3/18/2010

The Healthcare Diff Part 2


I received some good comments on my post The Healthcare Diff including some on Hacker News. One reader pointed to this excellent article in The New Yorker by Atul Gawande. Gawande says the Senate healthcare bill is chock-full of experiments, it's just they are called pilot programs. The article includes an extended analogy between healthcare today and the state of agriculture in the early 20th century. He asserts the transition to a modern efficient system of food production was largely due to government sponsored pilot programs.

This is very encouraging.

One reason information about the healthcare bill's contents is not widely known is "the process story".



NPR reported that the media loves explaining the process by which a bill is making its way through Congress, but they generally minimize discussion of the bills themselves. For example here is the top hit in a search for "healthcare" on Google News for each of the last 14 days:

March 17th: Nuns in US back healthcare bill despite Catholic bishops' opposition
March 16th: Democrats Gain Momentum for Healthcare vote, but Process Draws GOP Attacks
March 15th: House Democrats Begin Final Push on Healthcare as Pressures Intensify
March 14th: Democrats lack votes to pass healthcare bill, but White House confident
March 13th: Obama delays Asia trip to push healthcare overhaul
March 12th: Middle East peace efforts: lessons from healthcare reform
March 11th: Democrats Edge Nearer Agreement on Final Healthcare Package, but Obstacles Remain
March 10th: Panel on Compromises to Pass Health Care; What's Next in Afghanistan?
March 9th: Abortion could stymie healthcare reform legislation
March 8th: Obama adds fire to healthcare debate
March 7th: Anthem a boon to Obama's healthcare efforts
March 6th: Obama: Congress 'Must Act Now' On Health Care Bill
March 5th: Obama's Health Care Push: The Race is On
March 4th: Pressure mounts for/against healthcare bill

It's clear that a casual observation of the daily news will not teach you much about the bill itself, only about its status. As the NPR reporter quipped "news is what's new". A good reason to continue to support long-form journalism like The New Yorker!


Two other good links from the comments
  • Impressive RAND study conducted from 1971 and 1982 about "cost sharing" and health care effectiveness
  • Paul Fromer talk on "Charter Cities", a radical call for experimental governments.

3/12/2010

The Healthcare Diff

On November 7, 2009 the House narrowly passed its health care bill. On December 24th the Senate passed their own version. Today several months later a "reconciliation" between the two is in progress, the final version is expected "soon".

It is a wonder of the modern age that you can pull up the full text of either bill with a single click. Each is a relatively small file, much smaller than a YouTube video. Here is the 1990 page House bill or the 2074 page Senate bill.

Of course having access to the text is one thing, understanding it is another matter. Aside from the flowery and confusing prose in general certain passages stand out as particularly opaque. Consider this gem on page 876 of the Senate bill:



The reason this is hard to read is that it doesn't stand alone. It is a change to existing legislation, in this case the Social Security Act. You need to look up the passage is question and manually apply the changes.

A software person immediately recognizes this as a "diff". A diff in software is a "difference report", a listing of differences between two versions of a program. Programmers live and breathe diffs, they are both routine and essential.

The style of diffs in these bills manages to be both verbose and cryptic. It is a surgical description of the exact change with zero context. Compare this with a software-style diff of the same change:



Here we plainly see two lines are going away and are being replaced by 4 new ones. This already is much clearer than the bill. Clearer still is a graphical diff which shows the changes side-by-side:


Click above image to enlarge.

Even if the bills replaced their cryptic diffs with beautiful graphical ones, there would still be a big problem. The changes represented by these bills are completely untested.

Programmers "branch" when making big changes. They create two whole copies of the software. Changes can be applied to the branch without harming the main version. If the branch proves to be successful, after extensive testing, the branched version can be "rolled back" into the main version.

Or consider Google. Google handles hundreds of millions of searches every day. But not everyone is treated equally. With every search there is a small probability you will be part of an experiment. Google runs hundreds of experiments simultaneously. Some are minor variations like a different font or color, while some are major and return completely different search results.

Google never bugs you with a survey for feedback, they simply collect data about what results you click on or the timing and pattern of your follow-on queries. The results of the experiments are used to improve the service, which generates every more people to use in future experiments.

Our approach to legislation is that we don't branch and we don't experiment. We fight and argue and cook up a giant legislation-bomb where half the people think it will work and half think it will be a complete disaster, then we just try it out.

Instead of arguing over the one true solution on the basis of hunches and intuition, we should implement more than one approach. Pick the best 2 or best 5 solutions and try them all. We have 307M people in this country, they could be generating and enormous stream of empirical data about what works and what doesn't. Statisticians could be poring over patient satisfaction surveys, hospital expense reports, bankruptcy rates. Find out what settings on the knobs actually solve the problem instead of just winging it.

The early internet developers shunned hammering out agreements in detail, instead they valued "rough consensus and running code". Ship early, iterate often.