Fixing Healthcare: Some Introductory Thoughts

This is not an easy article to write. Healthcare is a complex problem that defies simple or neat or rapid solutions. It requires that we ask hard questions and work out difficult options. At the root of it are two ‘simple’ questions: how much is being healthy worth to you? Once you answer that, the second question is this: who should determine what your healthcare coverage ‘looks’ like?

So, How do we fix healthcare? It’s a question everyone seems to be asking these days. But the first thing we need to ask is: is this the right question? Is healthcare really broken? The fact is that for more than 85% of our citizens we already have the best healthcare in the world. So, what are we trying to ‘fix?’ Unfortunately, in most cases what we are hearing from politicians is the answer they think some – but not all of their constituents want, not because it will necessarily provide the best quality healthcare, but because it provides the answer they want to hear.

Let’s start at the top: What do we want? There are any number of options and choosing any one necessarily comes with limits. Do we want the best possible healthcare for the most people? How do we define best? Is this irrespective of cost? Do we want Universal Healthcare, that is, comprehensive healthcare for every citizen? Do we want Low cost Universal Healthcare, that is, comprehensive and responsive health care for every citizen, at some price lower than the price someone believes is too high? Or do we want ‘nearly Universal’ healthcare, that is, a system that will get 98 or 99% of everyone in the country healthcare, because 100% may be too hard? Or do we simply want cheaper healthcare? Should the system cover illegal immigrants? Should the system allow for elective surgery? Who defines elective? In fact, who defines all of the variables?

These points are simple, but critical. Because what the wags insist that we all really want is comprehensive, responsive, low cost, government controlled health care. And there is no such thing. It is a truism that we all want to pay less – for everything. That is hardly cause for any action by anyone in government. And no government anywhere has ever been able to provide both comprehensive and responsive low cost healthcare, never mind at the same time providing an environment that promotes further advancements in treatments.

So, let’s start by trying to define healthcare. Seems easy enough. But does ‘healthcare’ cover all preventative care? Should healthcare cover lifestyle issues? Does healthcare cover elective surgeries? (Again, define ‘elective.’) Private health insurance plans ask if you are a tobacco user. If the government is overseeing health insurance should the government have the authority to raise your rates if you smoke? And where does that stop? If you drink? If you eat fast food? If you engage in certain types of behavior (ride a motorcycle, skydive, etc.?) If you have a family history of heart disease or certain types of cancer? And where does government get that authority? Does an implied authority to provide healthcare, because it is not explicit in the Constitution, override the explicit individual rights of the Bill of Rights and other amendments? Or would these constitute de facto bills of attainder?

Instead of trying to define what we mean by various types of healthcare, let’s just look at the most easily measured piece of this entire issue – cost.

There are a host of variables that contribute to the cost of healthcare. The major items include: the number of physicians; the number of nurses; the number of hospital beds; the proliferation of new (and expensive) diagnostic devices (CAT scans, MRIs, etc.); improvements in medical techniques that allow more extensive treatments of various diseases and injuries; the cost to develop new drugs and treatments; the increase in specialization in medicine; the increase in life expectancy (we are living longer); the increase in the average age of the population; the high costs of insurance – particularly malpractice insurance; the increase in the size of federal, state and local government organizations that distribute, oversee or monitor healthcare; a change in the collective expectation when we visit the doctor’s office (we want more out of the doctor).

Unfortunately, it is not sufficient to simply change any one of those items to change the cost of health care. For example, while the US has nearly 800,000 MDs, the increase in specialization, a result both of the growth of the science of medicine and an outcome of numerous lawsuits and higher malpractice insurance premiums (routinely over $100,000 per year for some specialists), has pushed doctors to refer their patients to specialists rather than make a diagnosis themselves. The patient then sees two doctors vice one, is run through several batteries of tests and costs continue to climb.

But, the end result is that the patient receives higher quality care. Which is, in fact, what the patient wants. While much has been made over the fact that the US spends 1/7th of its GNP on healthcare, I’ve never seen anyone ask the public if they would be willing to be ‘less well’ if it saved them a little money. In short, I suspect, though it is impossible to definitively prove, we spend as much as we do on health care because we can. We want to be in the best health we can be, and we are willing to pay for it. We would like to pay less, but that is truly a meaningless statement: we would all like to pay less for everything. (This also has implications in understanding the intentions of many (but not all) who have no health insurance: they choose to have no coverage because they perceive themselves to be young enough and healthy enough to defer such coverage.)

Of course, while life expectancy has continued to improve over the past 100 years, the major changes have been as a result of basic medicine: vaccines against certain diseases, the elimination of certain diseases, the nearly universal availability of certain types of care, improvements in diets and sanitary conditions (to include our food and water.) While we all want the best possible care, and while there certainly is a concern about catastrophic care, the fact is that giving everyone in the US comprehensive healthcare – however it is paid for – will not result in a substantial increase in life expectancy or quality of life. Certain technologies and discoveries might do that, but current technology won’t.

There is, in fact, no way to correlate your healthcare expenses and your life expectancy. You might spend $1 million dollars on healthcare over the course of 65 or 70 years, or $100,000. No one will ever know how much longer you would have lived or how much more ‘quality of life’ you would have had if you had spent 5% more or 10% more, or even 1000% more.

But, the question facing us now is whether you want to make that decision yourself or whether you want someone else to make that decision. If you simply ‘redistribute’ healthcare – which is what will eventually happen under a government controlled plan – than you will be forced to answer this question because you will get 5% less healthcare. Will it mean a shorter life? A lower quality of life in your later years? In the end, you won’t get to decide, a functionary who you will likely never meet will write a set of standards and you will be forced to live with them. This is a crucial point: the Congress will pass legislation setting very broad standards and mandating certain types of coverage, but there is simply no way that a bill in Congress can cover specific situations. That will be left to the Department of Health and Human Services (HHS, the Executive Department that now overseas programs such as Medicaid and Medicare). HHS rules, regulations and policies will be set by bureaucrats, not by doctors, and certainly not by doctors who know you. Those rules and regulations will determine what kind of healthcare you receive.

That being said, is there a way to reduce medical costs so that more people can afford more healthcare? Remember, there are in fact only a few paths we can pursue: we can increase the ‘supply’ of healthcare – that is, more doctors, nurses, beds, etc.; we can reduce the demand (ration healthcare either by direct government dictate, or by government controlled (rising) prices); we can create new medical technologies that dramatically lower the cost of individual care (which consists of hoping a miracle occurs); or, to be truly draconian and evil, we can eliminate sick people. There are no other ‘paths’ that will change the equation for healthcare for the average citizen.

Therefore, the simple answer to the question ‘is there a way to reduce healthcare costs’ is: not in the short term. In the long term the only real options are either: ration healthcare: the 85% of the people already with healthcare would all get a little less, so that the other 15% could have some; or increase the supply.

If the government is going to pay for it, the government must generate the money to pay for the healthcare and government does that through taxation. But increased taxation does not generate an increase in the total amount of healthcare. The fact is that the government plan is not about creating more healthcare; it is about controlling healthcare. So, the size of the ‘pie’ remains the same (in fact, the ‘pie’ would probably shrink a bit because of the added costs of government bureaucracy). But, instead of being used by 255 million Americans, the ‘pie’ will be used by 314 million Americans (303 million citizens and 11 million illegal immigrants). The 255 million people who now receive 100% of the healthcare (except emergency care), will now receive 81% of the healthcare.

(A word on actual costs: the US spends roughly $2 trillion per year on health care. If the Federal Government directs that either you buy into a private healthcare insurance program or a government one (four of the five bills in Congress provide a government insurance plan), the Federal Government needs to pay for that insurance. If 255 million people consume $2 trillion in healthcare per year, the 56 million more that would be covered under these new programs would cost another $400 to 500 million per year, not the $1 trillion over ten years that has been claimed by those in Washington.)

The other option, the one we should all be calling for, is: put in motion plans that would increase the amount of healthcare available, which is not what the federal government is talking about. Such a plan would require government incentives (at the federal and state level) for medical and nursing schools to produce more doctors and nurses – particularly more general practitioners (GPs); increasing the number of GPs and Nurse Practitioners would allow more medical practice to take place within a context of doctors and nurses who know their patients for many years and can provide more accurate and complex diagnoses earlier – thereby focusing effort, if not reducing costs; place some restrictions or limits on malpractice lawsuit settlements to help curtail the costs of malpractice insurance; provide tax incentives to drug and medical equipment developers to speed the development of new treatments and pharmaceuticals; provide funding (and tax incentives) to promote the development of new technologies that will allow for ever more distributed healthcare (allowing a patient to benefit from the expertise of an MD electronically, as is now done in such areas as interpreting an MRI); press state and local governments to provide further tax breaks that would allow the building of more hospitals (or the expansion of existing ones), thereby providing more hospital beds.

The fact is that currently the Federal government does not create healthcare and has no plan to do so. Forcing everyone who can afford to, to buy healthcare insurance does not begin to address the fundamental issue of increasing the supply of available healthcare. (And if the past is any indication at all, employers will pay penalties and let their workers default to government provided insurance to avoid all the complications. Providing federal government payment (insurance) for those who can’t or won’t buy insurance (to include 11 million plus illegal immigrant) will cost at least several hundred billion dollars more per year. Meanwhile, government regulation will prevent any changes in pricing and provide no incentive to increase the supply of healthcare.

Despite all the talk about healthcare costing too much, no one wants less healthcare. The only reasonable approach is to create more healthcare, something government can best do by providing basic incentives and then getting out of the way, and accepting that as the overall availability increases, and the technology continues to improve, the costs will eventually begin to flatten out.

40 Anniversary

40 years ago today man first stepped on the Moon. They were able to accomplish this because they, and a great many others, embraced the best that is in us: they reached beyond their grasp, they strove to do what was said to be impossible, they aimed for a goal that was greater than any that had come before. This spirit of adventure and the conquest of the frontier is the very core of the survival of mankind. They were successful as a result of the efforts of literally thousands of men and women, and though only 12 men actually made it to the surface, each of these thousands share in the success, though we don’t remember their names.

Nevertheless, there are a few figures who stand out. One is President Kennedy, who galvanized the nation and the world and focused the efforts of those thousands with his leadership into space. Below is that speech. Following it is the list of all the Apollo astronauts, to include the three men of Apollo 1 who died in the fire on the launch pad.


PRESIDENT JOHN KENNEDY'S RICE STADIUM MOON SPEECH
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September 12, 1962

President Pitzer, Mr. Vice President, Governor, Congressman Thomas, Senator Wiley, and Congressman Miller, Mr. Webb, Mr. Bell, scientists, distinguished guests, and ladies and gentlemen:

I appreciate your president having made me an honorary visiting professor, and I will assure you that my first lecture will be very brief.

I am delighted to be here and I'm particularly delighted to be here on this occasion.

We meet at a college noted for knowledge, in a city noted for progress, in a State noted for strength, and we stand in need of all three, for we meet in an hour of change and challenge, in a decade of hope and fear, in an age of both knowledge and ignorance. The greater our knowledge increases, the greater our ignorance unfolds.

Despite the striking fact that most of the scientists that the world has ever known are alive and working today, despite the fact that this Nation¹s own scientific manpower is doubling every 12 years in a rate of growth more than three times that of our population as a whole, despite that, the vast stretches of the unknown and the unanswered and the unfinished still far outstrip our collective comprehension.

No man can fully grasp how far and how fast we have come, but condense, if you will, the 50,000 years of man¹s recorded history in a time span of but a half-century. Stated in these terms, we know very little about the first 40 years, except at the end of them advanced man had learned to use the skins of animals to cover them. Then about 10 years ago, under this standard, man emerged from his caves to construct other kinds of shelter. Only five years ago man learned to write and use a cart with wheels. Christianity began less than two years ago. The printing press came this year, and then less than two months ago, during this whole 50-year span of human history, the steam engine provided a new source of power.

Newton explored the meaning of gravity. Last month electric lights and telephones and automobiles and airplanes became available. Only last week did we develop penicillin and television and nuclear power, and now if America's new spacecraft succeeds in reaching Venus, we will have literally reached the stars before midnight tonight.

This is a breathtaking pace, and such a pace cannot help but create new ills as it dispels old, new ignorance, new problems, new dangers. Surely the opening vistas of space promise high costs and hardships, as well as high reward.

So it is not surprising that some would have us stay where we are a little longer to rest, to wait. But this city of Houston, this State of Texas, this country of the United States was not built by those who waited and rested and wished to look behind them. This country was conquered by those who moved forward--and so will space.

William Bradford, speaking in 1630 of the founding of the Plymouth Bay Colony, said that all great and honorable actions are accompanied with great difficulties, and both must be enterprised and overcome with answerable courage.

If this capsule history of our progress teaches us anything, it is that man, in his quest for knowledge and progress, is determined and cannot be deterred. The exploration of space will go ahead, whether we join in it or not, and it is one of the great adventures of all time, and no nation which expects to be the leader of other nations can expect to stay behind in the race for space.

Those who came before us made certain that this country rode the first waves of the industrial revolutions, the first waves of modern invention, and the first wave of nuclear power, and this generation does not intend to founder in the backwash of the coming age of space. We mean to be a part of it--we mean to lead it. For the eyes of the world now look into space, to the moon and to the planets beyond, and we have vowed that we shall not see it governed by a hostile flag of conquest, but by a banner of freedom and peace. We have vowed that we shall not see space filled with weapons of mass destruction, but with instruments of knowledge and understanding.

Yet the vows of this Nation can only be fulfilled if we in this Nation are first, and, therefore, we intend to be first. In short, our leadership in science and in industry, our hopes for peace and security, our obligations to ourselves as well as others, all require us to make this effort, to solve these mysteries, to solve them for the good of all men, and to become the world's leading space-faring nation.

We set sail on this new sea because there is new knowledge to be gained, and new rights to be won, and they must be won and used for the progress of all people. For space science, like nuclear science and all technology, has no conscience of its own. Whether it will become a force for good or ill depends on man, and only if the United States occupies a position of pre-eminence can we help decide whether this new ocean will be a sea of peace or a new terrifying theater of war. I do not say the we should or will go unprotected against the hostile misuse of space any more than we go unprotected against the hostile use of land or sea, but I do say that space can be explored and mastered without feeding the fires of war, without repeating the mistakes that man has made in extending his writ around this globe of ours.

There is no strife, no prejudice, no national conflict in outer space as yet. Its hazards are hostile to us all. Its conquest deserves the best of all mankind, and its opportunity for peaceful cooperation may never come again. But why, some say, the moon? Why choose this as our goal? And they may well ask why climb the highest mountain? Why, 35 years ago, fly the Atlantic? Why does Rice play Texas?

We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.

It is for these reasons that I regard the decision last year to shift our efforts in space from low to high gear as among the most important decisions that will be made during my incumbency in the office of the Presidency.

In the last 24 hours we have seen facilities now being created for the greatest and most complex exploration in man's history. We have felt the ground shake and the air shattered by the testing of a Saturn C-1 booster rocket, many times as powerful as the Atlas which launched John Glenn, generating power equivalent to 10,000 automobiles with their accelerators on the floor. We have seen the site where the F-1 rocket engines, each one as powerful as all eight engines of the Saturn combined, will be clustered together to make the advanced Saturn missile, assembled in a new building to be built at Cape Canaveral as tall as a 48 story structure, as wide as a city block, and as long as two lengths of this field.

Within these last 19 months at least 45 satellites have circled the earth. Some 40 of them were "made in the United States of America" and they were far more sophisticated and supplied far more knowledge to the people of the world than those of the Soviet Union.

The Mariner spacecraft now on its way to Venus is the most intricate instrument in the history of space science. The accuracy of that shot is comparable to firing a missile from Cape Canaveral and dropping it in this stadium between the 40-yard lines.

Transit satellites are helping our ships at sea to steer a safer course. Tiros satellites have given us unprecedented warnings of hurricanes and storms, and will do the same for forest fires and icebergs.

We have had our failures, but so have others, even if they do not admit them. And they may be less public.

To be sure, we are behind, and will be behind for some time in manned flight. But we do not intend to stay behind, and in this decade, we shall make up and move ahead.

The growth of our science and education will be enriched by new knowledge of our universe and environment, by new techniques of learning and mapping and observation, by new tools and computers for industry, medicine, the home as well as the school. Technical institutions, such as Rice, will reap the harvest of these gains.

And finally, the space effort itself, while still in its infancy, has already created a great number of new companies, and tens of thousands of new jobs. Space and related industries are generating new demands in investment and skilled personnel, and this city and this State, and this region, will share greatly in this growth. What was once the furthest outpost on the old frontier of the West will be the furthest outpost on the new frontier of science and space. Houston, your City of Houston, with its Manned Spacecraft Center, will become the heart of a large scientific and engineering community. During the next 5 years the National Aeronautics and Space Administration expects to double the number of scientists and engineers in this area, to increase its outlays for salaries and expenses to $60 million a year; to invest some $200 million in plant and laboratory facilities; and to direct or contract for new space efforts over $1 billion from this Center in this City.

To be sure, all this costs us all a good deal of money. This year¹s space budget is three times what it was in January 1961, and it is greater than the space budget of the previous eight years combined. That budget now stands at $5,400 million a year--a staggering sum, though somewhat less than we pay for cigarettes and cigars every year. Space expenditures will soon rise some more, from 40 cents per person per week to more than 50 cents a week for every man, woman and child in the United Stated, for we have given this program a high national priority--even though I realize that this is in some measure an act of faith and vision, for we do not now know what benefits await us.

But if I were to say, my fellow citizens, that we shall send to the moon, 240,000 miles away from the control station in Houston, a giant rocket more than 300 feet tall, the length of this football field, made of new metal alloys, some of which have not yet been invented, capable of standing heat and stresses several times more than have ever been experienced, fitted together with a precision better than the finest watch, carrying all the equipment needed for propulsion, guidance, control, communications, food and survival, on an untried mission, to an unknown celestial body, and then return it safely to earth, re-entering the atmosphere at speeds of over 25,000 miles per hour, causing heat about half that of the temperature of the sun--almost as hot as it is here today--and do all this, and do it right, and do it first before this decade is out--then we must be bold.

I'm the one who is doing all the work, so we just want you to stay cool for a minute. [laughter]

However, I think we're going to do it, and I think that we must pay what needs to be paid. I don't think we ought to waste any money, but I think we ought to do the job. And this will be done in the decade of the sixties. It may be done while some of you are still here at school at this college and university. It will be done during the term of office of some of the people who sit here on this platform. But it will be done. And it will be done before the end of this decade.

I am delighted that this university is playing a part in putting a man on the moon as part of a great national effort of the United States of America.

Many years ago the great British explorer George Mallory, who was to die on Mount Everest, was asked why did he want to climb it. He said, "Because it is there."

Well, space is there, and we're going to climb it, and the moon and the planets are there, and new hopes for knowledge and peace are there. And, therefore, as we set sail we ask God's blessing on the most hazardous and dangerous and greatest adventure on which man has ever embarked.

Thank you.



The Apollo Crews

Apollo 1
Virgil "Gus" Grissom, Commander
Edward White, command module pilot

Roger Chaffee, lunar module pilot

Apollo 7
Walter Schirra, Jr, commander

Donn Eisele, command module pilot

Walter Cunningham, lunar module pilot

Apollo 8
Frank Borman, commander

James A. Lovell, command module pilot

William A. Anders, lunar module pilot

Apollo 9
Commander James McDivitt, commander
David Scott, command module pilot
Russell Schweickart, lunar module pilot

Apollo 10
Thomas P. Stafford, commander
John W. Young, command module pilot
Eugene A. Cernan, lunar module pilot

Apollo 11
Neil A. Armstrong, commander

Michael Collins, command module pilot

Edwin E. Aldrin, Jr., lunar module pilot

Apollo 12
Charles Conrad, Jr., commander
Richard F. Gordon, command module pilot

Alan L. Bean, lunar module pilot

Apollo 13
James A. Lovell, commander

John L. Swigert, Jr., command module pilot
Fred W. Haise, Jr., lunar module pilot

Apollo 14
Alan B. Shepard, Jr., commander

Stuart A. Roosa, command module pilot
Edgar D. Mitchell, lunar module pilot

Apollo 15
David R. Scott, commander

Alfred M. Worden, command module pilot

James B. Irwin, lunar module pilot

Apollo 16
John W. Young, commander

Thomas K. Mattingly II, command module pilot
Charles M. Duke, Jr., lunar module pilot

Apollo 17
Eugene A. Cernan, commander

Ronald E. Evans, command module pilot

Harrison H. Schmitt, lunar module pilot

A President's Duty

The President’s oath of office (and that of virtually everyone in the executive branch) calls for him to ‘preserve, protect and defend the Constitution of the United States.’ To accomplish this task the Presidents have been given a wide range of tools that run across the complete range of political, economic, legal and military means. In fact, the last twelve Presidents (since Truman) have had the ability to destroy large segments of humanity in order to ensure the survival of the Constitution and the nation it created and governs.

What has that got to do with the events of the day? Well, there seems to be a bit of angst over the issue of whether the US Government, specifically the CIA, should have been considering assassinating Usama bin Laden and other key members of al Qaeda.

The relevant law is a neat little piece of prose called ‘Executive Order 12333, as amended.’ The ‘as amended’ part is important as the Executive Order, first issued by President Reagan in on 4 December 1981, has been amended several times to keep it current. The Executive Order is unclassified and can be found on line. Literally, and I do mean literally, every member of the US Government, uniformed or civilian, who has been in any way associated with intelligence operations, collection or handling or processing receives training on the contents of the Executive Order.

The Executive Order states the specific policies that govern how the US will, and will not, conduct intelligence activities, in the broadest sense. It was drafted to tie together a series of loosely knit rules that had accumulated over the previous three decades and, in particular, stated firmly the policies of the US Government in regard to certain gray areas that had been of concern during the various Congressional hearings in the 1970s into intelligence community activities. One of the specific issues was assassination. Simply put, assassination is not allowed. (Executive Order 11905, signed out by President Ford in February of 1976 was the first Executive Order to specifically forbid assassination). The pertinent section of Executive Order 12333 – 2.11 – states:

“No person employed by or acting on behalf of the United States Government shall engage in, or conspire to engage in, assassination.”

Most of you are probably aware of the nuances of the law and will respond that there is an obvious way around this: this is an Executive Order and so it can be superceded by another Executive Order. Any President who wanted to have someone assassinated could simply sign a special Executive Order temporarily suspending or in some other way negating 12333, and then order the assassination. Technically, it is correct that any Executive Order can be suspended at will by a President, and every one of them has done so from time to time. The President can even do it secretly.

But, is it right?

Frankly, the current media and Congressional swirl over the CIA ‘plan’ to assassinate Usama bin Laden is, at best, bad farce, and misses the more important point. Are the people making this statement asserting that the President and the CIA should not have been trying to kill Usama bin Laden? Should the US be conducting this war with the proviso that if we do find them we shouldn’t drop a bomb on them? Killing our enemies in time of war (call it assassination if you wish) isn’t normally done with poisoned needles on the ends of umbrellas. It is, in fact, more likely to be a guided missile or some other precision weapon. The question we need to ask is there any meaningful use of the word ‘assassination’ in regard to one’s enemies during a hot war? Should the allies have deferred from bombing or shelling Berlin because of concern that Hitler or his ministers or members of the general staff might be killed (assassinated?)

This is not an argument for the President to begin to assassinate his opposition. God forbid. Executive Order 12333 is a sound document. But, the point of the ban on assassination centered (and centers) on the use of this activity to affect massive political change during the Cold War or, subsequently, without resorting to open conflict. In short, as in a wide range of Hollywood movies, a head of state or senior politician or head of some political movement is killed (assassinated) in order to bring about substantive political change. It is rightly considered a bad idea. Such considerations change once the US has gone to war. We are publicly committed not to simply bringing about political change vis-à-vis al Qaeda, we are trying to eliminate al Qaeda. We don’t want to rehabilitate the organization and turn it into a charity. We want to destroy it for all time. It is worth remembering that there were editorials from mainstream writers shortly after September 11th that said that the President would be justified in using nuclear weapons to eliminate al Qaeda’s threat to the US. But somehow trying to specifically kill Usama bin Laden and his lieutenants is wrong?

The fact is that the decision was made publicly and discussed publicly at the beginning of this war. Usama bin Laden was clearly and publicly targeted when US and allied forces went into Tora Bora. (Look up ‘the Battle of Tora Bora’ on line and check US intentions.) Similarly, during the early stages of OIF the USAF dropped bombs on what were thought to be Saddam’s bunkers. Reuters reported on March 28, 2003 that a 2000lb ‘bunker buster’ was dropped on Saddam’s bunker. Apparently, the coalition was trying to kill Saddam. I’m not sure why else we would have been bombing his bunker.

Obviously, this was clearly and simply justified as he was the centerpiece of all command and control in Iraq. Any argument that this was ‘assassination’ must have been put to bed fairly early and the bombs were dropped – just as they had been at Tora Bora.

If the CIA had a plan to track down and kill Usama bin Laden and his deputies, and they were unable to execute it because of lack of enough detailed intelligence, that is one thing. On the other hand, if the plan was not executed because someone thought it was the wrong thing to do, that is quite another. In such a case, we would have to ask exactly what those who were responsible for defending the country and Constitution were doing with their time? Do we really want the folks at CIA to NOT have a plan to kill our enemies after we have been attacked and are engaged in a hot war?

Perhaps this entire discussion can be distilled into a debate on the use of the word ‘assassinate.’ But, in a time of a shooting war is there any meaningful difference between killing the enemy and assassinating the enemy? A paper prepared for Congress shortly after this war began opined that one of the differences between assassination and other acts of violence is that assassination is for purely political purposes. But war is a purely political event. The textbook definition of war is that it is ‘an extension of political policy by other means.’

Are the wags engaged in this debate trying to further US efforts to eliminate the threats to the US? Or is this an effort to make political hay not only at the expense of political enemies, but also at the expense of those trying to defend the nation? It is worth noting that Senators and Representatives also take an oath to ‘preserve, protect and defend the Constitution of the United States.’ Our Congressmen and Senators need to put this issue behind them and get back to their real business.

Leadership Needed in Richmond

The campaign for Richmond has begun and we have had a clear demonstration of what is wrong with the last several holders of the governor’s office in Richmond: the Hampton Road Bridge Tunnel.

Let me be clear, the Hampton Road Bridge Tunnel is by no means the critical element of the Governor’s office. But, in this particular case, it is indicative of something larger being very wrong.

I first moved to the Hampton Roads area in the summer of 2004, courtesy of the Navy. Shortly after I arrived there was a hurricane warning and there was the usual talk about possible evacuations, etc. Since then each summer storm season has brought new revelations about the preparations, or lack thereof, of the various tunnels in the Hampton Roads area.

What this all has to do with the governor is fairly straightforward. Hampton Roads is the largest port in the commonwealth and the largest metropolitan area. It is also the site of the largest Naval port in the world, which, while obviously not being a direct responsibility of the governor, should highlight that particular care and preparation should be made to ensure that, beyond the preparations made by the military, it is incumbent on the commonwealth to also be prepared to address crises or various disasters in the port.

As I was interested both from a professional perspective and a personal one (my wife and I now lived here), shortly after we transferred here I asked around to see what the various plans looked like. I never found any copies of the plans but I was assured that there were plans and that they were well worked out and that they were regularly exercised.

And so, yesterday, July 2nd 2009, after several squalls passed through the area, the Hampton Roads Bridge Tunnel began to flood. When all was said and done, westbound traffic was stopped for roughly eight hours. The public was informed this morning that additional work will be required on the tunnel tonight (the 3rd).

Several observations should be made:

The Commonwealth’s “contingency plans” are no good. Whatever the plans were, they don’t work. Which means that, in the event of the need for a real evacuation, the evacuation plan probably won’t work – unless you expect that when ordered there are no accidents and no surprises, not exactly a good planning assumption.

There will be immediate responses that the plan is being revised, etc. Revising the plan now, even if it could be revised within the next several weeks, still won’t address the simple fact that the ‘new’ plan has not been ‘exercised.’ No one will have practiced implementing this new plan. In short, the area and the Commonwealth are not ready for a major storm or other crisis event.

The planning process is broken. Good planning is based on a sound planning process. In this case it is demonstrably incapable of producing a good plan. The process needs to be changed. And the people who manage the planning process need to be changed – they failed.

This is major problem. Putting together crisis and contingency plans is the most basic type of planning: the plan is limited in scope, it is short in duration, and there is a general understanding that whatever assets are needed during the crisis will be provided. In short, a crisis is, from a planning perspective, putting together a crisis plan is the easiest planning you will do.

Therefore, is we find that the Commonwealth and VDOT are incapable of putting together a workable crisis plan that addresses a contingent loss of the Hampton Roads Bridge Tunnel (HRBT), then we must conclude that the more difficult long term plans for the Commonwealth are in fact poorly crafted and probably less likely to work than the plans for the HRBT.

Furthermore, whatever the claim that is made about how well the ‘seven cities’ (Norfolk, Virginia Beach, Chesapeake, Hampton, Newport News, Portsmouth, and Suffolk) work together, clearly it isn’t well enough to at least identify that the various disaster plans don’t work. That the governor, who ostensibly should be interested in the area, should provide both leadership and pressure to the leadership of the seven cities to help facilitate these plans, goes without saying. That the last several governors have failed to do so is also now glaringly clear.

The process for testing and exercising the plans also is broken. Good plans require more than a sound process, they require exercising and review – looking at the ‘game film’ – as part of a process of making the plan better. The mayors’ offices and city councils and the fire and police departments and other first responders are all staffed by dedicated and hard-working men and women. But the exercise process and the inspection, review and lessons learned process failed, as has key elements of the leadership. There needs to be a detailed review of the entire exercise and review process and the appropriate parties need to be retrained.

The fact is that leadership failed at several levels, to include the governor’s office. The citizens of Virginia need to address that problem this year. It will do us no good to select someone who talks a good game but can’t deliver on the most basic requirement of a government: providing for public safety. The next governor of Virginia should be more than a mouthpiece, he has to be both competent in organizing and leading, as well as committed to doing the hard work, the planning and the execution of the plan, to keep the commonwealth ready and secure. Instead of talk, let’s insist on a governor who ahs real leadership experience, and a demonstrated track record pulling together a team, crafting a plan and carrying out the plan.

Fixing Healthcare: Some Introductory Thoughts

Unless you have been hunting in the back woods, you have heard a great deal recently about healthcare. The politicians in Washington have made some interesting claims lately and today I’d like to talk about one simple issue: cost.

As of 2006 total healthcare costs in the US exceeded $2.1 Trillion, or $7,000 per US citizen. Of that, the Federal government provides roughly $650 billion. It is also noted that roughly 45 million US citizens have no health insurance. (Note that these 45 million are not the 45 million poorest in the nation – they (the poorest) are provided healthcare through Medicaid and other elements of the existing healthcare law. Rather, the bulk of those who have no health insurance are those in the next income slice of the nation, made up usually of young adults who have just entered the work force and choose to delay health care coverage.)

What that means is that the cost of care for those that are covered is roughly $8200 per year. Simple arithmetic means that if you want everyone to receive essentially the same average coverage that the majority now receives will require a total health care cost of $2.5 trillion. If the health care is to be truly universal, allowing the provision of healthcare to illegal immigrants, as has been suggested, that would add an additional 11 million people and $90+ billion, bringing costs to almost $2.6 trillion.

So, if nothing else is done, “universal healthcare’ will require an additional $500 billion per year committed to healthcare, assuming healthcare costs have remained flat since 2006 (they have not).

On the other hand, if we want to keep costs flat, as some politicians have claimed is possible, we need to parse out $2.1 trillion among 45 million more US citizens, and possibly an additional 11 million illegal aliens. That would mean that the average actually spent on each citizen would need to drop from $8200 to $6688, a reduction of nearly 19%.

The politicians are claiming that they can reduce the real cost and keep the level of service unchanged in the face of this simple accounting (though none of them bring up the numbers). There are only a couple of ways that is possible:

1) Actively control costs. The government would then tell everyone associated with the healthcare community how much they can charge. Because the healthcare community is so large (1/7th of the US economy), this would require exercising control over everyone who relates to the healthcare community, such as the people who are building the new hospital wing (plumbers, brick layers, electricians, etc.,) the people who supply hospitals (caterers and food workers, linen, drycleaners, etc.) and limiting the income of everyone employed by the healthcare community, to include all their retirement and benefits programs. They will need to control everything that directly or indirectly affects healthcare costs, because it is such a huge industry.

2) Expand supply. Develop new and substantially cheaper means of producing health care of the same quality, or hope that someone else does. In short, get more for the same dollar. This sounds good, but hope is not a plan. In fact, the economic history of healthcare over the past 50 years is one of continually improving technology, treatment and medicines, but all at increased costs. This option is also known as “And now a miracle occurs.”

3) Control demand. Seriously review how healthcare is provided to the individual, reducing the amount of healthcare that each can receive so that all receive some. That is, re-align and ration the existing level of healthcare. (A recent paper from the Congressional Budget Office discussed ‘overuse’ of the healthcare system and discussed means that might be employed to force recipients to use less healthcare.) This will require the development of an even larger government bureaucracy to oversee the process – an additional expense that will need to be factored in.

4) Fib.

There may be other options, but in fact they all fit into one of the four categories outlines above. The only other option to expand healthcare is to actually expand available healthcare, without regard to cost. That is not something the federal government is likely to get right. I’ll discuss why tomorrow.

Michael Jackson, William F. Buckley, Jr. and Balanced Budgets

Michael Jackson was a spectacular showman and entertainer and his death is untimely. He appears to have been a man who struggled his entire life with the cost of the celebrity lifestyle and his passing is unfortunate. May he rest in peace.

What does that have to do with William F. Buckley, Jr. and Balanced Budgets?

‘Only’ this: the news channels have been bombarding the nation and the world with every detail of Michael Jackson, his life and his music and video production, for the last several days. I suspect that all the weekly news magazines will feature his death as their lead article this coming week, and he will probably be featured on the cover of these magazines at least once or perhaps twice over the next several months.

William F. Buckley, Jr. died on February 27th, 2008. I’m not sure any major news channel gave his death more than a single line of coverage, with the exception of perhaps Fox News. Yet, he was the perhaps the key figure of the recovery of conservative thought in not simply the US but the west over the past 50 years. Beyond that, Buckley set the stage that led not simply to the Reagan revolution, he set the stage for a change in language and thinking in and around government world-wide. The Buckley-Reagan nexus was responsible for the overturning of the ‘common-knowledge’ of the 1960’s and 1970’s that ‘controlled,’ ever upward spiraling deficit spending was the only way to manage the government’s tax and spend policy

Despite what Reagan naysayers may insist, Reagan’s tax cuts caused a massive increase in overall tax revenues. Only because Congress continued to add to the largesse of the entitlement programs on top of the Reagan defense increases did the deficit grow despite the huge revenue increase of the Reagan presidency. Nevertheless, it was Reagan who brought about the change in dialogue and language, that resulted in Bill Clinton running for the Presidency with promises to balance the budget, and virtually every candidate since 1992, Democrat, Republican, Independent or Libertarian has made the same promise.

And, at its root, that is a direct fruit of the labor of William F. Buckley.

The point is that we – the whole planet – are unbalanced. Riots continue in Iran, but Jackson’s autopsy gets more press than the riots, the deliberations on cap-and-trade and the rest of the climate bill, and a wide range of other issues. The press is consumed with the lives, and deaths, of entertainers but mainly ignores the fundamentals. How many remember that Aleksandr Solzhenitsyn died almost a year ago? How much press did he receive? Precious little as I remember. Let’s bring a little balance back to our lives.