Reading the Entrails

I often come across arguments to the effect that humans aren't really unique or special, we're just one animal among all the others. I find this assertion, frankly, just silly. Every species is unique in some ways, of course, that's why we can classify them. But humans are highly unusual in very important ways. For example, the biomass of domesticated mammals exceeds that of all the other mammals on earth combined; and the biomass of domesticated poultry -- mostly chickens -- is three times the biomass of all other birds on earth.

This happened in part because of language, which is an absolutely unique human capacity that allows for an unparalleled degree of cooperation, and for the accumulation of knowledge and technological advancement over time. But what I want to talk about today is our very rich awareness of the future and out intense interest in it. We can't really say to what extent other creatures have foresight. Some mammals are affected by the death of relatives in ways that suggests they may be aware of their own mortality. Many engage in behaviors that are tied to future benefit, such as squirrels storing nuts, but whether there is any real awareness of the future associated with this we cannot say. 

Humans are entirely unique in the elaborate and flexible ways we plan for the future. Building a house requires the assumption that we're going to live in it, and we think carefully about the kind of environment we want to create, in the context of the expected climate, possible extreme weather or earthquakes, possible future children, and much more. Unlike birds or bees, we create an unlimited variety of houses depending on our individual desires, the available resources, and the future we anticipate.

But what struck me today is the problematic value of uncertain predictions. The prognosticators spent the past few days spouting alerts and warnings at us, even talking about roofs collapsing, because of a "high impact," "long duration," "powerful northeaster" with heavy, wet snow and screaming winds that was going to knock out power to tens of thousands of Connecticut customers. They did say that the deepest snow would be in the higher elevations of the northwest part of the state, but where I live they were predicting four to eight inches of snow and they stuck with that right to the end. The schools dismissed at noon yesterday because of the coming apocalypse. I just happened to need to go shopping and the grocery store was mobbed, people apparently fearing they would starve if they didn't strip the shelves of milk and eggs. Hundreds of events were cancelled, businesses closed, the snowplows geared up.

We got 12 hours of chilly rain. Total snow accumulation here was zero. No snow at all. There was a lot of snow farther north and  west, but they got the rain/snow line badly wrong. That we would get no snow at all was not within the range of uncertainty they presented. So the possible benefit of correct predictions has to be weighed against the harm that may come from wrong ones. 

 

The problem is compounded when predictions themselves affect the future.This is particularly evident in the economy. Investors are always trying to predict the future and obviously, many of their prophecies are self-fulfilling. If they think stocks will go down,  that's what happens. The reason for the recent bank failures is not, as Republicans ludicrously claim, because the banks had gay board members or diversity and inclusion policies, but because many of their depositors, all at once, started to fear that the banks might fail and went to withdraw their money. The banks' assets were illiquid, the result of incorrect predictions on the part of the bank managers, and they couldn't meet their obligations. 

Prediction is very problematic in medicine as well. Physicians' prognoses determine people's decisions about painful or expensive treatments, or foregoing treatment at all. I've decided to have cataract surgery but it's entirely possible that I'd be able to get by just fine with glasses for years. We had to make a guess and act on it. Right now people are filling out their NCAA basketball tournament brackets and hoping to win a few bucks in the office pool, but in case you didn't know the odds of filling out a perfect bracket are 1 in a number that exceeds the number of stars in the universe. (Or something like that, it's a really big number.)

I'm not saying we shouldn't make predictions. We have to. But we should be very reluctant to do so and keenly aware of the possibility of error. I think people generally have a bias toward too much confidence in prediction. Trust Yogi Berra on this one.

Wednesday Bible Study: Hit the snooze button

Thank the Lord, we're almost through Chronicles. Just a few more chapters to go. Jotham is mentioned very briefly in the Book of Kings, so that is not the source referred to at the end here. What is odd, however, is that the Chronicler usually refers to what appear to be two separate books, the book of the Kings of Judah and the book of the Kings of Israel. Here he refers to a single book, but it can't be the canonical Book of Kings because that does not include any additional detail about Jotham.

Of course we get the usual absurd amounts of tribute.

27 Jotham was twenty-five years old when he became king, and he reigned in Jerusalem sixteen years. His mother’s name was Jerusha daughter of Zadok. ² He did what was right in the eyes of the Lord, just as his father Uzziah had done, but unlike him he did not enter the temple of the Lord. The people, however, continued their corrupt practices. ³ Jotham rebuilt the Upper Gate of the temple of the Lord and did extensive work on the wall at the hill of Ophel. ⁴ He built towns in the hill country of Judah and forts and towers in the wooded areas.

⁵ Jotham waged war against the king of the Ammonites and conquered them. That year the Ammonites paid him a hundred talents^[a] of silver, ten thousand cors^[b] of wheat and ten thousand cors^[c] of barley. The Ammonites brought him the same amount also in the second and third years.

⁶ Jotham grew powerful because he walked steadfastly before the Lord his God.

⁷ The other events in Jotham’s reign, including all his wars and the other things he did, are written in the book of the kings of Israel and Judah. ⁸ He was twenty-five years old when he became king, and he reigned in Jerusalem sixteen years. ⁹ Jotham rested with his ancestors and was buried in the City of David. And Ahaz his son succeeded him as king.

Footnotes

1. 2 Chronicles 27:5 That is, about 3 3/4 tons or about 3.4 metric tons
2. 2 Chronicles 27:5 That is, probably about 1,800 tons or about 1,600 metric tons of wheat
3. 2 Chronicles 27:5 That is, probably about 1,500 tons or about 1,350 metric tons of barley

Ruling out

People who, for ideological reasons,  don't actually want to do what is necessary to solve the problem of excessive spending  on health care often claim that the real problem is the cost of malpractice insurance. So they propose "tort reform" as the solution. The argument is that it isn't just the direct cost of insurance that's to blame, but also that physicians practice "defensive medicine," ordering unnecessary tests and procedures, to avoid possible liability.

First, let's just get the extent of the problem, if any, out of the way. The best estimate is that liability costs -- including both components, insurance premiums and any defensive medicine that may be happening -- account for 2.4% of health care spending in the U.S. Even if it were eliminated entirely, it wouldn't make a dent in the difference between spending in the U.S. and the rest of the world, but of course medical liability exists in every other country as well and people who are harmed by negligence, incompetence or malice should be compensated. 

So no, if this is a problem at all it is not a big problem, at least not compared to our other problems. That is not to say, however, that the status quo is ideal. Medical procedures sometimes go awry and people are harmed, but they can't get compensation unless they can convince a jury that a physician's negligence caused the bad outcome. (And no, "frivolous" cases don't make it to a jury. A judge will throw them out first and for that reason lawyers won't normally take them.) That means a lot of people who are seriously injured, even permanently disabled, can't get a dime. 

A better way is to create a pool of money to compensate people who suffer iatrogenic harm (i.e. harm caused by medicine) and to set up a separate procedure to decide whether a physician bears responsibility and some action should be taken. That could range from retraining, to restricting scope of practice, to delicensure. Of course, if wee had universal health care people's medical expenses would be taken care of anyway so we'd only be talking about compensation for other losses, such as lost income or the need for supportive services. Again, this wouldn't save much money, if any, but it would take money away from lawyers and give it to people who need it, and it would be more fair and constructive.

But you know, socialism.

Sunday Sermonette: Do not mess with the guys who wrote this

The story of Uzziah, including his transgression and consequential leprosy, is told briefly in the Book of Kings, embedded in a much longer discussion of goings on in the northern kingdom at the time. The Chronicler as usual has no interest in the northern kingdom, but he has a great deal of interest in the prerogatives of the priesthood so he makes that the focus. There have been instances in the past when the priests have put kings in their place, although in the early part of the Deuteronomistic History kings sometimes made sacrifices and apparently it was okay.  The Chronicler wants to be very clear that kings cannot get away with usurping the role of the priesthood, even by burning incense, and that Yahweh agrees. The point is all the sharper because Uzziah gets a big build up to that point -- he's the most successful king since Jehoshaphat. But that doesn't earn him any slack when it comes to the temple.

The reference at the end is not to the canonical Book of Isaiah, which only mentions Uzziah in passing, but to some lost book. Since the existing Book of Isaiah was written much later than these events, perhaps around the same time as Chronicles, it could not add any historical reliability. I should mention once again that "leprosy" does not refer to the disease known by that name in modern times (now called Hansen's disease) but to what are probably understood to be several different dermatological conditions today. 

26 Then all the people of Judah took Uzziah,^[a] who was sixteen years old, and made him king in place of his father Amaziah. ² He was the one who rebuilt Elath and restored it to Judah after Amaziah rested with his ancestors.

³ Uzziah was sixteen years old when he became king, and he reigned in Jerusalem fifty-two years. His mother’s name was Jekoliah; she was from Jerusalem. ⁴ He did what was right in the eyes of the Lord, just as his father Amaziah had done. ⁵ He sought God during the days of Zechariah, who instructed him in the fear^[b] of God. As long as he sought the Lord, God gave him success.

⁶ He went to war against the Philistines and broke down the walls of Gath, Jabneh and Ashdod. He then rebuilt towns near Ashdod and elsewhere among the Philistines. ⁷ God helped him against the Philistines and against the Arabs who lived in Gur Baal and against the Meunites. ⁸ The Ammonites brought tribute to Uzziah, and his fame spread as far as the border of Egypt, because he had become very powerful.

⁹ Uzziah built towers in Jerusalem at the Corner Gate, at the Valley Gate and at the angle of the wall, and he fortified them. ¹⁰ He also built towers in the wilderness and dug many cisterns, because he had much livestock in the foothills and in the plain. He had people working his fields and vineyards in the hills and in the fertile lands, for he loved the soil.

¹¹ Uzziah had a well-trained army, ready to go out by divisions according to their numbers as mustered by Jeiel the secretary and Maaseiah the officer under the direction of Hananiah, one of the royal officials. ¹² The total number of family leaders over the fighting men was 2,600. ¹³ Under their command was an army of 307,500 men trained for war, a powerful force to support the king against his enemies. ¹⁴ Uzziah provided shields, spears, helmets, coats of armor, bows and slingstones for the entire army. ¹⁵ In Jerusalem he made devices invented for use on the towers and on the corner defenses so that soldiers could shoot arrows and hurl large stones from the walls. His fame spread far and wide, for he was greatly helped until he became powerful.

¹⁶ But after Uzziah became powerful, his pride led to his downfall. He was unfaithful to the Lord his God, and entered the temple of the Lord to burn incense on the altar of incense. ¹⁷ Azariah the priest with eighty other courageous priests of the Lord followed him in. ¹⁸ They confronted King Uzziah and said, “It is not right for you, Uzziah, to burn incense to the Lord. That is for the priests, the descendants of Aaron, who have been consecrated to burn incense. Leave the sanctuary, for you have been unfaithful; and you will not be honored by the Lord God.”

¹⁹ Uzziah, who had a censer in his hand ready to burn incense, became angry. While he was raging at the priests in their presence before the incense altar in the Lord’s temple, leprosy^[c] broke out on his forehead. ²⁰ When Azariah the chief priest and all the other priests looked at him, they saw that he had leprosy on his forehead, so they hurried him out. Indeed, he himself was eager to leave, because the Lord had afflicted him.

²¹ King Uzziah had leprosy until the day he died. He lived in a separate house^[d]—leprous, and banned from the temple of the Lord. Jotham his son had charge of the palace and governed the people of the land.

²² The other events of Uzziah’s reign, from beginning to end, are recorded by the prophet Isaiah son of Amoz. ²³ Uzziah rested with his ancestors and was buried near them in a cemetery that belonged to the kings, for people said, “He had leprosy.” And Jotham his son succeeded him as king.

Footnotes

1. 2 Chronicles 26:1 Also called Azariah
2. 2 Chronicles 26:5 Many Hebrew manuscripts, Septuagint and Syriac; other Hebrew manuscripts vision
3. 2 Chronicles 26:19 The Hebrew for leprosy was used for various diseases affecting the skin; also in verses 20, 21 and 23.
4. 2 Chronicles 26:21 Or in a house where he was relieved of responsibilities

Why we don't get what we pay for

Before I take up the subject of this post, a note about commenting. I wish I could publish more comments but most of them are ridiculous or off topic. For example, I wrote a post about Kanye West. He was the subject of the post. It was about him. And I get a comment to the effect of Why won't I talk about Black antisemitism? WTF? I post about the high cost of health care in the U.S. and I get a comment about total federal revenues and the federal budget deficit. BTW, obviously federal revenues will generally increase over time because the economy and the population grow. Also you have to adjust for inflation. But that's all irrelevant, it isn't what we're talking about right now. You can see in the side bar that off topic comments will not be punished. I'm actually fairly liberal about that, but if you're deliberately being off topic just to be annoying it ain't gonna happen. Also, if you're banned, you're banned, so give it up.

To understand why we pay more for medical services than the rest of the world, and why we get less for it, we need to take both sides of the question separately. We pay more because of the way we finance the industry. Here are the major bullet points.

1.      Administrative costs: The U.S. healthcare system has a complex administrative structure, which adds to the overall cost of healthcare.

2.      Fee-for-service billing: The U.S. healthcare system often uses a fee-for-service billing model, which incentivizes healthcare providers to order more tests and procedures, thereby driving up the cost of care.

3.      Limited competition: In many parts of the U.S., there is limited competition among healthcare providers, which can lead to higher prices for services.

4.      Drug prices: The high cost of prescription drugs in the U.S. is a major factor driving up the cost of healthcare.

 

These moving parts work together. Health care in the U.S. is paid for by innumerable entities, mostly private insurance companies. (Even public funds -- Medicare and Medicaid -- are usually passed through private insurance companies that actually pay doctors and hospitals.) That means there are high administrative costs on both sides. The insurance companies pay profits to their shareholders, big salaries to their executives, and spend money on marketing. Traditional Medicare, in which the government reimburses providers directly, is much more efficient - only 2 or 3% in administrative costs, compared with 15% or more for private insurers. On the other side, providers need to spend a lot of money figuring out to bill many different payers, that have different rules about what they will pay for and pay different amounts. They also spend money figuring out how to game those systems and squeeze the most they can out of the various payers.  

 

Fee for service billing means that providers get paid to do things to you, not to get results. Since they're the experts, and you don't know what you really need, their bias is to just do more stuff, even if it's low value or even probably bad for you. But that also means they have to do the above, i.e. figure out who to bill and how to bill them for the most. And in many parts of the country, there just isn't a lot of choice of hospitals or providers, which means the payers don't have a lot of leverage. Drug prices are higher in the U.S. than in the rest of the world because the pharmaceutical industry is politically powerful and they have gotten politicians to create a regulatory system that restricts competition and let's them charge as much as they can get. If there's only one manufacturer, and you need the drug or you'll die, and they're charging a quarter of a million dollars for it, they're often gonna get that much.

None of this pertains in civilized countries. Next up: why we're healthy, why we're sick, why we live and why we die.

Wednesday Bible Study: A shaggy dog tale

(Posting late today because I had a meeting all morning.) 

 

Portions of this story are told in 2 Kings 14 but it seems to come largely from a different source, or in this case sources, the lost Chronicles of the Kings of Judah and Chronicles of the Kings of Israel. Amaziah's big mistake is to get involved with the northern kingdom, which is out of favor with the big guy in the sky, and that seems to be the main point of this. Why the Chronicler is so obsessed with trashing the northern kingdom is hard to fathom since it had long since ceased to exist by the time he wrote this. But whatever.

25 Amaziah was twenty-five years old when he became king, and he reigned in Jerusalem twenty-nine years. His mother’s name was Jehoaddan; she was from Jerusalem. ² He did what was right in the eyes of the Lord, but not wholeheartedly. ³ After the kingdom was firmly in his control, he executed the officials who had murdered his father the king. ⁴ Yet he did not put their children to death, but acted in accordance with what is written in the Law, in the Book of Moses, where the Lord commanded: “Parents shall not be put to death for their children, nor children be put to death for their parents; each will die for their own sin.”^[a]

⁵ Amaziah called the people of Judah together and assigned them according to their families to commanders of thousands and commanders of hundreds for all Judah and Benjamin. He then mustered those twenty years old or more and found that there were three hundred thousand men fit for military service, able to handle the spear and shield. ⁶ He also hired a hundred thousand fighting men from Israel for a hundred talents^[b] of silver.

⁷ But a man of God came to him and said, “Your Majesty, these troops from Israel must not march with you, for the Lord is not with Israel—not with any of the people of Ephraim. ⁸ Even if you go and fight courageously in battle, God will overthrow you before the enemy, for God has the power to help or to overthrow.”

⁹ Amaziah asked the man of God, “But what about the hundred talents I paid for these Israelite troops?”

The man of God replied, “The Lord can give you much more than that.”

¹⁰ So Amaziah dismissed the troops who had come to him from Ephraim and sent them home. They were furious with Judah and left for home in a great rage.

¹¹ Amaziah then marshaled his strength and led his army to the Valley of Salt, where he killed ten thousand men of Seir. ¹² The army of Judah also captured ten thousand men alive, took them to the top of a cliff and threw them down so that all were dashed to pieces.

¹³ Meanwhile the troops that Amaziah had sent back and had not allowed to take part in the war raided towns belonging to Judah from Samaria to Beth Horon. They killed three thousand people and carried off great quantities of plunder.

¹⁴ When Amaziah returned from slaughtering the Edomites, he brought back the gods of the people of Seir. He set them up as his own gods, bowed down to them and burned sacrifices to them. ¹⁵ The anger of the Lord burned against Amaziah, and he sent a prophet to him, who said, “Why do you consult this people’s gods, which could not save their own people from your hand?”

¹⁶ While he was still speaking, the king said to him, “Have we appointed you an adviser to the king? Stop! Why be struck down?”

So the prophet stopped but said, “I know that God has determined to destroy you, because you have done this and have not listened to my counsel.”

¹⁷ After Amaziah king of Judah consulted his advisers, he sent this challenge to Jehoash^[c] son of Jehoahaz, the son of Jehu, king of Israel: “Come, let us face each other in battle.”

¹⁸ But Jehoash king of Israel replied to Amaziah king of Judah: “A thistle in Lebanon sent a message to a cedar in Lebanon, ‘Give your daughter to my son in marriage.’ Then a wild beast in Lebanon came along and trampled the thistle underfoot. ¹⁹ You say to yourself that you have defeated Edom, and now you are arrogant and proud. But stay at home! Why ask for trouble and cause your own downfall and that of Judah also?”

²⁰ Amaziah, however, would not listen, for God so worked that he might deliver them into the hands of Jehoash, because they sought the gods of Edom. ²¹ So Jehoash king of Israel attacked. He and Amaziah king of Judah faced each other at Beth Shemesh in Judah. ²² Judah was routed by Israel, and every man fled to his home. ²³ Jehoash king of Israel captured Amaziah king of Judah, the son of Joash, the son of Ahaziah,^[d] at Beth Shemesh. Then Jehoash brought him to Jerusalem and broke down the wall of Jerusalem from the Ephraim Gate to the Corner Gate—a section about four hundred cubits^[e] long. ²⁴ He took all the gold and silver and all the articles found in the temple of God that had been in the care of Obed-Edom, together with the palace treasures and the hostages, and returned to Samaria.

²⁵ Amaziah son of Joash king of Judah lived for fifteen years after the death of Jehoash son of Jehoahaz king of Israel. ²⁶ As for the other events of Amaziah’s reign, from beginning to end, are they not written in the book of the kings of Judah and Israel? ²⁷ From the time that Amaziah turned away from following the Lord, they conspired against him in Jerusalem and he fled to Lachish, but they sent men after him to Lachish and killed him there. ²⁸ He was brought back by horse and was buried with his ancestors in the City of Judah.^[f]

Footnotes

1. 2 Chronicles 25:4 Deut. 24:16
2. 2 Chronicles 25:6 That is, about 3 3/4 tons or about 3.4 metric tons; also in verse 9
3. 2 Chronicles 25:17 Hebrew Joash, a variant of Jehoash; also in verses 18, 21, 23 and 25
4. 2 Chronicles 25:23 Hebrew Jehoahaz, a variant of Ahaziah
5. 2 Chronicles 25:23 That is, about 600 feet or about 180 meters
6. 2 Chronicles 25:28 Most Hebrew manuscripts; some Hebrew manuscripts, Septuagint, Vulgate and Syriac (see also 2 Kings 14:20) David

Health care economics 101

I don't actually like the term "health care" (or healthcare, sometimes it's even one word). That implies that it's about two things -- health and care -- whereas it's more about disease than health and more about money than care. In fact, the money part is very notable: it's really expensive, more and more so all the time:

 

 

Right now it's at about 18% of GDP. Well, you might say, that's because medical technology has gotten better and better, there's good reason to spend more on it. There is some truth to that, but then there's this:

 

 

Hmm. We're spending twice as much as the average wealthy country, and three times as much as the Japanese. Well, you may say, we have the highest quality health care in the world, that's why it costs more. Hmm. 

 

Whatever the quality of our health care, it isn't managing to keep us alive as well as that cheaper health care in other countries. As a matter of fact Japan, with the lowest spending, has the highest life expectancy of any country on earth. So whatever we're doing, we aren't spending our money wisely. We'll have more to say about this.