BEIR VII, cancer drugs, cancer risk, child-care, cost benefit, dose coefficient, drug costs, elder care, health care, health care costs, ICRP, INWORKS, life shortening cancers, major hazard management, medical care, NRC, nuclear accident, nuclear effluents, nuclear industry, nuclear power, nuclear workers study, pharmaceutical industry, radiation and cancer risks, regulatory con game, risk coefficient, risk management, US NRC, value of death, value of life, value of statistical life
Reassessment of NRC’s Dollar Per Person-Rem Conversion Factor Policy Docket ID: NRC-2015-0063Agency: Nuclear Regulatory Commission (NRC) http://www.regulations.gov/#!docketDetail;D=NRC-2015-0063
This comment deadline, of November 3rd, 11.59 PM, is but the opening salvo of another life and death battle between the nuclear industry and the public, in the war over the people’s health vs the profits of nuclear utilities-nuclear industry. The deadline near All Hallows’, All Saints and All Souls/traditional days of the dead/death of the year, could not be more appropriate. [The comment deadline is over, but the information remains useful.]
The USNRC pretends to be updating its value of statistical life to $9 million to look good, but it’s not really doing it. What they pretend is $9 million is actually $5 million, and perhaps as low as $500,000 (or less). Plus it doesn’t apply for some things, and appears to lack legally binding teeth. Any improvement, of course, is better than no improvement. But, they are still playing their usual sleazy tricks. It is more trick than treat. And, it is important for honest citizens to learn how such con games are run. After suffering through the NRC document, one learns that their recommendations apparently have no regulatory teeth, and there are the usual exceptions and exemptions. It could, however, lead to legally binding recommendations, in time. Even the original legal rule itself has loopholes.
Currently the USNRC formula uses $1,000 per person rem (10 mSv) value of exposure avoided in cost-benefit considerations (note that the benefits only fall to the utility and stock owners). Using BEIR VII risk estimates, this is $1 million per excess cancer avoided. Based on the new INWORKS study, the risk appears ten times or more higher, and thus the value of life, using this $1,000 becomes only $100,000.
According to BEIR VII, for those who die, the life-shortening effects are on the order of 14 to 15 years. Currently the average monthly cost of new cancer medications, according to Memorial Sloane-Kettering, is around $10,000 per month (median), which is $120,000 per year, and thus $1.8 million for 15 years, if the prices don’t rise, but the prices have been rising and rapidly so. This is cost of medication alone, and excludes the cost of doctors, hospitals, and social or financial cost of caregivers for the ill, and lost of “free” caregivers for children and the elderly, by loss of those who are middle aged, through illness and/or death. In short, it excludes value of work done, whether paid or unpaid. Women are disproportionately impacted by radiation induced cancers, as well, and women as a whole do much of the unpaid work, which allows continuing functioning of a household, and without which there may be need for hiring a maid. Already the high cancer drug prices are being decried, even by some with ties to big pharma, it’s so bad. Life-boat ethics is kicking in. For instance, some cancer drugs are unavailable in the UK Public Health System due to high price and cost-cutting (even while they, like the US, find money to subsidize the mostly foreign nuclear industry). Even where people have private insurance, there are limitations in coverage; bankruptcy may have to be declared, and the taxpayer most likely picks up cost (or the person doesn’t get the needed care). Even the IMF considers medical costs from pollution an unfair subsidy to the energy sector, which should be factored in, and they have pointed this out repeatedly. http://www.imf.org/external/pubs/ft/survey/so/2015/NEW070215A.htm
While the NRC pretends otherwise, the figure they are using is only estimated cancer death rates. Cancer rates are almost double. Cancer is not simply an individual problem, but has heavy social and economic costs to society as a whole. And, cancer is not the only radiation induced health problem, either.
Instead of using the US government’s BEIR VII, the NRC seems to be using the international pro-radiation ICRP “standard”, or more dated information. Between 1991 and 2007 the ICRP actually reduced “detriment”, even though research has shown that radiation hazard is worse than previously thought. It appears impossible to sort out the mumbo jumbo of the supposed difference in the 1991 and 2007 ICRP. Just before BEIR VII was completed in 2005, a 15 country study of nuclear workers was published, which showed that the cancer risks were much higher than stated in the BEIR report. In an Appendix, BEIR VII says that they did not have time to take it into consideration. Additionally, there is a very recent 3 country INWORKS study of nuclear workers, which suggests that excess cancer rates from ionizing radiation are around 10 times higher than concluded by the BEIR report. Frighteningly, this appears a middle of the road number, which sits between BEIR VII and the 15 country INWORKS study.
Following BEIR VII, the person rem value of statistical life, based on the NRC’s $1,000, is only $1,000,000, if you take into consideration both average risk of cancer and risk of death. But, it gets worse. There is currently a “recommendation” on NRC books that the value of life be $3,000,000, which by using a low risk coefficient (death only though they allege otherwise) and rounding down gives them $2,000 (under BEIR VII this would be $2,000,000).
However, they have yet another trick up their sleeves! They have decided that they will discount this $2,000 backwards from the date of an accident (which is unknown!). They discount backwards uses a 7% discount rate (See NUREG/BR-0184). Can anyone even recall when interest rates were 7%? This is one argument against discount. But, it is more logical for the amount to be compounded forward, rather than discounted backwards.
Over the course of 25 years, which they use in an example in NUREG/BR-0184, pp. B-3 to B-4, this would reduce the $2,000 to $368. This then reduces the value of life to $368,000, which with 15 years of life lost is $24,533 per year-significantly under average earnings of $45,000. And, for 10 years of cancer treatment, and possible inability to work, would be a mere $36,800 per year. Pro-nuclear MIT said the price of life-extending drugs is currently $207,000 per additional year of life. (Memorial Sloane Kettering put the figure at $10,000 per month). Who pays the difference? And, this MIT study says that cancer drug prices are increasing by 10% per year, even adjusting for inflation.
According to pro-nuclear MIT:
“Since 1995, a group of 58 leading cancer drugs has increased in price by 10 percent annually, even when adjusted for inflation and incremental health benefits, the study finds. More specifically, in 1995, cancer drugs in this group cost about $54,100 for each year of life they were estimated to add; by 2013, such drugs cost about $207,000 per each additional year of life.” http://news.mit.edu/2015/cancer-drug-prices-rise-10-percent-annually-0318
Would $9 million even be sufficient? BEIR VII estimates that radiation-induced deaths are life-shortening by 14 to 15 years. Pro-nuclear MIT puts the 2013 price of life-extending cancer drugs at $207,000 per additional year of life. That puts us up to $3,105,000 already for 15 years of life-extending cancer drugs if the cost of the medications didn’t rise, but the cost is, and rapidly so.
With 10% increase in drug cost per year, if your cancer takes 10 years to declare itself, the first year cost of cancer medication (only) would be $536,905 and by between the 10th and 11th year you would have exceeded the $9 million. We will let you keep calculating to estimate the cost of 15 years of medicine, or how much the medicine would cost if a cancer declares itself in 25 years and there are 15 years of treatment. Even if the $536,905 figure didn’t increase further, 15 years of treatment would still cost over $8 million.
So, clearly this would exceed the $9 million, but this is only cost of drugs. There is nothing included for surgery, doctor bills, caregivers, loss of non-paid activities (care of parents and grandchildren, housekeeping, which someone will then have to pay for.) There is nothing included for other radiation induced diseases such as cataracts, and cataract surgery.
How many of the approximately half that would die due to radiation could be saved by the right drugs, but will not due to cost?
“The changes in the real median earnings of men and women who worked full time, year- round between 2013 and 2014 were not statistically significant. In 2014, the median earnings of women who worked full time, year-round ($39,621) was 79 percent of that for men working full time, year-round ($50,383) ─ not statistically different from the 2013 ratio.”
If we average this as $45,000 then, on average, $675,000 of earnings will have been lost. Of course, the way the life-shortening works, people will probably die around retirement age. However, many poorer people continue to work into retirement.
They claim to consider “Human Capital”, but appear not to have. Furthermore, the value of life of older, educated, experienced people is less, according to the NRC, because they are already more likely to get cancer due to age!
“Human capital is the stock of knowledge, habits, social and personality attributes, including creativity, embodied in the ability to perform labor so as to produce economic value.
Alternatively, Human capital is a collection of resources—all the knowledge, talents, skills, abilities, experience, intelligence, training, judgment, and wisdom possessed individually and collectively by individuals in a population. These resources are the total capacity of the people that represents a form of wealth which can be directed to accomplish the goals of the nation or state or a portion thereof.
It is an aggregate economic view of the human being acting within economies, which is an attempt to capture the social, biological, cultural and psychological complexity as they interact in explicit and/or economic transactions. Many theories explicitly connect investment in human capital development to education, and the role of human capital in economic development, productivity growth, and innovation has frequently been cited as a justification for government subsidies for education and job skills training ” https://en.wikipedia.org/wiki/Human_capital
Their Draft Report for Comment provides a good primer for the tricks used by the NRC to help the nuclear industry to avoid financial liability.
From: “Reassessment of NRC’s Dollar Per Person-Rem Conversion Factor
Policy Draft Report for Comment
Office of Nuclear Reactor Regulation
NUREG-1530, Rev. 1
[Our Annotations in brackets. Emphasis added.]
p. iii: “ABSTRACT
This proposed revision to NUREG-1530, “Reassessment of NRC’s Dollar per Person-Rem Conversion Factor Policy,” revises the dollar per person-rem conversion factor (NRC, 1995a). NUREG-1530 was initially published in December 1995.” [person-rem used to be called man-rem and is 10 mSv] “The U.S. Nuclear Regulatory Commission (NRC) uses the dollar per person-rem conversion in cost-benefit analyses to determine the monetary valuation of the consequences associated with radiological exposure and establishes this factor by multiplying a value of a statistical life coefficient by a nominal risk coefficient.. [They choose to use the ICRP rather than the US government’s own taxpayer funded National Academy of Sciences BEIR VII, which estimates a higher risk for cancer only. Choosing the ICRP risk coefficient, rather than BEIR, is one way they are lowballing cost. The ICRP has actually reduced its risk coefficient, for reasons which are unclear. Two international studies of nuclear workers, funded largely by pro-nuclear entities, show that cancer risks are greater than previously believed.] “The 1995 version of NUREG-1530 set the dollar per-person rem value at $2,000. This number resulted from the multiplication of the value of a statistical life ($3 million) by the risk coefficient for stochastic health effects (7.3 x 10-4 per person-rem)“. [The risk coefficient is thus 0.00073. They round down from $2190. If they used BEIR VII estimates for excess cancer risks they would have to use $3,000, or state that the value is $2 million. The BEIR VII excess cancer risk is 0.001 per rem (10mSv). This excludes other diseases, and other impacts. The recent INWORKS study appears to give an excess cancer risk of around 0.01 per person rem.] “NUREG-1530 instructs the staff to round the dollar per person-rem conversion factor to the nearest $1,000 value.“[Not only have they low balled by using ICRP for risk conversion, but later in the document they pretend that this applies to the year of the accident and apply a discount rate! This reduces the amount to $368, if they decide that the accident will occur 25 years in the future! This makes the value of life only $36,800, using BEIR VII risk. Thus, they are claiming $2 or $3 million and it may be $36,800 or less. Perhaps as low as $3,680 or lower!] “This revision to NUREG-1530 makes five changes to the previous version. First, it updates the dollar per person-rem conversion factor to $5,100 per person-rem “[They don’t explain if they use the discount on this or not. However, it is only $5.1 million in the best case scenario.] “The value is based on an updated value of a statistical life of $9.0 million and a nominal risk coefficient factor of 5.7 x 10-4 per person-rem” [Notice they REDUCED the dose coefficient, even though they increased the supposed value of statistical life. Using BEIR VII excess cancer risk estimates, the number would need to be $9,000 for cancer risk only. This excludes other radiation induced health conditions, such as cataracts, damage to offspring, etc. Using the new study which suggests the excess cancer risks are 10 times higher than BEIR means that the number would need to be $90,000 to really be $9 million]. “Second, it uses low and high estimates of a statistical life value instead of a single value. Third, it directs the staff to round the conversion factor to two significant figures instead of simply rounding to the nearest $1,000 value. Fourth, it establishes a method for keeping the dollar per person-rem conversion factor current. Finally, it provides guidance to the staff on when to use a higher dollar per person-rem conversion factor.” [Later in the text, it becomes clear that if people are older, then they have more of a risk of getting cancer anyway, and thus they can be put near nuclear facilities, and it counts as less risk! Expect your retirement home next to a nuclear facility, if you don’t act now, and if you live that long! Your genetics may mean you should live to 100 or 104, for instance, and if the nuclear industry shortens your life by 14 to 15 years with what BEIR VII calls a “life-shortening” cancer, then you will slip under the radar because your death will be around current “average” age. This average age will be dropping soon if nothing is done to stop these monsters.]
“1 The International Commission on Radiological Protection defines nominal risk coefficient as the “sex-averaged and age-at-exposure-averaged lifetime risk estimates for a representative population.” This coefficient combines the cancer risks and heritable risks from radiation exposure (ICRP, 2007)“. [They allege this but it is untrue!]
“2 In order to be consistent with the Commission’s policy on metrication (57 FR 46202), the conversion factor should be expressed in dollars per person-sievert (Sv) with the value in English units following parenthetically. Note that a sievert (Sv) is equal to 100 rem. Therefore, for example, $2,000 per person-rem is equal to $200,000 per person Sv. However, for purposes of continuity and to facilitate review, dollars per person-rem shall be the unit used throughout this report.
[Why are they reporting in Sieverts when exposure limit allowed by the USNRC and ICRP is reported in millisieverts? 1 mSv is the dose limit for the NRC and ICRP, but it is 0.25 mSv for the US EPA. They appear to prefer Rem and Sievert to millirem and millisievert to make it less precise and make it appear smaller.]
“3 Stochastic health effects refer to the likelihood that effects will occur from long-term, low-level exposure to radiation.”
[STOCHASTIC REFERS TO THE RANDOM NATURE OF RADIATION DAMAGE, WHICH MAY THEN LEAD TO LONG-TERM HEALTH IMPACTS. BECAUSE THE DAMAGE IS RANDOM, INCREASED EXPOSURE INCREASES RISK, JUST LIKE SOMEONE MAY BE KILLED BY A RANDOM BULLET BUT MORE LIKELY TO BE KILLED BY MANY.
ANOTHER MAJOR CON IS THAT THEY DO SURVEYS AND ASK HOW MUCH THE PERSON WOULD PAY TO REDUCE RISK. IT IS THE CORPORATIONS WHO SHOULD PAY – THESE ARE HUGE UTILITIES AND CORPORATIONS. AS IT STANDS, THE POPULATION WILL PAY EITHER THROUGH TAXES OR HIGHER INSURANCE PREMIUMS.]
For all activities regulated by the U.S. Nuclear Regulatory Commission (NRC), the Commission has the authority to require safety improvements necessary to ensure adequate protection of the health and safety of the public. The NRC uses various tools to determine whether a safety improvement is needed, including a cost-benefit analysis. The NRC’s cost-benefit analyses rely, in part, on monetizing the health detriment of radiation exposure. The NRC monetizes the total health detriment of radiation as dollars per person-rem of collective dose.” [As already noted, odds of death is far from total detriment. Furthermore, the benefit accrues to the nuclear utility-facility in the form of cost savings-profits, and the detriment falls on those who get no benefit.]
“For approximately the last two decades, the NRC has used a conversion factor of $2,000 per person-rem [10 mSv] as the monetary valuation of the consequences associated with radiological exposure. That is, an increase or decrease in person-rem is valued at $2,000 per person-rem in order to allow a quantitative comparison of the costs and benefits associated with a proposed regulatory decision.
This value has been used as a reference point in NRC regulatory analyses including those involving:
(1) routine liquid and gaseous effluent releases,
(2) accidental releases,
(3) Title 10 27 of the Code of Federal Regulations (10 CFR), Part 20, “Standards for Protection Against Radiation,” in dose minimization programs,
(4) backfit analyses, and
(5) environmental analyses.
The NRC prepares regulatory analyses for proposed actions that would impose requirements on NRC licensees. The analyses include an examination of the benefits and costs associated with alternative approaches to meeting the particular regulatory objectives. The NRC requires a regulatory analysis for a broad range of regulatory actions. In general, all mechanisms used by the staff to establish or communicate generic requirements, requests, or staff positions, that would effect a change in the use of resources by the licensees will include an accompanying regulatory analysis. These mechanisms include rules, bulletins, generic letters, regulatory guides, orders, standard review plans, branch technical positions, and standard technical specifications. The conclusions and recommendations included in a regulatory analysis are neither final nor binding, but rather are intended to improve decisions made by NRC managers and the Commission. Regulatory actions needed to ensure adequate protection of the health and safety of the public or the common defense and security from the operation of production and utilization facilities do not require a regulatory analysis. Thus the $2,000 per person-rem conversion factor does not apply to these actions, except in assessing alternative approaches to achieving adequate protection. The NRC has become aware of alternative estimates and methods for arriving at a conversion factor. In addition, the continued validity of the $2,000 per person-rem conversion factor has been questioned because estimates and bases for the value of a statistical life (VSL) and nominal risk coefficients are different since the NRC published NUREG-1530, “Reassessment 51 of NRC’s Dollar per Person-Rem Conversion Factor Policy,” in 1995 (NRC, 1995a). The NRC’s revision is based on the logic in which the new dollar per person-rem conversion factor attempts to capture a reasonable dollar value of the total health detriment resulting from radiation exposure.
Footnote”1 Total health detriment combines both mortality (e.g., fatal cancers) and morbidity effects (e.g., nonfatal cancers and hereditary effects).” [This is what ICRP alleges, but their numbers are not even in line with BEIR VII, and more recent research for cancer alone. It’s difficult to see how ICRP came up with this. It appears, in part, that they discount cancers from which individuals rarely die, while excluding healthcare costs. They also discount early miscarriages as unimportant, even as many couples pay large amounts for fertility treatment. Furthermore, ICRP clearly excludes health-care costs and costs to society in the form of loss of unpaid care-giving labor, and the added costs of paid care-giving. It remains shocking that the nuclear industry hasn’t been shut down strictly due to high health-care costs. France cracked down on smoking for this reason. The life-shortening effects of 14 to 15 years will first decimate the population most likely to provide free child care for grandchildren and free elder-care for their parents. This means that someone will have to pay for the child-care, elder-care, as well as those who would normally provide these services for free. This unpaid caregiving also includes cooking and cleaning. The figures given also appear to exclude lost earnings. ]
“2 See section 182(a) of the Atomic Energy Act, as amended, (AEA) and 10 CFR 50.109(a)(4)(ii).
p. 2 As such, the proposed dollar per person-rem factor considers the VSL and a nominal risk coefficient that establishes the nominal probability for stochastic health effects attributable to radiological exposure. The nominal risk coefficient takes into account fatal and nonfatal cancers and hereditary effects.” [ICRP alleges this is so. However, there is no clear explanation of why they have decreased their dose coefficient between 1991 and 2007, even while research has shown increased risk. Their risk coefficient is actually only accounting for cancer deaths, whatever they claim, and may seriously underestimate that, based on the 15 country study (2005) and 3 country study (2015) of nuclear workers!] “The resulting dollar per person-rem conversion factor is not applicable to deterministic health effects, including early fatalities, which would result from acute high doses to particular individuals. Thus, the conversion factor is compatible with the Commission’s reactor safety goal policy that states, “[t]he Commission wants to make clear that no death attributable to nuclear power plant operation will ever be ‘acceptable’ in the sense that the Commission would regard it as a routine or permissible event” (NRC, 1986).“[What liars they are.]
“3 Deterministic health effects in humans can result from general or localized tissue irradiation causing an amount of cell killing that cannot be compensated for by the proliferation of viable cells. The resulting loss of cells can cause severe and clinically detectable impairment of function in a tissue or organ (ICRP, 1991). [Yes, like death within days or weeks.]
“3 REGULATORY APPLICATIONS
The U.S. Nuclear Regulatory Commission (NRC) has applied the dollar per person-rem conversion factor in a variety of regulatory applications including the evaluation of routine effluent releases from nuclear power plants, accident releases, and radiation protection practices, as well as regulatory analyses, backfit analyses, and environmental analyses.” [THUS THE NUMBERS CHOSEN MATTER!]
“3.1 Routine Liquid and Gaseous Effluent Releases from Nuclear Power Plants
The dollar per person-rem conversion factor value appears in the NRC’s regulations only in 10 Title 10 of the Code of Federal Regulations (10 CFR) Part 50, “Domestic Licensing of 11 Production and Utilization Facilities,” Appendix I, “Numerical Guides for Design Objectives and Limiting Conditions for Operation to Meet the Criterion ‘As Low as is Reasonably Achievable’ for Radioactive Material in Light-Water-Cooled Nuclear Power Reactor Effluents,” (Section II, 14 Paragraph D) in a paragraph related to items to be included in a license applicant’s radioactive waste system. That regulation states, in part:
As an interim measure and until establishment and adoption of better values (or other appropriate criteria), the values $1,000 per total body man-rem and $1,000 per man-thyroid-rem (or such lesser values as may be demonstrated to be suitable in a particular case) shall be used in this cost-benefit analysis.
The conversion factor cited in this regulation has not been updated since the rule was promulgated in 1975 (NRC, 1975a). Since this conversion factor is a regulatory requirement, the staff and applicants have been using the $1,000 per total body man-rem and $1,000 per 25 man-thyroid-rem in their evaluations and not the $2,000 per person-rem of NUREG-1530 or 26 NUREG/BR-0058.” [Discounting the $2,000 can make it less than $1,000, unless they discount it too. Cost of living, wages, and health-care have increased a lot since 1975.]
“In designing radioactive waste processing systems, licensees and applicants are not required to install additional effluent controls to reduce routine effluent releases below 3 millirem per year for liquid effluents and 5 millirem per year for gaseous effluents if the cost of the resultant reduction in the population exposure within 50 miles of the reactor is greater than $1,000 per total body man-rem and $1,000 per man-thyroid-rem (NRC, 1975a).” [That is a total of 8 millirem per year or 0.08 mSv. This would allow exposure to 3 facilities without exceeding the 25 mrem (0.25 mSv) which is the US EPA’s current limit. It shows how astronomically high the 1 mSv limit approved by the ICRP and NRC is. Even the EPA number is comparatively high. This was 1975. Filtration options have increased and prices decreased (at least comparatively and possibly absolutely), over the course of 40 years. This should mean that it can be done better. And, why should these nuclear facilities leak at all? Much of the radiation stays in the environment forever! How about the plants and animals? Of course, they don’t count for anything under these rules. They can’t vote. Neither can children or future generations. This 0.08 mSv is actually the ALARA rule, which appears a sort of life insurance to protect against the low-ball value of human life. Nonetheless, even the ALARA rule has apparent loopholes. The nuclear industry clearly want ALARA gone, however. ICRP’s 1 mSv is supposed to assume possible exposure to multiple facilities, too, but is 12.5 times higher than ALARA. Then, of course, there is HOW the dose is calculated, which leaves room for manipulation. Extremely short-lived radiation can be, should be, and sometimes are, held and released as non-radioactive. However, intermediate and long-lived radionuclides continue to build up in the environment. And, even many short-lived radionuclides stay in the environment for extended periods of time. For instance, Iodine 131, half-life of 8 days, stays radioactive for months.]
“In considering the installation of additional radioactive waste processing equipment, licensees and applicants must include all items of reasonably demonstrated technology such that when added sequentially and in order of diminishing cost-benefit returns can effect reductions in population doses.”
“3.2 Accidental Releases
The dollar per person-rem conversion factor value is used frequently when accidental radiological releases are a consideration.” [In other words, if the value of life is low, then it helps nuclear facilities avoid upgrades to prevent a nuclear accidents-radiological emissions. It also means that the value of life of older people and those living in rural areas near nuclear reactors is less. The value of elderly living near nuclear reactors is the lowest of all.] “Accidental releases are factored into safety enhancement considerations. As discussed in the Handbook, when calculating accident-related attributes, the NRC staff draws from risk/reliability assessments or statistically-based analyses (NRC, 1997). As further discussed in the Regulatory Analyses and Backfit Analyses sections”
Footnote: “3 The NRC staff notes that the NRC staff and licensees shall use this conversion factor of $1,000 per total body man-rem and $1,000 per man-thyroid-rem for applying for design approvals for radioactive waste systems, and not the values discussed in this report.” [Thus, no regulatory teeth until the actual rule is changes?]
“4 The terminology for population dose was changed in the 1980’s from “man-rem” to “person-rem” to be more in line with societal expectations. They are equivalent for the purposes of radiological effects.” [Well, actually not really. Women are more at risk. A change in nomenclature is a poor substitute for safety considerations.]
“below, the NRC staff calculates the incremental change in public risk that would result from the proposed regulatory action and converts it to a dollar per person-rem value using discounted factors.” [And, if you go to the referenced text they really DO mean discounted! In other words, the $2,000 is the value at the time the accident is predicted! And, they discount backwards by 7% per year to the present time! Even by NRC standards this is mind-boggling and appalling!]
“3.3 10 CFR Part 20 ALARA Program
As required by 10 CFR 20.1101(b), licensees should make every reasonable effort to keep radiation exposures, and releases of radioactive materials, as low as is reasonably achievable (ALARA). This regulation applies to all NRC licensees and is concerned with the release of radioactive material and associated occupational and public dose incurred as a result of normal licensee activities. ALARA as defined at 10 CFR 20.1003, “Definitions,” means making every reasonable effort to maintain radiation exposure as far below the dose limits set forth in Part 20 as is practical, taking into account the current state of technology, the economics of improvements in relation to benefits to the public health and safety, and other societal and socioeconomic considerations, and the utilization of nuclear energy in the public interest. Given this definition, it would appear that a dollar per person-rem value should be an important factor in cost-benefit tradeoffs used in establishing reasonableness under the ALARA program.” [Cost benefit is illegitimate in this context because the cost falls on those who do not benefit!] “In this regard, the NRC is aware that current industry practice, particularly within power reactors, is to voluntarily value an averted person-rem at a higher dollar value owing to manpower constraints and other labor cost considerations that are integral to licensees’ cost-benefit tradeoffs.” [Here they may be referring to workers.] “Regulatory Guide (RG) 8.37, “ALARA Levels for Effluents from Materials Facilities,” advises materials licenses that they should consider engineering options to achieve ALARA goals in the release of effluents and that modifications should be implemented unless an analysis indicates that a substantial reduction in collective dose would not result or the costs are considered unreasonable. One basis for reasonableness identified in this regulatory guide is a quantitative cost-benefit analysis which requires the use of a dollar value per unit dose averted. RG 8.37 recommends the use of $1,000 per person-rem, and acknowledges that a wide range of values could be justified (NRC, 1993).” [ALARA undermined by fraudulent cost-benefit and fraudulent value of life. One cannot speak of cost benefit when the benefits go to the nuclear facilities-utilities and the costs are paid by the public! They are low-balling value of life, too.]
“3.4 Regulatory Analyses
NRC staff guidance for preparing regulatory analyses is discussed in NUREG/BR-0058, “Regulatory Analysis Guidelines of the U.S. Nuclear Regulatory Commission.” When preparing regulatory analyses, NUREG/BR-0058 instructs the NRC staff to use a conversion factor that can place all values and impacts (i.e. benefits and costs) on a common basis (NRC, 2004). NUREG/BR-0058, revision 4, discusses the policy concepts for regulatory analysis and instructs the NRC staff to use the dollar per person-rem conversion factor to calculate a common monetary value of radiation exposure. This value captures the health effects attributable to radiological exposure, and does not capture other consequences such as non-health impacts and offsite property damage (NRC, 2004). NUREG/BR-0184 translates the policy concepts in NUREG/BR-0058 into six steps for preparing regulatory analysis into implementable methodologies for the analyst. NUREG/BR-0184 instructs the staff to use the $2,000 per person-rem value for the year in which the exposure is expected to occur and then discounted to present value for purposes of evaluating benefits and costs (NRC, 1997). [This is where their numbers become even more ridiculous. According to a chart in NUREG/BR-0184, over a 25 year period they would reduce the $2,000 to $368, which as noted above, gives a value of life of $368,000, and maybe as low as $36,800 or less!. This is outrageous! It remains unclear if this discount will be used for the proposed $5,000.]
“3.5 Backfit Analyses
Backfitting is defined by 10 CFR 50.109(a)(1) as the modification of or addition to systems, structures, components, or design of a facility; or the design approval or manufacturing license for a facility; or the procedures or organization required to design, construct or operate a facility; any of which may result from a new or amended provision in the Commission’s regulations or the imposition of a regulatory staff position interpreting the Commission’s regulations that is either new or different from a previously applicable staff position. Except as required under 10 CFR 50.109(a)(4), NRC regulations require backfitting only when it determines that there is a cost-justified substantial safety or security enhancement. The decision criterion in a backfit analysis is whether the proposed backfit is a “substantial increase” in protection to public health and safety or common defense and security and that the costs are justified by the benefit.” [FINANCIAL COST TO UTILITIES, DUMP OWNERS, ETC, BUT BENEFITS TO PUBLIC HEALTH AND SAFETY VS. COST TO PUBLIC HEALTH AND FINANCIAL BENEFIT TO UTILITIES, DUMP OWNERS, ETC. USING COST-BENEFIT IN THIS CONTEXT IS SO FRAUDULENT.]
“Concepts relating to backfitting are discussed in NUREG-1409, “Backfitting Guidelines” (NRC, 13 1990). Similar to backfitting, 10 CFR Part 52, “Licenses, Certifications, and Approvals for Nuclear Power Plants,” includes provisions on issue finality. Issue finality is defined in 10 CFR 15 52.39 for early site permits, 10 CFR 52.63 for standard design certifications, 10 CFR 52.98 for combined licenses, 10 CFR 52.145 for standard design approvals, and 10 CFR 52.171 for manufacturing licenses. Moreover, 10 CFR Part 52 defines requirements, under Section VIII for each certified design appended in the regulations, in initiating processes for changes and departures to a specific design. The Handbook discusses how to perform a backfit analysis (NRC, 1997). In order to impose a backfit, the NRC staff must demonstrate that there is a substantial increase in the overall protection of the public health and safety or the common defense and security derived from the backfit and that the direct and indirect costs of implementation for the subject facility are justified in view of this increase protection. In order to quantify the benefit of averted dose, the dollar per person-rem conversion factor is used.” [Thus, the chosen risk factor and value of life matter.]
“3.6 Environmental Analyses
An analysis of Severe Accident Mitigation Alternatives (SAMAs) is included as part of the environmental review conducted for license renewal if it had not been considered earlier for the facility“. [Humans have little value in this system and plants and animals surely none. Agricultural land is perhaps considered separately as property damage. Lawsuits seem to have gotten further using the property damage argument, rather than health.] “For new reactors, an analysis of SAMDAs is included as part of the environmental review for construction permits, design certifications, and combined licenses. The SAMA review is an evaluation of alternatives to mitigate severe accidents. Severe accidents are those that could result in substantial damage to the reactor core, whether or not there are serious offsite consequences. NRC staff reviews and evaluates SAMAs to ensure that changes that could improve severe accident safety performance are identified and evaluated. Potential improvements could include hardware modifications, changes to procedures, and changes to the training program (NRC, 2006).
“Standard Review Plans for Environmental Reviews for Nuclear Power Plants,” NUREG-1555, Section 7.3 (NRC, 2007) for new reactors and NUREG-1555, Supplement 1, revision 1 (NRC, 43 2013c) for operating license renewal, provides guidance on the analysis and assessment of SAMAs. The guidance instructs NRC staff on how to evaluate the estimated cost, risk reduction, and dollar benefits for selected SAMAs and the assumptions used to make these estimates. “
FN: 5 Analogous backfitting provisions applicable to nuclear power licenses and regulatory approvals, differing in some regards from those in 10 CFR 50.109, are set forth in 10 CFR Part 52 (“issue finality” provisions). Backfit provisions applicable to material licenses and regulatory approvals, are defined in 10 CFR 70.76, 72.62, and 76.76.
“The cost-benefit comparison is further evaluated to determine if it is consistent with the cost-benefit balance criteria and methodology given in NUREG/BR-0184 (NRC 1997) and NUREG/BR-0058, revision 4, (NRC 2004). In addition, during license renewal reviews, any SAMAs with estimated implementation costs within a factor of 2 to 5 of the estimated dollar benefits is further analyzed to ensure that a sufficient margin is present to account for uncertainties in assumptions used to determine the cost and benefit estimates (NRC, 2013c). To evaluate each benefit-cost criterion, NRC staff uses the $2,000 per person-rem averted amount for health effects from NUREG/BR-0058 (NRC, 1999). As required by 10 CFR 51.71(d), NRC environmental impact statements (EISs) are required to “include a consideration of the economic, technical, and other benefits and costs of the proposed licensing action and alternatives.” However, supplemental EISs prepared at the license renewal stage are not required to discuss the economic or technical benefits and costs of either the proposed action or alternatives except if benefits and costs are either essential for a determination regarding the inclusion of an alternative in the range of alternatives considered or relevant to mitigation.
Other than directing NRC staff to “obtain data relative to the costs of postulated accidents,” environmental reviews do not utilize the dollar per person-rem factor in cost-benefit analyses conducted for new reactor EISs (NRC, 2007). This is because the dollar per person-rem factor is used in SAMA and SAMDA analyses. In addition, NUREG-1555, Sections 10.4.1 “Benefits” and 10.4.2 “Costs,” do not reference NUREG/BR-0058, NUREG-0184, or NUREG-1530 (NRC, 22 2007). Conversely, since SAMA/SAMDA analyses are not conducted as part of the materials license environmental review, guidance in NUREG-1748, “Environmental Review Guidance for Licensing Actions Associated with NMSS Programs,” Sections 5.7 and 6.7, Cost-Benefit Analysis, includes references to both NUREG/BR-0058 and NUREG-1530 for more detailed guidance in determining public health and safety impact valuations (NRC, 2003).”
FN: “6 As required by 10 CFR 51.95(c)“.
“4 VALUE OF A STATISTICAL LIFE
The concept of value of a statistical life (VSL) is used throughout the federal government to monetize the health benefits of a safety regulation.” [It would be interesting to know if they cheat as much as the NRC.] “The analyses generally begin with a risk assessment that estimates the change in mortality risks likely to be experienced by the affected population.” [To a large extent this means that the older you are, the less valuable is your life. If you are of a social or ethnic group already considered at risk for cancer, the value of your life is lower. Shouldn’t these fragile groups be protected, instead of subjected to more risk? Of course, it is based on the nearby population as a whole, but usually those with similar social characteristics live near each other in America.] “These assessments do not predict which individuals might die if the hazard is not abated; they estimate only the change in mortality risk over a defined period for members of the affected population.” [Thus “excess risk”, “excess relative risk”, etc.] “It is important to note that VSL (and therefore the associated dollar per person-rem conversion factor) corresponds to society’s willingness-to-pay (WTP) for small reductions in a particular mortality risk.” [This is a major con! They don’t ask if people think that utilities should pay more, but if they want to pay more! Only to the extent that utilities pass the cost to the consumer does this become quasi-legitimate. However, they are certainly not offered safe alternatives, such as solar. They don’t say “are you willing to get cancer or die for the local nuclear power plant” or live and have solar! If they ask the utilities even worse! The nuclear utilities don’t care if people live or die. They only care about their profits.] “In other words, VSL is not a measurement or valuation of a human life.” [Of course it wouldn’t be! The nuclear industry hates all life. And, the NRC works for the nuclear industry.] “Office of Management and Budget (OMB) Circular A-4 provides guidance for 11 communicating the concept of VSL in regulatory analyses. OMB Circular A-4 states (OMB, 2003): Some describe the monetized value of small changes in fatality risk as the “value of statistical life” (VSL) or, less precisely, the “value of a life.” The latter phrase can be misleading because it suggests erroneously that the monetization exercise tries to place a “value” on individual lives. You should make clear that these terms refer to the measurement of willingness to pay for reductions in only small risks of premature death.” [WHO IS WILLING TO PAY OR NOT FOR WHOSE LIFE?] “They have no application to an identifiable individual or to very large reductions in individual risks. “They do not suggest that any individual’s life can be expressed in monetary terms. Their sole purpose is to help describe better the likely benefits of a regulatory action. Confusion about the term “statistical life” is also widespread. This term refers to the sum of risk reductions expected in a population. For example, if the annual risk of death is reduced by one in a million for each of two million people, that is said to represent two “statistical lives” extended per year (2 million people x 28 1/1,000,000 = 2). If the annual risk of death is reduced by one in 10 million for each of 20 million people, that also represents two statistical lives extended.”
“4.1 Approaches to Calculate VSL
NUREG-1530, revision 0, provides an overview of different methods of calculating VSL. In that report, the U.S. Nuclear Regulatory Commission (NRC) chose the WTP method resulting in a VSL of $3 million. The NRC chose this value because:
This value is (1) consistent with results from the WTP approach, which is recommended by OMB and the Administrative Conference of the United States and is most favored in the literature studied; (2) reflects median values of a statistical life estimated in many studies; (3) is representative of values used by other Federal agencies responsible for public health and safety; (4) is in general agreement with values used for regulatory decisionmaking in other countries; (5) is specifically cited by OMB as the “best estimate” for the value of statistical life using the WTP approach.
The methods analyzed were 1) the human capital method, 2) the willingness-to-pay method, 3) values implied by government agency expenditures, 4) inferences from values implied by regulatory requirements imposed by government agencies, and 5) values based on radiation protection activities in foreign countries. [So, if a foreign country opts to exterminate its own people, that should be a consideration?]
FN: “8 OMB, 1993.”
5 NOMINAL RISK COEFFICIENT
Once an appropriate value of a statistical life (VSL) has been estimated, the parameter needed to convert that value to a dollar per person-rem figure is the risk coefficient that establishes the nominal probability for stochastic health effects attributable to radiological exposure. Since 1928, the International Commission on Radiological Protection (ICRP) has developed, maintained, and elaborated the International System of Radiological Protection that is used as a common basis for radiological protection standards, guidelines, and programs. ICRP has published more than one hundred reports on all aspects of radiological protection. Most address a particular area within radiological protection, but a handful of publications describe the overall system of radiological protection. The International System of Radiological Protection has been developed by ICRP based on: (1) the current understanding of the science of radiation exposures and effects,” [PATENTLY FALSE!] “and (2) value judgments.” [THEY CLEARLY ARE USING “VALUE JUDGEMENTS” TO LOW-BALL THE RISK COEFFICIENT!] “These value judgments take into account societal expectations, ethics, and experience gained in application of the system.” [PATENT LIES! NO ONE IN ANY COUNTRY EXPECTS TO BE EXTERMINATED FOR THE PROFITS OF THE NUCLEAR INDUSTRY. IT IS TOTALLY UNETHICAL TO DO COST BENEFITS WHERE IT IS THE PROFITS OF ONE PARTY VS. THE HEALTH OF THE POPULATION!] The U.S. Nuclear Regulatory Commission’s (NRC’s) current dollar per person-rem conversion factor in NUREG-1530, revision 0, is based on the recommendations in ICRP Publication Number 60, published in 1991 (ICRP, 1991). In general, for doses to the population, the ICRP recommendation is a risk coefficient value of 7.3 x 10-4 per rem. This coefficient accounts for the probability of occurrence of a harmful health effect and a judgment of the severity of the effect.” Notice, they JUDGE how bad it is for people to have cancer! They clearly judge non-fatal cancers as no big deal. Clearly nothing in this risk coefficient other than death.] “The coefficient includes allowances for fatal and nonfatal cancers and for severe hereditary effects. The nonfatal cancers and hereditary effects are translated into loss-of-life measures based on a perceived relationship between quality of life and loss of life. [Their perception.] “In this way, the value of a statistical life is applicable across all contributors to the total health risk coefficient. In the ICRP recommendation in Publication Number 103, (ICRP, 2007), the ICRP total risk coefficient decreased by about 20 percent, from 7.3 x 10-4 per rem in 1991 to 5.7 x 10-4 per rem.” [i.e. from 0.00073 to 0.00057] “ICRP states that this change is due primarily to improved methods in the calculation of heritable risks and significant advances in understanding of the mutational process. Also, the ICRP 32 calculated its values differently in ICRP 103 than ICRP 60. In ICRP Publication 60, nominal cancer risks were computed based on fatal cancer risk weighted for nonfatal cancer, relative life lost for fatal cancer and life impairment for nonfatal cancer, but in ICRP Publication 35 Number 103, risk estimates are based principally on cancer incidence data weighted for lethality and life impairment.” [They removed the average of 14-15 years of life lost for those who died, it seems, and perhaps life impairment for nonfatal cancers.] “The reason for the change is that cancer incidence data provide a more complete description of the cancer burden than do mortality data, particularly for cancers that have a high survival rate.” [So why aren’t they following BEIR VII then?] “ICRP 103 provides the following information: It is important to note that the detriment-adjusted nominal risk coefficient for cancer estimated here has been computed in a different manner from that of Publication 60. The present estimate is based upon lethality/life-impairment-weighted data on cancer incidence with adjustment for relative life lost, whereas in publication 60 detriment was based upon fatal cancer risk weighted for non-fatal cancer, relative life lost for fatal cancers and life impairment for non-fatal cancer. In this respect it is also notable that the detriment-unadjusted nominal risk coefficient for fatal cancer in the whole population that may be projected from the cancer incidence-based data of ”
“The NRC staff recommendation to use the nominal risk coefficient value is for the whole population. For simplicity, the NRC staff does not recommend low and high nominal risk coefficient factors for use in sensitivity analyses“.
FN 3 “In certain scenarios (e.g., occupational health (routine) or occupational health (accident) as defined in NUREG/BR-0184), the NRC staff could use the nominal risk value of 4.2 ˣ 10-4 because workers at nuclear power plants are adults.”
“DOLLAR PER PERSON-REM CONVERSION FACTOR
The dollar per person-rem conversion factor for health effects is calculated as the product of the value of a statistical life (VSL) and the nominal risk coefficient. Based on the preceding recommendations concerning VSL ($9.0 million) and the use of the International Commission on Radiological Protection (ICRP) Publication Number 103 total detriment coefficient (5.7 ˣ 10-4 per rem)[0.00057 per rem [10 mSv], “the dollar conversion factor would be equal to $5,100 in per person-rem 2014 dollars. A low dollar per person-rem value of $3,000 per person-rem and $7,500 for a high dollar per person-rem value will be adopted. Thus, the U.S. Nuclear Regulatory Commission (NRC) will adopt the above dollar per person-rem estimates to be used for routine effluent releases, accidental releases, 10 CFR Part 20 as low as is reasonably achieveable (ALARA) programs (i.e., occupational exposures), regulatory analyses, backfit analyses, and environmental analyses. Pertaining to occupational exposures, the NRC staff acknowledges that, for ALARA determinations, many licensees may employ conversion factors in excess of $5,100 per person-rem. This is particularly true in non-design ALARA determinations where licensees consider tradeoffs between occupational dose and alternative technologies and procedures (e.g., use of additional shielding, remote or robotic tools for given a plant maintenance evolution). These higher values are typically influenced by utility-specific manpower constraints and other labor cost considerations in employing workers with unique skill sets. These are valid utility considerations in evaluating occupational exposures, and licensees are expected to continue to use these higher conversion factors. Further, such estimates are not necessarily inconsistent with the NRC’s estimates that only capture health effects, as other impacts such as labor cost considerations can be treated as additive elements in the NRC’s cost-benefit analysis. The NRC acknowledges that there may be unique circumstances where other dollar conversion factors may warrant consideration. For example, doses to a population whose age distribution is not representative of the general population could be subject to a different risk coefficient because health risks are directly related to the age distribution of the affected population.” [THERE IT IS! THE OLDER YOU ARE, THE LESS VALUABLE IS YOUR LIFE! LONG GONE ARE THE DAYS OF RESPECT FOR ELDERS.] “Further, recognizing the uncertainties inherent in establishing a representative conversion factor, alternative values to capture the uncertainties may be warranted. Thus, it would be reasonable to expect an analyst to include alternative valuations in regulatory analyses in order to show the decision maker the sensitivities of the proposed action to relevant considerations. However, the base case computations in a regulatory analysis will use the recommended best estimate dollar conversion factor of $5,100 per person-rem, and apply the low and high estimates in illustrating sensitivity and in bounding the range and direction of the impacts. The dollar per person-rem conversion factor is for stochastic effects only and is not to be applied to deterministic effects. It should also not be applied to any individual dose that could result in an early fatality. These omissions are consistent with NRC’s view that the monetizing of mortality effects as it relates to the value of any single individual’s life is not appropriate. Rather, its use is as an estimate of the value of small reductions in the probability of total detriment for a given population. From a practical perspective, the NRC believes that regulatory…
1 See Appendix B of this report for discussion on adjusting the cancer risk coefficient, and hence the dollar per person-rem conversion factor, for high rate exposure scenarios.”
METHODOLOGY FOR MAINTAINING THE CONVERSION FACTORS CURRENT
In updating VSL, the NRC staff will annually calculate changes in inflation and real income growth. Changes in the VSL base year and income elasticity won’t change unless there is a structural change to the formula above during re-baselining as discussed in Section 7.3 of this report.
2 7.2 Updating Nominal Risk Coefficient
The NRC staff should periodically update the nominal risk coefficient used in the dollar per person-rem conversion factor when the ICRP provides new recommendations for its conversion factor.
7.3 Re-baselining Dollar per Person-Rem Conversion Factor
Although accounting for changing economic conditions (e.g., inflation and income growth) can provide a more realistic estimate of VSL (and therefore, the dollar per person-rem conversion factor), economic adjustments alone do not account for the full change in VSL over time. Therefore, the NRC staff should reevaluate its baseline values for VSL (to account for structural changes in the economy) and nominal risk coefficient approximately every five years, and update guidance and regulations as needed. This practice is consistent with other Federal agencies’ initiatives to establish formalized processes for re-baselining VSL, and therefore, dollar per person-rem. Established processes will be used to complete such updates, including notification of the public and the Commission.”
“8 IMPLICATIONS OF REVISED CONVERSION FACTOR POLICY
The $5,100 per person-rem conversion factor discussed in this report reflects an increase of about a factor of approximately 2.6 from the $2,000 per person-rem conversion factor that has been used by the U.S. Nuclear Regulatory Commission (NRC) since 1995. As part of the NRC’s update of the dollar per person-rem conversion factor, the NRC considered the potential impact of any change from the $2,000 per person-rem factor on current regulations and past regulatory decisions. In the introductory sections of this report, the NRC described the role that the dollar per person-rem conversion factor plays and is expected to exert in future NRC regulatory decisions. First, with regard to regulatory decisions concerning radioactive waste system design alternatives for nuclear power plants (10 CFR Part 50, Appendix I), the NRC staff involved in those assessments have indicated that increases in the conversion factor of at least an order of magnitude would be necessary to justify any reassessment of these decisions.” [THE INWORKS STUDIES OF NUCLEAR WORKERS SHOW AN INCREASE RISK OF AN ORDER OF MAGNITUDE.]
“Thus, the changes in the conversion factor policy as considered in this report would not bring into question these past decisions. Moreover, applicants for reactor licenses under Part 50 and Part 52, and the staff in its review of such applications, are still required to use the current conversion factor ($1,000 per total body man-rem and $1,000 per man-thyroid-rem) in Section II.D of Part 50, Appendix I until it is formally changed through a rulemaking.“[Law must still be changed!] “Second, for all other regulatory applications where $2,000 per person-rem has been used by the NRC, the NRC is not proposing that previous decisions be reviewed or updated based on this revised conversion factor policy. Furthermore, even for regulatory decisions involving safety enhancements for severe power reactor accidents following the Fukushima accident where the potential difference in total dollar valuation could be large, the NRC used $4,000 per person-rem as an alternative value estimate and does not propose revisiting these past regulatory decisions unless, on a case-specific basis, an unanticipated need to do so arises (NRC, 2012b).” Value of life for Fukushima upgrades is $4,000,000. This is probably why they haven’t implemented Fukushima lessons learned. It would be interesting to see if those reactors who aren’t required to do additional studies are in rural areas, where fewer people means less money spent.] “There are several reasons for this position. First, the $2,000 per person-rem value has been used by the NRC as a figure of merit, and as one input among many in the regulatory decision. Second, in recognition of the uncertainties inherent in such a figure of merit, NRC staff and decisionmakers would typically rely more heavily on other considerations when the break-even cost-beneficial determination was close (e.g., within a factor of five). Finally, the factors that justify an increase in the dollar per person-rem conversion factor have had a similar effect on the cost of modifying a licensed facility. Updated cost-benefit analysis results would most likely result in little, if any, change to past regulatory decisions.“(p.29)
“Reassessment of NRC’s Dollar Per Person-Rem Conversion Factor Policy
Draft Report for Comment
Office of Nuclear Reactor Regulation
NUREG-1530, Rev. 1
Entire original text found here: http://pbadupws.nrc.gov/docs/ML1523/ML15237A211.pdf
Memorial Sloane Kettering on the cost of drugs: https://www.mskcc.org/research-areas/programs-centers/health-policy-outcomes/cost-drugs
An article about gouging on drug costs: http://www.commondreams.org/further/2015/10/23/creepy-pharma-bro-just-got-owned
UK Cancer Drugs Denial of Care: http://www.theguardian.com/business/2015/sep/23/uk-cancer-patients-being-denied-drugs-due-to-inflated-prices-say-experts
Their amazing policy of discounting the low value of life still further! There’s no other way to interpret this based on their example! NUREG/BR 0184
They need to compound forward and not discount backwards! The cost of cancer drugs, medical care, etc. increases over time.