Now they tell us

NBC News has a good, readable summary correcting common misconceptions about the Affordable Care Act.

It isn't just about extending health insurance coverage, it has provisions reforming Medicare (and others the article doesn't mention such as the Patient Centered Outcomes Research Institute) intended to constrain the cost of health care while making it more effective and better meet people's needs.

It isn't government insurance. It's a mechanism for making private insurance more available and affordable to people who don't get insurance through employment, Medicare, the military or VA. Most people don't get their insurance through the ACA. Whatever is happening to your employer-provided insurance that you don't like, don't blame the ACA. Blame your employer.

It didn't make your premiums go up. (Contrary to a recent commenter.) Health care costs have been increasing forever. If anything the ACA has slowed this process down.

Yes, premiums for many plans on the exchanges will go up this year compared to last. That wasn't caused by the ACA, it happened because insurers underestimated how much new enrollees would cost.  People who have been without health care for a while often have expensive problems such as uncontrolled diabetes. But, government subsidies will take care of most of the increase for most people, and if the ACA were allowed to remain in place, this problem would ease over time.

Here's my complaint. Throughout the campaign, indeed the last seven years, through all the screaming and yelling about how the ACA was socialism with death panels and a government takeover and government coming between you and your doctor, they never bothered to sit down and carefully explain to people that none of that is true. They just channeled whatever lies the politicians were telling. Only after the disastrous election of 2016 do we suddenly start getting these simple, factual stories about public policy.

Since we seem to have different claims about the popularity of the ACA . . .

here is recent polling from the Kaiser Family Foundation. Highlights:

While health care was not a leading factor in voters’ presidential decisions, President-elect Trump and Republican lawmakers have made it clear that one of their top priorities is the repeal of the 2010 health care law. Americans are divided on what they want to see lawmakers do to the ACA with one-fourth of Americans (26 percent) wanting to see President-elect Donald Trump and the next Congress repeal the entire law while an additional 17 percent want them to scale back what the law does. This is compared to 30 percent of the public who want to see the law expanded and 19 percent who want to see lawmakers move forward with implementing the law as it is.

While President-elect Trump and Republican members of Congress work on a replacement to the ACA, this month’s survey finds that many of the law’s major provisions continue to be quite popular, even across party lines. The notable exception is the requirement that nearly all Americans have health insurance or else pay a fine.

The problem is that people do not understand that the only way to make health insurance available and affordable for everyone is to get everyone into the pool. You can't have the popular provisions without the mandate. It is unseverable. That doesn't fit on a bumper sticker, but it's how the world works. 

They don't know why, they just know they're supposed to hate it . . .

That would be Republicans and the Affordable Care Act. This just hit my in-box.

The rate and number of insured Americans reached historic highs in the years following passage of the Affordable Care Act (ACA). In a new report, researchers from the Urban Institute — with funding from the Robert Wood Johnson Foundation — provide a granular perspective on the 19 million people who gained coverage (2010-2015) and where they live.

Coverage rates increased broadly across age, gender, race/ethnicity, education, and state. The Urban researchers found that a large share of the nonelderly adult coverage gains occurred among those without a college degree – 87 percent. Fifty-seven percent of the children and adults gaining coverage were nonwhite or Hispanic.

"In recent years we have seen unprecedented gains in health insurance coverage,” said Kathy Hempstead of the Robert Wood Johnson Foundation. "What happens next is uncertain, and the ability to maintain these gains will undoubtedly be a central issue for policymakers to consider.”     

The report includes state-by-state breakdowns by key demographics to illustrate who gained coverage under the law. Highlights include: 

·         Among nonelderly adults gaining coverage, 14.1 million did not have a college degree; within this group, 44 percent were non-Hispanic white.

·         In California, 3.8 million people gained coverage and the uninsured rate dropped 53.4 percent after state policymakers expanded Medicaid eligibility.

·         In Florida and Texas, 3.2 million people gained coverage, even though these two Southern states chose not to expand Medicaid.

·         In Illinois, Michigan, Ohio, and Wisconsin, more than 2.3 million people gained coverage – accounting for a 38 to 49 percent drop in the percentage of people without health insurance across these Midwestern states.

Notice anything about bullets 1, 3 and 4? They're about to get what they voted for. I hope they enjoy it.

Another data point on the Fermi paradox

This Phys.org summary takes a while to get to the point, but it's an enlightening while. It doesn't quite explain everything it ought to explain, so I'll fill in the blanks for those of you who may need it.

Life on earth is something more than 3 billion years old. To be sure, Republicans don't believe this, but it is true. However, the metazoans -- a fancy name for the animals, that include us -- and plants haven't been around nearly as long, only (hah!) about 800 million years. We know that what made metazoan life possible was the rather abrupt enrichment of the earth's atmosphere with oxygen, which as I'm sure you have noticed animals need. This was brought about by an explosion in the population of photosynthetic organisms called cyanobacteria (often called by the misnomer "blue-green algae"). The cyanobacteria are still around, but they also made plants possible by getting themselves incorporated into plant cells as endosymbionts that today do the photosynthesizing work for your petunias.

The metazoans were made possible not only by the availability of oxygen, but also by another endosymbiotic event in which another line of bacteria became what are today the mitochondria, our cells' power plants. And plants also have those. Both kinds need a lot of phosphorous to thrive. The problem was, it wasn't around for the first 2 billion plus years, according to this new research -- or rather, it was sequestered deep in the ocean, where photosynthesis couldn't happen. Then TaDa! It showed up in substantial quantities in shallow coastal waters, cyanobacteria were in business, and 800 million years later, so were we.

This suggests that if whatever the key event was had not occurred, earth would still be inhabited by nothing but slime. It also suggests that many or most earth-like planets might never have hit the inside straight, which would help explain the Fermi paradox. It's also all the more reason not to do ourselves in. A) The environment that supports our kind of life is fragile and it can be screwed up and B) it may be quite rate in the universe so there' s nobody out there to carry on the cause of wondering about the universe and starting to understand it.  Let's take this historical moment very, very seriously.

Not that I want to bring you down . . .

but while the New York Times was obsessing over Hillary Clinton's e-mails this was happening. (Yes, there are still newspapers in Britain.)

The warming arctic and the disappearance of the arctic sea ice have caused the jet stream to weaken and meander. This has a few consequences including pulling down cold air to the south, and warm air to the north; increasing the intensity of storms; and causing weather patterns to become static over particular regions resulting in prolonged periods of storminess, or droughts.

That one of the two major parties in the U.S. is committed to denying this incontrovertible reality should scare the shit out of you.

Zdravstvuj tovarisch

There is a whole lot that is bizarre about the impending presidency, but surely the most perplexing but at the same time revealing weirdness is the apparent acceptance by the Republican party that our new BFF is Vladimir Putin. Nina Kruscheva, who ought to know, discusses the Russian takeover of the United States. I will put this in bullet points in case your attention span is flagging.

• Trump responded to reports that the CIA had concluded Russia was behind the hacking of the DNC and John Podesta by deriding the CIA as a tool of Hillary Clinton. Quoth NK, "The idea that a US president-elect would take the word of the Kremlin over that of CIA officials and even the most senior members of his own party is already bizarre and dangerous."

•  But then there is Secretary of State nominee Tillerson,  for whom "taking Russia’s side against the US is nothing new." 

• And National Security Adviser Michael Flynn, who, "like Tillerson, has also been feasting at the Kremlin trough. After being fired by Obama for his incompetent management of the Defense Intelligence Agency, Flynn immediately began to cultivate Russian business contacts. And Putin seems to have been more than happy to see that commercial doors were opened to Flynn. There is a now-infamous photograph of Flynn seated next to Putin at a banquet for RT (Russia Today), the Kremlin-backed cable news network that was a prime source of the slanted, and even fake, news that inundated the US during the recent election campaign. "

• "As for Trump, statements made by his sons suggest that, if the American public ever got a look at his tax returns and business loans, they would find that he has also been feathering his nest with Kremlin gold for some time."

•  And of course there is Paul Manafort

Kruscheva thinks that Trump is likely involved in criminal activity. Although she doesn't specify, violation of sanctions against Russia, tax evasion, or collusion in the hacking are all possible. She doesn't mention the likelihood that Putin has information with which to blackmail Trump. All of this is just fine with the Republicans in the House and Senate. And the news media, which are largely incurious about it. How deeply strange.

Thoughts on resistance

Randall Kennedy has some.

I actually think -- and I'm probably naive -- that many of the squishes, including even some Republican politicians, who initially decided to go with the flow and pretend everything was normal and they would try to figure out ways to use the famously unfocused and flighty orange orangutan for their own purposes are now starting to realize that he is even crazier than he seemed and touching him in any way is extremely dangerous.

In other words, it's possible that the Senate won't go along with handing the country over to Vladimir Putin, and once the Republicans contemplate the likely political cost of doing all the stuff they have been promising to do for the past 8 years they may go a bit soft. Where we are definitely screwed is on the environment including the fate of you know, the planet, but we'll still be around after 4 years to change that around. Voter suppression is definitely resistible, as is intimidation of dissent and of the press. Our political culture has a much stronger reserve of democratic norms than Germany or Italy did in 1939. Robert Kuttner checks off the parallels to fascism (see section 2 of this long essay) but noting how Trumpism is like fascism leaves out how the historical time and place is different. He concludes with more or less what I am saying:

An astute observation is ascribed to Mark Twain: It is easier to fool people than to convince them they’ve been fooled. True enough, but the contradictions are piling up. Even hardcore Trump voters are starting to experience buyer’s remorse.

We can place our hope in his incompetence. As long as we can avoid a ruinous war.

Philosophy after the Enlightenment

Metaphysics is essentially dead. Speculation about the ultimate nature of reality seems a waste of time when we can actually study the universe and learn about it. Whatever metaphysical speculation you come up with may one day be proved true or false, in which case why not wait for the answer? Alternatively, there may be no means of verifying or falsifying it, in which case why bother even to think about it, when we can spend our resources on questions that might have answers?

So here's Tim Urban discussing the Fermi paradox. Basically, even using the most conservative assumptions, if life develops on earth-like planets, even fairly infrequently; and it technological civilizations subsequently evolve, again even infrequently, there should be something like 100,000 technological civilizations in our galaxy, many of them presumably far more advanced and powerful than little old us.

So where are they? We have detected absolutely nothing that is suggestive of any technological civilization. Urban's discussion is very well organized and fascinating, so do read it. But I will say that the main possibilities include that life is actually exceedingly rare. That would be surprising because cosmologists have adopted the habit of thinking that our planet is nothing special. It would also be surprising because it seem evident from thinking about evolution on earth that if you get any sort of system that self-replicates with occasional mistakes, you are going to get evolution. But does evolution necessarily have to lead to multicellular organisms and nervous systems? Maybe the universe is full of pond scum, and nothing much more than that.

Another possibility is that technological civilizations arise,  but inevitably self-destruct because they can't handle the power they gain for themselves. That's certainly plausible, we almost did it during the Cold War and we might be about to do it now. On the other hand at least some of us are wise enough to avoid that. Why couldn't even 1% of civilized beings be more generally wise?

And there is the possibility that they're out there, but we can't detect them because they aren't emitting any signals that we would perceive as coming from a technological civilization. There is also the nasty possibility that a predatory species rules the galaxy and wipes out any competitors, in which case we may be on the menu.

These speculations are mostly fairly disturbing, but the point is, we may one day -- even soon! -- know the answer. Hegel, however, could never know anything.

Just to be clear about "Repeal Now, Replace Later"

The Republican proposal to repeal the Affordable Care Act but not actually abolish it until 2019 at which time they will purportedly have figured out what to replace it with comes with a bonus: it will immediately eliminate the taxes which finance the ACA, 100% of which fall on people making more than $200,000 a year. That would be $346 billion over ten years.

So where are they going to get the money from to "replace" the ACA? Are they going to reinstate those taxes? I really don't think so. Of course, that has always been the real reason Republicans don't like the ACA. What are the chances the people who vote for them will ever understand this?

Not Stayin' Alive So Much

You may have heard already that CDC is reporting that U.S. life expectancy declined by about 1/10 of a year from 2014 to 2015. (Link is to a PDF. If you prefer, you can go to the National Center for Health Statistics home page here.)

Now, this might not mean anything. Life expectancy in the U.S., while it lags behind other wealthy countries, has been steadily increasing. That's why it's a bit of a shock to see a decrease but one year does not a trend make. It's also hard to know what to make of the internals. The age adjusted death rate increased for Black men, and for white men and women, but not for Black women or Latinos. The age adjusted death rate for cancer went down: the main contributors to increased death rates included heart disease and stroke, lower respiratory disease (which is mostly due to tobacco), unintentional injuries, and suicide. While the prevalence of smoking has been going down substantially in the past couple of decades, it's possible that the earlier smoking epidemic is catching up with people now. Obesity may also be contributing to the heart disease and stroke increase.

Unintentional injuries aren't decomposed in this report, but I suspect they're a combination of motor vehicle crashes and drug overdoses. Infant mortality increased, in substantial part due to unintentional injuries, which I would guess points to motor vehicle fatalities.

An oddity is a sharp increase in the age adjusted death rate from Alzheimer's disease. Since it's age-adjusted, it wouldn't seem to be an artifact of the aging population but that could be wrong -- I'd have to see exactly how they did the age adjustment. If they capped out at 85+, that could explain it.

Apart from that, this is consistent with the story we've been hearing about our major public health problems: obesity, cars, opioids and suicide. All problems we can do something about.

Outsourcing . . .

To Maciej Cegłowski.

Just go there. Read. Understand. This is the hinge of history.

Here's a letter I wrote to my colleagues . . .

. . . along with one of them.

This is a critical time for the future of health care policy, and all policies affecting public health in the United States. The incoming president and congress have promised to take actions that will profoundly change our health care system, along with environmental regulation, immigration policy, labor policy, and much more that will affect the health and well-being of the population. Some of the rhetoric in the recent campaign has also affected the social and political culture of the nation with unpredictable but likely worrisome consequences.

            We were deeply concerned by the scarcity of informed and even accurate discussion of public policy in the recent campaign. It appears that voters have little understanding of what government does or how government policies and practices affect their lives. The news media largely failed to explain the facts and controversies underlying policy choices, and allowed empty rhetoric and personal questions about the candidates to dominate the communal discourse.

            We believe that we, as experts in policy issues that are of the greatest importance for our nation and its citizens, can and should do more to contribute to the public discourse beyond our traditional focus on publishing in journals that are read only by our peers. We believe that we need to define an expanded role for public health researchers that brings our science out into the world and engages with people from all communities and walks of life. Voters cannot make appropriate decisions if they cannot meaningfully evaluate what candidates say and promise.

            We hope to join with our colleagues, starting within the department but perhaps expanding to the entire school of public health and ultimately beyond to other institutions, in an effort to democratize our work. By this we mean listening and engaging communities in helping us to understand what matters to people, and how we can best serve the public interest through our scholarly work, but just as importantly o through effective dissemination of knowledge and empowering people to be informed civic actors.

            We have discussed a few ideas about what some components of this effort might be. We do know that it calls for re-examining the institutional expectation for how public health scholars will focus their time and how their accomplishments will be evaluated. But there is much we can do now, that we believe we should be doing as a matter of urgency. We hope that some of you will join us in discussion leading to action. Please let either or both of us know if you want to join us, and we will convene those interested.

I'm not the only one who feels this way -- for example there's the well-publicized open letter from MIT faculty -- but I'm not just talking about writing open letters or op-eds. I'm talking about working with community-based organizations to engage people directly in understanding the facts underlying policy choices and how government matters to their lives. We cannot survive in a post-factual world.

Not exactly news . . .

The Commonwealth Fund has done the latest in its series of surveys of 11 countries (western Europe, Canada and the U.S.) and, well, you already know:

• Adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs. One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs. This percentage is down from the 2013 survey (37%). [But it's about to go back up!] As few as 7 percent of respondents in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these affordability problems.
• U.S. adults were also the most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.
• Half of U.S. adults struggled to get health care on the weekends and evenings without going to an emergency department. Between 40 percent and 64 percent of adults in the other countries reported the same. The Netherlands had the lowest rate on this measure, 25 percent.
• Adults in the U.S. (19%) and France (24%) were the most likely to say that their medical records or test results had not been available at the time of an appointment or that duplicate tests had been ordered in the past two years. These problems were reported less commonly in the other countries.
• Fourteen percent of chronically ill U.S. adults said they did not get the support they needed from health care providers to manage their conditions. This was twice the rate in Australia, Germany, the Netherlands, New Zealand, and Switzerland.

So the Republicans take over and vow to make all this worse -- much, much worse. My question is simple: what is the constituency for this? Why do we so passionately want to hurt ourselves?

We'll be in for a lot of this . . .

Sam Stein and Matt Fuller for the Puffington Host report on the 21st Century Cures Act, which appears likely to pass. Believe it or not, it does some things Democrats want to do, including providing some additional funding for NIH and money to the states to combat opioid addiction.

But of course, there's a high price to be paid. It also makes it easier to get medical treatments approved without demonstrating that they are safe and effective. Senator Warren has denounced this as a corrupt bargain. The Democrats in congress will be offered more of these corrupt bargains in the coming years, such as the phony infrastructure plan that really consists of giving away public goods to capitalists. The Republicans haven't been afraid to obstruct everything for the past 8 years -- how will the Democrats behave now?

Stay tuned.

Speaking of scams . . .

While the new president and his minions are busy selling out the country for personal enrichment, the pharmaceutical companies will not be left behind.

This is a slightly complicated scam, so you might want to read the essay in NEJM by Dafny, et al. For those with short attention spans, I will try to explain. There are lots of medications available to treat most conditions. The FDA has to approve them if they are safe and effective, but they don't have to be superior to existing treatments. Comparative effectiveness research doesn't always get done, but sometimes we know that a less expensive drug works as well as a more expensive one, at least for most people. Also, of course, once marketing exclusivity expires there are often cheaper generic alternatives to brand name drugs.

So, insurance companies put drugs in different "tiers" with consumers facing higher co-pays for medications the insurers want to steer people away from, because they are more expensive or less effective, or both. This helps them make money, sure, but it also helps keep premiums down for all of us. So what do the drug companies do when they want to keep selling their more expensive brand name drugs?

They pretend to be doing you a favor by giving out coupons that cover the co-pay. But they aren't doing you any favor, they're screwing you. Let's say a drug costs the insurance company eight times as much and they give you a coupon for a 20% copay? You use the brand name drug instead of the generic, which might have a much smaller copay but with the coupon the brand name drug is free. But the cost to your insurance company is much higher. The drug company gets their ill-gotten gains and ultimately, it comes out of your wallet anyway in the form of higher premiums.

I wouldn't count on your friends in congress to do anything about this.

The New Normal

Simon Maloy thinks Trump's corruption will sink the Republican party. To which I say, poppycock.

According to the New York Times and the rest of the corporate media, Hillary Clinton was the corrupt candidate. Can you imagine if Clinton had just settled a fraud lawsuit for $25 million, or the Clinton Foundation had admitted to self-dealing? My imagination can't even encompass what the news coverage would be like.

But they are doing their best to ignore Trump's blatant and proven corruption -- one brief story on each revelation, and we move on. What makes Maloy think that's going to change?

Theories of History

There are several approaches to understanding and writing about history. There is the Great Man (rarely Woman) school, which consists largely of biography. There are grand theories that explain history as a process shaped by large forces in which the choices of individuals have little weight, from Marxism to the inevitability of neoliberal dominance of the planet. The latter didn't exactly have a name but lots of people believed in it.

Then there are those who say, sure, there are grand forces -- technological change, climate, resource depletion, demographics -- but against that background, a lot of shit  just happens. Call this the "for want of a nail" theory of history. Well, it's true.

No-one can enumerate the links in the causal chain that led to our present disaster, but we can spot a few that are both necessary and basically stochastic. Hillary Clinton actually won the election by quite a substantial majority, but thanks to the historical anachronism of the electoral college, it doesn't count. There is no argument that I can see that makes this the right result. A few thousand votes in a key state tips the whole thing. In past elections that has been consequential but in this election it puts the country on a path completely opposite to what would otherwise have been.

Another necessary link was the Comey letter. There is plenty of evidence that it flipped the election, and probably the Senate. This of course would not have happened in the corporate media hadn't been obsessed with the completely bogus non-issue of Hillary Clinton's e-mails to begin with. But they were, and Comey  knew it.

Comey could not have played his dirty trick, however, if he didn't have Anthony Weiner's computer. Ergo, if the ridiculous and ridiculously named Anthony Weiner did not have an incorrigible habit of tweeting his junk, Hillary Clinton would be preparing to assume the presidency and appoint a young liberal justice to the Supreme Court.

In other words, this whole thing doesn't mean shit. It's a horrible accident. Jessica Williams (a Daily Show regular with John Stewart for those who aren't with it) said, "The first rule of politics is, Don't Tweet Your Junk," which presumably Weiner would have learned when it cost him his congressional seat. He did not, causing him to lose his chance to be mayor of New York and prompting Williams to say, "The second rule of politics is, Don't Tweet Your Junk."

Apparently we need a third rule. "Don't Tweet Your Junk."

Resistance

So, Paul Ryan says his first priority in 2017 is to phase out Medicare. He'll give people vouchers that will cover part of the cost of private insurance instead, but obviously the whole point is that they won't be sufficient. Medicare is much more cost-efficient than private insurance, because it doesn't have to pay for marketing, multi-million dollar executive salaries, or profits. And insurance companies have all kinds of ways of avoiding the most costly customers and screwing people out of benefits. Read the linked post if you want more details, but . . .

What is most strange about this is that it has almost no constituency, apart from a few extremist ideologues and plutocrats who don't want to pay taxes. Retired people and people who will retire depend on the program (as do people with disabilities). Doctors and hospitals get most of their revenue from it. The only way Republicans can advance their agenda is to lie to people, which is what Ryan is doing.

It seems to me that now that Republicans have total control over the federal government, and it actually comes time for them to do everything they have promised to do, it's suddenly going to get difficult. The first thing George W. Bush said after he was reelected was that he wanted to privatize Social Security. Funny thing about that, it didn't happen.

We need to resist everything, everywhere, with maximum energy. There is still plenty of life in the American republic and the progressive vision. We will win in the end.

How worried should we be?

I commend to your attention this essay by Ezra Klein. Before I try to very briefly summarize his argument (but do read this, although it's long form) I want to pull this:

He is a man who routinely praises dictators. Of Vladimir Putin, Trump said, "He's running his country, and at least he's a leader, unlike what we have in this country." Of Kim Jong Un, Trump said, "You've got to give him credit. He goes in, he takes over, and he's the boss. It's incredible." Of Saddam Hussein, Trump said, "He killed terrorists. He did that so good. They didn't read them the rights."

It’s not just that Trump admires authoritarians; it’s that the thing he admires about them is their authoritarianism — their ability to dispense with niceties like a free press, due process, and political opposition.

Trump has promised — in public, and repeatedly — to bring this hammer to American governance. He stood in a nationally televised debate and vowed to jail his opponent if elected. He has proposed strengthening libel laws to make it easier to cow the press and antitrust laws to punish Jeff Bezos and Amazon for the Washington Post’s coverage of his candidacy. In a recent speech at Gettysburg meant to preview his first 100 days in office, Trump said he would sue all of the women who accused him of sexual assault. 

During rallies, Trump has exhorted his followers to assault protestors, and has promised to pay their legal fees if their thuggery leads to arrest. He has warned that the only way he could lose the election would be if it is rigged, and has suggested he may refuse to concede.

And all this ignores his more basic flaws. He is cruel, lazy, and reckless. He knows nothing of policy and has not bothered to find anything out. He is easily baited, reliant on sycophants, and prone to conspiracy theories. He is a bigot who slimed an American-born judge for his Mexican heritage and a misogynist who boasted that his celebrity gave him license to commit sexual assault. He has cast doubt on America’s commitment to the NATO alliance and offhandedly encouraged Saudi Arabia and Japan to build nuclear weapons. His business is rife with conflicts of interest, and his campaign has been amateurish and poorly managed.

 Klein wrote this before the election, when he expected Trump to narrowly lose. (Actually, he did lose the popular vote, and it wasn't particularly close. But the problem of the electoral college is for another day. He got plenty of votes.)

Klein's basic claim is that the gatekeepers who once had control of the nominating process -- party elites, mostly, but corporate media as well -- have completely lost influence. But while the parties are institutionally weak, the public is more partisan than ever. The result is that once Trump got the nomination, Republican voters stuck with him despite whatever doubts some of them may have had. And party elites could not afford to abandon him lest their voters retaliate against them.

We can forget about checks and balances because soon, far right extremists will control all three branches of the federal government. They will do whatever they want, and believe me, New York Times editorials won't slow them down.

Gross Domestic Problem

Back when I was a 22 year old Nader's Raider I heard Hazel Henderson speak at one of our conferences and she was already saying what Edoardo Campanella apparently thinks is a radical new idea, which is that Gross Domestic Product is not a valid measure of well-being, and not even a valid measure of economic activity.

Hazel was not the only person to figure this out 40 years ago and plenty of people have kept hammering on the fairly obvious truth of it since, but it's just pissing into the wind. The corporate media and political leaders continue to treat GDP growth as the measure of a "healthy" economy.

The reasons why this is wrong are so many and so gross that nobody should be arguing about it, but apparently we have to do it anyway. Here are a few:

GDP does not account for externalities. You know, air pollution, stuff like that.

It treats resource extraction as production, even though the resource is gone.

It treats harms as goods. For example, a hurricane that destroys houses becomes economic growth because the cost of rebuilding them is counted as a positive while their destruction is ignored. Same with automobile crashes, disease (which leads to health care spending), basically anything that goes wrong and has to be fixed.

As a corollary, saving money is bad. Preventing disease, avoiding disasters, improving public safety - these are all negative for GDP.

It doesn't properly account for the value of technological advances. As the same goods and services get cheaper, we still have the value, or even greater value, but the contribution to GDP goes down.

It takes no account of inequality. If one person gets all the loot and the rest starve, it doesn't matter.

It takes no account of any activity that doesn't involve exchange of money -- from household work to volunteering. Take care of your elderly parent yourself, zero contribution. Hire somebody to do it, GDP. 

More money flowing around does not translate into human happiness. No account of community, friendship, the value of common space, free concerts on the green, mutual respect, you name it.

Do we really need to keep having this pointless discussion?

The grotesque corporate media

Jesse Berney and Matthew Yglesias have posted very similar essays, which means they are channeling a collective consciousness, not that one is stealing from the other. As Berney puts it:

You start with the assumption that Hillary Clinton is corrupt. After all, there have been whispers and accusations and investigations and allegations and scandals with ominous names like WHITEWATER and BENGHAZI for years. Even if you can't describe exactly what she's done wrong, there must be something to all these stories, right?

Or, in the words of Yglesias:

The latest Hillary Clinton email revelations arose out of an unrelated investigation into Anthony Weiner’s sexting. The best way to understand this odd hopscotch is through the Prime Directive of Clinton investigations: We know the Clintons are guilty; the only question is what are they guilty of and when will we find the evidence?

Berney:

When I fired up the New York Times app on my phone Saturday morning, I had to scroll through four full screens before I got to a headline that wasn't about FBI Director James Comey's letter to Congress that the bureau had discovered emails on Anthony Weiner's computer that possibly maybe perhaps might be related to its earlier investigation of Clinton’s private email server. With zero information about what is in those emails, zero information about any connection to Clinton, zero new allegations of wrongdoing, the Times and much of the media treated this story with the kind of wall-to-wall coverage usually reserved for the first moon landing.

Yglesias:

There are several rules that govern media coverage of the Clintons, but this year the Prime Directive has dominated them all. Network news has devoted more minutes of coverage to Clinton’s emails than to all policy issues combined, even as email investigations have not uncovered any wrongdoing. It’s inexplicable news judgment, unless you simply assume there’s a crime out there.

On their editorial and opinion pages, the corporate media from the New York Times to CNN all say that Trump is unqualified to be president and that his candidacy presents an unprecedented risk to the republic. But in their news pages all they ever talk about is phony Clinton scandals, while Donald Trump's innumerable very real scandals are completely ignored, even when they are reported by credible single sources such as  David Corn, David Farenthold and Kurt Eichenwald -- as are issues of public policy.

I am very puzzled by this.

Also, too, what Digby says.

All of this raises a question The Washington Post’s Paul Waldman raised two months ago: How is it possible that Clinton’s email brouhaha has marked her as thoroughly corrupt and dishonest, while Trump’s monumentally nefarious past, present and future are overlooked? Waldman’s assumption is probably the correct one: The narratives were set early in the campaign cycle, with Trump being the bigoted, crazy one and Clinton being the corrupt one. That’s just how the media frames the contest. They got it wrong. Yes, Trump is the crazy, bigoted one. He’s also a misogynist and worse. But he’s also the corrupt one, perhaps even more than most of us who had already understood that ever imagined.

Something vs. Nothing ought to win every time . . .

. . . but it's uncomfortably close. The New England Journal of Medicine informs thusly:

The editors invited the Democratic and Republican presidential nominees, Hillary Clinton and Donald Trump, to answer the following question for Journal readers: What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation? Secretary Clinton responded. Mr. Trump did not respond.

I expect he found it difficult what with his 200 word vocabulary. Anyway, you can read Hillary Clinton's response here. Sure, there's a lot of rhetoric in there and some non-specific promises but there are also some very specific, real and progressive items. Of course, they won't get through Congress unless Nov. 8 is nuclear, but for what it's worth here are a few highlights:

• Enhance tax credits to make insurance on the exchanges more affordable
• Public option in every state
• Medicare buy-in for people 55 and older*
• Streamline approval of generic drugs
• Require drug companies to justify their prices
• Allow Medicare to negotiate drug prices
• Expand payment reform
• Promote integrated medical and mental health care
• Expand funding for community health centers
• Assure access to affordable contraception and abortion
• Increase investment in medical research 

This is a real, progressive platform that would make a huge difference in people's lives. You can vote for it, or you can vote for nothing.

*Sets up the slippery slope to single payer national health care, in case you didn't get that.

The 60s

The death of Tom Hayden is a timely reminder of a previous turbulent time in our history. I was a teenager, and I just missed the Vietnam draft. (I turned 18 in the last year of the draft and had a high lottery number.) To me, and in my circle of friends and acquaintances, it as just normal and natural to view the U.S. as war in Vietnam as a crime against humanity, to see the government as largely an agent of plutocrats, the society as fundamentally racist, and capitalism as fundamentally exploitive.

I haven't really changed those views, but of course I'm more jaded now. The revolution never came, though we did make some progress. The 1960s left was male dominated and took patriarchy for granted; women were largely placed in a subservient role. As Hayden's obituary notes, he was part of the problem, and he eventually got slammed for it as feminism rose up within the left. Nowadays we see gender equality -- and gender equality going beyond the binary male/female categories we took for granted -- as being essential to progressivism.

George W. Bush got his illegal war of aggression but there was much more resistance early on than there had been to the Vietnam atrocity. We learned the hard lesson that the widespread resistance to the Vietnam war that eventually emerged was driven in considerable part by the draft that threatened middle class white kids. With no draft, the Iraq war, while controversial and ultimately repudiated by most responsible commentators and the public, generated far less passionate dissent.

Women and gender minorities have come a long way since the '60s, we did get Medicare and Medicaid, but the plutocrats still rule. In fact inequality has only increased. Racism is less socially respectable but I'd be hard pressed to say there is a whole lot less of it. The military-industrial complex is as entrenched as ever and we can't say the national surveillance state is less intrusive than it was in the days of J. Edgar Hoover. And what progress we've made on environmental protection faces continual rearguard action and we're pretty much neglecting the existential crisis of civilization facing humanity.

An extremist ideology has taken over one of the two major parties and managed to insert some false premises into the conventional wisdom, particularly that the national debt is an urgent problem and we need to cut entitlement spending, threatening the gains of the New Deal and Great Society. (Viz. Krugzilla.) Voter rights are under assault once again. I'm not sure whether Hayden looked back on his lifetime of advocacy with some small degree of satisfaction or if he felt essential despair. My own feeling is that progressive ideals generally have wider currency but do not have proportionate political effectiveness. I wouldn't say we've gone backwards but we're climbing the ratchet of progress very slowly.

Providence, RI exercises common sense

Our previous Director of the state health department convened an Emergency Medical Services working group, consisting mostly of fire chiefs and EMS personnel but also including me as the token academic. It was fun. I would wear the firefighter jacket I inherited from my father.

Anyhow, one of the big issues for EMS is what they call Frequent Fliers. I forget the exact percentage, but the majority of ambulance runs transport a small number of people who ride anywhere from once a month to, seriously, one guy who was transported 235 times in 2014. How can this be, you may ask? Well, a lot of them are incorrigible alcoholics. The problem for EMS is that they had no place to take them but the emergency department. There were legal and financial issues involved, as well as the simple lack of an alternative. As you presumably know, emergency departments are expensive and they have a lot of what drunks don't need and nothing that they do need. They'd just sit there until their blood alcohol went down, get kicked out, and come back a few days later.

So, it required an act of the legislature to do three things: protect EMS from liability for transporting people elsewhere than the ED; allow them to be paid for doing so; and create the place to take the drunks. The place hasn't opened yet but it's under construction. The people will get counseling and other services. Whether that will lead to any of them getting sober is unclear, but it will save the city and state some money and who knows, maybe it will actually help some people.

The strange thing is that it took so long to figure this out, and that most cities still operate as Providence has done until now. We just get stuck doing things the wrong way, it seems.

Back to the Knitting

Haven't posted for a couple of days because it felt like, what's the use? The world has gone insane. But what the heck, we're still here and there are still problems that matter so let's talk about some of them.

This week's NEJM puts the focus on serious mental illness -- the people who used to be in what were called "insane asylums" but are now more commonly living on the street or in prison. Lisa Rosenbaum discusses the history and the dilemmas created by the current situation. In a companion essay, Christine Montross discusses mentally ill people in prison.

You probably have heard about conditions in mental hospitals back in the day. They were indeed totalitarian realms in which patients were often degraded and abused. When antipsychotic drugs became available that could control symptoms of severe mental illness, a movement sprang up to move people out of mental hospitals and into supportive community settings. Everybody thought that was a great idea so they largely closed down the state hospitals and moved the people out. However, they didn't do part B, which was to create the supportive settings in the community. Part A saved a lot of money, or seemed to; part B would have required spending money.

So homeless shelters and prisons, rather than group homes, ended up replacing the asylum. Many people with severe mental illness can't behave the way prisoners are supposed to behave so they end up in solitary confinement. People who are (maybe) lucky enough not to be in jail are sleeping on the street. If you live in the city you see them all the time. And no, we aren't saving money. Prisons are expensive, and so are hospital emergency departments which people with serious mental illness land in with sometimes astonishing frequency. (Providence EMS, I am told, transported one individual more than 200 times in 2014.)

We might have a discussion of these issues in our political campaigns, or so you might think.

Threatened Sanity

As I may have mentioned once or twice, I have a long commute. I have what I am increasingly deciding is a bad habit of listening to National Pubic Radio under the misapprehension that I am making some positive use of the time.

Currently they are doing the common lazy journalistic stunt of rounding up random nobodies-in-particular and getting them to talk about why they are going to vote for candidate A or B.. In this case 50% of them are going to vote for the Cheeto dusted megalomaniac.

These people all have one thing in common. They are blithering idiots who presumably are able to dress themselves or they wouldn't be out in public, yet that seems implausible. I discovered that I cannot listen to their drivel so I have to turn the radio off for a couple of minutes until I'm sure it's safe.

Many people are now questioning the viability of our electoral republic. The tolerability of letting idiots vote is dependent on the proportion of idiots in the population and it is evidently much too high. Of course there is a disease vector for the epidemic of idiocy -- the corporate media.

There are signs that some editors are waking up to the horrific danger they have created. The New York Times has improved a bit in the past couple of weeks, although they are still gasping desperately for balance, as with a recent long-form piece discussing Bill Clinton's extramarital adventures. But even the victories are Pyrrhic. We're talking about how the candidate insulted a former beauty queen and whether he pays taxes. As Krugzilla notes, we aren't hearing a word about the crisis facing industrial civilization; and I could add, pretty much anything else of substance. Apart from the border wall and the Muslim ban, both of which may or may not currently be operative, the people don't know anything about policy differences. Well, okay, one candidate doesn't really have policies but he will sign everything that Paul Ryan and Mitch McConnell put on his desk and appoint Rush Limbaugh to the Supreme Court.

The discourse is so debased and depraved that it makes you wish for a philosopher king.

Why premiums are rising on the ACA exchanges -- and the deeper meaning

Health economist Uwe Reinhardt professorsplains it for you.

There are a couple of moving parts to keep in mind here. The first is that for any given health care service or product, the price is higher in the U.S. than in the rest of the world. It just costs more to deliver the same amount of health care here as it does elsewhere. There are a couple of reasons for this, which I'll mostly leave for another day, but this is a hard problem to fix because obviously those high prices are going into the pockets of people who are politically influential.

The next point, which Reinhardt shows you in graphic form (do lick link) is that 50% of people account for 97% of all health care spending, and the top 10% account for 65%. That's okay -- that's the whole reason why we have health insurance at all, because very few people in the top 10% have even a fraction of the income they would need to pay their own way. Health care is completely unlike other basic goods. We all need about the same amount of food, and the cost of basic shelter and clothing are about the same for everybody.

Now obviously if you're well off you can buy fancier food and clothing and bigger houses, but that's pretty much beside the point. Few of us want to consume more health care than we need -- with the exception of a very small number of people with psychological disorders, it's no fun at all, in fact it's often painful and otherwise unpleasant. And vanity cosmetic surgery is not paid for by insurance so that's also beside the point. Those people who are consuming a lot of health care need it.

So the way civilized countries solve this problem is that they give everybody basic health care coverage and finance it from some sort of a universal levy that has people paying a share they can afford -- simplest is a system funded from a progressive income tax, but some countries use kludgier systems just because.

Before Obamacare, people generally either had coverage through employment; or through government -- Medicare, Medicaid, military service and veterans' benefits. People were eligible for this coverage regardless of their need for health care, which meant broad risk pools including people who consumed relatively little health care, making the whole thing affordable. But people who didn't have coverage through these means couldn't buy insurance if they happened to be sick and actually need it, because it would be very expensive, precisely because otherwise uninsured people who were healthy would not choose to buy insurance and therefore they would be joining a very expensive risk pool.

So the Affordable Care Act forced participating insurers to issue policies to all comers, and to offer them all the same premium. The individual mandate was necessary to force young and healthy people into the pool, but for political reasons, the penalty was set much too low. Therefore insurers discovered that policies sold through the exchanges were costing them more than they expected, therefore they are jacking up the rates (or getting out of the market), which is just going to cause even more relatively healthy people to forego insurance and pay the penalty and so on. This is called the death spiral.

Solutions:

A) Jack up the penalty for not buying insurance. Stat.
B) Pay for universal health care through the tax system. Yes, that means higher taxes but you won't be paying insurance premiums, so you'll actually save money. (And if you get health care through your employer, you're paying for it whether you know it or now.)

But we have a weird, ideological aversion to anything called taxes. We want what they buy, but we don't want to pay for it. Because Freedom.

Brave New World?

There has been a lot of yammering but very little explanation or understanding of the baby recently born to a Jordanian couple which is purported to have "three parents." The technique which made this possible is illegal in the United States and apparently for some reason offensive to many people.

The baby does not have three parents, he has two. What he also does not have is Leigh's disease, which is the whole reason the procedure was done. But in order to really understand what happened, you need to understand something about the history of life on earth, which was not created in seven days 10,000 years ago.

Some time around 2 billion years ago (no way to be at all exact) one cell absorbed a smaller one, which survived and reproduced inside it and so the smaller cell's descendants continued to inhabit the larger cells descendants after the larger cell divided. The two cell types then evolved together as a symbiotic community. The smaller cell gradually lost most of its genetic material (some of it may have migrated to the nucleus of the larger cell) and was reduced to specialty functions, most notably as the manufacturer of Adenosine Triphosphate, the cell's energy source. The DNA that remains in the mitochondrion is only what is needed for mitochondrial functioning. It has not influence on the development or characteristics of the organism beyond any effect of defective mitochondrial functioning, an example of which is Leigh's disease.

The nuclear DNA is the DNA that combines chromosomes from the mother and father, and determines everything else about our genetic inheritance. The mitochondria are inherited exclusively from the mother through the cytoplasm of the ovum. You could vacuum out all the healthy mitochondria from a fertilized ovum (gamete) and replace them with equally healthy mitochondria from a different, completely unrelated person and the resulting human would be completely unaffected.

In this case, the mother had some healthy mitochondria and others that had a fatal mutation. She had enough healthy ones that she was not ill, at least not seriously; but there's no telling what the proportion of functional and non-functional mitochondria will be in any of her ova. Unfortunately, she'd had the bad luck to have two babies who were severely affected and who died young. What the doctors did in this case was simply to transplant the nucleus from one of her ova into another woman's ovum from which the nucleus had been removed, and fertilize it with her husband's sperm. Result: baby with two parents and no mitochondrial disease.

It had to be done in Mexico because it's illegal in the U.S. I await an explanation of why this is unethical.