Did I ever mention that we need universal, comprehensive, single payer national health care?

I may have noted that once or twice.

Anyway, as I have also noted, Obamacare is an improvement on what we had before. In fact it's worked better than expected! But it's a very kludgy fix.

The consulting firm Avalere Health, which for some reason sends me free excellent analysis every couple of days, finds a lot of "churn" in the exchanges from year to year. Specifically, only 1/3 of people who were enrolled in 2015 kept the same plan in 2016. They figure this is because most people who buy insurance through the exchanges are low income, and very sensitive to price. That means they are always shopping for a cheaper deal.

On the one hand, that doesn't sound like such a bad thing. In fact, if you're a conservative free market ideologue, you should be super duper happy. Consumer choice! Competition! Adam Smith!

The bad news is, however, that this likely means for many of them that they end up changing providers. Continuity of care is very beneficial. You know your doctor, your doctor knows you. You don't have to tell your story all over again, get records transferred, navigate unfamiliar systems. You get better outcomes. Even if your doctor retires or moves to Borneo, she can manage a smooth transfer to a colleague.

There isn't actually any benefit in this phony choice among insurance companies. If we had universal, comprehensive, single payer national health care then you could pick any doctor who had an opening and stay with him or her if you liked the relationship, or move on if you didn't. The single payer would get a single, fair price from everybody, and could pay for results, not volume. And the insurance companies wouldn't be skimming off profits, marketing and administrative costs. We'd all be better off.

But you know, soshulism.

The Chronosynclastic Infundibulum

As Vonnegut fans know, that's an anomaly in space-time where every possible belief is true, more or less. Or more accurately, where there are infinitely many ways to be absolutely right about everything. It's somewhat like post-modernism, or the 2016 presidential campaign.

My greatest philosophical conundrum is that I want to be respectful of democracy and to promote open discourse and dialogue; but you know, there are just some things that are true that I am right about and some people are flat wrong about. But how do I know this when the people who are wrong also know that they are right?

You most likely heard about Robert DeNiro back-dooring the Andrew Wakefield fraudumentary "Vaxxed" into the Tribeca Film Festival, only to reverse the decision after an organized outcry from the scientific community. (I've covered the issue here extensively but not for a while. Wakefield was a British physician, now de-licensed, who published a fraudulent study in The Lancet claiming evidence that the measles vaccine causes autism. He's disgraced, the paper retracted, and immense overwhelming evidence shows that it just isn't true, but Wakefield still has a small army of believers.)

So, of course, reporteth The Guardian:

By Monday, conspiracy theorist websites were portraying the decision to pull Vaxxed as an act of censorship perpetuated by the “vaccine mafia”. Wakefield and the film’s producer Del Bigtree put out a statement saying: “We have just witnessed yet another example of the power of corporate interests censoring free speech, art, and truth.” 

Now here's the problem. Corporate interests do have a big influence on what ideas and facts make it into the corporate media; and they have succeeded for long periods in concealing the truth from the people -- about lead, tobacco, climate change, and other important issues. How do I know if I'm being duped?

Well, in some areas I'm enough of an expert that I can read the scientific literature critically. I know enough about epidemiology that I can do that in the case of vaccine safety, and I have. There is a describable process of inference that has been applied to this question and there is an answer that satisfies everybody who understands how to read the literature critically. I can see the motivated reasoning and/or ignorance on the part of the anti-vaxxers.

In other fields, however, I do have to put more faith in the expertise of others. I've read enough about climate change to be convinced,  and honestly, I approached the question skeptically. But I haven't actually evaluated the models used to make predictions. I'm not competent to do so. I do know, however, that the proposition of a conspiracy involving thousands of scientists, hundreds of research institutions, and most of the world's governments, to promote this as a falsehood, is preposterous. I have to go with the maximum likelihood solution.

So no, you can't verify every question for yourself, but you do need to have a smart idea about which institutions to trust.

This and that

Sorry for the absence, been busier than I have been motivated.

Dan Drezner is right: it's no use writing about Donald Trump. What is there to add to the obvious?

The trouble with writing about Trump is that he has no complexity. There is no subtext to what Trump says or does — it’s all on the surface. He’s so basic that it’s impossible to find any deeper meaning or counterintuitive take.

As usual, you have to read European media to learn that the CIA took naked photographs of people before sending them off to be tortured by foreign co-conspirators. This was ostensibly to prove that the CIA hadn't beaten them up too badly before having somebody else do it (some of them were bruised, however) but sexual humiliation is also a war crime. But you know, we're looking forward, not back.

All these "Christian" legislators voting for bills to permit discrimination is getting old. Fortunately, Republican governor Nathan Deal is more beholden to business interests than he is to religious fanatics so he is going to veto the Georgia version. Note that these Christians who hate gay people are no doubt very supportive of the CIA sadistic psychopaths who got off on shoving various items into prisoners' rectums (as the Spencer Ackerman piece in the previous link reminds us). Today is a good day to say that I have had far more than enough of Christians.

Happy Birthday!

to the Affordable Care Act, which became law 6 years ago today. Now that we have all grown accustomed to the Death Panels and the government bureaucrats sitting between you and your doctor, not to mention the destruction of millions of jobs and the forced abortions, we can take stock of the good stuff:

• 20 million people have gained insurance
• Share of the population without insurance is below 10% for the first time ever
• Workers with no limit on out of pocket spending fall from 18% to 2%
• Health care prices have risen at the slowest rate in 50 years
• Premium growth for job-based coverage is sharply lower
• Federal deficit between now and 2025 is reduced by $353 billion
• Medicare trust fund projected to remain solvent for an additional 13 years
• Rate of patient harm in hospitals has fallen by 17%
• 565,000 Medicare hospital re-admissions have been avoided
• Businesses have added 14.3 million jobs

Thanks Obama!

I get e-mail

I have previously defended open access publishing here. It's a model of scientific publishing in which publication costs are paid for out of the grant funds that support the research, rather than subscriptions. Subscriptions to scientific journals can cost hundreds of dollars a year or even thousands, which means that only people with access to major university libraries can read many of them; and that even university faculty in low-income countries often cannot.

Science should be a democratic enterprise, available to all. So I'm all for open access. And there are important, reputable open access publishers, notably Public Library of Science (PLoS) and BioMed Central, among others.

Alas, the model invites scams. Just found a phony scientific journal, publish pretty much anything that comes over the transom, and collect the publication fees (typically $750-1,500). These execrable enterprises are proliferating like cockroaches; I have to delete solicitations from my in-box every day. They usually have a phony address in the U.S. but obviously originate abroad, and typically by people who do not speak English. This one I got today is pretty funny! Worth a laugh:

Peertechz salutes you for your compendium of writings which immensely help the global society and their descendants understand and shed light on and about Archives of Nursing Practice and Care. Your published manuscripts are evidence that you have innate ability and prodigies for research and writing. . .

But then again, we know that to gain the affection of an elegant author like you, we require some unmatchable spheres. So, here we are for you with some expounding uniqueness.

Join your writing ambitions with us and we assure that your manuscripts reach maximum hands. We invite you passionately to join Peertechz family.  

Should I go for it?

Comparative Terrorism

The bombings in Brussels are wall-to-wall in the corporate media and blogs. And yeah, it's a terrible occurrence. Funny thing though, there were two bombings in Turkey that killed as many people just last week, and you could be forgiven for not even knowing it happened. There were also numerous bombings -- terror bombings of civilians, not collateral damage of combat -- in Iraq, but that's pretty much routine so who cares, right?

There is a good deal that can be said about the many wrong and counterproductive responses to such events. But I'll just say that the tribalism shown here -- Christian, European victims matter, southwest Asian Muslims don't --  is a good place to start thinking about the problem in a different, and better, way.

You can't put a price on human life, right?

An odd glitch in the conservative mind is the claim, on the one hand, that human life is infinitely precious and it would be a crime to "ration" health care; and on the other that environmental, worker and consumer safety regulations are intolerable because they cost too much.

Obviously nobody actually believes that human life is infinitely precious or that you can't put a price on it because we put a price on human life all the time. Cars and highways, workplaces, stores and restaurants, homes, sidewalks, public parks, every environment that people spend time in could be made safer by spending more money. The air and water could be cleaner, the food supply could be safer. But we balance the benefits of regulation against the costs. (I'll leave war, guns and the death penalty out of it for now because that leads into other thickets.)

Conservatives generally favor spending less on public safety in all of these domains, because it would "burden business" and force people to pay taxes. Yet for some reason the equation flips when it comes to health care. Not spending hundreds of thousands of dollars to extend a life -- even a hopelessly compromised and limited life -- by even a short time is unconscionable. Note that this only applies to people who happen to have insurance, however. Which means that other people are paying for it. People who don't have insurance, and can't pay? The rest of us have no obligation to them.

Before you can even being to think about health care policy, you have to get your thinking straight on this. Resources are finite. There has to be some mechanism for allocating them. You and I may have different ethical principles, but at least you need to be consistent. Conservatives, of all stripes, whether libertarian or religious, are not.

Why we need the death panel

The UK's National Institute for Health and Clinical Excellence, which is abbreviated NICE because a) that sounds, well, nice and b) the word health was added to the name later, is an essential institution. I do not expect to see an equivalent in the U.S. in my lifetime. (I'm not sure if you can get behind the paywall for the link.)

This is a subject I used to write about a lot here and then I figured okay, I've been there and done that. But it was a few years ago and the political context has changed, so I'll revisit. NICE is not actually much like Sarah Palin's imaginary death panels. It doesn't rule on individual cases. (Well, there's a bit of an unfortunate exception, which I will get to, but it has been mostly reversed.) Rather, it decides whether the National Health Service will pay for specific treatments for general classes of people, and yes, it includes cost in the calculation.

I will write about the complexities of this at greater length in future posts, but today I will just set up the basic problem, which is absolutely inescapable. The National Health Service provides comprehensive health care for all of Her Majesty's subjects. The parliament approves a finite budget for the NHS every year. Ergo, said comprehensive health care must have limits, because it must be provided within said finite budget.

Q.E.D.

Our situation in the U.S. is comparable to the extent that we do provide government funded health care for everybody 65 and older. We do so as an entitlement, which means Congress does not limit spending on Medicare. This means that Medicare has to pay whatever the drug companies want to charge for say, cancer treatments that might extend a person's life by a couple of months. We do not, however, provide universal comprehensive health care to everybody under age 65, the ACA notwisthstanding. And there is a lot more we don't do that the Brits do, even under their current comparatively stingy Tory government. The point being, resources are finite and every country makes political decisions about how much to spend on what. In those decisions, some people die who would not have under a different allocation scheme. There are always death panels, even though they are mostly invisible. There always will be and there always must be.

So, how does NICE actually make these calculations? We'll discuss that next. 

Hillary's Brain Fart

I'm sure you already know that Hillary Clinton praised Ronald and Nancy Reagan for their courageous advocacy on behalf of people with AIDS . (I give you Dan Savage's horrified response.)

As with the recent death of thuggish legal sophists and enemy of humanity Nino Scalia, there seems an inexplicable reflex on the part of people who ought to know better to come up with praise for the departed which is a) completely the opposite of the truth and b) counterproductive to the interests and purposes of the speaker.

Death does not erase history. While it is arguably impolite to offend people who are acutely grieving, I do not think that Nancy Reagan's family and friends particularly needed to hear Hillary Clinton say something nice about NR that wasn't true. I actually don't have anything nice to say about Nancy Reagan, and I think it's important that political discourse be ruled by fact, so I won't make anything up. I don't think she was particularly important, except as a bad example. Her signature cause as First Lady was going around saying "Just say no to drugs," which was singularly unhelpful because it did not cause people to say no to drugs and it substituted for actually doing anything about drug abuse (which includes alcohol and tobacco and therefore the slogan was doubly misleading.)

Other than that she advised her husband on the basis of astrology. Those were her contributions. Enough with the crocodile tears.

Suffer the Children

JAMA has an interview with Mona Hanna-Attisha, a pediatrician in Flint Michigan who oversaw the tests on children's blood lead levels after the contaminated water was discovered, and now leads efforts to take care of the kids. This is a disaster that will reverberate for decades, cost taxpayers untold tens or hundreds of millions of dollars, and of course most important, damage hundreds of children. As Dr. Hanna-Attisha says,

[T]he consequences of lead exposure are forever. It [has long-term] impacts [on] cognition and behavior: those are the 2 we care about most. It affects every organ system. It drops IQ. Imagine what we have done to our entire population: we have shifted the IQ curve down. It impacts behavior, so it causes lots of problems with learning, focusing, conduct disorder, impulse disorder, and it has even been linked to criminality. Lead has these life-damning consequences.

 The doctors found that the prevalence of acute, detectable lead in blood in flint more than doubled, to 4.9%, but that's an underestimate. We don't even know how many children are affected because many of them were poisoned as infants and may not have been tested in time to discover it. We haven't worried much about infants in the past because most lead exposure has come from paint and kids who aren't crawling around on the floor yet and aren't engaged in hand to mouth activity weren't considered at risk. But Flint is a different story. As the good doctor says:

Our population was already rattled with toxic stresses. We have a 40% poverty rate, high rates of unemployment, high rates of violence, and high rates of single parents. We have no grocery stores in Flint. The people in Flint have a 20-year lower life expectancy than people in a neighboring suburb. We were already struggling with every barrier to our children’s success. Then we gave them lead. This is added toxic stress to the toxic stresses we already had. . . .  Parents are traumatized. For almost 2 years, we were betrayed. There is a huge lack of trust in the government and a fear of the unknown.

Rick Snyder is still the governor, still drawing his salary, still sitting in the corner office, putting his own kids in private school, no doubt. [I don't actually know that.] That's not where he belongs.

Cartoonist David Rees has only one shortcoming . . .

He can't draw. Therefore, he asks readers to render his ideas for cartoons in actual art work.

I fear this particular idea is impractical, but if you have a knack with a pencil, do give it a try.

I get that you're worried about who might have his finger on the button next January . . .

but this should take your mind off of that. (Sorry, no consolation.) Eric Holthaus discusses the ongoing global temperature anomaly and it's yuuuuge. The climate goals negotiated last year in Paris aimed at limiting warming to 1.5 degrees centigrade by the end of the century. Well, it's probably temporary but the last couple of months, we're already there.

There is no snow on the ground in Anchorage, so they sent in a trainload of snow to make the Iditarod sled dog race possible. The arctic sea ice reached its lowest maximum extent since data collection began, and the south Pacific just experienced the strongest cyclone in history.

We aren't talking 2030 or 2050. We're talking right now. Today. But who needs Miami Beach anyway?

We've always known drug companies are evil

Now it turns out they sell expensive cancer drugs exclusively in doses that are too large for the average person, forcing $3 billion a year in excess chemicals to be paid for, and then discarded. (Basically the clinics that administer the drugs aren't allowed to keep the excess to use on somebody else.)

Yes, drug companies are evil. But the reason this continue is because there is plenty of evil to go around. The doctors who administer the drugs sell them to patients (or their insurance companies) at a markup, and they charge for the waste. So they aren't complaining. And the FDA can only regulate drugs based on safety and effectiveness, Congress does not allow them to regulate based on considerations of cost. In Europe, these same drugs are sold in smaller quantities so there is much less waste.

Yes, this is the magic of the Free Market™ at work.