Tuesday, February 24, 2009

Another National Health Insurance Hit Piece

This time it's an article in The Atlantic in which a breast cancer survivor talks about how the drug that she hopes has eliminated her cancer would not have been covered in New Zealand. The basic thrust of the article is that the author—Virginia Postrel—survived as a consequence of spending $60,000 on a drug called Herceptin, which is very effective for certain cancers when taken early; she claims that if she had not had access to the American health care system, she would have died or been bankrupted. She justifies this by saying that the treatment protocol she followed was not covered in New Zealand or the U.K. until recently.

There are a number of problems with this. The first is that when the New Zealand health authorities decided not to fund the $60,000 one-year Herceptin treatment, there was massive and effective national protest, and as a consequence of this, they began funding it. So in fact New Zealand does now fund the full one-year Herceptin treatment. In the U.K., the government bypassed the standard evaluation process to make sure that the treatment was available, because it was such a highly-charged political issue.

Nevertheless, Ms. Postrel claims in her article that the U.S. system is better, because her treatment was covered. She fails to point out that here in the U.S., unless you happen to have health insurance, which a large minority of Americans do not, you can't possibly afford the Herceptin treatment. So, to paraphrase what she says at the beginning of the article, if she were one of those Americans, she would probably be dead.

She also fails to point out that even insured Americans face varying standards of practice. Breast cancer is not something you anticipate—it is a surprise. It becomes an urgent thing when you are diagnosed. Before that, you may check carefully to see if the cancer treatments you might need are covered by your current insurance, or you may not. You may guess right, or you may not. You may have the choice of an insurance policy that covers early Herceptin treatments, or you may not. Whether or not you have coverage for this particular treatment is a crap shoot—it is by no means certain.

So the fact that her particular insurance policy covered Herceptin should not be taken by Americans who are fortunate enough to have health insurance as an indication that they too would be covered in the event that they get the same kind of cancer. No, they had better check their own policies carefully.

She goes on to talk about the fact that kidney cancer, which affects many fewer patients, has four competing treatments, none of which is clearly preferable. She points out that in the U.K., unless you happen to be paying for private "topping up" coverage, you will not be able to try all four treatments. Of course, she again fails to mention that here in the U.S., unless you can afford private insurance, you definitely won't be able to try any treatments, nor will you be able to be treated for any other disease you may get that is covered by the National Health Service in the U.K.

So yes, if you happen to have the bad luck to get kidney cancer, you are worse off in the U.K. than you are in the U.S., if you happen to have a policy that has the kind of generous coverage she assumes all U.S. insurance policies have. But in general you are probably better off, because if you can afford "top up" coverage, you can get whatever treatment you need, and if you can't, you are still covered for the majority of different kinds of bad luck you might experience, including at least some treatment for your kidney cancer. Here in the U.S., there's a good chance that you have no coverage at all. Of course if you are a person who does have coverage, the U.S. system may seem preferable, if you happen to get kidney cancer, and if the treatment you need happens to be covered by your particular insurance policy.

She set out to prove that national health care is a bad thing, because some expensive drugs aren't covered. She actually proved the opposite. The health care systems she criticizes are doing the right thing, by her own definition. They are doing it precisely because the public has a say in what is covered and what is not.

She implies that competition between health insurance providers in the U.S. means that her drug is covered, but fails to point out that except for high-profile drugs, no such competition exists, because we choose our health insurance before we get sick. We can't anticipate which drugs we will need. So we can't check to see if they are covered.

Things didn't turn out well for her because she is an American. They turned out well for her because she is a very fortunate American.

Monday, February 23, 2009

Technology time-line

Charlie Stross blogged a better than average roving questionnaire (please don't call it a "meme") today. I answered on his blog, but the process was interesting enough that I thought I'd share it here. The question is, what technology has changed your life, and when did you first meet it? I didn't have time to really do it justice, but I had a lot of fun answering it anyway.

Electronics lab kit: aged 10. My parents were good about giving me learning gear, so I got my first electronics lab kit (basically a board with a bunch of spring connectors connected to various electronic parts that could be connected together temporarily to form various circuits) when I was about ten, and got newer ones every year or two for a couple of years after that.

3-speed bicycle: aged 10. I'm guessing on the age, but this was revolutionary for me because I lived in a rural area, and for the first time I could actually get into town without my parents' help (how times have changed!).

Pocket calculator: age 10. This was my mom's calculator - a non-programmable TI model with rechargeable NiCd batteries. I took the thing apart, examined it in detail, figured out how to compute square roots on it using the newtonian method. I suspect that the time I spent playing with this is what developed the programmer's mindset that served me well later on.

Ham radio, age 10. Lots of really old surplus equipment, and later on equipment given to me by older (much!) ham friends. Learned about ham fests (swap meets) and boat anchors (equipment you don't need, but can't resist buying). Fortunately I didn't have much money.

Mini-computer: age 11. My high school had access to a PDP-11/45 over a 110-baud modem link. This is where I started to learn to program.

Reel-to-reel stereo tape, around age 13. Somewhere in here my father stopped telling me I couldn't use his Hi-Fi (remember that term?). So I'd listen to his tapes, and I also bought tapes of my own and used them to record off the air.

GAME:ADVENT, age 13. Sometimes in the evening when the computer center wasn't crowded, Estatrek (that's what we called the sysadmin there, Jay Estabrook) would allocate us the 16k of core needed to run Adventure, and we would explore the colossal cave. Normally we only had 8k, which was not enough.

Sears 10-speed bike, age 14. The thing weighed a ton, but it was fast enough and light enough to get me all the way into the computer center without having to ask my dad to drive me. Sometimes he would track me down at the computer center and drive me home, though. I still give him a hard time about that - he didn't think computers were good for much back then. I still love bicycles, 29 years later.

Apple II, age 15. The same high school, years later, set up a computer lab with Apple II computers, which is where I first encountered machine language programming and a computer that wasn't shared, and thus on which one could not get in trouble by getting supervisor privileges. This is also where I first encountered Pascal and the UCSD p-system.

Atari 800, Age 16. The atari was a bit revolutionary for me because it had such a complex set of I/O and graphics systems, some of which could only be programmed usefully at interrupt-time, so I got my first taste of real-time programming here.

DECsystem 20, age 17. A real computer, finally. This is where I first encountered EMACS, a real LISP system (not that I got to play with it much), a real Pascal compiler, etc. I even got to hack on the Johnson portable C compiler - we did a port that ran on the '20.

Car, age 19. I did actually buy a new car when I got my first job. In retrospect, not a very smart decision, but it made sense at the time. Prior to this I'd used a bicycle for most transportation, including bicycling home from college (about 50 miles).

Oscilloscope, age 19. I worked for a company that did both digital and analog, and the hardware engineer was willing to show me things, so I learned how to use a 'scope for debugging real-time software.

Logic analyzer, age 20. Even cooler than a 'scope, because it could track CPU cycles and figure out what instructions the CPU was executing, in real time. This was back in the days when we had pipelines, but not multiple execution units, so simulating the internal state of the chip was still possible.

Free Software, age 21. Somewhere in here I encountered the Free Software Foundation and started hacking on the GNU C compiler. (I realize that you may have meant hardware more than software, but to me some of the most interesting technology I've encountered was software). This is also when I really started to grok LISP. Free software was a huge deal to me because I got kicked out of my high school for cracking security on their PDP-11 so that I could read the O.S. sources.

Internet, age 21. My first personal encounter with the Internet was at the Free Software Foundation, which was essentially a bunch of turists at MIT's artificial intelligence lab. The Internet really revolutionized my ability to waste time.

Motorcycle, age 23. This was the first ICE I had access to that was something I could actually work on myself. Not that I ever turned into a serious gearhead, but it was nice to stop being helpless around motors - over the years I had many opportunities to fix problems like water in the gas line, clogged carbs, wrong air mixture, dead battery, and so on.

Open source kernel, age 27. For the first time, access to a real operating system in source code form that I could improve and the changes to which I could share (NetBSD).

56k link to the internet from my house, age 29. My first online presence, my own domain, my own SMTP server, my own FTP server. No web at that point.

TDMA cell phone, age 30. With the small battery, it would fit in my pocket. It seemed like a win at the time, but over the years I've grown disenchanted.

Laptop, age 33. Not my first laptop, but the first one that was really useable as a computer. Running NetBSD. I never went back - laptops have pretty much freed me from being stuck in one place, so that now I can travel anywhere and still work full time or as much as I need to.

Slashdot, age 34. The first news feed I'd encountered for geeks (aside from RISKS). I don't think we've yet seen the full implications of the shift that sites like /. began, but at this point I do not really read any news other than news sourced from feed sites like /. I'm not sure whether this is a good thing or a bad thing.

Mac OS X. Age 38. Commercial unix on a laptop, with a nice UI. The shine is off the apple a bit at this point, but at the time it was huge.

Prius. Age 40. Possible to take road trips again.

iPhone, age 42. Makes road trips a lot easier. Can check email anywhere, even between towns. Don't have to stay at brand-name motels. Can find exactly what I want (I'm a foodie) even in a town I've never visited. Useful enough that I remember to keep the battery charged (mostly).

OLPC XO, age 42. Finally someone attacks the price half of the price/performance curve instead of the performance half. And a screen that can be read in the sunlight. I really, really hope this goes mainstream (none of the netbooks I've seen yet really qualify, but Pixel Qi is making interesting noises, and it's starting to sound like some ARM-based netbooks might hit the streets in the next six months).

Facebook, age 43. It's been tried before, and facebook still doesn't have it quite right, but it's the first really plausible social networking site that's believable enough that most of the people I know have joined. People worry about privacy on facebook, but facebook has an aspect of Little Brother about it that I think people are currently underestimating.

Saturday, February 14, 2009

Danger, Will Robinson...

I noticed something going around on Facebook - a questionnaire (I hate to call it a meme, because meme actually means something different that's quite important) that asks you to make up a bunch of names for yourself. It seems like great fun on the surface, but the instructions it gives for making up names actually looks like a con.

Here are the questions:
  • YOUR SPY NAME (middle name and current street name)
  • YOUR MOVIE STAR NAME (grandfather/mother on your dad's side and your favorite candy):
  • YOUR RAP NAME (first initial of first name and first 3,4 or 5 letters of your last name):
  • YOUR GAMER TAG (a favorite color, a favorite animal)
  • YOUR SOAP OPERA NAME (middle name, and city you were born in:
  • YOUR STAR WARS NAME (first three letters of your last name, last three letters of mother's maiden name, first three letters of your pet's name)
  • JEDI NAME (middle name spelled backwards, your mom's maiden name spelled backwards)
  • PORN STAR NAME (first pet's name, the street you grew up on):
  • SUPERHERO NAME: ("The", your favorite color and the automobile your dad drives)
  • YOUR ACTION HERO NAME (first name of the main character in the last film you watched, last food you ate)
So if you answer these questions, anybody who has access to your answers has the following information about you that banks commonly use to verify your identity:
  • Your full name, including your full middle name.
  • Your paternal grandfather or grandmother's name
  • The town where you were born
  • Your pet's name
  • Your mother's maiden name
  • The name of the street you grew up on
  • Your favorite color
I'm not sure that my point here is that you shouldn't post answers to this poll on your facebook page. The fact is that these are actually all lousy authenticators. You shouldn't have given this information to your bank, and therefore they shouldn't have it to authenticate you. But maybe you did. It's something to think about.

In other news, I did a three-ish mile ride with the handlebars lowered. It seemed like an improvement, but now the shelf of the seat is starting to dig into my thighs a little more, and it feels like the seat is too low. I'm starting to think that these seats are better suited to someone who thinks that a 20-mile ride is a big deal, and takes more than two hours to complete one.

Friday, February 13, 2009

Spongy Wonder, and other stories...

Wow, when I look back at my recent blog entries, it's a weird combination of sensible things and extremist things. I call on people to be reasonable, and in the next sentence I talk about how awful some group of people is, or call our former president a robot. Sigh.

But that's not what I'm here to talk about today. Ever since a bit before I broke my wrist, I've been getting worse and worse at getting exercise. While my father goes out and walks three miles a day a few months after having a triple bypass, I just lie around all day hacking or reading the news or debating with people. So a couple of weeks ago I decided to do something about that, and what I decided to do was to start bicycling again. Bicycling is the one form of exercise that's been with me since I was quite young, and at which I have ever been able to be consistent.

So I started riding. Problems arose. The two first things that come up when bicycling in Arizona is that the air is extremely dry, and the sun is brutal, even in the winter. Not only do I despise sunblock, but it takes a while to put on, and longer to get off when you're done. I'm a strong sniffer, and so the smell of it drives me nuts. This has kept me from riding in Arizona for a long time. Fortunately Andrea came up with an answer - I'd been thinking of using a balaclava, but she came up with a sort of lycra tube that's been doing a good job. It's called a Buff, and it protects my face against sun better than a bandanna, while still being breathable. It's also quite stylish:

Anyway, this worked surprisingly well - not only does it protect my face from the sun, but it turns out that if I breathe through my mouth (which Lisa-ji probably would not recommend) my breath condenses on the Buff on the way out, and then evaporates into the air I inhale, so that my throat doesn't get so dry. It's a remarkably strong effect - if I take the Buff off, my throat starts to dry out almost immediately.

So with that obstacle gone, I started riding a lot. Ten miles a day was no problem, and I did a nice ride up to La Encantada one day that was about twenty miles. These are not long rides by bicyclist standards, but if you do them every day they start to add up. This is when the next problem began: the bicycle seat.

I have a really nice racing bike - not a high-end one, but it was near the top of the line the year I bought it, and it's a Lemond, which was a pretty spiffy brand at the time. It's about fifteen years old now, but still a really nice bike. The trouble with racing bikes is that they're compromised for a riding position that pretty much assumes you are a bicycle racer. That is to say, you push hard the whole ride. You really aren't expected to put much weight on the seat.

So here I am, just starting out, putting way too much weight on the seat. And I don't really expect that to change - I'm looking for a nice hour-long workout, not a speed race. Even as I get into better shape, racing in the hot Arizona sun doesn't seem like a bright idea. I know what heat exhaustion feels like, and I'm happy to avoid it at all costs.

So I decided to try a new seat. I've been meaning to try one of these for a long time - not necessarily the particular one that I bought, but certainly something like it. The seat I decided to try is called the Spongy Wonder. The idea with this seat is that you are supposed to sit on it with your sitz bones, so the fact that you are putting a lot of weight on your bicycle seat won't matter - your sitz bones can take it. The seat looks like this:

I've taken it out twice so far, so it's too soon to tell how it's going to work out, but it's been an interesting experience already. Some people who try seats like this complain about it because they feel out of control when they ride with it. This is because they are accustomed to using the horn of the saddle as a lever to oppose the out-of-balance pedaling force they are applying. Without the horn of the saddle, you have two choices - you can balance out the forces with your hands, which exerts a twisting expansive force on your spine, or you can rotate your hips to remain in balance as you pedal. It's not clear to me that the ergonomics of either of these solutions is very good, but the point is that I actually haven't felt at all out of control with this saddle - even on the first ride, my main concerns were with the ergonomics of the thing, not with remaining in control.

I've already done quite a bit of adjusting. It feels like the saddle needs to lean forward a little farther than I can make it lean with the saddle post mount that I currently have. The first time I rode on it most of my weight was actually on my gluteus maximus muscles, not on my sitz bones. In order to correct this, I needed to lower the seat. I rode about six or seven miles today with the lowered seat, and while I think I was still hitting my glutes, it wasn't very noticeable - the sitting aspect of the seat felt fine.

This brings us to the next adjustment problem, though. When you are riding a bicycle, your body touches the bike in three places: the handlebars, the pedal, and the seat. With a traditional racing bike seat, a certain amount of your weight presses down on the saddle horn. If you're a strong racer, this isn't enough to do any harm, but for the average rider, it's certainly uncomfortable, and there's a growing consensus that it's actually harmful to the nerves that run through your perineum. In any case, the amount of weight that's pressing down, for the average rider, is substantial.

So the problem is that if you take this weight off, it has to go somewhere else. In my ride today, it went to the handlebars. This is a problem because the wrists are no less delicate than the perineum. A solution that transfers weight from the perineum to the wrists isn't much help. I raised the bars as high as they would go before my ride today, because this is what the manufacturer recommends, but it didn't really help, and I'm not convinced it's even the right idea. Depending on how far forward you bend, there's a point where you have to support your weight, and there's a point where your musculature starts to resist further bending, and thus begins to take on the weight of your torso, transferring it back to the seat and the pedals.

So my latest adjustment has been to actually *lower* the handlebars as far as they will go, to see how this affects the weight distribution. A brief ride this evening suggested to me that it does work, but it's a more extreme riding position, and so I'm not convinced it's going to actually be comfortable on a long ride. I guess I'll find out tomorrow.