02 November 2009

PelosiCare Bureaucracy Break-out

Via a conversation in a comment thread on Facebook, I went through all 111 of the new bureaucratic agencies/programs/whatnot that would be created by the House health care bill, as laid out here. I did a quick topical sort on them, based on a variety of keywords that jumped out at me as seeming important. There are some items that would fall under multiple categories; I weakly cross-referenced these with a mention of the number from the original list.

Quoted here is my response comment, roughly tied to the list pasted below. It's lacking some context, regrettably, but I think still makes some useful points:

To the first: Criticism accepted, I trusted the source without double-checking that all 111 were independent. However, I just went through and loosely categorized each of them (will post this as a note here shortly & share it), and I see very few, if any, that are identical duplicates. There are a number that apply to the same general entity/concept/whatever but that are distinct.

To the second: what does it matter if these are independent or not? Independence has no obvious causal link to, and to my mind even an implication of, greater cost. Subordinate, dependent, or corollary, it matters little - they'll still suck down resources. Further, out of the 111 entities listed, only 26 or so contain the word 'grant', and I could find only one contains 'scholarship'. In context, that's hardly 'many'. And, these grant programs, too, will require funding. And, thus, oversight to determine where the funding will go; and, thus, a director or committee to handle this oversight. $$$.

To the third: Do you really expect these few 'transitional' committees for the establishment of whatnot will allow themselves to dissolve out of existence once their nominal function is achieved? Further, I see only two with names implying a transitory function, #10 and #111. The rest are boards, committees, programs, grants, funds, trustees, secretaries and the like.

In short, it's a forest's worth of paper, laden with bureaucratic-job-creating, special-interest-pandering, taxpayer-money-wasting, cost-bloating fail.

And, the list:

Simplification and Improvement
4. Program of administrative simplification (Section 115, p. 76)
58. Center for Quality Improvement (Section 2401, p. 1322)

Advisory committees
5. Health Benefits Advisory Committee (Section 223, p. 111)
17. Telehealth Advisory Committee (Section 1191 (b), p. 589)
50. Advisory Committee on Health Workforce Evaluation and Assessment (Section 2261, p. 1275)
92. Personal Care Attendant Workforce Advisory Panel (Section 2589(a)(2), p. 1624)
(#100, Indian matters)

Demonstration programs (incl. #55)
18. Demonstration program providing reimbursement for "culturally and linguistically appropriate services" (Section 1222, p. 617)
19. Demonstration program for shared decision making using patient decision aids (Section 1236, p. 648)
23. Independence at home demonstration program (Section 1312, p. 718)
32. Demonstration program for approved teaching health centers with respect to Medicare GME (Section 1502(d), p. 933)
38. Demonstration program for Medicaid coverage to stabilize emergency medical conditions in institutions for mental diseases (Section 1787, p. 1149)
64. "No Child Left Unimmunized Against Influenza" demonstration grant program (Section 2524, p. 1391)
79. Grant program to support demonstration programs that design and implement regionalized emergency care systems (Section 2553, p. 1480)
95. Demonstration program for chronic shortages of health professionals (Section 3101, p. 1717)
96. Demonstration program for substance abuse counselor educational curricula (Section 3101, p. 1719)

Demonstration 'projects'
76. Demonstration project of grants to medical-legal partnerships (Section 2537, p. 1464)
102. Indian Health Service tribal facilities joint venture demonstration projects (Section 3101, p. 1809)
107. Indian youth telemental health demonstration project (Section 3101, p. 1909)
103. Urban youth treatment center demonstration project (Section 3101, p. 1873)

Wellness grants
2. Grant program for wellness programs to small employers (Section 112, p. 62)
54. Grant program for community prevention and wellness research (Section 2301, p. 1305)
55. Grant program for research and demonstration projects related to wellness incentives (Section 2301, p. 1305)
56. Grant program for community prevention and wellness services (Section 2301, p. 1308)

Women's Health
90. Health Resources and Services Administration Office of Women's Health (Section 2588, p. 1618)
91. Food and Drug Administration Office of Women's Health (Section 2588, p. 1621)
86. Health and Human Services Coordinating Committee on Women's Health (Section 2588, p. 1610)
87. National Women's Health Information Center (Section 2588, p. 1611)
88. Centers for Disease Control Office of Women's Health (Section 2588, p. 1614)
89. Agency for Healthcare Research and Quality Office of Women's Health and Gender-Based Research (Section 2588, p. 1617)

6. Health Choices Administration (Section 241, p. 131)
10. Mechanism for insurance risk pooling to be established by Health Choices Commissioner (Section 306(b), p. 194)

8. Health Insurance Exchange (Section 201, p. 155)
9. Program for technical assistance to employees of small businesses buying Exchange coverage (Section 305(h), p. 191)
11. Health Insurance Exchange Trust Fund (Section 307, p. 195)
12. State-based Health Insurance Exchanges (Section 308, p. 197)
34. Special Inspector General for the Health Insurance Exchange (Section 1647, p. 1000)

'Public Health Insurance Option'
14. "Public Health Insurance Option" (Section 321, p. 211)
15. Ombudsman for "Public Health Insurance Option" (Section 321(d), p. 213)
16. Account for receipts and disbursements for "Public Health Insurance Option" (Section 322(b), p. 215)
42. Public Health Investment Fund (Section 2002, p. 1214)
46. Public Health Workforce Corps (Section 2231, p. 1253)
47. Public health workforce scholarship program (Section 2231, p. 1254)
48. Public health workforce loan forgiveness program (Section 2231, p. 1258)
57. Grant program for public health infrastructure (Section 2301, p. 1313)

'Accountable Care'
20. Accountable Care Organization pilot program under Medicare (Section 1301, p. 653)
36. Accountable Care Organization pilot program under Medicaid (Section 1730A, p. 1073)

'Home pilot' programs
21. Independent patient-centered medical home pilot program under Medicare (Section 1302, p. 672)
22. Community-based medical home pilot program under Medicare (Section 1302(d), p. 681)
35. Medical home pilot program under Medicaid (Section 1722, p. 1058)

'Comparative Effectiveness'
24. Center for Comparative Effectiveness Research (Section 1401(a), p. 734)
25. Comparative Effectiveness Research Commission (Section 1401(a), p. 738)
26. Patient ombudsman for comparative effectiveness research (Section 1401(a), p. 753)
39. Comparative Effectiveness Research Trust Fund (Section 1802, p. 1162)

Nursing facilities (both 'skilled nursing' and 'nursing' - difference in jargon terms?)
27. Quality assurance and performance improvement program for skilled nursing facilities (Section 1412(b)(1), p. 784)
28. Quality assurance and performance improvement program for nursing facilities (Section 1412 (b)(2), p. 786)
29. Special focus facility program for skilled nursing facilities (Section 1413(a)(3), p. 796)
30. Special focus facility program for nursing facilities (Section 1413(b)(3), p. 804)
31. National independent monitor pilot program for skilled nursing facilities and nursing facilities (Section 1422, p. 859)
37. Nursing facility supplemental payment program (Section 1745, p. 1106)

Anti-fraud (note: *one* entity)
33. Pilot program to develop anti-fraud compliance systems for Medicare providers (Section 1635, p. 978)

Tracking to prevent 'double-dipping' (*ONE* entity)
40. "Identifiable office or program" within CMS to "provide for improved coordination between Medicare and Medicaid in the case of dual eligibles" (Section 1905, p. 1191)

41. Center for Medicare and Medicaid Innovation (Section 1907, p. 1198)
49. Grant program for innovations in interdisciplinary care (Section 2252, p. 1272)

'Grant programs'
3. Grant program for State health access programs (Section 114, p. 72)
13. Grant program for health insurance cooperatives (Section 310, p. 206)
45. Grant program for training in dentistry programs (Section 2215, p. 1240)
60. Grant program to support the operation of school-based health clinics (Section 2511, p. 1352)
61. Grant program for nurse-managed health centers (Section 2512, p. 1361)
62. Grants for labor-management programs for nursing training (Section 2521, p. 1372)
63. Grant program for interdisciplinary mental and behavioral health training (Section 2522, p. 1382)
65. Healthy Teen Initiative grant program regarding teen pregnancy (Section 2526, p. 1398)
66. Grant program for interdisciplinary training, education, and services for individuals with autism (Section 2527(a), p. 1402)
68. Grant program to implement medication therapy management services (Section 2528, p. 1412)
69. Grant program to promote positive health behaviors in underserved communities (Section 2530, p. 1422)
70. Grant program for State alternative medical liability laws (Section 2531, p. 1431)
71. Grant program to develop infant mortality programs (Section 2532, p. 1433)
72. Grant program to prepare secondary school students for careers in health professions (Section 2533, p. 1437)
73. Grant program for community-based collaborative care (Section 2534, p. 1440)
74. Grant program for community-based overweight and obesity prevention (Section 2535, p. 1457)
75. Grant program for reducing the student-to-school nurse ratio in primary and secondary schools (Section 2536, p. 1462)
80. Grant program to assist veterans who wish to become emergency medical technicians upon discharge (Section 2554, p. 1487)
93. Grant program for national health workforce online training (Section 2591, p. 1629)
94. Grant program to disseminate best practices on implementing health workforce investment programs (Section 2591, p. 1632)
(plus others?)

American Indian
97. Program of Indian community education on mental illness (Section 3101, p. 1722)
98. Intergovernmental Task Force on Indian environmental and nuclear hazards (Section 3101, p. 1754)
99. Office of Indian Men's Health (Section 3101, p. 1765)
100. Indian Health facilities appropriation advisory board (Section 3101, p. 1774)
101. Indian Health facilities needs assessment workgroup (Section 3101, p. 1775)
104. Grants to Urban Indian Organizations for diabetes prevention (Section 3101, p. 1874)
105. Grants to Urban Indian Organizations for health IT adoption (Section 3101, p. 1877
110. Native American Health and Wellness Foundation (Section 3103, p. 1966)
111. Committee for the Establishment of the Native American Health and Wellness Foundation (Section 3103, p. 1968)

1. Retiree Reserve Trust Fund (Section 111(d), p. 61)
51. Prevention and Wellness Trust (Section 2301, p. 1286)

43. Scholarships for service in health professional needs areas (Section 2211, p. 1224)

52. Clinical Prevention Stakeholders Board (Section 2301, p. 1295)
53. Community Prevention Stakeholders Board (Section 2301, p. 1301)

Training programs
44. Program for training medical residents in community-based settings (Section 2214, p. 1236)
106. Mental health technician training program (Section 3101, p. 1898)

83. CLASS Independence Fund (Section 2581, p. 1597)
84. CLASS Independence Fund Board of Trustees (Section 2581, p. 1598)
85. CLASS Independence Advisory Council (Section 2581, p. 1602)

Emergency Care
77. Center for Emergency Care under the Assistant Secretary for Preparedness and Response (Section 2552, p. 1478)
78. Council for Emergency Care (Section 2552, p 1479)

Treatment programs
108. Program for treatment of child sexual abuse victims and perpetrators (Section 3101, p. 1925)
109. Program for treatment of domestic violence and sexual abuse (Section 3101, p. 1927)

7. Qualified Health Benefits Plan Ombudsman (Section 244, p. 138)
59. Assistant Secretary for Health Information (Section 2402, p. 1330)
67. University centers for excellence in developmental disabilities education (Section 2527(b), p. 1410)
81. Interagency Pain Research Coordinating Committee (Section 2562, p. 1494)
82. National Medical Device Registry (Section 2571, p. 1501)

Call your representatives and tell them they'll lose your vote next November if they vote for this monstrosity...

31 August 2009

Linking Facebook & Blogger

Soo... Facebook and Twitter integrate well - any tweets I make that aren't direct replies to people are automatically shunted into FB status updates as well. This is nifty.

However, there've been some really good discussions going on in some comment threads of some of my FB posts, and I would really like to open them up to a broader audience, if I could. Does anybody know of a way to tightly integrate comments on a particular blog post on Blogger with the comments on a particular FB link/status update/other entity?

I wouldn't want it to be across-the-board, and the initial link wouldn't necessarily need to be automatic. (That is, I'd be happy to have to establish the initial link between blog post and FB post manually, as long as all the comment integration proceeded automatically from there.)

Anybody have any ideas, or know of anything that would achieve this?

13 April 2009

Facebook and Twitter

To let anyone know who might happen to check this blog regularly, most of my online interactions lately have been on Facebook (find me at brian[dot]skinn[at]gmail[dot]com) and/or Twitter (khemboy). There are a few things I have rattling around that might make it up here eventually, mostly some long-form thoughts and/or social/political/etc. analysis... but for the most part, if you want (for whatever strange reason ;-) an idea of what's rattling around in my head, look for me there.

08 April 2009

Mike Judge, Almost FTW

Just about anyone reading this blog probably has seen Office Space, and as such will nigh-on automatically grin at the mention of 'TPS reports'. Ten years after the original launch of the film, its creator, Mike Judge, revealed that the acronym stands for 'Test Program Set'.

However, the use of TPS is potentially ironic in an entirely different way. Toyota, well known for its manufacturing efficiency, has developed an integrated system and philosophy for its production facilities, called the 'Toyota Production System'... which also fits the 'TPS' acronym. How awesome would it have been if Mike Judge had used as an emblem of corporate bureaucratic drudgery a system that in real life represents one of the most successful examples of streamlined industrial efficiency?

Teh *sigh*...

06 February 2009

Incidental Words

It's remarkable how words that mean one thing in my mind, can mean so many different things in someone else's. How there is so much potential for miscommunication, in virtually every interaction we have with others. How a word, chosen carelessly (or sometimes even carefully), can profoundly alter a situation or a relationship.

How profoundly comforting, then, that though 'man looks at the outward appearance, the Lord looks at the heart.' (1 Samuel 16:7) Regardless of the words (or even non-words) we use, we need never fear God misunderstanding the intent, the heart, that moves our prayers.

04 February 2009


I've always been sort of fascinated by other people listening to headphones, or other people reading. I marvel at how this other person is experiencing something ... hearing sounds or reading words - taking in something that I have no knowledge of whatsoever. They could be listening to a song that would become my favorite, if I could but hear it. They could be reading words that would change my life, if I were but to glance at them. Regardless, they are absorbed in a world of their own in which I cannot share.

I guess it really drives home to me our separateness - how each of us is, on some level, truly alone, truly individual. It gives lie to the philosophy that the world around me is just a construction of my mind - how could I conjure up all those words on all those pages, all those sounds heard by a thousand ears other than mine, and yet not know a single one of them? It also touches on a theme discussed by Henri Nouwen and Paula Ripple, that loneliness is a 'constant companion', to use Ripple's words - that no matter how many people with whom we surround ourselves, no matter how close we may get to a spouse or a friend, a measure of loneliness will remain with us. Or, in contemporary musical parlance, there will remain a "God-shaped hole" in us, that only He can fill - and in this life, only incompletely. That we cannot but "groan inwardly as we wait eagerly for our adoption as sons, the redemption of our bodies1", looking forward to our being "united with him in his resurrection2".

But... Christians are called to stay in this world that is not our home3, that is passing away4, because we are charged as ambassadors of Christ to the world5. Were it not for this responsibility, what would keep Christians here? As Paul says, "to live is Christ, to die is gain6" - without this calling, this commission7, why not speed reunion with God? I suspect this is something that too many believers consider too little, and too lightly... very likely including myself.

What message are we bringing to those around us? Are we, as Nouwen puts it, offering healing to others by "[inviting them] to recognize [their] loneliness on a level where it can be shared8"? By experiencing their emptinesses along with them, coming alongside their burdens and pains, and helping them to understand that the only hope of true healing is not to be found in this temporal realm? Or are we simply seeking salves for our own loneliness in others, things, prosperity... too focused on treating our own wounds to minister to those of others?

We are called to a narrow path, and a narrow gate9. This is a hard teaching10, but to whom else shall we go11?

1 Rom. 8:23
2 Rom. 6:5
3 1 Pet. 2:11
4 1 Cor. 7:31
5 2 Cor. 5:20
6 Phil. 1:21
7 Matt. 28:16-20
8 The Wounded Healer, Ch. IV, Section II.2
9 Matt. 7:14
10 John 6:60
11 John 6:68

19 January 2009

Strikingly Pleasant, And Strikingly Unpleasant

Just now read through the AP/Yahoo piece on the developments in the investigation on the plane that was forced to emergency-land in the Hudson river on Thursday. Pleasant and unpleasant things aside, I heartily applaud the professionalism and cool-headedness of the pilots and crew that prevented the death of anyone on the plane. They deserve whatever commendations they might receive from whatever organizations might offer them.

However, one thing that really struck me positively was this:

The pilot, who has not publicly talked about the crash, canceled what was to be his first interview Monday, on NBC's "Today" show. The show said it would interview Sullenberger in a couple of days.

Stephen Bradford, president of the U.S. Airline Pilots Association, said he asked Sullenberger not to talk to the media to avoid jeoparding the association's "interested party" status with the NTSB, which allows it to participate in the investigation.

"If the NTSB perceives that we are in any way compromising the objectivity of the investigation by innocuously releasing information to the media, our status will be rescinded and we will be unable to help determine the causal factors leading up to this very positive and well-documented outcome," he said.

Also, nowhere in the article did any "anonymous sources" come forth to provide insider information. It bothers me to no end how so often information comes from sources '... who spoke on condition of anonymity because they were not authorized to speak publicly ...' on the matter at hand. I have a lot of respect for the crew of this plane, for their respective decisions to refrain from commenting before an appropriate time. Kudos to them!

Contrariwise, strikingly unpleasant to me was this:

Kelsey Higginbotham, a 20-year-old student at East Tennessee State University, looked at the damaged aircraft Sunday from behind police barricades.

She and a friend had been to Times Square, Central Park and the site of the World Trade Center, where nearly 2,800 people were killed in the Sept. 11 attacks. She said she was struck by the contrast between one disaster in which so many people died and another in which everyone survived.

"It's a miracle," she said. "I guess New Yorkers can't take any more tragedy."

Attempting to establish a moral equivalency, via calling both simply 'disasters', between a malicious, willful attack and an accidental collision with a flock of birds? Whether it was Ms. Higginbotham herself attempting to draw this equivalency, or the writer of the article (or both): Shame on you!

05 January 2009

Returning Solar Energy To The Grid

Listening to the 29-Oct-2008 entry from NPR's Technology Podcast, where they're talking about residents and businesses who're going for 'energy zero' (or some term like that, I don't remember it exactly) construction: building homes and buildings with modern materials, solar panels, etc. such that their net draw on utilities is essentially zero. One of the points they bring up is how the reimbursement for excess energy generated and returned to the grid (i.e., the energy use of the home/building is "negative") is paltry compared to the cost of 'positive' energy use, matched per kilowatt-hour, or whatever. The rep they talk to from the utility company (or regulatory body or whatever) brings up some of the various breaks they give to people who build green, and talks about how challenging it is to deal well with customers returning their excess energy to the grid.

Firstly, I'm not sure I really follow why it's all that hard. My brother is currently working in a chemical plant where they often generate excess electricity from their on-site generators, and they have an agreement worked out with the utility company where they return their excess generation to the grid, no problem. (Sure, I expect it's more complex than I realize... still, the capability is there.) What's to stop them from broadening this?

Well. Technologically, perhaps nothing... but from both a logistical sense and a market-share sense, no utility company worth its salt would willingly choose to outsource (essentially) its generation to its customers as things sit right now. On the one hand, if this 'networked' power generation from many thousands of individuals were as robust as the Internet has been for data transfer, then maybe there wouldn't be any logistical problems at all. Buuuut... think of the lawsuits that could be brought! Barring legislative changes (I assume, anyways), the utility company would be liable for the actions of its customers, should those actions result in interruption in the supply of electricity (especially in emergency or critical situations). I can't imagine any power company willingly going along with that!

Further, (loosely) in terms of market share, if a critical mass of customers shifted to 'energy-zero', the utility company would be left to maintain all of its power transmission infrastructure... but with severely curtailed revenues! The current billing approach (at least, on my bill) for electricity is to scale both generation and distribution costs by the amount of electricity consumed. So, if I use 200 kWh one month and 300 kWh the next, both the generation and distribution costs on my bill will be half again as large in that second month (assuming no change in their per-unit costs). But, if I convert my house to 'energy-zero' prior to that third month... I could use that same 200 kWh as the first month on the cloudy days, but return 205 kWh to the grid on the sunny days. Boom presto, based on the current usage-indexed billing system, if I got one-for-one credit for electricity returned to the grid, I would get a refund on that extra 5 kWh... but the grid bore the burden of 405 kWh for my total 'positive' and 'negative' usage!

Rejigger billing so that distribution costs are charged both on energy usage and energy return, and restructure laws & regulations to give the utility companies some protections in an environment where customers will morph into customer-suppliers, and I think we'll have a start toward a much more logical and sustainable power grid. Politics aside, thinking green can really make sense... it just has to be done... well, sensibly.