Single Payer: Realistic or Just Politics?

There has been a growing push from the left wing to do a single payer system because of the complexity of implementing the ACA. There are obvious reasons why any Government attempt will be flawed, especially if the Government tries to do anything leading edge. Just look at DoD, it takes dozens of tries before anything gets done. In addition in DoD, just take a destroyer or a Littoral craft, they thrown everything including the kitchen sink into the design. In WW II we could build a destroyer in months, now it takes a decade. Why? Because everyone gets a chance to add and change. The cost is irrelevant.

Now the Princeton Professor has a piece arguing that as a result of the fiasco we should really do a single payer. He states:

Imagine, now, a much simpler system in which the government just pays your major medical expenses. In this hypothetical system you wouldn’t have to shop for insurance, nor would you have to provide lots of personal details. The government would be your insurer, and you’d be covered automatically by virtue of being an American. 

 Now is this the easiest and best way? Well it depends. A little more than four years ago I wrote a piece on how Health Care could be delivered to all using subsidies but via a private mechanism. Just like home, car, life insurance. It works, and often times better than any Government plan. Just look at Flood Insurance, the Government stalls and stalls just due to Government's inherent incompetence.

Now what are the benefits of Private insurance? Simple:

1. It already exists.

2. It is competitive and can be made more so.

3. It allows choice.

4. It is the negotiator for the buyer.

Now when I proposed such a plan I did so making a few changes:

1. The individual was responsible for their own insurance. No company or union paid plans. Also I would not allow a tax deduction. By the way, that is how Medicare works. It is the individual's plan, it is after tax dollars and you still pay even after you retire, often a high amount depending on your income.

2. The plan should really be for catastrophic coverage, not for oil changes. If some one wants a "oil change" plan so be it but they pay. It is not required. The biggest problem with the ACA is its demands for so extensive a coverage plan. For example, take a PSA test, one should not have to have that included but if you want one then you may pay out of pocket. Birth control, and many other life style choices should remain that way, individual choice and payment.

3. Penalties for life style based disease should be present and allowed. Thus for smokers, obese individuals, drug users, etc the prices should reflect the risks they have assumed. The same is true for life and auto insurance. If one has dozens of speeding tickets then the premium should and frankly must reflect the higher personal risk.

I then worked through the financial details. It worked! The Gnome from the South does not present any such plan or details. He suggest we just put it all on the Government tab.

Individual choice and responsibility is a core to our society. If we agglomerate everything to the Government we create a Collapse of the Commons syndrome, no personal choice or responsibility and abuse of the system. Frankly the explosive expansion of Food Stamps is a clear example. Childhood obesity is much more of a problem than starvation. I would argue that the obesity problem is a Collapse of the Commons.

As the Professor concludes:

In saying this I don’t mean to excuse the officials and contractors who made such a mess of health reform’s first month. Nor, on the other side, am I suggesting that health reform should have waited until the political system was ready for single-payer. For now, the priority is to get this kludge working, and once that’s done, America will become a better place. 

In the longer run, however, we have to tackle that ideology. A society committed to the notion that government is always bad will have bad government. And it doesn’t have to be that way. 

 There is no proof that America will be a better place. There is no evidence that a single payer is the better system. One can envision many deleterious "unintended consequences" from a single payer. It is a monopsony, with the Government as the single buyer, and the single arbiter, a rather off-putting thought.

Finally one should remember the two prime  elements of Marxist dogma; centralized control and planning, and Government (in Lenin's view the Party) control over all. Namely for any good Marxist there is a belief in the ultimate a predictable movement of society and the beneficial and necessary need for central planning by the select few. Sound familiar? One should read Asimov, Foundation Trilogy, the Gnome's idol.

Economics Again

The Noble Prize in Economics, it is not really a real Noble Prize but let's not split hairs, went to two opposing schools of thought. One of those schools went about telling everyone they could why they were right and the other fellow was wrong. Today's NY Times presents one of the arguments.

The author, one of the "Winners" states:

Actually, I do not completely oppose the efficient-markets theory. I have been calling it a half-truth. If the theory said nothing more than that it is unlikely that the average amateur investor can get rich quickly by trading in the markets based on publicly available information, the theory would be spot on. I personally believe this, and in my own investing I have avoided trading too much, and have a high level of skepticism about investing tips. 

But the theory is commonly thought, at least by enthusiasts, to imply much more. Notably, it has been argued that regular movements in the markets reflect a wisdom that transcends the best understanding of even the top professionals, and that it is hopeless for an ordinary mortal, even with a lifetime of work and preparation, to question pricing. Market prices are esteemed as if they were oracles. 

This view grew to dominate much professional thinking in economics, and its implications are dangerous. It is a substantial reason for the economic crisis we have been stuck in for the past five years, for it led authorities in the United States and elsewhere to be complacent about asset mispricing, about growing leverage in financial markets and about the instability of the global system. In fact, markets are not perfect, and really need regulation, much more than Professor Fama’s theories would allow. 

 Point well taken, indeed there is all too often insider information, timing variances and technological leverage, and finally cost leverage. High speed trading is a way to beat the market, a way that actually drives values of equities, not just responds to them. The price may reflect many things, the last trade, the latest financial release, the health of the president. It may reflect the past, present and future. Furthermore it may reflect guesses and hopes. 

I wrote a piece on the Rowe Conjecture a few years ago. This was a conjecture by Nick Rowe where he speculated the idea that perhaps the real world oscillates between reality and assumption. Rowe is one of the more realistic of economists, often rationally questioning assumptions and not just pontificating on high. Rowe often brings a sense of the common to economics.

Now to refresh on the Rowe Conjecture. We can assume that the EFH, efficient market hypothesis, actually is in play or not, and likewise we can oscillate between what people think, that it works or not. The result as I demonstrated using a simple analysis is an oscillating market of highs and lows all do to what people think and what reality is doing. This is kind of balancing the views of the two contestants in the economics war of words, which seems to be just one sided now.

But last week the Times had a piece by some Harvard economist alleging that fundamentally Economics was a science. The author states:

It is true that the answers to many “big picture” macroeconomic questions — like the causes of recessions or the determinants of growth — remain elusive. But in this respect, the challenges faced by economists are no different from those encountered in medicine and public health. Health researchers have worked for more than a century to understand the “big picture” questions of how diet and lifestyle affect health and aging, yet they still do not have a full scientific understanding of these connections. Some studies tell us to consume more coffee, wine and chocolate; others recommend the opposite. But few people would argue that medicine should not be approached as a science or that doctors should not make decisions based on the best available evidence. 

As is the case with epidemiologists, the fundamental challenge faced by economists — and a root cause of many disagreements in the field — is our limited ability to run experiments. If we could randomize policy decisions and then observe what happens to the economy and people’s lives, we would be able to get a precise understanding of how the economy works and how to improve policy. But the practical and ethical costs of such experiments preclude this sort of approach. (Surely we don’t want to create more financial crises just to understand how they work.) 

Yes, go pick on medicine. They are just a bunch of "witch doctors".  Or as the author appears to argue they are just like economics. Not really.

Consider Biology; in the first half of the 20th century it was slowly moving from a study of classifying "stuff". After all Jim Watson was originally an ornithologist, a studier of birds. But in the early 1950s Biology went from something akin to economics, a collector of data, and a proposer of relationships, to a real science. DNA made that possible. Now regarding science we have the ability to predict and then test our predictions. We now know that BRAF V600 is a gene which enables melanoma to aggressively metastasize. We know where it is in the internal pathway of the cell and we can, understanding the structure of the gene, deliver a therapeutic to block it and stop the growth. We also know that MEK can then become aberrant and we have a way to block it. We have a road map, we can make predictions, we can design a therapeutic, and it works, every time. Can any economist say that? No way. So the author of the above piece, Harvard not withstanding, has somehow missed what has happened to medicine. It is now truly a science.

Economics is where plant classification was in the 19th century, at best. One collects data, looks at relationships, and perhaps fins a new species. One cannot not predict what will happen. Medicine can, everything that is a science can. The introduction of imatinib for CML, a kinase inhibitor, was the first break out point for medicine in such a new world. There is no such example for macroeconomists. 

Consider one of the final statements:

Using a data set with anonymous records on 2.5 million students, we found that high-quality teachers significantly improved their students’ performance on standardized tests and, more important, increased their earnings and college attendance rates, and reduced their risk of teenage pregnancy. These findings — which have since been replicated in other school districts — provide policy makers with guidance on how to measure and improve teacher quality. 

 In my opinion this is an ad hoc propiter hoc argument. Bad teachers are just that, bad. I had a few, so what does one do, find a way to work around them. No, not every student can do that, but it does challenge the good students to actually get better.

Overall, economics is at best two things; (i) the collection of data and its analysis, and, (ii) the proposal of political views oftentimes using ersatz mathematics. Mathematics for building a bridge is good mathematics. Mathematics for proposing a social policy is "shingling the roof in the fog".

Would You Buy a Car From These People?

Now I do not think a great deal about economists and their "science". But the CEA, the Administrations economic mouthpiece, remember Romer and her "scientific" predictions, have now analyzed the closing of the Government.

They state:

A number of private sector analyses have estimated that the shutdown reduced the annualized growth rate of GDP in the fourth quarter by anywhere from 0.2 percentage point (as estimated by JP Morgan) to 0.6 percentage point (as estimated by Standard and Poor’s), with intermediate estimates of 0.2 percentage point and 0.5 percentage point from Macroeconomic Advisers and Goldman Sachs respectively. Most of the private sector analyses are based on models that predict the impact of the shutdown based on the reduction in government services over that period. Very few of them are based on an actual analysis of economic performance during the period of the shutdown and very few take into account the secondary effects on the private sector of the cessation of government services or the effects on confidence and uncertainty associated with both the shutdown and the debt limit brinksmanship. But we know that these effects can be large; for example, the debt limit brinksmanship in the summer of 2011 had an adverse economic impact even though it was not accompanied by a shutdown nor did it lead to an actual default on U.S. government obligations. While useful in understanding the costs of the shutdown and brinksmanship, the available private-sector analyses present only part of the picture.

This report attempts to estimate the actual impact of the shutdown and default brinksmanship on economic activity as measured by eight different daily or weekly economic indicators. Overall it finds that a range of eight economic indicators combined in what this report calls a “Weekly Economic Index” are consistent with a 0.25 percentage point reduction in the annualized GDP growth rate in the fourth quarter and a reduction of about 120,000 private-sector jobs in the first two weeks of October (estimates use indicators available through October 12th.)

Assuming anything in the above is even close to true, remember we have one of those rating agencies who got us in this mess it is alleged, and an bank receiving near free money from the FED, one could ask as Congress pays for non working hours will that pop up the numbers again?

Also are we just measuring noise at this level of granularity?

Software: Making It Work

First, there is a law of Nature that is immutable: Government never makes any software work the first time, or the second, or the third. The Corollary is that any Government software projects take five time longer and costs ten times as much as any commercial project.

Thus the obvious collapse of the ACA sites is hardly unexpected. Add to that a Canadian company with I gather a less than exemplary record and what would one expect. Now I started programming in 1962, a while ago, and worked on a few projects over the years. They all had their problems. But they all went through independent validation and verification, IVV. That way we knew if they dd what we expected them to before they were released. Also they were incremental.

Thus when I see people who apparently have had no experience opining on the topic I just am not surprised that they do so, after all they apparently have been doing it all their lives. Now an example is in the Times today:

What went wrong? My diagnosis is that there were three big mistakes.First, the ... administration acted too slowly. It waited too long to release specific regulations and guidance on how the exchange would work. It also waited too long to begin building the physical Web site. These delays were largely because the administration wanted to avoid election-year controversy. 

Yes, but.  Was there an architecture, architect. Did they get the best people or was it purely a political mess. I suspect the latter. So what have we changed to eliminate this factor? Nothing. Just a new political player.

Second, the ostensible quarterback of the federal health care exchanges, with responsibility for integrating all the various components, is the Centers for Medicare and Medicaid Services. While the agency has expertise in issuing reimbursement rules and overseeing large-scale claims-processing operations, it has little expertise in creating a complex e-commerce Web site. 

First this is not a Web Site. This is a transaction processing system interconnected to other existing systems with a front end web page which is tertiary at best. Also good web design means simple not one filled with useless pictures. Look at Google. Simple. Form follow function and having smiling people does not reflect function, especially if it does not work.

Finally, this was not the first health insurance exchange ever created. Massachusetts has had years of experience with its exchange, and there are private exchanges, like eHealth, where individuals can shop for insurance. In addition, many states, like California, Connecticut and Kentucky, had already spent around two years building their exchanges, gaining experience and proving it was possible to create a good customer shopping experience. It does not appear that the Centers for Medicare and Medicaid Services or its contractors spent much time reviewing these models and adopting best practices.  

And by the way CMS will be the same set of humanitarians controlling people's lives. Yes there are many functioning sites, even the Government has its own for employee registration every year. Why not just expand that? Because they wanted total control to reflect their own agenda.

So what would one do in the commercial world? Fire the management, get people who can do the job, and reward success and punish failure. And get the Government out of the way. But alas it will go in the other direction.

So despite what the author of the above suggests it will not happen.

The French Mind, The French Soul

The book by Carroll, Brave Genius, is a wonderfully and lucidly crafted exposition of two major French figures at mid twentieth century; Camus and Monod. In CP Snow’s book, The Two Cultures, written about the same time of these events of the book which bemoans the gap between the cultural intellectual and the scientist. This book clearly belies that tale.

This is a tale of two men, from and in different walks of life in their day “jobs” and yet drawn to a common theme by the invasion and capture of France in the early 1940s (1940-1944). It tells the tale of each of them, their divergent lives and the convergence of common interests. It is, in many ways, a uniquely French tale of intellect, action, culture and friendships.

Monod is the biologist, seen first as a student seeking, albeit slowly, what to focus on. Monod clearly has little personal angst due to his coming from a solid middle class family, his mother even being American. He is a multi-talented young man, married to a Jewish woman. Camus on the other hand is from Algeria, from near poverty, but educated and with the intents of being a writer. His early work is marginally accepted yet he continues to extol the ideas of what was to become broadly speaking, the Existential School.

Camus is well known for his works such as The Plague and the Myth of Sisyphus; Monod, for explaining the details of DNA to protein synthesis. Monod complemented the work of Watson and Crick, it let those of us in the late 50s and early 60s to say; oh, that is how it works. Camus also framed the challenge of life for many in the same period, as a clear voice for those seeking the meaning of existence, and also as a strong counter voice to Sartre.

This book throws these two together, not in an artificial way, but as a telling of the factual interaction of what would become two Nobel Prize winners; Camus for Literature and Monod for Medicine and Physiology.

The book starts before the War and its main discussion is during the War itself and the actions of Camus on the underground paper Combat and Monod as a significant participant in the underground. The book details their exploits, of frustrating the Germans and of their cat and mouse games of avoiding being identified or capture. Monod is a most interesting character since at one time he is trying to pursue his research career while at the same time he is rapidly moving up in the Resistance hierarchy. Camus, still hindered by his Tuberculosis, manages to continually get his underground newspaper out which is an ongoing assault to the Germans. Both Monod and Camus have by this time interacted but their lives are each dominated by their goal to defeat the Germans by deed or word.

The book does discuss the significant ambivalence of many of the French during the occupation. Many just wanted to allow the Germans to occupy them and not make things worse. In effect whether in Occupied France or in Vichy the attitude was that they would like to have things as “normal” as possible. In contrast it was truly a small band of quite brave resistors like Camus and Monod who took a stand which not only placed them at odds with the German occupiers but also with many of their French compatriots. The book does tell the tale of the German opposition side but could have somewhat better explored the dissonance in the French people at large. For it was the latter that often created the greatest risks?

The last part of the book concerns the two of them and the post War life and politics in France. French intellectuals of many types were often Socialists and Communists. That included Camus and Monod. But the challenge came when the Stalin and his extreme treatment of the people and truth became common knowledge. For Monod it was Lysenko and the Stalinist theory of genetics.

For Monod this was a breaking point and he took a public stand and denounced Lysenko and by default Russian Communism. For that he received the reprobation of the French Communists. For example on p. 279 the author states: “…The fundamental flaw in Mendel’s … and other Western scientists’ theories…was this insistence that inheritance was independent of the conditions experienced by animals and plants, such that no characteristics acquired during their lives were passed on to the next generation…the Lenin Academy objected to the idea that the hereditary substance of animals and plants was not influenced by the conditions experienced by the organism and that it acted alone in determining inheritance…”  

To this Monod took a strong negative position. Ironically it would take another fifty plus years to somewhat alter the facts. Although the gene was the controlling factor, and genes were passed on in a manner according to Mendel, the impact of conditions of the parents, not just their genes, could give rise to hypermethylation, which could them be imprinted and in effect be passed down. The irony was that this was being demonstrated as a result of the German starvation of the Dutch people (Dutch Famine 1944-1945).

Probably the most moving part of the book is the letter Monod wrote to the US Counsel Office after his visa to the US was rejected because of Communist affiliation. This letter on 305-306 is worth reading several times, and it was subsequently published in Science.

For Camus it was the denouncing of Stalinist tactic of suppression of Russians and their imprisonment. This was exemplified by the classic battle in the press between him and Sartre. Sartre remained a devout Communist and Camus moved into what at best could be termed the French anti-Communist camp.

By the mid-50s Camus had begun to be well recognized for his writings and in 1957 he is awarded the Nobel Prize for Literature. To some this was a surprise but to others who had seen his reputation and literary influence spread it was anticipated.

The book is exceptionally well written and smoothly interlaces the stories of each man. Overall it does a superb task of blending together two lives, arts and science, into a coherent tale which is truly French; Camus and the absurd and Monod and the control of cellular metabolism at the genetic level. It would have been an improvement if the author, a skilled research in the field, took the reader a bit more thoroughly along the details of Monod’s work and the problems he was addressing. Understanding the work of Watson and Crick, and then taking it to another level, via brilliant experimental technique, would have truly brought this work to the fore. The Watson book, The Double Helix, reads like a detective novel, and one can feel the excitement as they progress to the discovery of the DNA structure and function. This book takes you down the path with Monod but somehow it lacks the intensity.

Secondly the Camus tale could also have discussed his world view a bit more, by using context, and it would have been interesting to see his works in contrast to say Sartre, who became an antagonist in later parts of his life. There are discussion regarding this but they assume a somewhat well-read reader.

Overall, the book is a wonderful addition to the literature on Camus and adds to an understanding of Monod, a man of dimension and character.

College and Benefits

The Becker-Posner posts speak of the benefits of college albeit the rising costs. They state:

As Posner discusses, tuition and other college costs have risen greatly during the past 30 years. So too have the many benefits from college, including the greater earnings, health, and even marriage rates of college graduates compared to high school graduates. Moreover, the return on a college education has also increased, as measured by the higher benefits of college net of the increase in college costs. As a result, college is even a better deal than it was 30 years ago for most of the students who can afford the higher tuition.

 This I find impossible to believe. Take 1963, fifty years ago. Two numbers. The cost per year at MIT was about $1,250 Tuition. Back in those days tuition equaled room and board. Today room and board is a fifth of tuition. Now look at starting salaries. Then it was $9,600 per year. That is 8 times annual tuition. Now the tuition is approaching $60,000 and to my knowledge we are not seeing students getting starting salaries of $480,000. Just a reality check for the Profs.

So why does someone go to college. If you are not a Trust Fund Kid, TFK, you go to get a job. Yes, that is right a job. You do not go to learn English, Fine Arts, or even History. You learn Chinese to be a translator, Accounting, Engineering, Biology, or possibly Chemistry. Fine Arts majors will have a tough job, unless they are just gritty and connected.

Now what type of job do you get educated for? Simple. One that earns money, for a while. For how log, well just look at the last few decades, Chemists have seen mass reduction in demand, why?, because their job has been automated. Chemical Engineers however have remained steady. Civil Engineers are also in demand, not great, but there is a demand to build things. Electrical Engineers and Computer Engineers still have a future, unless Chine gets all the jobs. Biotech is a hot area but more than half the new papers are from China also. So will those jobs remain here?

Thus if one looks at the risk factors and one does a discounted cash flow, even with a zero risk for cost of money the added risk due to the market will discount the future earnings dramatically. That means the "value". net present value if one desires, of a college education is highly problematic.

If one were an economist, or teaching at a business school, or say a legal scholar in the economics area, one would have used a DCF approach. In this case the DCF would have a risk discount factor in double digits, percent wise.

Thus, despite the dramatic reduction in initial salary from fifty years ago, and despite the dramatic discount factor, we see these folks saying the sky is not falling, even as chunks of it are hitting our heads!

Then the author states:

Increased competition for better students has gone hand in hand with greater competition for better faculty. Just as returns to college have increased more for better students, it is likely (there is little quantitative evidence on this) that returns from college have also grown more from an education with better faculty and a more effective education program. In any case, the stronger competition for college faculty has been one important source of the growth in college costs since faculty is by far the dominant cost of a college education.

Back fifty years ago the better students were very hard working street kids who were the top 5-10% of the US graduating High School classes, remember not all went to college.  But the instructors were also pretty good, just look at the literature. Yet they were not paid as highly and the schools did not have monuments they had to feed and Administrative overhead that provided just added loads and no benefits.

Reality seems to contradict the Professor in this case, and a reality that I suspect he should have considered. Perhaps being an electrician would be better. I can always go back and renew my license, PhD not withstanding.

In the corresponding Posner post he discusses costs and then MOOCs. He states:

I see hope, however, in the MOOCs—massive open online courses, which offer enormous potential cost savings and quality improvements for colleges. They can eliminate most of the living expenses associated with college (students can live at home, presumably cheaply) while enabling a reduction in faculty size (because there is no limit to the number of students in an online course) coupled with an increase in average faculty quality, since there is no limit on the number of students that a superb teacher can teach online. The MOOCs are not a panacea, but they are the most promising response to the problem of the high costs of a college education in America.

I am still not convinced with MOOCs. They lack the student inter-communications, and often are dominate by anonymous blather. Also the problem I have is that the software is still a bit messy. When they first came out it was a disaster. Now, say with MIT's 7.00x, it almost is there but it still has some problems. Perhaps the kids brought up with the approach will do better, I still like paper to scribble on and the hand, eye, keyboard screen efforts still face a challenge.

As to costs, Posner states:

The causes are various. They include the enormous—I am tempted to say the stifling—increase in legal and other regulation of colleges (and universities, but for simplicity I’ll use “college” to denote all higher education), the decline in financial subsidies to state colleges, the increased cost of scientific equipment, and the expense of computerization and other electronics. But another important cause,paradoxically, is the increased cost of college education, which tilts the student body toward richer kids—and rich kids and their parents expect superior amenities in the way of housing, food, athletic facilities, and police protection. Such students expected to be treated as consumers, rather than as kids with no rights or representation (the situation of students at Yale in the 1950s; there was no student government, and no appeal from expulsion). 

Again I disagree, looking at the MIT and Harvard costs, especially MITs, I see the explosive burden of overhead on massive construction. The maintenance costs are excessive. The second is the Administrative burden, we now have Deans for everything. Frankly all we need is a Dean of Science, Engineering, and well Business, kind of. So what  are the other Deans for, overhead!

Wilson: An Example of a Professor in the Presidency

The book by Knock, To End All Wars, is a superbly written analysis of Wilson, WW I and his attempts to use it as a vehicle for his world view. This is not a biography of Wilson nor is it an analysis of the Treaty that ended WW I. It is as the author states an interweaving of Wilson, the man and the President, into, through and after the War. Wilson was a complex person, at times very idealistic, and at others quite pragmatic. However as the author demonstrates the more idealistic Wilson prevailed through his attempts to reach agreements at the end of the War which he felt promoted World peace.

The author commences with an excellent discussion of Wilson and some elements of the Socialist movement. On the one hand he saw them as fellow progressives and on the other hand, as the case with Debs and my grandmother (she was one of the heads of the Socialist Party in NY and I recall many of the details of Wilson and he somewhat heavy handed way of dealing with differing views; she is third from the right above just before Wilson ordered the imprisonment of all of the women above in Lorton), he saw them as threats to his unlimited power. Thus there was a love and hate relationship. The author focuses on the productive parts of the relationship in the early years when their interests coincided. Yet the Socialists were not just one group, there were many flavors of Socialism and this, in itself, made it difficult to understand. Wilson as the author indicates tries to benefit from their support.

Then the author discusses the internationalism of Wilson. His interactions with Croly of the New Republic and also with Lippmann, were positive initially and they were supporters. But those relationships were to falter as Wilson exercised his approach to Presidential power.

Wilson seemed to deal with international relations in the almost academic framework that he did with most everything else. For example and as discussed the Mexican War was an out and out fiasco. The US Army wandered around Mexico without maps searching for Villa as an attempt to solidify American interests. It accomplished nothing other than demonstrating that Pershing and his forces were totally unprepared to even capture one wandering band of “outlaws”. Regrettably the same leadership sent the Army to France, often coatless and untrained and ill equipped.

The author spends a considerable amount of time discussing the negotiations and Wilsons almost arrogant teacher like approach dealing with very sophisticated politicians in France and the UK.

On p 210 ius the most telling of all descriptions: “Everything reminded me of a faculty committee meeting, rather than a gathering of statesmen.” is the quote from one observer. On p 204 the author effectively tells why: “Wilson wrote two constitutions for the League of Nations…”

Namely Wilson had the continuing desire to do the work himself and then try to cajole the others into his way of thinking. These observations are just a few of the battery of focused observations made by the author that demonstrate better than almost all other writers on Wilson his true weakness. Namely he believed he could lead all the others by the power of his intellect and delivering in words fait accompli. But to the old European players at the table the work was often done in classic Byzantine manner, no pun intended.

There are several points which the author has noted adequately covered which I believe are germane to this topic. Specifically:

1. Wilson’s Health: Wilson had significant cardiovascular problems, most likely suffering from mild strokes on prior occasions and ultimately, while pushing the League, suffered a massive stroke. His health was always an issue, delimiting the time he spent on ever more complex issues. It would have been fruitful to have melded the health issues into the timing of many of the decisions.

2. Wilson’s Second Wife: The death of his first wife and the near instant remarrying to a strong and controlling second wife was undoubtedly a significant factor in his thinking. Yet understanding that has always been a complex task and the author sidesteps this issue. The author treats Wilson as the President and does not reflect on this type of influence. How important this was can be debated but her influence cannot.

3. Wilson and House: House, the self-appointed Colonel, had attached himself to Wilson and for years was apparently the driving force for many of Wilson’s efforts, especially towards the end of the War where House actually represented the US with foreign entities, albeit having no real recognized official position. Then almost suddenly at the end of the negotiations there is a break with House, Wilson just seizes the moment and send him off. One can look at the positive and negative side of the Wilson-House relationship but it was clear that House was a significant factor. The author correctly acknowledges House’s presence but his influence should have been more extensively explored.

4. Wilson’s Limited International Exposure: American Presidents all too often have delimited international experience. Teddy Roosevelt just seemed to bluster his way about and was in effect the first internationally influencing president. But TR’s impact was limited. On the other hand Wilson was the first President to fully step upon the world stage. Unlike FDR who had multiple internal advisers as well as building his relationships with Churchill and Stalin, Wilson had not real exposure to the field of international diplomacy. In fact when he completed his PhD at Hopkins he barely got passed his German requirement, and some say barely is being generous. Thus having no alliances, having no experience, and having no understanding of the depth of historical precedents, he walked into the middle of negotiations assuming them to be created of whole cloth. He soon found to the contrary. This would have been of interest to have been developed a bit more.

Notwithstanding the above fine points, personal in nature, this is one of the best works on Wilson available. It manages to tie together all of the key facts and allows the reader to have a better understanding of the man and his abilities and lack thereof. I would strongly recommend this to anyone trying to understand Wilson and more importantly anyone trying to understand the Presidency and the issues that can arise from a poorly prepared person who attains that position. In this case the past is always prologue to the future.

Real Peer Review

Over the past fifty years or so I have become less and less enamored with peer review. The problem? First is the anonymity. Who is this person? Why do they think they know the issue better? They may, but then I would like to know. Better yet are reviews that flatly state that all of this has been done before. Oh, but where? They never say. What of peer review of peer review. And the list goes on.

In a recent set of articles in Science this is all discussed in light of Open Access publishing. They state:

"Peer review is sick and collapsing under its own weight," he contends. The biggest problem, he says, is the anonymity granted to reviewers, who are often competing fiercely for priority with authors they are reviewing. "What would be their reason to do it quickly?" Tracz asks. "Why would they not steal" ideas or data? 

Anonymous review, Tracz notes, is the primary reason why months pass between submission and publication of findings. "Delayed publishing is criminal; it's nonsensical," he says. "It's an artifact from an irrational, almost religious belief" in the peer-review system. 

As an antidote, the heretic in January launched a new venture that has dispensed altogether with anonymous peer review: F1000Research, an online outlet for immediate scholarly publishing. "As soon as we receive a paper, we publish it," after a cursory quality check. Peer review happens after publication, and in the light of day. F1000Research selects referees, who post their names and affiliations alongside their critiques. Papers become like wikis, with reviewers and authors posting comments and revisions as the need arises. 

I have advocated this before. Peer review is a non-anonymous process post public release. What does this accomplish? The following:

1. You get to judge the author and the reviewer side by side. 

2. Reviewers with an axe to grind are exposed.

3. Anyone can review the piece subject to certain rules. Anonymity is prohibited. You must list your name and contact information. Your review must contain details and data and backup.

4. The Editor still plays a role but a role of orchestrating the reviews. Some reviews will be just junk, as usual there are always people with "stuff" to say. Let then say it elsewhere.

5. Self policing is essential. The readers should police the comments so as to drive out the bad ones, again policing must never by anonymous. If you decide to vote out a comment then you do so in the light of day. There has been the argument that Grad students could never put out bad comments on say a Department Head. But others could and should. Perhaps the truth will out.

6. It then begs the question of; what is the paper? Is it the original posting or the amalgamation of it and all the comments? If so then who is the author? This is a challenge, yet one we face all the time.

The article concludes:

Tracz acknowledges that in reshaping peer review, he's taking on a sacred cow. "There will be some growing pains," he says. But his maverick ideas tend to become mainstream over time. "At the beginning of open access," one colleague says, Tracz "was ridiculed by other [publishers]." No one ridicules open access now. 

"He's not radical," Eisen insists, "just sensible. Sensible doesn't [usually] happen in scientific publishing." The coming years will see whether open peer review is sensible—or too radical for most researchers to stomach. 

The comments above are suggestions based on thinking about this for a while. The  driver is the change in the distribution channel for scientific data. Namely the Internet changes everything. One can put things out there and see what happens. I have placed Drafts on line and have seen tens of thousands of downloads on several ones. Who, why, what did they think of it? That process is not working yet as one would like but the spread of the information does work.

A change in peer review is essential. Today it protects the interests of a few. It should be useful by expanding the interests of the many.

PSA is still a Battle Ground

In the European Cancer Congress of 2013 one of the authors states in the Abstract the following:

We estimated the number of individuals needed to harm associated with PSA testing by applying different side effect estimates to a virtual population of 1,000 men aged 55–69 exposed to PSA testing and another 1,000 not exposed to PSA testing. 

Following a systematic literature review, we extracted results of PSA testing, biopsy rates and impact on prostate specific mortality from the European Randomized Study on Screening for Prostate Cancer (ERSPC) which is the study with the most favourable outcome to PSA screening. 

We also extracted, from reports with such information, data on mortality following prostatic biopsy, on mortality associated with radical prostatectomy as well as side effects of radical prostatectomy and hospitalisation rates following prostatic biopsy....

Overall, under the best scenario of screening efficiency, the prevention of 1 death from prostate cancer is associated with a significant additional adverse-effect burden from the biopsy and from the treatment of the additional prostate cancer diagnosed. 

These will severely impact the quality of life of patients and argues against using PSA testing for mass screening of prostate cancer. 

Note the phrasing, "number of individuals needed to harm.." , as a phrasing that any biopsy harms the patient. The problem often is that the biopsy may have been done poorly thus subjecting the patient to infection. That is a problem with practice and not procedure. Also note the phrase "severely impact the quality of life". What does that mean. If you have a biopsy and no PCa then you may have a small chance of an infection. If you have prepped properly and the Urologist is skilled and you take care afterwards, it is fairly probable that there is no problem.

On the other hand if you have PCa, then the issue is what to do. Is is indolent or aggressive? Most likely you cannot readily tell. So then what? Here is where the real issue is. Some men will look at family history to help. If your father died 20 months after diagnosis you may want to hedge your bets and be aggressive in treatment. But if dad and Uncle Joe died with it and it never did much to them, perhaps a different story. Thus, it all depends. No good answer!

As is stated in Healio:

“When discussing the use of the PSA test with patients, physicians should make them aware of the limitations of the test and the likelihood of it causing harm,” Boniol said. “We hope that our research findings will help clinicians to make decisions as to when to propose a PSA test, and to help the patient to decide whether or not to accept this recommendation.”

Now the problem with PCa in the first place is that like many cancers it does not behave the same in all people. Some few are very aggressive. Many are indolent. But to know which are which is still a work in progress.

In my Draft volume on Prostate Cancer  I have tried to examine this as best as possible. However even there we have missed may subtle but now potentially powerful forces in the epigenetic areas. Methylation may be playing a significant part as are miRNAs and lncRNAs. Thus, although we understand many pathways and translocations that may cause an aggressive PCa we do not fully understand the epigenetic forces.

Thus a blanket denial of use of PSA is a "head in the sand" strategy that will harm more than help, at least in my opinion. As for the above mentioned European Study, I have discussed its fatal flaws in my opinion and thus have no basis for its reliance.

Health Care Cost Allocation

In a recent AHRQ study there is an analysis of the distribution of health care costs. It is instructive. Two major conclusions are of merit:

In 2010, the top 1 percent ranked by their health care expenses accounted for 21.4 percent of total health care expenditures with an annual mean expenditure of $87,570. Overall, the top 50 percent of the population ranked by their expenditures accounted for 97.2 percent of overall health care expenditures while the lower 50 percent accounted for only 2.8 percent of the total.

The top 5 percent of individuals with four or more chronic conditions accounted for 29.7 percent of health care expenditures for this subpopulation with an annual mean of $81,790. Based on chronic condition status, persons with four or more chronic conditions had the lowest concentrated levels of health care expenditures and the highest annual mean expenses at the top quantiles of the expenditure distribution.

 Let us consider the total costs as shown below:

Note the high level of the highest users, over $80,000 per year. The average is well below a tenth of that number.

Then by age we have the above expenditures. As would be expected the oldest dominate the amount in the top 5% level. The younger are less than a fourth of the older. This ratio holds throughout.

Finally we have the percentages above.

The conclusion is simply that a small percentage are the dominant users. Similar results are the same in many insurance claims. The question is; can we find ways to reduce the costs of this higher group or is this the nature of the problem?

A Secure Internet?

Back in 2001 I was the Vice Chairman of the Presidential Commission on the Internet and we published a report entitled The Internet's Coming of Age. Today there is an article in the NY Times bemoaning the lack of security in the Internet.

Having been involved in what the Internet was from 1972 onwards I can say at least until the present that the intent was to have an open network with all of then intelligence on the periphery. This would be totally unlike the old telephone networks with dumb devices on the end and complexity in the middle.

Inherent in this hourglass principle was that the Internet would be simple and the burden would be on the end users to seek whatever services they sought.

The article states:

But while such vulnerabilities are worrisome, equally important — and because of their technical nature, far less widely understood — are the weaknesses that the N.S.A. seems to have built into the very infrastructure of the Internet. The agency’s “upstream collection” capabilities, programs with names like Fairview and Blarney, monitor Internet traffic as it passes through the guts of the system: the cables and routers and switches. 

The concern is that even if consumer software companies like Microsoft and telecommunications companies like AT&T and Verizon stop cooperating with the N.S.A., your online security will remain compromised as long as the agency can still take advantage of weaknesses in the Internet itself. Fortunately, there is something we can do: encourage the development of an “open hardware” movement — an extension of the open-source movement that has led to software products like the Mozilla browser and the Linux operating system. 

Just what this means is confusing. The Internet is open, by definition, design and deployment. The problem is that the service providers are in collusion with others often to use that openness to third party advantages.

The IETF had established various open support options to allow enhancements at the edge. These RFC, Requests for Comments, were the ultimate in open source. There is very little proprietary "stuff" unless one adds it deliberately in a proprietary network.

Frankly the piece in the Times makes no sense. The threats to privacy can be controlled by end to end secure encryption and authentication. They can be made, or at least for a short while. Using a Government approved encryption is an oxymoron, it is not secure, at least not between the sender and the Government. But anyone who knows anything knows that.

One suspects that anyone desiring to be secure may seek secure ways to be secure! They still exist but get more complex in today's world. But creating open source stuff just does not make any sense.

Are There Any Teachers Left?

There is an article in the NY Times speaking of a proposed and at times implemented technique of having students watch video lectures and then spend class time doing homework. They state:

one where students watch teachers’ lectures at home and do what we’d otherwise call “homework” in class. Teachers record video lessons, which students watch on their smartphones, home computers or at lunch in the school’s tech lab. In class, they do projects, exercises or lab experiments in small groups while the teacher circulates.

 Frankly one then wonders what the teacher is doing? I have seen this in certain environments. It is a MOOC at Grade School. It is a cop-out for teachers to just wander and leave the burden on the student.

The problem with US education is the continual introduction of new techniques while having all too often poor teachers. Or worse, having good teachers made poor by technique.