Friday, August 14, 2009

Healthcare Reform, Part One: The Self-Licking Ice Cream Cone

OV-099, the United States space shuttle Challenger disintegrated seventy-one seconds after launch on the morning of January 28, 1986.

I was living in Spain at the time.  It was a long, long time ago now, but I remember it like it was yesterday.

My friend and and occasional Stonekettle Station commenter, Beastly (AKA Senior Chief Shawn Riley, USN, Ret), and I were in the base galley at Rota, having dinner prior to going on watch, when news of the unfolding disaster came on the TV. In those days, in Spain as American servicemen, if you wanted to see American news broadcasting you had to go to base and watch the Armed Forces Radio/TV System (AFRTS, pronounced Aay-Farts), usually it was a day late but it was better than nothing.  So we’d eat dinner in the galley on base once or twice a week in order to see the news. 

I remember being stunned at the magnitude of the disaster.  I still have copies of the pictures and news clippings from that day.  I remember being outraged at the TV reporters who swung their cameras over onto Krista McAuliffe’s parents, gaping in horror and disbelieving shock as their daughter and her six shipmates fell more than seven flaming miles to certain death when what was left of their magnificent ship impacted in the Atlantic.  I thought then that those images, the ones of Ed and Grace Corrigan watching their daughter die, were one of the most despicable and obscene things I’d ever witnessed. I still do.

But the greater obscenity came over a year later when the cause of the accident was made public.


Seventeen years later, almost to the day, on February 1st, 2003, I again stood far from home on a US Navy Base and watched seven American astronauts die.

This time I was in Bahrain, on a brief liberty from the brewing conflict in Iraq. I’d gotten a pizza and coke and was sitting in the phone center, just enjoying the smell of real food and the warmth of the box in my hands. I was waiting for my turn to call my wife and son in distant California and let them know I was still alive and mostly whole. Once again there was a TV broadcasting AFRTN (now a network instead of a system, ruining the traditional pronunciation). And once again, flaming pieces of spacecraft fell like meteors from the sky. This time it was OV-102, Columbia, disintegrating during atmospheric reentry upon its return to Earth after two weeks in space.  It seemed like hours, my dinner grew cold and lay uneaten and unremembered in my lap, My shipmates and I, men who only moments before had been raucously celebrating just being alive and out of the conflict if only for a moment, watched as constellations of shooting stars that had once been men and yet another magnificent machine fell to earth at more than eighteen times the speed of sound.

The pictures were eerily similar to the Challenger disaster nearly two decades before. This was how spaceships died. This was how dreams died. This was how astronauts died.  As shooting stars on CNN.

And once again, the true obscenity of the disaster didn’t become fully apparent until the cause was made public many months later.


Neither disaster was an accident.

Oh, the loss of both ships were called accidents, but those tragedies were anything but accidental.

The loss of both the Challenger and the Columbia, the loss of fourteen average and yet extraordinary human beings, and the loss of our dreams and nearly the manned American space program were all caused by the same malignancy. 

Both disasters had exactly the same cause.

The morning Challenger made her final fateful launch was a crisp cold Florida winter day. The coldest ever for a shuttle launch.  You, of course, know what happened, either because like me you lived through it or because you googled it just now. The O-rings sealing hot exhaust gases inside the Solid Rocket Boosters became less flexible, much less flexible actually, because of the twenty degree temperatures on the launch pad. At booster ignition the frozen gaskets failed to seal between the bottom sections of the right SRB.  Seventy-one seconds later, moving at a speed of nearly Mach 2 and 46,000 feet up, the joint failed.  A blowtorch of flame burned through the shuttle’s enormous external fuel tank, the SRB lower attachment struts failed, the booster began to pivot driving the vehicle off course, and load stresses in excess of 20g caused the shuttle to disintegrate. The External tank ruptured in a cloud of hydrogen and oxygen, which mixed and then flashed into an enormous ball of flame (it’s a common myth that the Challenger exploded, it didn’t. Instead it was torn apart by aerodynamic forces, by the time the fuel exploded the shuttle had already been destroyed).  The boosters ripped loose from the disintegrating spaceship and streaked away - and were destroyed by the Range Safety Officer.

Columbia was also destroyed by cold.  Indirectly, to be sure.  A piece of foam used to insulate the cryogenic cold of the shuttle’s liquid hydrogen fuel fell from the external tank during launch and punched a hole in the leading edge of the ship’s left wing.  During reentry, star hot plasma from the shuttle’s Mach 18 plunge through Earth’s atmosphere tore through that hole and entered the structure of the ship itself.  The commander, Colonel Rick Husband, and ground controllers monitoring the ship’s telemetry had less than a second to realize what was happening before the maelstrom blasted apart the internal structure of the wing. The wing ripped off and the ship tumbled and again the incredible aerodynamic stresses ripped the ship to pieces in a millisecond. The crew died without even knowing that they were in trouble.

Do you see it?

No, the common factor is not the cold, or aerodynamic stress.  One ship was destroyed during launch, one returning to Earth. One was destroyed by failing gaskets, one by falling foam.

On the surface it would appear that my statement above alluding to a common cause is simply Palinesque raving.

But it’s not.

See, I didn’t tell you the whole story.  I left something out.

In both cases, the disaster was predicted by experts. By rocket scientists, if you will. 

The night before Challenger made that fateful leap into the sky, the lead engineers for Morton-Thiokol, the men who designed and built the Solid Rocket Boosters - and analyzed them after they returned to earth - told their bosses that they were opposed to the launch. They saw that every time the launch temperatures were low, the gaskets leaked. Only the redundancy of the system had prevented disaster so far.  They predicted that the O-rings would fail completely in the record low temperatures of that morning, and in fact they expected the boosters to explode on the launch pad. They presented charts and data and spoke passionately, and they convinced Morton-Thiokol managers to give a no-launch recommendation to NASA.  NASA administrators were outraged, even though this was the first no-launch recommendation given by Morton-Thiokol in twelve years of shuttle flight. A high level NASA official said he was “appalled” by such a recommendation.  There was talk of monetary penalties and negative publicity and scapegoating and blame laying. There were threats about future contracts. NASA was under pressure to launch the first teacher into space and by God that’s what was going to happen. But the engineers, led by Roger Boisjoly, one of the foremost experts on Solid Rocket Boosters, stood firm in their opposition.  Nevertheless, Thiokol managers capitulated to NASA’s bullying and rescinded their objection and the engineers’ worst fears were realized.

Seventeen years later, senior NASA engineers found themselves in exactly the same situation.  Analysis of the launch videos showed foam striking Columbia’s fragile wings. The engineers were deeply concerned. They were afraid that the ship’s heat shielding might have been holed.  They went to the administrators and asked that certain available military photosats be redirected to take high resolution images of Columbia in orbit.  They asked the administrators to alter the mission schedule and have the astronauts themselves inspect the wing, either with the robotic arm or by direct inspection via spacewalk.  The administrators refused. They justified their decision by reasoning that even if the ship was breached, there was nothing that could be done, therefore there was neither reason to panic the astronauts and the public or spend scare funds in the redirection of military satellites. They didn’t want to raise undue fuss – but more than anything what mattered to the administrators in that moment was keeping the engineers in their place. In an organization dedicated to the quest for knowledge, those with the greatest knowledge are second class citizens.

In both cases the ships were lost – specifically because professional administrators who lacked detailed technical training and a working engineering expertise in a highly specialized and complex field of endeavor were allowed drive the process.  Those administrators deliberately ignored the warnings and recommendations of people who were experts, the foremost experts in the world in fact.  The NASA administrators placed schedules and procedures and red tape and bureaucracy and personal desires and their careers and profit above their duty, above the lives they were entrusted to protect, above moral and ethical action. Both disasters were preventable. But the climate of risk, the climate of profit over duty, the climate of good-enough and bullet-dodging fostered by poor and selfish leadership led directly and inevitably to both disasters.

The decisions of those bean counters directly killed fourteen people and cost this country hundreds of billions.

The manned spaceflight portion of NASA has become an organization run almost entirely by bean counters, administrators, hanger-ons. Red tape and bureaucracy are the norm. Those who build and fly the ships have very little to do with the decision making process.  It is inevitable that in such an organization, those with the technical knowledge, the scientists and the engineers and the astronauts and technicians, would be separated from the decision making process – they are a direct threat to the professional administrators.

NASA is not unique in this regard.

Great businesses and financial institutions are often built by people of vision and technical knowledge – as NASA was.  But come back a couple of generations later, and you’ll find damned few engineers in the front office. Nowadays, the once mighty American industries are captained by professional administrators, MBA’s and bean counters with little or no technical knowledge and no interest in gaining any. A key indicator of this malady is the term “product.”  Professional administrators refer to a company’s output as product. To them it is the same whether the company is making a box of turkey franks or a Prius Hybrid or flying to Mars.

It’s all part of a set piece.

Which takes us, as promised, to healthcare reform.

Those arguing most strenuously against healthcare reform are the professional administrators.  These are the same folks who have taken over healthcare and worked diligently to remove the medical experts from the decision making loop.  How many hospital administrators are doctors?  How many Insurance company CEO’s are doctors? How many insurance company claims adjustors have a formal working knowledge of medicine?  How many politicians currently fighting reform are medical professionals? 

There’s a reason for this.

NASA has become a hidebound, administrator heavy organization. No real remake of the agency is possible without changing this fact.  As long as the technical experts have no power and are regarded with contempt, NASA will continue to kill astronauts and lose spacecraft. It is inevitable.

As long as the basic organizational structure of Wall Street remains unchanged, as long as the professional CEOs are running the show, the underlying causes of the recent financial collapse remain a very real threat.  Another boom and bubble and bust is inevitable. The names change, Dot Com, Junk Bond, Interest Only Mortgage – but the end result is always the same.

As long as the auto industry remains under the control of professional administrators and refuses to change how they do business – eventual extinction is inevitable, no matter how much money you pump into them.

And as long as the current healthcare system remains in its present form, under the control professional administrators, under control of for-profit insurance companies in a de facto monopoly, under control of bean counters who have nothing whatsoever to do with healthcare – nothing will change.  There is absolutely no incentive for it to change. 

The insurance companies complain about the cost of healthcare, but they are the principle reason that the costs are so high.

Let me give you an example:  A couple of months back, I sliced my hand open with a wood chisel in my workshop.  I nicked an artery.  I was bleeding profusely.  I wrapped the damaged finger in gaze and called my wife to drive me to the hospital.  As to medical care, we had several choices – we live about ten miles from MatSu Regional and their Emergency Room.  But we also live only about three miles from the Palmer Urgent Care Clinic. The hospital is down a long winding dangerous road, the clinic is a much easier and quicker trip.  The emergency room is crowded and at least three times as costly. I was bleeding badly, but I just needed some stitches.  We went to the clinic and I got sewed up by an LPN.

I’m covered by no less than three insurance companies.  All refused to pay the roughly $600 dollar bill in full. Instead one insurance company paid $12, the other paid $150 or so. Leaving me with a $400 tab. The reason?  I didn’t go to the emergency room.  They would have paid for the emergency room visit in full – and paid anywhere from $1500 to $3000 depending on a number of factors.  I appealed the claim, it’s being reprocessed now – but I was admonished to go to the emergency room in the future, not the nearest healthcare facility (which, by the way, takes all of my insurance and regularly sees me and for whom the insurance companies would have paid in full for an “office” visit).  The difference being a technicality – the clinic is Urgent Care and I had an emergency care situation, never mind the fact that no matter which facility I went to, including if I’d chosen to drive 60 miles into Anchorage to the base hospital or the VA hospital or the civilian Providence Hospital emergency room – the treatment is exactly the same, ten stitches - which could be put in by a nurse practitioner or a physician’s assistant or a highly trained emergency room physician who should have been treating somebody much worse off than me. 

The insurance companies demand that I utilize the most expensive option. Period. The insurance companies demand that I tie up a highly trained and specialized and scarce emergency room doctor when an LPN will do.  Period. Or I will be punished to the tune of $400.

The insurance companies give me no choice whatsoever.  Their rules shall not be violated.

Those who so self-righteously claim that they have a right to chose under the current system are deluded fools – the only thing they’ve chosen is the name of their dictator.

There is no conceivable reason for this nonsense. It is not deliberate malice on the part of the insurance company.  It is not greed – obviously. It is the inevitable result of the professional administrator, of bureaucracy, and bean counters and people who make rules and decisions solely to prove their power in the organization. Somewhere behind this rule is a web of shadowy fuzzy logic that appears sound (what if he gets to the clinic and they can’t help him and then he has to go to the emergency room anyway? Now we have to pay for both visits and an ambulance to boot. What if we find a hole in the wing? What then?) until it is examined closely. This is the result of administrivia. Of bean counter bloat. Of petty little people who have no real skill, who are not experts, who are not doctors or nurses or medical professionals, and who make rules and regulations and procedures and adjudications and adjustments because that is what they do.

This, more than anything else, is why healthcare costs you so goddamned much.

You can’t legislate it away.

Not directly anyway.

But what you can do is create an environment of competition.

See, right now there is no competition. Not in healthcare insurance.  All other forms of insurance you can shop around, you can buy individually – but not health insurance. For some reason that’s special, or so we’re told.  I wrecked my truck, my auto insurance company paid me the blue book value three days later, no bullshit, no adjuster telling me that the drunk driver who hit me head on was a pre-existing condition, no problem. I didn’t need two insurers, both of which decide not to pay what they are contracted for and instead hide behind treatment codes and the definition of Urgent vs Emergency.   And there is a wide variety in auto insurance, and different coverage plans, and choices of deductibles and premiums. But, not in health insurance. And why not?

Because health insurance has become a self-licking ice cream cone that exists primarily to keep existing. It consumes resources and excretes waste, sometimes it’s a symbiote - but more often it’s a parasite. You can’t fix it. Attempting to do so, will only increase the number of administrators and make the situation worse.

But by creating a public option, a federally run healthcare option with fixed costs that anybody can access, you force the health insurance industry to fix itself.  It will have to.  It will have to make itself more attractive to the average Joe than the “free” government option. There are many many ways to do this.  Ideally what you’d end up with is something that looks a lot like the choices you have with cell phone plans nowadays (Anybody want to guess what those would look like if Ma Bell was still the only telephone provider in the United States? And what they would cost?).

Those who oppose a public health care plan bloviate endlessly about socialism.

But they are wrong.

Done right, a national healthcare plan would force the industry to adopt a truly capitalist system for the first time.

There are, of course, dangers.

We’ll talk about those tomorrow, in part two of this post.


  1. Administrators. The culture has come to be that anyone with an MBA can manage anything (even with no experience), that theory trumps practice in every case.

    Not all professionals are any good as managers [personal anecdote deleted], but this development of a managerial/administrative class, and the primacy of the bottom line, is most definitely not the correct solution.

    The two major symptoms as far as I can see are the creation of inflexible regulations and the emphasis on measuring success by easily quantifiable metrics regardless of their actual relevance.

  2. Except for the NASA example, that's exactly the argument I made to my Senators to keep the Public Option.

  3. Great post, Jim. You "nailed" this one.

  4. I agree, well said. I haven't been able to formulate a post on this topic because I just sit at the key board and foam at the mouth when I contemplate insurance companies and the torture it is to get them to agree to testing and/or treatment for patients. It blows chunks from this side of the fence too.

    Back when I was burning out in my prior job, I would say that I wanted to go work for an insurance company. The job would be easy -- I would be given a red stamp that says "NO!", and I'd be all set.

  5. I am not invalidating your central point (which I think is absolutely 100% correct) but the Challenger disaster isn't as cut and dried as you make it sound. Edward Tufte has a great presentation on exactly *how* the dangers were presented to NASA and how poorly they were communicated to administrators making the decisions. In reading the PowerPoint it was literally impossible to decipher that there was a problem - and obviously the verbal component of the presentation was not enough.

    of course that statement "administrators making the decisions" is your central issue

  6. Mark,

    I am, in fact, a student of Professor Tufte's and a graduate of his course. I attended his classes as part of my advanced Intelligence/Information Warfare training.

    I'm sitting about three feet from three of his signed books and actually have Visual Explanations open to the Challenger chapter next to me on the desk.

    I did indeed simplify his analysis for this post - because I didn't want this to be a discussion of the the Challenger accident. You are correct in that that Boisjoly's presentation didn't convince the managers. But that's really my whole point - NASA and Morton-Thiokol employed those people because they were experts, the experts. This is true in any walk of life: I depend on experts to assure me that the LHC isn't going to spawn world destroying black holes. You can show me the math all day, I won't understand it. I don't have the education. But if Stephen Hawking says we're good, I'm going to believe him because he's Stephen Hawking. If he says, wait, don't turn that thing on, I'm going to start getting concerned. Even if the managers didn't understand the engineering - they still should have listened to the engineers, that's what they paid them for.

    Tufte's argument is that the engineers should have made a better presentation, and the professor and I went around on this when I was in his class. My argument is that the managers shouldn't have been in charge in the first place - specifically in matters of safety and engineering, they weren't qualified. Hell, they weren't even qualified to understand a layman's explanation. In a dangerous endeavor such as manned spaceflight those with the go/no-go authority should ONLY be astronauts - and in this case the ultimate authority for launch should be solely in the hands of the mission commander. Dick Scobee should have been fully briefed as to the status of his ship and the specific Operational Risk Management conditions present that morning, and then made the decision. Same with Columbia. As long as non-experts have the power to make life and death decisions based on highly technical situations we're saying that a highly trained specialist like Commander Scobee is the same when it comes to flight decisions as some accountant. This is obviously wrong. Provably wrong. Demonstratively wrong as both the Challenger and Columbia accidents show.

    I see this as a metaphor for the the healthcare debate. When an MBA or a claims adjuster or an accountant or an insurance company CEO can change your perscription, can determine your medical treatment protocol, can determine what specialists you see - then you have the same situation. The experts, i.e. the Doctors, aren't in charge of the treatment. The decisions of the non-experts are given more weight than the medical experts. This is just as foolish and in the long run has killed ten thousand times more people than the NASA administers have.

    If I've got cancer, I want to see a doctor, not Bob the CPA.

  7. A nicely worded revelation Jim, I couldn't agree more!


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