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Friday, October 6, 2017

Rational Approach to Health Care

The ability of private health insurance companies to limit lifetime cost and deny coverage of preexisting conditions is the prime factor in the overly expensive health care costs in the United States. The web of cost and payment systems is built on these two lee ways.

The limits on lifetime costs creates many instances where a person who begins a lifetime of medical intervention exhausts their available payments. Once that threshold is reached, the person and his/her family must beg for services and utilize the ER system in order to receive urgent care. They must seek out philanthropic sources to obtain treatment which cannot be had from an Emergency room visit. Many times the medical facility must write off the costs to the actual patient and instead allocate them to overhead and charge the insurance providers a higher amount. This is why a $2 bag of saline is charged at $800. As long as the insurance provider is in the loop the medical facility gets paid. This scenario of cost allocation puts an undue burden on people who do not have coverage and are similarly charged the $800 amount.

In the mix of who pays for what, the insurance company gets to limit their exposure to payouts and doesn't have an incentive to contain the costs.

By being able to exclude high risk patients and high cost procedures and medications the insurance companies shift the costs over to charitable, philanthropic and public assistance budgets such as Medicaid, SCHIP and Medicare Disability coverages. The exclusions for unfavorable items such as abortions, contraceptives, mental health, dental and elective surgeries likewise drive up the costs to people who do not have coverage.

As long as certain people can be excluded and certain procedures and therapies not covered there will be inequities and cost shifting rather than true cost containment.

Medicare, for instance, is prohibited from negotiating with the pharmaceutical industry for bulk buying prices. For the people who are covered by private insurance they do not need to worry (for the most part) about the costs. For people who are covered by Medicare or Medicaid the co-pay amounts can be prohibitive. The ostensible reason for co-pays is to make the patient partly responsible for limiting the demand for medications. The real reason is the funding sources for drugs will only pay a certain amount and the manufacturer wants more than that.

If the insurance industry could not deny a patient, charge a deductible and a copay, then they and the pharmaceutical industry would have to come to terms for the actual costs. One or both industries would have to accept a smaller profit margin.

Of course this treatise is leading in the direction of a single payer health care system for the United States. This doesn't mean the entire healthcare insurance industry would be scrapped. Someone still needs to administer the system and monitor it for efficiencies. That entity (those entities) can easily be the existing insurance corporation. It would necessarily limit the salaries and other compensation of the top executives and the ROI for investors.  On the positive side, everyone would be able to receive care. When a need for facility and personnel expansion is identified building would be built, personnel would be trained. In the agglomerated mash up of services and administration there is no rational relationship between the number of doctors, nurses and technicians who are trained. The industry does not act on the attrition of personnel via retirement and career switching. The industry doesn't act on the projections of population, age demographics or emerging disease crises.

One can take as an example the number of and locations of dialysis units around the country. While any business which decides to build a facility can be assured of its full use capacity, they rarely take into consideration that getting there and home is an integral part of the treatment. Precisely where the patients live relative to the dialysis unit is an external factor as far as the dialysis provider is concerned. As long as they do not have to consider the transportation element, cost will be high and patients will have difficulty obtaining their essential treatment.

The first steps in health care justice is to not allow insurance companies to deny coverage. Then put a price limit on the "essential" coverages. They will have to work together with their vendors to buy the hardware and drugs they cover. Lastly, they would have access to public funds to make up the difference.

Yeah, you can call that socialist. It is. So are the Police Department, Fire Department, Public Works Department, Highway Department, and those pesky socialists who plow and salt the highways each winter. It is time the single largest economic cost division get in line with the remainder of the economy.


Fewer and fewer people are employed today than before due to job migration and automation. Fewer of the remaining jobs will be full-time and of a compensation level which includes health insurance. In 12 years, the last of the Baby Boom generation of 59 million people will reach age 65. Owing to the actuarial tables, there will be somewhere around 120 million Americans who are Medicare age. The planners in our society and the Legislators we elect need to take a hard look at what the future will be and devise a new system of health care delivery and payment.

Sunday, August 6, 2017

Will Persons with Disabilities be Left Out of the AV Revolution?


Automobile manufacturers are teaming with city planners, traffic planners and highway Engineers in the hopes of reducing urban traffic, parking demands, and collision injuries and deaths on the nation's highways. Millions of dollars are being sped to Research and Development to address those concerns.

The theory of AV deployment is that such conveyances will not consume parking space thereby reducing the capital costs of urban buildings. Vehicles will be shared-use and be made available on demand like in traditional taxicabs, Uber and Lyft services except without the cost of a driver.

The vast number of collisions, injury and death on the nation's highways are the result of driver error. The hypothesis is in one takes the humans out of the control system then fatigue, distraction, aggressive behaviors and limited reflex/reaction times will not be the cause of those injuries and death. Most of all the effects of intoxication, responsible for fully half of highway deaths, will be solved. These motives are admirable in and of themselves.

The neglected motive for deploying AV is for people who cannot drive due to age, poor eyesight, other disability or waning ability. For such people taxicabs and other modern variants remain beyond the scope of the business model.

As with the vast majority of business models the plan is to skim off the top the most easily served customers and leave the remaining ones for someone else to handle. The customer using a wheelchair has been relegated to an inferior service model called Complementary Paratransit. "Complementary" refers not to being free but being alongside fixed-route public transit.

Taxicab operators have been slow or complete resistant to accessible vehicles for wheelchair using customers even though since 1990 they have been under regulation to serve persons with disabilities. They have not done so using the logic "we don't do that." The Uber and Lyft operations have likewise kept their model such that they do not serve the entire public. They only serve the segment which they deem comfortable doing and profitable.

Urban-based AV are going to be the next generation of automation to eliminate human employment. Taxis and Ubers already serve the limited public who can enter and exit the vehicle which it is still in the travel lane of the urban street. Serving the remaining public is the challenge of AV developers.

Highway driving AV will typically be owner-occupied. That is people will purchase an AV and commute their 30-50 mile radius and make their occasional long-distance inter-city trips. For them the AV is a convenience rather than a necessity. Yes, the AV should significantly reduce the collision rate of such long trips.

The urban circulation of people and vehicles will require 1,000s of hours of "learning" for the AV to be effective. Fortunately such learning is transferable from vehicle to vehicle unlike the learning process of a human driver.

Detroit's Automated People Mover
For persons with disabilities who have been neglected for decades, the AV promises to be the difference between night and day. Unlike the general public, to obtain individualized trips within a local region presently persons with disabilities must apply for and be ruled eligible for Complementary Paratransit services provided by a local transit agency. They must make a reservation one or more days in advance. Such reservations must include the Origin, Destination, desired Pickup time and anticipated return time. Then a shared ride vehicle arrives within a 15 to 20 minute (earlier/later) time frame. Unlike shared use vehicles where a multiple people use the same vehicle one after the other, this ride will be shared ride with other passengers at the same time. Such scheduling seeks to optimize the ride carrying capacity of the vehicle. The passengers get no choice in how many people share their ride, where they are going or for what reason.

AV which can accommodate a wheelchair or two plus a few ambulatory passengers and that can find the curb would be the solution many persons with disabilities have sought for many decades.

The development of an accessible AV system would have some typical characteristics.

  • It would be a minivan sized vehicle that can seat 2 wheelchairs and 3 or 4 ambulatory passengers in the primary passengers group.
  • It would have curb access with ramps on both sides of the vehicle to accommodate service on one-way streets.
  • It would not rely exclusively on voice commands to initiate and conclude a trip.
  • It would be able to find the curb and stop close enough to pickup and discharge the passengers.
  • It would be able to recognize curbside barriers such as utility poles, trees, parking meters, trash bins, benches, fire hydrants, mailboxes, etc. and not stop there.
  • It would be able to attach a form of mobility aid securement to the aid if the passenger or his designated assistant could not do it instead.
  • Such AV stock would be plentiful enough to afford persons with disabilities with the same level of service, timeliness and reliability.


In order for the promise of AV to be realized the users need to be inside the urban service area. This means they will dwell there or will arrive there by other means than a private automobile (AV or otherwise). This opens the market for vanpools, biking, trains, walking and commuter buses. Some of those modes may also be equipped with AI to operate them.

The scenario of an sedan-sized AV being used to first make a long commute then go into service as an urban circulator is a non-starter. Needing to store a car in the city during the day also defeats the purposes of AV in the first place.

Pittsburgh's Failed SKYBUS Project (Circa 1964)
Some cities already have driverless automated transit modes and have for many years. Detroit's People Mover is such a system and is already 30 years old. It operates in a 2.9 mile loop in the central city. Miami operates the Metro Mover on 4.4 miles of elevated track. Both systems are electric and are fully automated. Their usage helps define where future development will occur.  In 1964, Pittsburgh, PA started the controversial Skybus system. It was to be a fully automated rubber tire vehicle which traveled on a concrete fixed guideway.  Even with a demonstration track in the South Hills the project lost political favor and was cancelled.

AV for city streets is a goal to bring such people moving capabilities to private seating running on existing public rights-of-way. While that lofty goal is admirable, cities will ultimately need to invest heavily in new architecture and amenities to make AV a viable form of inner city transportation for everyone.


Thursday, August 3, 2017

Integrating BRT and Bike Lanes into an Inclusive Urban Design


Following the lead of Curitiba, Brazil in dedicated transit priorities many US Cities have become enamored of the idea for allocating existing right-of-way space to dedicated bus and bike lanes.

The cities are responding to the lobbying pressures of bike-riding constituents and their representative organizations to improve biking safety by creating curbside protected lanes. These physically separated bikeways may very well decrease the frequency and severity of bike/motor vehicle collisions but they also limit access to the sidewalks by taxis, Ubers and Lyfts, and the transit authorities mandatory Complementary Paratransit services for persons with disabilities under the Americans with Disabilities Act.

In locations where the business community is sufficiently vocal, the non-protected bike lanes are being striped between the curbside larking lane and the rightmost motor vehicle travel lane. In such locations, bike riders continue to be in jeopardy of suddenly opened parked car doors and the need for fixed route transit buses to cross to reach the bus stops at the curb.

The protected bike lanes create shared use limitations for persons with disabilities who arrive and depart an address on the block via Complementary Paratransit services. Whereas the general public has no specific right to be picked up or dropped off nearest their intended destinations, persons with disabilities DO have such a Civil Right as enumerated in CRF Part 49, Sections 27 and 28, and guaranteed by the Americans with Disabilities Act since 1990.

The rise of Bus Rapid Transit (BRT) service designs are beginning to create similar access limitations for persons with disabilities too. Where the BRT buses are on wholly separated guideways, they may present limitations for bus access for persons with disabilities, but they do not limit to the curb from adjacent travel lanes.

Where the existing right-of-way is being reconfigured to accommodate dedicated bus travel, long stretches of urban street may be unavailable for Complementary Paratransit vehicles to services passengers with disabilities who need to visit the specific block where the BRT lane restricts access.

In a worst-case scenario, as in the Oakland section of Pittsburgh, PA, there is already a counter flow dedicated bus lane on the left side of the street and a proposed protected bike lane for the right side. This configuration runs for several blocks through the University of Pittsburgh and would create an "access desert" in one of the most highly visited sections of the city.

Several alternatives are under consideration for this BRT/Bike Lane development. The clear take away from the initial studies is that access by Complementary Paratransit vehicles is a complete afterthought.

While the final design criteria has not officially been adopted, many advocates of persons with disabilities have voiced their concerns and want to shape the implementation in advance of construction. None of the alignments or street profiles address how a Complementary Paratransit vehicle will access the sidewalks.

   


Minnesota DOT hired a consultant in 2013 to identify bike lane development criteria which included upfront and continual participation of advocates for biking as both Recreation and as Transportation. This planning process is analogous to the one that should be employed in the early development of BRT and other public projects which restrict or eliminate access to the curb by public and private vehicles serving persons with disabilities. While transit use promotes walking as one of the trip legs and a 1/4 to 1/2 mile distance may not be onerous for the general public, persons with disabilities may not be able to traverse even one block from vehicle to door.

The accommodation to persons with disabilities use wheelchairs is the smaller portion of the overall mobility limited population who need to be heard and served. Frail elderly, blind, and other semi-ambulatory people are part of what "accessibility" is designed for.


Some suggestions are to create "Paratransit Stops" at the lead or trailing end of the block to allow Complementary Paratransit vehicles to cross the bike lane demarcations to service scheduled passengers. A similar design parameter would allow the Complementary Paratransit vehicles to travel a single block of the BRT or counter flow bus lane and stop at a curb inset to pickup and drop off their passengers. Specific geometries need to be evaluated for each type of accommodation. Because all of these solutions will involve infrastructure modification as well as policy decisions, this is where consumer input would be most valuable.

Thursday, July 20, 2017

Will Brownouts Return to America?

Back in the 1970s and 80s America experienced what was referred to as "brownouts". It was not a blackout of electric service, but it heralded an era of possible shortages of electricity to power our energy intensive civilization. Brownouts occurred on days and during hours of high demand for electric power primarily to run all the air conditioners people had become accustomed to and dependent on.

As with all impending crises the a/c was not the sole culprit when the power became short. The brownout occurred when too many users demanded too much power from the grid that the voltage dropped below the acceptable 110-volt threshold. Incandescent bulbs would dim. Compressor motors would strain to stay running to pump the heat out of our houses, officers and apartment. Many commercial HVAC systems had under-volt protection so the motors did not overheat and become damaged. Lesser systems merely strained until they failed.

The utility companies were faced with the prospects of building another generation plant at a cost of hundreds of millions to billions of dollars. Even with funding available, it would take years and even decades to bring a new plant online.

As mentioned above, it was not merely the A/C demand that browned-out the grid. It was all the dishwashers, laundromats, 100-watt bulbs and refrigerators all plugged in and pulling power at the same time. There arose an alternative to building more capacity which would be less expensive and faster to market. That idea was conservation.

The utility companies devised marketing campaigns to limit electric demand during peak hours and days. The appliance manufacturers (under pressure from the EPA and other Federal government agencies) increased the efficiency of their products. Incandescent lightbulbs were replaced first with Compact Florescent bulbs (later LEDs) which consumed far less electricity. Homeowners were encouraged to wash dishes and laundry at night when other demand was lower. The strategy worked because spending $10 million on conservation marketing campaigns to save 10% of use eliminated the need to spend $100 million or more for 10% increase in capacity.

Today utility companies have Internet-connected metering to record how much electricity a customer uses during each hour of the day. Pricing is time dependent.

Using a combination of persuasion and heavy-handed regulations we as a nation averted the brownout crises and now have fewer days and times when the power is not sufficient. This short-term remedy cannot continue indefinitely. There is a mathematical limit to how much less electricity we can use. Along the way toward balancing the demand with the capacity we even had the time to better insulate our dwellings against heat migration in and out thereby lowering the energy demand of the millions of dwelling in this country.

But now, three trends are making an uptick in electricity demand. More houses/apartments for a growing population, more appliances left connected and using electricity and the popularity of electric automobiles. All of these items make conventional electricity generation even more a problem for the environment. Coal and gas fired plants make additional CO2 loading in the air which then leads to hotter weather and an increased need for electricity to run A/C systems. This is called a "feedback loop". The cause leads to the effect which in turn exacerbates the cause. Hydro-electric plants require a massive commitment of land and must be located where there is a river of sufficient flow and a deep valley in which to impound the water. Nuclear reactors need the river water flow for cooling and they produce massive amounts of 10,000-year toxic wastes. They take decades to build and bring online.
  
This is the Before picture
This is the After picture
Each of these primary sources of electricity have a massive downside with which to contend. By comparison, solar PV and wind turbine fields do not produce ongoing quantities of toxic wastes. They can be upgraded in stages, unit by unit, as better technologies emerge. They can be located on land which is otherwise underutilized or sitting unused at all. Most of all they can be relocated over time as needed and desired.     








Construction times for Wind and Solar fields are also much shorter than for any other method of generation. The styles and configuration of Wind and Solar installations are likewise evolving and are able to keep ahead of the demands and the aesthetics of the system.

We can coast along denying that man is responsible for the melting of land-bound ice, the acidification of the oceans, heating of the atmosphere and wait for the ultimate outcome to manifest itself. Or we can do everything within our capabilities to forestall that bleak result. Even if some celestial event, or geologic process turns back the clock on climate change, that too will be a factor of climate change with which we will have to address. Getting colder or getting hotter is equally detrimental for us and tens of thousands of species on this Earth we all share.