the authority to prescribe mental health meds and specialized technical training in mental health care. This would be handled on a more wholistic model than the transactional disease model common today - most mental health patients would see a treating professional at least once or twice a year their home and at least once or twice a year within some context of their daily life outside their home and outside the professional's office.

* Substance abuse would be treatable highly effectively with drugs. Improved, cheap diagnostic "labs on a chip" would facilite more accurate diagnosis of mental health conditions and would reduce the amount of trial and error involved in developing optimal treatment plans.

* An effective permanent "cure" for PTSD would be developed.

* There would be significant "nudges" to influence people needing it to obtain mental health care without going all the way to a court order to compel it involuntariliy in the vast majority of case.

* Evidence based, reliable risk assessment tools and early warning systems would identify people who should not possess firearms due to their current mental health and be implemented in a way that provides genuine and effective barriers to access to firearms for those individuals during those periods.

* The stigma of needing mental health care would be reduced. Indeed, mental health care might be integrated into a larger comprehensive system that reviewed the overall well being of each individual on a regular basis in a wide variety of respects.

* Minimally restrictive residential options for significantly impaired individuals with mental health issues would be about as common as and about as decent as assisted living facilities for the elderly are today.

* There would be adequate psychiatric hospital resources for the most severely impaired individuals with mental health issues, sometime accute and sometimes long term, which would be comparable in quality of life to the nicer private rehab centers today.

Transportation

* Medium and large sized cities would have transit systems that would make up a large share of intracity passenger and parcel traffic, and all places would have transit systems sufficient to meet the needs of those who can't drive.

* Intracity transportation, including cargo delivery, would be almost entirely with electrically powered vehicles in urban areas, and these vehicles would have enhanced safety systems to intervene in cases of operator error or incapacity. Intercity freight bound for urban areas even as small as very small cities and towns would move predominantly by rail rather than trucks.

* High speed rail would have a large share of of inter-city passenger and parcel traffic for distances of under three hundred miles between major urban centers and high volume destinations.

* A family taking a trip on an airplane for Thanksgiving or Christmas could reasonable expect to arrive at an airport 45 minutes before takeoff and make their flight; business traveler traveling light at non-peak times could reasonable expect to arrive at an airport an airport 30 minutes before takeoff and make their flight. Checking baggage would add only about 10 minutes to a typical traveller's travel time.

* Commercial airports would routinely have good quality transit that is comfortable, accomodate typical amounts of luggage easily, and be faster than travelling by car and parking at the airport, and no more expensive than it is to drive to an airport in a car and park there now.

* Most ocean freighters would use some form of sail to be more fuel efficient.

* Very low population density areas would be connected by airplanes, boats, and airships rather than roads, which would be removed from these areas.

* Hydrocarbon fueled vehicles would be predominantly used in niche applications in rural settings and in ocean fishing and pleasure boats where a dense electrical repowering grid for vehicles taking short intracity trips was not practical.

Energy

* Electric vehicles, wider use of transit and freight rail, and wider use of alternative fuels would dramatically reduce petroleum consumption.

* Wider use of renewable energy sources like improved solar and wind technology, tidal power, heat pumps with underground loops, and micro-hydropower would reduce coal consumption.

* Comprehensive conservation efforts would reduce energy consumption through means like better insulation, less electricity hungry appliances and devices, and more efficient energy storage devices.

* Nuclear fusion power including recycling of spent high level nuclear waste would provide a much larger share of electrical power and would be available in small scale versions that do not pose weapons proliferation risks in many small communities. Reasonably safe nuclear waste diposal facilities would come on line eliminating existing backlogs and meeting future needs.

* A significant share of coal consumption would involve converting coal into synthetic liquid and gas phase hydrocarbon fuels that would reduce the amount of air pollution generated by the coal. Coal burning would be subject to carbon taxes that reflected their environmental impact and as a result would be used only in niche applications where there were not other economically viable alternatives.

Food, Agriculture and Rural Life

* Organic farming would become the predominant type of agricultural production for most kinds of agricultural products. Petrochemical use in agriculture would decline greatly.

* Automation and other technologies would continue to increase productivity of farms per farmer resulting in a greatly decreased population in places with farm economies. Farmers would be more affluent as a result, and would mostly send their children to boarding schools for middle school and high school since population densities would be too low to support decent local day schools close enough to home.

* Most fish would be produced in fish farms. Better management of commercial fishing and water pollution would restore wild fisheries as well.

* Subsidies for rural living designed to assist economically stuggling farmers would be ended, this would also discourage exurban living.

* Rural governments would be consolidated to serve much larger rural populations over much larger areas and improve the professionalism of the services they provide.

* Meat consumption as a share of total food consumption would be reduced somewhat and more diverse kinds of meats would be available at affordable prices.

* Door to door delivery of mail in rural areas where it is not cost effective to do so would be replaced by post office pickup.

Education

* A system of state funded, secular schools would operate like charter schools do today and local elected school boards would cease to exist. Students would be allowed to choose to attend any of these school free of charge, schools would be compensated based on enrollment and enrolled student need, schools that failed to secure enough students choosing to attend or failed to meet minimum standards would fold, and neither the state board of education nor elected local school board would have day to day managerial control over their operations. Instead, there would be basic health and safety standards, minimum business model approvals, some standardization of the admissions and transfer process, and impartial government administered student performance and satisfaction evaluations. The schools would have the same sort of legal status as public colleges and universities as governmental entities subject to constitutional standards applicable to public actors such as due process and the First Amendment.

* A system of higher education funding that would provide financial assistance to students through scholarships with both need and merit components. The system would commit to meeting 100% of financial need through grants for the best students, 100% of financial need through a combination of grants and loans (no more than 50% loans) for students with less academic merit, and on public grant or loan assistance for academic higher education for studnets with only marginal academic merit.

* Quality vocational education programs would be a respectable and reasonably popular choice for students who were not particularly strong academically and completion of these program would provide graduates with a reasonable prospect of a steady employment in an upper working class to middle middle class career.

* High school graduates would leave school with significant practical knowledge of physical health and mental health matters in connection with the health care system, to the extent necessary to care for themselves, family members, and strangers in emergency situations in a way consistent with evidence based best practices in a manner rooted in a genuine layman's level understanding of the physical processes behind what they need to do.

* Students at high risk of failing academically, ending up engaged in criminal activity, lifelong economic failure, and dysfunctional relationships would be accurately identified by an early warning system in place by pre-school that would devote significant resources starting as early as possible to support them in changing their course, and to the extent that high risks are not corrected by adulthood to intervene appropriately to protect them and others in a pro-active way that is only actually punitive to the extent that it authorized by crimes, child abuse and neglect, domestic violence, financial defaults or similar events.

Criminal Justice

* Criminal defendants are entitled to a public defender with a manageable case load who is paid enough to attract competent lawyers without regard to ability to pay. Criminal defendants can opt to use the funds that would have been used for their defense to apply towards the cost of hiring private counsel instead.

* The primary penalty for failing to enter into a plea bargain would be a court cost assessed against defendants found guilty to cover the cost of the public defender, the prosecutor, and the judicial system in the case, rather than large differences in sentencing outcomes.

* Evidence based statistical evaluation instruments would pay a strong part in determing the kind of sentence appropriate for particular crimes, and the evidence would be regularly re-evaluated in a transparent and open process. Only individuals whose release would pose a significant threat to others from serious recidivism incidents would be released.

* The criminal justice system would make wider use of sanctions intermediate between probation and long periods of incarceration in prisons, particularly for non-violent offenses, such as electrically monitored house arrest, large but proportionate fines and restitution awards, and low security community corrections/low security facilities for low risk prisoners.

* The process of integrating incarcerated individuals back into the community would be more structured, more supportive and less punitive, particularly for the first two or three years, in order to reduce recidivism.

* Prostitution and recreational drug use would be regulated from a public health perspective, but not criminalized.

* Incarceration rates would be significantly lower.

* Prisons would be safer for prisoners and guards, and prison gangs would be more effectively disrupted.

* Law enforcement officers who were caught lying or engaging in police brutality would routinely and promptly be fired even in cases where the proof of the misconduct while solid, was not beyond a reasonable doubt, and would be entered into a national registry of bad cops. The past cases of bad cops would then routinely and systematically investigated to determine if anyone else had been a victim of misconduct by the officer, and law enforcement associates of dismissed bad cops would be have their past patterns of conduct investigated. Incentives to engage in police misconduct would be identified and addressed. Law enforcement officers who did not personally engage in misconduct would have strong incentives individually and collectively to report it and cooperate in investigating it. Employers of law enforcement officials would be vicarciously liable for misconduct by their law enforcement employees without regard to fault.

* A systematic process to allow for the early release of individuals who were given excessive sentences that would not longer be imposed under existing law and sentencing standards whose post-incarceration conduct was acceptable, would be established.

Family Law

* Gay marriage would be legal and accepted.

* The welfare state and legal system would be more accomodating of and sensitive to the needs and expectations of people in extended family and communal living arrangement situations.

* An early warning system and societal norms would encourage earlier intervention in potentially coercive or violent relationships by better informing and empowering potential victims.

* The financial consequences of a divorce in terms of property division and maintenance would be highly predictable due to well defined and easy to apply rules that afford at least rough justice, and as a result, would be far less acrimonious.

* Disputes over parenting time, parental decision making, child abuse and neglect and paternity would be segregated into legal system separate from the financial part of a divorce that would apply without regard to marital status. In this system, advocates for each party, who would not necessarily be lawyer, would be available without regard to ability to pay. This system would be set up to reflect the fact that parenting issues are ongoing matters, rather than something to be resolved once and for all.

READ MORE - Elements Of Ideal World

Health Insurers: Co-ops Too Awesome For Colorado

Usually, the argument for having the private for profit sector of the economy do something is that it lowers costs and is more efficient.

But, that isn't the argument that opponents of a plan to established a health care cooperative (i.e. a patient owned health insurance company) have made to Colorado's General Assembly in response to Senate Bill 168 which calls for establishing a commission to present the co-op proposal to voters in 2013.

According the today's Denver Daily News, "State Senator Shawn Mitchell, R-Broomfield, acknowledged that the plan itself does not create single-payer system in Colorado," but, he believes that it is likely that a co-op would expand and drive private carriers out of the market, becoming a single-payer or predominant payer in the state.

In other words, Mitchell believes that a co-op would provide a better deal to Colorado health care consumers that they would choose over the status quo of private health insurance companies.

Mark Reese, a spokesman for the Colorado Association of Health Plans, said as many of 20,000 people employed by the private health care insurance industry in Colorado would lose their jobs as a result of a universal cooperative.

Translation: Health insurance companies are so wildly inefficient that a health insurance cooperative could do the same job with 20,000 fewer people.

As Senator Mitchell notes, this would not be a single payer health care plan like they have in Canada:

Senate Bill 168 would create a board of health care and policy experts [funded with $1.2 million of private donations] to develop details for implementing a health care cooperative that would include all Coloradoans as members. . . .

Coloradoans would be allowed to kept their primary insurance provide and instead use the cooperative as a supplemental policy.

Coloradoans would also be allowed to choose medical provider that is not part of the system. In those cases, patients would be required to pay the gap between the cooperative's reimbursement and the provider's charges.

The status quo indicates that there is considerable truth to the argument of cooperative opponents that government can manage health insurance claims with fewer employees than health insurance companies do. The Medicaid program in Colorado, for example, processes all of its claims in the state for its 553,800 beneficiaries with fewer than 900 employees.

Co-operatives are alternatives to anti-trust regulation and government owned enterprises that rely on the say members have in how the co-operative is run to keep them working in the member's best interests.

If a health care co-operative will, as opponents claim, provide health care at a lower cost than health insurance companies do, by providing health care with 20,000 fewer health insurance company employees whose wasteful paperwork is driving up the cost of health care in Colorado, then I am all for it.

The last time I checked, the objective of Republicans and Democrats alike was to reduce health care costs and cut waste in the health insurance industry without making unnecessary cuts in the health care that was provided. Indeed, the Republican critics of health care reform in Congress specifically made a point of criticising health care reform's failure to include enough of a focus on cost savings.

One doesn't have to be a died in wool ideological supporter of co-operatives for co-operatives sake to say that co-operatives are a good option when consumers choose them the buy services also offered by investor owned corporations in circumstances where co-operatives provide lower prices through more efficient operations.

It isn't as if Republicans in Colorado as a whole have some deep ideological opposition to co-operatives as a form of business organization in any case. In rural Colorado, co-operatives are the primary way people get electricity, receive their telephone service, buy their farm supplies, store their grain, sell their crops, and buy their water. In Denver, Republicans make up a disproportionate share of people who send their children to pre-school through co-operatives, and many people in Colorado already get life insurance, disability insurance and casualty insurance from mutual insurance companies (which is just another name for a consumer's co-operative) like Northwestern Mutual or Amica. A citizen owned football team won the Superbowl this year. Almost every law firm, accounting firm and medical practice in the state is organized as an employee owned enterprise.

None of this changes how health care providers are organized. From their perspective, a health care co-operative is just one more health insurance company to deal with in the billing process - a big one, according to opponents, but not an organization that is actually providing medical services directly to patients.

READ MORE - Health Insurers: Co-ops Too Awesome For Colorado

Falling Behind In Answering The Mail

The notion that private enterprises are efficient and well run is a persistent but profoundly inaccurate myth.

Falling Behind In Answering The Mail

Delta Airlines is about a month behind in opening and dealing with mail from its customers according to a customer service representative in its frequent flier mile department. Imagine what would happen to a typical law practice, or a typical household, if you were routinely opening mail received and dealing with it a month late. But, this seems to be business as usual at the moment at Delta.

Loan modification application processing by mortgage lenders and mortgage services is just as much of a morass. Papers sent to lenders are routinely lost. It is hard for borrowers to find out what more information or action is expected of them. And, completed files languish for months until the information in them becomes outdated.

Private Industry Not Precisely Fiscally Responsible Either

While large financial institutions, as well as companies and governments that issue bonds are considered to be at the brink of collapse if they make scheduled payments even a day or two late, it can be stunning how far behind on their accounts payable small and medium sized businesses and trade credit payments by large "real economy" firms can get on a fairly routine basis. Back in the days when I did defense work for casualty insurance companies, it was routine to have bills paid several months after they were submitted to these large, publicly held companies.

Few industries have escaped having entities that collapsed financially due to major missteps in their business plans. Among the major companies that have gone bankrupt, failed, or needed a bailout to survive (or to that didn't survive) in the last decade or so are: General Motors, Chrysler, Blockbuster, Enron, Circuit City, Adam Aircraft, Bennigans, eToys, Frontier Airlines, Crabtree & Evelyn, The Walking Company, Daphne's Greek Cafe, Old Country Buffet, Village Inn, Mrs. Fields Famous Brands, Ponderosa, Ritz Camera, Sportsman's Warehouse, Big 10 Tire Stores, Inc., Z Gallerie, Filene's Basement, Eddie Bauer, Dunkin' Donuts, Samsonite, Max & Erma's, Unos Pizza, Schlotzsky's, the Chicago Tribune, the Los Angeles Times, the Hartford Courant, the Orlando Sentinel, the South Florida Sun-Sentinel, the Baltimore Sun, The Morning Call, ForSaleByOwner.com, South Park, the Chicago Cubs, WGN 720 AM, KWGN, the Denver Post, the Rocky Mountain News, the Tucson Citizen, the Baltimore Examiner, the Cincinnati Post, the Albuquerque Tribune, the Honolulu Advertiser, Los Angeles Daily News, the Boulder Daily Camera, the Brush News-Tribune, the Fort Morgan Times, the Lamar Daily News of Lamar, the Sterling Colorado Journal Advocate, the Oakland Tribune, KTVA in Anchorage, The Augusta Chronicle, the Savannah Morning News, the Juneau Empire, AIG, Lehman Brothers, the Shane Company, the Mexicana Airline, Movie Gallery, Japan Airlines, Skybus, Northwest Airlines, Aloha Airlines, Delta Airlines, Mervyns, MCI, Montgomery Ward, MGM (movie studio), U.S. Airways, Air Canada, United Airlines, TWA, Washington Mutual, any subprime mortgage finance company, Six Flags Fannie Mae, Freddie Mac, Indy Mac Bank, the Bank of New England, the Arena Football League, Goldman Sachs, or any of a host of other major American businesses.

The Abyss Of Health Care Administration

Oh, and don't get me started about the arcane and mysterious world of health care billing and health insurance claims processing. It isn't uncommon for even the most routine preventative care visit to become mired in billing mistakes, and any medical condition of consequence is almost sure to require phone calls and correspondence that takes much longer than the medical care itself did to resolve. While these mistakes made by medical office administrative staff and insurance companies are worked out, often over a period of many months, medical office billing personnel (often outsourced) make dire threats to patients explaining that the patient will be held responsible and treated as a bad debtor if the insurance company fails to live up to its promises to the patient.

And, of course, the number of medical appointments that frequently take just a few minutes themselves, are often delayed beyond their scheduled times make the ontime rates of major airlines look absolutely stellar by comparison. An hour delay at a doctor's office for a three minute visit is routine.

There is little wonder that it is complex, because the distinctions made often make no sense at the patient level. For example, a specialist doctor's office that is independent of any hospital, and one that has some sort of hospital affiliation look identical from a patient's point of view in all respects. The waiting room, the interaction with the office staff, the treatment room, and what takes place in the visit with the doctor are the same. The hospital affiliation is rarely proclaimed loudly, there are no benefits in patient service that result, and the specialist doctor's office is often in a separate building from the hospital. But, the patient's share of the cost under an insurance contract is often much lower in a specialist doctor's office that is independent of any hospital than it is from one with a hospital affiliation.

Moreover, it isn't uncommon for a visit to a hospital affiliated specialist doctor's office to produce three or more separate invoices - once for the doctor, one for the hospital and one for laboratory tests. Actual inpatient stays at hospitals are even worse. It isn't unusual for a single brief inpatient stay to produce invoices from half a dozen different providers, each processed in a vacuum by the health insurance company and each with its own outsourced billing firm. Even huge law firms that keep track in itemized invoices of dozens of different kinds of costs and service providers over the course of work for a single client usually manage to consolidate their charges into one or two invoices (sometimes an expert witness or local counsel providing services at a separate geographic location sends separate invoices).

Needless to say, medical providers (with the sometimes exception of dentists) almost never make public their schedule of fees or even tell patients what their visits will cost in advance. And, medical providers routine charge wildly differing amounts to different people for the same service based on their insurance company and/or ability to negotiate a price based on a cash up front payment and/or ability to pay. Like the prices of hotel rooms that are publicly posted, almost nobody pays the "regular price" for health care services except those who are uninsured and can't pay in cash -- most of the "regular price" for health care services is really a hidden finance charge.

Health insurance companies provide more information, but since some of their charges depend upon what providers charge, and since rates negotiated with providers are not generally disclosed to patients until after services are provided, and since the distinctions health insurance companies make often make no sense to patients, even post-health insurance prices of health care are hard to predict. Frequently in hospitals and hospital affiliated situations, the patient doesn't even know who the providers managed by their physician or the hospital were until after the bill is received.

Don't forget that everybody, not just administratively competent college graduates, needs health care services, that health care needs are frequently urgent in ways that make comparison shopping for price (even if prices were available, which they aren't) impossible, and that many patients dealing with health care billing messes are sick themselves.

Is it any wonder that market based capitalism doesn't work well in these circumstances?

Health care reform, if House Republicans in Congress don't manage to derail it, will at least finally bring the United States much closer to a universal ability to pay for health care and will control some medical costs, but even this juggernaut of allegedly dramatic reform doesn't seriously deal with the absolute disaster that is medical billing in this country.

Government Bureaucracy Snafus

This isn't to say that large government bureaucracies are good examples either. Bill Johnson discusses in his Denver Post column the troubling delays that Colorado is experiencing in processing food stamp recertification. Colorado's unemployment office is almost as backed up as Delta is in dealing with claims. Mostly, these problems are due to ongoing problems with profoundly flawed execution of contracts to upgrade the state's computers made by very expensive private contractors who failed to deliver the services promised in prior gubernatorial administrations.

The IRS isn't even going to start processing certain kinds of tax returns until Valentine's Day because it's computers need to be reprogrammed to handle last minute changes in the tax laws (mostly due to the failure of Congress to pass tax laws for 2011 until the lame duck session in December). It is a rare day indeed that a major Department of Defense contract is performed on time and on budget. I've had the Patent and Trademark Office lose materials that I've properly submitted to them several times in a single application.

At a smaller scale, the Douglas County Schools in Colorado, as of this point in January already, have still provided no meaningful budget planning guidance to its employees for the coming year. Voucher debates and strategic planning have pushed the day to day business of running their district off the school board's agenda.

READ MORE - Falling Behind In Answering The Mail

Short Takes

* I went to the Burger King restaurant in Cherry Creek earlier this week to get a cheap breakfast sandwich while I waited for the bank to open. The location was previously famous for being the parking nazi of Cherry Creek North, aggressively booting people in its lot. This time, I had to wait several minutes for anyone who worked there to appear, even after calling out an "anybody home?" Their bathroom is also the skankiest in all of Cherry Creek.

* Radio stations in Denver are in a slump. I have twelve FM and six AM pre-sets on my car radio, which I regularly revise with the best available options on the airwaves. Yet, several times in the last week, the elevator music in retail stores around town has been fresher and more interesting than what I can hear on any of those eighteen stations.

* Science Fair is over for another year. Next up, History Day.

* What is with all of the little banks on and around 1st Avenue in Cherry Creek? There must be twenty of them in the neighborhood, most with just one or two locations. You'd think it was Bern, Switzerland, or Luxembourg, or the Cayman Islands. I almost never see anyone actually doing business there, but presumably they have enough customers to stay afloat. I presume that they are catering mostly to a high end, local market clientele making loans to businesses, real estate developers, wealthy individuals and medium sized businesses, but I'm really not entirely clear what the business model is, although it seems to be a very similar business model for all of the banks that are not retail customer oriented.

* Even though Denver was almost 20% below average in precipitation in 2010, the snow pack in all of the state's major river basins was well above average, and since that is what really matters most for both Front Range water users and for the Colorado tourism industry, it's all good.

* Justice Kagan wrote her first U.S. Supreme Court opinion on the subject of the proper way to calculate the car expense in Chapter 13 plan calculations. The ruling was 8-1 with only Scalia dissenting. I agree that her reading was the better interpretation of the statute (it disallowed the expense when there was no actual loan or lease on a vehicle that had to be paid). The court took the case because there was a circuit split on the issue.

* The Article I immigration court based in Denver has a new judge who is married to one of the ICE prosecutors in the Denver office who presses these cases. The new administrative law judge must "must recuse herself from any case directed by her husband" but I have real doubts about whether that is sufficient to remove the appearance of impropriety in this situation.

In an ordinary court, only part of the docket involves cases brought by the government. But, all of the cases before this administrative law judge will be brought by the office of which her husband is a part. The pervasive association the new immigration judge has with one side of every single case before her creates a clear appearance of impropriety. I can't imagine how I could possibly be impartial in her shoes. Immigration judges have immense discretion. Statistically, the judge a person with a case in immigration court is assigned to is the single most important factor in determining the outcome of the case. Inappropriate use of that discretion by immigration judges, mostly to the detriment of immigrants, has flooded the federal appellate courts in recent years, and has cast grave disrepute on the credibility of the immigration courts as institutions where any meaningful kind of due process exists. This development certainly doesn't help the situation. If the recusal were from all cases with ICE involvement, that would probably resolve the problem, but that isn't a viable option for an immigration court judge.

I feel for the couple, who are no doubt both very smart, competent immigration lawyers, each of whom has a good federal government jobs. Neither has personally done anything wrong. But, maintaining this kind of status quo, even with recusals from cases where the other is personally involved really doesn't cut it. In government contexts the concern is not primarily ex parte communications about particular cases or personal gain (the government lawyers don't win or lose anything as a result of the outcome of particular cases), but about bias towards one side or the other on the part of the office, which is just as strong even without personal involvement in the same cases. We are not such a parochial backwater in Denver that we have no choice but to have a conflicted immigration court system because no one else is up to the job.

* Once again, Denver cops are being sued in a police brutality case and fraudulent police report case arising from a January 2009 traffic stop. Westword has more details.

* Marginal Revolution is a superior blog that I will add to my sidebar in due course.

* The percentage of women in Colorado's General Assembly (41 out of 99) is the highest of any state in the United States. The national average is 23.4%.

* Republicans are constantly accusing liberals of inventing constitutional rights that aren't supported by the language of the constitution. But, these days, the shoe is on the other foot. John Tomasic at the Colorado Independent nails it with this headline:

King to Polis: Healthcare law infringes on right to have babies in garbage cans

He goes on to explain:

Iowa Rep. Steve King today on Capitol Hill at a Rules Committee hearing on the GOP plan to repeal the healthcare reform law. He ended up telling Colorado Rep. Jared Polis that the law is unconstitutional because, for instance, it forces uninsured women who deliver babies in garbage cans to buy health insurance. Polis, aghast, searched for words.

Isn't funny how the rights Republicans want to invent always seem to be ones you have no desire to actually exercise?

READ MORE - Short Takes

Do We Need A Better Early Warning System?

Meet Mr. Loughner

Jared Lee Loughner, the Tuscon assassin, was a troubled young man.

It was clear that he was a problem, possibly a violent one, in the community college he attended:

Pima Community College, in Tucson, issued a statement identifying Loughner as the suspect. It said he was a student from the summer of 2005 to fall of 2010, but he was suspended Sept. 29 for conduct violations. It said he agreed to withdrew from the college on Oct. 4.

The college said that from February to September of 2010, Loughner had five contacts with college police for disrupting classrooms and the library. It said he was prohibited from returning to the college.

A spokesman for the college said Loughner's videos troubled administrators and campus police, leading to his suspension. In one video, he "claims that the College is illegal according to the U.S. Constitution, and makes other claims," the college's statement said.

Loughner and his parents, Amy and Randy Loughner, met with administrators, who required him to be obtain a certification that "in the opinion of a mental health professional, his presence at the College does not present a danger to himself or others." . . .

Lynda Sorenson said she took a math class with Loughner last summer at Pima Community College's Northwest campus and told the Arizona Daily Star he was "obviously very disturbed."

"He disrupted class frequently with nonsensical outbursts," she said.

The community college alerted his parents that there was problem, something that they probably already knew. He apparently lived at home with them.

While he has in college, he was prosecuted for a minor drug related charge:

The Arizona Republic reported that the charge was for possession of drug paraphernalia. The charge was dismissed in 2008 by the city attorney after Loughner entered a pre-trial diversion program.

He left his high school after his junior year, despite not leaving the area, and around the time he started in at community college:

Tamara Crawley, director of the Marana Unified School District in Tucson, said Loughner attended Mountain View High School in Tucson for three years but withdrew after completing his junior year in 2006. . . . [A high school and college classmate] described him as having a lot of friends "until he got alcohol poisoning in '06" and dropped out of school.

He wrote odd and disburbing things on the Internet.

In November, less than two months after he was kicked out of college, Loughner had bought a Glock, purchased legally from a Sportsman's Warehouse in Tucson. Less than two months after that six people are dead and fourteen people are wounded, many of them seriously.

Spree Killings Are A Distinct Kind Of Crime

When one looks at the profile of people who commit these kinds of horrific one time explosions of violence, a good share share of them are people like Loughner. The warning signs in Loughner's case were similar to those involving Matthew J. Murray who went on a shooting spree in Arvada and Colorado Springs in 2007. They resemble those of Aaron Synder who tried to kill Governor Ritter in 2007. They have similarities to those shown by Seung-Hui Cho, who carried out the Virgina Tech massacre in 2007. They resemble Robert A. Hawkins who carried out the Westroads Mall shooting in 2007. They show resemblances to Eric Harris and Dylan Klebold who carried out the Columbine High School massacre in 1999.

These cases aren't that different from that of Malik Nidal Hasan, the Army medical officer who was responsible for the Fort Hood shooting in 2009, and Kyle Aaron Huff who carried out the Capitol Hill massacre in Seattle in 2006. They resemble Charles Joseph Whitman who in 1966 went on a shooting rampage at the University of Texas at Austin.

The Malaysians had a word for these kind of acts carried out by these kinds people long before we did that has entered the English language in the phase "running amok", although the force of the term has been diminished from overly casual use in English. The home made equivalent ideom, which has the Malayian meaning of "amok" is "going postal." The more clinical term used by the FBI for this kind of individual is "spree killer".

Spree killings aren't very common, but they do occur at a more or less steady pace all over the world and inevitably make headlines when they happen. The spree killers are almost always men. They almost always commit suicide, are killed by someone else in the course of their spree, or are caught and detained for life.

These men are very distinct psychologically from serial killers, from people who are part of criminal gangs or are "professional" criminals who kill in the course of their crimes, from paid hit men, from people who are normal when they aren't drunk or on drugs, and from people who carry out mass killings in connection with aggressive approaches to a position of authority like police, national guardsmen or soldiers.

While they often have grievances and concerns with a political slant and perhaps colored by the political and religious discussions of the day, and these men generally act alone or with a very small circle of troubled friends rather than as part of an organization, often have vague or irrational agendas. Generally, there is no "sane" person personally coaxing them to engage in violence.

Their crimes involve pre-meditation and planning, and the people who commit them are no doing so with any hope of bettering themselves. They expect to die or be incarcerated forever. These are acts more akin to suicide than to homicides carried out with a rational motive. They are terrorist suicide killings carried out by rebels without a cause that makes any sense. The lack of self-regard make them immune to the deterrence threat of punishment in the criminal justice system. Who cares about the death penalty when you expect that there is a good chance that you will die in the course of your crime anyway?

The Problem Of Definition

In an ideal world, we would have a well honed societal early warning system that would alert authorities to what family members, classmates, co-workers, school administators, bosses, and maybe even police already know, that a particular individual has a real problem and is at grave risk of causing massive harm to other despite having no strong history of violence causing injury, and would have a way of intervening to prevent this individual from causing harm to others.

American law permits involuntary mental health treatment and civil detention for someone who presents a danger to himself or others, aluded to by Pima College in the Loughner case, and we also have a civil restaining order system in place that receives quite heavy use in cases where the danger to others that is particularized to a small number of identifable others. Existing law, although ineffectively implemented, also prohibits those who have been involuntarily committed from buying guns, but bureaucratically, there is not good systemic integration of involuntary commitment records with instant background check systems, and substantively, this narrow definition of mental health problems is grossly underinclusive, particularly in an era in which over the last four decades or so, outpatient treatment of mental health issues have become the near universal approach to treating these issues with institutionalization limited to a very narrow subset of all people with serious mental health problems.

But, the existing system isn't very effective. It isn't clear who is responsible for intervening. It often isn't clear to those around the disturbed individual, especially in the case of an adult, who has the authority to intervene and what that authority entails. Most of all, it isn't clear when intervention is appropriate because often no one person has enough information to clearly establish a danger to others alone, even if many people have enough information to suspect it, and because the symptoms that establish that someone is a danger to others are not well defined.

This is particularly problematic in the American legal system, because our legal system and political culture is particularly suspicious of intrusions on autonomy and freedom for the greater good based on acts on might take, rather than acts one has taken.

On one hand, it is frequently obvious to those who interact with them that something is future spree killers are disturbed individuals. On the other hand, it is often not at all obvious where the line should be drawn. Perhaps one man in a thousand is as intuitively "off" as the people who end up committing spree killings, even though only a handful of spree killings take place in any given year in the entire United States, out of a population of tens of millions of men in the age range of people who commit these crimes.

Statistically, spree killings aren't a major cause of death. But, the immense psychological trauma they impose on the population makes them notable.

An ability to identify a group of fifty thousand people in the United States, from whom it is extremely likely that almost all of the several spree killings a year will be committed would be pretty impressive, compared in scale to the massive and not very effective probation and parole system we have in place. Since most spree killers obtain weapons legally, and many lack adequate mental health care, and a good share of no one who feels responsible for monitoring their well being.

If those individuals could be identified, disqualified from owning firearms via the database used to screen gun purchasers now, pro-actively offered and nudged into seeking mental health treatment, and subjected to light monitoring that would reveal major life changes or disruptions in mental health treatment and would be specifically designed to have a group of designated informants among school, work, family, treating medical professionals, and social contacts who would feel some slight obligation to alert a monitor if the person's situation seemed to be taking a turn for the worse, and that monitor had the authority and responsibility to intervene in those situations, a lot of these incidents could be prevented. The level of intervention required could be somewhat less intense than the kind of supervision that someone on probation or parole receives and still have a measurable effect. It might be that a large set of people so identified would have less intense supervision, simply being banned from purchasing firearms, offered free access to mental health treatment, and annually checking in close associates to let them know who to call if the circumstances changed or the situation appeared to escalate, while others who posed a higher risk would be monitored much more intensely. This would take a tiny share of the societal resources that we devote to the criminal justice system to implement, and it would also help to destigmatize mental illness and reduce the fear people have of the mentally ill who were not identified as high risk.

The payback of this kind of system would be considerably greater than simply reducing the incidence of spree killings for one out of a ten thousand supervised individuals. For every spree killer, there are no doubt tens or hundreds of people or more with a profile that puts them at high risk of becoming spree killers, who commit suicide, who would otherwise kill a particular loved one, who would neglect or abuse a child, who would lapse in taking psychiatric medicines and as a result see their careers and educational aspirations and personal relationships collapse, who would want mental health treatment if they knew it was available and could gain access to it, who cause serious damage to property, who kill someone's beloved pet, who injures others, who commits "suicide by cop," who ends up in prison, or who engages in reckless acts that endanger the public that are on the line between accidents and generalized malice.

Few people who fit a "spree killer" profile may actually commit a spree killing, but a very large share of people who fit that profile would benefit personally, and/or have people associated with them who would benefit, from intervention in their lives.

But, crafting an operational definition that is inclusive of almost all potential spree killers, while excluding people who are not at high risk for being either spree killers or otherwise being a danger to themselves or others, that can be vigorously applied without undue abuse and without unduly impairing the liberties of people who are merely "different" or have principled objections to the mainstream medical approach to treating mental health conditions is not an easy task.

Yet, this must be the kind of definition that becomes as distinct a part of popular culture as CPR instruction, "drop and roll" for people who are on fire, "direct pressure" as the cure all for bleeding, "don't drive drunk," "no means no" and other public health and safety messages, and to be effective, it has to win widespread societal acceptance from a significant share of people even in a lot of fairly anti-authoritarian subcultures. It needs to have the perceived authority of science behind it. It needs to be accepted as legitimate, if not by all people who fit this definition, at least, by a large share of all people who are friends and family and colleagues of people who fit this definition. The closest precedent would probably be the system that requires a large swath of people to report child abuse and neglect and provides a place for others to report it voluntarily.

Almost invariably, when serious consequences are attached to conduct or a condition that is described overinclusively, a large share of all people who suffer those consequences come under the overbroad part of that definition. For example, a surprisingly large share of first degree murder prosecutions involve women who kill their infants in the throes of childbirth or criminal accomplices who did not anticipate that a murder would be committed in the crime that they were involved in and had no personal participation in that murder. Similarly, a very large of racketeering cases involve relatively minor white collar crimes committed in an organized way, rather than anything closely resembling the kind of mafia activities that generated political support for RICO's tough sentences.

Slight overbroadness in defining a high risk category risks bringing far more people than necessary into the net, making the program much more expensive to manage, making the people who run the system less alert to the risk among those they are monitoring than they need to be, and making the intrusion into liberty interests involved much greater.

Another approach to deal with the limits of lay expertise in mental health diagnosis akin to the reasonable suspicion for a "Terry stop" v. probable cause for a "search or seizure" distinction in U.S. law under the 4th Amendment, would be to have a low threshold at which an individual could simply be compelled to receive a mental health evaluation and diagnosis, while limiting anything else to individuals who were diagnosed in a voluntary or involuntary mental health evaluation as suffering from a particular set of symptoms, or were found by some sort of public body (perhaps a tribunal or public office) to have that set of symptoms based on information received in cases where diagnosis is unavailable. Mental health evaluations might also be made a standard part of every criminal case more serious than a traffic stop, even if it is resolved with a diversion program or deferred prosecution.

A two tiered approach might also make members of the public less wary of intervening, as insisting that someone seek professional advice is less weighty making a complaint about someone that would lead directly to significant personal consequences for the person about whom authorities were alerted.

Including a voluntary diagnosis would disturb a bedrock foundation of confidentiality in the mental health care system, but the justification that privacy is necessary to cause people to seek help might be less compelling in a context where the government had the legal authority to compel someone to seek mental health evaluation and diagnosis on the basis of a reasonable suspicion (or probable cause to believe) merely that the individual was clinically mentally ill and could benefit from treatment. And, the individual alerting the system to the need might simply be told as feedback that "an inquiry was conducted based upon the information provided and that it was resolved in accordance with the law" rather than provided with detailed information on how it was handled. In all likelihood, in many cases, alerts would come for individuals who had already been evaluated and diagnosed and were in the system, and would simply lead to a brief memo to a designated mental health care provider.

I don't have great faith that psychiatrists can generally determine with much accuracy at all using existing methods whether or not someone poses a risk of future dangerousness. But, I do have greater comfort that psychiatrists can be reasonably accurate in diagnosing mental health conditions, and that it is possible to distinguish mental health conditions in which there is an elevated risk of someone fitting a "spree killer" profile from those where there is no elevated risk of that kind of activity, and the set of diagnoses where there is an elevated risk is, I suspect, a rather modest subset of all mental health conditions, and this designation is one case where a blanket gender distinction probably makes sense given the gross disproportion of men to women who commit these incidents. (The only American woman who might even remotely qualify is Caril Ann Fugate who claimed innocence but was convincted in a crime that her boyfriend admittedly was involved in committing in 1958 in Nebraska in a episode that is in any case a poor fit to the mental health driven spree killing model described above.)

In an ideal world, an in depth mental health inquiry and background check might be linked to eligibility to purchase guns, since spree killings are almost exclusively committed by people who have purchased firearms, allowing people who choose not to purchase guns and as a result pose far less of a threat to the public to escape supervision in most cases, and casting the mental health inquiry as rationally related and narrowly tailored to a right to do something in particular that poses an elevated risk, a bit like a driver's license, rather than as a punishment. After this inquiry was completed, it would be revocable if new information came to light, but might not have to be re-examined for each new purchase. This kind of inquiry also would have prevented at least some of the small number of shooting range shootings that take place, such as the attempted suicide pact of twins at the Family Shooting Center in Colorado in 2010, where at least one of the suicidal twins had a history of despondancy.

In the current political climate, that is probably not a possibility in the short run, given the strong association of the ascendant Tea Party faction of the Republican party with the Second Amendment and weak gun control laws. Although, even the NRA has supported improved record keeping to prevent those who have been civilly committed from being able to lawfully purchase guns, and many gun owners recognize that a large share of gun control efforts are driven by events like spree killings, and that gun control efforts might be far less intense if there were reasonable measures in place to reduce their incidence, even though spree killings a tiny share of all gun murders. The Heller ruling of the U.S. Supreme Court in 2008 that declared the right to bear arms for self-defense to be a constitutional right made clear in dicta that prohibitions under current laws on gun purchases by the mentally ill were permitted under the Second Amendment.

While the short run political climate may make this approach untenable, I think that one long run, bipartisan secular change in policy attitudes over the rest of my lifetime is going to be increasing intolerance of predictable and preventable tragedies. The more clear it becomes that there is a way to prevent tragedies, the more pressure there will be to take strong measures to prevent them.

Notably, along these lines, in Britain, Doctors agreed this summer to breach medical confidentiality if patients who own guns become seriously mentally ill.

READ MORE - Do We Need A Better Early Warning System?