Map of life expectancy at birth from Global Education Project.

Saturday, April 22, 2017

This is amusing . . .

Someone (an anonymous coward) wrote this in a comment:

Imagine trying to explain to a bunch of liberal professors that in the history of the world, no other economic system has created more wealth for more people than capitalism. It just goes against their deeply held socialist and political beliefs.
It's fascinating what people think goes on in universities. In all of my travels through Tufts, Brandeis,  Boston University and Brown University as a graduate student and faculty member, I have never met a single liberal (or other) professor who does not know that economies that fall broadly into the classification of capitalist have become the wealthiest. As a matter of fact (funny thing here!) Karl Marx believed that capitalism was the most dynamic economic system for creating wealth. Nowadays, there are very few professors anywhere in the U.S. who think that Marx mostly had things right, but even if there are a few, they do not need to be convinced that "no other economic system has created more wealth than capitalism." All those liberal professors, with their briar pipes and leather patches on the elbows of their tweed jackets, believe it or not, actually know this.

However, economists -- and other people who think about the economy, such as sociologists, political scientists, and historians -- have various viewpoints about how best to organize and manage complex, modern economies. Capitalism, as I have suggested, is quite a broad concept and there are many capitalist economies in the world today, and in history, that have had differing characteristics. I should also add that the term "socialist" has come to be conflated with Soviet communism, which leads to much misunderstanding.

In Europe, the term "democratic socialism" as most people use it refers to advocacy for a program in which government assures certain standards of welfare within an entrepreneurial, market economy. As in the U.S., there is also some amount of government enterprise and economic activity -- perhaps our correspondent has noticed that someone maintains the roads, puts out fires, educates children and so on. People who call themselves socialists may want to see government do more to invest in human, physical, and intellectual capital than it does now. But socialism as it is commonly used today really refers to a form of capitalism.

Economists today -- even respectable conservative economists -- understand that markets are not forces of nature. They are social constructs. They require various forms of regulation and public infrastructure to function. The question is how best to structure and regulate them, not whether they ought to exist.

If you are interested in what liberal professors really think and argue about the economy, you might check out the blog of Bradford DeLong, a Berkeley (I know) professor, which is very active and has all sorts of interesting material pretty much daily. He's an economic historian, so there's a lot of emphasis on that, but there's plenty of other stuff as well.

Educate yourself, is always my advice.

Friday, April 21, 2017

Science and Politics

I would imagine I don't have to tell you that I think objections to the March for Science on the grounds that science shouldn't be "politicized" are absurd. Science is already politicized, which is exactly the point. Here's one take that's worth reading from Tim Requarth.

We eggheads get all scrambled trying to understand why people just won't listen when we 'splain the scientific truth to them. As Requarth explains, the problem isn't that they have a knowledge deficit that we can plug with our smart words. It's that they are motivated to believe by particular interests or loyalties. Scientists spend years getting their brains trained to apply certain standards of evidence and to change their conclusions when the evidence calls for it. But that makes us weird.

Here's Dave Levitan on the ways politicians deny and distort science. One pull quote I like:

Q. The “I’m not a scientist” line has become all-too-common, and it’s the basis of your book title. Why is this refrain bullshit in your view?

Dave Levitan: The basic reason is it's absurd for politicians to have to tell us what they're not an expert in. They don't say I'm not an economist. They don't say I don't have a degree in Middle Eastern studies or civil engineering, yet they're still perfectly willing to opine on these issues. So it's sort of a bizarre subset that they think it's a reasonable thing to say.

Here's why this is hard to talk about. We do claim to be experts in our fields, and we do make a privileged claim to truth. Cosmologists do not consider the age of the universe to be subject to debate (within a margin of error); biologists do not consider the fact of evolution and the antiquity of life (again, within a range) to be matters of opinion; climate scientists state that anthropogenic global warming is a fact, no longer a hypothesis. An if you disagree, you are just wrong. We know more than you do.

People don't like to hear that. However, as Levitan suggests, they commonly make exceptions. They respect the expertise of their physicians, plumbers and auto mechanics. On the other hand, I have to agree, all three categories of professional are capable of corruption, and of fudging or even lying in the service of a bigger paycheck. People might think that scientists are doing the same, to get grants or whatever.

Here's what's wrong with that. We aren't one auto mechanic trying to sell you a transmission rebuild that you don't really need. Science is a community of millions of investigators, graduate students, research assistants, and administrators. There is nothing that a scientist wants more than to prove that everybody else was wrong and get credit for a breakthrough. And there is no way that all those people are somehow going to successfully conspire to fool the entire world, and nobody is going to blow the whistle on them.

But it's also hard to explain to people that errors do happen -- in fact, we think that in some sense, everything we think we know is wrong because we can ultimately find a more precise answer. But the errors get fixed, the precision increases. Newton's theory of gravitation has been supplanted by Einstein's. In a sense Newton was "wrong," but he was a lot closer to the truth than Ptolemy. There is some question now about whether general relativity is exactly correct. Maybe physicists will improve on Einstein some day. They're trying really hard! But relativity works well enough for the Global Positioning System and robot probes to Jupiter, so you'd be a fool to deny it.

So I'm not sure what to do. Trying to explain stuff to people that they are motivated not to understand isn't going to get us very far, especially if they feel they are being talked down to or what they think is their own expertise isn't respected. Well sorry, but if you aren't an expert in physics and biology then no, you don't know as much as somebody who is. You should try to learn more if you are interested, but you need to approach that learning with a truly open mind. And if you can't be bothered, that's fine too, but then you need to stop thinking you know better.

* Mine is policy and practice related, so it's factual basis does inevitably get mixed up with values. But I find a lot of critics here don't succeed in separating out my factual assertions -- they end up arguing against facts because they are unwilling to state their value disagreements.

Tuesday, April 18, 2017

Too Long, you don't have to read . . .

. . . because I'll tell you, as a follow-up to my previous post. David Gorski has good things to say, as he does here, but if brevity is the soul of wit Dr. Gorski is not at all witty. (I think he already knows that but he can't help himself.)

Anyway, so-called "Right to Try" legislation has passed in 33 states, and an effort is underway to pass a federal version. This is one of those policy ideas that looks great on a bumper sticker and is impossible to refute in 30 words or less. Since the voting public gets turned off by wonkery, politicians who know better duck and cover when these proposals come along, so they pass.

The idea is that terminally ill people should have the right to try experimental treatments. Maybe they haven't been proven safe and effective yet, but they got through the first round of trials so it appears they might work, and what have you got to lose? You're dying! Why would the nanny state deprive people of a chance to extend their own lives if that's what they want to do?

Okay. First of all you need to know that the formal process for drug approval consists of three "phases" of trials. Phase one just consists of giving small and gradually escalating doses to a small number of patients, maybe 30, just to establish a level that doesn't produce acute toxicity. Passing this stage is all that is needed for the "right to try" to kick in.

But these drugs may not even have passed phase II trials. These are somewhat larger and last longer. They are underpowered to prove that a drug is safe and effective. They are intended to establish that the trends are in the right direction and that no obvious safety issues emerge in longer term use, so that the much larger investment in a Phase III trial can be justified. Only after successfully completing at least one Phase III trial can a drug be considered for approval.

It turns out that only 30% of drugs that enter Phase II trials even go on to Phase III, let alone win ultimate approval. So the first thing you need to know is that the likelihood that people could benefit from "right to try" is lower than you probably thought. Since the ostensible beneficiaries are already terminally ill, it's actually extremely low. Even safe and effective drugs are almost never miracle cures -- they might extend life for cancer patients if used early enough, but they almost never reverse advanced cancer. And yes, they can indeed harm people.

Terminal illness is actually a pretty loose concept. Doctors are very bad at predicting how long people have to live; it's very common to outlive a prognosis of 6 months to live, by a lot. So it's possible to significantly shorten the life of a person with a supposedly terminal illness. It's also possible to make them sicker. So gambling with an unproven treatment is not a no-cost bet.

And "right-to-try" legislation forbids insurance companies paying for these treatments, at their own insistence. That means the legislation affects only people with the means to pay out of pocket; and the drug companies can charge whatever they want, which is probably a lot. So you're handing over your kids' inheritance for something that is more likely to harm you than to help you.

Finally, the existence of "right-to-try" may deter people from participating in clinical trials in which they might get the placebo. Which means it will be harder for us ever to know for sure whether the stuff works. The proposed federal legislation is even worse because it actively forbids the FDA from taking adverse events in "right-to-try" patients into account in evaluating the treatment. The only point of that is to relieve the drug companies of all risk.

This is nothing but a cynical move to take money from desperate people and give it to drug companies, under cover of fake compassion and the usual nonsensical libertarian arguments. The FDA already has the authority to approve "compassionate use" of experimental medications on a case-by-case basis. That's how it should stay.

Thursday, April 13, 2017

Libertarian pharmacy policy

It's a famous story. Thalidomide is a sedative which was prescribed for morning sickness in pregnant women, starting in about 1960, in countries around the world. Not, however, in the U.S., because an official of the Food and Drug Administration named Frances Kelsey felt the application had insufficient data on safety, including whether the drug crosses the placenta. Turns out it does, and it can cause severe birth defects in which babies are born with flipper-like limbs.

At that time the FDA did not oversee clinical trials, and it pretty much took the drug companies' word for it about safety. As the linked article says:

The tragedy surrounding thalidomide and Kelsey’s wise refusal to approve the drug helped motivate profound changes in the FDA. By passing the Kefauver-Harris Drug Amendments Act in 1962, legislators tightened restrictions surrounding the surveillance and approval process for drugs to be sold in the U.S., requiring that manufacturers prove they are both safe and effective before they are marketed. Now, drug approval can take between eight and twelve years, involving animal testing and tightly regulated human clinical trials.

Drug companies don't necessarily like this. Some do, because they feel they depend on their reputation for safety, although as we have discussed here many times they frequently game the system by keeping unfavorable trial results hidden, and other unsavory practices. Recent efforts at reform have aimed at improving the system, by requiring registration of clinical trials and public availability of all results, among other reforms.

Comes now a reality TV star who wants to appoint as FDA commissioner a man with no research experience or academic background who is an investment adviser and member of pharmaceutical company boards. As Daniel Carpenter informs us in NEJM, "The Trump administration’s approach to the Food and Drug Administration (FDA) is guided by a libertarian belief in markets over science, and Gottlieb apparently shares this view." The idea is that bad drugs will be driven out of the market by consumer experience.

Of course, if your baby is born without arms it will be a bit too late for you, but that isn't the only problem with this philosophy. Lots of diseases and symptoms get better on their own. You can't necessarily tell whether the medication helped or not. Nor do you necessarily know that an adverse effect is attributable to the drug. You should read Carpenter's essay, but here's how he finishes:

The medical community and the Senate should greet this nomination with scrutiny. To this end, I propose some questions for Gottlieb. Perhaps the most important is one that can be answered only by his behavior: Will Gottlieb, if confirmed, listen more to FDA scientists or to his Trump administration superiors, corporate-board colleagues, and think-tank associates? At stake is not just the FDA, but the scientific regime of clinical pharmacology and the credibility of American therapeutics.

Questions for Scott Gottlieb.

  • • You will have to recuse yourself from decisions about certain companies’ products because of conflicts of interest. How many companies, and which ones?
  • • You have argued that there are “interim endpoints that can be used to more quickly gauge a medicine’s benefit.” Under your leadership, how would the agency commit to restricting the use of a drug or removing it from the market if later-stage evidence turns out to present a much weaker benefit profile?
  • • You have argued that the FDA has an “unreasonable hunger for statistical certainty.” How, then, do you explain the fact that the FDA approves new drugs and devices more quickly than any other regulatory agency? Do you see accelerated approval, compassionate use, and breakthrough designations as inadequate, and if so, why?

Wednesday, April 12, 2017

Saint Ronald

Iraq and Iran fought a horrific war from 1980 to 1988. Saddam Hussein was unquestionably the perpetrator. He repeatedly used chemical weapons against Iranian troops, then in 1988 he attacked the Kurdish village of Halabja, in northern Iraq, with mustard gas, killing thousands of civilians.

The president of the United States was conservative demi-God Ronald Reagan:

In 1983, President Reagan sent a special envoy to Baghdad. He was Donald Rumsfeld, and that visit resulted in the now famous picture of Rumsfeld shaking hands with Saddam Hussein. This was in December of 1983. This was at a time when the US was secretly aware that Iraq was using chemical weapons against the Iranians almost daily. There's evidence that the battlefield intelligence provided to Iraq helped the Iraqis better calibrate their gas attacks against the Iranians. Around this time, the administration concluded that Iraq's defeat in the war would be contrary to US interests in the Persian Gulf. The economic aid to Iraq started in 1983, and by the end of the war amounted to more than a billion dollars. . . .

Near the end of the war when Saddam Hussein used chemical weapons against his own citizens, the Kurds. We know a great deal about this now. At the time, the United States prevented a move in the UN to impose economic sanctions against Iraq, saying that the sanctions would be useless or counterproductive. So in effect, the United States defended Saddam Hussein's use of chemical weapons even as late as 1988, and this kind of a relationship continued through the Reagan administration and into the first President Bush administration until the very day that Iraq invaded Kuwait in early August 1990.
Just so you know.

Thursday, April 06, 2017

Gas Schmas

It's interesting that the Assad regime's nerve gas attack on a village in Idlib has generated sudden outrage, including from people who thought Assad was just peachy until yesterday such as the White House resident. We're having an emergency meeting of the UN Security Council and the U.S. is threatening to take unilateral action -- presumably meaning bombing some things and people -- if the UN doesn't act.

I agree that it is bad to attack civilians with poison gas. It is also bad to blow up 3,800 people using rockets and artillery shells, summarily execute tens of thousands in mass hangings, blow up hospitals and mosques, and starve people to death. The Assad regime did all of that, and more, before the nerve gas attack, which was apparently okay.

Look, I'm against all kinds of war. But to freak out over chemical weapons in this way is to imply that bombing, torturing and starving people is okay. This is an idiotic, meaningless distinction. We need to get over it.

Thursday, March 30, 2017

More simple proof that libertarianism is a crock

The right to ride a motorcycle on public highways without a helmet is a classic liberty claim. So what if it's risky, or the nanny state thinks it is? It's my right to make the choice -- it's my life.

As the linked essay by Busko, et al demonstrates, it is in fact risky, although opponents of helmet laws will often proffer alternative facts. In 1967, under the oppressive rule of Communist president Ronald Reagan, the Department of Transportation issued a program standard making helmets mandatory for motorcyclists, and congress voted to withhold federal highway funds from states that didn't enforce the guidelines. Soon, all but three states had helmet laws. There ensued a sharp decrease in motorcycle fatalities and head injuries.

All glory to Her Holiness Ayn Rand, freedom again prevailed in 1976, when people's choice president Gerald Ford signed legislation repealing the mandate. The following year, motorcycle-related fatalities increased by 23%. Free at last, thank God almighty we're free at last! By the way, just so you know, motorcycle fatalities are 14% of traffic deaths, even though motorcycles account for less than 1% of miles traveled; and motorcyclists are 27 times as likely to die in a crash as automobile occupants. Have fun!

Now maybe you think it's just fine if fools want to kill themselves and it's no business of the government to tell them not to. (I won't speculate about what freedoms you don't want people to have, I'll stipulate for the sake of argument that you aren't an outrageously blatant hypocrite. But do think about that.)

Here's the problem.  Two thirds of the cost of treatment for motorcycle-related injuries are borne by the public, mostly Medicaid. Bikers who are disabled cannot work, and usually become public charges. They, along with the dead ones, no longer pay taxes and their families are deprived of support, may also become public charges, and in any event their children and other loved ones will suffer. While your liberty to be a moron is at stake, so is my liberty not to have to pay for your foolishness.

This is the fundamental problem with libertarianism. All decisions involve tradeoffs between one person's liberty and another's. Your liberties don't stop with you.

Tuesday, March 28, 2017

Ratcheting up

Here's a long form piece in the Gray Lady about the history, present and likely future of Medicaid. I think you should read the whole thing but I'll give you a couple of pull outs.

Medicaid started small, as a minor add-on to Medicare. Originally, it was coupled to what was generally called "welfare," Aid to Families with Dependent Children, and hardly anybody noticed. But over the years, bit by bit, Democrats managed to expand its scope to include people with disabilities, elderly people in nursing homes, and low income families that were not on welfare. By now, the assumption that able-bodied adults should be able to afford health insurance is decisively false.

In fact, far from creating a culture of dependency and discouraging people from working, Medicaid makes work possible for people with children with disabilities and/or severe health care needs; or elderly relatives who need care. And it keeps people in the labor force who need health care to be able to work. So part of the cost is recouped in taxes. Anyway, people generally don't seem to understand that government spending isn't like household spending. Every dime spent on Medicaid is income for health care providers, pharmaceutical and medical device manufacturers, and related services; and profit for shareholders.

Medicaid pays for half of all childbirths in the U.S. A large majority of Americans either benefit from it themselves, or have friends and relatives who do. The Republicans' disastrous American Health Care Act would have taken Medicaid away from the population that benefited from the ACA expansion, and then gradually reduced funding over the years forcing the states to spend more of their own money, or drop beneficiaries and services. That turned out to be politically impossible.

The Republicans aren't going to take away Medicare or Social Security either. Once people got these benefits, and realized how much better they made life for everybody, eliminating them became politically impossible. He was obviously lying, as he always does, but when Ronald T. Dump was campaigning for president, he promised to protect Medicare, Medicaid and Social Security, and even to provide health care for all. He knew he needed to speak those lies in order to have a chance. Of course, in reality, he supported Paul Ryan's bill that would have destroyed Medicaid. But they failed. Now we can go about the business of continuing to expand Medicare and Medicaid, providing a public option on the ACA exchanges, and one day --

Universal, comprehensive, single payer national health care. That is our right.

Monday, March 27, 2017

Reclaiming Truth

When the Internet, and particularly the World Wide Web were young, many people had a utopian vision of a global free market of knowledge and ideas. Everyone could contribute to the total mass of truth, logic and debate, and we would ultimately enter an age of enlightenment.

Something like the opposite seems to have happened. Lots of people have gone through the looking glass into their own alternate realities. We have a "president" who lies so habitually that it's a surprise if he says anything that's true. Yet his true believers enthusiastically follow him into opposite world. We have the outlandish pizzagate, global climate change denial, birtherism  . . .

A partial explanation is this concept of blue lies. (Apparently that's supposed to be somewhere between white and black but I think it's horribly kludgy term.) The idea is that lies that don't hurt your own tribe or in-group, but are directed outward, strengthen group solidarity. It overlaps somewhat with confirmation bias, because deciding we were wrong about something doesn't only threaten our own ego, it may threaten our group identification.

I don't claim to be completely immune from these afflictions, but I think I'm less susceptible than most, because I am trained as a scientist and I make a conscious effort to practice critical thinking. I work hard all the time to evaluate evidence and not to come to firm conclusions that don't have strong support. And I do change my mind when confronted with good evidence that contradicts my previous beliefs. That is why, for example, I am now an atheist after once preparing for confirmation.

We are in desperate trouble if we can't get more people to think critically and start basing their beliefs on good evidence. The first thing people need to do is put more trust in the scientific enterprise. Yes there is scientific fraud and there are unreproducible findings. Scientific claims lie along a continuum of credibility. Don't believe the hype about a single clinical trial or a finding in laboratory rats -- it's a long way from initial observations and hypotheses to strong scientific consensus.

However, there is a great deal that we know. The universe is more than 13 billion years old. Life on earth is more than 3 billion years old and we got here by way of evolution. People are burning so much fossil fuel that we are putting carbon dioxide into the atmosphere at a rate which is causing the climate to warm, storms to become more violent, and the seas to rise. Cutting taxes on wealthy people does not make working people better off. And so on. We need to accept a common reality, or we are doomed.

Friday, March 24, 2017

The Art of the Fail

Orange Julius spent the campaign, the transition, and the first month of his occupancy of the office of president proclaiming that his great new health care plan would cover everybody, with better health care, at lower cost. Only a few fringe lunatics like Paul Krugman and Cervantes had the audacity to claim this was not possible.

After 8 years of screaming about death panels and socialism, and passing -- what was it, 36? -- bills to repeal the ACA, secure in the knowledge that president Obama would veto them, Republicans suddenly found themselves in the untenable position of actually being able to do what they had campaigned on for the past 8 years. What we learned from the exercise is that they do not in fact know anything about health care policy.

There is no such thing as a free market for health care, there are no free market solutions, and the only way to secure liberty for people is through a market that is structured and regulated by government. The best way is universal, comprehensive single payer national health care; but some countries manage to do it with kludgier solutions. Switzerland, for example, has Obamacare +. It has private insurance companies competing for customers, selling tightly regulated policies. They cut out the middleman with the individual mandate and subsidies, and instead give everybody a voucher to buy insurance, funded by taxes. Britain has real socialized medicine, with physicians as government employees. Canada's physicians are mostly private entrepreneurs, but their customers have insurance provided by the government.

There are a few ways to do it but the reality is:

  • Every affluent, capitalist democracy on earth spends less -- a lot less -- on health care than the U.S.
  • Every one of them covers 100% of their citizens and legal residents, with good, comprehensive insurance.
  • Their populations are healthier than ours and live longer.
  • Their people are more content with their health care systems than we are.
  • They all enjoy freedom or liberty or whatever you want to call it more than we do, because they don't live in perpetual fear of being wiped out by serious illness or dying on the street. 
This is reality. It is the truth.  There are no alternative facts.

Sunday, March 19, 2017


Really, fucking nuts. The news media and politicians of all stripes are struggling with how to respond to a "president" who is manifestly insane.

To be clear, I have absolutely no interest in this ridiculous debate over whether psychiatrists should apply a diagnostic label to him. The very idea that there are entities called "personality disorders" that constitute specific, identifiable diseases is nonsense, as far as I'm concerned. Some people behave in ways that create unnecessary difficulties for themselves and/or others. There is nothing to be gained by declaring that this person has "narcissistic personality disorder," or "psychopathy," or whatever word you care to sling.

But, he does what he does, which is to habitually assert preposterous falsehoods and then refuse to back down in the face of overwhelming evidence and reason; and order his flunkies to participate in his alternative reality. That is insane, in the vernacular use  of the word.

Here is one take from the estimable Josh Marshall. "The real story here is that the President, by force of his office and audacity, was able to inject into the national conversation a preposterous claim which the country has spent two weeks debating. . . . I would say that this ability - both the President's pathological lying and our institutions' inability to grapple with it - is the big, big story." He concludes that "this is a warning case of people in power deciding what's true and false which is a harbinger of free government dying." (I draw to your attention what I believe is the relatively new motto of the Washington Post: "Democracy dies in the dark.")

However, I am more inclined to Simon Malloy's view. The fact is that nobody except for Trump's equally deluded juggalos credits his fantasies. The spectacle of Republican politicians trying to evade forthright comment, or of reporters unable to find the letters l, i and e on the keyboard is disheartening, but none of this will lead to any sort of concrete result. In other words the Justice Department isn't about to prosecute Barack Obama and the U.S. isn't going to recall the British ambassador. (No doubt about that -- there isn't one.)

So for the immediate term, this is basically a distraction. The real danger is that we have a "president" who nobody with any sense will believe about anything. So what happens when there is a crisis of some sort and the nation, and the world, depend on presidential leadership? Congress doesn't have to pass the worst atrocities in his budget proposal, and they won't, but the time will come when a president with no  credibility will be catastrophic.

Monday, March 13, 2017

And another outrage you probably never heard about

A component of the Affordable Care Act which doesn't get a lot of attention is called the Prevention and Public Health Fund. Most of the money goes to CDC which uses it to track disease outbreaks and get vaccines to places where they are needed and vaccinate people who can't afford to pay. It also sends $625 million a year to the states, which using the money for vaccination and other preventive services. The bill in congress to "replace" the ACA eliminates all of this funding.

The BMJ asked the Dept. of Health and Human Services whether this has anything to do with "president" Trump's belief that vaccination causes autism, but got no response.

Now, if you're a Republican, you think that government spending is evil a fortiori because it requires taxation. But you might consider the following information from the linked article:

The $1bn funding also covers all of CDC’s lead exposure testing and risk reduction efforts. CDC estimated that the current rate of lead exposure, with at least 535 000 children with toxic blood concentrations, will cost America $59bn in lost lifetime productivity. Research has shown that each dollar spent on reducing exposure to lead delivers a return of $17 to $221.5

CDC has estimated that vaccination among American children born from 1994 to 2013 would prevent around 21 million admissions to hospital and 732 000 deaths over the course of their lifetimes, with a net savings of $295bn in direct costs and $1.38 trillion in total societal costs.6
But it's more important that rich people not pay taxes.

Tuesday, March 07, 2017

Okay, so why Trumpcare?

Ezra Klein is puzzled. Why are the Republicans in congress proposing an Affordable Care Act replacement that will:

  • Balloon the federal deficit;
  • Take insurance away from maybe 15 million people; and
  • Make it more costly for millions more
  • Destroy the market for individual insurance
Klein says: :

It is difficult to say what question, or set of questions, would lead to this bill as an answer. Were voters clamoring for a bill that cut taxes on the rich, raised premiums on the old, and cut subsidies for the poor? Will Americans be happy when 15 million people lose their health insurance and many of those remaining face higher deductibles? 
Well, the voters weren't clamoring for cutting taxes on the rich, but that's all the Republicans in congress actually care about. But Krugthulu has one additional point:

Obviously, Republicans backed themselves into a corner: after all those years denouncing Obamacare, they felt they had to do something, but in fact had no good ideas about what to offer as a replacement. So they went with really bad ideas instead.
Not to worry, it isn't going to pass as it is. But I still expect something bad to happen.

Monday, March 06, 2017

The worm Ouroborous

We don't expect the reporters who work for the corporate media to be very intelligent, so let me help them out.

Donald Trump is the president of the United States. If he has information that Barack Obama ordered somebody (presumably the FBI) to "tap his wires," as he put it, for political reasons, he can produce it. It is within his power to declassify and make public any information at all. For him to call for a congressional investigation of this charge is ridiculous. The congress would simply subpoena records which are, at this very moment, in his possession. He is asking them, in other words, to investigate himself in order to force him to produce what he can already produce if he so chooses.

Ergo, no such records exist and he is a big fat liar. But we already knew that. The problem is that our "journalists" can just say so. Oh yeah, then there are those Republicans in congress  . . .

Then there's the case of James Comey, who is screwed, but I have no sympathy for him, it's his own fault. Expect him to be fired shortly. Then the DoJ Inspector General's report will come out . . .

Tuesday, February 28, 2017

Death, doubt and doom loom.

Bazz fazz. (All of the above quoted from Pogo.)

Admittedly we have enough to be worried about but this at least is solvable. The WHO once again raises the alarm on antibiotic resistance. Not that this blog hasn't passed this way before, but the problem isn't going away. We have made progress on improving hygiene in hospitals but that isn't getting a the main sources of the problem which still include feeding antibiotics to livestock and inappropriate prescribing.

If we don't find new ways to combat bacterial infection, and fairly soon, we'll be back to the pre-antibiotic world. Minor wounds and common childhood infections will kill, much of the surgery we do today will be impossible, or at least not worth the risk, and life spans will collapse.

The Free Market™ won't save you, because antibiotics just aren't very profitable for drug companies. People need only a short course of treatment, unlike the big moneymaker pills people take for months or forever. Those are the ones they advertise heavily, along with the ones that cost $100,000 for a course of treatment. In fact, if they do come up with a new antibiotic, it will sell very little because doctors will keep it as a last resort.

This requires government investment. Yes, Big Government. We could take 3 or 4 billion of that $54 billion Orange Julius wants to dump into useless military boondoggles and save humanity instead. What do you want to bet will happen?

Friday, February 24, 2017

Oh no! The politicization of science!

Nothing frosts my pumpkin like these doofi (doofuses? I always have trouble with the Latin plurals) who decry the Scientists' March on Washington because it will "politicize science." Purportedly science needs to remain aloof from politics lest scientists be accused of partisanship and lose the trust of the public.

Wow folks, you are growing with your heads in the ground and talking out of your nether orifices. Science has already been "politicized" and accused of partisanship. EPA scientists are forbidden to release any studies or data to the public without review by political appointees. The CDC abruptly cancelled a long-planned conference on climate change. Cabinet appointees in general deny the reality of anthropogenic climate change, as does the "president." The administration wants the FDA to approve drugs that don't actually work, while the "president" believes that vaccines cause autism. We could go on with this but you get the idea.

It is true that scientists make a claim of epistemological preeminence. We are committed to using a particular toolkit to discover truth. We -- or at least most of us -- agree that there are what Habermas calls different classes of "criticizable validity claims," and that science concerns only one of them. Harking back to Plato, Habermas calls these the True, the Good, and the Beautiful. You can decide for yourself what you think is right or wrong, and what gives you pleasure. But the Truth is out there, to be discovered. It is what it is whether you like it or not. And yes, scientists, through long training and disciplined application, develop expertise that most people -- including most other scientists -- do not have to make truth claims about specific questions.

This doesn't mean we think we're better than you. If you are a skilled plumber, auto mechanic, carpenter or bassoon player, scientists will pay you to do what they cannot. Auto mechanics don't think that chemists or climatologists know as much about automobile repair as they do, but scientists don't resent them for that.

It is a basic value of science to try to keep an open mind and to be extremely reluctant to call conclusions absolutely definitive and not subject to legitimate question. But as evidence builds for theories, and they integrate seamlessly with broader theories, as multiple lines of evidence converge, some conclusions become unworthy of question. Vaccines do not cause autism. Humans burning fossil fuels add carbon dioxide to the atmosphere which is causing the climate to change with unprecedented rapidity. Particulate matter from motor vehicle exhaust and coal-fired power plants, among other sources, causes serious adverse health consequences. And so on. These are truths. Denying them is political; asserting them is science.

What we are asking is that you base your policies on the truth, in light of your values and preferences. If you believe that it is right and beautiful to destroy civilization in order to further enrich the Koch brothers, then by all means say so. But don't lie and say it isn't happening.

That's what the march is about.

Wednesday, February 22, 2017

Kenneth Arrow, 1921-2017

The death of economist Kenneth Arrow offers an opportunity for me to revisit a subject of great importance, that I have discussed here before. It is perhaps more urgent than ever as the congress prepares to deprive millions of people of health care. You can read an important paper of his here if you like, from 1963, but I will state the case more accessibly, I hope, and also put it in larger context.

A constant refrain of conservatives is that the Free Market® is the best solution to resource allocation. Interfering in the Free Market® is tantamount to depriving individuals of their freedom. The Free Market® is conceived of as a force of nature, existing independent of society and suffering only damage from political interference.

Of course, this theology is invoked only hypocritically. When capitalists want government to do something for them, they forget about it completely for as long as it is convenient.  The conventional wisdom among economists and moderately sane politicians is that "market failures" do exist, such that intervention is occasionally called for; but these are abnormal and require special justification.

This is all completely bullshit. In the first place, there is no such thing as a Free Market®, never has been, and never can be. Markets are social constructions. In modern, complex societies, they require continuous, pervasive government activity in order to function at all. All markets are structured and regulated, the question is not whether this happens, but on whose behalf?

Let us consider the theoretical conditions necessary for the functioning of a Free Market®, and consider whether medical care can conceivably be allocated through such a mechanism. (Note that the Free Market® always fails, for all good and services, and I can prove it. But it's more obvious in the case of medical services so I'll stick to the knitting for now.)

We'll begin with demand. People have a largely predictable need for typical commodities such as food and clothing, and a desire for some other goods such as entertainment that they will satisfy as their means allow. However, we have no idea what medical services we may need tomorrow or next year, and we rarely desire them at all. The need for medical services is an unpredictable misfortune. Furthermore, it is entirely possible that the cost of what is necessary will entirely exceed our means, while our more fortunate neighbor has negligible medical expenses. The only solution is some form of insurance -- a mechanism for pooling risk.

However, for profit insurance companies have an unavoidable incentive not to accept customers who are at high risk, and to try to avoid paying claims if they can get away with it. So in order for health insurance markets to function at all, they must be regulated.

At the same time, to the extent we have to rely on the monetary contributions individuals are willing and able to make to risk pools voluntarily, medical services will be underfunded and underproduced. There are several reasons for this. One should be obvious: transmissible diseases threaten everyone. Disease prevention and treatment benefits everyone beyond the cost for the individual. Furthermore, sick people can't work or take care of dependents to the extent healthy people can, if at all, and having sick friends and relatives, or even seeing strangers suffer, makes at least some of us sad.

Furthermore, as consumers, we are not only involuntary but incompetent. We depend on physicians' expertise to decide what to purchase, or to have purchased on our behalf by our insurer. While the current fashion is to involve patients in decision making, our capacity for that involvement is limited. We still need providers to explain our options accurately, in a way that we can understand and is relevant to us. But they're making more money by some choices than by others. So it matters how these incentives are structured.

There is a good deal more I could say about this, but the unavoidable conclusion is that we need a universal risk pool, regulated medical practice with some constraints on spending, and that people pay no more than they can afford to participate. Universal, comprehensive, single payer national health care accomplishes this. And it makes us all more free. 

Thursday, February 16, 2017

Fiscal responsibility. Also, Freedom.

One of the most popular methods for not stayin' alive in the U.S. is the motor vehicle crash. You may have heard about the sharp reversal of the long-term trend in traffic deaths over he past two years.

This cuts against improvements in the safety features of vehicles and the design of highways, which had helped bring down the fatality rate over decades. We don't have the hard core evidence to explain the reversal, but experts offer a few suggestions. Yes, we have more ways to be distracted by our gadgets. However, sayeth the Sage of 41st St.:

Government officials and safety advocates contend, however, that more than anything else, the increase in deaths has been caused by more lenient enforcement of seatbelt, drunken driving and speeding regulations by authorities and a reluctance by lawmakers to pass more restrictive measures.
In Alabama, crashes are up only 5% but fatalities are up 25%. That's because more people are speeding -- obviously the faster you're going the more  deadly your crash will be. Continuous budget cuts have reduced the number of state troopers -- now there are only 2 on duty at times in entire counties. Texas has raised its highways speed limits to 85. Seat belt laws are unenforced, where they are in place in meaningful form at all. Other approaches to improving safety, such as traffic monitoring cameras and ignition interlocks for people convicted of DUI, are also contrary to Ayn Rand.

Libertarian claims about traffic safety legislation are obviously nonsensical because you aren't necessarily just killing yourself. But even if you were, crashes, deadly or otherwise, cost the rest of us money. They block traffic, they cause lifelong disability with enormous cost, they destroy property, they deprive children of parents and I could go on and on.

Driving is not a right, and any freedom to drive is constrained by the freedom of the rest of us not to be endangered by you. It is a privilege in return for which you owe it to the rest of us to be responsible. And that must be encoded in the law, and the law must be enforced.

I will just mention that I witnessed a crash on Rte. 6 in Johnston, RI a few weeks ago in which two teenagers were killed, and it could have been a lot worse. A bystander car was also struck, and driven into a gas pump, which exploded. Fortunately, the driver was inside paying. So yeah, I've been thinking about it.

Monday, February 13, 2017

Simple Arithmetic

Making affordable health care available for people with low incomes costs money. It has to come from somewhere. The Affordable Care Act is financed by taxes. The Republican congress wants to eliminate those taxes, because they fall mostly on wealthy people. (There are some additional levies on insurance and pharmaceutical companies that pay for parts of the act that are really side issues.) But they also know they will pay a political price for eliminating health insurance for millions of people, and specifically for sick people who really need it.

There is no way to square this circle. But most citizens don't understand this basic fact. Many of them don't even know that Obamacare and the Affordable Care Act are the same thing. And:

[O]nly 61 percent of adults knew that many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted. In contrast, approximately one in six Americans, or 16 percent, said that “coverage through Medicaid and subsidies that help people buy private health insurance would not be affected” by repeal, and 23 percent did not know.

It's no wonder that no legislation has moved yet in the Congress. There is no alternative to the ACA that won't kick millions of people off of the insurance roles, make insurance worse for most other people, and won't require taxes. Therefore the Republicans will never be able to do what they have promised to do.

What will they do instead?

Tuesday, February 07, 2017

Global impact

Sorry for the absence. Frankly, I've felt that writing about quotidian subjects is somehow futile or beside the point. Truth and logic no longer matter in the making of policy. But, I suppose life must go on.

We Americans are often too self-obsessed and don't bother to know or understand much about the rest of the world. On the other hand, the U.S. does matter, a lot. Reading the new BMJ (British Medical Journal) illustrates the point. It's as much about the U.S. as it is about Britain.

For example, there's Travel ban threatens medical research and access to care in the US, medical groups warn. This tells the story of a resident physician at the Cleveland Clinic who was refused re-entry because she holds a Sudanese passport.

Nitin S Damle, president of the American College of Physicians, said that foreign physicians and medical students working in the US have to be “thoroughly vetted” to obtain their visas. The order was “discrimination based on religion” and should be rescinded, he said. “If the executive order is not permanently rescinded, blocked by the courts, or reversed by Congress, it will hinder the free exchange of information and travel among doctors around the world,” he said.

The president and chief executive of the Association of American Medical Colleges, Darrel C Kirch, said that international graduates played an essential role in US healthcare, accounting for 25% of the workforce, and that the ability of the US to attract top talent to its medical centers had helped make it a global leader in medical research. “Because disease knows no geographic boundaries, it is essential to ensure that we continue to foster, rather than impede, scientific cooperation with physicians and researchers of all nationalities, as we strive to keep our country healthy,” he said.
Then there's this, on the proposed of a bilateral trade deal between the U.S. and Britain which the "president' is pushing to facilitate the breakup of the E.U. Doesn't sound like a bad thing, right? Well, it's a bit complicated, but it could be very bad for Britain, given the highly unequal negotiating power between two economies of such disparate size. Read if you want to get a little more sophisticated about trade.

Then there's the global gag rule. Republican presidents always forbid U.S. funding of agencies abroad that make referrals for abortion or even discuss it with patients. But the "president" has gone beyond George W. Bush's version to extend it to all U.S. departments and agencies, not just AID, including the CDC, NIH and FDA.

The administrative burdens of implementing this rule, on both US agencies and aid recipients, could be very large. Such rules are likely to prevent the US from effectively tackling a problem like the Zika virus.

The consequences of this action can be expected to be widespread and contrary to the stated intent of the rule. If the goal of this policy is to reduce the number of abortions worldwide, then it will fail. Countries exposed to the gag rule show a rise in abortion rates when the rule is in effect and a reduction when it is not.2 Policies that curtail investments into comprehensive family planning programmes reduce the outreach of these programmes to the rural areas where the majority of people in sub-Saharan Africa live.

By limiting women’s access to modern contraception, the rate of unwanted pregnancies rises. In this situation women will often turn to abortion.
Reducing access to abortion and contraception results in shorter birth intervals, which negatively impact the health of women and their children and result in higher levels of child malnutrition.3 Rather than improving the health of women and children in the world’s poorest countries, the global gag order increases maternal and child morbidity and mortality.
In short, making policy based on ignorance and prejudice is usually not a good idea.

Tuesday, January 31, 2017

It's personal

Syrian doctor studying in U.S. stuck abroad, while his pregnant wife is here in Providence. Specifically, he's Khaled Almilaji, who is a student in our School of Public Health of which I am a faculty member.

He says the United States is enriched by many cultures and that would be a sad thing to lose. The 35-year-old Almilaji received a scholarship to earn a master’s degree in public health at Brown University. He moved to Providence in August on a student visa with his wife. Almilaji coordinated a campaign that vaccinated 1.4 million Syrian children and provided medical care during Syria’s civil war.

Thank God we're safe from him.

Friday, January 27, 2017

There's more to the ACA than health insurance

It's amusing to watch the Republicans continue to flail as they try to figure out how to screw millions of people out of health care without getting blamed for it. But they can do a lot to make health care in the U.S. worse without it being so obvious.

For example, the ACA includes funding for the Center for Medicare and Medicaid innovation, which supports demonstration projects to find way of delivering better care at lower cost. If you read this blog, you know that we pay a lot more for health care than other wealthy countries -- yeah, the ones who cover everybody because of socialism -- and we get worse results. Because freedom. CMMI is trying to bend the cost curve down while getting better results. But of course you have to spend money to do that, so socialism.

The ACA also established a fund for public health programs to prevent chronic diseases. Oh yeah -- it goes to the states. But that costs money too, so socialism.

Then there is the Patient Centered Outcomes Research Institute (which, full disclosure, has funded some of my research). PCORI compares treatments to learn which are better. Of course, that also costs money, which comes form a tax on insurance premiums, so socialism.

If they repeal all this, it will just make us less healthy in the first place, we'll pay more for health care, and we'll get worse results. But that's better than socialism. Oh wait, I mean it's better than making rich people pay taxes.

Wednesday, January 25, 2017

Repealing the Enlightenment

PZ Myers reviews the "president's" war on science. Go ahead and read it. Here's my personal stake:

The lunatics who have taken over the country seem to want to undo the Enlightenment. That isn’t actually possible but they can cause horrible carnage. I’m an NIH-funded researcher and our entire school of public health largely depends on federal funding — and a lot of it is stuff that Republicans don’t like. They don’t want to know about social determinants of health, inequities, health of people they don’t like such as gay men and drug addicts, marketing of drugs for useless or unsafe purposes, hospitals raking in money for useless procedures, and a whole lot else. So yeah, I’m worried.

Monday, January 23, 2017

Objectively Evil

I don't know if you remember, but the popular vote loser in the recent presidential campaign promised repeatedly that he would not cut social security, Medicare, or Medicaid. Purportedly that helped him get votes from people who don't normally vote for Republicans.

Uh huh. His nominee for secretary of HHS wants to cut Medicare and Medicaid spending, by a lot, and in his confirmation hearing he refused to say that he would honor Trump's promise. No surprise, Trump's flunky KellyAnne Conway now says yup, he wants to convert Medicaid to a block grant, which is just a path to cutting it.

If you're like most people, you probably think that Medicaid spends all its money on welfare queens in Cadillacs trading food stamps for vodka. Actually 21% is spent on elderly people (much of that going to people in long-term care in nursing homes who have exhausted their assets); 42% on people with disabilities; and 21% on children.

When the money goes away, what happens? I'll bet you can figure it out.

Friday, January 20, 2017

System and Lifeworld

That's the subtitle of the second volume of The Theory of Communicative Action, by Jurgen Habermas. It's very heavy going so I don't necessarily recommend that you try to read it. But it seemed like a good title for this post.

Our modern, complex society is nothing like the kind of societies in which humans evolved. People lived in bands in which everybody knew everybody else, in fact they had varying degrees of kinship, and they communicated face-to-face. Many people are still part of communities like that, to some degree, although for most of us they are more diffuse. We're mobile, we don't see most of our kin regularly. Most of our daily interactions are in the form of narrow role relationships -- worker and boss, customer and server, teacher and student, colleague. And of course there is a vast system of mass communication that is our only window into a world far wider than the village or band, that affects us in ways that are often mysterious, in the face of which we feel largely helpless.

People's brains aren't really built for this. It's not hard to understand why people who are frustrated about the conditions of their lives would have mistaken ideas about what is causing their problems and what to do about it. It's perhaps a bit less obvious, but I hope it is now that I point it out, that messages may come through the system that people perceive as slights, or offend their sense of propriety. But in the old days any such message would come from a person you could have a conversation with. You could tell them how you felt, hopefully work out an understanding, or choose to avoid that person in the future. But people can't talk back to their televisions.

NPR has devoted about half of its news content of late to interviews with Donald Trump supporters. I can't even listen any more, I turn off the radio during my commute whenever they do this. It's just too disturbing to realize that we wound up with a malignant narcissist, authoritarian blithering idiot as president because these people are so deeply incapable of critical thinking. But as Chauncey DeVega explains, perhaps with a subtext less sympathetic than I would like, the shit will hit the lifeworld.

No, they won't get well-paying jobs bolting cars together or mining coal. If the Mexicans all get shipped back to Michoacan, their food will get more expensive. In fact, more of it will be imported and a lot of the local farms will go out of business. If we throw up high tariffs, everything in WalMart will cost more and our export industries will decline. If they repeal the affordable care act, a lot of them will lose their health care and it will get more expensive for the rest of them. And those are just the promises Trump made that they thought they liked. He's going to trash their public schools, make them breathe toxic fumes, cut their social security benefits, and oh yeah, their taxes will go up even as their wages go down.

The dirty secret is that federal taxpayer funds flow from states with liberal electorates to Republican states. As DeVega writes:

As philosopher Henry Girioux has repeatedly warned, the “dead zone of capitalism” will only be expanded by Donald Trump and the Republican Party’s obsessive advancement of predatory capitalism and austerity. “Red State” America is already economically unproductive and parasitic, largely dependent on the taxes and economic activity generated in “Blue State” America. As such, Trump’s policies will disproportionately punish his greatest supporters.

So what will happen when they look around in a couple of years and find themselves worse off? We'll find out.

Thursday, January 19, 2017

The dog who caught the car

It's actually amusing watching the Republicans in congress flailing around trying to figure out how to repeal Obamacare. It turns out they didn't actually understand what it does and have no idea of what to do instead. Here's Sen. Schatz (D-HI) telling the amusing tale of Republicans begging him for help because they don't want to own what they are about to do.

"They want to be able to claim this is part of a good faith negotiation, but it's simply not.They have no idea what comes next so they want some bipartisan cover for their nonsense behavior," Schatz said.

He also said Republicans were looking for Democratic cooperation so that they can share the blame."They're really worried because anyone who pays any attention to health care knows exactly what is about to happen to the system, to the market and to individuals, and they don't want to be blamed for it so they're trying to see if they can take us off the cliff with them and we aren't going to abide by it," Schatz said.
They've been spending the last seven years telling people they're supposed to hate the Affordable Care Act, but they never got around to explaining why they are supposed to hate it. The fact is, the only way to extend affordable coverage to the population is to do what the ACA does: get everybody into the pool, require community rating (i.e. don't charge more to sick people), and provide subsidies for low income people and families. There's no other way. The ACA is something of a Rube Goldberg contraption, but that's because Congress is unwilling to pass the right solution, which is:

Universal, comprehensive, single payer national health care.

UPDATE: I commend to your attention Kevin Drum, who also asks why Republicans hate Obamacare. He notes that when polled, people like all the individual pieces of it; they also like it much better if it's called Kynect or the Affordable Care Act. Quoth Mr. Drum:

So why the continued rabid opposition to Obamacare? It's not because the government has taken over the health care market. On the contrary, Obamacare affects only a tiny part of the health insurance market and mostly relies on taking advantage of existing market forces. It's not because the benefits are too stingy. That's because Democrats kept funding at modest levels, something Republicans approve of. It's not because premiums are out of control. Republicans know perfectly well that premiums have simply caught up to CBO projections this year—and federal subsidies protect most people from increases anyway. It's not because everyone hates what Obamacare does. Even Republicans mostly like it. The GOP leadership in Congress could pass a virtually identical bill under a different name and it would be wildly popular. In the end, somehow, this really seems to be the answer:

Republicans hate the idea that we're spending money on the working class and the poor. They hate the idea that Barack Obama is responsible for a pretty successful program. They hate the idea that taxes on the wealthy went up a bit. They hate the idea that a social welfare program can do a lot of good for a lot of people at a fairly modest price.
What kind of person hates all these things?

Monday, January 16, 2017

Words of Wisdom

As I've been struggling to understand how so many voters -- not the majority,  we need to keep repeating -- but a lot, could have possibly thought it was in their interest or the world's to make a malignant narcissist, raging idiot and bigot president of the United States, along comes George Lakoff to remind us of how electoral politics really works.

I have noted that most voters have little understanding of public policy. I'm a particularly rational type of person. I try to collect information and work out the logic of problems. I study public policy the way academics do, because that's what I am. But few people have the time or inclination to do that. People live in constructed worlds, what Lakoff calls frames. Any information that doesn't fit in the frame will be ignored, disbelieved, or dismissed as anomalous.

What he is a bit less explicit about, but I believe he would agree with this formulation, is that the frames are built out of words. There are images in there as well but Lakoff focuses mostly on language. The words connect with each other in a web of presumptive causal and affinal relationships, and they have positive and negative connotations. Lakoff also says that frames contain value systems, and he sees a divide in U.S. (and possibly other countries') political culture between a system based on the view of the family as nurturant, and a contrasting view of the family as authoritarian. The family is our fundamental metaphor for the organization of society at higher levels, so these views of the family shape people's political allegiances.

Conservative political activists understand all this better than liberals because they study business and marketing in college, while we're off studying history and biology and useless stuff like that. Marketers know how to reach people, and they are totally amoral. Sell the sizzle, not the steak, the saying goes. Buy this car and you'll get a hot girlfriend. Drink this beer and you'll be a fascinating person. Vote Trump and win, win, win!

We need to learn these lessons. Elections are not machinery for turning people's self-interest into policy. If they were, the self-interest of 5% or less of the population would not continually prevail. We need to get a bit cynical, I think, and start talking to people in their own language.

Anyway, read Lakoff.

Wednesday, January 11, 2017

Tragedy or Farce?

It's getting to the point that I can't write anything because I don't know where to begin. The idea of Donald Trump as president was preposterous from the beginning, but nobody could quite imagine what the reality would be like. At this point it's an even bet, for me, whether the Trump presidency self-destructs in an explosion of idiocy, or whether it destroys us first.

The oppo research memo on the Russian connection is a lot of fun, but the absurd prospect of appointing RFK Jr. to head a presidential commission on vaccine safety is more telling. This will almost certainly not end up convincing people not to vaccinate their kids -- instead it will convince people that Donald Trump is a fool. If he wants funding for it he'll need legislation, which he won't get. If he tries to let Kennedy mess with the CDC in any way, the entire medical establishment will rise up in outrage. He is certain to make blunders of the same magnitude almost daily. For example, Ben Carson as secretary of HUD is similarly buffoonish, although HUD doesn't have such an influential constituency.

My thinking is that it's going to become increasingly damaging to the Republican party to continue owning him. They're going to start flailing for a way out. They are already flailing with the realization that they can't just repeal the ACA, but their president in waiting is trying to order them to do it next week. Their Chamber of Commerce constituency most definitely does not want tariffs and they don't want their low wage workers deported either. Their foreign policy establishment is going to howl like a pack of wolves with their tails on fire about buddying up with Vlad.

Public policy doesn't really matter to voters, who don't understand it anyway, but the man is a clown. The Republicans benefited enormously from Ronald Reagan's avuncular persona -- it's cast a glow over them ever since, despite Reagan's manifest incompetence. Trump, in contrast, will go down in a golden shower of ridicule. That gives me hope.

Monday, January 09, 2017

The historical moment

The historian Andrew Bacevich takes a step back from the present wailing and gnashing of teeth to look at the big picture. He should concede that there is a stochastic element to the outcome of the election, and that massive failure by the corporate media is a necessary condition for it as well. Nevertheless he has much of interest to say about the discontents that were also a necessary condition.

I am old enough to remember the existential dread of the Cold War and Mutual Assured Destruction. I saw the country torn apart by Vietnam, the Civil Rights movement and the countercultural movement(s) of what are usually called The Sixties, which actually lasted from about 1963 to 1974.  Then there were all the min-wars and interventions.

Bacevich's key point is that with the fall of the Berlin wall, followed by the collapse of the Soviet Union in 1991, U.S. elites  thought they bestrode the narrow world like a colossus.* "We" had won and now the U.S., the sole superpower, was going to lead the world into a new era of globalized  neo-liberal capitalism, and end all dispute. Instead we got one failure and disaster after another. The Clinton impeachment followed by the Supreme Court installing his witless successor. The terror attack in 2001, followed by a "mindless . . . and unsuccessful war launched on the basis of false claims and outright lies." The destruction of New Orleans. (He doesn't mention the poisoning of the Gulf of Mexico.) The crash of 2008. Meanwhile the neo-liberal revolution had made rich people richer, but left everybody else behind. And the cultural revolution that started in the 1960s was threatening and disturbing to many people.

The Obama presidency seemed to hold promise for real change, but hopes were dashed. The wars ground on, wages stayed stagnant, politics became more bitter than ever. The elites of the Democratic party, Hillary Clinton and her associates, were blind to the extent and nature of disaffection. Yes, fake news and conspiracy theories, and failure of the corporate media to talk about public policy certainly hurt her. But she was the exact symbol of everything that fueled discontent: however belatedly she tried to reinvent herself, she was a known to be a champion of free trade and failed wars. And of course the cultural upheavals.

Bacevich thinks Trump is transitional, not transformative. He doesn't have a coherent ideology or program and his rhetoric is empty. It seems very unlikely he will survive re-election - or perhaps even last until then. There isn't really any such thing as Trumpism, he is just a vessel for rejection. If we can survive the next four years the question is what happens next. That we can see only through a glass darkly.

* Allusion is to Shakespeare's Julius Caesar.

Wednesday, January 04, 2017

Mistakes were made

I believe the full article is off-limits to you common riffraff, but here at least is the abstract of a recent essay in JAMA about the consequences of the mass shuttering of psychiatric hospitals that happened in the 1990s. This happened for good and just reasons: mental hospitals were inhumane totalitarian institutions, it was generally believed that antipsychotic medications would enable people with serious mental illness to function more independently, and that people had a right to an environment that was the least restrictive and most integrated into the community that they could safely live in.

You may recall that this movement coincided more or less with the movement to liberalize the prescribing of opioid analgesics, also on humanitarian grounds, and you know where that got us.

This is not entirely parallel by any means. The problem with the desintitutionalization of the mentally ill is partly that the second half of the concept -- creating community based supportive living arrangements -- didn't happen. The states saved a lot of money by closing their mental hospitals, but they never got around to spending it on an adequate community based mental health system. The result is that seriously mentally ill people now wind up in jail when they aren't on the street.

What Bastiampillai and colleagues also note is that people do sometimes actually need hospitalization for acute psychiatric episodes. Maybe this is more true than it would be if they had adequate support in the community, but given the current situation, the availability of beds in psychiatric hospitals is simply inadequate. They think this may be associated with rising suicide rates. I don't know, I don't think that's been proven. But I will say that the Affordable Care Act mandated mental health parity and of course, extended coverage to a lot of people who really needed it. It's been a boon to the mental health system. It doesn't provide people with housing and other non-medical services that they also need, however.

Obviously rather than repeal the ACA we need to expand services for people with serious and persistent mental illness, including providing co-located and coordinated mental health and medical care. (They tend to have complex physical comorbidities as well.) The group homes that were supposed to follow deinstitutionalization also need to become real. Maybe if Donald Trump were to pay taxes we could afford it.

Monday, January 02, 2017

Fear and trembling

Probably the hardest thing about this historical moment, for me, is its profound uncertainty. We really do not understand what has happened, and have only the dimmest vision of what may happen after January 20.

Hunter extensively chronicles the president-elect's cognitive deficits. He knows nothing about public policy, either can't remember or doesn't care what he said yesterday, and his only coherent ideology is narcissism. We can get a fair idea of what a Trump administration is likely to do based on the people he has nominated to cabinet positions, and it's fair to assume that he'll sign any legislation the Republican congress puts on his desk. But on the other hand his incompetence raises the possibility that some of the worst may be avoided. The congressional Democrats have an agenda that is far more popular, and they won't face a coherent president who can articulate a Republican narrative.

At the same time, his business empire is extremely vulnerable, precariously balanced on a mountain of debt and quite possibly underwater.  We've all heard that he may be in hock up to his ears to Russian oligarchs close to Putin. But as James Wimberly points out, he is definitely in hock to Deutsche Bank, which is critically illiquid and could probably ruin him by calling in their loans. And, Angela Merkel can probably force them to do this. It is also unclear what Putin's actual agenda is re his orange-haired poodle. Having the U.S. president on a leash and his buddy from Exxon as secretary of state might enable him to develop some oil fields but it's not clear how much more Russia, in economic and social decline, can gain.

Trump also has a lot of legal problems including the possibility of a fraud indictment over the Trump Foundation. That would come from the Attorney General of New York so he can't prevent it. There are likely any number of revelations that could emerge at any time that would make it very difficult for the Republicans in congress to allow him to remain in office. Not that president Pence would be much of an improvement, but the spectacle of impeachment would wipe out most of the first year of the administration and leave the party badly weakened.

None of this is grounds for optimism, don't get me wrong. The disaster has already befallen us, we just aren't sure what exact form it will take. But if we can get through the next two years and the people come to their senses . . .