Tuesday, January 18, 2011

Healthcare Reform: The Beta

I visited an old publishing buddy the other day, and he related a story about how a boss had said "You DO NOT want to miss the dates on this project. We can find places to hide low quality." I immediately remarked that publishing seemed to be getting further down the road towards the software industry production model. You rush a buggy product to market to be first to meet a need, and you let customers find and maybe even fix the bugs. You can release patches or a beta version later. Customers? They're used to it, especially if they are early adopters.

When it comes to healthcare reform, I think the software production model is a useful analogue. A buggy product was rushed to market within a short time frame. Perhaps for defensible reasons and perhaps not. Doesn't matter.

What we now have is something that meets some needs, solves some problems. Like access. And does nothing about others. Especially cost. Because our politics is characterized by the bipolarism of the Democrats and Republicans, the debate is being framed in terms of whether or not to reject it as is.

I don't ultimately care which we do, only that we find ways to manage access and cost. In other words, as long as the next result is better for regular folks. But we all know that any "from scratch" effort
• Will face all the same problems the last one did, and 
• can't begin in earnest until the current reform is repealed, which cannot happen until 2013 at the earliest
So, if congress really wants to work now on making our healthcare system better, what they should really do is work on an Obamacare Beta that finds patches to the bugs found by customers and accountants and so on. If Republicans were willing to fake this tack, they should ask in return that Democrats concede that existing law does nothing substantive to control costs.


  1. Lessee, the system was in bad shape before, ObamaCare made it worse, so it's better to modify ObamaCare than go back to the beginning less-sucky baseline ...

    Not buying it. To adopt the analogy (and I would dispute it's all that applicable on a straight apples/oranges) it sounds like the Win98/WinME approach to health care. Take bad, make it worse with added kludges, then start adding new kludges to offset the added kludges.

    Remember you are NOT solving for access just by extending coverage. Coverage and access are not remotely synonymous, as any MCD recipient can tell you. Increasing coverage can (and does) actively reduce per-capita access unless there is an accompanying increase in actual supply -- demand rises immediately, but supply does not. Just as handing out more bus passes does not increase the number of bus seats available ... or give you better buses or add routes. The result is not something that meets some needs while not meeting others, save in the sense that it changes which needs are being met while producing new (and bigger) problems.

    Better, faster, cheaper. Pick any two.

  2. Not really my point. My point is that it's better to act now to find ways to continue to improve the system than to wait 2+ years to do that.

    So my reasoning is based on the certainty that it won't be repealed any sooner than 2013. I am not commenting on the merits of repeal.

    Remember you are NOT solving for access just by extending coverage. Coverage and access are not remotely synonymous, as any MCD recipient can tell you. Increasing coverage can (and does) actively reduce per-capita access unless there is an accompanying increase in actual supply -- demand rises immediately, but supply does not.

    A fair point. Not sure whether average access is the ultimate point, though. I care somewhat less about the average amount of pie consumed than I do that everyone who needs some pie is able to get some pie.

    That doesn't mean, though, that I am unconcerned with the problem of having enough pie to go around. As we know, without increasing the pie, we can only expand the number of slices by decreasing their size. Which as some point becomes pointless. The point is not simply to "have" pie some abstract, but to have a minimal amount that makes pie enjoyable, or useful or whatever.

    Seems to me that after the repeal effort fails in this session, congress is going to undertake some sorts of efforts at a Beta version. And that makes sense to me. Crappy with patches is better than crappy without patches.

    The unfortunate thing is that all such efforts are going to be clouded by the "repeal versus no repeal" debate, which is not about quality of reform as much as it is about who gets credit.

  3. Let me be clear: I don't think it's a terribly apt analogy, and reasoning from it is therefore not terribly useful.

    But if you want to explore the analogy, I'd suggest that OS rather than general software is a better fit, poor as it is, and what we're talking about here is a bloatware OS that not only does not solve for any serious system flaws of what it's meant to replace, but loads enough kludges into trying to "fix" smaller stuff with large code insertions that it threatens to crash the system through sheer overload. Like WinME or Vista, it creates more problems than it solves, and the problems it creates seriously impede overall system function and performance.

    Stepping aside from that analogy, we're not just talking about splitting the pie into more pieces, but actually even shrinking the pie in the process. Because price demand for the "good" is fairly inelastic, odds are that prices will rise to absorb any new revenues and then some, leaving less actual overall goods being delivered to an expanded number of customers.

    You just can't load that much new overhead onto a system without hurting performance overall, much less on a per-capita basis. In this case supply is relatively inflexible in the short and medium run. We can't train doctors fast enough. Heck, we can't train nurses fast enough. The current nursing shortage is decades-old.

    We'll end up facing the classic problem of all command economies that indulge in price-fixing: rationing and shortages, with the controlled goods doled out to the favored by the government. Or we'll get goods of much lesser quality. Or both. Joy.

    "Better, faster, cheaper. Pick any two." It isn't just a glib saying, it's an active maxim.

    I expect what we will see over the next year is at least the GOP trying to find the parts and pieces of ObamaCare that are actually useful while trying to repeal piecemeal the worst parts, and defunding any that they can't get the votes for repeal.

    I also expect Reid to do everything in his power and then some to prevent these efforts from getting ANY votes in the Senate. Every single vote would require one of those vulnerable 23 Dem senators up for re-election in 2012 to take a stand on the record, and for many of them doing so could be the kiss of career death, either in primary or general. And any vote that passed with Dem support would force Obama to the veto pen, which would also beat down his re-election hopes.

  4. I pick better and cheaper. Which two do you pick?

    So, we end up needing to slow down some things. I would pick that we slow down the pace of innovation so that America isn't paying most of the early adopter tax. I'm sure you'll say that inevitably we'll see longer wait times for visits. I wouldn't dispute that.

    There's no need here to be wedded to the analogy. My point is that if we presume [1] Obamacare now is malformed, and [2] repeal is essentially impossible until 2013 at the very earliest, and could be difficult even then, it makes sense to try to address its faults now.

    Perhaps the threatened cudgel of repeal is necessary to focus folks minds on addressing some of its faults now. What irritates me most is how much energy must be consumed by blamestorming and credit-taking. I am not interested in chest-thumping and finger-pointing. I want to see asses and elbows.

  5. It's Congress, and you're complaining of a shortage of asses? :-D

    I'd go with better and cheaper too. Heck, I'd settle for cheaper (holding all else constant) which would solve all kinds of problems. Longer wait lines? If our efforts were focused more to delivery than development, I'd expect the opposite. Not that longer lines couldn't happen, but ...

    Most important to realize is that we can't solve what is essentially a supply problem by stimulating demand. Indeed, that's how we got in this mess, restricting supply while stimulating demand.