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American Healthcare - Part IV: An Unpredictable Event
July 1st, 2012 | View Post
On the evening of April 8th, 2009, I was in a motorcycle accident just a few miles from my home. When I awoke, I was laying on my side in the middle of a four-lane road, surrounded by people. The next sixteen hours provided me with a first-hand glance of how our emergency care system purports itself to work, as well as how it actually works. At a time when I legitimately needed to ensure my own well being, the events following the crash tested my principles far more than my pain tolerance.

The background of the accident is fairly a straightforward story. As I traveled northbound on a local arterial road, the driver of a vehicle three cars ahead of me slammed on the brakes and made an unexpected illegal left turn through a median at the bottom of a hill. The two cars in front of me were forced to slam on their brakes as well, narrowly avoiding one another in the process. I was later told that pedestrians in the vicinity heard the screeching of their tires, saw smoke rising from the burning rubber, and witnessed a red motorcycle crash into the back of a Ford Explorer and its passenger launched through the air.

Although I had seen the entire chain of events unfold before me and took every evasive action I could, the brakes on my motorcycle locked and threw me into a skid. Unable to control my motorcycle, I veered directly towards the back of the SUV. I turned the bike sharply to the left as a last ditch effort to avoid the car, but evidently did not come to the decision quickly enough. My motorcycle slammed into the vehicle instantly throwing me forward. As I flew forward through the air, my legs clipped the handlebars and the right side of my body forcefully slammed into the back of the Explorer. I wound up landing headfirst several feet away on the hard asphalt below. Had I not been wearing a helmet and minimum safety gear, I suspect the impact would have killed me, or at least left me with a severe brain injury. To those immediately on the scene, I appeared as nothing but a lifeless body laying in the fetal position. It is still unclear whether I fell temporarily unconscious, but I certainly was not moving – yet.

After some unaccounted period of time I found myself peacefully gazing up through my helmet’s visor at a growing crowd of people. Some sounded emotional; others as if they were trying to control the space around me, but to the best of my recollection, all sounded legitimately concerned about my well being. I could hear several speaking with emergency dispatchers from their cell phones. As I began hearing sirens in the distance, it occured to me what the ensuing medical costs would be for a medical transport and I decided at that moment I would need to take some action. Much to the verbal dismay of the onlookers, I carefully stood up in a mild stupor, brought my motorcycle upright, and proceeded to walk it off of the road so the growing traffic jam could pass. A number of individuals helped me to the side of the road and sat me down on the grass to wait for the fleet of emergency vehicles to arrive. One of the girls helping me was on the phone with EMS and told me an ambulance was on its way. Despite the condition I was in, I asked her to tell EMS that I did not require their assistance as I was not interested in paying the several hundred-dollar price tag that I knew would be associated with it. She did relay this message, but it was the policy of the emergency crew to show up on the scene anyway.

When the medical team arrived on the scene, they asked me a number of questions related to my condition and performed a very basic examination of my neck and spine. Even though they suggested it was in my best interest to go to the hospital with them, they were polite and professional as I declined their services. The chief police officer on the scene was incredibly considerate throughout the ordeal and ensured that I did not wish for any additional medical services before eventually waving the ambulance off. As the ambulance drove off and the traffic flowed regularly, those who had stopped to look slowly began to disperse.

In the end, the car that had turned illegally was nowhere to be found and my collision with the Explorer was ruled a no-fault accident by the police. I managed to get a ride back to my house from the local motorcycle towing company on the scene, but my ordeal with American healthcare was just beginning. I first attempted to get in touch with my insurance provider to determine if this sort of incident would be covered by my catastrophic plan. I ultimately gave up after about forty-five minutes, as I was unable to get in touch with anyone, though I did later find out that any costs would simply have been applied towards my catastrophic deductible. With my pain worsening by the minute, particularly as the adrenaline from the accident had worn off, I was clearly in need of medical attention. I relayed the details of the accident to an ex-girlfriend and she graciously came to my assistance and took me to the hospital.

Torn, bloodied, and unable to move my right arm, I hobbled into the emergency waiting room and spoke to a nurse about needing medical attention. Seeing the condition I was in, she quickly brought me into the admittance room to check my vitals and gather some information from me. The check-in process itself was very fast and efficient, and there was no wait to be assigned to a private trauma room. As the nurses concluded the check-in process and wrapped the iconic medical bracelet around my left wrist, I paused and asked them what I assumed at the time was a very common question. I asked them how much the examination was going to cost. Both nurses appeared almost startled that I would be asking such a question under the circumstances. One of them responded very curtly that she did not know and that it was unimportant given my current condition. I felt as if I had asked her something offensive.

I explained calmly and clearly my understanding of how it would be difficult to provide an exact dollar amount, and that I was merely asking for a ballpark figure. I even went on to explain that I simply wanted a very basic medical examination to be sure that I did not have any internal bleeding and that my skull was not fractured. Anything more would be a huge bonus to me. Regardless of this clarification, I was again told that it would be impossible to give me any sort of a figure and that I should not be concerning myself with the medical costs.

After pushing for what seemed like several minutes, one of the nurses eventually relented to my increasing agitation and informed me that the medical attention would likely cost between five and seven thousand dollars. Although I did plead unsuccessfully for a more reasonable price, particularly given the attention I felt I needed, I informed the hospital that I could not justify paying such a high fee for the basic care I was seeking and that I did not want to receive medical treatment. The stunned expressions on the nurses’ faces left quite an impression upon me and I was promptly asked to leave the admittance room.

Literally dripping blood with each step, I slowly hobbled back across the waiting room towards the front door and was driven back home. My ex-girlfriend, brother, and another dear friend kept their eyes on me throughout the evening as I waited for the local urgent-care facility to open. Ten hours after the accident I was taken by my brother to an urgent-care facility and finally received a full, and much needed medical examination. Doctors examined my neck and spine, checked for signs of head injuries and internal bleeding, tended to dozens of lacerations, took and interpreted eleven x-rays of my arm, leg, head and neck, and provided me with antibiotics and pain medication. I paid my bill in full on the spot without any type of insurance for a grand total of $252, almost twenty times cheaper than the lowest figure the emergency room nurse had estimated.

continued in "Part V: Impractical Expectations"
American Healthcare - Part V: Impractical Expectations
July 1st, 2012 | View Post
Obviously every medical emergency is different and every patient unique. However, if you take that story into consideration without applying any type of political bias, there is at least one point of comparison that should stand out above all else. How is it that the price of one health care option is able to outweigh another by twenty fold? Is it actually possible that I, or any other patient, could have been the recipient of twenty times the level of care? It is highly unlikely.

Had I been comprehensively insured at the time of my accident, it is a fact that that I would have received the highest level of care immediately following the accident. Furthermore, it is highly unlikely that I would have questioned any of the associated finances with the examination since I would not be directly responsible for them. But in a healthcare system whereby finances must be accounted for in one way or another, the question still remains of how the two estimates of care could have varied by so much. This is why having a thorough grasp on the economics of modern health insurance is so important. These huge cost differentials are common and due to the fact that there is no incentive to control costs within any step of the process. Insurance companies and medical corporations massively benefit from the liberal and often unnecessary applications of their products. This is exactly why the hospital bill would have been so much more expensive than the minor care facility turned out to be; I would have paid twenty times the cost for a fractionally more accurate diagnosis, all the while experiencing a barrage of the latest and greatest medical technologies.

The question that should be asked of all Americans is whether our expectation of a healthcare system is to save lives, or to provide individuals with every advanced comfort available regardless of the broader scope of costs. It seems that the expectation from most people who supported the healthcare bill is the latter; every medical condition should be accounted for, regardless of the costs involved. Not only is this impossible, it is unconscionably selfish. There are a finite amount of monetary resources available within the United States and every medical procedure uses up some of these resources. When we waste precious resources in an effort to make fractionally better diagnoses, there are simply less resources available for the greater good. The consequence of this will be an increase of medical spending across the entire country, albeit abstracted through insurance premiums. Of course with any type of spending increase, those at the bottom are always going to get hit harder than those at the top.

In the nineteenth century it would have been considered a medical luxury for one to have access to a drug like acetylsalicylic acid. Despite the comfort it could have provided to millions at the time, there were still costs involved in its production and thus it was generally administered only when absolutely necessary. As medical and technological advancements were made, the drug became cheaper to manufacture. Eventually it became readily available, albeit as something called Aspirin. This type of history is significant to our current predicament. Not all medicines can be made instantly available to those who need them. If politicians had a genuine interest in helping to solve the American healthcare debacle, they would be working to reduce healthcare costs. They would be ensuring that the costs of modern drugs were decreasing and becoming more accessible to Americans, much like Aspirin once did. They would not be instituting policies guaranteed to increase the level of medical spending under the false pretense that this will somehow result in better healthcare.

Any politician who would attempt to convince people that the intent of mandatory insurance is to put everyone on equal footing should have his or her motives severely scrutinized. The notion is both impractical and illogical. If we assume for a moment that every single American were somehow provided the exact same quality, convenience, and cost of healthcare, then we would also have to assume that not one other American (of over 300 million) would attempt to find a medical product or service even slightly better, more convenient, or cheaper. Of course human beings simply do not function in that way. This is why the tenants of capitalism, despite the flaws, are what drive a free society. Perhaps not surprisingly then, the bill also addresses at least one capitalist enterprise.

The healthcare act of 2010 curiously contains a provision for levying additional taxes against tanning salons. This is actually one of the mechanisms installed to cover the additional costs, albeit a seemingly small one. The idea behind the tax is that since tanning salons are unnecessary (according to the state) and increase the risk of skin cancer, then they should be taxed accordingly. The idea is actually quite logical; the higher the risk of adverse health effects, the higher the tax should be. But this is an extremely dangerous precedent we have permitted the government to set for itself. By what authority does the United States federal government have to dictate what is “good” for us, and what is “bad” for us? Moreover, who makes that decision?

While I personally believe a tanning salon is a ridiculous waste of money, many would say the same of a motorcycle. Many might also say that a motorcycle is far more dangerous; why not tax motorcycles in the same way? Statistically speaking, they pose a far more significant risk to riders than those of cars. What about the correlation of fast foods to obesity and diabetes, or perhaps the ratio of adventure activities to injuries, or promiscuity to pregnancy and disease? There is an almost never-ending list of causality in our world. It would stand to reason that within this government-controlled framework, any type of non-essential, higher-risk activity could be subjected to arbitrary government taxation in the name of better healthcare. If I had to guess, I would imagine tanning salons simply lacked the necessary lobbying power in Washington prior to the bill’s passage.

Allowing the government to be the judge and jury of what constitutes acceptable risk would lead to a nanny-state of unfathomable dystopian proportion. The United States was founded on the idea that people control their government, not the other way around. This basic concept is responsible for the entire western notion of democracy. But given the obvious dependencies we all have on healthcare, is it really so wise to promote a system that exploits this dependency in the name of better health? The Bush Administration made a case that it was necessary to forgo certain civil liberties (outlined in the Patriot Act) in order to remain safe from terrorists. These types of hollow promises in the name of security and well being run contrary to the American foundation of liberty. They exploit the fears and needs of Americans to promote policies that benefit others. The healthcare bill has is no exception to this rule.

I would completely agree that nobody in the United States, citizen or otherwise, should have to suffer unduly at the hand of a medical catastrophe. The country is far too wealthy and technologically advanced to accept such a subpar standard of human accountability and compassion. But at the same time, neither should any person be legally mandated, especially at the federal level, to provide private industry of any kind with his or her business. While about half of the country might still be convincing themselves that their party would never have led them astray, the reality is that in due time, the healthcare bill will prove to be far worse than having done nothing at all. We cannot have a system built upon financial risk mitigation whereby nobody loses and meanwhile expect it to become more affordable; it is a mathematical impossibility.

The basic misconception lies with people believing that smaller incremental costs are somehow better or cheaper than one lump sum. This might be true if we spread those costs out ourselves, but in reality, we just wind up paying substantially more for goods and services that we never needed in the first place. This is very similar to the idea behind gift cards that we explored earlier in the book. The more you abstract the cost of something, the less likely people are to consider the price, and the more wasteful they ultimately become. But that does not change the original cost of the good or service from existing. Rest assured, we do pay for those costs, as well as all of the administrative costs that go into managing them. They are merely abstracted into smaller monthly or quarterly payments.

continued in "Part VI: Practical Healthcare Proposals"
American Healthcare - Part VI: Practical Healthcare Proposals
July 1st, 2012 | View Post
After decades of poorly crafted medical policies, and between all of the civil discontent that has resulted from the passing of the healthcare bill, it seems reasonable to doubt whether the United States is capable of having a balanced, equitable, and practical healthcare system that all can agree upon. Achieving this type of balance presents a difficult puzzle for lawmakers. At the heart of the best working systems are simplicity, practicality, and accountability, none of which lawmakers appear to have any interest in discussing, much less attempting to legislate.

Before any other changes are adopted, I would encourage all Americans to urge members of Congress to repeal the Patient Protection and Affordable Care Act of 2010. It is important to note, however, that this should not be done to upset the left or appease the right. It should be done because it was poorly crafted legislation.

Constitutionally speaking, if Congress intends to create and enforce any type of federal healthcare mandate, an amendment should be properly made to the Constitution, ratified by the states, and executed, just as the process has required for over two hundred years. Neither the Democrats nor the Republicans have any constitutional authority simply to dictate such wide-stretching federal legislation. Even beyond the Constitution, it should be common sense that the legal empowerment of multinational corporations with a guaranteed marketplace will, among many other things, only help to ensure the expansion of lobbyists and special interest groups. This is sure to result in nothing but higher healthcare costs, poorer service, and an even less manageable bureaucracy. How can Americans possibly expect any level of impartiality between the various branches of healthcare while they are legally joined as one?

But it is not enough just to repeal the law. In parallel to the time it would take Congress to remove the legislation, there are several very simple and practical improvements that could be debated and readied for implementation across the country. Individuals have an incredible ability to control the direction of healthcare through the power of our capitalist market. While politicians might continue to remind us of how they know best in the matter, immediate and positive change requires nothing more than for us to be responsible and accountable, and to hold others to these same standards. But everybody must do his or her part.

First, and above anything else, it is important for our society to start an open dialogue on the differences between healthcare and health insurance. One of the dangers that this lack of understanding has wrought on society is that it removes the base principles of calculated risk from public discussion and debate. Politicians, both Democrats and Republicans, have long since capitalized on this and as of 2009, made the modern healthcare debate almost exclusively about insurance. Instead of discussing some base expectation or level of healthcare, as would perhaps be a progressive step for our society, they have instead debated whether or not people should be legally required to hold private health insurance. This has been paired with the notion that health insurance should be responsible for every single treatment we ever receive, regardless of how routine it may be. This whole idea is absurd in almost every respect and provides insurance companies with enormous powers and profits.

I would suggest to all Americans, particularly those who are self-insured, that they closely examine the true costs of their insurance package. Consider the monthly cost, the deductible, any copayments, and any percentage of care they are still responsible for beyond the insurance coverage (this can often be 20% or more). Compare that to what yearly medical costs have traditionally been, and many people may be surprised to learn how much they are actually spending just to visit the doctor a few times a year. As an alternative to a comprehensive health insurance plan, consider combining a catastrophic plan with a health savings account (typically called an HSA). Catastrophic medical insurance plans often come with relatively high deductibles that are neither appropriate nor practical for routine healthcare. They do, however, more appropriately embrace the fundamental idea of how insurance is mathematically calculated and is designed to function. Catastrophic plans are specifically intended to treat medical emergencies and more severe healthcare needs as they arise. Health savings accounts work very similarly to retirement accounts (such as IRAs and 401Ks), are available to anybody, and allow individuals to make yearly tax-deductible contributions of up to $3,050 (as of 2010). That is about the same amount of money one might expect to spend annually on a premium health insurance policy. Moreover, the money within the HSA can even be invested just like most retirement accounts allow for. But one of the key benefits to an HSA is that it provides the individual with the ability to manage and offset his or her own financial risk. In other words, if the individual happens to not require medical care over a given period of time, the money they would have otherwise spent on insurance is theirs to keep. This can significantly cut back on needless monthly expenditures and help individuals to save money. When the individual needs to pay for a medical expense, the money comes directly out of the HSA provided that the medical expense qualifies (as most do). Ironically, under the new healthcare law over-the-counter medications no longer qualify for this program without a doctor’s prescription. Why would the bill remove medical tax exemptions if its very purpose is to make healthcare more affordable?

Of course on the opposite end of the health insurance spectrum, many people enjoy absolutely wonderful benefits at a very low monthly rate through a company program. Although I am certainly in favor of individuals receiving these types of benefits, it is important to understand that this does not change the underlying cost of the insurance package. In these cases, the costs are simply defrayed by the company as part of an employee perk. If you are one of the millions that enjoy these top-shelf plans at a low monthly rate, take a moment to ask your human resources director what your monthly rate actually costs the company. Most people will be shocked to learn how much money is spent on them annually, regardless of whether or not they even use the coverage. These benefits might seem free to us, but the company is passing along the costs to their employees one way or another, be it through lower salaries, fewer stock options, or various other cost-cutting measures. This is also one of the reasons that companies are becoming increasingly inclined to hire contract workers instead of permanent employees; the costs associated with acquiring new employees is simply getting too expensive.

Although individuals can take it upon themselves to more responsibly manage their own healthcare coverage, government does need to play a role in helping to ensure sufficient facilities exist. A practical Congressional measure would be for the federal government to provide incentives (as opposed to mandates) for cities and states to ensure the 24-hour operation of minor care centers. These centers could operate as stand-alone facilities, or to be directly connected with local hospitals. Much like my personal experience with the motorcycle accident, the twenty-fold cost differential was a result of the hospital preparing to admit me into a full trauma room. Whether one has been seriously injured, or merely nicked their finger with a kitchen knife, many hospitals will admit the patient to a facility capable of providing the same high level of care. Of course, hospitals also come a premium rate. Any trained medical professional should be able to judge, within reason, what type of medical care a patient is in need of. Opponents of that idea will argue that the decision can be ethically wrong and could potentially jeopardize the care of a patient. But this counter-argument is essentially the same thing as suggesting everybody should be entitled to the best medical care possible, all of the time, regardless of the circumstance; it ignores certain boundaries and practicalities that the real world is forced to operate within. Moreover, in all medical cases, doctors are constantly required to take calculated risks for the well being of their patients. They use the information that they have gathered to make the most effective medical judgments possible. Why should this be any different with respect to the type of facility a patient is admitted to?

It is also worth considering how in the absence of this system, insurance companies can more easily assert their grip on medical costs. In reality, when the need for medical care arises, people rarely have the convenience of “shopping around” for a better deal; they are likely in need of immediate care. Provided the patient is insured, neither the hospital nor the insurance company has much incentive to try and keep costs low.

Another necessary component for establishing sensible healthcare policies is to remove the financial abstractions from within the medical marketplace. It is important to understand that those needing medical attention are customers, however unfortunate their circumstances may be. As customers, they will undoubtedly receive a bill for any treatments they receive. I would strongly advocate the government mandating that doctors and hospitals be required to provide all costs up front. Although I generally reject mandates on principle, this type of mandate in no way affects the private dealings of the market; it simply provides the consumer with information that they are already legally entitled to be provided.

I have heard it argued primarily by those in the medical field that it is simply too difficult to know what medical attention will cost before seeing a doctor, and therefore unreasonable to predict estimated costs up front. This is the primary reason why medical costs are typically not disclosed before service. However, this whole idea is baseless and falls somewhere between arrogance and conspiracy.

There are few service-based industries in the entire world whereby the service provider knows exactly what up front costs will be involved. And yet, in every one of these industries, the business is still expected to provide a cost estimate. For example, if you consider something as commonplace as having a vehicle diagnosed by a mechanic, how could they possibly be expected to know how long it will take, or exactly what types of tests they would to run? There are simply too many unknowns. This is easily solved by basic communication. There are certain costs that are provided to the customer up-front, and the rest are approved as progress is made. This is not a difficult system to understand, and yet we are made to believe that it is somehow an incalculable operation on the part of most medical facilities. Interestingly, dentists and veterinarians are able to provide accurate estimates before treatment.

Aside from it being too difficult, another counter-argument that will arise is that the medical industry has a unique moral responsibility to their patient. The claim is that, after all, how can anybody put a price on the wellness of a human being? That sounds nice, but it also tends to blind people from the reality that the medical industry is a business and will put a price on that aforementioned wellness, even when the industry attempts to form an argument to the contrary. It is therefore only reasonable that they be held to the same consumer business standards that any other industry would be held to.

This alleged moral responsibility would be a much more reasonable claim if we adopted a healthcare system whereby all costs were fully covered or reimbursed. In that case it might not make sense to ever disclose costs to the patient. But that is only because they would truly be a patient, and not a paying customer. Of course that model does not exist within the country, nor is it practical for the obvious associated costs. Consequently, so long as the United States healthcare system continues to operate as a private industry (which I anticipate being the case), then like all other private industry, it should not be exempt from having to provide the customer with the associated costs before they are incurred. In the absence of this, there is simply no mechanism in place for even the most basic of checks and balances to exist. Medical practitioners, hospitals, and insurance companies are free to manipulate the bill without ever even involving the customer. Incidentally however, the customer is still the one responsible for this bill.

Still, doctors and other medical professionals do have one very valid reason for arguing why they must provide the most comprehensive medical care to all patients, regardless of any costs, and that is due to medical malpractice. Medical malpractice lawsuits have steadily escalated for years throughout most of the most of the United States and as of 2009 were responsible for over $30 billion in litigation alone. As a direct consequence, doctors spend tens of thousands and sometimes even hundreds of thousands of dollars annually on insurance policies protecting them against malpractice lawsuits. Naturally these costs are indirectly passed onto the patients through more expensive billing and other service cost increases. But the problem is not as simple as just paying for the doctor’s insurance premiums. Because doctors want to avoid being sued in the first place, and certainly want to have a defense for when they are, it winds up being in their personal interest to run every medical test conceivably possible. This often results in patients receiving expensive and unnecessary tests from state of the art medical equipment. While some more advanced screenings can undoubtedly detect malignancies that doctors perhaps would not be able to on their own, the increased chance of detection is generally insignificant when contrasted with the significantly higher costs that will be billed to insurance. In other words, a ninety-five percent accurate diagnosis at the cost of one dollar is more useful than a ninety-eight percent accurate diagnosis at the cost of one hundred dollars.

Those interested in reducing the quantity and variety of claims arising from medical malpractice are generally said to be seeking tort reform. Although the term has been received more attention in Congress over recent years, it is not always made entirely clear what tort law is and why the reforming of it could be beneficial. Tort law is simply the branch of law within the United States (and other common law countries) that involves a breach of a civil duty owed to someone else. Plaintiffs of such suits are generally seeking some type of monetary damages from the defendant or defendants. Each of the sub-branches within the scope of tort law has their own criteria that generally must be shown in order to prove a breach. When people are said to call for tort reform within the medical industry, they are usually implying that the criteria needed to show medical negligence should be modified so that frivolous claims are less likely to occur.

In 2003, the State of Texas created legislation to reform medical liability laws in an attempt to address the growing problem. That same year, medical license applications across the state rose from 2,561 to 4,041, an increase of almost 58%. This statistic is relevant in illustrating at least one of the direct benefits to having some type of tort reform. Unless we assume doctors began migrating to Texas just for the opportunity to practice medicine more carelessly, the unprecedented yearly increase shows how negatively our current legal system affects doctors. The State of California actually began addressing the problem as early as 1975 by passing the Medical Information Compensation Reform Act, otherwise known as MICRA. The state’s legislation, which is very similar to what Texas adopted in 2003, placed a number of fiscal caps on damages from medical malpractice suits.

Opponents of tort reform argue that increasing the burden of proof for medical negligence, or capping compensatory damages may not hold as many medical practitioners properly accountable for negligent acts. Statistically speaking, this is very likely true. Assuming that it were more difficult seek damages, or less lucrative for lawyers to pursue them, common sense would suggest that there would be less claims filed, and consequently more legitimate claims not investigated. But this is the type of balancing act that we need to consider very seriously. Nobody wants to see truly negligent claims wind up unresolved, nor should doctors be protected from the consequences of such incidents. But by not amending the very broad definition of negligence that medical practitioners can be sued for, we are only further jeopardizing our own healthcare system. So long as we continue forcing doctors to hold expensive insurance packages as protection from all too common frivolous suits, we can expect patients to continue paying for this through higher costs. Medicine is a science, and like all other sciences is not perfect in its application. It would benefit us as a society to comprehend this and to frown upon those who would seek to exploit minor mishaps for their own financial gain. Although it would take the leadership of Congress to actually begin drawing these lines, doing so would be to benefit of all society.

Finally, the United States needs more doctors. One of the simplest ways to address this problem would be for the government to create an incentive for students to seek a medical degree. A program like this would give students a full-ride through medical school. In exchange, they would be required to dedicate at least seven years of professional work to an accredited hospital as a general practitioner. Once this time period had expired, they would be free to practice medicine however they saw fit. This kind of reciprocal arrangement could be structured in any number of ways. For example, medical facilities could be granted full or even double tax deductions for privately establishing and managing the programs. Alternatively, debt-forgiveness programs could also be put into place. Once doctors completed their state obligation, their education debt would be forgiven in full. This latter type of program could be further administered through bonds, thus ensuring it remained solvent. However the funds were distributed, saturating the market with new waves of doctors would only help to reduce the increasing cost burden of healthcare. It would also have the ancillary benefit of not burdening students with an otherwise unmanageable level of debt.

In the years since I was involved in the motorcycle accident, I have had the pleasure of sharing my experience with hundreds of individuals from varying political and economic backgrounds. As a result, I have heard a wide range of responses to the situation I was in. Some have told me that my decision to leave the hospital was foolish, that I am not a doctor and should not have presumed to know the extent of my injuries. Others have told me that this was a sound decision and that if I was coherent enough to be mindful of the ensuing costs, then I was fully capable of determining where and how I should receive medical attention. But across the spectrum of responses, I have been consistently pleased to hear people express disgust for the situation and commend my effort of sticking to a principle amidst legitimate personal turmoil. I suspect that encouraging people to potentially jeopardize their own well being in order to make their point heard is generally frowned upon. But how else is a free society able to change its ways if it is unwilling to take action during difficult times? Anybody can succeed in favorable times. It is how we handle bouts of adversity that define us.

There are likely hundreds of simple and practical ideas just like those in this section that could be implemented in relatively short periods of time to help strengthen and improve the healthcare of the United States. But one thing is for certain, so long as the health insurance companies, pharmaceutical companies, and politicians remain in cahoots, the price of healthcare will unquestionably continue to rise. Americans should not expect this type of behavior is going to be changed just on good fortune and happenstance, nor is the drive to increase profit margins likely to disappear.

The United States was founded on the idea that people should not have to sit idly by and merely hope for the best. They reserve the right at all times to stand up and demand change. And when that fails, it is the responsibility of every American to take action and to stand up for the collective good of the entire nation. The rich must enable the poor, the educated must defend the illiterate, and those who can lead must speak out for those who cannot. If the American people would be willing to stand up for what is right and refuse to participate in systems that so clearly favor corporate and political interests, that collective will would be virtually unstoppable. This is how the healthcare system of the United States will return to greatness, not by playing the victims of special interests and expecting politicians will dictate what is right.
Window Resealing Experiment
June 14th, 2012 | View Post
One of the problems we've had to deal with are some leaky windows. This problem was unfortunately made clear to us about a month ago after a solid week of storms rolled through. The coach portion of the bus has 12 square windows, 1 large rectangular window in the rear, and 2 convex port hole windows towards the front. Of those, at least 4 of the square windows leak pretty significantly as does the large rectangular one. A few of the other ones only let in a little moisture in a torrential downpour.

But in keeping with the restoration, the plan has been to go ahead and reseal all of them. We went ahead and completed one of them this evening just to get a feel for how long the process would take. Although it took us about an hour to do it, I think we could probably do them all at once and spend maybe 20 minutes per window, still about a 6 hour project.

In our case, the inside bolts holding the window frame in are about 30 years old so we went ahead and replaced all of them with machine screws from Austin Bolt Company. The new screws actually make the interior much nicer with their shininess.

Tools necessary:
  • 1/4" Socket and Phillips Screwdriver
  • Butyl Tape
  • Putty Knife
  • Razor Blades
  • Rubber Gloves
  • Silicon Caulk
  • Caulk Gun
  • Cloth or Paper Towels (excess Caulk)

The side of the bus with the first window removed.

Caroline using a putty knife to remove all of the old sealant tape from the window frame.

Caroline applying the butyl tape around the perimeter of the window opening. The corners were a little trickier to do.

With the window back in place, we just had to cut the excess butyl tape off. The 2" width I purchased was WAY too much, but I didn't know how far in the seal went. One inch would have been just fine, but fortunately it cuts very easily with a razor blade.

Finally all that was left was to seal the edges with some clear silicon sealant. Once it dries, this window should be good for another 30 years.

Simple Podcast Manager v1.1
May 30th, 2012 | View Post
The Simple Podcast manager is a podcast manager designed to work specifically with iTunes. It has no bells and whistles, but allows one to quickly and easily put a new podcast online.

I actually built this project as a favor for Bill Burr a few years back. He had just started his now famous, Monday Morning Podcast, and needed a way to manage his podcasts. His audience eventually grew beyond the capacity that I could keep up with and so I suggested implementing a commercial solution. When we eventually stopped using the Podcast Manager in exchange for something else, I decided I'd go ahead and release it for public consumption. It comes with no guarantees or warranties, but it works well.

I've released it under the GPL license, so please do what you will with it.

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Bayesian Flooding and Facebook Manipulation
May 22nd, 2012 | View Post
For the past few months I've been conducting an open online experiment. It's really an extension of a seven-year project I've been working on, but this newer portion is exclusively focused on Facebook. The purpose of the experiment is to explore how much control a typical Facebook user has over his or her personal information online, not what is externally visible, but what is internally being analyzed. In other words, is it possible to manipulate the flow of information being collected for advertising and marketing purposes?

The consideration behind this idea is due to three basic realities:
  1. The advancement of online technology and communication is not going to slow down, much less stop. Social networking plays a vital role in this.
  2. In order to participate in society, one cannot simply hide from technology.
  3. There is a lucrative market for acquiring and selling private, personal information (demographics, lifestyle choices, spending habits, interests, etc.).

Over the past few years I've had dozens of people ask me if I thought they could remove themselves from the watchful eyes of Facebook. My answer is always no. The problem is that once the information has been collected, it will always be stored and associated with you. I have therefore devised a slightly different method for dealing with this problem. Rather than trying to hide information from Facebook, it may be possible simply to overwhelm it with too much information. While this may sound counter-intuitive, there is a well-known mathematical theorem that may in fact validate the idea.

Imagine if you were asked to look inside of a friend's pantry or cupboard for 30 seconds, and then to make a guess about their general diet. For most people this would be a pretty simple exercise and the results would probably be very accurate. But now imagine that when you peered inside, their pantry was magically the size of an entire grocery store and contained just as many products. Other than the fact that they weren't starving, what could you really report about this friend's diet? The amount of variation available would make the analysis very difficult. This is the basic idea.

Target and Teenage Pregnancy

Back in February of this year, Forbes released an article detailing how Target successfully determined that a teenage girl was pregnant before her father was able to. The girl had received coupons in the mail for a host of maternity items. This prompted her father to call Target's customer service department and complain how it was inappropriate to send a teenage girl such material. Target was quick to apologize, but a few days later the father actually wound up apologizing to Target noting that his daughter was indeed pregnant. The question is, how could Target possibly have known this?

Like most big-box stores, Target tracks everything that their customers purchase. According to the article, customers are assigned a "guest ID number, tied to their credit card, name, or email address that becomes a bucket that stores a history of everything they've bought and any demographic information Target has collected from them or bought from other sources". So not only does Target keep a history of what customers buy, but they purchase demographic information about these customers from other companies as well. Perhaps companies like Facebook.

They are then able to have programmers and statisticians analyze giant chunks of data and assemble patterns of consumer spending habits. In the case of Target, the statisticians noticed that women tend to stock up on health supplements in their first trimester, and unscented lotions in their second trimester. As it turns out, they claim to have about 25 products that they use to indicate a pregnancy score - the likeliness that a customer is pregnant. The article explains that when just four of those products are purchased by the same customer, the likeliness of them being pregnant is a whopping 87%.

It might sound a bit like witchcraft, but it's the type powerful of statistical analysis that can be done with such large data pools. Imagine the selling power a company like Facebook has when it comes to providing supplemental demographic information to a company like Target. Whether or not they do sell such information is a matter of their internal business practices, but the data they are regularly collecting is priceless. This provides them with a continued incentive to collect and store personal data about individuals.

Email Extrapolation

In 2004 I was working for an email marketing company. Naturally we were eager to analyze potential customers any way that we could, but often had little more to work with than their email address (incidentally these were typically acquired via some pseudo-scandalous online promotion). I began working independently on an interpretive email address analyzer and after leaving the company, had mixed success in marketing the product to other businesses. The relevance to this experience is how much can be ascertained just from a single email address, never mind the hoards of voluntary information associated with a Facebook profile.

The basic process would run an email address through a series of filters I had devised. Each filter would output how the email address scored against the particular filter. For example, say we wanted to analyze the gender of a user. If the email address reads, it's pretty likely it belongs to a female for the obvious reason that "Susan" is a female's name. The program would cross-reference a database of names and assign a probable score of the user being female. But consider a less obvious address like A different gender filter would extrapolate the word "steeler", cross reference a list of sports teams, and associate it with the Pittsburgh Steelers. It would then score the user as a male, albeit with much less certainty than the previous example. The logic being that females tend not to associate their email addresses with sports teams. There could be dozens of filters applied just to determine the likely gender of the person. And of course other filters would perform completely different tasks. In this case one would also extrapolate the "67" and interpret it as a birth year.

Without performing this kind of analysis we just have a customer email address. But with this analysis we potentially have a 45 year old male living in Pennsylvania who likes football. That's a lot of data to extract from a single address, even if it is speculative.

This type of analysis is certainly not always accurate, but it is statistically very relevant, and can greatly affect the usefulness of large datasets. More importantly, when we apply the analysis of these filters to other collected demographic information, the results tend to improve very significantly. When these methodologies are applied to tens of millions of customer records, the aggregate change in revenue can increase tremendously. Advertising to a 13-year-old female versus a 62-year-old man requires a pretty substantial change in advertising content. Simply knowing this is invaluable to a company.

If I was able to successfully extrapolate so much information just from an email address, think of how accurate Facebook can be with all of the information users provide them.

Bayesian Flooding

A look at Facebook's Advertising system.
Click for Full Size
Facebook no doubt uses methods similar to the two described above, but they also enjoy the luxury of collecting large amounts of personal data directly from users - this is exclusively what their service does. In turn, they're able to use the information collected to advertise to their users. If you've ever used their advertising system, you probably know just how powerful it is. The level of granularity and depth one is able to target for advertising purposes is far beyond the scope of Google. And yet this powerful advertising model may still suffer from a rather obvious Achilles' heel. For the time being at least, it appears to depend very heavily upon the honesty of its users.

This is where the experiment I have been working on comes directly into play.

Over the past several months I have entered a myriad of life-events to my Facebook profile using their new Timeline feature. Some of those life-events are true, and some of them are not. In my fictitious life I've explored a dozen different religions, had countless injuries and broken bones, suffered twice through cancer, been married, divorced, fathered children all around the world, and have even fought for numerous foreign militaries.

This is what I refer to as Bayesian Flooding, and to be perfectly honest, it's turned out to be a great deal of fun. My intent was to coin the term within the same sphere as Bayesian Filtering, a common method of filtering junk email by word analysis. Of course both terms pay homage to Thomas Bayes, a mathematician best known for Bayes' Theorem.

The basic formula describing Bayes' Theorem. It depicts the conditional probability of event A given event B has occurred.
Bayes' Theorem is a commonly applied mathematical formula used for calculating the conditional probability of some event given that some additional event has occurred, or that some additional knowledge has been gained. For example, if someone told you they had a nice conversation on a train, the probability it was a woman they spoke with is 50%. If they told you the person they spoke to was going to attend a quilt exhibition, it is far more likely than 50% it is a woman[1].

The probability of correctly assuming the gender increases because you have gained more information about the original problem. Mathematically speaking, you are now considering the probability that the person is a woman given that you know the person was attending a quilt exhibition; knitting, crocheting, and quilting are more typically associated as being female hobbies. An interesting quirk of Bayes' Theorem is that it heavily relies upon sexism, racism, ageism, and every other type of generalization imaginable in order to draw assumptions. This is not because it is somehow prejudiced, but rather because such categorizations can be shown to be statistically accurate. The key is to have accurate statistics about the topic being generalized. To borrow from the esteemed Sherlock Holmes, "You can never foretell what any one man will do, but you can say with precision what an average number will be up to." This is essentially the backbone of Bayes' Theorem.

When Facebook analyzes my profile and notices that I have participated in a dozen different religions over the past 30 years, their engine should make the assumption that I am interested in theology and various disciplines of spirituality. As a result, they're more likely to serve me ads and recommendations within this realm, perhaps for spiritual books, personal retreats, or the like. For a sizable majority of people, these assumptions and recommendations will be accurate and should result in a better click-through rate and ultimately more revenue. But the truth is that I'm an agnostic atheist and certainly couldn't care less about religious topics.

It might seem like childish anarchy, but there is a legitimate rationale behind wanting to fool the engine. As data analysis becomes more and more detailed (namely due to our world being digitally cataloged), companies are inventing coercive psychological tricks that manipulate consumers into spending more, plain and simple. The products aren't necessary getting better, rather the science of selling the products is. Advertisers argue there are benefits to more efficiently targeting customers, but I believe these benefits fail to acknowledge the downside consumers face. It's simply a matter of knowing far too much about a person while having the singular goal of acquiring their money. If consumer manipulation is harmless, I would have to strongly question why we condemn psychics for applying similar tricks, while at the same time congratulating the business world.

Beyond psychological manipulation, there are also legitimate privacy concerns that need to be taken into consideration, much like the case of the pregnant teen. If advertisements became completely personalized, it would be possible to learn virtually anything about someone just by observing what they were suggested to buy, never mind what they actually bought. Whether or not a teenager should be made to disclose her pregnancy to her father is a matter for a different debate. But I believe it's a pretty unanimous position that Target should not be involved at any level of the discussion.

There are dozens of very large players in this game at the moment, but Facebook and Google are most likely the two best-known. Even people who may not grasp the complexity of personal data collection probably still suspect they're being cataloged - and they're right. But an interesting difference with Facebook versus say, Google, is that I believe their data pool can be distorted without inhibiting one from using their site. If Facebook became the go-to source for private, personal information, and that information was flawed, it would potentially affect all other analysis of the individual as well.

The theoretical advantage a company like Google has is that it would extremely difficult to apply an idea like Bayesian Flooding to their model with any level of practicality. Google's paid advertising is primarily based upon the user's active search query. If you enter a false query, you'll get answers to questions unimportant to you; it would be a futile exercise. Conversely, and when you actually need to search for something, the ad engine would still be just as effective since it runs in real-time. This is especially true of services like Gmail. In order to flood a Gmail account, not only would you have to send non-sensible emails to contacts with some regularity (often referred to in this sense as Bayesian Poisoning), but recipients would have to reply in a similar manner. Of course the only reason one sends email in the first place is to exchange communication and thus the purpose of the tool would again be lost, at least in practical terms.

By contrast, applying Bayesian Flooding to a Facebook profile is quite trivial and in no way inhibits one from still enjoying the many facets of their service. The method only disturbs the advertising and recommendation model, not the actual tool. It is still possible to share photos, exchange stories and ideas, and comment on posts regardless of any superfluous details that happen to be associated with one's profile. What's the real harm if someone on Facebook thinks I spent two years in the Pakistani National Army so long as I can still share photos with them from my recent trip to Canada? With the release of their Timeline system, anybody is free to add such details, regardless of how accurate they are.

Now that Facebook has decided to become a publicly traded company, it seems to me this is a pretty significant detail shareholders are likely to begin questioning. It may even be one of the reasons as to why they have recently become so anxious to get people using their email services; such services are much more complicated to fool (as described via Google above). The more people that begin to use Facebook for day-to-day emailing and chatting, the more accurate and valuable each individual dossier becomes.

Results of the Experiment

Some of my current recommendations from the Facebook robot.
Thus far, my experiment seems to be producing exactly the results I had hypothesized it would. Whatever algorithm(s) Facebook uses to recommend pages is evidently picking up on my colorful assortment of life-changing events. This is a promising start for those interested in reducing what they're worth to Facebook as a human commodity.

Companies are willing to pay for advertisements because ads produce quantitative, measurable results. If one receives an advertisement that is irrelevant to them, the cost of that ad space has been wasted. If the cost of advertising outweighs the return on investment, companies tend to stop advertising. This is an oversimplification of the whole cycle, but illustrates the basic premise.

Of course there are numerous methods Facebook uses to provide recommendations and advertisements to people. Some are based on the 'likes' of Facebook friends, some are based on COOKIES from other sites, and I would imagine that some are even based on internal browsing history. So while it may not be possible to manipulate all of the personal information being collected about you, the Timeline feature can at least be used to manipulate it to some degree - at least per my own experimentation.

Incidentally I've also discovered numerous bugs in their system, most of them related to dates on the Timeline. Although Facebook does not allow you add life-events prior to your birth, they do permit you to include other people in your life-events that occurred before they were born. I'm sure Facebook will eventually fix this, but for the time being I suspect it makes their Bayesian analysis that much more inaccurate.

Algorithmic Corrections

It might be fair to ask if a company like Facebook would be able to adapt to something like Bayesian Flooding. The short answer is that yes, they most definitely would be able to. Data-mining companies can analyze all sorts of patterns illustrating how "normal people" tend to enter personal data. Once normal behavior patterns are established, it is not particularly difficult to flag outliers. Of course what Facebook might do with such outliers requires a bit of speculation.

At worst they could be banned for intentionally misusing the system. However, it seems this would be a little short-sighted as the user still carries a marketable value, perhaps just less of one. Instead I suspect they would be flagged to not receive certain kinds of advertisements thus not wasting advertisers money. After all, the company hosting the ad wants the product to sell as much as the company selling the product does. Why else would the advertising dollars continue to pour in?

If Facebook chose to implement filters to detect this type of Bayesian Flooding, people like myself would simply concoct new ways to further interfere with those filters, perhaps by adding events at a slower rate, or adding events more central to my actual life. Facebook would then try to correct those methods, and so on. This is how technological cat and mouse games get started, similar to fighting SPAM or attempting to prevent piracy. As a technological rule of thumb, every measure invented to curb a certain practice eventually has a counter-measure to circumvent it.

But having written that, there is an upside to those who take to Bayesian Flooding. I very sincerely doubt enough people will be interested in the idea to create a blip on Facebook's radar, much less change anything. That probably means those wishing to partake would find success in the idea.


While I'll definitely keep experimenting with their system, it does seem for the time being that people can directly affect what advertisements they receive simply by flooding their profile. The new Facebook Timeline feature makes this simple and even fun. And though the idea may appear petty to some people, those of us wishing to protect our privacy and avoid being cataloged by corporate America may find it beneficial to our cause.

If you have any comments or thoughts on this process, please feel free to contact me as always.