Health Care Economics

September 19, 2009

Obviously, there is a great deal of discussion going on in the US at the moment around the issues involved in health care reform.  It is a lamentable fact that the US spends more money per capita than any other country in the world; yet the US, on the basis of many standard public health measures (e.g., life expectancy, infant mortality), gets far from the best outcomes.

There have been many reasons adduced for this sorry state of affairs — and I certainly do not intend to discuss them all here — but a recent article in the New York Times has confirmed the involvement of one of the usual suspects: stupidity.

There are people who, suffering from a variety of health problems, including ALS (also called Lou Gehrig’s disease), Down syndrome, and strokes, need the use of a computer-driven voice synthesizer to turn text into spoken language.  (Physicist and Nobel Prize winner Professor Stephen Hawking is probably the most well-known.)  These devices can make an enormous difference in the person’s quality of life, not to mention their potential to contribute to society, but it was initially a struggle to get insurance to cover them at all:

In the case of A.L.S., also called Lou Gehrig’s disease, advocates spent years fighting to have any speech-specific devices covered by insurance, finally succeeding in 2001.

Although some patients require very specialized equipment, many have found that they are able to manage with, and in fact prefer, using everyday devices with appropriate software.  According to the Times article, Ms. Kara Lynn has found that an Apple iPhone ($300) with text-to-speech software ($150) is preferable to a cumbersome and much more expensive PC-based device:

Ms. Lynn, who is 48 and lives in Poughkeepsie, N.Y., said it worked better and let her “wear her voice” around her neck while snuggling with her 5-year-old son, Aiden, who has Down syndrome.

There is only one problem.  Medicare, and private insurance companies, will generally pay for the $ 8,000 PC system, but they will not pay for the alternative using the iPhone which is 94% cheaper.  And although the PC system uses a Microsoft Windows operating system, and therefore might be used for other functions, too, the public and private insurers insist that its ability to do anything else (like send E-mail, or surf the Web) be disabled.  The “reasoning” behind this policy is worthy of Through the Looking Glass:

The logic: Insurance is supposed to cover medical devices, and smartphones or PCs can be used for non-medical purposes, like playing video games or Web browsing.

“We would not cover the iPhones and netbooks with speech-generating software capabilities because they are useful in the absence of an illness or injury,” said Peter Ashkenaz, a spokesman for the federal Centers for Medicare and Medicaid Services.  Private insurers tend to follow the government’s lead in matters of coverage.

In other words, in order to be reimbursed, the patient must obtain a machine that costs 10-20 times what an equivalent machine would cost on the open market, so that some of the device’s functions can be disabled.  Just to make the lunacy complete, in some cases the patient can then pay to have the disabled capability re-enabled, once reimbursement has been obtained:

DynaVox, a leading maker of devices for the speech-impaired, has computers that start at $8,000 and run Windows, just like 90 percent of all PCs. To meet insurance rules, DynaVox disables the general computing tools. After the insurer pays, customers can pay $50 to DynaVox to reactivate the full functions.

If the patient wants a smaller, cheaper device (like Ms. Lynn’s iPhone), the only way to get is to pay for it out-of-pocket.

Now maybe I am being too harsh.  Perhaps the fear is that unscrupulous people will use a claimed need for a speech-synthesizing device to finagle a PC paid for by their health insurance.  I have not personally applied to get one of these devices — anybody that knows me at all knows that I am quite capable of talking — but I presume that some sort of medical need certification is required before a reimbursement is approved.  In order for the existing rule to make sense, the insurers must believe that they would get (and approve) at least 9 bogus claims for every real one.  Although I’m sure that they are more acquainted with their own incompetence than I am, this seems a trifle unlikely.

Unfortunately, I think this illustrates an all-too-common mentality within the health care industry in general, and the insurance industry in particular, that the patients are adversaries who have to be prevented from getting things that they don’t really deserve.

I am glad that  Prof. Hawking is a British citizen who is covered by the National Health Service, so the equipment he needed to carry on his life and work was paid for.  (We are bound to remember, in this connection, the ludicrous claim originally published in the Investor’s Business Daily that “scientist Stephen Hawking wouldn’t have a chance in the UK, where the National Health Service would say the life of this brilliant man… is essentially worthless”.)  Prof. Hawking, who I think can be presumed to know something about his own situation, was quoted by the New Scientist as saying, “I wouldn’t be here today if it were not for the NHS”.  And, yes, he said it via his speech synthesizer.

Firefox Gets Pass on Export Controls

September 19, 2009

Unless you are a brand-new reader of  this blog, you know that I am generally a fan of the open-source approach to software design.  One of the more successful recent open-source projects is Mozilla’s Firefox Web browser, which has managed to acquire an estimated 23% of the browser market.  Besides its own success, it has arguably pushed Microsoft to upgrade its browser, Internet Explorer, more frequently, even as Internet Explorer’s market share has dropped from 90+% to about 66%.

Since the early days of the Web, there has been a technical and legal issue, little known except among lawyers and hard-core geeks,  that has affected Web browsers.  In order to implement the TSL/SSL  protocol that is used to secure communications between the browser and the Web site (often indicated by the little lock icon shown), SSL/TSL Secure Sitethe browser must include cryptographic software.

And therein lies the rub.  For many years, the export of cryptographic devices and software has been regulated by the Arms Export Control Act, implemented by the International Traffic in Arms Regulations [ITAR], published by the Department of State.  From Wikipedia:

For practical purposes, ITAR regulations dictate that information and material pertaining to defense and military related technologies (for items listed on the US Munitions List) may only be shared with US Persons unless authorization from the Department of State is received or a special exemption is used.

A “US Person” is a US citizen, a permanent resident not employed by a foreign government or organization, a part of the US government, or a corporation or other organization located in the US and subject to US law.  Up until 1996-97, strong cryptography was covered and its export was forbidden.  (I have, somewhere, a T-shirt that in the early 1990s was classified as a munition of war, because it had one of the encryption algorithms used in the PGP software package printed on it.  Even to wear it in a place where one of my English or German friends might see it would violate the law.   Note that they would not have to actually see it; merely the possibility that they might would violate the law.)  So, for years, “export” versions of browsers could use encryption keys no longer than 40 bits.

After a couple of US Appeals Court rulings that printed materials  (e.g., books) containing cryptographic algorithms were protected as free speech under the First Amendment to the US Constitution, the rules were relaxed in the late 1990s.  However, persons associated with certain specified countries (e.g., Cuba, North Korea) were still subject to export prohibitions.

For a commercial software publisher like Microsoft, this is a bloody nuisance, especially in an era when software is commonly distributed over the Internet.  For a free software project, which is not only distributed but developed over the Internet, it is a rule almost impossible to comply with, since the source code is freely available.   Although the rules do contain an exemption for open-source software, that exemption is not universal:

However, that exemption is nullified if the source code is distributed to any of the countries on the U.S embargo list, such as Cuba, Iran or North Korea.

Fortunately, Internet News is reporting that Mozilla has obtained a “no violation”  letter from the US government, affirming that its “exports” are permitted.  Although it is not an all-purpose “Get Out of Jail Free” card (the Mozilla organization would probably get in trouble if they were to sell cryptographic software to the government of Iran, for example), the letter does provide an exemption for the distribution and development of source code that are crucial to the project.

It is heartening to see all the parties involved come to a sensible conclusion.

%d bloggers like this: