SELECT, JOIN and a bit of Perl? $10K

Database nerds will like this one. The state of Nevada has a database system for the permanent records of children in the state education system. One parent, an opponent of the Common Core national curriculum which is sweeping the US public education, wanted to know what his childrens' permanent record said. He asked for a copy, but it wasn't available for free:

Because the SAIN system is not designed to create reports that display individual student data in a readable format, the parent was initially told that the requested reports do not exist and cannot be produced
[...]
[Nevada Department of Education] staff determined that it would take at least 3 weeks (120 hours) of dedicated programming time to fulfill the parent's request. At the applicable wage rate of $84.95/hour, the requested work resulted in a $10,194 price tag.

Not designed to create reports that "display individual student data in a readable format"? That's a new one on me. So when education officials threaten to put a student's trangression on their permanent record, that actually means "a place that no-one will look because it's not readable"?

The really shocking aspect is that Nevada is employing IT experts at $85/hour who can't knock up an appropriate couple of SQL statements like:

SELECT GradeReport.Grade, GradeReport.Text, Students.StudentName, GradeReport.ReportDate
FROM GradeReport INNER JOIN Students
ON GradeReport.StudentID=Students.StudentID
WHERE Students.StudentName = "Fred Eppolito" AND 
 Students.SchoolID = 12345;
 -- choose whatever fields are needed to uniquely identify a student

I'm fairly sure that writing the query, testing it, dumping that data out in CSV format, eyeballing it to check that nothing's bad and then sending on the file can be done in the space of an hour.

If the Department of Education IT staff can't do this for $85 per hour, which is about $175K per year, perhaps they shouldn't be paid so much. Otherwise, one might think that the state of Nevada can't be trusted to spend taxpayer money at all...

Healthcare.gov - it's not over yet

After the well-publicised last-minute save of the Healthcare.gov federal health insurance exchange in 2013, there was a general sighing of relief from the Affordable Care Act's supporters. The months of suspense and error codes had been very painful, but finally the federal exchange was working more or less, and millions were able to enroll in time for the deadline (even if they couldn't then find a doctor who would accept their plan).

It seems that such confidence may have been misplaced; the federal site was fixed but a number of states decided to implement their own exchanges and it hasn't turned out too well for many of them, and people with badges are looking at Oregon's exchange quite hard:

The various state exchanges were funded by the U.S. Center for Medicare and Medicaid Services. As of March 28, it had awarded $4.7 billion in grants nationally. Oregon has been awarded $303 million in five increments.
Typically in federally funded projects, states must show evidence they've met certain milestones before they get additional grants. In Oregon's case, the Oregon Health Authority at first, and later Cover Oregon, had several "gate reviews" where federal officials reviewed progress on the project.
Documents show Oregon may have presented a misleading picture to the federal government.

Oregon has a population of about 4 million people. Since ACA sign-up is about 2.5% of the US population, let's be generous and say 3% for Oregon; that's $303 million for 120K people, or about $2500 per sign-up - just for the website. They've now dropped the idea entirely and fallen back to use the federal site which at least kind of works.

Most of the money went to Covered Oregon's contractor Oracle, who probably won't be promoting this as a triumph because the website has not managed to enroll a single private customer:

After discovering a series of technical problems before the Oct. 1 launch -- including inaccurate calculations of the tax subsidies for which consumers would be eligible -- Cover Oregon decided to scratch its plans to go live along with the rest of the country and never managed to get online enrollment started.

This hasn't come from out of the blue: back in November Oracle were being grilled about missed deadlines. Their VP Tom Budnar reported that they were bringing in an Oracle "SWAT team" but it would appear their efforts were in vain. Oracle's stock price has steadily risen from $39.5 to $42 in the past month, so at least Mr. Budnar doesn't have to worry about loss of public confidence in the company. Mind you, a search of Oracle's website doesn't show any results with his surname, so maybe they're already planning to cut him loose - if they've not done so already. He's going to have a difficult round of interviews if that's the case; I'd advise him to take a year of sabbatical and hope most people have forgotten about Oregon...

Oregon is egregiously bad, but unfortunately not too far out of line with other states' exchanges. As NPR reports this week, costs per enrollee of the exchanges have made the federal effort look like a model project:

Even Covered California, the most efficient of the state-run exchanges at $758 per enrollee, still spent more than the average for the federal exchange. And California was the only state-run exchange with a per-person average under $1,000.

Okay, so why did this cost so much? We can look at a comparable solution in the private sector in the USA: TurboTax (web edition) which is delivered by the firm Intuit. Filing federal and state taxes in the USA is a substantial undertaking; most people either go to a tax preparer (H+R Block is a popular one for lower-income taxpayers) or use some tax prep software. Filling in Form 1099 and its many supplemental forms by hand is a great way to lose money, get audited, develop a drinking habit and hate of humanity, or all three. TurboTax is a popular web system for filing taxes; it does automatic imports of data from a number of sources (major employees and brokerages), has a user-friendly interface, lets you submit forms electronically, and generally makes tax preparation a breeze. My expat colleagues who have used TurboTax sing its praises as being slightly easier to use than the short-form UK tax form, performing substantially more complex calculations and optimizations.

US tax season is not dissimilar to healthcare signups - a short period (1-2 months) after you get the tax information from your employer and brokerages and before the April 15th deadline, usage spiking in evenings and on weekends. So lots (millions, I'd estimate) of users crowd onto the TurboTax site in a short time, with downtime or even slowness being commercially unacceptable - there are several alternatives to TurboTax. Turbotax covers its costs and generates income by serving basic users for free, simple uses for $30 per user and complex uses for $50 per user (state filing is an additional $20 or so). You can even cover your costs if you use Amazon heavily.

It's not an exaggeration to say that if the states and federal goverment had contracted TurboTax's Intuit to build and operate the site for $70 per user - one tenth of the current cost in reality - then they could probably have made it work. They already have the storage and serving systems capable of handling that level of traffic, the marginal cost is probably less than developing from scratch. So why didn't the states and feds do this? Why did Oregon contract Oracle? Because Oracle and other consulting firms are very good at bidding for federal and state contracts. They're pretty awful at making them work, but this doesn't matter - strange to relate, contracts are not issued and paid based on whether the delivered solution actually works. The incentives in government contracting have generated an ecosystem where actual ability to build working systems is one of the less important characteristics for which the environment selects.

The defence of the federal contracting system (instead of assigning the contract to a company who might actually be able to make the contract work) starts with "we have to protect the taxpayer from being exploited in no-bid contracts." Except that it seems that the taxpayer is already being exploited. If Intuit charged $400 per user, made out like a bandit, gave bonuses through the company right down to the mailroom boy's cat and sent the execs off on 1 year fact-finding trip to the Bahamas, the taxpayer would still come out ahead, and would have the bonus of a website that actually worked well and was user-friendly.

The next stage in the gentrification wars

This is going to be interesting. The "techie scum" who are moving into and gentrifying various parts of San Franciso and Oakland have had a few months of their buses being blocked and Google Glass ripped off their faces, but now the local residents have decided to up the ante and attack the businesses that serve the gentrifyers. Four high-end grocery stores were tagged with graffiti demanding that they clear out of town:

Milgrom and his workers spent the day cleaning graffiti from all four stores. He says this isn't the first time it's happened. Recently windows have been broken as well.

I suppose it's quite a clever strategy; don't go after individuals, because if they move out then others will just replace them. Instead target the aspects of the area that they like and that you don't like. I wonder who will be the next target: Chi-chi cocktail joints? Places that sell coats for small dogs?

Looking at the reviews for the local market part of the business you can see its target market: its provisions include lamb ragu, Japanese pumpkin and duck confit. This is clearly not catering to low-income locals. The fact that it's a group of four establishments means that you can amplify your message and make it clear that this isn't just some random graffiti - the owners are left in no doubt that they are being targeted. The Local's Corner restaurant part of the business has a negative review giving more clues:

Funny that this place is called Local's Corner, as it's a new restaurant that is part of the gentrification of the Mission and thus directly involved in displacing long-term residents (ie, locals)

Apparently the opposite of gentrification is "neighbourhood decay" but I'm sure there should be a snappier term for it; I'm plumping for "communirot".

Local communirotter Mary Magee of "Alliance of Californians for Community Empowerment" (who needs better branding) is not a big fan of the establishment, claiming that groups of "people of color" are not welcome at Local's:

Magee said ACEE [sic] is asking people to boycott all four stores, claiming people in the area have complained that they were told to leave or turned away because they didn't fit the restaurant's clientele. [...] Magee went on to say the Local brand also has a high price point, which ACEE feels is a form of gentrification because many of those living in the area can't afford it.

Judging by Mary's Facebook page she's as white as they come and painfully right-on. Her colleague Julien Ball is possibly even more of a cliche: anti-Israel, anti-death-penalty, active on change.org, anti-discriminatory-lending... I find it amusing that Mary and Julien chooses to speak for the "people of color" rather than, say, letting them speak for themselves. But it becomes clearer when the article reports that ACCE wants Local to hold "sensitivity training". How nice for poor bespectacled owner Yaron Milgrom:

Milgrom told KTVU he fell in love with the area because of its diversity. He can't believe he is now being accused of not embracing it.

Oh, believe it Yaron. If you're lucky, this is merely a shakedown operation to whip you into line and make it clear that the community activists in the area are in charge. If you're unlucky, they've taken a dislike to you and you're going to have to sell up and eat a huge loss (for what sane gentrifying business would want to take your place in the firing line?) or be run out of town on a rail.

Tanya Gold on mountaineering

Alas, Tanya Gold of The Guardian has descended to clickbait headlines to keep up interest in her articles; her latest on the Everest avalanche that killed thirteen Sherpas is particularly painful:

As commercial climbing has exploded, Everest has shifted from an explicit wasteland to a moral and internal one which also serves as a perfect metaphor for the contempt in which we hold the planet.
It is not simply the ordinary exploitation of the Sherpas, which is soothed away with the knowledge that in Nepal, where the average annual wage is $700, a Sherpa can make $5,000 in a two-month season – although it is impossible to imagine this kind of death rate being tolerated if the dead were rich and white.

The fall of a serac in the Khumbu icefall was tragic, but by no means a bolt from the blue. Jon Krakauer's account of the 1996 Everest disaster that killed eight climbers (which Tanya references) describes how perilous the icefall can be - falls of huge, building-sized chunks of ice can happen without any more warning than a "look out!" from your companions, and even an injury such as a broken leg can prove fatal in the perilously hazardous conditions of 18000+ feet altitude where simply being there can provoke debilitating or fatal altitude sickness.

The Everest climber fatality rate between 1922 and 2006 is about 2% overall, and about 1.4% if you exclude porters (Sherpas and others). Certainly, being a Sherpa is more dangerous than being a paying climber, but as a Sherpa you're still about the fatality rate of an astronaut and your relative compensation is better - if a Sherpa makes 7x the average annual wage, look at a top-end salary for an astronaut based in Houston, TX which is about $141K, or about 2.5x the mean US wage. This is not comparing apples to apples, but at least gives you a ballpark picture of how well Sherpas are compensated. Sure, they have a dangerous job, but no-one is forcing them into it and they probably have a better understanding of the dangers than most of the climbers. So when Tanya says:

...although it is impossible to imagine this kind of death rate being tolerated if the dead were rich and white.

it turns out we actually tolerate this death rate already, even though the dead are moderately well paid and mostly white. Perhaps Tanya doesn't have a great imagination.

Looking at Tanya, I think it's safe to say that she's in no danger of attempting to summit Everest (or indeed any peak more challenging than Brown Willy) any time soon. Perhaps then she cannot appreciate what drives people to push themselves to their physical and mental limits to overcome the imposing challenge of high altitude mountaineering, and we should not blame her for that. We should, however, nail her to the wall for comments claiming that money trumps humanity for climbers:

But more tourists claim "tunnel vision" and "summit fever". They do not pause; they are slaked on their own fantasies; they paid too much. Madness indeed.

At Everest summit altitudes, even a very fit climber has to draw on all their reserves of strength to survive the Death Zone. Even a small amount of additional exertion in aiding a fellow climber can cause them to collapse and double the number of people that need help. When you're on a climb to the summit of Everest, your survival is your own responsibility; it's unlikely that anyone will be able to help you; trying to help someone else can make you pay much, much more than just your climbing fees. All climbers who have reached the final base camp will know and understand this, much more than someone like Tanya can even strain to appreciate.

Strategy in 2048

I've been playing the 2048 game which (if you haven't played it yet) is the most phenomenonal time sink invented. To save people from sanity, here are some general game hints; using this strategy I manage to obtain the 2048 tile in roughly 50% of games.

1. Start by building up the big numbers in the lower left corner, spreading along the bottom row.
2. As the bottom row is nearly full (say you have [16, 8, 4, _] start filling the third row with numbers starting from half the lower left number (say, [8, 4, 2, _)
3. When the opportunity arises to have the bottom row full and the third row filling 3 of 4, right shift the board so the third row numbers line up above the same numbers on the bottom row and then drop them down and shift left to increase your bottom row numbers by a factor of 2.
4. When the bottom row starts getting big (say, 64+ as the left corner number) start trying to order the third row in the opposite direction. If the bottom row is [128, 64, 32, 16] start trying to create 16 at the end of the third row. Whenever you can, drop numbers into the bottow row.
5. At nearly all cost, avoid filling row 2 so that you have no option but to move the board up - that will trap small numbers under your row of big numbers. If that happens, drop the board again immediately (and hope).
6. If you end up with 2 or 4 tile to the left of a big number tile on your bottom row, focus on increasing that tile number until it matches your big number so you can left-shift the bottom row and have the biggest tile in the bottom left corner.

Good luck!

Assuaging public concern by taking the piss

It seems that homeopathy is gaining adherents in Portland, USA: 38 million gallons of water had to be flushed from a reservoir after a guy took a leak in it:

The Portland Water Bureau there's little risk to the public's health but bureau administrator David Shaff says, "Our customers have an expectation that their water is not deliberately contaminated. We have the ability to meet that expectation."

Um, yes, but ability and requirement are not the same thing...

Now this wasn't as expensive as it could have been elsewhere in the country, e.g. neighbour California is in a drought and water is a precious resource there, whereas Portland is famous for its damp climate. Still, treating water costs actual money. Why did the Portland Water Bureau feel compelled to take this drastic action? A pint of urine in a 38M gallon reservoir would have been practically impossible to detect, let alone have any effect. You'd get more contamination every day from birds pooping.

It's all about perception, of course. Once it became known that someone had peed in the reservoir, if the PWB had done nothing then there would have been a popular outcry (fuelled by the press, who love a story like this; can you imagine the puns if the Sun wrote this up?) The PWB is merely pre-empting these protests, saving itself from the grief by expending someone else's money. Wouldn't you?

Mind, anyone in Portland who still drinks Budweiser or Coors wouldn't have much room to complain...

Dodgy assertions from CASH's head medic

The salt-haters have been praising the reduction in dietary salt for an important role in the 42% fewer stroke fatalities and 40% drop in those dying from coronary heart disease:

The researchers, who include Britain's leading campaigner against added salt in food, claim that diminishing levels of salt was "an important contributor" to falls in blood pressure over the eight-year period. "As a result, the decrease in salt intake would have played an important role in the reduction of stroke and ischaemic heart disease mortality during this period," say the authors.

"Would have played"? That's a funny way of saying "was shown at a 95% confidence level to have played"... Co-author Graham MacGregor is the chair of CASH; his daytime job is Professor of cardiovascular medicine at the Wolfson Institute of Preventive Medicine at Queen Mary. So surely we can expect a rigorous and impartial analysis of the data from him.

If I'd been looking to prove or disprove this assertion, I'd have looked at stroke and heart disease rates in a range of patients over this time frame, where I had some objective measure of salt in their diet (urine samples), and looked to see whether patients with lower salt levels (in a group of patients with otherwise similar exercise, age, gender, racial stats) were correlated with lower stroke and heart disease rates. Is this what they did?

Patrick Wolfe, professor of statistics at University College London, took issue with the authors for assuming that the improved blood pressure seen in the 2003-2011 was largely the result of reduced salt intake. "Plausibility of assumption does not equal evidence," he said.

Oh. Apparently not, then. That's a piss-poor basis for the claims CASH (and international co-conspirator WASH) have been touting around about salt reduction. As commentor ID4968047 notes this reduction in strokes and heart disease could equally have come from the reduction in smoking in the past 10 years - the obligation is on Prof. MacGregor to show otherwise. Looking at CASH's writeup of the paper (the link to the paper isn't available yet, looks like) they say:

Confounding factors that were looked at include age, gender, ethnicity, education, incomes, alcohol consumption, fruit and vegetable intake and BMI.

Exercise and smoking are not mentioned. Nor do they reference the increase in statin use - and indeed Aseem Malhotra from Action on Sugar claims that statins are harmful and don't reduce mortality which is interesting as they seem to be a prime competitor to CASH/Action on Sugar's crusades against sugar and salt. Malhotra's claims got panned for lack of evidence by Prof. Rory Collins from Oxford.

It seems that others in the medical stats community have doubts too:

David Spiegelhalter, professor of the public understanding of risk at Cambridge university, cited the researchers' admission that the fall over that time in systolic blood pressure would be expected to reduce strokes by just 11% and heart attacks by 6%, small amounts of the total falls. [my emphasis] Reduced blood pressure did not represent the authors' claimed "substantial contribution" to the reduced death rates.

This is not to say that Graham MacGregor is obviously wrong in his claims. They might be true but it is a real reach to claim that this study supports them. And if this is the best he can do, I'd suggest the Marcela Trust / OMC Investments crowd who are backing CASH find someone with a better stats background to organise their crusade against salt and sugar.

Update: just managed to dig up the link to the full text in BMJ Open. From a quick look the focus was on linking salt reduction with BP reduction but not explicitly with stroke/CVD reduction.

The authors themselves admit:

It is likely that several factors, that is, the fall in BP, total cholesterol and smoking prevalence, the reduction in salt intake and the increase in the consumption of fruit and vegetables, along with improvements in the treatments of BP, cholesterol and CVD, contributed to the decrease in stroke and IHD mortality.

They have a stab at isolating the effect of salt by casting tea leaves:

it was estimated that a 2.7 mm Hg reduction in systolic BP that occurred with salt reduction would be predicted to reduce stroke by approximately 11% and IHD by 6%.

but even then the 2.7mmm Hg reduction figure they quote is the net over 8 years including factors such as decrease in smoking and increase in statins, so to attribute it to just salt reduction is "optimistic". They appeal to studies in Japan and Finland in the late 60's / early 70's but the huge gaps in time, diet and environment between now and then render the comparison unconvincing. If that's the best argument they've got to offer, I'd hate to see the ones that didn't get selected for use in the paper.

The conclusions are what kill the paper for me:

The reduction in salt intake is likely to be an important contributor to the falls in BP in England from 2003 to 2011. As a result, the decrease in salt intake would have played an important role in the reduction in stroke and IHD mortality during this period. [my emphasis]

That's a terribly weak conclusion even to my relatively untrained eyes. If they could state this more strongly, they would. Instead, they reserve their strength for polemic:

... the mean salt intake in England (8.1 g/day in 2011) was still 35% higher than the recommended level of 6 g/day, and 70% of the adult population (80% men and 58% women) had a daily salt intake above the recommended level.[14] Therefore, continuing and much greater efforts are needed to achieve further reductions in salt intake to prevent the maximum number of stroke and IHD deaths.

Reference 14 doesn't justify the 6g/day level, it's just a measurement of sodium levels. The authors don't make any reference I can see to why the recommended level should be 6g/day and not (say) 10g/day or 3g/day. If you're appealing to magic figures in your conclusion it doesn't give great confidence in the rest of your article.

A lesson from OpenSSL

If you are paranoid about secrecy on the web, today's news about a bug in OpenSSL may make you feel justified. OpenSSL is an open source library that is used by companies, individuals and governments around the word to secure their systems. It's very widely used for two reasons: 1) a very useful set of licensing conditions that essentially say you're fine to use it as long as you credit the right authors in the source and 2) because so many commercial firms depend on it, its source has been scrutinised to death to spot both performance and functional bugs.

A one-paragraph primer on SSL (Secure Sockets Layer): it's the method by which a regular web browser and a secure web server communicate. You're using it whenever the address bar in your browser displays a URL starting with "https:" instead of "http" - so that's your online banking, Facebook, Google, Twitter, Amazon... Most of these secure web servers will be using OpenSSL - there are alternatives to OpenSSL but none of them are compellingly better, and in fact the widespread usage of OpenSSL probably makes it less likely to contain security bugs than the alternatives so there's safety in belonging to the herd.

Anyone who's thinking "aha, my company should avoid this problem by developing their own SSL implementation" or better yet "my company should develop a more secure protocol than SSL, and then implement that!" has not spent much time in the security space.

And yet, someone has just discovered a bug in a very widely used version of OpenSSL - and the bug is bad.

To get some perspective on how bad this is, the Heartbleed.com site has a nice summary:

The Heartbleed bug allows anyone on the Internet to read the memory of the systems protected by the vulnerable versions of the OpenSSL software. This compromises the secret keys used to identify the service providers and to encrypt the traffic, the names and passwords of the users and the actual content. This allows attackers to eavesdrop on communications, steal data directly from the services and users and to impersonate services and users.

Sounds dire, no? Actually the above description is the worst case; the bug gives an attacker access to memory on the secure server that they shouldn't have, and that memory *might* contain secrets, but the attacker doesn't get to control which area of memory they can read. They'd have to make many queries to be likely to gain access to secrets, and it's not too hard to spot when one small area of the Internet has that kind of unusual access pattern to your server. Even if they make 1000 reads and get one secret, they still have to be able to recognise that the data they get back (which will look like white noise) has a secret somewhere in it. I don't want to downplay how serious the bug is - anyone running an OpenSSL server should upgrade it to get the fix as soon as humanly possible - but it's not the end of the world as long as you're paying attention to the potential of attacks on your servers.

Still, isn't this bug a massive indictment of the principle of Open Source (that you'll have fewer bugs than commercial alternatives)? It's appropriate here to quote Linus's Law, codified by Open Source advocate Eric Raymond and named after the founder of the Linux operating system Linus Torvalds:

"Given enough eyeballs, all bugs are shallow"
or more formally:
"Given a large enough beta-tester and co-developer base, almost every problem will be characterized quickly and the fix will be obvious to someone."

Unfortunately, the larger and more complex your codebase, the larger the tester and developer base has to be and the longer it takes to find problems...

It's tempting to look at this security alert and declare that Open Source has allowed a critical bug to creep into a key Internet infrastructure component (clearly true) and declare that this can't be the right approach for security. But you have to look at the alternatives: what if OpenSSL was instead ClosedSSL, a library sold at relatively low cost by respected security stalwart IBM? ClosedSSL wouldn't have public alerts like this; if IBM analysis found bugs in the implementation then they'd just make an incremental version release with the fix. But the bug would still be there and would not be any less exploitable for the lack of announcement. You'd have to assume that government agencies (foreign and domestic) would bust their guts to plant someone or something with access to the ClosedSSL team mail, and in parallel apply object code analysis to spot flaws. The flaw would not be much less exploitable for lack of publicity, and would likely be in the wild longer because IBM would never announce a flaw so vocally and so users would be more lax about upgrades.

There are then two lessons from OpenSSL: 1) that even Open Source inspection by motivated agencies can't prevent critical bugs from creeping into security software and 2) that no matter how bad the current situation is, it would be worse if the software was closed-source.

Diversity in everything except opinion

This is terrifying. Mozilla CEO Brendan Eich has been forced out because of his personal position against gay marriage. If you don't believe me, read the mail from painfully hip lawyer and Mozilla Foundation chair Mitchell Baker:

We didn’t act like you’d expect Mozilla to act. We didn’t move fast enough to engage with people once the controversy started. We’re sorry. We must do better.
Brendan Eich has chosen [ah! free choice? really?] to step down from his role as CEO. He's made this decision for Mozilla and our community. [He's been given the choice to resign or be fired.]
Mozilla believes both in equality and freedom of speech. Equality is necessary for meaningful speech. And you need free speech to fight for equality. Figuring out how to stand for both at the same time can be hard.

Yes, it can be hard to stand for equality and freedom of speech, but clearly you've opted out of that stance and gone for sucking up to the media-approved line of thought. 60% of Americans support gay marriage (at least publicly) so it may be a majority opinion but opposition can't reasonably be dismissed as a small clique of bigots. It seems that opposing the majority opinion is only allowed when the majority opinion is "wrong". Let's remember that the California Supreme Court (no bastion of political orthodoxy) did not see anything wrong with allowing Californian voters to vote freely on whether marriage should be restricted to male-female partners in California.

I'm reminded of Bob Hope's quote after the 1975 Consenting Adult Sex Bill was passed:

I've just flown in from California, where they've made homosexuality legal. I thought I'd get out before they make it compulsory.

You're still allowed to choose to be heterosexual, but if you value your job and career you'd be a brave person to even hint at wavering on the issue of gay marriage.

Gay arch-blogger Andrew Sullivan can see where this is leading and he's really not convinced it's a good idea:

If this is the gay rights movement today – hounding our opponents with a fanaticism more like the religious right than anyone else – then count me out. If we are about intimidating the free speech of others, we are no better than the anti-gay bullies who came before us.

Allowing the media to dictate the acceptable positions on thought is not going to end well, and I wonder if the gay marriage lobby have really thought this one through. If Fox News continues its rise and the (more left-leaning) rest of the media continues its decline, do they want opposition to Fox editorial policies to become grounds for hate campaigns against people?

Obamacare is going to have a doctor problem

An aspect of the American Affordable Care Act (aka Obamacare) which I hadn't appreciated until this week was the degree to which it may be scuppered by primary care physicians (PCP, the USA equivalent of a GP). Chatting with a middle-aged friend who is moving to a small-ish American town and changing jobs, she opened my eyes to the mysteriously unpublicised problems which the implementation of the ACA is about to cause everyone.

She was visiting her new town last week, sorting out her house and meeting her new workmates in preparation for moving there for good in June. One item on her list was sorting out a new PCP. She had the details for her new insurance plan with one of the state providers, so dropped by a doctor's office near her house to register. No joy, that doctor wasn't accepting new patients. OK, so go back to the insurance provider website to identify a wider shortlist of providers in town.

No joy at the first doctor. Or the second. Or the third. This was getting ridiculous. She had a friend already working in her new workplace, so asked him if he could help. His doctor wasn't accepting new patients either, but the friend had a good relationship with the doctor, so asked him directly. Still no luck. Eventually my friend managed to find a large medical center open to new patients - over 60 miles away. She signed up, because that was the best offer there was.

There was one doctor in a nearby town open to new patients, but after a quick check on his reviews it became rapidly clear why. It sounds like he hadn't progressed much past the "trial by ordeal" approach to illness, and was still reading pre-Pasteur literature on infection control.

Why this insanity of unavailability? It turns out that the coming avalanche of patients signed up on ACA-compliant plans is not making doctors sleep well at night. Not only are these patients much more likely to be sick than their current patients, the main concern of practices is that they're going to lose money on treating these patients. The remuneration rate for doctors for ACA patients is - at least in some states, and I suspect all - based on 80% of the standard practice fees from 3 years ago. That's not great, but much worse is the experience with Medicare (federal medical coverage for the elderly). My friend used to work in a doctor's office, and they had a profitably employed office employee whose sole job was to push back against government agencies spuriously denying payment for Medicare claims. If there were any abnormalities at all in a claim, Medicare would deny it in the hope that only solidly valid claims would be retried. A denial is, after all, cheap.

I digress, but bear with me. Do you older readers remember when The Simpsons started and they introduced us to Marge's sisters Patty and Selma, stalwart misanthropic employees of the local Department of Motor Vehicles? There's a reason why the American viewers of the show laughed, and it wasn't to do with absurdity. There's no-one more un-fireable than a federal or state bureaucrat, and their attitude to their customers is exactly what you'd expect - entirely down to their general disposition to humanity. That's what the doctors' billing teams are going to be dealing with. Only by being better acquainted with the rulebook will they be able to get their due payments out of the ACA system, and even then those payments will be small and paid late.

Having a new government agency and new set of rules means that small practices are extremely worried about their costs and ability to maintain existing patients. Because (I believe, from chatting to the front desks of a few offices) you can't be selectively open to new patients based on their particular insurer, the easiest option for small providers is to batten down the hatches until the picture is clearer. Only the very large healthcare centers can take advantage of their economy of scale to accept the new stream of ACA-covered patients - and with them the standard employer-covered and easier to manage new patients.

I wonder whether this problem with finding doctors is behind the proposed rise in rates for ACA-compliant plans? Perhaps you will be able to look at the rate rise in the next few years and extrapolate the "marginal cost of doing business with government". As it stands, the best they can hope for is to break even:

Cigna, which is selling Obamacare plans in five states and is considering whether to expand that further in 2015, has said it won't make money on the business this year. It expects to have signed up as many as 100,000 new members under the program for this year.

So for the Affordable Care Act, if you're sick then you may be able to get coverage where you couldn't before, but sure as heck if you're outside a major city then you're going to find it a challenge to get a primary care physician to see you and get your care started. Now I'm wondering what the ER departments of ACA-plan-accepting hospitals are going to experience in the next year.