I have a Patreon page

I created a Patreon page just before leaving for vacation on 2 Aug. The background to this is that while I’m now getting some regular bucks for working on NTPsec, it’s not a lot. Royalties from my books have been dwindling and my wife Cathy isn’t making all that much from legal contract gigs that are all she can get since Obamacare costs killed her full-time law job. Add the fact that our eight-year-old car has developed problems that would cost more to fix than its book value, and the house needs a new roof, and it’s looking pretty broke out.

(Yes, we do have some savings and stock. No, I don’t want to tap them, because thank you I do not want to be on the dole or dead of starvation and exposure when I’m really old. And, even if doing so weren’t in conflict with my values, counting on the U.S. government to be able to keep me in enough money for food and shelter in 2035 or so would be deeply stupid.)

Rather to my surprise, the page has attracted a whole 67 patrons and $409.17 in monthly pledges. I wasn’t actually expecting Patreon to yield that much, as it seems to be strongly oriented towards the beret-and-nose-ring crowd. It’ll help, some.

All this is by way of explaining why from now on my new-release announcements will probably be going to Patreon, mostly, rather than here on the blog. They’re the closest I have to the kind of artistic content releases the Patreon base seems to expect, and do seem to actually produce upticks in pledges.

My first month’s Patreon pledges will just about cover the additional 32GB of memory I dropped into the Great Beast in order to work on GCC’s Subversion-to-Git conversion. It’s not going to make much of a dent in (for example) medical insurance, thanks to the statist bastards who’ve driven health-care costs into the stratosphere through their incessant meddling. (They cost my wife her job, too – that’s been psychologically rough on her.)

If you enjoy this blog, please pledge generously. Whether you file the cost under “entertainment” or “keep an infrastructure gnome fed so your civilization will keep working”, a little help from each one of a lot of people can go a long way.

238 thoughts on “I have a Patreon page

  1. But haven’t you heard? Obama rescued the economy, and the recession has been over for years now!

    Seriously, good luck with the Patreon, but I’m still hoping for posts on Trump, the Hugo results, and the current status of Android/iOS….

  2. I’m sorry things are tough, Eric. If I wasn’t broke I’d make a contribution because despite our political differences I’ve always been very impressed with your work in/writings on software. I hope you find some good paid consulting work and your wife gets a full-time job.

  3. Raise your rates and *tell* people that that is because your health insurance rates when up. I’ve been looking for a job for the last 2 months (being picky because I am still working) and I am very explicit with recruiters–my rates are $X and hour because health insurance/health care cost me 8 dollars an hour, and that is now built directly into my costs. The more they can reduce those costs the less I’m willing make per hour.

    People are shocked when I tell them what the “bronze” plan costs a family of 4 for insurance that has insane deductibles (it looks like they went up to 5k/person 10k/family) they are shocked.

    And by “stock” I hope you really mean “widely diversified holdings in no-load mutual funds”.

  4. Petro: It’s darkly ironic that one of the original arguments for Obamacare’s outlawing of inexpensive “junk insurance policies” was that many had deductibles that were “too high.” So now we’ve got expensive policies with high deductibles that are too high….

  5. As I’ve said before, you’re one of the guys who has made my livelihood possible. I’m happy to chip in, and I posted the link to my FB account, where I have a lot of friends who work in the IT field and are likely to throw in a few more bucks.

    A simple thank you for all you’ve done to help so many of us over the years.

  6. No beret or nose ring here, but I do support about 58 people on Patreon with small donations. I’ve added you to my list!

  7. Don’t be too surprised by the amount of money you’ve managed to bring in through Patreon: My parents have been living entirely off of donations since before I was born: I was quite literally born on a fundraising trip and raised on donated money. The amount of effort you need to devote to fundraising to make a living that way is non-trivial, but is manageable.

    Anyway, as I have, in previous comments here, advocated patronage as the business model that should be used for software development, I am putting my money where my mouth is.

    • >Wouldn’t ICEI help support NTPsec? Or did that hit the skids too?

      ICEI’s oxygen mostly got cut off wnen CII announced its existence. We’re still trying to recover from that.

  8. In the UK in theory we pay that ‘medical insurance’ direct to the government who pick up the bill for the entire medical system. Not sure that it is any better a model to cover the costs given it makes the country far too attractive to migrants, but my own income has just about been destroyed by the fact that third world countries can provide much of what we do without ANY of these overheads. Until the playing field is a lot flatter we are not going to get a fair share but at least this side of the pond when they kill off some of my income they also loose out on the tax :)

    • >ICEI? CII?

      ICEI = Internet Civil Engineering Institute, a nonprofit I was trying to bring up to raise funds for Internet infrastructure work. CII = Core Infrastructure Initiative, similar idea with lots of industry funding that launched with big fanfare as ICEI was preparing to go public.

  9. Sad to hear your book royalties are dwindling – I think there are several good books worth of material in this blog and it does not require too much in the way of editing. Excerpts from best comments could be put into floating bubbles inside the text, that would make a cool, readable format. Think like this – your name is a brand name, it sells stuff. And books are probably the kind of stuff it sells best. It sells software too, it is just far harder to figure out how make people actually pay up for it.

    Speaking engagements at LUGs and similar places? They dried up? Practically because you won? If yes, that would actually make an excellent book, to document how you won – not many people won causes as big as this. “How To Actually Change The World Like I Did” or something would make a bestseller.

    • >Speaking engagements at LUGs and similar places? They dried up?

      I never charged anything but expenses for those. I felt it was important for my positioning that it not appear I was trying to milk profit from the movement I was then leading.

      >“How To Actually Change The World Like I Did” or something would make a bestseller.

      It’s an interesting thought, but the way I did it was so particularly tied to my idiosyncratic mix of skills and the contingent circumstances of history that I doubt I could teach anyone else to replicate it.

      Which is not quite to say I have nothing to teach – some of my tools are more generally applicable. I have blogged about some of them.

  10. “Towards Zero Defects Software” would be a nice book to read (based among others on your experience developing GPSD)…

    • >“Towards Zero Defects Software” would be a nice book to read (based among others on your experience developing GPSD)…

      That’s more plausible, yes.

  11. What about book about proper version control and DVCS migration?

    The version control can be generalized so it is not tied with Git.
    Add some patterns and antipatterns observed during project conversions.
    A few reposurgeoun cleanup examples.
    Hopefully the repo conversion becomes unnecessary soon, but proper repo cleanup will always be needed.

  12. Would be nice to have ‘Zero Change Software’ so we can just get on using it rather than having to learn new user interfaces every few months. My phone is still hassling me to ‘use our new user experience’ but I’m happier with what I know ESPECIALLY hands free in the car!

  13. > What about book about proper version control and DVCS migration?

    > The version control can be generalized so it is not tied with Git.
    > Add some patterns and antipatterns observed during project conversions.
    > A few reposurgeoun cleanup examples.
    > Hopefully the repo conversion becomes unnecessary soon, but proper repo cleanup will always be needed.

    This project has the advantage that is at least partially written as “Understanding Version-Control Systems (DRAFT)”[1], which in turn was cited[2] in Eric Sink “Version Control by Example” book (available free online, published by Pyrenean Gold Press, available on Amazon).

    [1]: http://www.catb.org/esr/writings/version-control/version-control.html
    [2]: http://ericsink.com/vcbe/html/history_of_version_control.html

  14. > What about book about proper version control and DVCS migration?
    [the link-free version, while the 2-link version avaits moderation]

    > The version control can be generalized so it is not tied with Git.
    > Add some patterns and antipatterns observed during project conversions.
    > A few reposurgeoun cleanup examples.
    > Hopefully the repo conversion becomes unnecessary soon, but proper repo cleanup will always be needed.

    This project has the advantage that is at least partially written by ESR as “Understanding Version-Control Systems (DRAFT)”, which in turn was cited by Eric Sink in his “Version Control by Example” book (available free online, published by Pyrenean Gold Press, available on Amazon).

  15. I must admit, I did wonder how you kept yourself in bread – the work you’ve spent your life on is important, but never seemed to be long on compensation.

    I’m too skint right now to chip in, but *insert statement of moral support here*.

  16. At least in the long run, Obamacare will decrease health-care costs and probably raise life span. Switzerland has had the same system for many years now, and has had lower health-care costs and higher life expectancy than the US for all the time we didn’t have it. (They’re also more urbanized, but still.)

  17. @EMF
    “Switzerland has had the same system for many years now,”

    Not quite. The US has been able to take a straightforward system, like Switzerland, Canada, or many others, and has mangled into some devious system that combines the worst of all worlds.

    http://www.nationalreview.com/article/362443/obamacare-worst-case-scenario-kevin-d-williamson

    http://www.vox.com/2014/6/16/5812898/five-ways-the-american-health-care-system-is-literally-the-worst

  18. I’m sorry your healthcare costs went up. On the other hand my diabetic cousin is now able to get insurance. Before, no insurance company would touch him with a 10 foot pole, leaving him one bad day away from bankruptcy and death.

  19. I am sorry to intrude, but how does a medical insurance cost somebody a job? I ask genuinely because I don’t know about US politics all that much.

    I am curious because I am presently working in an insurance company as a legal officer. I had to get a full-time job because my law practice wasn’t going as well as I hoped and I have monthly commitments to meet. :)

    • >I am sorry to intrude, but how does a medical insurance cost somebody a job?

      The short version is that Obamacare mandates have added so much to an employer’s overhead for anyone full-time that the full-time job is being effectively abolished. Even professionals like lawyers are being fired to be replaced with contractors who have to buy their health insurance a la carte.

      It’s a double whammy – first Obamacare destroys secure employment, then it saddles people living hand-to-mouth with ruinously high costs. Our health-insurance premiums are higher than our mortgage.

  20. Congratulations on the patreon going well.

    The beret-and-nose-ring crowd? Does this actually make sense? The beats and the popularity of modern piercing are some fifty years or more apart. There isn’t a single crowd, and On the Road would be very different if the trip had been crowdfunded.

    I’m not sure what you had in mind by the “beret-and-nose-ring crowd”* — too arty? Too young? Too left-wing? For what it’s worth, one of my friends says he knows a bunch of stuff supported by patreons, and it’s typically pretty mainstream.

    I don’t know whether you put off setting up a patreon (as distinct from not expecting much from it) because you thought it wasn’t for your kind of people, but if you did put it off, you might consider months when you could have been raising money.

    In a previous post, you mentioned worrying about becoming mentally ossified. You’re in good shape for computer programming, but I think you’re missing out on what’s happening socially.

    People who recommend that Eric pull together a best of Armed and Dangerous collection are probably underestimating the amount of work involved in editing that much material.

    “Zero Defects Programming” might also be a place for a topic you’ve told me about but which I don’t think has turned up in your writing. You seem to be good at staying focused on the goal of a program, and I don’t get the impression this is universal among programmers.

    *I’ve been thinking about the effects of vague insults like “puppy” and “literary science fiction”. It’s interesting to see how poor the quality of communication is.

    • >The beret-and-nose-ring crowd? Does this actually make sense?

      Yes, it does. You haven’t been to Seattle recently, have you? A difference from the Beat era is that nowadays it is almost always women wearing the berets. Back in the 1950s it was mostly men, judging from the pictures.

      >I’m not sure what you had in mind by the “beret-and-nose-ring crowd”* — too arty? Too young? Too left-wing?

      Too arty. Look at the producer categories – they’re all arts and media except for “Science”, which I wedged myself under because everything else was a worse fit.

      >I don’t know whether you put off setting up a patreon (as distinct from not expecting much from it) because you thought it wasn’t for your kind of people

      Actually, nothing like that. I didn’t do Patreon because I was counting on Gittip/Gratipay for this – but it never worked very well, and eventually ran into some regulatory snafu that caused it to back out of supporting individuals.

      >People who recommend that Eric pull together a best of Armed and Dangerous collection are probably underestimating the amount of work involved in editing that much material.

      I fear so.

      >“Zero Defects Programming” might also be a place for a topic you’ve told me about but which I don’t think has turned up in your writing

      I did write a paper on GPSD as a case study in very-high-reliability software: http://www.aosabook.org/en/gpsd.html

  21. >>The beats and the popularity of modern piercing are some fifty years or more apart.
    Fallacious: assumes only beatniks wear berets.

    >>It’s interesting to see how poor the quality of communication is.
    Actually, I’ve found over the past two years that the quality of the communication on this site is far above most others that I visit. Even the comments, which is saying quite a bit.

    >>I’ve been thinking about the effects of vague insults like “puppy” and “literary science fiction”.
    The insults aren’t vague. They’re carefully chosen for their effect. A puppy is young and enthusiastic, but not necessarily overly bright or wise. Literary Science Fiction is covered in great detail in other posts.
    As for their effects, they are *insults*. Their intent is to offend. Looks like they were sucessful.

  22. While Patreon is an obvious match to things like comics or other clearly recurring events, I’ve wondered if it would be possible to be an open source developer on Patreon. It can be a surprisingly efficient aggregator for low amounts of money per month.

    Probably the problem with trying to do that with ntp is that only companies care, and getting a company signed up to Patreon would probably be a trial. Something with a more plausible use case for “normal people” could probably do better. If you’re interested in minmaxing this a bit, you could consider also pledging some support for Battle for Wesnoth and seeing if some players might chip in. (I say this more in the spirit of rolling ideas around than necessarily a “suggestion”.)

    Don’t apologize for supporting someone for only $1 or $2 a month… a few hundred people do that and soon you’re talking real money.

  23. It’s a double whammy – first Obamacare destroys secure employment, then it saddles people living hand-to-mouth with ruinously high costs. Our health-insurance premiums are higher than our mortgage.

    Obamacare is a massive sop to big insurance disguised as “doing something” about the health-care crisis.

    And it’s really emblematic of the problem with America vs. The Entire Rest of the Fucking Planet: other civilized countries’ policies make a good-faith effort to solve the problem, while the American policy was authored by lobbyists to benefit the lobbying organizations and disguised with Bernays black magic to look like an effective solution to an unwitting populace even though it was engineered to be nothing of the sort.

    In the case of health care, the solution the civilized world arrived at is cheap, easy, provides equal health outcomes regardless of SES and better health outcomes overall, and has been universally adopted (except of course in the USA): single payer.

    • Single-payer. Yeah, that’s the “solution” under which hospital patients die in agony of dehydration because the government employees can’t be arsed to bring them a drink of water when they’ve been pleading for days (England’s NHS). When the government employees are paying attention, they covertly instititionalize involuntary euthanasia to pull down costs (the Netherlands). Or you get hospitals choked with filth and feces, where the only thing not in short supply is cockroaches the size of your hand (Cuba).

      No matter how bad the results of government intervention are, more intervention can be counted on to make things worse. Health care illustrates this in particularly gruesome fashion.

  24. The beret-and-nose-ring crowd? Does this actually make sense? The beats and the popularity of modern piercing are some fifty years or more apart. There isn’t a single crowd, and On the Road would be very different if the trip had been crowdfunded.

    Young intellectual counterculturalists today are often called by the same moniker as young intellectual counterculturalists of the Beat era: hipsters. The reasons why are not coincidental, as the latter are often engaged in a game of NLP-esque cargo cult mimicry of the former, in the romantic hope of reviving a more authentic past.

    I believe this is rooted in a sort of reactionary disdain for post-1980s high-tech modernity and that Patrick Farley’s comic “The Guy I Almost Was” is good expository material for the phenomenon.

  25. Sorry, switch “former” and “latter” in the above. I know that “aging hipster” is a stereotype but I’ve yet to see any geriatrics who were active in the Beat era hold forth on which was better: Nirvana before Nevermind or after.

    Maybe that’s just because I don’t read enough Rolling Stone though…

  26. >At least in the long run, Obamacare will decrease health-care costs and
    > probably raise life span.

    That is such BS. It’s not happening, prices are going up, insurance rates are STILL going up, people have *less* access to doctors–one of the common complaints here is that the medical care networks are fracturing, and people can’t use the doctors they did before. Health care is *NOT* a commodity. Doctors are as much or more “hackers” than programmers. Bad ones are hard to distinguish from good ones until you see their work, and by then it’s often too late. Great ones are *INCREDIBLY* useful, but everyone wants them.

    The “Bronze” health insurance plan (the cheapest one on the Exchange, and the minimum that private insurance companies can offer (except under certain narrow conditions) has NO HEALTH CARE IN IT. You get *ONE* “preventative” visit a year, and everything else up to the deductible (a few thousand dollars per person) is paid out of pocket.

    How does that make health care better?

    > Switzerland has had the same system for many years now, and has had lower
    > health-care costs and higher life expectancy than the US for all the time we
    > didn’t have it. (They’re also more urbanized, but still.)

    http://www.forbes.com/sites/peterubel/2014/04/18/the-real-health-care-subsidy-problem/

    They’re also a very tight and (relative to the rest of Europe and the US) homogenous culture.

    Switzerland has about 8 million people +/-. You know what we call 8 million people in the US? New York City. Or, for slightly more than 8m “The Chicago Metro Area”.

    Freaken COOK COUNTY Illinois has *almost* that many people (5+ million) in an area you could (if you were in shape) walk across in 24 hours. Looking at the demographics of Switerland, I had more diverse barracks in the freaken military.

    When the dominate culture is northern-european, and you’ve got a small (relatively) number of people in a small (relatively) geographic area to take care of, certain socialistic policies have a reasonable chance of working–when the dominate culture says “don’t be a lazy schmuck” and when lazy schmucks become social outcasts, well, people don’t want to be that.

    You simply can’t look at the little flyspec european countries actions since the end of WWII and compare them to what happens in the US. Switzerland, size wise, falls somewhere between Maryland (42nd) and West Virginia (41st) in size.

    Of course, that culture is changing, their immigration rate from non-european countries is going up. Get back to me on how they’re doing when over 10% of their population is not of European Christian descent (This isn’t about race, it’s about *culture*. Watch).

    I’ve worked in Health Care in the US, and our two biggest problems in health care boil down to refusal to adhere to doctors orders. This comes from (a) directly not following them (take these pills EVERY DAY/Until they’re all gone, exercise, don’t eat crap) or (b) following stupid, unscientific, fraudulent advice from the likes of Dr. Oz and his criminally negligent guests. (See sciencebasedmedicine.org) You *routinely* hear people in the US bemoaning that “Doctors don’t know shit” as they shovel a Denny’s Grand Slam into their mouth in-between insulin injections. You’re just not going to get good medical outcomes NO MATTER HOW MUCH YOU SPEND if you don’t have good science and good compliance.

    Switzerland, Canada, and the Netherlands (to name a few) are basically the sociological equivalent of middle and upper middle class America demographically. The simple don’t have the same percentages of urban and fringe-rural poor (those who have the worst compliance and are the most suspicious of and resistant to good health care practices).

  27. Jeff Read: In the UK it turns out the single payer only pays if you’re willing to wait for months in agony for your operation. If not, you dip into your savings.

  28. DysgraphicProgrammer on 2015-09-02 at 11:15:27 said:
    > I’m sorry your healthcare costs went up. On the other hand my diabetic cousin is
    > now able to get insurance. Before, no insurance company would touch him with a
    > 10 foot pole, leaving him one bad day away from bankruptcy and death.

    Well, if my 8 year old breaks a leg or gets Leukemia I’ll tell her that it’s just too bad we can’t afford to get it fixed properly because Daddy–who has paid for his OWN damn health insurance since he was 18, was priced out of the market because the best and the brightest people in the US could find only ONE way to get people the health INSURANCE they needed.

    Yeah, your cousin can get his health insurance, but I *can’t* because people like Jeff Read really, really want their government to run EVERY part of our lives, and won’t let us make our own contracts. No, it’s got to be SINGLE PAYER or we’re “uncivilized”.

  29. Fucking hell I have to pay $0.80/month in VAT to the British government for the privilege of encouraging you to write about why I shouldn’t have to pay tax! You’d better deliver, Raymond!

  30. In the UK it turns out the single payer only pays if you’re willing to wait for months in agony for your operation. If not, you dip into your savings.

    Only because in America the path to the OR is greased with cold hard cash.

    The NHS is still a vast improvement over American style private insurance. Months in agony is better than the death sentence you would receive for the crime of being poor and sick in America. The Guardian and other British publications are full of stories aimed at NHS critics of the form “it could be worse… we could have (dun dun dun!) the American healthcare system.”

    Fun fact: in Canada life expectancy is uniformly into the early 80s for the entire population. In the USA, life expectancy is a function of wealth; only the richest Americans ever achieve Canada’s life expectancy.

  31. What gets me is that pretty much everyone has abandoned the idea that “single-payer” is the best way to provide food, clothing, housing, manufactured goods, education, or pretty much anything other than health care. What makes health care so special that it avoids the catastrophes that “single-payer” created in all those other areas? If the response is: “But medicine can cost too much when you have cancer” (or whatever), you’ve already lost half the argument, because much of health care is not that expensive: check-ups, birth control, etc. The entire single-payer argument is based on obsolete 20th century thinking: “Just centralize it all under the federal government, and it will work fairly and efficiently.” As it turns out, no, it does not.

    • >The actual statistics say otherwise:

      You misspelled “A notoriously left-wing source says otherwise”. I am unimpressed. I’ve seen the pictures of the Cuban filth and cockroaches; there’s your single-payer utopia, right there.

  32. James Noyes, I meant that the quality of communication when people use vague insults is poor, not that the quality of communication on this site is generally poor or has become worse. I suppose this is an example of what I was talking about.

    Eric, my apologies– I didn’t realize berets and nose-rings had become a thing in Seattle.

    • >Eric, my apologies– I didn’t realize berets and nose-rings had become a thing in Seattle.

      And a lot of college towns, even off the coasts. You could go to any coffee shop in Ann Arbor or Austin and you’d see hipsters ironically wearing what they take to be Beat garb. Well, except their Beat prototypes didn’t do nose rings.

      Heh. And it was supposed to be me that was “missing out on what’s happening socially”. No blame attaches; I travel more than you do and I think I spend proportionally more time around twentysomethings, like at FOSSCON 2015 in Philadelphia a couple weeks ago.

      This can have some entertaining effects. One of the local hackerspaces was exhibiting a silly project named Clyde, a “robot” that looked like Irwin Allen’s idea of a computer and gave (actually random) yes/no answers to questions spoken into a microphone, in a cheesy Robby-the-Robot voice.

      Hackerspace people: all twentysomething geeks, very clean-cut and earnest, mostly doing a pretty good job of hiding how impressed they were to have “ESR” sitting on the couch in their hangout space.

      So, the game was, the hackerspace people would jokingly try to convince those who wandered in that the robot had real AI in it. Why not join the fun? So to one of the bemused passers-by asking what Robbie could do, I said, very straight-faced “Just don’t ask him about tomorrow’s sport scores; his hyperspatial prognosticator is on the fritz.”

      One of the hackerspace kids looks at me and says, sounding a bit surprised, “He fits right in…”

      And the tone of surprise was just a little irritating, so I gave him my most disarming grin and said “Dude. I designed your culture”

      He looked thunderstruck for a moment, recovered gamely, and said “Fair enough!”

  33. That there is a lot of miss information is a simple fact. There are rotten apples everywhere and as soon as they are identified one would like to think they are dealt with appropriately? Perhaps the ‘need’ to keep changing things is all pervasive? Just how many laws do you need to change each year and how many are changed just to justify having politicians? One countries practices are simply not suitable for another, but with all the migration more and more people seem to think they can force their views on the majority and impractical compromises inevitably result. How often nowadays are changes pushed through which ARE stupid, but are the only way to get the main business accepted? Not sure if a ‘clear majority’ as the current UK government is any better than compromise with a coalition … I simply don’t trust any politician to do the right thing :)

  34. And the tone of surprise was just a little irritating, so I gave him my most disarming grin and said “Dude. I designed your culture”

    Bet it chuffed you nearly as much to drop that bomb as did “I’m your worst nightmare” on that Microsoftie in the elevator…

  35. the current status of Android/iOS….

    Current status is, under US law Android is stolen tech.

    Rumor has it that Google has super-seekrit internal builds of Android with an all-new native-code runtime (i.e., not ART) and a different C++ API. By about the time Necco Wafer or Oreo gets released, they will probably be forced to deploy it because of the copyright-infringement judgement against them, as well as pay billions in back royalties to Oracle.

    And this is why most of the next generation’s software leaders will not be from the USA.

  36. I wasn’t intending to taunt esr, but his predictions of a few years ago re the Android vs. iPhone have not happened, and I’m interested to hear what he has to say about the topic these days. There was supposed to be a market share tipping point, and Apple’s closed-code approach would fall to the “Android army.” But Android’s market share seem to have stopped increasing, and even shrunk by some measures. And nobody besides Samsung seems to be making much money from it, and even Samsung isn’t doing too great these days.

  37. I don’t get ideological objections to things that, in practice, work pretty well.
    In practice, single-payer in Canada works very well. One indicator is that you’d find very, very few people who would trade it for what we see down south. There are private clinics around if you want them, but the middle classes don’t go there. Just sports figures, politicians and the wealthy.

    And yes, there are waitlists, but these are triaged and prioritized. It’s manageable.
    Yes, you’ll see stories about the poor lady who didn’t want to wait six months for a hip replacement and so headed down to the Mayo Clinic, but these are pretty rare. (We call these “whiners”) Last time I got an MRI, I was told the wait would be two months. It was not urgent, so that was okay. (Turns out I got in due to a cancellation in a few days) Emergency cases do not generally wait.

    The doctors don’t make as much money. It’s good money, but not rock-star money. Most seem okay with that. Some head down south.

    The real downside is taxes. They’re too damned high. (only partly due to Medicare)
    But I can change jobs without worrying about my kids pre-existing conditions. We can worry about my dad’s cancer rather than his medical bills. That’s pretty nice.

    • >One indicator is that you’d find very, very few people who would trade it for what we see down south.

      By report, this is not true. Canadians with serious illnesses are notoriously prone to book to the U.S. if they can afford to do it.

  38. Let me point out the Association of American Physicians and Surgeons at http://www.aapsonline.org/ .

    This is a group of doctors who practice on contract, with (usually) a monthly subscription fee: — what are sometimes called “concierge practices.” They tend to be conservativish politically, I think, although some practice “alternative” medicine as well as Western Conventional (if I may so call it). They are certainly against (at least most) governmental involvement in health care, and have been since the organization was founded in 1943.

    They aim to make their living by providing the best care at the least cost.

    Here is the current lead posting on the site:

    Direct Payment / Cash Friendly Practices
    Mar 15, 2015

    More and more patients are looking to work directly with their physicians without the government or insurance company in the exam room.

    To see a list of physicians with direct payment / cash friendly practices please visit:

    https://aaps.wufoo.com/reports/m5p6z0/.

    As this list grows we will work to make it more user friendly. It is sorted by state by default but can be sorted by any other column by clicking on the column heading.

    There’s also a link for interested doctors there.

    See also the “About” page: http://www.aapsonline.org/index.php/about_us/ . This page has full contact information, as well as a “mission statement” and other info.

    I discovered them while UT-surfing. Their “Thrive Not Just Survive” series of videos is intended for docs, but gives a good feel for the project to us laymen (prospective patients). Select “Resources” in the menu across the top, and “Video” on the (voluminous) “Resources” page.

    To see what may be available in your state, visit the link above. Page introduction:

    Cash / Direct-Payment-Friendly Practices

    The below physicians [sic] will accept payment directly from their patients without involvement of the insurance company or government. AAPS is providing this list for information purposes only. The information contained in the list was supplied by and is the responsibility of the physician/practice not AAPS.

  39. I don’t get ideological objections to things that, in practice, work pretty well. In practice, single-payer in Canada works very well.

    It’s important to note that you’re not getting an ideological objection here. It’s contingent. People who oppose single-payer don’t simply have some niggling urge to oppose the government. If single payer really did work, a lot of people would be all for it.

    It’s just that it doesn’t actually work that well, when one looks closely. (Unless by “works well”, you mean “feels simple and unobtrusive so long as I’m willing to wait a long time for care”. For most Canadians, as for most people in general, particularly younger people, it wouldn’t surprise me if that were satisfactory.)

  40. What’s your complaint about single-payer? It’s cheaper and seems to lead to better life expectancy, especially for the poor. Also see Iconoclast’s point about waitlists being triaged, so that if you can’t wait, you won’t have to. And if you can wait, you should, so that those who can’t will get in first.

    • >It’s cheaper and seems to lead to better life expectancy, especially for the poor.

      My complaint is that I don’t believe either of those claims.

      You have to be very careful about comparing international life-expectancy statistics. Comparisons with the U.S. are badly skewed by a difference in reporting practices; neonatal deaths that are filed under “infant mortality” here are often not counted in other jurisdictions.

  41. The Australian version of single-payer keeps victims on the waiting list for a waiting list slot until they die there and are no longer cluttering up the government’s statistics.

    “If you can’t wait, you won’t have to” is aspirational – assuming that $IDEALISED_POLITICIAN is in charge, has a solid legislative coalition at his back giving him a free hand, has unlimited budget to live the dream, is glorious leader of an adequate-sized army of fanatically loyal bureaucrats, and will never make serious policy mistakes.

    “If you elect us, we promise to at least try to make the waiting lists look shorter” is where the electoral discourse has actually gotten to:

    https://www.qld.gov.au/health/services/hospital-care/waiting-lists/

    Note they don’t define “elective surgery” as “you could do without it, if you can wait, you should, so that those who can’t will get in first”. They define elective surgery as “planned surgery that can be booked in advance.” If failing to get to the head of the Category 3 waiting list for your elective surgery in time will kill you, well, more room for the rest of us.

    The government department that defines that categories is the same one that is accountable for the waiting list statistics.

    So, I’ve been covered by private health insurance since I was old enough to afford it. Public policy here is that everyone who can be, should. They don’t have to mandate community rating or online exchanges to make this happen. They just have to make it not illegal for people with cash to buy their own insurance, and make the purchase a tax-advantageous move.

  42. @esr
    “they covertly instititionalize involuntary euthanasia to pull down costs (the Netherlands). ”

    So you get to the point that you accuse us from murdering people to stay on the cheap. Last time this discussion went on, you still denied that.

    You should know better, especially as this accusation has come up on this very blog and you participated. The article Jeff linked to in the Washington post is accurate.

    This is the same type of thing as abortion. When it becomes legal, the rate often reduces from the previous illegal practice. The same with euthanasia. Euthanasia does happen in the USA too. There it is disguised as palliative care, but that just means terminal patients are brought into a drug induced coma and are then let to die. An overdose of morphine does not really kill you, so they have to stop giving you liquid or food or do something else that will make the breathing stop. It happens in the USA too.

    Patients are desperate and medical practitioners want to help. By making it illegal, patients and doctors have to resort to sub-optimal solutions which often increase suffering.

    For the rest, our health care system, and that of the Germans and British and French, works pretty well. The Dutch system is on the expensive side, but we manage. It does not matter much how you organize it. What matters is that you organize it around getting people the health care they need.

    The US discussions never are about how everyone can get the health care they need. It is always only about the rules and regulations. And so they created a monster.

    If it were not such a sad thing, it would be funny that with all their might the US were unable to create a system that could even match that of either of their neighbors to the north and south.

    • >Last time this discussion went on, you still denied that.

      Correct. Now I think I have better information. When the evidence changes, I change my mind.

      >Patients are desperate and medical practitioners want to help. By making it illegal, patients and doctors have to resort to sub-optimal solutions which often increase suffering.

      Apples and oranges. I’m not one of those who thinks abortion should be illegal; nor do I think doctor-assisted suicide should be illegal. Government-run hospitals witholding care to hold down terminal-patient costs is a completely different issue; I find reports of it credible because the incentives in a single-payer system favor that behavior.

      If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them alive as long as possible. If their care is being paid out of a fixed pot of single-payer funds, killing them is revenue-neutral and may even feel justified as a way of redirecting rivalrous resources to where they might save a less ill patient.

  43. The pre-existing condition thing is a bit overhyped about the US system. There was already rules in place that if you had coverage in the 6 months before you get your current job, that the pre-existing conditions were covered. Changing jobs is no problem. It’s only people who were completely uninsured while the condition was found that would have a problem. Those things were eventually covered after a year iirc.

  44. Of course most people who have it wouldn’t trade away single-payer health care. Most people are healthy, and single-payer healthcare is well-designed to make healthy people happy, by bundling all the bills for their routine health care (or the expensive care for their sick relatives) in the tax bill. Which is then hidden from them reasonably well by being taken up by paycheck withholding and in the sticker price of goods charged VAT. That you have to wait longer for, say, modern diagnostic tests (Canada had one-third as many MRI units per capita as the US in 2007, which was still only two-thirds the number per-capita that the US had in 1995) doesn’t intrude much; you undergo the test when it’s scheduled, after all, without much idea of how much faster it would be if there were more machines. If you die because you go undiagnosed because your symptoms weren’t acute enough to get you even scheduled for a test on the fewer available machines, well, hey, you’re not a voter anymore, unlike the uninsured guy in the US who got a fat bill for it. How many of your relatives are, as a result of your death, going to start a crusade for replacing single-payer with a system that will charge them for office visits but increase the number of MRI machines?

    Yes, yes, you can argue all day over specific questions of the efficient rate of testing, and whether overtesting then gets you iatrogenic troubles as a result, etc. The point is Bastiat’s seen versus unseen; single-payer’s costs tend to accumulate in the realm of the unseen, which is not the same as being costless.

    Ah, you say! But if the hidden costs really were at the expense of health, it would show up in the life expectancy!

    Well, yes, if life expectancy is a monotonic function of health care quality without any confounding factors.

    It’s pretty hard to blame the US health system for the far higher annual per capita rate of fatal car accidents in the US than in the Netherlands, after all (though some people will try). And somebody dying at age 20 instead of 80 on the scene of a car accident depresses life expectancy stats more than you improve it by your superior system saving the lives of ten people at age 75 who go on to live to 80. And setting aside that sort of thing, there’s no monotonicity, either. If a premature infant is born at a hospital where there is no medical technology sufficient to keep it alive, it goes into the books as born non-viable and isn’t counted in life expectancy stats (or infant mortality, for that matter). If it’s born at a hospital where it can be saved with a 50-50 chance, and then succumbs after a week, it goes into the life expectancy stats as a death after seven days of life — and now your better system (since it sends home half of those kids alive instead all of them to the grave) will have to save forty 75 year-olds for age 80 to break even on the life expectancy you lost because you had the ability to try to save the premature baby.

    But, of course, while you can point out all the potential confounders of the numbers, how does one go about making the numbers rigorous enough across whole-population studies of multiple countries to actually reach a reasonably-hard number that can tell you about relative quality of health care systems?

    With the available data, one can’t. Nobody’s even tried to fund the studies to do it. So it’s perfectly possible to look fairly at the data and conclude that the rest of the industrialized world produces better outcomes from equivalent input, on average, than the US. It’s just that anyone who refuses to grant that a fair look can result in the opposite conclusion is blinded by some combination of ignorance and ideology.

  45. Austria reporting in: most doctors run parallel public and private practices, so I can get a tax-paid appointment in two months advance, or pay out of my pocket about €100 for a 45 min visit and get one in three days. This is a very simple cash fee paid directly to the doctor, avoiding the US type insurance bureaucracy nightmare.

    Overally the public part of it sucks, I mean the waiting lists. Although my wife’s childbirth experience was very good, I guess that is a smart move, one way to fight dropping demographics is investing money into making childbirth safer and less of a nightmare. Every mother got a private room with full complete equipment, oxygen to epidural, and a team of one doc and two midwives. That was pretty impressive for me. Other than the positive birth experience, the public part is all waiting lists, overcrowded emergency rooms and hurried, rude doctors.

    But I wonder if the public part plays a role in keeping the private part fairly cheap, so that doctors have to keep their prices competitive, by competing with “free” ?

    I don’t really understand the economics of it all really well. I try not to use the public part of it, but I do think the public part helps in keeping the cash paid, not-insurance-based private part kinda cheap.

    Thankfully, they let private entrepreneurs in the public part as well, which makes it far more bearable. There is one thing I love about Austrian healthcare that is so different from e.g. the UK is that there is no puritan spirit. There is a bar right in the center of our local hospital, the Donauspital, with booze and pizza. http://www.herold.at/FS/picture/6/7/2/2520276.jpg After my daughter was born and she and her mom fell asleep around 06:00 I was doing beer and jäger in this hospital bar / cafe, calling my relatives. It felt a bit surreal. Also, there is a hairdresser, beauty salon etc. so hospitalized people basically feel like they are in a mall, having a good time, not in some puritan monastery. And all these are of course private entrepreneurs renting space, so they actually reduce the taxpayers bill. I was completely dumbfounded. Why doesn’t all of Europe do this? Especially back home in Hungary, we are generally considered a partying type of people and yet the only accepted behaviour in hospitals is, apparently, suffering in silence and consuming unappetizing health-food. Smuggling in a beer would be a scandal. Monastery spirit, puritanical spirit, a place to atone for your sins… and it would cost nothing to the government to change it, in fact it would bring a revenue, just let entrepreneur rent hospital floor space and the rest would be sorted out by the market.

  46. @esr
    “Correct. Now I think I have better information. When the evidence changes, I change my mind.”

    I would really like to see that evidence.

    What I generally see in the US is a complete lack of any understanding of how the systems outside the USA work. Like that hyped “death panels” in Canada.
    http://www.slate.com/articles/news_and_politics/jurisprudence/2013/10/canada_has_death_panels_and_that_s_a_good_thing.html

    The Netherlands is no different, ignorance rules in the USA about our euthanasia system.

    The discussion about how much an extra month of life is worth rages periodically through Dutch politics. No one wants to touch it. As a result, doctors do not touch it too. Given the strict regulations for euthanasia, which include involving OTHER people, no institution will even contemplate using euthanasia to get rid of patients. And thus we see a very small number of euthanasia requests.

    So, what problems we have in our health care system do not include too much euthanasia. Actually, the complaint is that it is much too difficult to get euthanasia when you really want it.

    Btw, when you cannot get a treatment in the Netherlands in time, you are allowed to go abroad and get refunded.

  47. If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them alive as long as possible. If their care is being paid out of a fixed pot of single-payer funds, killing them is revenue-neutral and may even feel justified as a way of redirecting rivalrous resources to where they might save a less ill patient
    In the UK this is probably the most messy area? Legally euthanasia is blocked preventing a few small number of people who know they are going to become unable to do anything themselves and be reliant on machines to make a choice. If they have money they can go abroad but have to do that before they NEED to, but if they stay in the UK then it may be more ethical not to keep a shell alive.
    A slightly more difficult one in my book is the VAST sums of monies drug companies charge for some treatments many of which are developments of work our charity sector have funded when they were not ‘economically viable’. Why should someone who has money get a few more weeks/months when someone who may well have contributed to that research all their lives is denied it because they can’t afford it? ebola is probably a good example of why the whole system is broken, and while yes drug companies have to make money when does profit become excessive?
    On the American model currently just how much money goes to ‘caring for health’ and how much to enhancing the bottom line? The problem perhaps is one of just what ‘acceptable profit’ is built into the system and when you compare between countries with different practices this messes up the picture?

  48. @Lester Caine –

    Easiest way to do quotes is with “<blockquote>” and “</blockquote>” tags. Results like this:

    ( HOW DO YOU ADD A QUOTE? The first paragraph was ‘quoted’ )

  49. A waiting list is called “scarcity”. Centrally managed health care causes scarcity. The only thing keeping any of these government programs going in any of the countries mentioned above is central bank printing presses. As I’ve said to unwilling ears too many times, the problem with healthcare run by Washington DC is that you’re talking about 340 million people run out of the most corrupt and crooked city in America. When people talk about Sweden healthcare, they’re ought to be talking about Connecticut. When people talk about Netherlands they should be referring to Iowa. But no, we hear constant references to how things are going “well, perhaps OK, it kinda works” – which is in and of itself and admission that things are not very good and we then project that onto a nation that is an order of magnitude larger than said “meh healthcare” country. Why do technical people here not think about the SCALE of the problem. Healthcare in the US is going to be the next USSR food lines. Because of the sheer scale of the problem, no central government can possibly manage it. Yes, I too am now an independent consultant and contractor with doubled healthcare costs.

  50. If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them alive as long as possible. If their care is being paid out of a fixed pot of single-payer funds, killing them is revenue-neutral and may even feel justified as a way of redirecting rivalrous resources to where they might save a less ill patient.

    If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them sick as long as possible (or at least prescribe expensive, unnecessary diagnostics and treatments). If their care is being paid out of a fixed pot of single-payer funds, healing them is revenue-neutral and the hospital is incentivized to do so efficiently as a way of redirecting rivalrous resources to where they might save a more ill patient.

    Seriously, Eric, go back and read Arrow’s 1963 paper on why health care is not a market good. And while you’re at it, peep some statistics on the actual health outcomes of single payer vs. American style privately funded.

    You can start here: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

    This is consistent with just about everyone else who’s bothered to gather statistics on this issue, and not first run it through a right-wing spin machine. Americans pay more for far lower quality care than do Europeans or Canadians.

    What about this is so hard to understand?

  51. @Jeff
    “What about this is so hard to understand?”

    I suspect that the main pain point that prevents understanding that it implies that government intervention can be effective, and more efficient than the market.

    When I read US publications, that statement seems to be like saying that water can run uphill.

    And admitting the US is worse performing than any other country in anything seems to be a problem, in general.

  52. > The short version is that Obamacare mandates have added so much to an employer’s overhead for anyone full-time that the full-time job is being effectively abolished.

    OK, got it.

  53. “By report, this is not true. Canadians with serious illnesses are notoriously prone to book to the U.S. if they can afford to do it.”

    Yep. Hockey players, certain politicians, and the very wealthy. Anyone who doesn’t need insurance in the first place. You’ll hear more about them in the corporate press, of course, because single-payer is the socialist boogeyman. Who else could afford it?

    I do hear about people running across the border for MRIs or CAT scans sometimes. For a couple hundred bucks you can save a few months wait. That’s a reasonable cost-benefit tradeoff. If there is a backlog here, they will sometimes pay to send people across the border. That’s just good overflow handling.

    Then there are the folks with the sob stories who need a $50k/month experimental drug treatment for some rare dread disease. Sorry, not happening. But for nearly everyone else, I think most would agree we have it pretty good.

    BTW, what we have here is actually a hybrid system outside of the hospitals. Doctors run their own practices; all the imaging/bloodwork clinics outside of hospitals are privately run. But the rates are set and the bill goes to the Ministry of Health.

    Anyway, Obamacare does seem to be the worst of both worlds. Good luck.

  54. Iconoclast,

    Have you ever looked at the parking lots of clinics/hospitals in International Falls or Buffalo? More Canadian plates than American ones. If Canada’s system is soooo superior, then why are they coming down here for treatment? The last time I went fishing up in Western Ontario in 2009, we stopped a gas station to fill up before crossing the border in International Falls. There was a medical clinic across the street that had 10 Canadian plates for every one Minnesota plate on the cars in the parking lot. I know because I went across the street and counted them.

    • >There was a medical clinic across the street that had 10 Canadian plates for every one Minnesota plate on the cars in the parking lot. I know because I went across the street and counted them.

      Facts trump theory. Nobody got shot crossing the Berlin Wall from west to east. When people vote with their feet, believe the people, not apologists for statism like Winter and Jeff Read.

  55. If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them sick as long as possible (or at least prescribe expensive, unnecessary diagnostics and treatments).

    This implicitly assumes that handling new patient brings less revenue than prolonging care of an existing patient, and that there is no competition among doctors and hospitals, and medical groups.

    Your reasoning, if transformed to e.g. taxi service would mean that each taxi driver would go as long as possible instead of straight to destination, isn’t it?

  56. @ Jeff Read:

    … read Arrow’s 1963 paper on why health care is not a market good.

    I just did, and it was fascinating. Skipping through most of the maths, what is it that Arrow himself proposes as the solution for this crisis of market inefficiency in medicine (emphasis mine)?

    “Suppose, therefore, a large agency or the government stands ready to offer insurance against medical costs on an actuarially fair basis; … ”

    In other words, not single payer, but the sort of healthcare insurance market that has existed since the paper’s publication! (One might even argue Arrow ‘predicts’ the rise of HSAs and HMOs by noting that consumers are better served by pre-payment and multiple doctor conglomerates.) However, that wasn’t the part that had my attention. No, in fact it was where he defined what he considered “non-market” goods:

    “The value of information is frequently not known in any meaningful sense to the buyer; if, indeed, he knew enough to measure the value of information, he would know the information itself. But information, in the form of skilled care, is precisely what is being bouight from most physicians, and, indeed, from most professionals. The elusive character of information as a commodity suggests that it departs considerably from the usual marketability assumptions about commodities.”

    In other words, when you take your car to the mechanic, hire a tax professional or other accountant, architect, software programmer, or any other “knowledge worker”, you are trading in what Arrow has just declared a non-marketable good. I don’t know how to fix every problem with my car, so I must trust the person who does to be honest.

    Funny though: automotive insurance covers liability for accidents, but not maintenance. In fact, I am not aware of any “automotive healthcare” insurance plans. I wonder why then that market is never declared a failure in the same manner as actual healthcare?

  57. Lester,
    Who determines when profit is “excessive?”

    I’d like to say the general public … but the best example is perhaps the fiasco in the very system that invests those profits. Who trusts a bank these days yet they still feel perfectly entitled to take obscene bonuses out of the losses WE have had to cover.
    Then is the price Microsoft and Apple charge justified given the amount of money they have sitting in those banks? Microsoft have wiped out most of my best business in the UK simply by demanding more money to replace perfectly functional XP systems and giving replacements for my systems free in the ‘deal’ to upgrade. THAT is another drain of funds from the NHS in the UK when perhaps we should have been writing contracts to require suppliers to FIX faulty and insecure systems?
    Everybody expects their cut so as I asked – how much actually goes on the service.

  58. “Have you ever looked at the parking lots of clinics/hospitals in International Falls or Buffalo? More Canadian plates than American ones. If Canada’s system is soooo superior, then why are they coming down here for treatment?”

    Good question. Diagnostics? I don’t know. Plus, border towns have their own dynamics. Buffalo is larger and closer to the Niagara area than Toronto is. I don’t know Wisconsin, but Fort Frances (International Falls) appears to be the largest town between Thunder Bay and Kenora, a hundred miles or so each way. There is a whole lotta nuttin out there.

    And I didn’t say it was “sooo superior”… I said it was good enough.

  59. I misread the map… Fort Frances is the small town on the CDN side. International Falls is the much larger US side. And I didn’t mean to say Buffalo was bigger than Toronto, but bigger than anything around Niagara.

  60. @esr
    “When people vote with their feet, believe the people, not apologists for statism like Winter and Jeff Read.”

    Then we would need the numbers of (poor) US citizens trying to get health care in Canada.

    The point has never been that the US can deliver the best quality health care money can buy. The point was always what happens when you do not have the money to buy this care?

    How many people in the US were not or under insured?

    The study that has been linked several times already shows that US citizens do not get value for money, far from it. And they leave out far to many people already. Medical costs are the main cause of private bankruptcy.

    • >Then we would need the numbers of (poor) US citizens trying to get health care in Canada.

      Can’t be done at all, not without identity theft. There’s a limited exception for hospital emergency room visits.

      >Medical costs are the main cause of private bankruptcy.

      No, they aren’t. Elizabeth Warren got famous by making this claim but her methodology was shoddy, designed to sweep in people who had medical costs as an incidental rather than primary financial problem. Later studies making similar claims mistook correlation for causation. When you reexamine that data it turns out not to support the conclusion. See for example

      http://content.healthaffairs.org/content/25/2/w74.full

      “A reexamination of their data suggests that medical bills are a contributing factor in just 17 percent of personal bankruptcies and that those affected tend to have incomes closer to poverty level than to middle class.”

      The pattern of errors seems eerily familiar to me from experience with bogus studies on firearms policy.

  61. @Bob

    I didn’t know that; however, if full-maintenance plans for automobiles are restricted to the luxury brands, what does that analogy imply about the promises of universal healthcare?

  62. If patients are paying for their own care, they are revenue sources and the hospital’s incentive will be to keep them sick as long as possible (or at least prescribe expensive, unnecessary diagnostics and treatments)

    If customers are paying for their own food, they are revenue sources and the restaurant’s incentive will be to keep them hungry as long as possible (or at least suggest expensive, unnecessary dishes)….

  63. Eric,

    Facts trump theory.

    Indeed, so why do you pound the theory when the facts say you’re wrong?

    Once again, the people who actually run the numbers say that Canadians seeking health care in the USA constotute a near-infinitesimal minority, and it is usually for exotic treatments that are available in the USA but not yet in Canada:

    http://m.content.healthaffairs.org/content/21/3/19.full

    But I’m sure you’ll introduce a “liberal bias” epicycle or some such, to correct the facts to fit your theory.

    • >Indeed, so why do you pound the theory when the facts say you’re wrong?

      Canadian license plates commonly outnumbering U.S. ones in clinics near the border is a fact, not a theory.

      >usually for exotic treatments that are available in the USA but not yet in Canada:

      Let’s suppose this is true. Now actually think about what it implies, if you are capable.

  64. Yesterday I dropped off some books at the library and encountered a man sitting behind a card table badgering people to sign a petition “to make universal healthcare affordable in Colorado.” The first line of the petition stated, “That taxes shall be increased by $25 billion . . .” Parasitism has no endpoint until the host is dead.

  65. @esr
    “Let’s suppose this is true. Now actually think about what it implies, if you are capable.”

    That Costa Rica and Thailand have better health care? Because these are some of the popular destinations.

    You know, when some rich third worlder needs complex treatment, they go to the UK, or France, or whatever is politically convenient. Rich medical tourists go where they can spend their money.

    If you want to go beyond looking at number plates:
    Canada’s turbulent medical tourism industry
    http://www.cfp.ca/content/58/4/371.full.pdf

    What do we know about Canadian involvement in medical tourism? A scoping review
    http://www.openmedicine.ca/article/view/442/421

  66. Yes, Winter, by some measures Costa Rica and Thailand do have better health care, because they have more of a free market than the US, and that helps keep costs down.

  67. The first line of the petition stated, “That taxes shall be increased by $25 billion . . .” Parasitism has no endpoint until the host is dead.

    Unfortunately, the devil is in the details. Under this plan, can the government use its power to negotiate the price of drugs in a downward direction? If so, that’s good. If not, that’s really, really bad.

    Is there a robust, transparent mechanism for keeping graft and corruption out of the system? If so, good. If not, bad.

    Is there some kind of provision to make sure that the government purchases, installs, maintains, and makes available for use the correct number of MRI machines? (Or any other medical good.) Does the government get to use its power to negotiate the price of those MRI machines, including such issues as installation and maintenance? Does the law include some kind of reporting requirement so the public can see that the money is being spent correctly? Etc.,

    As far as paying for the service, does the proposed law shift the burden of paying for insurance from business to the consumer? If so, the customer has lost thousands from their paycheck every year. If not, is the proposed system immune to being gamed by businesses or those wealthy enough to afford tax advisors?

    My point in asking these questions is that this particular issue is too-easily reduced to some kind of “four legs good” sloganeering and that doesn’t help much because there are so many variables which make single payer good if implemented one way and bad if implemented another.

  68. Mr Caine;

    Even the White House admits: stagnant wages in America are cause by “health care.” Of course, how much of this increase is medical care, and how much goes to “carrying charges?” Read on.

    The current spike dates back to the US Senate’s tax “reform” in 1986, when they uncapped “health insurance” deductions (great if you’re rich, or in the old UAW). But American health was unfree long before that.

    Like Europe, U.S. “health insurance” takes money away from the filthy poor people and then doles it back out to them*, charging them a stiff fee for all the government paperwork and waiting lists, much of which is a supply-side, hidden tax you are not allowed to see. This punishes poor people, who sometimes buy beer instead of health care, to the satisfaction of others.

    It’s obvious, I hope, that insurance payments, government or private, must carry a large surcharge (or a sizable deductible) for fraud. (Note: I did not say prevention.) Obviously, it would be far cheaper to schedule and pay for dental cleanings and checkups yourself, and reserve insurance for real emergencies, but then Government might be in danger of you realizing your “free” healthcare… isn’t.

    Think about a free market and your health: you have a job (and the housewives of yore had jobs, yes, not getting a paycheck does not mean you are not creating value such as hygienic quarters, cooked, healthy food and/or clothing.) Let’s say you have a broken leg. You need to pay the doctor, but you’re a farmer and can’t work with an unhealed compound fracture. Or you have cancer. How much will you spend beating the cancer?

    Obviously, you need to weigh your future income versus your present costs. Your future income, of course, is also your old age savings. We will spend lavishly on a child with leukemia, but cancer at 84 just isn’t worth the same panicked drive, is it?

    Since we aren’t paying our health care out of income (pricing disability risk), savings (pricing our life expectancy / quality / future income), or our non-negligible insurance cost (pricing emergencies), we can’t price it properly. But all these factors *directly* impact our cost/care evaluations.

    Note how tightly I bind retirement funds into health care. They are indeed like identical twins. Social Security is a 12.5% regressive tax on all working Americans (again, we pay a lot for our “free” retirement). But, with gay marriage legalized, I predict legal polygamy in fifteen or twenty years. At that point, the three wives and eight children of a bus boy who died of sexual exhaustion will apply for full Social Security benefits *and* *they* *will* *get* *them*, and at that point, America is bankrupt.

    So… something to look forward to.

    * Much of Europe as well, though it is a continent with highly diversified market models for health care, a fact no one in the MSM ever mentions.

  69. somercet – totally agree, but you seem to miss one thing – the first world is already bankrupt! And the debt is going up daily. So just like Eric, many of us are now earning less than they were because the budgets are being cut, but the ‘fat cats’ are still living in cloud coo-coo land thinking their salaries are safe while milking the rest of us. At the end of the day no country can afford the cost of some of the current life lengthening treatments and all we are really arguing about is who tells the patient they can’t have it?

  70. Have any of you guys wanting government run health care considered that most of the money will go to pay the bureaucratic overhead? Government agencies have absolutely NO incentive to keep overhead low. They will expand to the limits of their budget and then demand even more. At least the “evil” insurance companies keep the overhead as low as possible to maximize profits. I have seen estimates that as much as 70% of any agency’s budget goes to pay salaries/benefits of the bureaucrats, whereas most private companies panic at any more than 10%. Also, with Civil Service rules being what they are, it is impossible to get rid of incompetent and lazy employees. .

  71. Under this plan, can the government use its power to negotiate the price of drugs in a downward direction? If so, that’s good. If not, that’s really, really bad.

    Well, one of the biggest reasons drugs are so expensive is because drug research is expensive. Drug research is expensive mainly because of Phase III clinical trial costs. Phase III clinical trials could be skipped, and the cost brought down significantly… except that Phase III trials are mandated by the FDA.

    Meaning that the government requires drugs to be expensive, and demands they be inexpensive, simultaneously.

  72. I’m not a fan of Obamacare. However, I have to suspect you’re doing very well if it’s increased your costs.

    In my case, it’s going to mean completely free health coverage next year, after I’ve gotten my paperwork in order. Of course, I make all of about $13,000/year. Yes, you can live on that. Sort-of.

  73. @ Troutwaxer – ‘this particular issue is too-easily reduced to some kind of “four legs good” sloganeering and that doesn’t help’

    It would be nice if the majority of US voters were intelligent, highly informed, and possessed the motivation and time to fully analyze complex issues like government-run universal healthcare and then vote accordingly. Unfortunately, that does not appear to be the case. It seems to me that most voters are habitual based upon political bias and primarily respond to sloganeering put forth by favored politicians. I think history will soon show that we have already passed the tipping point here in the US, and that more people now vote for a living than work for a living. If so, then government growth will continue until we run out of other people’s money.

  74. @Paul Brinkley:
    That drugs are expensive because of Phase III trials is a fallacy. Specifically, it’s the sunk-cost fallacy. The profit-maximizing price for a drug doesn’t depend on development costs, only on supply costs and demand. Anyone telling you otherwise is most likely lying or mistaken.

  75. EMF: So the $800 million to $1 billion cost to get a drug past the FDA has no bearing on the final cost? And the costs of trials for all the drugs that fail don’t matter, either?

    Paul Brinkley: And note that when foreign governments bargain down the costs of US drugs, their savings are made up by higher prices here.

  76. Mr Caine;

    No, you still don’t get it. *No* *one* is orchestrating this. Lots of companies and pols are bilking the system, but it is entirely in response to *us*. We are begging them to do it. We vote them into office promising to do it to us.

    Just like the subprime bubble. Yeah, the Boston Federal Reserve wrote up the subprime justification, and the NY Fed kept it going, but Barney Frank and Barack Obama were proud of it. They thought it was a brilliant thing.

    And actually, that is so much more devastating than some Godfather of “health care” picking our pockets. So much more contingent, more accidental, more mindless… a slaughter of wealth that should mostly have gone to the lower third of American income earners.

  77. it seems to be strongly oriented towards the beret-and-nose-ring crowd

    Hey, now.

    I don’t wear a beret.

    (Though I also use Patreon to support webcomics.)

  78. That drugs are expensive because of Phase III trials is a fallacy. Specifically, it’s the sunk-cost fallacy. The profit-maximizing price for a drug doesn’t depend on development costs, only on supply costs and demand

    For production of a single drug that already exists, you are absolutely correct.

    However, to actually get drugs discovered, tested, and made, it won’t suffice.

    Because most drugs never make it to production, thus those that do have to cover the R+D and testing costs of the whole mess.

    Because if they don’t, nobody will even start the process; why would they? Who’d put up the money? Who’ll keep it going through the inevitable string of failures?

    (It ain’t the Government – they won’t be any better at it than the private sector, and have plenty of perverse incentives not to be.

    Nobody ever got fired for not releasing a drug, but people lose careers over approving things that end up being bad for people in a decade! Which are you gonna do, as a Federal bureaucrat?

    And every year when billions on end go into Government Drug Labs and we don’t get anything more out, people will demand it be “fixed”, not realizing that it’s not something that can be “fixed” like that.

    We’re better off with what we have, by far.

    At least if we ever want to see new medicines.

    If all we ever want is what we have now, and damn anyone with an untreated disease or poorly managed symptoms, well, your idea will work fine.)

  79. somercet – I get perfectly that no one is in control … at least in the US there is a better chance of a politician actually HAVING a majority, but in the UK at least you only need one third of the country to support you to be able to dictate to the rest. Money is the only thing that has any control and yes the financial institutions still have more control over what is allowed to move forward than the supposedly elected politicians?
    I’d just prefer not to reward them by privatizing everything … how much has the current situation in the US been manged by having to keep the ‘investors’ on side? They are all just gambling and fixing the systems to make a better profit?

  80. Lester Caine on 2015-09-02 at 08:00:53 said:

    Would be nice to have ‘Zero Change Software’ so we can just get on using it rather than having to learn new user interfaces every few months.

    I couldn’t possibly agree more, Mr. Caine! Thank you so much for saying so out loud. :)

  81. I’m sorry to “hear” this, Eric. Your wife had said something about her “employment situation” becoming “unstable” in one of her blogs; but I didn’t realize the extent of your problems. Nevertheless, it was inconsiderate of me not to cut the shenanigans (asking lots of questions, making stupid jokes, discussing candies and shit like that), so I apologize. (And are you sure my lurking in her blogs doesn’t bother her? ‘Cause I can stop that, too. I’m ultimately a stranger, so I’d understand.)

    Maybe I’m worrying too much again, but I’ve been wanting to say this ever since I read the OP a couple of days ago. I cannot, in good conscience, remain silent about this – especially given the repercussion your statement has had. Peace of mind…

    > > People who recommend that Eric pull together a best of Armed and Dangerous collection are probably underestimating the amount of work involved in editing that much material.

    > I fear so.

    Perhaps I could help with the editing? I suppose I’d need some briefing, but I’d do the work enthusiastically. Since I cannot help you financially, I’m eager to help you in any way I can, however modest. It’s certainly true that your blog is rich in killer material; for example, the other day I read (or reread?) “When there’s nothing left to say, self-parody is the way”, and loved it. Succint and right on target! :-)

    • >Nevertheless, it was inconsiderate of me not to cut the shenanigans (asking lots of questions, making stupid jokes, discussing candies and shit like that), so I apologize

      Oh, stop. Your “shenanigans” are a break from my real troubles.

      >Perhaps I could help with the editing?

      Or anyway the beta reading. I’ll consider it.

      The main problem with “Eric should write another book” proposals is that writing a book is a time investment I can’t really make in the near future, not until NTP is in far better shape.

  82. I grew up in poverty in West Virginia, and I’ve spent most of my adult life working food industry. At 26 year old, I got my CCNA certification this year, and I start my first internship in September. I owe that almost entirely to running into your articles when I was a teenager and remembering them when I decided I’d had enough of my old lifestyle and knew it needed changing.

    If I can turn this internship into full time employment, I’ll donate something small monthly. I promise.

  83. Just like the subprime bubble. Yeah, the Boston Federal Reserve wrote up the subprime justification, and the NY Fed kept it going, but Barney Frank and Barack Obama were proud of it. They thought it was a brilliant thing.

    Except that the subprime bubble popped in October of 2008, a month before Obama’s election, and four months before he was sworn into office. I’m not a huge fan of Obama, but at least get your facts straight – this took place on Bush’s watch.

  84. I’m not a huge fan of Obama, but at least get your facts straight – this took place on Bush’s watch.

    Who continued policies instituted by Clinton, particularly the CRA reforms that turned loan standards into political footballs. Nobody’s got clean hands here.

  85. Who continued policies instituted by Clinton, particularly the CRA reforms that turned loan standards into political footballs. Nobody’s got clean hands here.

    This is very true. From my point of view the major problem with our politics is not a particular viewpoint, party, or ideology. It’s corruption, pure and simple.

  86. I was thinking about it on the way home, and I’ve come to the conclusion that maybe we shouldn’t discuss politics on this particular thread; I think we should put our brainpower to work on the problem of Eric’s income. I’d like to propose that we drop any political discussion* and brainstorm on how to get Eric a better income, and if possible, how to get Cathy a full-time job – maybe someone has some contacts in the right part of New England or something.

    Unfortunately, I’ve got nothing for Cathy; my contacts and experience fit lawyers in New England the way a cheap corset fits Yog Sothoth!

    But I was thinking about Eric making more money, and I’m wondering if part of the problem is that the subjects Eric is working on, while important to the deep issues of computer infrastructure, are a little too obscure to be good money makers… so I’ll start the ball rolling with the idea that maybe Eric should start an open source project that fills a need for some large business sector where there might be some money in adding features, customization and tech support.

    Ideally such a project would be fairly simple and would involve a programming language like Ruby or Python which can produce results quickly so Eric doesn’t spend too much time on the project (really, we need him working on the infrastructure stuff) and others can get involved without too much overhead. The project should do one thing and do it really, really well, and it should colonize a niche which is not currently inhabited by decent software. Ideally the project should be something that one of us has the connections to use or support in the real world

    The example I’m going to use probably doesn’t fit Eric very well, (though he’s welcome to it if he wants) but I think it provides some useful guidance. I’ve been examining (on my own behalf) the idea of a CMS (content management system) for restaurant menus. This solves a major problem for restaurant owners as the cost of retooling menu boards, reprinting menus, etc. every time a price changes is enormous. Wouldn’t it be easier and cheaper to hang a sixty-inch HDMI in a conspicuous area of the restaurant and make all changes in software (and maybe export the latest menu to your website?) The same solution scales from the diner on the corner to big companies like Jack In The Box, and the need to customize this solution, add features, provide support, etc., is probably enormous…

    Note that this program solves one problem really, really well and I can cannibalize other projects for things like login code. The rest is easily implemented. Heck, a simple menu is only one table in a relational database! If I do the project I’ll use Ruby because I can make stuff happen quickly with the language even in my spare time, (not a Pythonista) and I have contacts at a national-level provider of field techs which can install the hardware throughout fifty states!

    Can we come up with something like this for Eric? Something easy to create/maintain that colonizes a niche, which we can help him leverage?

    Or maybe someone has some contacts that Eric can use… or there is a problem worthy of his mettle as a contractor… or maybe someone needs to handle a deep infrastructure issue and is willing to pay the big bucks. What do we have for Eric?

    * I’m always happy to discuss politics on another thread.

  87. @esr
    “The main problem with “Eric should write another book” proposals is that writing a book is a time investment I can’t really make in the near future, not until NTP is in far better shape.”

    It would be marvelous if you could combine them and use your NTP & GPSd experience to write a book about Open Source robust and secure ICT infrastructure development. That is sort of, in the picture nowadays. I have read (most of) your earlier books and such a book would be welcome.

    As I mentioned before, someone already wrote a book where NTP was the hidden attack vector.
    http://www.amazon.com/The-Lafayette-Campaign-Deception-Elections-ebook/dp/B010RF882O

  88. The main problem with “Eric should write another book” proposals is that writing a book is a time investment I can’t really make in the near future, not until NTP is in far better shape.

    I think a lot of us are in much the same place Eric. This side of the pond anything non-essential gets funding pulled so while we can always find jobs that need doing it’s finding enough that pay the bills while still maintaining the more philanthropic contributions :(
    Belt tightening just needs to be a little better spread around so everybody does their bit?

  89. @esr
    “Facts trump theory. Nobody got shot crossing the Berlin Wall from west to east. When people vote with their feet, believe the people, not apologists for statism like Winter and Jeff Read.”

    How true!

    https://en.wikipedia.org/wiki/Medical_tourism#United_States

    A McKinsey and Co. report from 2008 found that between 60,000 to 85,000 medical tourists were traveling to the United States for the purpose of receiving in-patient medical care.[66] The same McKinsey study estimated that 750,000 American medical tourists traveled from the United States to other countries in 2007 (up from 500,000 in 2006).[67] The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the U.S. for medical care,[66] whereas the low costs for hospital stays and major/complex procedures at Western-accredited medical facilities abroad are cited as major motivators for American travelers.[67] Also, the decline in value of the U.S. dollar is offering additional incentive for foreign travel to the U.S., although cost differences between the US and many locations in Asia are larger than any currency fluctuations.

    Ten times as many USA citizens travel to foreign nations for medical treatment than the reverse.

    • >Ten times as many USA citizens travel to foreign nations for medical treatment than the reverse.

      I have no doubt this is true. If you look into it, you will pretty certainly find that medical tourism always goes from places where there is more government intervention in health-care delivery to where there is less.

  90. Except that the subprime bubble popped in October of 2008, a month before Obama’s election, and four months before he was sworn into office. I’m not a huge fan of Obama, but at least get your facts straight – this took place on Bush’s watch.

    Obama did hold office at the time — as a U.S. Senator. Whether or not he was in the Oval Office at the time, his championing the government underwriting sketchy mortgages is a bit of a black mark on his record.

    And the bill that authorized Fannie Mae to provide low-income housing was passed during the administration of President George H.W. Bush.

  91. Winter: how it is as a percentage of population of US and countries which citizens can freely travel to US, eh?

  92. I pledged.

    I have a feeling I will soon be seeing a *lot* of these sorts of posts, all of them from people I admire who are struggling through our endless national Recovery Summer. On the other hand, if 10% of your blog readership pledged at even small monthly amounts, you’d probably survive the next endless 17 months rather handily.

    Love reading the endless explanations in your combox about how wonderful our current political elites are, how brilliant our current economic management is, how the only thing holding us back from Utopia are those stubborn reactionary wreckers, etc. etc. etc.

    I can’t help wondering how utterly delusional the explanations will have gotten by Jan. 2017.

  93. zephvark on 2015-09-03 at 16:01:49 said:
    I’m not a fan of Obamacare. However, I have to suspect you’re doing very well if it’s increased your costs.

    It didn’t increase my costs as I simply could not afford it.

    Let me fix this for you:

    In my case, it’s going to mean health coverage completely paid for by other people next year, after I’ve gotten my paperwork in order. Of course, I make all of about $13,000/year. Yes, you can pay for some stuff on that while other people pay the rest of what it costs for me to live

  94. @Jakub
    “Winter: how it is as a percentage of population of US and countries which citizens can freely travel to US, eh?”

    That would be a few billion people that can travel into the USA. But that makes the foot-voting even more lopsided: US citizens are much more likely to shop for medical treatment abroad than foreigners are likely to travel to the US to buy care.

    Or what was your point?

  95. > Oh, stop. Your “shenanigans” are a break from my real troubles.

    I’m not sure what you mean. If you’re saying my antics distract you from the troubles, I’ll keep performing them. :o)

    In any case, you seem to have taken my comment rather well. That relieves me: I’d posted it because I feared what you’d think of me if I didn’t; but after posting it, I started fearing it might end up being counterproductive! That’s funny: a friend of my father’s recently told me I should be fearless in my interactions with people. I’d like to follow his advice, but… you know: old habits die hard. :-(

    (For some reason, I’m generally fearless in my interactions with dogs or cats. Go figure.)

    > Or anyway the beta reading. I’ll consider it.

    Gladly, if it comes to that.

    > …writing a book is a time investment I can’t really make in the near future, not until NTP is in far better shape.

    Of course. But if you do think of anything else I could do for you, please let me know. That’s what fanboys are for. ^_^

  96. I have no doubt this is true. If you look into it, you will pretty certainly find that medical tourism always goes from places where there is more government intervention in health-care delivery to where there is less.

    Given that literally every other country likely to have health care acceptable to Americans has adopted a single payer scheme of some sort — either exclusive of or supplementary to private care — I don’t think a lack of government presence has much at all to do with the reasons why Americans travel abroad.

    I mean the simple answer is “it’s cheaper abroad” and there are two factors in that: one is the strong dollar relative to the currency of countries where Americans go for medical procedures; the other is that in these countries, as in Europe and Canada (which, according to Deloitte, is becoming an attractive destination for US patients seeking affordable care), government intervention in health care helps keep costs down.

    • >government intervention in health care helps keep costs down.

      Uh huh. Here’s the NHS version of cost-cutting:

      Thousands of cancer patients to be denied treatment. The story continues “Common drugs for breast, bowel, prostate, pancreatic and blood cancer will no longer be funded by the NHS following sweeping cutbacks”

      Death by bureaucratic fiat. The natural, indeed inevitable consequence of surrendering health care to the state.

  97. @Winter:
    I suspect the numbers on Wikipedia have been misapplied or misinterpreted. Following the citation [#66] in Wikipedia to the source article for the numerical claim, we find this quote (emphasis mine):

    “An estimated 40% of all medical travelers are looking for the world’s most advanced technologies, worrying little about the proximity of the destination or cost, according to consulting firm McKinsey & Co. It narrowly defined medical travelers as only those whose primary and explicit purpose in traveling was to obtain in-patient medical treatment in a foreign country, putting the total number of travelers at 60,000 to 85,000 per year.

    Most of those patients in search of the best care, including 38% from Latin America, 35% from the Middle East, 16% from Europe and 7% from Canada, are heading to the United States.”

    In that context, the 85,000 figure is not the entrants to the US, but the total global medical tourism industry. If “most” of those head to the US, how can we figure there are 750,000 Americans—a full ten times that figure—going abroad?

    If we check the original survey, or at least the lead, the wording is even clearer on the worldwide nature of this figure. “…McKinsey studied more than 20 medical-travel destinations; analyzed primary data on the number, type, and origin of medical travelers; and conducted interviews with providers, patients, and intermediaries in 20 countries. We place the current market at 60,000 to 85,000 inpatient medical travelers a year—…” (A bit more searching turned up a full copy of the article in PDF form here.)

    I don’t know what generated the 750,000 Americans figure, because there’s no way to derive it from the McKinsey article. In fact, the highest number of “medical tourists” I could see that survey supporting is only ~250,000 persons (re-adding the exclusions listed in Exhibit 1). That’s still a third of the figure given by Wikipedia… do you have any ideas of where I might find that number’s original source?

  98. @ Alex K.

    When a casual reader accepts Wikipedia as implicit truth, this medical condition is known as Wikinsanity.

  99. @TomA:

    That’s a very unfair reading of my objection. After all, there are numerous studies which show Wikipedia is as accurate as the Encyclopedia Brittanica. The problem is not treating “Wikipedia as implicit truth”, because for well over 99% of the content it is accurate.

    No, the problem is: Wikipedia is not a primary source. Furthermore, for these statistics, Wikipedia does not directly cite the primary source—rather than reference the McKinsey survey, they point to Forbes instead, which still isn’t the referenced survey. When I went to read that primary source, it didn’t include the data that Wikipedia claims it does. So where did that number originate? How authoritative is that estimate, really? (And does the same source have a different estimate of the number of total medical tourists, or have something to say about inbound-to-US vs outbound numbers?)

  100. @Alex K.
    Thanks for the clarification. I know about the limitations of Wikipedia and agree with you on this. I mainly use it to find primary sources. But is indeed a good source when you are unable to go to the bottom (as I did here).

    But I wonder whether 80,000 medical tourists world wide can be accurate. I would expect much more. Maybe this has to do with their definition using in-patient care.

  101. Watching Americans debate healthcare policy is like stepping into a reality-free zone.

    By the way – Eric, if you are banging the begging bowl why not just post a donation bitcoin address here or wherever you think it will get the most views?

    Bitcoin is programmable money that facilitates ultra-lown cost micro payments – it seems to me there must be ways that innovators can use this technology to help solve the sort of economic problem you are describing.

    Or even

  102. Winter:
    85,000 worldwide travelers is absolutely too low of a figure for what I think just about everyone here would include as medical tourism (for me: someone vising a foreign country with the non-exclusive purpose of seeking medical care). The McKinsey survey most expressly would under count this, as they disclaimed any attempt to quantify outpatient medical services. Someone visiting (as an example) Mexico from the US for kidney dialysis or oral surgery would not be counted, but should.

    While I feel that the 750,000 figure is in the right ballpark (perhaps a whisker’s breath too high for 2008, but a lowball estimate for today) I certainly can’t find a solid source starting from Wikipedia. Using a “wikiblame” website, I was able to find when that statistic was added; unsurprisingly it references a totally different survey than the current page. I’m not going to cite the entire chain, but that survey led down a rabbit hole to wonderland (which is to say, when I found the earliest source for all other citations, I didn’t consider the author to be very realistic or authoritative).

    In a broader search, the only open data source I can find is patientsbeyondborders.com, who claim (as of 2014) there were 1.2 million Americans travelling abroad for medical care and 800,000 visitors to the US for the same. [There is also an annual survey done by the International Medical Travel Journal, but that is locked behind a paywall.] Those numbers seem believable, but show a far smaller gap than Wikipedia.

  103. “Yes, you’ll see stories about the poor lady who didn’t want to wait six months for a hip replacement and so headed down to the Mayo Clinic, but these are pretty rare.”

    My wife saw a surgeon because of abdominal pain and was diagnosed with “we need to remove your gall bladder.” The doctor wanted to know if we could schedule the surgery for two days later. I guess if she were Canadian she could just suck up the cramps for half a year.

  104. @ Alex K.

    My Wikinsanity reference was aimed at the “750,000 medical tourists” guestimate that you have already extensively researched and found to be lacking in clear or reliable supporting documentation. “It sounds about right to me” is not a very high standard for a website that purports to be a foundational information resource.

  105. @TomA
    You are quick to point fingers, but Alex is dead right and you seem to be clueless (which I am getting used to)

    http://www.cdc.gov/features/medicaltourism/

    “Medical tourism” refers to traveling to another country for medical care. It’s estimated that up to 750,000 US residents travel abroad for care each year. Many people who travel for care do so because treatment is much cheaper in another country. In addition, a large number of medical tourists are immigrants to the United States returning to their home country for care. The most common procedures that people undergo on medical tourism trips include cosmetic surgery, dentistry, and heart surgery.

  106. Death by bureaucratic fiat. The natural, indeed inevitable consequence of surrendering health care to the state.

    More like “the natural, indeed inevitable consequence of a Tory government”. Conservatives in many nations are notorious for chopping off their country’s nose to spite its face. Stephen Harper’s government is drastically cutting back home postal delivery in Canada, forcing little old ladies in rural and suburban areas to traipse to the post office to pick up the mail.

    • >More like “the natural, indeed inevitable consequence of a Tory government”.

      You miss the point. Whether it’s a Tory cutback or not, the moment you have surrendered your health care to the state, you can die because someone else decided cost-cutting was more important than your life and your choices. It’s execution by death panel, and the death panel’s specific motives or rationale are insignificant compared to the mere fact of its existence and power over you.

  107. In other words, once again liberals spend money they don’t have, and then when the bills come due, it’s the fault of conservatives for being big meanies.

  108. @PapayaSF
    “In other words, once again liberals spend money they don’t have, and then when the bills come due, it’s the fault of conservatives for being big meanies.”

    You obviously have no idea what you are talking about.

    The British Health care bill is the lowest of the developed world. If anything, the NHS is too cheap. Actually, as a percentage of GDP the health care costs in the UK are close to half that of the USA, 9.1% vs 17.1%.
    http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS

    The USA would save 8% of GDP in health care costs if they would introduce the NHS.

  109. @esr
    “Thousands of cancer patients to be denied treatment. The story continues “Common drugs for breast, bowel, prostate, pancreatic and blood cancer will no longer be funded by the NHS following sweeping cutbacks””

    First, these are still plans. We have seen these things before. They will be opposed by the public and mostly retracted. Meanwhile, this will be used to pressure the manufactorers to reduce the prices.

    These are not life saving drugs but life extending drugs. This discussion rages periodically. How many 100k should we spend on average to extend life for another month?

  110. Death by bureaucratic fiat. The natural, indeed inevitable consequence of surrendering health care to the state.

    Actually this is the ideal example of the current problem. This fund was set up to pay for the newer drugs many of which never existed 5 years ago. £200 million was thought enough to pay for the EXTRA drugs bill to provide a few extra months for a few thousand patients. What price does the US system pay out for a few extra months of life today which was simply not an option 5 years ago? The cost this year was £380 million or around £100000 per patient all of whom would have been dead already if these drugs had not been created, so does the US system have any cap on these escalating drugs prices? Yes in an ideal world everybody would have the right to these drugs WORLDWIDE, but just who picks up the bill?

  111. @ Winter – “you seem to be clueless (which I am getting used to)”

    Now go to the citation page in your response and then use it to trace backwards to an actual reference document that substantiates the claims made in the text. An assertion is not evidence.

  112. These are not life saving drugs but life extending drugs.

    Strictly speaking *all* medicines are life extending, but that is a semantic argument.

    This discussion rages periodically. How many 100k should we spend on average to extend life for another month?

    Oh look! Its the death panels you people keep denying.

  113. @TomA
    “An assertion is not evidence.”

    Numbers given by the CDC tend to be authorative. They are the ones paid to know these statistics.

    Given a choice between wild accussations by anonymous commenters with a history of unfounded suspicions and the CDC, I go for the CDC. But if you have better numbers, go for it and prove me wrong.

    @Foo Quuxman
    “Its the death panels you people keep denying.”

    What death panels?

    This is about deciding which drugs will be renumerated by the NHS. Drugs must be (cost-) effective and there is a limit to what can be paid. For someone from the US with their frequent capped inssurrance, you should know that.

    http://www.nbcnews.com/id/25644309/ns/health-health_care/t/health-insurance-caps-leave-patients-stranded/

    It is quite easy to spend billions on extending life for days. So choices will have to be made.
    Note that the NHS has no life-time caps.

  114. @esr
    “the moment you have surrendered your health care to the state, you can die because someone else decided cost-cutting was more important than your life and your choices.”

    But history shows that without state intervention, many people would not even have a choice. They would not get the health care they needed because they simply could not afford it. The story about the life-time cap I linked to was from 2008.

    And the use of the term “death panel” is pure propaganda. These “panels” in the UK do not decide on patients, but in which drugs and treatments are renumerated. Every health care system in the world, including the USA have these panels. And they have always had them.

  115. You miss the point. Whether it’s a Tory cutback or not, the moment you have surrendered your health care to the state, you can die because someone else decided cost-cutting was more important than your life and your choices. It’s execution by death panel, and the death panel’s specific motives or rationale are insignificant compared to the mere fact of its existence and power over you.
    Since only a few people would be able to pick up a £100k a year drugs bill, many of us are reliant on the generosity of others, be that an insurance company who must make a profit to please shareholders, or some other shared payment method. If a drugs company comes up with a new drug that costs £100k per month to provide a few more weeks of life then would any provider not have to adjust prices to cover these sort of costs? The UK system does not have an open ended cheque book and while personally I’d prefer we funded a few more drugs rather than paying the US even larger sums for ‘Trident’ our democracy has decided that one is more important than the other? Which is perhaps why the fact that the government only has the support of 1/3rd of people who voted is irritating, but we have to live with it.

  116. Winter, measuring healthcare by percentage of GDP spent is misleading and foolish. By that measure, every time a US porn star gets a boob job, or an actor a face lift, it somehow “proves” that UK healthcare is superior. Would Americans want the results of British dentistry because it’s a smaller portion of GDP? I don’t think so. Richer countries spend more on health. That doesn’t necessarily make the results optimum, but it’s not necessarily bad, either.

  117. @ Winter – “Numbers given by the CDC tend to be authorative.”

    The appeal to authority argument is intellectually lazy, and really only justified when expediency is an imperative. A charlatan cares not for the validity of a source, only its propaganda value.

    Sorry, I.m not buying your “trust me I’m right” argument.

  118. @esr

    “…the moment you have surrendered your health care to the state, you can die because someone else decided cost-cutting was more important than your life and your choices.”

    The moment you have surrendered your health care to an insurance company, you can die because someone else decided cost-cutting (e.g., to help keep premiums affordable) was more important than your life and your choices.

    Once the cost of the treatment you want exceeds your ability to pay for it from your own resources, you are necessarily at the mercy of a tradeoff made by someone else, whether it be a government, an insurance company, a charity, or whatever. There’s certainly plenty of room to analyze and debate the particulars about how political and non-political factors influence these tradeoffs under various mixes of public and private provision of health insurance and health care. But there’s no such thing as an unlimited free lunch on someone else’s dime.

    • >The moment you have surrendered your health care to an insurance company, you can die because someone else decided cost-cutting (e.g., to help keep premiums affordable) was more important than your life and your choices.

      Wrong. In a market system, you have the option of paying for your own care. In a single-payer one, you don’t. The situation isn’t symmetrical.

  119. @TomA
    “The appeal to authority argument is intellectually lazy, and really only justified when expediency is an imperative.”

    Your doctor, your hospital, your state executive and your government trust the numbers from the CDC. Most of these parties trust them blindly. Hence, your life is to some extend in the hands of the numbers of the CDC.

    When I wrote “authorative”, I did not mean trust, but that they are the ones who collect the official statistics for the USA. The numbers gathered by the CDC are the Official numbers.

    You might chose to question the CDC. But the people in the medical field will just ignore whatever you say after that.

    Don’t believe me, ask your doctor next time you see him

  120. Eric, you’ve created a Mad Lib for healthcare rants. All we have to do is remove a few words and replace them with blanks!

    You miss the point. Whether it’s a __________ cutback or not, the moment you have surrendered your health care to ___________, you can die because someone else decided cost-cutting was more important than your life and your choices. It’s execution by ___________, and the ____________ specific motives or rationale are insignificant compared to the mere fact of its existence and power over you.

    You can fill in the blanks with words like “Cigna” OR “Obamacare.” Words like “government” OR “big business.” Words like “death panel” OR “corporate accountant.” Depending on the words you use, it’s a Liberal, Libertarian, or Conservative rant, which probably means the complaint is universal. Regardless of who runs the system, someone has to make the difficult decisions about how much it’s worth to prolong the life of a cancer patient by six months.

    In any system imaginable, the amount of money available is finite, the amount of need is damn-near infinite, and there will always be really hard questions like “If we pay for grandma to use the super-expensive cancer drug, can we afford to vaccinate all the little babies?” In short, its a fundamentally difficult decision!

    Anyone who complains about government death panels while receiving health care from a corporation is missing the point very badly indeed. Someone, corporate or otherwise, will always be making those decisions.

    Eric, you’re too smart by far to be reducing complex issues to Fox News-like rants. This is really, really hard stuff, and ranting about death panels may relieve some stress, but it does nothing to address the issue.

    ** Since nobody wants to brainstorm Eric’s issues I’m talking politics, I guess. Feh!

    • >Someone, corporate or otherwise, will always be making those decisions.

      Yes. But there are still fundamental questions about whether market allocation works better than political allocation. In true single-payer there is only one death panel, no way around it, you’re not allowed out from under except by fleeing the jurisdiction, and there is effectively no pressure to keep the process overhead low. In a market system there are at least multiple insurance companies and they are under market pressure.

      The worst problems with the U.S. system all trace to the fact that since 1948 the U.S. government has created a web of regulation, subsidies, and perverse incentives that have badly distorted price signaling in the system. Reliably, when the person who pays for a service is not the person who consumes it, you get cost inflation. If food were regulated the way health care is, it too would be eye-wateringly expensive and the monopoly of a rent-seeking specialist caste.

  121. @ Troutwaxer

    > Since nobody wants to brainstorm Eric’s issues I’m talking politics, I guess. Feh!

    But I like your idea of brainstorming Eric’s issues. I’m confused, though: you said something about lawyers in New England. I thought the Raymonds lived in Pennsylvania; did they move to one of the New England states while I wasn’t paying attention? :S

    @ anyone

    If the next administration turns out to be Republican, is there a chance Obamacare will be repealed?

  122. Wrong. In a market system, you have the option of paying for your own care. In a single-payer one, you don’t. The situation isn’t symmetrical.

    Some very small percentage of us can pay for our own care without damaging our finances horribly. I’ve worked in medical billing and it was awful twenty years ago – the Cardiologist’s portion alone for a balloon angioplasty billed out at around $2000 in the early nineties* and that doesn’t count the cost of the operating room or the nursing/technical staff! And balloon angioplasties are well-known, fairly simple procedures that are done every day and only take a couple hours (at most.) I’d guess that paying for one on your own is something like $15-20,000 these days.

    My wife’s 4-month hospital stay in 1990 billed out at around 1.5 million dollars. (Fortunately, she was insured and one particular surgery made the Doctor’s reputation, so the $125,000 we owed mysteriously vanished one day!)

    The idea that anyone really has the option of paying for more than very simple stuff is complete nonsense. I would have to admit that “single-payer plus add-your-own-cash for stuff the government doesn’t cover” is fairly attractive.**

    * Just for the record, insurance would pay between 1000-1600, with the patient paying anywhere from 50-500 dollars!

    ** The devil, as I said above, is in the details!

    • >My wife’s 4-month hospital stay in 1990 billed out at around 1.5 million dollars.

      This is what happens when you fuck up price signalling and encourage provider monopolies for sixty years.

  123. I’m confused, though: you said something about lawyers in New England. I thought the Raymonds lived in Pennsylvania; did they move to one of the New England states while I wasn’t paying attention?

    I’m a little vague on where Eric lives. Sorry.

  124. @Troutwaxer: Nobody disputes that in extreme situations like that, bills are very high, but what used to be called “major medical” insurance doesn’t have to be that expensive. When defenders claim that Obamacare “is really the Heritage Foundation plan!” they are talking about an old proposal for mandated “major medical only” insurance. It would have cost a fraction of what Obamacare costs, because the original plan wasn’t larded up with mandates. Imagine what your car insurance would cost if it was forced to include free towing, oil changes, brake jobs, tire inflation, windshield wipers, and detailing.

    Everything can be made much cheaper by reducing regulation, allowing competition, encouraging more price transparency and straight payment for services, removing subsidies, and so on. Then, extreme medical catastrophes can be covered by partial self-funding, plus affordable insurance, charity, and (why not?) crowdfunding.

  125. The enemy of competition is not the state, it’s the competitors, each of which want to use the power of the state to make themselves the only competitor (or at worst, part of a cartel). ““People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.” —Adam Smith (the original)

  126. @PapayaSF
    “Nobody disputes that in extreme situations like that, bills are very high, but what used to be called “major medical” insurance doesn’t have to be that expensive.”

    That kind of insurance is so cheap because the main driver of health-care costs is in care for chronic conditions:
    Chronic Disease Overview
    http://www.cdc.gov/chronicdisease/overview/index.htm#sec3
    In Chronic Condition: Experiences Of Patients With Complex Health Care Needs, In Eight Countries, 2008
    http://content.healthaffairs.org/content/28/1/w1.full.pdf+html

    You often find numbers in the order of 75% of total costs:
    The Impact of Chronic Diseases on Healthcare
    http://www.forahealthieramerica.com/ds/impact-of-chronic-disease.html

    In short, when you offer insurance for chronic conditions,there will be no cost benefit.

    (If you want primary sources for such glaring facts, I suggest you do your own research)

  127. Wrong. In a market system, you have the option of paying for your own care. In a single-payer one, you don’t. The situation isn’t symmetrical.

    Eric … there is nothing stopping UK residents paying for their own health care. That was the one thing that could not be changed when the NHS was set up. It sounds as if ‘Medicare’ is the American equivalent of the NHS? So isn’t just the split between who gets access and who doesn’t the question here? In the UK it’s 100% in the US is ?% …
    There have been high profile cases over here where people who can raise the funds for some alternative treatment which might have some slightly higher chance of success than the one available in the UK. There is nothing stopping them despite what they might think. Is it wrong to run expensive equipment manned by highly experienced staff who get better and better results year on year, or should we scrap that kit as soon as some other alternative with is ‘a little bit better on some conditions’ comes along? Kit which will take years for the users to be come as competent as they are with the kit they are already used to. The goalposts are moving monthly on medical treatment options.
    http://www.theguardian.com/society/2010/jul/19/health-insurance-slumps is a little out of date, but does highlight that in the UK we do have options, we perhaps trust the con artists in government more than those in the insurance business? But as with everything to do with money, nothing is a certainty … everyone is gambling with it these days!

    • >Eric … there is nothing stopping UK residents paying for their own health care.

      Hm. So England isn’t de jure single payer. I didn’t know that.

      There’s some hope for the market to subvert the regulation, then. It’s beginning to happen here in small ways – cheap clinics in Walmarts, doctors who’ve noticed that if they bail out of Medicare they can spend enough time seeing patyents rather than doing paperwork that their margins go up.

  128. @Troutwaxer –

    In any system imaginable, the amount of money available is finite, the amount of need is damn-near infinite, and there will always be really hard questions …. Someone, corporate or otherwise, will always be making those decisions.

    Eric’s premise is – the the consumer makes those hard decisions. No one else could possibly have all the information. Yes, there will always be a gap between demand and supply. Why should a distant third party try to arbitrate that? And any attempt to fill it in will necessarily either [a] regulate prices and wages in the health-care industry, which will discourage investment and desire to work in it, or [b] be taking other peoples’ money.

    What if health insurances plans were voluntary, non-profit co-ops, like credit unions are set up here in the US (contrasted with the for-profit banks)? Different groups could agree to cover each other for various levels of risk or to various levels of comprehensiveness, depending on what everyone agrees to and is willing to pay for. Push both authority and responsibility as low on the ladder as possible.

  129. @esr –

    The worst problems with the U.S. system all trace to the fact that since 1948 the U.S. government has created a web of regulation, subsidies, and perverse incentives

    ISTR that I read someplace (sorry, original cite lost in the mists of time) that (one of) the roots of the problem was the government-mandated wage freezes during WWII. Companies started offering “free” health insurance, since they couldn’t offer greater wages.

  130. Eric … there is nothing stopping UK residents paying for their own health care.
    Hm. So England isn’t de jure single payer. I didn’t know that.

    It never has been although the ‘private sector’ does get blamed for some of the NHS queues in areas where the private sector gets priority or have a monopoly on the service.
    Just as there is no ‘death panel’ … if you have the hundreds of thousands for one of the drugs which will give you a few more weeks, the NHS will still provide the rest of your treatment! If there is something approved which ‘NICE’ have considered both safe and practical then that is provided instead. Yes there is distortion, but only on the very edge cases which any commercial enterprise would have to factor into costings?

  131. Politicians tend to lose elections when they overtly raise taxes by large amounts. Consequently, subterfuge is necessity to avoid blame and voter backlash. Best to camouflage a large tax increase as something else; say for example, social security or single payer universal healthcare.

  132. @TomA
    “Best to camouflage a large tax increase as something else; say for example, social security or single payer universal healthcare.”

    That might work in the USA.

    In most countries I know the electorate have a keen eye on health care and pension benefits. Doing creative things with these budgets makes for very big headlines.

  133. @esr
    “Hm. So England isn’t de jure single payer. I didn’t know that.”

    Neither in the rest of Europe. I do not even know whether such countries exist.

    Continental Europe is riddled with private clinics. These are mostly used for cosmetic surgery and diagnostics (MRI on demand etc). Both are not covered by the national systems. Diagnostics are limited because doing more than necessary leads to high costs and unnecessary treatments (you will always find something “worrying” on a MRI).

  134. @esr

    “Wrong. In a market system, you have the option of paying for your own care. In a single-payer one, you don’t. The situation isn’t symmetrical.”

    You left out my following sentence, which made a point that others have raised as well:

    “Once the cost of the treatment you want exceeds your ability to pay for it from your own resources, you are necessarily at the mercy of a tradeoff made by someone else, whether it be a government, an insurance company, a charity, or whatever.”

    As for this…

    “In a market system there are at least multiple insurance companies and they are under market pressure.”

    How much do you know about how health insurance companies in the United States and elsewhere create and manage their coverage policies, and what that means for beneficiary access to expensive and/or investigational diagnostics and treatments? “It doesn’t matter because the whole system is so distorted by government regulation” is not a substantive or useful answer.

    Health care poses genuinely difficult problems that would persist under any possible system of government. You can make an argument in favor of a purely hands-off approach, reflecting your values. If you want to be credible, you need to demonstrate a realistic understanding of how health care works and be willing to own all of the likely consequences.

    Most fundamentally, “realistic understanding of how health care works” means coming to grips with the profound knowledge problems that are characteristic of medical practice, policy and innovation; the unavoidable limits to our capacity to solve those knowledge problems; and the precise shape of the collective-action problems and freedom-vs-something-else tradeoffs that result.

  135. Winter:
    That link may be the Deloitte study referenced elsewhere, but it is not “the original source of the 750,000 number”. If you look at the line in that study where the figure is provided:

    In the Deloitte Center for Health Solutions’ 2008 report, Medical Tourism: Consumers in Search of Value, we reviewed the medical tourism industry and projected patient flow rates and financial implications over the next 10 years. 750,000 Americans traveled abroad for medical care in 2007. [footnotes 2 & 3]

    Footnote 2 is a direct link to the “earliest source” I had mentioned before (although my link was via archive.org as the original copy is no longer online). Footnote three points to a second study which, when establishing the medical tourism market size, contains a footnote to the exact same page. As a result, that number seems to me not to have been generated in a methodological fashion, but merely cited often enough to become “true” (the CDC doesn’t give any citation for their usage, but seeing the exact same numerical value has me suspecting it came from one of the sources already discussed).

    The independent second source I found, while potentially biased toward announcing as large a value as possible and provided no explanation of their methods, was still rather close in magnitude. Therefore, while it certainly approximates the true value, the 750,000 figure itself should not be considered substantiated based on any of the articles provided. I’m certainly not saying to stop using it, but merely that there is a strong case against its’ validity.

  136. @ Troutwaxer

    > I’m a little vague on where Eric lives. Sorry.

    That’s okay. He was born in Boston, after all. ;-) Also, his cat is a (beautiful) Maine Coon. And, according to a map on his personal page (near the bottom), he’s visited all the New England states except Vermont and Rhode Island. Perhaps the map is outdated and he’s since visited those two states; in fact, I’m sure the maps are out of date, for the second one doesn’t reflect the fact that he has visited Brazil.

    TBH, I don’t know as much about American geography as the previous paragraph might suggest; I merely looked a couple of things up ad hoc for this conversation. :-P But I do want to learn more about American geography and history – especially the latter. It’s an admirable country, except for the politicians (and lobbyists?) who betray its founding principles and whom Eric justly calls “statist bastards”.

  137. @Health Care Analyst (2015-09-06 at 13:46:56)

    Piffle.

    In particular, “It doesn’t matter because the whole system is so distorted by government regulation” IS both substantive and useful. Observe, for example, the rise (return, really) of cash-only doctors. Or, for that matter, compare veterinary care, where insurance is an oddity.

    Go DISQUALIFY! somewhere else. Special knowledge of the gory details of a system that no one wants is not necessary to a discussion on what to replace that system with.

    The free market solution is simple enough. Decouple medical insurance from employment. Decouple it from regulation that requires it to also be not-insurance, but allow that option if the market prefers it. Also, remove geographic restrictions and obnoxious administrative burdens.

    In that system, there would be HSAs, there would be major medical insurance, long-term disability insurance, short-term disability insurance, I-just-got-diagnosed-with-an-expensive-chronic-condition insurance, etc. Presumably, there would also be bundles too.

    P.S. Whenever you use a phrase like “unavoidable limits to our capacity to solve those knowledge problems” around here you’d better have a free-market solution under your hat. Plenty of folks here have read The Fatal Conceit and aren’t going to take your word for it that you’ve discovered a way to make all the decisions without a mechanism for collecting all the information.

  138. @patrioticduo

    >When people talk about Sweden healthcare, they’re ought to be talking about Connecticut.

    This is a very good point. The proper comparison of the US FedGov is with the EU as such. 340M vs 550M is a bit off in the other direction, but still closer than any country level ones.

    (I have noticed that 90% of libertarian sentiment in the US is directed at the Feds and not state or municipal level. The properly sized parallel for that is called EU-skepticism.)

    And yes, I think having the EU ran healthcare or anything big would be an absolute nightmare. As a comparison, there is the HAACP, EU level regulation, which regulates,among others, restaurant kitchens. The goal is to prevent food poisoning. The primary issue is that it is so expensive that the poorer countries in the South and East cannot possibly keep up. Things like separated wash basins, keeping a manual cooler temperature journal, different fridges for everything etc. if it was followed to the letter, the average Pole or Greek could never afford a restaurant dinner. What happens is, usually, bribery, when the controller comes. So in practice it is yet another source of graft, private taxation. Even the richer corporations, like IKEA Austria, cannot really keep up with it. When there is a heat wave, there is often 16C (60F) in their restaurant fridges and then the employees whisper to the customer “you don’t really want that cream cake, trust me”.

    In a small country, the practice of the public side of healthcare keeping the private side fairly cheap and yet quick and efficient, seems to be workable, although I would rather not even calculate how much I am paying for that public side that I try hard to avoid using. Blowing that up to EU or US Fed level would be an absolute quagmire. And there are fights even on this level – there is an initative in Austria that every doctor should keep all their patient data in a central electronic database. Every doctor I know fights hard against it, saying that patient data belongs to patients and them. With some paranoia, this could be seen a step towards the nationalization of the private side of healthcare. What is your opinion? When a government, even if a small country or small US state, wants to be the central depository and caretaker of data in a certain field of human activity, time to get paranoid?

  139. Random off topic question:

    Can anybody provide pointers to introductory resources on the Linux virtual memory subsystem? Googling results in a whole bunch of links to a resource titled “Understanding The Linux Virtual Memory Manager” by Mel Gorman. This seems to be about what I’m looking for, however, it seems to be over a decade old, and mentions kernel version 2.6 in the future tense.

    Therefore:

    1) Are there any comparable, but more recent resources?

    2) Has memory management in the kernel changed enough in the past decade that I would need to find more recent resources, or does this remain a good primer?

  140. @Shenpen
    “And yes, I think having the EU ran healthcare or anything big would be an absolute nightmare. ”

    But then, the EU countries do a reasonable job of getting everyone covered by affordable health care insurance. The problem in the USA was that most (almost all?) states did not have a system in place to get everyone covered. Most did not even had plans to get everyone covered. Moreover, the integration in the USA has gone on for over two centuries. The EU is still trying to integrate basic things in the members (say, power outlets).

    The whole complaining about Obamacare by the right just disregards that the Republicans never had a plan to get everyone covered under affordable health care (we just had 8 years of Bush). The only thing the Republicans did was to sabotage anyone who tried.

  141. kjj
    Also, remove geographic restrictions and obnoxious administrative burdens.

    I did not get what Health Care Analyst or you were going on about, but this one statement is perhaps the whole point today. There were 4 emails in my junk box this morning offering software development or web support at sub £5 per hour but while ‘off shoring’ is still a problem people in the UK at least are realizing that it’s not simply a matter of saving money since laying local staff off costs more in ‘administrative burdens’ than are saved by ‘remove geographic restrictions’. China is currently coming to a point where they expect wages to be more in line with the rest of the world, so often now it’s actually cheaper to build locally again.
    Once one has a level playing field one can compare systems, and perhaps the millions of people descending on Europe at the moment could be reversed? So perhaps now is the time to pull up the drawbridge, seal the channel tunnel and sink any ships that don’t have the right paperwork :)

  142. >Hm. So England isn’t de jure single payer. I didn’t know that.

    In fact, lots of people have private health care insurance in the UK. I do. It costs me less than £100/month for full cover, including access to all the high-end private hospitals in and around London. I’m truly baffled by the cost of insurance in the US.

  143. “In fact, lots of people have private health care insurance in the UK. I do. It costs me less than £100/month for full cover, including access to all the high-end private hospitals in and around London. I’m truly baffled by the cost of insurance in the US.”

    More or less the same over here. In the Netherlands, it is mandatory for every person to take health care insurance. It costs around 100 euro a month for basic coverage. Children are free until they reach 18. People pay for their own insurance, but those on low income get financial assistance to help pay that bill.

    Long term care is covered by a separate system, paid out of taxes.

    https://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands

    Insurers are commercial, but they are required to unconditionally take everyone that applies for the basic universal coverage. Basic coverage covers everything that is medically necessary. There is no medical reason to take more insurance. Coverage is uncapped.

    In addition to that you can insure whatever extras you want with whoever wants to insure it. That will cost you around 10 euros a month depending on what you want. Otherwise, you will have to pay for the extras. I only take world-wide coverage, because I travel a lot. I do not see the need for the other extras.

    There is no law against you paying out of your own pocket for whatever medical treatment you want, wherever you want it.

    What surprises me most is how little people from the USA know about health care practices around the world, even in the UK and Canada. A mouth dropping amount of ignorance remains after years of debating health care systems in the US.

  144. Winter: “I do not even know whether [de jure single payer] countries exist.”

    North Korea and Canada. Naturally, details are sketchy re NK.

    An accurate summary of the Canadian rule can be found here. Canadians are generally happy with the system they’ve constructed. It’s relatively inexpensive because it’s a legislated monopsony. Administrative costs are lower than the US model. Mortality outcomes are comparable. Complaints arise almost entirely from delays in providing non-urgent but still medically necessary care (think hip replacement, e.g.). It is illegal to pay for such services privately (they won’t prosecute a patient but they will go after the doctor or clinic), either in cash or via insurance, so queues develop in the public system. See e.g. this. The governor on the length of the queues is determined by (provincial) politics.

    It’s a completely Stalinist regime, but not one Canadian in fifty thinks the US system – now or pre-Obamacare – is preferable. Yes, per the anecdotes above, some near the US border will cross over to lay down $200 for an MRI next week instead of two months from now because it will shorten the wait time to book an appointment with the orthopedist. No, they will not lay down $40,000 to get a hip replaced by an American orthopedist; they will grin and bear the pain for six months and get it “free” in Canada.

  145. Eric, thanks for all you have done for the open source movement. I think what you are doing is cool, and wanted to let you know. I’m still thinking about the idea of supporting you through Patreon. I did do something long overdue, and just ordered a copy of The Cathedral and The Bazaar from Amazon.

  146. Eric,
    A belated happy Labor Day.
    I just wondered if you were aware of ‘Open Source Pharma’.
    If not, perhaps a visit to Andy Updegrove’s http://www.consortiuminfo.org might be in order.
    Scroll down to The Standards Blog: “What is Open Source Pharma (and why should you care)?” article.
    I thought that if they succeed in raising said $1 billion, they might have a $100K+ p.a. slot for someone with skills like yours (NTPsec permitting). Although I fear that the proposed data might overwhelm The Great Beast Of Malvern!

    • >I thought that if they succeed in raising said $1 billion, they might have a $100K+ p.a. slot for someone with skills like yours

      What’s a “p.a. slot”?

    • >What do you think of the GRSec closing stable patches of it’s derivative work debate?

      Given GPL terms, I think it’s on shaky legal ground and even shakier ethical ground.

    • >I think P.A. = Project Administrator.

      I hope not. Putting me in an administrative position would be crazy. First, while I am pretty good at leadership, I am at best only a marginally competent manager (very different skillset). Second, every hour I spend administering would be an hour I’m not spending on being a systems architect, which is the most effective use of my time.

  147. p.a. = per annum, slot = role/position (i.e. round peg in round hole).

    It occurred to me that they will need someone with extraordinary experience with large repositories of research data, and the ability to design a system that allows the extraction therefrom of relevant ‘search requests’ responses.

    Sorry for being obtuse.

  148. @Winter

    What, exactly, does “everyone covered” means? There is a different theoretical and practical approach here. Theoretically “everyone is covered” only when it is an entirely unconditional right. This is not true in the average EU country either, like here in Austria went from being covered by her employer to being covered as being on maternity leave and as the documentation of the maternity leave was difficult she spent a few months on being co-insured as a spouse to me. We also had a case when her last job was in France and benefits are not transferable, so she was not eligible for unemployment benefits here, meaning no automatic insurance coverage so we paid her insurance premiums out of the pocket. This clearly demonstrates even the EU does not have fully universal, unconditional coverage, there are theoretically holes a person can fall through.

    So while not having it in theory, EU countries tend to have practical near-universal coverage because the holes to fall through are fairly small. The worst case, the paying of insurance premiums out of the pocket, for the long-term unemployed, is something like €50 a month in Austria.

    So I think you should analyse the situation from this angle. It is not a binary universal vs. non universal healthcare, but more like a million little practical policies that ended up sewing the holes to fall through fairly small in the EU, while Republicans in the US were unable or unwilling to do that with state-level healthcare policies. But it is closer to a practical small hole sewing, or the lack of that, than some truly sweeping policy decision. If I had to make a wild guess why, I think they didn’t want attract illegals from Mexico too much. But I find it strange how not all college students were automatically insured. I think keeping good future taxpayers alive is usually a good financial investment for a state.

  149. @Shenpen
    “It is not a binary universal vs. non universal healthcare, but more like a million little practical policies that ended up sewing the holes to fall through fairly small in the EU, while Republicans in the US were unable or unwilling to do that with state-level healthcare policies.”

    I think that is a good assessment. Also, because fairly few people fall through the cracks, there is usually some way to paper over that. Over here, doctors and hospitals insist on treating all, even the uninsured (mostly illegal immigrants that show up in a hospital). There is then some behind the scenes wrangling on who will pay the bill.

    @Shenpen
    “But I find it strange how not all college students were automatically insured.”

    I think that is no accident. I got the strong suspicion that the foundation of the US system was the illusion that it was “everyone for himself”, and that there should be no one who would have to pay for someone else. Paying for other people, even students, would be heretical.

    In reality, I think the whole system only worked because of the large federal programs (medicaid and medicare).

  150. @Winter not only those programs, mutual benefit societies were widespread in the US, which went strongly against your supposed principle of every man for himself. The idea of a mutual benefit society is strongly based on solidarity, except that it is a grassroots organization, not a government-organized one. This should be familiar for us as well, interestingly, in Scandinavia, the origins of universal healthcare do not begin with the big large centralized social insurance schemes, but by the government starting to subsidize already existing mutual benefit societies around 1912 or so. This was attitude was markedly different from the bureaucratic Beamter-cultures of Germany and Austria-Hungary where every government involvement meant making some huge centralized office and database and all that. Interestingly, America seems to have inherited German Beamter-culture somehow, it seem government involvement in America always means creating new agencies and many government jobs.

    Also, keep in mind that in say 1920 or medical care was cheap because it could not do shit. Most patients were cared for at home and even surgeries were performed at home. So the idea of health insurance in any form was all about the loss of income i.e. social security, and not about the doctors moderate fees.

    The idea that a hip replacement surgery could cost a car or a really nasty accident could cost a house is something entirely modern, so that medical costs can be, in themselves, catastrophic and better be really insured for it, is a few decades old at worst, a really modern phenomenon, and I think it was never really thought through because most countries – and this is key here! – just mindlessly extended their existing their previous insurance-for-loss-of-income type of sickness insurance programs for it. This is absolutely key and please try to keep this in mind, it really defines the picture.

    So the predictable, cheap kind of loss-of-income sickness insurance that was all about paying some guys wage for a few months until his broken leg mends got blown up into a spiralling medical costs insurance where tech develops so fast and it is so cutting edge that it can have enormous costs.

    So imagine this. In the modern world, there is a huge and high-tech industry, the medical industry, that lives practically entirely from insurance claims, be that public or private. This is really unique at that. We also insure our cars and houses, but builders and car makers have only a very low % of their income from people replaced cars that got totalled or houses that burnt down. And the reason the medical industry lives off insurance is that it was originally meant for the loss of income due to sickness, and then got mindlessly repurposed for it.

    I hope you are smelling something fishy here. Something comparable with the airline or car industries is not supposed to operate from insurance, public or private. There are huge issues there. Such as the lack of incentive to compete costs down.

    Of course it operates from insurance because people, psychologically, set their baseline expectations at being healthy, so everything that is necessary for being healthy again is seen as a catastrophic expense, i.e. to be insured. I don’t know how to fix this. This probably needs to be fixed, but I don’t know how. Keeping 90 years old people alive and mostly functioning is like buying them BMWs in costs. It is not going to be possible to finance this forever.

  151. Interestingly, America seems to have inherited German Beamter-culture somehow, it seem government involvement in America always means creating new agencies and many government jobs.

    I think the Nazis brought it over when we hired them to build our rockets after WWII.

    Whatever the case, building effective government infrastructure in a society which believes that government is inimical to freedom and well being — even when all available evidence indicates otherwise — is a fool’s game. Without a populace that is emotionally invested in the programs, they will become havens of lobbyist graft and/or be scuppered by conservatives seeking revenge.

  152. > Given GPL terms, I think it’s on shaky legal ground and even shakier ethical ground.

    Isn’t it a dangerous precedent to say that anyone who makes an open-source product automatically forfeits all trademark protection for their name?

  153. From the comments elsewhere:

    > Detractors then noted that licenses (creatures of property law) can be rescinded by the licensor at-will (barring estoppel), and in that case any contributor to the Linux Kernel code could rescind Brad Spengler’s permission to create derivative works of their code at will

    Speaking of dangerous precedents…

    (Though, in a world where this is true, the FSF’s insistence on having copyright transferred to them makes a lot more sense)

  154. a society which believes that government is inimical to freedom and well being — even when all available evidence indicates otherwise

    Yeah, where’s the evidence that government is ever inimical to freedom and well-being? History is a solid string of shining achievements of governments, with nary a blot!

  155. Suppose something like the “uid = 0” backdoor attempt of 2003 happened today, and successfully got into the wild, in a version of the kernel that GRSecurity hasn’t seen yet. But someone else has applied a GRSecurity patch (which, obviously, does not address this hole) to the version which did have the hole, and released it as “GRSecurity 4.3”. Can you claim that this would not harm their brand? This is the scenario they are terrified of when they see other people attach their name to distributions whose security they cannot guarantee.

  156. @Jeff @PapayaSF

    I have strongly in my cultural DNA that the purpose of government is war, war, war. Or, I mean, defense. It’s all the heroic stop-the-Ottomans-or-die-trying at Belgrade or Eger scenarios. The whole idea to use government as tool to improve some other aspect of social organization is historically novel to me – yes, it existed in the West for a few centuries, but Eastern Europe has always been to busy at warring or being occupied to really test this.

    I guess an organization meant for defense can be useful for other projects as long as they look like defense. The fire department is probably not a bad idea, although I love the Austrian concept of voluntary, free-time fire service as well. Winter tend to bring up Dutch dyke building, I guess that can be seen as a form of defense, or warring with the sea. Churchill supported the idea of the NHS as a war metaphor: “Disease must be attacked, whether it occurs in the poorest or the richest man or woman, simply on the ground that it is the enemy.”

    Given that I think folks like Churchill weren’t idiots, I cautiously accept the idea that government is a proper tool for solving problems as far as such solutions can be legitimately seen as defense, or war, even when not against human opponents: fire, natural disasters, contagion (think Spanish Flu post WWI) or the frickin’ sea. (Probably my most unlibertarian belief is that there are acceptable cases of economic protectionism: a sane country must have the industrial basis necessary for warfare inside it, even when it is uneconomical and the market would balance better at free trade. Same for strategic resources that can be used for blackmail – I am not fan of Russian energy diplomacy, “obey guys if you want to heat your flats in the winter” at all. I’d rather have my fossil fuels domestic or from friendly powers and without blackmail, even when the market thinks otherwise. Basically the ability to survive trade blockades and embargoes is a legitimate political goal, because it is clearly a form of defense, and it means protectionism.) Still, with stuff like war on poverty or war on drugs, this metaphor clearly became a huge stretch. I think one current challenge is engineering non-governmental actors for non-defense types of social investment, because just being a naysayer doesn’t really work. I mean, asking progressives here, what is so progressive about repurposing the 500 years old Westphalian nation-state, meant for warfare, for education and healthcare and social welfare? New wine in old skins? People could be more creative than that… I wish I could interview Nassim Taleb on this.

  157. …and apparently my paste didn’t work and I didn’t notice. Previous in reply to Shenpen.

  158. kjj on 2015-09-07 at 02:21:50 said:

    > …if the market prefers it.

    Shenpen on 2015-09-09 at 04:37:53 said:

    > …even when the market thinks otherwise.

    Silly question: in sentences where “market” or “markets” is followed by a verb that’s characteristic of human behavior, it’s because it functions as shorthand for “market actors” or something of the sort, right? If so, I’ve screwed up (see a pattern here?): I once called derecho64 on it, suspecting he was reifying the concept of market. Now I think I was unfair; maybe I did it because he happened to be a non-libertarian, and I probably wanted to score cheap points (“Look, Eric! I’m a libertarian kid! I want your approval!”). I hereby apologize to derecho64, but I don’t know if he still reads this blog. I may have made him feel unwelcome here.

  159. Silly question: in sentences where “market” or “markets” is followed by a verb that’s characteristic of human behavior, it’s because it functions as shorthand for “market actors” or something of the sort, right?

    That’s a decent way to explain it. More generally, in such instances, a methodological individualist views such statements–whether about “the market”, “the government”, or that ne plus ultra of handwaves, “society”–as applying some sort of reduction function to a group of individual people.

    One of the advantages of using a market as a coordination mechanism is that the reduction function, price, serves both as an indicator of collectively desired behavior and a direct incentive to respond to that behavior, whereas those two components are disjoint in most other mechanisms.

  160. I think the problem with methodological individualism is the lack of awareness for coordination problems. Awareness for coordination problems (nicknamed Moloch) is one of the great truly non-partisan aspects of getting politics and economics right: this is basicially one thing what extremely smart people on the moderate left (Scott Alexander) and reactionary right (Nick Land, xenosystems.net) agree upon.

    The point is, the market is a coordinator. It cannot be entirely reduced to market actors – it is an institution in itself, which is meant to reduce coordination problems between market actors.

    Overally, the political debate should be largely about market coordination vs. governmental coordination, or suchlike. But the point is, the market is definitely a thing, a coordination institution, which is what IMHO methodological individualism tends to neglect.

    My point was largely that market coordination in peacetime tends to not really price in the potential wartime circumstances, but that is a minor point really, not really important to dwell upon in this thread.

  161. I think the problem with methodological individualism is the lack of awareness for coordination problems.

    The concept of a coordination game only makes sense from the viewpoint of considering the players as distinct entities in the first place.

    The point is, the market is a coordinator. It cannot be entirely reduced to market actors – it is an institution in itself, which is meant to reduce coordination problems between market actors.

    Why can’t it be reduced to market actors? Take out the people who make the market (including their direct proxies such as automated trading), and there’s nothing left. The “institution” is simply a set of rules for the game that the people play together. The game is much easier when the rules are clearly understood and simple to follow. The NYSE is “an institution”, certainly, that makes matchups between investors wishing to buy and sell easier—but the exchange itself is made up of individuals seeking a profit for providing clearing services.

  162. Just one example, Christopher – if and when civil lawsuits don’t work, you instantly have a very different, actually much worse market, even with the same individuals. This is why it is not really reducible to the individuals. The rules, sure, and then the rule enforcers, and the things people do when the rules are not so well enforced (i.e. sell and buy to trusted buddies) and so on.

    For example I saw in post-Soviet countries how the lack of functional civil lawsuit system meant lack of capital investment i.e. every enterpreneur could only use capital he personally owned or was loaned by a cousin or invested by a gangster who did not have to rely on courts to enforce contracts (rather goons). It was a vastly different and vastly worse market than the one you know because capital investment is capitalism’s lifeblood.

    This is just one example. It’s complicated, only simple if you work from a self-sufficient frontier-homesteader basis, which is the exception.

    There is a tiny but interesting school of econ (econ history) called New Instutitionalism. https://en.wikipedia.org/wiki/Douglass_North#Institutions_.281991.29 Ages ago I saw a PhD paper where a guy took the macro from there and used Austrian methodological individualism as microfoundations. It was the best thing ever, but unfortunately not published in English. My point is simply, meth. inv. is all fine for microfoundations, a useful way of analysis, but not exclusive, there are higher level, less reducible stuff on top of that.

  163. @Jorge Dujan

    In the phrase you quoted, I intended “if the market prefers it” to mean “if there are enough customers to sustain that product”. My “the market” there is “the customers”, rather than “The Market(tm)”. I probably should have used a different phrase, since the phrase I used evokes a common cliche (which is probably why it came to mind instead of something more accurate).

  164. I was going to write a point about the UK health service system here after reading this last night – mainly that it isn’t single player but apparently this has been covered. Although I would like to make a few more points regarding the NHS since there seems to be a lot of misunderstanding about what it is and what it does.

    As previously stated the NHS is not a state monopoly on health care many private firms do in fact compete with the NHS for customers and they get them. Secondly the NHS isn’t funded by anyone tax and saying the taxpayer pays for it is kind of misleading. The tax payer pays for Government and Government pays for the NHS.

    This is important for two reasons. Firstly the Government can be changed by the democratic will of the people, if the people were unsatisfied with the NHS they could get rid of it. Of course there is no political will to do so because, even the Conservatives managed to realize that poor people out number rich people and poor people tend to like the NHS.

    Secondly of course is that while everyone pays taxes people do not pay taxes equally. Some people pay more – others pay less. Saying the taxpayer pays for the NHS is a nice way of making it sound like everyone makes a massive contribution to this service and getting people who would otherwise be worse off without it. To side with people who out of, the cynic in me says ‘greed’ and ‘narcissism’ want to get rid of it. The taxpayer no more pays for the NHS than I pay for Larry Page’s mortgage. In practice I do, true – but in actuality Larry Page pays for his mortgage and I have no say in telling him he should get a smaller house or rent instead to save me money. (Down to I could possibly not buy an Android phone until he could not pay for his mortgage but at the end of the day that is significantly less power than I have wielding a piece of paper with the name of someone I want to elect to serve me on it.)

    Of course Government backing of a player make fiscal and economic sense too. In ‘In Place of Fear’ the Aneurin Beven argued this by stating that the NHS can buy things cheaper than any other player can simply due to scale. If a single private hospital wants to buy bed sheets it’s significantly more expensive for them than the NHS who wants to buy bed sheets for a few thousand hospitals across the entirety of the UK. Products always get cheaper in bulk and healthcare is no exception.

    There’s also the fact the NHS was supposed to also be in some ways a private institution with a capitalistic arm. ‘Capitalism in the NHS’ I can hear the outcries now but it’s not in the way the Tories, or, the Tory-Lite New Labour Party envisage capitalism in the NHS. It was supposed to sell products overseas in much the same way the BBC has its BBC Worldwide arm. I think the original thesis was based on hearing aids because it turns out people needed those and all the ones on the market when the NHS was founded were either poor quality or abysmally expensive.

    The other point is that the NHS is supposed to provide a base level of health care coverage – the universal and, if you believe it, intrinsic right everyone should have to healthcare level. Obviously the Government can’t afford to foot the bill for every possible treatment they have other things they need to purchase – such as ineffectual and massively expensive anti-terrorism operations. So the NICE system was created to justify whether medication or treatment should be provided by the NHS or not. (I believe it’s something like £80,000 per Year of Life saved. Which is pretty high when you consider most people aren’t worth £80k a year according to capitalism anyway.) Anyone who thinks they are worth more than that can, of course, go private – either outright buying their own healthcare – or as is more the case buying insurance.

    On a final point of course most people don’t pay for their healthcare, they buy insurance and the insurance pays for their healthcare. The example given of hospitals keeping people alive to make more money under private healthcare is of course equally flawed as the previous since the hospital doesn’t make money from their patients but from the people gambling with how long they are going to live for and how expensive their end of life care is.

    Under both systems the healthcare providers have as much incentive to keep people alive and functioning as they do under the other. They are both paid for by third parties and the third parties are paid for by the patients.

    Mind you I find the claim ESR invented hacker culture mildly entertaining. Seems everyone forgets about MIT Hackers these days and the ones who came before.

    • >Mind you I find the claim ESR invented hacker culture mildly entertaining.

      Perhaps you misunderstood. “Your culture” was not in this instance the hacker culture but the latter-day makerspace culture, which I inadvertently designed (at least in part) by propagating hacker memes forward to it. AFAICT those kids mostly seem to have had very little direct contact with old-school hackers, so my transmission had extra importance there.

      I think the kid got that; the incident would become more startling (and to me a bit disturbing) if he made the same error you appear to have.

      That said, while claiming that I designed today’s hacker culture would be wrong, it wouldn’t be obviously crazy wrong. Given enough ignorance of my sources I think a person could be pardoned for making that error, especially a person under 30 or so. If this ever occurs in my presence, I will of course correct it.

  165. > Perhaps you misunderstood. “Your culture” was not in this instance the hacker culture but the latter-day makerspace culture, which I inadvertently designed (at least in part) by propagating hacker memes forward to it. AFAICT those kids mostly seem to have had very little direct contact with old-school hackers, so my transmission had extra importance there.

    Well, for one thing, you’ve got a funny definition of “designed”. And I’m not sure how exactly you are drawing the line between “distinct culture with memes propagated forward into it from hacker culture” vs “evolution of hacker culture”. Why would direct contact be required?

    • >Why would direct contact be required?

      Clearly it wasn’t required; the makerspace kids are a lot like hackers, and know that they are, and like that they are. In that respect, at least, I did a good job of forward transmission.

      More direct contact would have hedged against the possibility that I inadvertently distorted or narrowed what I passed on to them, that’s all. I worry a little sometimes that what I did for the propagation of hacker culture might be a bit like what population biologists call a genetic bottleneck – evolution, yes, but a kind that discards a lot of previous genetic variation. Genetic bottlenecks leave species that are homogenous and terrifically well adapted to a specific set of circumstances, but fragile – prone to be wiped out by disease or minor ecological shifts.

      Then I go to something like FOSSCON and a see a really vigorous, happy, flourishing hacker population that is doing neat stuff and trying new things, and I’m reassured. Adaptive radiation into new niches in action; it’s a good thing.

  166. Why not just get a job? You’d be surprised how far $1500 a week goes toward paying the bills. Millions of us do/did it and never made a web site asking for money. Do it for 5 years and then write a book about that. As the song says, you don’t have to live like a refugee.

    • >Why not just get a job?

      To quote the page: “Unlike most artists, it wouldn’t be difficult for me to get a well-paid job – but then I’d have to work on what an employer wants, rather than what the world actually needs.”

  167. Would you care to add some context for those who happens to live outside of North America? I thought obamacare is just yet another health insurance scheme – how can it possibly kill lawyer job? And what does it have to do with statistics?

    • >I thought obamacare is just yet another health insurance scheme – how can it possibly kill lawyer job?

      It has loaded such high costs on employers that they’re desperate to dump full-time employees and hire contractors, who if they work less than 30 hours a week don’t trigger the regulations that impose the costs.

      And of course as with every single politically rigged attempt to lower the price of commodity X ever, the price of commodity X has skyrocketed. So people earning fewer dollars a week are forced to spend more of them on health insurance.

  168. > I’ve seen the pictures of the Cuban filth and cockroaches;

    Come on now, I hoped at least you are better than that. I’ve seen pics of a little green man riding on the ponies – it doesn’t make it valid argument for discussion about extraterrestrial life.

  169. > It has loaded such high costs on employers that they’re desperate to dump full-time employees and hire contractors, who if they work less than 30 hours a week don’t trigger the regulations that impose the costs.

    Here in some cases I have heard of downsizing was accompanied by suggestion that former employees form single-person companies / consultancies that would work for their former employer… what isn’t said that it is without lot of benefits that wage employee has (like medical insurance and social security), and of course higher work costs that pay for it. Working around the law, as is.

    I guess that wasn’t possible in yours case?

  170. It’s far belated at this point, but…

    esr: When the government employees are paying attention, they covertly instititionalize involuntary euthanasia to pull down costs (the Netherlands).

    Scott Alexander did a deep dive on this issue about two years ago which you might be interested in. (His conclusion, along with some excellent bear puns, was that reports of happy old folks being shuffled off for the sake of convenience are unsupportable.)

  171. > The article classifies patients whose lives were shortened by only a few horrible hours as “euthanized without consent”.

    Of course it does. The “christian” position is that obviously God would have come through at the last minute with a miracle to bring them back to full health if only those horrible atheistic doctors had allowed those last few hours to pass.

    Any anti-euthanasia writing must be looked at with suspicion of being tainted by this kind of ideological bias.

    • >Any anti-euthanasia writing must be looked at with suspicion of being tainted by this kind of ideological bias.

      You raise a valid point. I will re-tune my bullshit filters accordingly.

  172. @Random832
    “The “christian” position is that obviously God would have come through at the last minute with a miracle to bring them back to full health if only those horrible atheistic doctors had allowed those last few hours to pass.”

    As far as I know, the Christian position is that your horrible last hours are God’s gift and you are not allowed to interfere with His work. And indeed, such people often also refuse other medical treatment.

    I liked that Scott Alexander piece. It was quite accurate (I live in the Netherlands). The biggest complaint from old people is not a fear for unwanted euthanasia, but for a denial of euthanasia when wanted. Too many doctors refuse to allow euthanasia on (religious) principle, leaving their dying patient no recourse. Some religiously based caring homes are notorious for that.

    • >BREAKING: Patreon cracked:

      So far, I think I am not affected. First reports indicate it was patron data cracked and I’m not actually registered as a patron – I know because it still prompts me to do this on the version of my page I can see.

    • >At the very least, according to https://haveibeenpwned.com/ your email address is present in the dump (mine too). Probably any private messages between you and your patrons are there as well.

      My email address is already public, and my count of private messages is zero.

  173. @ esr

    > My email address is already public

    This reminds me of a question I’ve considered asking you (sorry for doing this so often). Your home page reads:

    You can fetch my GPG public key here. I support widespread use of strong cryptography for privacy, and encourage you to use GPG encryption with this key when sending me messages.

    I don’t know how to use GPG yet, but want to learn; and I’ve already found a couple of tutorials. Suppose that, once I’ve set GPG up, I decide to send you an encrypted message as a test. But suppose I did something wrong when setting it up. Could that damage you somehow?

  174. @Jorge I can think of two possibilities, both of them remote.

    One would be if you held some piece of information that Eric wanted you to keep in confidence, and sent it somewhere in a form readable by an adversary, when you meant to encrypt it.

    The other would be to clutter up public keyservers with useless or misleading information about Eric’s key, such as by uploading a key that looks like it belongs to him but doesn’t, or adding a bunch of useless signatures so his key becomes huge. But anybody can do this to anyone at any time. It’s just part of how the keyserver system works.

  175. @ Daniel Franke

    Thanks for the info. I guess that, for the time being, I’ll stick to my current policy: communicating with Eric exclusively via A&D. :-) After all, I can’t think of anything I’d say to him that I’m not willing to say publicly, right here.

  176. Pingback: RE: The Best Lack All Conviction | Dividuals

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