I found Seema Verma’s op-ed in the Wall Street Journal on Medicare and Medicaid reform a mixture of sound advice and wishful thinking. As is pretty typical in these pieces she does a pretty decent job of stating the problem she wants to solve:

The current rate of growth in Medicare and Medicaid is unsustainable and jeopardizes the country’s ability to fund other priorities such as education, infrastructure and public safety. While the Medicare board of trustees has warned that the program is headed for insolvency in as little as six years, Medicaid has become the largest budget item in most states. Medicare and Medicaid collectively are one of the largest contributors to the national debt and will be the largest federal budget item by 2030, according to the Congressional Budget Office.

It’s her proposed solution that caused me to raise an eyebrow. She suggests changing from the present “fee for services” system to a capitation system.

I’ve written favorably about capitation systems in the past. Under a capitation system a physician is paid a fixed amount for each patient under his or her care. Part of the payment is related to patient outcomes. The advantage of a capitation system is that it aligns the physician’s, patient’s, and the taxpayer’s interests. Here’s her description:

In value-based care, instead of getting paid only when a patient gets sick or for rendering a specific treatment, a doctor is prepaid a fixed amount based on the patient’s health status. This payment method, called capitated payment, is used to cover all the patient’s healthcare-related costs. The prepaid amount creates incentives for the provider to make investments in the type of care that avoids expensive emergency-room visits and hospital stays.

To ensure that care isn’t rationed, part of the doctor’s reimbursement is tied to quality and patient outcomes. For example, doctors can use part of the capitated payment to cover the costs of home modifications to prevent falls, to provide medically tailored meals for diabetics, or to send a nurse to a patient’s home to administer medications.

Value-based reimbursement can also be used to address new high-cost medications. If a patient doesn’t show meaningful improvement after taking the medication, the drug manufacturer’s reimbursement would be reduced or not paid at all.

I’m skeptical for a number of reasons first and foremost because I find it hard to imagine how a capitation system could work alongside a fee for services system for private insurance. I think the only way it would work would be within the context of a full-fledged national health system. Another issue is that historically such systems have been resisted by physicians and medical practices. A capitation system for the U. S. was proposed 80 years ago. The idea died in its infancy due to physician opposition. Again, a capitation system for Medicare was tried in the 1970s. It gained very little participation from physicians. What’s different now?

Something she doesn’t mention. For such a system to work, physicians would not be able to pick and choose among patients. Practices would either be closed to new patients or open to any patient. It’s hard for me to see that gaining much acceptance.

The Air Force shot down another “object” over Lake Huron yesterday. Ka-ching! At the Associated Press Colleen Long, Lolita C. Baldor, and Zeke Miller report:

WASHINGTON (AP) — A U.S. fighter jet shot down an “unidentified object” over Lake Huron on Sunday on orders from President Joe Biden. It was the fourth such downing in eight days and the latest military strike in an extraordinary chain of events over U.S. airspace that Pentagon officials believe has no peacetime precedent.

Part of the reason for the repeated shootdowns is a “heightened alert” following a spy balloon from China that emerged over U.S. airspace in late January, Gen. Glen VanHerck, head of NORAD and U.S. Northern Command, said in a briefing with reporters.

Since then, fighter jets last week also shot down objects over Canada and Alaska. Pentagon officials said they posed no security threats, but so little was known about them that Pentagon officials were ruling nothing out — not even UFOs.

“We have been more closely scrutinizing our airspace at these altitudes, including enhancing our radar, which may at least partly explain the increase,” said Melissa Dalton, assistant defense secretary for homeland defense.

Meanwhile, the Chinese have said that at least ten U. S. balloons have entered their airspace in the last year. From Lily Kuo at the Washington Post:

China’s Foreign Ministry on Monday said the United States has sent at least 10 unsanctioned balloons into Chinese airspace since last year, as the two countries feud over a Chinese airship discovered and shot down by the U.S. military earlier this month. The United States denied the allegation.

and the Taiwanese say that Chinese balloons enter their airspace all of the time. From Kathrin Hille at Financial Times:

Taiwan has observed dozens of Chinese military balloon flights in its airspace in recent years, far more than previously known, adding to concerns that Beijing could be preparing for an attack on the country.

“They come very frequently, the last one just a few weeks ago,” said a senior Taiwanese official. Another person briefed on the matter said such incursions were happening on average once a month.

Previously, Taiwan’s defence ministry had only confirmed one incident in February last year, in which multiple Chinese balloons in four batches loitered over the north of the country.

Other countries in the region, including Japan and the Philippines, have observed balloon incursions into their airspace, but their governments have given little detail.

I’m still trying to figure out what the model is. We need to spend $2 trillion a year on our military to be unprepared to deal with $1,000 lighter-than-air craft other than by shooting $400,000 missiles at them? And we only do it when a civilian points it out?

Update

The editors of the Wall Street Journal declaim:

The military operations in North America have Americans concerned, all the more so because the Administration has been both tight-lipped and dissembling. It didn’t disclose the presence of the first balloon until civilians spotted it over Montana. Then it claimed it posed no threat, only to shoot it down after political criticism. President Biden said it was “not a major breach” but still shot it down.

The Administration also whispered to its media mouthpieces that the Trump Administration had tolerated such balloon intrusions in U.S. airspace, only to correct that story after Trump officials denied any such knowledge. Turns out the Trump-era balloons were discovered only after the fact using intelligence methods.

which is not precisely reassuring. They conclude:

Are we seeing these objects now only because we are suddenly looking for them? Are they sent by foreign actors, or someone else? Do they pose a threat, and we don’t mean only to civilian air traffic? What the hell is going on up there, Mr. President?

I’m more concerned about what the heck is going on down here. Why hasn’t our military been concerned about this?

Even as survivors continue to be pulled from the rubble following the earthquake that struck Turkey and Syria last week, the death toll continue to mount. As of this writing it was around 30,000. Why?

My speculations are:

• Low construction standards and lack of civil enforcement
• Crowding
• Poor civilian infrastructure—much of the area struck was out in the middle of nowhere and consequently hard to reach
• Poor government response—lot of Turks are pointing to this
• Poor preparedness—they really don’t have the equipment, medical resources, etc. to deal with an incident like this

George Friedman asks six very good questions about the prospect of war with China:

• Who will start the war?
• Why would they wait to start the war?
• What does the aggressor hope to accomplish, and is it worth the risk?
• Will the war be on land, in the air, at sea, or some combination of the three?
• Are their respective economies healthy enough to support a war?
• Why would either side leak its intentions?

Given recent news stories war with China may already have begun and it has started in space or, at least, “near space”.

I have several thoughts on this. First, I think that war with China is extremely unlikely. Or, at least, China is extremely unlikely to start a war with us.

Second, I think that war with China would be economically ruinous for the United States but not for China.

And, as I have said before including recently, we are pursuing our own self-destruction so assiduously and enthusiastically we are our own worst enemy.

At The Hill Brad Dress takes note of former acting SecDef Christopher C. Miller’s case that we should cut our defense budget in half:

Former acting Defense Secretary Chris Miller is making the case for the Pentagon’s budget to be cut in half in his new memoir, “Soldier Secretary,” arguing the U.S. military should be molded into a leaner and nimbler fighting force with prioritized areas of focus.

At the end of his memoir, Miller writes the U.S. must adapt to the threats posed by foreign adversaries like Russia and China by reforming the military, which he calls “too big and bloated and wasteful.”

“Our colossal military establishment was essential for our Cold War victory, but the Cold War has been over for 30 years,” Miller writes. “If we are truly going to end American adventurism and retool our military to face the challenges of the next century, we should cut military spending by 40-50 percent.”

The National Defense Authorization Act (NDAA) for fiscal 2023 authorized $857 billion in topline defense spending, an increase from the $777 billion passed in the last fiscal year.

The U.S. spends far more than any other nation on defense, including China, which is in second place, spending around $300 billion on defense.

“We could cut our defense budget in half and it would still be twice as big as China’s,” Miller writes in his memoir.

I’m sympathetic with that and think we need to do some soul searching. Are we cutting enough “bang for our buck”? Does spending more on defense actually give us the defense we need and want or does it actually make it less effective? Would cutting the defense budget result in less “adventurism” as argued by Sec. Miller or would we still be engaging in ongoing conflicts and aggressive moves, just doing it less effectively and fraying around the edges more?

My own rather unpopular view is that reducing the number of general officers and flag officers sharply would both cut spending and improve our efficiency. It should also be noted that the “topline defense spending” is only a fraction of what we spend on defense when you take the total cost into consideration. That’s well over a trillion. I also think that cuts should be concentrated in the standing army but that’s getting into ways and means.

At this point we can’t seem to cut defense spending at all let alone cut it in half. Support for more defense spending has become a “valence issue“.

First it’s a weather surveillance balloon traversing the United States and a good chunk of Canada. Since then two additional flying things have been shot down over Alaska and Canada. Amazing what a o little embarrassment will do. I say “things” because details on what they actually were have not been released as of this writing. They seem to be smaller than the balloon and they’re flying but that’s all I know.

I think there are some things we really need to know. First, how long has this been going on? Weeks? Months? Years? Forever? Are we only learning about it now because some passenger on a commercial flight saw that balloon fluing above the flight he/she was one and took a picture of it with his or her smartphone?

And, related, has their frequency increased?

My speculation about it being a “probing attack” (with no actual attack) is looking less likely.

Update

There’s something I wanted to mention in this post but neglected to do so. A high altitude weather balloon can be purchased for on the order of $1,000. Let’s conjecture that the Chinese balloon cost ten times that. The Sidewinder missile used to take it down cost $400,000. Floating balloons over the U. S. could turn into a reasonably cheap, easy way to sap U. S. strength and inflate our costs. We should probably figure out a different way of dealing with them. We should probably take them down but we probably shouldn’t spend a $1 million per balloon.

In one of their “Five Facts” pieces at RealClearPolicy one of the organization “No Label’s” facts is this: 82% of Americans hold an unfavorable opinion of China. I find that distressing in the extreme. China is a country of 1.4 billion people that occupies an area of nearly 4 million square miles.

I think that any American should hold an unfavorable opinion of the Chinese Communist Party. The only way it could be 82% is if more than 10% of Americans claimed to have no opinion or refused to answer.

But China is so vast and so varied that it is otherwise difficult to make a true generalization about the country. The very thought makes my blood boil.

And such a thing is terribly dangerous. The United States and Russia each have the ability to destroy the world many times over with nuclear weapons. China is not far behind and gaining fast. That’s a true generalization.

Personally, I’ve like nearly all of the Chinese people I’ve met. For one thing I’ve found them funny.

Here’s a thought-provoking remark from the editors of the Sun-Times:

Residents in the West Side’s 60624 ZIP code wouldn’t be inflating the truth if they made that proclamation. It would be an understatement, particularly when it comes to the dangers young men face, a new study funded by the National Institutes of Health found.

The risk of men between the ages of 18 and 29 losing their lives in a shooting in this part of the city is higher than the death rate of U.S. soldiers who fought in Afghanistan or Iraq. Of the three other cities researched — Philadelphia, New York and Los Angeles — only Philadelphia has neighborhoods where the chance of a deadly encounter was higher than in recent military action overseas.

Yet the death rate is worse in the 60624 ZIP code, which includes Garfield Park, as the Sun-Times’ Frank Main points out in his story on the study.

The solutions are obvious but somehow the editors never arrive at it. There need to be other social supports than criminal gangs for young men in those zip codes. And the gangs must be removed root and branch. The first requires social change and the second requires vigorous law enforcement.

Blaming it on “systemic racism” is a cop out.

There’s another issue which may or may not be distinctive to Chicago. The street gangs and political leaders are in cahoots. They may call them “community activists” but they’re street gangs. It’s like Sinn Fein and the IRA. What’s the difference? There is none. One is political and the other the armed wing of the Irish republican movement. But one hand washes the other.

I found this post by Alex Berenson a bit distressing. Here’s the gist:

Last month, three scientists pointed out flu shots barely work and couldn’t be approved based on the standards used for vaccines like measles:

“After more than 60 years of experience with influenza vaccines, very little improvement in vaccine prevention of infection has been noted… our best approved influenza vaccines would be inadequate for licensure for most other vaccine-preventable diseases.” [emphasis added]

True. Several rigorous papers have proven that flu shots are placebos masquerading as public policy.

But the same scientists then compared our beloved and groundbreaking Covid vaccines to those pointless flu jabs:

As variant SARS-CoV-2 strains have emerged, deficiencies in these [Covid] vaccines reminiscent of influenza vaccines have become apparent.

Just who are these vicious anti-vax rebels?

Three researchers at the National Institutes for Health. Including one whose name may ring a bell: the now-retired Dr. Anthony S. Fauci.

Yet the Covid/flu shot comparison is only one of the article’s bombshells.

At its core, the piece raises the question of whether any vaccines can ever work well enough to matter against bugs like common coronaviruses, influenza, and RSV.

And that question hides an even more troubling one, one the authors do not ask: have our efforts to beat Sars-Cov-2 by driving our immune response in ways it was not designed to go caused dangers we are only beginning to understand?

I chose to be vaccinated—two primary courses and two boosters. I weighed the risks and benefits and decided it was the best choice for me. I don’t regret my choice but part of the reason for that may be that I did my homework and made my choice based on that. I have not gotten the additional booster because, once again, I evaluated the risks and benefits and decided that was the best course of action. I know several physicians around my age (not as healthy as I) who are doing the same thing.

Given that it appears to be the case that Sars-CoV-2 mutates sufficiently rapidly that we will never achieve “herd immunity” it seems to me that the risks and benefits are quite different from something like smallpox, polio, or measles. Additionally, at this point the long term risks of mRNA vaccines are unknown. We’ll know in due course.

I don’t believe the analogy with the flu vaccine is particularly good but even if it is, the effectiveness of the flu vaccine is extremely variable from year to year.

In some seasons (2010-2011) it was pretty effective. In others (2014-2015) it wasn’t very effective at all. I also find it worrisome that the trend in its efficacy appears to be going down. Is that because the efficacy of the vaccines is declining, our ability to find the right cocktail is declining, or just dumb luck?

Annual immunizations is a relatively recent phenomenon. It may be that it isn’t a particularly good practice. We’ll see.