Maybe Barry can leverage this to a second term
Now that we are mostly wired for broadband and Telephone Triage Nursing has been tested and proven to be effective and efficient, the next step towards reworking healthcare and reducing the $50 Trillion Medicare liability is to adopt products like Intel's Medical Monitor device for home care of the ill
http://news.cnet.com/8301-17938_105-10086401-1.html
Its not just unclogging the waiting rooms of Internists across the land, it is truly about better outcomes from more thorough data collection so that intradaily trends and intervention inflection points can be accurately determined. The amount of data that we will shortly have on average Joes not in hospitals will be astounding. The amount of sophisticated clinical studies they will enable is even more mind binding. Medical diagnoses and prescriptions are about to be rewritten in a very serious way by this ability.
And this just in from Drudge: SICK SURVEILLANCE: GOOGLE REPORTS FLU SEARCHES, LOCATIONS TO FEDS. All those promises from WebMD back in 2000 may be ready for primetime.
--
- Carlos's blog
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for Johnson & Johnson. It has enough smarts to store and forward testing data to your health care provider via a web service. I'll probably apply this architecture to some other J&J products.
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)Glucosimeters, BP cuffs, scales, accelerometers, spirometers, plus other devices that dole out medicines can/have been enabled for electronic communication to computer aggregators like this...and J&J's HeathMedia site.
The hurdle to overcome is cost and ease of use.
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| parent )Refactored the whole thing to take a regular mini-USB to regular USB cable. It's a trivial thing at the facade level of the API to redo it as WiFi.
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| parent )If I never hear "we have to refactor the whole thing" again from an IS guy, it'll be too soon.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )I generally hate electronic products that use a proprietary connector for USB, but then again, those mini USB connectors fail like crazy if they constantly have plugs going in and out all the time. However, compared to the 4-wire firewire 400 connector, the mini-USB is great, relatively speaking.
The worst connector ever, (in common useage) is the:
Stereo mini - although the screw-in version is an improvement, and the 4-conductor mini connector should be banned from the Earth. The problem is repeated plugging in and out, although I have problems with my mini jack on my brand new Mac.
The next worst is the:
Firewire 400 4-wire (mini) - I've had too many tragically fail to even count. Cameras, video and digital still, recorders, laptops, desktops, you name it. This is a bad connector. This is compounded by the fact that it is installed in such a fashion that it's extremely expensive, labor-wise, to replace.
Simple plug in connectors in general, the 1/4" mono and stereo, the RCA for audio and video and now digital audio, and all versions of the 1/8" mini and the even smaller sub-mini all have unacceptably high failure rates, imo. The only thing that works without fail are bayonet style or push-pull style multi-pin connectors. They ain't cheap, but they don't fail. I wish that all this stuff would hook up with Lemo brand connectors. They work well, although it adds at least $10 per connector to the cost of the product.
--Me: We! -- Ali
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| parent )- Login or register to post comments
)Who needs another database? What we need is better intradaily monitoring.
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| parent )it's a platform.
http://code.google.com/apis/health/
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| parent )but it isn't going to effect patient outcomes if people don't have access to primary care (i.e. if they're uninsured.)
Not to say it's a bad idea, but I'm more interested in how you diagnose the uninsured with hypertension or diabetes and cover their care. Saving Aetna money shouldn't be a high priority.
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| parent )Mr. JKC,
If you are able to slow the present growth in Medicare from 7.9% down to say 3% through improved disease management then you have freed up some money to subsidize another part of the population...maybe even the poor uninsured.
Better yet, we could take a step back one hundred years to when many common ailments were managed without physicians. Unfortunately, they weren't managed well, but then again, the physicians weren't much help either back then. What I'm getting at is the fact that there is a basis to believe that people are willing to take care of themselves without involving the medical industry directly one on one. Tools such as Google Health, WebMD, and now these medical communicators/data-aggregators hold out hope that individuals can develop the power and knowledge to lead their medical treatment rather than be led by an uncaring medical industry (note: I did not say uncaring medical professionals)
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| parent )anyone who's ever studied the medical literature will tell you that the largest sums of money are spent on end-of-life care. That was certainly true in the case of my recently departed father-in-law until he went into hospice. His endocrinologist tried like hell to keep his diabetes under control, and was doing a fairly good job, too. Unfortunately, his kidneys gave out after a cardiac catheterization, and his last years were for more unpleasant than he deserved. Two words: dialysis sucks.
The problem as I see it, Carlos, is that for every reputable site like WebMD out there, there are a couple that are either fronts for big Pharma, or are run by quacks. I always cringe inside these days when I hear a patient say "I read on the Internet..." Sometimes they've gotten good information, sometimes not.
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| parent )I love Righty anger. It feels like victory.
--But she's a queen, and such are queens
that your laughter is sucked in their brains. -D. Bowie
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)I don't think Carlos was expressing any sort of anger at all. What are you talking about?
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )Are *any* healthcare metrics going to improve as a result of this?
http://www.who.int/whosis/data/
Thanks for the links. I'm going to use it for a presentation tomorrow about the disconnect between expectation and reality.
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)Medical decisions are based on pathetically low numbers of patients in trials due to actual costs and liabilities. Add to that the extreme difficulty in getting good longitudinal data from actual patients, not in a trial, for modifications to conventional protocols and you end up with a huge need for such a device simply for its data collection value. EMRs will not do this nearly as well as they only reanalyze the data they already have in their clinical records.
What is needed is an ability to closely monitor individual patients as they monkey with medications, therapy, and other lifestyle changes to discern whether or not their present course is working. We are all different and respond very differently to drugs and therapies. A device like this will find a large need in healthcare, IMO, and could significantly lower costs.
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| parent )from people is data collection for its own sake. Sure, its nice to know it can be done. But will it yield results? Continuous monitoring isn't even done routinely in hospital, except in ORs and intensive care units. Even in ORs full monitoring is not done in the minor ORs.
So lets look at intensive care units. If we look at the amount of realtime data generated in an ICU and the effect the continuous record has on clinical decision-making, the result is probably 30%, no more. Because continuous monitoring is so expensive, we did a small pilot study recently looking at the number of continuously monitored datapoints that resulted in a change in clinical decision-making and that was the figure. Sure, the data can be collected. But unless it is actually used, its taking up more time - in recording and analysis. We also found that the time spent by nurses in recording data was inversely proportional to the time spent in actual care provision (which seems an intuitive idea, but didn't seem obvious to that hospital's management). There are a few nurses here, perhaps they could tell us if our IT-centric views are correct.
If this approach was logical, then the first place to apply it would be to hospital wards, where the next hierarchy of care becomes applicable. There's a reason why people aren't continuously monitored while in a hospital ward - the reason is that the data-yield:clinical decision change ratio isn't cost-effective.
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| parent )collection. Cardiac conditions warrant data collection. Epilepsy warrants it. We're now learning how realtime analysis of PQRS intervals can predict heart attacks: a healthy heart has a certain amount of randomness in the mix. A heart in trouble loses the randomness. Something to do with Bundle of His and Purkinje fibers, vagus nerve, we're not entirely sure what's going on, but just before a heart attack, the heartbeat becomes machine-like. Someone looking at a standard scope would never see this happening: it can only be seen in software. Pretty much everything can go home with the patient.
Anything you can do in a custom piece of OR monitoring hardware I can duplicate on your computer. The idea an entire CAT scan can be mastered off to a DVD, then used as a basis for comparison against a later CAT scan, that's just beyond wonderful.
I'll grant you, health care practitioners are inundated in data. If they can't use it, why gather it? But if they don't know how to use it, that's another problem.
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| parent )I think you get to a point where there's so much data that the signal-to-noise ratio gets out of whack.
The cardiology example is a good one (and if you could e-mail me a link to the article you found, I'd love to see it.) While that real-time monitoring sounds great, how do you figure out who needs that level of monitoring? There are tools you can use to stratify risk, but they're not perfect, and I wonder if the cost wouldn't be prohibitive.
Diabetes is a better example, I guess: in the case of type 2 diabetics, knowing if they have spikes in their blood glucose after meals or if they have consistently high fasting glucose levels would be a big help in selecting appropriate therapy. Compliance gets to be an issue, though: fingersticks hurt!
I think too many conservatives (Newt Gingrich comes to mind) view technology as a panacea for our problems in health care. Don't get me wrong: I think computers are great (when they work properly), and I'd love to see a functional EMR in the hospital where I practice. But all that tech doesn't solve the problem of access. Uninsured people aren't going to get diagnosed with diabetes until major complications have set in, because they can't get in to see a primary care doc. We need to solve the access problem first.
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| parent )Fairly straightforward tutorial here.
Diabetes is its own problem. Turns out most of these insulin pumps could benefit from better data. An A1C test is a good test for how much trouble the patient's been getting into with un-metabolized glucose. Patient's glucose readings could look pretty good, but if the A1C tells you something else, you know to change the testing or insulin protocols. Body behaves differently sleeping and waking, granted, you can't test them when they're sleeping, but it would be incredibly useful if we could apply heuristics to the insulin protocol. Surprising how little we understand about the pancreas, even now.
Carlos observes something every pragmatist knows: we're throwing money into problems when they're huge, not when they're small. If people could just walk into a clinic and get the most rudimentary of examinations, costs would go down, waaay down. Granted, we'd be treating more patients, but we wouldn't be doing these horrible diabetes amputations and dealing with diabetes retinas, so sad to observe the consequences of untreated chronic conditions. Catch it early, it's a manageable problem.
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| parent )It is totally unintuitive. It looks like pure noise. It is only after massive computational analysis do you see the beautiful images.
And now with Functional MRI taking off, hospitals are being forced to find more computing power by setting up GRID computing structures to aid in the analytical demands of the measurement.
Our bodies put out massive amounts of signals. We are only collecting some of them. Today it is getting much cheaper to collect more and then sift through that data for golden nuggets.
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| parent )One of the reasons I went into AI and expert systems in the first place was to suss out those Golden Nuggets. See, machines do well with rules, people do better with exceptions. When you hear hoof beats, think horses, not zebras goes the old saying.
I came up under an old British McKinsey consultant, back when consultants were taken more seriously. He had an old joke about an Australian sheepherder sitting on a chair as an enormous herd of sheep were driven into a pen. "There's 254,864 sheep in that pen, mate" he said to a bystander.
"That's pretty amazing. How did you manage that?" the incredulous bystander asked.
"Ah, that's easy, chum. Counted the legs and divided by four"
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| parent )storage and computing power are cheap. human analysis time is expensive. The collection and storage of this type of information seems to be a no-brainer to me, and if the analysis can be automated that also seems like an inexpensive thing to do. The only problem is the availability of human to review the information, but in any case the storage of the data while it's waiting for future analysis is still pretty inexpensive.
--I blame it all on the Internet
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| parent )Which cuts down on some of the more routine diagnoses. Here's the way I think about an expert system:
Sort out any domain of problems on a spectrum. What's the most frequent problem? I'll bet you have a whole directory full of little scripts you routinely execute to solve such problems. How often do you go through a logfile in an editor, throwing out all the stuff which doesn't matter? I have a whole set of editor macros to throw out all those heartbeat messages I leave in logs. Bet you do, too.
Now, you know your own environment like the back of your hand. I'll bet you solve some problems on that domain so reflexively you don't even dedicate any analysis to them any more. This horrible hotel sometimes gets in DNS trouble, I've got a hot key wired to open a session, flush the DNS and exit. Always solves the problem. Left a printout at the hotel desk, so the clerks can tell others how to solve this problem. Had the manager leave me a note, thanking me for it, they use it all the time.
Humans are tool builders. Dedicating highly trained medical personnel to problems better solved at a lower level, that's a waste of resources. If the lower-level resource knows he's out of his league, he promotes the problem. That's where I see expert systems coming to into their own, augmenting those lower-level personnel with common-sense tools. Galen, the father of modern medicine, had his Doctrine of Signatures. That's the essence of the expert system.
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| parent )the analysis may be expensive and/or time consuming, I'm not familiar with the field enough to know. But communication and storage costs are so cheap that it's hard to argue against keeping the data just in case it turns out to be useful.
--I blame it all on the Internet
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| parent )In purely technical terms, agreed about costs.
But there is the whole accuracy issue here, especially in case of home-entered data, training the relevant people etc.
OK I re-read the article and links in more detail. It seems the programs will be targeted to special people with chronic problems where such monitoring has been shown to be useful, and who can (or their carers can) train themselves to collect data. This is much better and much more useful.
My point about its relevance to Joe Ordinary's medical data still remains valid, though, I think.
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| parent )...but automated or semi automated certified measurements that are directly attached to one of its 4 USB ports or wirelessly linked. The cost will be prohibitive for developing countries, but will be minimal compared to long term care of chronic conditions in America.
Joe Ordinary, presumably, is ordinary and has no serious medical conditions, so you are correct...no benefit there.
Up thread you mention that additional data doesn't aid medical treatment. That is because they have no protocols to act on it, nor do most physicians spend much time tweaking protocols to improve outcomes. They just don't have the time. And if they had the time, they wouldn't be able to use evidenced based medicine to do anything about it.
Now, we have the tools to collect massive amounts of intradaily data to build baselines and then begin modifying protocols in large longitudinal studies to determine which protocols are likely to work best on specific genetic pools and other complications
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| parent )might be overrated.
A philosophical note. A vegetarian diet, adequate exercise, clean air and water, not smoking and maintaining a correct body weight go far further, statistically, in improving health metrics, than a enormous spend on technology. OK this is a truism, but %GDP spend on healthcare after life expectancy reaches 79 is a game of quickly diminishing returns. So, whether tweaking medicalised protocols as a result of gathering masses of data will in truth improve health metrics significantly remains to be seen.
Asia Pacific Journal of Clinical Nutrition. Volume 10 Issue 2, Pages 154 - 158 - abstract
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| parent )and I am approaching this clinically. You get vast amounts of basic clinical data and then analyze the existing data to determine where the best ROI can be made. I think that you are finding fewer and fewer opportunities to advance health for the developed world. We already know that Americans are fat and don't eat correctly and don't exercise regularly. The question is what are you going to do about it? A friend of mine is promoting the idea that we use public ad campaigns to ostracize obesity similar to the way we did smoking. I think he is playing with fire. What do we get, restaurants that calculate your BMI before they give you the Obese menu versus the regular menu.
I believe that most basic clinical data is worthless for the sake of advancing health outcomes. Medicine should be considered an individually oriented practice, IMO, because individuals create so many barriers to standardized care unless they are in the hospital tied to a bed rail.
Today, medicine is being quickly converted to an epidemiologically controlled algorithmically based industry that even further detaches the individuality of the patient from the final prescription. "Nope, can't do that that alternative therapy is not usual and customary" What crap!
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| parent )of policy-making and metrics must justify healthcare spend.
If we are talking about the best way of spending scarce dollars, then we have to focus on the essentials. As JKC says above, lets focus on making access to healthcare available to the masses - as true in the US as it is over here. Let us agree on radically cutting smoking and alcohol intake. While maternal and infant mortality are pressing problems, obesity is rapidly becoming as significant a problem here as it is in the West.
If we must throw money at problems, let us throw it at where it is most effective. I learn that increasing numbers of people are now walking around in the US equipped with cardioverter-defibrillators - supposedly as a result of evidence-based medicine.
Yet the indications for this treatment continue to widen
In the beginning
OK so the therapy definitely works for the really sick. But we can't stop there, can we? Because we need to sell more of these devices. So then
Excuse me? 7% decrease in mortality over 5 years? And this is significant?
Yet, we continue to try every means to expand their use, even though evidence gets increasingly sparse as we try to sell the device to less sick people.
I hope I'm not into the evil capitalist shtick any more than anyone here. But, colour me sceptical when people try to push enormously expensive devices and treatments to those who probably do not need it.
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| parent )It is typical of every major medical advance. First they find it works on symptom X, then they try it on Y and Z and then try it on A,B,C.... Just natural hopefulness in action. The followup Phase IV studies show the real values and where and when it should be used. The reason for this is part human hopefulness and part pent up demand from the medical practicing industry for new products. I new medical device takes about ten years to get to market and usually it only has one approved indication. But once it gets to market, physicians get to use it off label without hassle. So they do, in a massive way. That may be for money or it could be for treatment of something without hope previously. Doctors seldom think in terms of ROI, that's a national think tank kind of issue. Patients just want their medical insurance to pay for everything that could possibly extend their lives.
Question: How to you force the obese to take better care of their bodies? Restrict the diabetic treatment until they drop 50-100 pounds? Tricky. However, Kaiser Permanente does just that for patients that want a gastric bypass. They must lose 10% of their body weight and survive on a 500-800 calorie/day liquid diet for several months before they grant them the bypass. Can you get that written into national healthcare reform legislation? Please.
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| parent )If we're ever to start doing predictive medicine, by far the most humane and cost-effective, the epidemiology will be the key. What you can prevent, you won't have to treat.
I think, in a decade, cardiac medicine will look back on what we've been doing for the last two decades as brutally stupid. Pacemakers will have gotten a whole lot smarter. We'll have a much better understanding of hypertension: as you point out, we know perfectly well what brings most cardiac patients to the ER on the gurney: a lifetime of steaks and scotch and Marlboros and sitting on their fat asses watching the television.
I see a big future for fat farms. Instead of that quintuple bypass, we'll send that fat fool to the fat farm for a month, put him on a managed diet, let him gently perspire and do his groaning as he sheds that avoirdupois, instead of waking up in the recovery room. Friend of mine just lost weight, but she mourns for the candy she can't eat any more. You can lose the weight, but you can't lose the desire....
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| parent )and his even more amazingly fit girlfriend, I shouldn't speak.
Anyone spotted Bill White yet?
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| parent )The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )I could take him.
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| parent )but ya gotta show up to do that!
edit: you could take me, but my GF would kick your ass.
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| parent )Any higher-order omnivore is subject to obesity. Evolution selected for gorging behavior while times were good, especially in temperate and subarctic domains. Humans, bears, pigs, mice all fatten up for the winter. Female whales will go months without feeding after calving, yet produce tons of rich milk and still have enough energy reserves to go thousands of miles back to the feeding ground, her calf in tow, a truly astonishing feat of calorie management.
Reading along in the journals, I now see references to two-way chemical communication between the fat cell and the brain. Seems the fat cell isn't as passive as we thought, and it seems adrenaline is somehow a factor, though endocrinology is in its infancy, lots of this is informed guesswork at this stage.
It's only been, what, maybe 5000 years or so that mankind has been farming and building civilizations. Far too short a time for any significant evolutionary pressure to build up against this gorging behavior. Despite all the pressure to be thin at the waist and face, we still select for large breasts, shiny hair and rounded hips in women, all directly related to a high calorie diet.
The Chinese are turning into blimps. They've been subject to famine pressures, time out of mind. They've been stuffing their children full of food, now that they've got access to enough food. Turns out, if the grandfather endured a famine, the grandchild has a predisposition for diabetes and heart disease. We don't have a clue why.
When a creature build for Feast or Famine gets three meals a day, there will be consequences.
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| parent )It is only now being confirmed that high body fat individuals possess additional hormonal feedback loops related to their fat cells. Many of those feedbacks appear to be towards feminization of the obese. As you note, fat doesn't appear to be the static player everyone has thought.
We should all consider food to be the most important medicine we take and worry about its consequences.
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| parent )The diabetes epidemic is concomitant with the obesity epidemic.
The problem started with sulfa drugs. Before sulfa drugs and anesthesia, medicine was stymied. Patients didn't survive surgery: medicine did its best to palliate suffering and gave stern advice about losing weight and suchlike. After sulfa drugs and anesthesia, doctors could save lives. The patient went from Margaret Smith to "the gallbladder in 219" Doctors grew arrogant and wealthy, over-prescribed everything in the pharmacy, and generally lost the human touch, especially surgeons.
The Okinawa study and others like it miss an important metric, and I'm frankly tired of hearing this simplistic drumbeat. The signal factor in the startling increase in human lifespan is the decrease in infant mortality. Visit any old graveyard and see the number of tiny infant tombstones. While there's a decreasing return on investment at the end of life, it's at the beginning of life where we can make it possible for human beings to reach the age of 40.
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| parent )Why we subsidize the elderly healthcare system and don't mandate that every child and woman of childbearing age receive modern medicine is beyond me. What idiocy?
Regarding life expectancy: Somehow I get to spend a little time dealing with the anti aging industry. What a trip that is. However, I have seen far too many 81 year old tennis players now to wave my hands at it anymore. The ill advised and very exploratory activities of this crowd will, I believe, eventually offer some significant life enhancements to some. They mainly focus on hormone therapies today. I'm ignoring all the skin treatments for the moment. The results can be very helpful, at least on the short term. It will be interesting to watch these treatments play out over the next ten years or so. Whether or not we see extended life spans, I don't know. But is that really the only goal? How about vitality, strength, alertness and quickness (mental and physical)?
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| parent )...between individual goods and any common good to be had, and specific individuals have access to a lot of the resources.
A) An oldster gains little directly from most investments in child medicine. Even if the grandkids catch something, it makes more sense to pay for advanced care for your specific kin than in general preventive medicine. (This might not hold for vaccination against some perennial faves like the flu, though.)
B) Oldsters gain very directly from investments in oldster medicine. The social gains are smaller, but the effects on the specific individuals involved can be large.
C) The oldsters have most of the cash.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )And they vote towards those ends as well. I couldn't find any data for this cycle but seniors 65+ accounted for 24% of the national vote in 2002. I suspect it is only going up due to simple demographics.
However, I had heard that the under 29 crowd only increased 1% this year over last cycle. So the following article
This article examines age cohort voting differentiation in the breakdown of the Leninist regimes in terms of the effects of rapid social change. The strong relationship found between age and conservative voting and the disproportionate vote of youth for all types of change-oriented parties in the “first” competitive elections (1989/1990) in Belarus, Bulgaria, Romania, Poland, Hungary, Czechoslovakia, East Germany, and Moscow is a product of cohort–period interaction with youth at the vanguard of social change. Taken together, a dramatic period effect (the rapid introduction of economic and political change), the skewing of younger groups in favor of more rapid social change, the generational socialization of the aged under communist values, and a greater investment of the elderly in the status quo explain age cohort voting in the breakdown of Leninism.
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W51-4534JX2-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_version=1&_urlVersion=0&_userid=10&md5=dfeaa10afbb87dc5a6b91a054a922891
may not be in the cards for America just yet. Those of us who do think the elderly are ripping off the young may have to whip up the flames of intergenerational warfare to drive an election win for the under 40 over the oldsters.
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| parent )And he never made it to the Oval Office.
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)It was at a U of A v ASU homecoming game. 50 yard line up high near the top. He was with his wife and I was his Boy Scout usher. He made it a point to chat with me, and tried out a couple of his faux populist ditties. I was impressed by his friendliness. Zero entourage or security. (pre JFK)
--Me: We! -- Ali
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| parent )I mean, yeah, we called W all kinds of things, but maybe we should wait until after he steals an election and allows the worst attack on US soil since WWII before using the nicknames.
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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)"we called W all kinds of things"
Your side doesn't have the moral high ground on this.
--"I want America to know that I'm, like, totally ready to lead." -- Paris Hilton
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| parent )It's just a wingtardy formulation meant to make the user feel clever while displaying, quite clearly, its opposite.
--To think is not enough; you must think of something -- Jules Renard
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| parent )"That Sam-I-am! That Sam-I-am! I do not like that Sam-I-am!"- Dr. Seuss
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| parent )....enough to give Barry (BO?) the benefit of the doubt. Besides, he without a doubt wants to raise mytaxes. Screw'im.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )He doesn't want to tax you. I do (and only you, BTW).
I figure that my diet of Fancy Feast will be downright palatable as long as you're buyin' it for me ;-)
I'll spring for the saltines though.
--Excess on occasion is exhilarating. It prevents moderation from acquiring the deadening effect of a habit. - W. Somerset Maugham
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| parent )that sounds fair.
--I blame it all on the Internet
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| parent )If I fork out now, it comes out of their inheritance, anyway. Besides, a pol can be reliably expected to take the path of least resistance. I'm expecting it'll get paid for via the inflation tax. Tho' I do wish Barry spent less time talking to Volcker, at least for the first term. :^) Gooooo Teaneck!
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )those earning 200k or more, didn'tya?
Maybe your self-interest isn't as enlightened as you suppose.
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| parent )Or maybe they feel guilty. :^)
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )they realize that the united states will require more revenue in order to make critical investments in infrastructure that will ensure their own ability to continue generating value and wealth over the long term, and they don't mind going back to reagan era levels of taxation to do so.
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| parent )....investments. In fact, the only folks who are managing to raise money in the current environment are infrastructure funds. So that particular argument I do not buy.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )actually, *I* do need government to levy taxes to support the infrastructure i depend on. not sure about you but i don't have the money to build the schools i went to, drive on the roads i drive, track the disease i should be protected from, etc. therefore i participate in a democratic process to add my voice to the fray and hope the stuff i feel is important gets funded.
but that's just picking on your poor wording (i assume you meant "one doesn't need taxes to make infrastructure investments.")
if that is what you meant than we don't disagree. nothing precludes the private sector from building and maintaining infrastructure. where we will no doubt disagree is the relative efficacy (not to mention likelihood) of such investment if undertaken by private sector agents.
or are you of the opinion that aside from fighter jets etc everything should be private? and if so, why not fighter jets too?
(i'm bracing myself for the reply ;0).... )
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| parent )...much beyond giving said infrastructure funds rights to the revenue for a while. But fine, let's substitute "one", or even better "the citizen".
My point, I think, withstands. This looks like weak grounds for deciding which way to vote. If I had to guess, I'd say "a general feeling of malaise" or "if you can't figh'em, join'em" or some such.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )i cited three specific examples. how would your "giving said infrastructure funds rights to the revenue for a while" apply in each case?
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| parent )Roads: Readily monetizable, private tolls roads are common.
Schools: Build-to-lease? If I were a developer right now, I think I'd much rather build a school with a long-term contract to lease to a municipality than build a mall with a short-term contract from an anchor retailer that might be bankrupt by January. (The lease may or may not require additional taxes; most municipalities are blowing a wad on keeping up a lot of crappy existing schools, so there should be funds available.) Private charters for the services? There are a number of schools in Newark that could benefit from being knocked down and sending the kids elsewhere.
Epidemiology: I'll demur on this one. They were discussing it on another thread.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )so you think every street in chicago could be subject to a toll? collected by a private entity?
should there be several roads next to each other so i can choose among them and these private interests will have a motive to compete for my driving pleasure and i will get the best service at the lowest cost?
do you think only the wealthy should send their children to school? no public schools? i guess poor children are SOL. i don't see how having a poorly educated citizenry serves the needs of teh rich since it is those poor folks they will need to exploit in order to maintain their wealth. other folks' level of education will direct affect theri bottom line, and they have no way of predicting 20 years out which folks will be working for them.
i don't know jack about epidemiology either but i think anyone can see that its an area where a collective effort is necessary. i mean, what are you gonna do, have competing CDC's and sell their advice to healthcare orgs that will resell that info somehow?
i know it really pains you, but at some point you must see sometimes collective action is necessary where a profit motive doesn't really have a place. or that the promised efficiencies of private enterprise often vanish when they are providing services which don't lend themselves to competition, like roads or water or electricity.
but you're a smart guy, and you know all this.
don't worry, i won't expect you to say so here, i know you do enjoy the pose of the steely amoral robber baron. ;)
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| parent )...onto the dread ground of the Fallacy of the Excluded Middle.
I did not say that there is no place for public money. (You mentioned jet fighters somewhere, right? Defense is a classic market failure.) But it in no way follows that the investment you claim to want needs to be financed directly via taxes. There's already spending on schools, both on the infrastructure and ongoing expenditure sides. Trust me, I'm quite certain of it; I just got my school tax bill. The fact remains that there are various ways to suck private capital into doing the job, and that the job currently being done by the taxing authorities often sucks. In NJ, Newark schools have some of the highest per-pupil spending in the state. I still wouldn't send my kid to one short of somebody marching us there at rifle-point. They're crap schools.
Actually, it always has a place. I'm surprised you don't see it. I, for instance, am in favor of public schooling. I'm certainly not so out of the goodness of my heart, though. In point of fact, it is precisely because I see some benefit to it of which, I estimate, I get a share worth more to me than what I'm forking over. Likewise for cops, courts, troops, etc. It's all profit motive, nils.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )i agree the cost/benfit is a factor -- that's my argument, in fact. but a favorable cost/benefit is not always translatable to a private profit. and a private profit will not guarantee favorable cost/benefit to the public.
this all started when i said that even some rich folks recognize that infrastructure investment may require increased taxation. where is the disagreement with that? that we don't need more revenue? that we could do teh same for less?
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| parent )what about necessary infrastructure whose "returns" are difficult or impossible to monetize?
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| parent )That's gotta be a sub-set, though. We know we can monetize bridges, roads, cables & fiber, power generation plants.
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )...dude, do you own stock in a transactions company or something?
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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| parent )I could have sworn I was pretty precise in my typing. Excluded Middle once again, next.
...And yes, I do own stock in transactions companies. You can even use them to pay your taxes! :^)
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )everything about it was difficult to see as a benefit. It's similar in a lot of high tech areas, it's hard to see the investment as anything but a waste of time and money until it takes off.
--I blame it all on the Internet
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| parent )how about a major govt. investment in energy R&D - say,10% of that $700 billion Three-Card Monte game Treasury and the Fed are running on us as we speak? We'll take turns picking the technology the money is spent on: I say modular nuke generator systems, you say solar, I say clean coal, you say wind, I say backyard BBQs for winter heating, you say burning banana peels indoors, etc.
--Even a dead midget is far from light. - Confucius
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| parent )before we start spending that money.
Besides, I thought conservatives were against industrial policy?
--I blame it all on the Internet
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| parent )IIRC Republicans, the nominally conservative party, were harshly criticized by many here when some of them didn't go along with the Bailout Bill. I recall two loudmouths here who consistently opposed the bailout, and still do: yours truly and "The Prognosticator Formerly Known As PM".
In all seriousness, we have reached the ludicrous point where amounts in the hundreds of billions of dollars are not considered significant, or even worthy of comment, by much of the public. No one seems to care where the $700 billion goes, or even about the fact that it will be more than a $trillion when the pols are done giving it away to their cronies.
So a pragmatist would say we should steer some of it (a mere ten percent, say) into programs that will dramatically help consumers and our security, not to mention reducing a net annual cash outflow, funds used to buy foreign oil, that equals the nominal bailout amount every year.
Or of you want to move this to a higher ethical, moral level (I don't - I'm allergic to that stuff), you could ask where we would be now in terms of midEast relationships and clout if we had kept half the money we've spent on rebuilding Iraqi oil infrastructure and spent it on our own nergy development needs instead.
--Even a dead midget is far from light. - Confucius
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| parent )we are now enjoying the essence of lame duck, a 60 day long no holds barred wrap up of the current administration. We may even see Dick Cheney emerge, blinking at the sunlight and cursing the damn hippies. Obama can't really do much except say what he'll undo in two months. It's a problem when there's a crisis during the interregnum, but that's the way the system is set up and there's no way to change it right now.
As far as the dollar figures, yes they are eye popping, but that just underlies how serious this problem is. The only way to get companies to back off from the trough is to ask for something painful in return - equity and board representation would go a long way to scaring off all but the truly messed up companies.
I'd prefer that spending be limited to what the original bill called for, if you want additional spending on other no doubt worthy issues pass a separate law for them.
--I blame it all on the Internet
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| parent )so I dunno now. The big issue which I opposed -- just buying the bad stuff at random prices -- appears to have been deemed too difficult in the short term (I still don't understand why I'm so consistently more correct on so much less information than they have), so now we're doing some other random thing.
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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| parent )mortgages on houses that will never be above water. there's even an outside risk that it might end up being a significant boon to the whole human race.
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| parent )...isn't a conservative. He just plays one on TV.
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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| parent )nt
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| parent )Not from me, anyway. :^)
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )Lady McBarry!!
--I had discovered a great secret. That everyone loves themselves more than they love anybody else. And if I wanted them to love me, I better be like THEM!... Ken Nordine
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| parent )and the presidency in this country.
Barry is well w/in my bounds.
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| parent )...I just like to call people by what they go by. "Barack" is fine. Sensitized by "Democrat Party," I guess.
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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| parent )....the next 4 years. :^)
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )Like "preznit" or "chimp" over the last 8 years, the derogative says more about the subject than the object.
--More Wagster!
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| parent )....so I see no reason to stop now. If the Presidency is normally weighed down with excessive pomp and respectfulness (and it is), this particular one will be doubly prone to it. You can see it already.
Also, it apparently pisses PM off, which is a worthwhile goal in and of itself. Win-win!
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )I'm already into "this person is terrifying and should be avoided at all costs; oh crap he probably has my IP" territory.
--It's impossible to debate if people simply hold beliefs that have no grounding in reality.
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| parent )OTOH, Hank most certainly has your IP. I figure anybody willing to buy that shirt must have been hidden away in a basement by their parents or something. Ticking time bomb!
[I kid, Hank. I only wish I could wear that shirt. Well, that I had the guts to wear it, anyway.]
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )I blame it all on the Internet
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| parent )And if you need proof, just watch him play Diplomacy.
(Zing!)
--Brevis esse laboro, obscurus fio.
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| parent )Apparently some of us still have jobs to maintain. :^)
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )If only you had more time, you wouldn't keep getting smacked around like the proverbial red-headed step-child on Christmas morn. That must be it.
--Brevis esse laboro, obscurus fio.
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| parent )Glad you're on board. And I don't know what people have against red-headed step-children....
--The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )But, being of conservative disposition, I don't question the inherited wisdom of those who have come before me.
--Brevis esse laboro, obscurus fio.
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| parent )The ultimate result of shielding man from the effects of folly is to people the world with fools. -Herbert Spencer
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| parent )I tried to think of some others, but all I could come up with was "Straussian stranglings." And that's just not as good.
So you win this round, you magnificent, heartless bastard.
--Brevis esse laboro, obscurus fio.
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| parent )i thought you were rich. ;)