How bad can it get?

I have a confession: I somewhat self-censor myself because I don't want to be Debby Downer. That may seem a bit terrifying because I probably don't come off here as a cockeyed optimist.

So, here's the straight dope. I am not entirely sure that our American polity, our Republic, our civil society, is going to hold together. And I don't just mean a time of turmoil like the '60s or the '30s. I'm not in favor of riots but a good dose of civic unrest wouldn't do us any harm right now. No, I'm talking about the country being governable, about what's left of broad based political participation in a political regime granted consensus legitimacy evaporating. To be replaced by . . .

Dunno. Fascism, secession, or just plain chaos are all possible. Here Peter Turchin sees things falling apart consistent with a historical cycle in which concentration of wealth reaches a destabilizing maximum. The mechanism he focuses on is only a small part of the story, in my view, although there is probably something to it. Basically, there aren't enough high status social resources and formal offices to go around among the elites, so the ruling class fractures and its factions exploit popular unrest in their competition with each other. Or, a governing faction gets wise and makes needed reforms to save capitalism and the state, as in the 1930s. If that doesn't happen, you get Naziism, Communism, civil war, or a failed state.

While we do have to pay attention to the ruling class, the loss of legitimacy among the common people, increasingly left out of the fruits of economic growth and economic advance is just as important in the story. And in this particular instance, we're up against some real physical limits that haven't previously existed for modern civilization, although such limits have destroyed earlier empires. Then as now elites aren't confronting them because they are trapped in their short-term view of their own self-interest.

Anyway, projections of the solvency of the Social Security Trust Fund in 2050 don't mean shit right now. That's my point. If nothing focuses the mind like a hanging, we should probably be focused by now. But we aren't.

Update on Previous Post

I have to link to The Guardian because as of this writing, it is completely unmentioned on the web sites of CNN, CBS, and ABC. (11:00 am ET)

Representatives of most of the world's poor countries have walked out of increasingly fractious climate negotiations after the EU, Australia, the US and other developed countries insisted that the question of who should pay compensation for extreme climate events be discussed only after 2015. The orchestrated move by the G77 and China bloc of 132 countries came during talks about "loss and damage" – how countries should respond to climate impacts that are difficult or impossible to adapt to, such as typhoon Haiyan.

We are well and totally screwed.

Update: As of 11:40 am, CNN is reporting that Chi Chi Rodriguez has been hit in the groin by a golf ball.

If you get your info from the corporate media . . .

you probably know that George Zimmerman has undergone his monthly arrest. Maria Bartiromo is moving to Fox (why even have to pretend to be a journalist?). Virginia State Senator Creigh Deed was stabbed, Rob Ford clotheslined a 5 foot tall Toronto City Councilor. Obamacare is a Trainwreck! It's a disaster! We're all going to die! (If you read some liberal blogs you will also learn that in fact, more and more people are signing up for it and, just like Cervantes told you, they're getting the web site fixed and come January 1, it will be a fait acompli. Nonetheless, it is true that we are all going to die.)

What you probably don't know is that right now, as I write this, and has been true for the past week, the Annual Conference of Parties to the United Nations Framework Convention on Climate Change has been happening in Warsaw. You might think it's kind of important, I suppose, but as far as CNN, ABC, and CBS are concerned, it's a secret. That's why I've had to refer you to Climate Progress, which is kind of like Wikileaks, I guess, in that they tell you stuff Americans aren't supposed to know.

There are important issues under discussion in Warsaw. No, it's not going to result in an international agreement to save civilization and, in addition, Miami Beach. It is, however, intended to set up for an agreement to be signed in 2015. Many important issues are under discussion including raising $100 billion, which used to be a lot of money; issues of justice and reparation for damage caused by climate change (and that's very deep stuff); and how the responsibilities for reducing carbon emissions and mitigating harm are to be distributed among the nations that were industrialized early, and those that are less developed.

These are difficult questions. The U.S., as the largest source of carbon emissions to date, is obviously very much affected by them. As perplexing and divisive as it may be for us to work through these problems, it is essential for Americans to be engaged in them. The U.S. must be a constructive participant in these talks, and actively engage in the plans and goals that result, if all this talk about what Social Security and Medicare will be like in 2050 even to matter. But we aren't. It isn't even on the front page of the CNN web site. Although Jonathan Edwards' new law practice is. Along with the question of whether a Kmart ad is too "racy" and the story of a 400 pound high school football player. At least we know what's important.

Should the Redskins change their name?

Enough of this sanctimonious political correctness. The Washington Redskins proudly bear their name as a symbol of something very important in our national heritage -- i.e., racism.. I think the NFL owners should continue to show solidarity and support the 'Skins and their owner Daniel Snyder by changing the names of some of the other teams.

The New York Giants should be named the Hymies. And the jets can be the Dagos. The San Francisco '49ers, obviously, will be the Poofters. And the Arizona Cardinals, the Wetbacks. And of course, the Detroit Tigers will be the Jigaboos. The Miami Spics. Problem solved. Why can't anybody else see the obvious?

Catholic Bishops: all the moral authority of a tapeworm

I'm a sociologist, and one focus of my study is how people understand their lifeworlds and their well being. So I ought to be good at understanding major social institutions and the basis of their attraction, like for example the Catholic Church. But I just don't get why this atavistic, intellectually ludicrous and morally depraved enterprise doesn't wither and blow away.

Here's the Bishop of Springfield, Illinois organizing an exorcism to drive Satan from the body politic, "in reparation for the sin of same-sex marriage." For all of the new Pope's conciliatory words, when he was still Jorge Bergoglio he said that gay marriage in Argentina was "a 'move' of the father of lies who wishes to confuse and deceive the children of God." So Bishop Paprocki will perform an exorcism as the governor signs the same sex marriage bill.

Here's the idea, as I understand it. God is beneficent, all knowing, and all powerful. God created the universe and people (the latter "in his own image"). He put the people in a garden in which he also placed two trees, from which he instructed them not to eat. Despite his being all powerful and all knowing, another being, in the form of a talking snake, succeeded in getting the people to eat an apple, which he didn't know about at the time because he was apparently distracted elsewhere. So God cursed the people for their sin of doing what he presumably knew they were going to do and which they did because they were of the nature which he made them.

Some time later (it used to be about 4,000 years later, but since the Bishops now say they accept scientific accounts of human antiquity it's impossible to say when all this shit supposedly happened nor is it in any way coherent) God impregnated a woman with his son, who was also himself, who he then deliberately had tortured to death to pay for the sin of eating the apple, but he wasn't really dead he just rose up into the sky. That means God will no longer have to torture everybody in hell forever, just the people who don't believe this crap.

Nowadays some of the people who God made in his own image are marrying people of the same sex, which God does not want them to do, but it's happening because some other dude -- maybe the same entity as the snake, it's not clear -- is making it possible. God can't do anything about that himself, but if a bunch of old men in fancy silk dresses chant and wave incense around and ring bells and snuff out candles, maybe the snake thing will slither away after all.

The old men will do this during their breaks from raping children, of course.

The 12th Century is so over. Get used to it.

Hey Indeedy . . .

Donald Berwick was Obama's nominee to be head of the Center for Medicare and Medicaid Services but served only during a recess appointment because the Republicans in the Senate called him a socialist. (He had praised the British National Health Service, among other evidences of Commie sympathies.) He has an essay in today's JAMA, which I think you probably can't read because you don't have the magic cookie. He says stuff I've said here before, but better, beginning with:

It could be exciting. The ambitious nation that rallied to create the Marshall Plan, get to the moon first, and birth Medicare and Medicaid decides to move toward the health care it needs: universal, responsive, and affordable. But that task does not unite the nation; it rends it into political tatters.

But why? What's his diagnosis? As he points out, we're spending twice what other affluent countries are spending, and getting less. They give quality care to everybody, with better patient safety, better outcomes and more investment in prevention. Here are his explanations:

Vested interests: We pay more than any other country, which means that people and institutions are on the receiving end of all that money. They happily invest some of it in lobbying and political contributions to keep the gravy train flowing.

Diffuse interests: The majority of ordinary people who would benefit from sensible reforms aren't organized or powerful. I will add that they are also misled.

Abdication of professional responsibility: The American Medical Association opposed Medicare and every other proposal to provide government-sponsored insurance throughout most of its history. The AMA has changed on that point but doctors still don't advocate for universal, comprehensive health care, single payer or otherwise. They're more interested in keeping their incomes high.

Public distrust of science: Don't get me started. It's easy to convince people that evidence-based guidelines discouraging overtreatment and overdiagnosis are a conspiracy to "ration" health care and murder grandma, because they think science is an elitist conspiracy against the people. Thank the Koch brothers.

Contempt for the poor: If people can't afford health care, it's obviously their own fault.

There's a bit more but those are the high points. Look, the Affordable Care Act isn't the greatest policymaking ever, by a lot. It was cobbled together so as to keep the insurance companies and hospitals and AMA from torpedoing it. But it will make things a bit better, and creates a base for substantial progress in the long term.

Bill Clinton needs to shut up and butt out. The Democratic panic and instinct to retreat in this situation is just pathetic. Stand up, stand your ground, wait out the tempest. In six months, it will be a fait acompli, and there will be no going back. 

Don't Panic

By the end of this week the federroble gummint has  promised to announce progress in enrollment in health insurance through the Affordable Care Act. Via my inbox, a preview from Avalere Health -- it's going to be a very small number, maybe just 50,000.

You already know how the corporate media will play this -- there seems to be a law that you have to say "trainwreck." Republicans will yell and scream that we have to repeal this disastrous mistake, and Democrats will start panicking and filing legislation to delay the individual mandate.

Pish tosh. Avalere also points out that enrollment in Medicare Part D - the Bush administration prescription drug benefit that is now taken for granted - was almost as slow. In fact, 2/3 of the people who ultimately voluntarily enrolled did so after coverage began, and fewer than 10% had enrolled one month before open enrollment ended. In other words, if we have the same experience, the Affordable Care Act will look like a big success by March, but it will look like a miserable failure in December.

Yeah, the bad web site has slowed things down a bit, but basically, people are procrastinators. The problems with the web site will be long forgotten by November of 2014.

It's complicated . . .

That would not be any particular romantic or other personal relationship, but rather the Affordable Care Act and the bizarre non-system it is jury-rigged to somewhat improve. It is a true fact, which the prez failed to make clear (or probably didn't really grok himself) that some of those people who are getting cancellation notices are actually relatively affluent individuals who intentionally chose cheap catastrophic coverage because they figure they can afford to pay out of pocket for routine medical expenses. That single class of people will now have to pay more for more comprehensive policies, and won't get enough subsidy for it to end up cheaper, or perhaps no subsidy at all.

I wish I could have explained even that little piece of the whole story more simply. Now, whether any particular one of those people ends up better or worse off depends on whether they are hit by a bus or something next year. If they are, before their catastrophic coverage kicks in the deductible from the old policy would have been more than the premium for the new one. (Still complicated, sorry.) But, they probably won't be and in any case, they feel as though their choices has been restricted.

True enough. It's also true when you pay into Social Security and Medicare and pay your regular income taxes of course. And Randroids don't like that. But it's nothing new and it isn't tyranny. Let's be up front here: there is a redistributive element to the Affordable Care Act. It's intended to make the working poor, childless unemployed people, and moderate income people better off, and somebody has to pay for that. There's a modest tax on medical devices, a tax on very high end insurance policies, reductions in Medicare spending that come out of hospital incomes (basically), limits on insurance company expenses and profits (which are somebodies' income), and oh yeah, some relatively well-to-do people will buy insurance with benefits they don't need or want and that will help subsidize needier people.

In other words, like every public policy ever promulgated, there are winners and losers. In this case, the losers are people who can afford it, for the most part. (Not clear whether some lower level jobs in the insurance industry will be lost since they aren't allowed to do medical underwriting any more. But more customers should mean it's a wash, at worst.) But to be clear, the howling over Obamacare isn't really because it's a trainwreck, or communism, or tyranny -- it's because a small number of relatively well off small business owners and trust fund babies will have to spend a few bucks they were planning on spending elsewhere. You can object to that if you like, but that's really what the issue is.

yes, we are idiots

I checked out one of your major broadcast network evening news shows last night. Item 1: Obamacareyaddayaddayadda. Item 2: Miami Dolphins 300 pound lineman is allegedly bullied. Item 2: IPCC issues new report. Commercial.

What sayeth said IPCC report? Oh, just stuff like this:

• Warming of the climate system is unequivocal, and since the 1950s, many of the observed changes are unprecedented over decades to millennia. The atmosphere and ocean have warmed, the amounts of snow and ice have diminished, sea level has risen, and the concentrations of greenhouse gases have increased.
• Each of the last three decades has been successively warmer at the Earth’s surface than any preceding decade since 1850. In the Northern Hemisphere, 1983–2012 was likely the warmest 30-year period of the last 1400 years (medium confidence).
• Ocean warming dominates the increase in energy stored in the climate system, accounting for more than 90% of the energy accumulated between 1971 and 2010 (high confidence). It is virtually certain that the upper ocean (0−700 m) warmed from 1971 to 2010, and it likely warmed between the 1870s and 1971.
• Over the last two decades, the Greenland and Antarctic ice sheets have been losing mass, glaciers have continued to shrink almost worldwide, and Arctic sea ice and Northern Hemisphere spring snow cover have continued to decrease in extent (high confidence).
• The rate of sea level rise since the mid-19th century has been larger than the mean rate during the previous two millennia (high confidence). Over the period 1901–2010, global mean sea level rose by 0.19 [0.17 to 0.21] m.
• The atmospheric concentrations of carbon dioxide (CO2), methane, and nitrous oxide have increased to levels unprecedented in at least the last 800,000 years. CO2 concentrations have increased by 40% since pre-industrial times, primarily from fossil fuel emissions and secondarily from net land use change emissions. The ocean has absorbed about 30% of the emitted anthropogenic carbon dioxide, causing ocean acidification.

And? Oh, just Stuff like this:

Thousands of people in vulnerable areas of the Philippines are being relocated as one of the strongest tropical cyclones ever observed spins toward the country. With sustained winds of 315 kph (195 mph) and gusts as strong as 380 kph (235 mph), Super Typhoon Haiyan was churning across the Western Pacific toward the central Philippines. . . . As it moves across heavily populated areas of the central Philippines, Haiyan's high winds and torrential rain are expected to affect millions of people. The storm system had a diameter of about 800 kilometers (500 miles) as of early Thursday afternoon.

But you know, we can't interfere with the right of the Koch brothers to increase their inherited fortune without limit, because Freedom.

The real meaning of Republicanism

This essay in NEJM is, unfortunately, off-limits to the common rabble as far as I know, but doctors Michael Stillman and Monalisa Tailor explain what these people who are fighting to their last breath to prevent people from having health insurance are really doing. Fair use excerpt:

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer. The year before, he'd had similar symptoms and visited a primary care physician, who had taken a cursory history, told Mr. Davis he'd need insurance to be adequately evaluated, and billed him $200 for the appointment. Since Mr. Davis was poor and ineligible for Kentucky Medicaid, however, he'd simply used enemas until he was unable to defecate. By the time of his emergency department evaluation, he had a fully obstructed colon and widespread disease and chose to forgo treatment. Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation. As his wife sobbed next to him in our examination room, he recounted his months of weight loss, the unbearable pain of his bowel movements, and his gnawing suspicion that he had cancer. “If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

They go on to tell of a woman with a lung nodule who couldn't afford a PET scan -- so the surgeon refused to operate; and other horror stories. Research has found that 45,000 Americans die every year because they can't afford health insurance -- and note that these are nearly all people under 65. But the disinformation campaign has been effective: " During our appointment with Mr. Davis, he worried aloud that under the ACA, “the government would tax him for not having insurance.” He was unaware (as many of our poor and uninsured patients may be) that under that law's final rule, he and his family would meet the eligibility criteria for Medicaid and hence have access to comprehensive and affordable care."

These conservative billionaires who fund the astroturf "Tea Party" and Sens. Cruz and Rubio and all their co-conspirators are evil, repulsive, psychopathic bastards. That anybody will vote for these disgusting creeps proves that our political culture is profoundly diseased. 

Guest lecture

Here's some of what I will be saying today. The students have read two histories of the controversy over leaded gasoline and its ultimate banning. (One is Kevin Drum's famous Mother Jones article, the other an academic essay by Herbert Needleman, a scientist who was a pioneer in recognizing the harm caused by low levels of exposure to lead.) A major part of this story is of course that a powerful industry for decades dishonestly attacked science and scientists, including Needleman, in the completely amoral pursuit of economic self-interest, at incalculable human cost. This plot has been reproduced endlessly -- tobacco, acid rain, pesticides, global warming, you name it.

But you need to understand not only that this happens, but why it works. The fact is, risk assessment is hard, and inevitably freighted with uncertainty. And even after you manage to narrow down those uncertainties, there are still value conflicts about the implications of our knowledge.

In order to understand an environmental risk, you need to go through four steps:

Hazard identification

Dose-response assessment

Exposure assessment

Risk Characterization

Hazard identification means that relevant people -- those who can cause the next steps to be taken  -- recognize that some chemical or other phenomenon present in the human environment might be dangerous and we ought to study it. The fact is that most of the chemicals commonly used in consumer products or emitted into the air, water and soil have not been studied much, if at all, for their potential harm to humans and other living things. Until Needleman and others came along, this was basically true of lead. We knew it was toxic at high doses, but assumed to be harmless at the levels of exposure people experienced from gasoline and paint.

Dose-response assessment means figuring out what the consequences are of exposure to the chemical at the continuum of plausible levels and patterns. This is very difficult because, obviously, you can't experiment on people. We do experiment on animals, notably mice, but let me give you the news: mice aren't people and there are plenty of well known cases in which exposure harmless to mice are dangerous to people, and vice versa. Epidemiological data is very difficult to interpret, for reasons I have discussed here before. Basically, it's difficult to separate out the exposure of interest from everything else that goes along with it, e.g. exposure to lead from gasoline depended on where you lived and spent your time so maybe the observed effects aren't because of lead at all. A corollary is that you can't easily measure people's exposure. In the case of lead, because it persists in the body, you can measure the concentration in blood, which helps. But there will still be arguments over acute vs. chronic exposure, and yes, there are confounders that go along with blood lead levels as well as imputed exposures. And you have to know what effects to look for. If you aren't measuring the relevant endpoints, you won't see them, obviously.

Exposure assessment means figuring out who is exposed to how much of the stuff and by what routes. This is also very difficult because chemicals travel through the environment along complicated paths that are affected by all sorts of influences -- wind, rain, temperature, the food chain, human behaviors, on and on. And chronicity of exposure matters as much as amount.

Finally, risk characterization means putting it all together: somehow multiplying the dose response by people's actual exposure to say "Ultrafine particle pollution from highways is causing 180,000 heart attacks each year in North America," or something like that. (I just made up the number but it does apparently cause cardiovascular disease and also triggers myocardial infarctions.) However, that's not the only consequence of UFP pollution and you need to somehow translate all of the harms of an exposure into a common currency that can be compared with the benefits. In other words, we aren't going to give up cars, trucks and buses even though we know they cause harms. We need some method of weighing harms against benefits. And of dealing with uncertainties while we do this.

Hence, people argue. That's never going to stop but at least we can develop a common understanding of the available information. Or at least it would be nice if we could.

A righteous rant

This one from British doc Iona Heath. (I'm not 100% sure you can read this, I can't test the site without my magic cookie.) Anyway, she reminds me of Ivan Illich's famous book Medical Nemesis. Illich, writing back in 1982, argued that medicine, on balance, did more harm than good. Heath doesn't go that far, and neither do I, although in 1982 Illich had a defensible case. Medical intervention has become more effective since then, as the longer survival of people with heart disease, which I discussed a couple of days ago, demonstrates. However . . .

In addition to the downside that those longer lives are often spent in a condition of sickness and disability, medicine inflicts harms directly. First of all, money wasted on ineffective, futile or harmful medical intervention is money taken from some better use. And that includes improving the social and physical conditions of people's lives in ways that will keep us all healthier in the first place. It also includes putting disease labels on people who have no symptoms and whose only "disease" is some lab test that is outside of an arbitrarily defined range of normality.

Those people then have to live with anxiety and the sense that they aren't really healthy after all. They may take pills that cost them money and have adverse effects. They may undergo biopsies, or surgery, go back for repeated physician visits just to be told the results of yet more and more lab tests. As Heath writes:

[W]e have, for the first time in history, separated our notions of disease from the human experience of suffering and have created an epidemic of disease without symptoms, defined only by aberrant biometrics. An ever greater proportion of healthcare resources are directed towards reducing these numbers to some fictitious state of normality. In the process, those who are perfectly well are not only assigned labels that in themselves can be shown to compromise health but are also exposed to treatments with significant adverse effects. . . . . If nothing else, this serves to distract attention from the government’s failure to meet its own responsibilities for health protection through fiscal and legislative measures, such as promoting greater socioeconomic equity, nurturing vulnerable families, and such policies as minimum pricing for alcohol, and plain packaging for cigarettes.

Extending the range of what is considered abnormal clearly expands markets for pharmaceutical and other interventions, and thereby the possibilities of maximising commercial profit. . . . As more and more people previously considered normal are included within the definition of, for example, hypertension, diabetes, or breast cancer, outcomes improve: rates of hypertensive stroke or diabetic foot amputation or breast cancer mortality seem to fall. In this way, extending the definitions of disease and lowering the thresholds for preventive interventions create the illusion of improved population outcomes, while there is no difference at all in the outcomes for affected individuals. Clinicians, health policy makers, and politicians have found it difficult to resist these seductive illusions of progress.

 We are chasing a mirage. Health is not a biological state read off of an elaborate construct of structured biological measurements. It is a condition to which medicine can contribute sometimes, in some circumstances, but too much medicine is bad medicine. Somehow our culture cannot encompass that.

There's a right way and a wrong way to do things . . .

As I was walking to my car last night I saw a big, beautiful blue helicopter marked "NYPD" land at the Providence heliport, which is near my office. The brilliant thought "WTF?" came to me. It turns out that's how New York City Police Commissioner Raymond Kelly travels -- at least when Marine One is unavailable -- and he was here to give a talk at an institute belonging to my employer.

Sadly, he was unable to speak because protesters shouted and jeered him off the stage. The photograph shows him with Providence Public Safety Commissioner Steven Paré, with whom I serve on the Commissioner of Health's Emergency Medical Services Working Group, and as you can see Steve does not look particularly happy. I wasn't there but I'm not happy either. I have previously expressed my unhappiness about this on Daily Kos and a commenter said there should be a limit to the people the university invites to speak, and how would I feel if they invited Glenn Beck or Rush Limbaugh?

Well, I'd feel just great, actually. Kelly was supposed to give brief remarks and then spend an hour in exchange with the audience. That was a world class opportunity to subject him to something he almost never gets: smart, informed people asking him tough questions and confronting him with the arguments about why his policies are counterproductive, unethical and contrary to the values we Americans claim to believe in. Reporters will never do that, but there were reporters in the room and they would have heard it. Even if they were fair and balanced, they would have had to report what those smart, informed people had to say.

Now that will never happen. Instead all we know is that east coast pointy-headed liberals won't even let the guy talk if they don't agree with him. Well, evidently that's true. It's also sad, and embarrassing, and it isn't smart or well-informed. It's FUAB. That is all.

Bad news?

Apparently so. Specifically, the bad news is that we're living longer. The linked analysis by Pandya et al is concerned specifically with heart disease. This is one area in which medical advances have unquestionably extended life. We haven't reduced the incidence of cardiovascular disease by much, but it doesn't kill people nearly as quickly as it used to. Fortunately, rates of smoking have declined, but the prevalence of obesity and diabetes is increasing. More people with heart disease, living longer, means a lot more people living with heart disease. These authors predict the prevalence will increase from about 11% for men and 8.6% for women today to 14.5% and 10.4%, respectively by 2030. And that will mean an enormous increase in disability, people living with poor quality of life, and of course Medicare spending.

What could be worse than that? If, as many predict, scientists figure out how to slow down the aging process by even just a little bit, say adding 2.2 years to life expectancy, that will be worth $7.1 trillion in benefits over 50 years, if we say a healthy year of life is worth just $100,000. But Medicare costs would increase by $3 trillion per year. (Social Security would go up by about $90 billion, which used to be a lot of money. All of this is in constant 2010 dollars.)

The problem is, are we willing to pay for that? We certainly could pay for it. We live in the wealthiest society ever. And we're all hoping to be in that old category some day. So shouldn't we decide, "This is a good way to spend our money"? Well, it doesn't look that way because rich people would have to pony up. And there seems to be a very strong correlation in this country between wealth and psychopathy.

Running on empty

The Republicans in congress seem to think that the not very functional Healthcare.gov website is their Watergate (since IRSgate, Benghazigate and FastandFuriousgate, among others, haven't panned out). And the corporate media seem to agree! Even John Stewart is piling on. The balky web site proves that the whole concept is unworkable, a trainwreck, and an embarrassment.

Well no. See, here's why this is not going to work as a campaign issue in 2014. They're fixing it. Day by day, they'll fix all the problems and then they will be done, and it will work just fine. And as Rachel Maddow explains via Ed Brayton, Social Security, Medicare and Medicare Part D all got off to rocky starts. Nobody remembers that now, and "Healthcare.gov didn't work right for a few weeks" is not going to be the basis of a a winning campaign in 2014.

People are worried, more substantively, that maybe those healthy young folks who we need to sign up will be discouraged by the crappy web site and we'll end up with adverse selection and a death spiral. Not to worry! The law is written so that we don't need them all to sign up right away. It would be a little bit wonky to explain in detail but basically, there's backup money and reinsurance built in to give us a year or more breathing space on that. Nice if a lot of them come in early, but not essential. Not a panic.

Here's a tip for Republican politicians: don't spend your air time making predictions of disaster that aren't going to come true, because reality will happen. Even the people who are getting ticked off now because their catastrophic coverage is being withdrawn will mostly end up happy when they find out they can get much better insurance, for not much more and maybe even cheaper if they qualify for subsidies. Just about everybody else, except for a few rich people like Ted Cruz who have cadillac plans (that will be taxed) will be better off. Even in Alabama! And they won't be communist slaves after all, either.

Once that actually, you know, happens, all the rhetoric of today will be gone the way of the snows of March. I mean, this is  evident to me. What am I missing?

Time Warp

Amanda Marcotte notices what seems to have been oddly under the radar lately, which is the Republican party taking up the cause of banning contraception. It went almost unnoticed that one of their fallback demands in the government shutdown was to eliminate the requirement for contraception coverage in insurance plans. Since 99% of women have used contraception, and only 8% of Americans think it's morally wrong, this does not seem to be a winning cause.

She has some good snark, too:

Clearly, no matter how much hand-waving is going on, many Republicans are trying to demonize contraception, a wildly unpopular position that frankly makes them look like lunatics. But they obviously don’t understand that this is what happens when they threaten to run the government into the ground to keep even a handful of women away from contraception or characterize one as “promiscuous” just because you don’t hate contraception.

Clearly, many Republicans live in a bubble world, constructed of right wing media and Bible-thumping bedroom communities where they get almost no exposure to the fact that some of their ideas are just plain weird. These politicians are supposed to be representatives of the people, but many of them clearly haven’t even considered the possibility that they sound like they’ve been transported here in a time machine from 1963. When I hear some Republican trying to imply that birth control pills are some kind of great controversy in America, I often wonder how their staffers hide the existence of color television from them, much less iPhones and electric cars. The modern world is clearly not the one they’re living in.

Well yeah. It does finally seem to have gotten to the point where their extremism, hypocrisy and detachment from reality are overcoming racial resentments and tribal loyalties to the point where even the Koch brothers' money can't save them. I'd like to think so anyway. Because the alternative, that these refugees from the 12th Century could actually seize state power in the U.S., is unthinkable.

Republicans is Weird

Now they're outraged that Healthcare.gov doesn't work right, demanding the head of Kathleen Sebelius and gearing up for endless hearings and hostile grillings of administration officials.

Am I missing something here? They don't want the website to work. If people sign up for insurance, it will be slavery, communism, and fascism. The only thing standing between us and the destruction of America as we know it is the fact that the web site doesn't work. If they fix it, we'll be living under the iron heel of tyranny like those enslaved Swedes and Canadians.

Well, actually it would be more like the Swiss, who are required by their sadistic overlords to blow giant wooden trumpets while wearing leather short pants with suspenders and expensive watches; and who also get to choose among various private insurance plans with subsidies for lower income people. Yes, it's a horrific vision. We will know that God has truly withdrawn his protection from America if the web site ever works.

The new luddites

The latest blooming meme -- transmitted by some very credible and buttoned-down thinkers, in many cases -- is that this time, the machines are taking our jobs and they aren't coming back. Yeah yeah, the power loom and the harvesting combine put people out of work, but the thereby wealthier economy found other jobs for them to do in the long run. But this time around, the machines aren't just physically powerful and fast, they're getting smart as well. The proposition is that we'll need fundamentally new social and economic structures to keep everybody supplied with an income and meaningful ways to spend their days.

Brad DeLong, no sidewalk raver to say the least, lays it out in telegraphic form. David Atkins sees IBM's Watson replacing oncologists as diagnosticians. I'm not sure that will happen, exactly -- people will still demand that a human make the final decision, I think, even though the human isn't really necessary or even doing anything regarding decision making. But the doctor will need to talk to the patient about Watson's conclusions and their implications. Still, the broader idea that even high level intellectual work is not safe for long seems to hold.

Tom Streithorts, in a compelling essay in the LA Review of Books, puts a positive spin on this as the problem of "post-scarcity economics." But he also considers that the end of scarcity is a big problem. If the economy produces all we need and more with little human effort, your labor -- of whatever sort it may be -- isn't worth anything. We distribute resources now by exchanging them for work, or giving them to rentiers and investors. If labor is worthless, then the 1% will have everything. Of course they won't be able to sell anything, because the rest of us won't have an income. You can see the problem.

The proponents of this claim say it's already happening, that the "natural" level of unemployment is rising. We'll never get back to 4 or 5 percent, and quite possibly we'll bounce off of 7.2% -- already misleadingly low because many people have left the labor force -- and see unemployment going up even as the economy grows. Obviously this is unsustainable, but the problem demands the precise opposite of what the conventional wisdom is saying. People won't just go out and find jobs if you cut off their food stamps and disability and Medicaid. There aren't any, and there won't be any.

I don't know for sure if this is true -- it was the dystopian vision in Vonnegut's novel Player Piano, and other visionaries have been imagining this scenario for a long time. But we need to think this through.

Apparently size does matter . . .

. . . for some people anyway. I have an excellent e-mail spam filter, and it never stops anything that should get through (I don't think, anyway). But, just for the heck of it, the other day I checked my spam folder.

G-mail only keeps the spam for 30 days, but 30 days worth turned out to be thousands of items. Ninety-five percent of which offered to enlarge my privates. One after another after another. Then the twentieth would be touting a penny stock. That was it. I deleted the entire folder and checked by 30 minutes later just to see what was happening. There were already 250 offers for anatomical enhancement.

Obviously, people wouldn't be doing this if it wasn't making them money, and we'd still be seeing Nigerian princes and Viagra if that's what was selling, Ergo, there are a helluva lot of guys out there who feel seriously defective. This could account for the gun culture and pickup trucks jacked up to six feet. Also the invasion of Iraq. In fact, come to think of it, Tom Friedman explained it just that way -- that's why he was for it, because it would make him prouder of his peter. Could this be the key to much of what ails our politics?

Hoisted from my comment . . .

On Charlie Pierce's blog  (which I heartily commend):

Some people here may view what I'm about to say as a bit contrarian, but believe me Paul Krugman agrees with me. Long-term, the cost of Medicare -- and Medicaid, and health care in general, but let's talk about medicare specifically -- is indeed a big problem, and it would be a good idea to start to get handle on it soon. (Conflating this with Social Security is indeed a scam.) Unfortunately, no politician, including BHO, is talking about the true nature of the problem and the needed solutions. No, we don't have to cut benefits, make beneficiaries pay more out of pocket, or even means test it (which would produce trivial revenues/savings). But we do need to a) pay less for drugs and overpaid medical specialists; b) stop doing unnecessary, useless and even harmless procedures (which is what Republicans call "death panels"), which requires basically changing the way we pay for health care; and c) invest more (not less as we are now discussing) in public health, social welfare and environmental protection programs that promote health, prevent disease, and will more than pay for themselves in avoided medical costs. And we need to do more comparative effectiveness and cost effectiveness research so we can figure out how to do all of the above right. That's the discussion we need to be having, but we aren't going near it.

My (unpublished) letter to the NYT

Much to my surprise, they sent me an e-mail saying they were considering publishing this, would I confirm I am the author? But of course they did not.

I am baffled as to why every journalist, including your own headline writer and reporter, are compelled to append the absurd phrase "the God particle" every time they mention the Higgs boson. The Higgs mechanism, Higgs field and Higgs boson have nothing whatever to do with God, an imaginary entity with no relevance to physics. Please stop it.

Reporters seem prone to these ridiculous verbal tics. I have written previously about "James 'Whitey" Bulger" and "Steven 'the Rifleman" Flemmi." Apparently it was illegal simply to print the men's names. Reporters also don't seem to know that they can stop using the word "alleged" after the person is convicted. Actually I don't think they know what it means or why they're supposed to say it in the first place.

Actually I'm being grumpy because I'm so disgusted with them on more substantive grounds. But you already knew that.

The real problem with health care in the U.S.

Here's a systematic analysis and a plausible tale told by Buz Cooper. In a pistachio shell:

Problem: U.S. spends more than 2X as much on health care as other affluent countries, gets worse health in return.

Buz says: :

1) Well, kinda, but U.S. is more affluent than most, so as a pct. of GDP we only spend 60% more.

My comment: Why does it follow that we should spend more on health care just because we're wealthier, if we aren't getting more for it? We don't eat six meals a day, or go to school for 30 years. If there's a "right" amount of health care we should just buy that much and spend more of our money on something else. But please go on.

 2)  The price of health care inputs is higher in the U.S. than elsewhere. Further correcting for that, we're only buying 31% more.

My comment: This is a good point, up to a point. On the other hand, given your point 1, incomes in the U.S. are higher than elsewhere so we would expect to pay higher salaries to doctors and nurses and EMTs and so on. But, on the other other hand, there's no reason why we should be paying higher prices for drugs and devices; and even in terms of our own general affluence, some medical specialties are definitely overcompensated. But either way yes, it's true that the higher spending doesn't entirely consist of higher consumption.

3)  The remaining 31% can be explained by general inequality. Poor people, of whom we have a lot compared to Europe and Canada, are less healthy and therefore need more health care.

My comment: Now you're talking. We need to spend much more, not less, on social welfare -- making sure that kids are well fed and educated; creating safe urban environments; providing affordable mass transit to connect people with jobs, and educational and cultural opportunities; providing affordable child care so parents can work safe in the knowledge that their children are well cared for; making sure decent housing is affordable for working people. And all that jazz. If we do that, we can get a huge return on our investment -- we'll save money on health care, have a stronger economy, and have healthier happier more fulfilled people. 

So why are we talking about doing the exact opposite? How did this moronic discourse come to rule our politics?

From Habermas to Cervantes

Habermas says that metaphysics is dead, epistemology is on life support, what really matters is epistemology. The philosophy of knowledge can only be pursued as the philosophy of communication. If I convince myself of a truth, and most do not agree with me, of what use is such a truth? Human reality has ineluctable elements, but it also has a huge socially constructed portion. How can we sort out the variety of claims -- of truth per se, or other kinds of validity -- and once have put them in appropriate buckets, how can we evaluate them? And how do we talk with each other about all of this?

I think these are indeed the pressing questions right now. With powerful people inhabiting inconsistent realities, we need to do better than just dismiss those wackos, or murder them, or whatever. We must figure out how to talk with each other. You go, Jurgen!

While Rome burns . . .

Of course, the wingnuts don't believe in the fire even as it scorches their own asses. BMJ today reminds us that antibiotics will stop working for us unless we stop feeding them to livestock. The Brits actually have pretty good policies about this but it doesn't matter because lots of other countries don't and antibiotic resistant pathogens cross international borders as freely as the wind. We might want to do something about this before our kids start dying of staph infections. We might.

Of course, that might actually be merciful if we don't urgently start to deal with climate change. But you know, it's a hoax. Thanks, I feel better now.

This is getting scary

I like to think that I've had a productive research career so far, that the methods I've developed are promising, and that I have a chance in the years I have left to help people take better care of themselves, work more effectively with their physicians, prevent some bad outcomes, and even save us all money in the process. But I've only been able to do this because the American people have valued medical and health services research, and been willing to pay for it. If that isn't true any more, my work is over. I'm not sure what other kind of  job I can get right now, but I need to start thinking about it. That's kind of sad.

Anyway, in case you didn't know it, the work we do is essential if we're going to provide a decent level of Medicare benefits to the growing elderly population in the coming decades. That is a legitimate concern. No, not the spending on food stamps and environmental protection and food safety and veterans benefits and Headstart and diplomacy and highways and bridges and all that stuff that the Republicans have already cut and are demanding to cut further. But the long-term fate of Medicare is a real problem.

But here's the fact: we don't have to limit benefits or make seniors pay more out of pocket or even means test Medicare. (Which maybe sounds like social justice but is a very bad idea politically and would save scarcely any money.) We can get most of the way there by getting more bang for our bucks. Figuring out how to do that is what we do. And we actually understand the problems, unlike the interchangeably ignorant Rand Paul and Paul Ryan.

Here are a couple of examples from the new JAMA. They're very wonky, and I think you'll be stopped at the abstract anyway, which is probably a blessing. Lewis Lipsitz discusses the so-called 3-Night rule, and Steven Landers discusses the future of Medicare home health benefits.

The 3-Night rule is that in order to qualify for care in a Skilled Nursing Facility (SNF), you first have to spend 3 nights in the hospital. Back when the rule was created, it usually took that long for proper assessment and stabilization of whatever acute episode the person had suffered. The rule was intended to make sure people didn't receive skilled nursing care, which is quite expensive, unnecessarily. But, nowadays, it's often the case that somebody come into the ED and they can quickly receive whatever acute services they need and could be immediately sent on to a SNF without even being admitted. However, if that happens, Medicare won't cover the bills in the SNF, which few families can afford. What often happens is that doctors end up keeping people for three nights, just so they'll qualify, but hospital care is even more expensive than SNF care. Also, being in the hospital is bad for you, especially if you're old and frail.

So why not just bag the rule? Well, a funny thing can happen. If people who are in a nursing home but not receiving skilled nursing care, the nursing home gets a relatively low reimbursement. If the person has some sort of a setback, the facility can decide to start charging the SNF rate even if the person doesn't really need skilled nursing care. If they have to send them to the hospital instead, and get a doctor's authorization, they can't get away with that. The result is that waiving the 3-Night rule so far has not consistently demonstrated cost savings. But, if you structure payment and regulation correctly, you could indeed get both cost savings and better experiences and outcomes for patients. It takes policy wonks to figure out how to do this correctly, and well-designed trials and data analysis to prove what works and what doesn't.

There are similar issues with home care: how to get people the services they need, that can keep them at home and out of the hospital or nursing home, without overpaying or inviting fraud. If we can figure out how to do these things correctly, along with many other challenges, we can make Medicare much more sustainable while taking better care of people. But that takes a) investment up front and b) honesty and wisdom from politicians who prefer to exploit fears about Medicare to scare people into voting against their own interests. I'm talking to you Paul Ryan.

Remember Reality?

Most people seem to have forgotten all about that concept but I haven't, and I happen to know that reality bites. Here's Michael Tomasky discussing the debt limit, including a warning that has already come true: that Republicans will start claiming that hitting the debt limit will be harmless, or even, in the case of the yoyo interviewed at the link, beneficial.

They're already claiming that the government shutdown is harmless, except when they're complaining about the specific government services that have been suspended, for some mysterious reason having nothing to do with their refusing to fund them. But listen up folks: when we hit the debt limit, one of two things will happen. Either the U.S. stops paying interest on debt, in which case financial markets will devolve into chaos; or it stops mailing out Social Security checks and Medicare reimbursements, in which case we will plunge into an economic depression and people will starve and stuff like that.

Third possibility: Obama takes advantage of one of the options he has for ignoring the debt limit (platinum coin, constitution requires payment of government obligations), whereupon the House impeaches him and sues in federal court and the government remains in total chaos until January of 2015; meanwhile the shutdown continues and we go into a second Great Depression anyway.

This will happen. Their denying it in advance won't change anything. Do they really not understand that?

Doctor Doofus

There's nothing I can do, and nothing original I can say about the collapse of our republic, I'll just outsource to Timothy Egan then move on to my regular blogging agenda. Or rather, I will say this. It is really depressing to think that there are horrid communities in this country, full of racist, ignorant, cruel and repulsive people who would actually vote for the malignant clowns who run the Republican party. I will make sure never to visit such places.

Now, on to Stayin' Alive. In spite of 20 years or more of serious efforts to improve the quality of medical care and to rein in overdiagnosis, overtreatment and just plain wrong treatment, all sorts of news today that shows we are failing. First, I believe I have written before about low back pain. Most of the time it resolves on its own after a while; there is no benefit to commonly performed surgical procedures, nor to ordering MRI or other imaging procedures on routine presentation, and definitely more harm than benefit to prescribing narcotics. Ordinary over-the-counter pain relievers, maybe physical therapy, and just waiting are the right course unless there are other symptoms indicating a possible serious problem.

Well, Mafi et al in JAMA Internal Medicine (I think you'll get stopped at the abstract, but I have the magic cookie) find that from 1999 to 2010, mistreatment of low back pain increased in the U.S.

Nonsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9%in 1999-2000 to 24.5%in 2009-2010 (unadjusted P < .001). In contrast, narcotic use increased from 19.3%to 29.1% (P < .001). Although physical therapy referrals remained unchanged at approximately 20%, physician referrals increased from 6.8%to 14.0%(P < .001). The number of radiographs remained stable at approximately 17%, whereas the number of computed tomograms or magnetic resonance images increased from 7.2%to 11.3%during the study period (P < .001).

Meanwhile, futile treatment of critically ill patients continues more or less unabated; doctors continue to prescribe antibiotics for upper respiratory tract infections which is a) generally useless and b) actually harmful to patients and c) harmful to all of society; and, in BMJ, we learn that most trials of cancer screening don't even bother to assess harms, which says a lot about the underlying psychology of physicians and clinical researchers. Obviously, if you only study potential benefits and ignore potential harms, you'll end up doing a lot of stuff you shouldn't do.

I almost despair, at times. Patients also think that more is necessarily better, and of course this fundamental misunderstanding contaminates our politics as well. No, efforts to reduce overdiagnosis and overtreatment are not "death panels." They are life panels. Reducing waste and harm in medical care is the only way to make the whole enterprise sustainable, affordable, and available to everybody and at the same time, it means better outcomes and healthier people.

And to hell with Republicans.

Pahhhhhtttyyy!

In case you didn't know, it's NHL opening night and the Canadiens are at home. You can't even imagine what's going on here. There's a huge plaza in the middle of Rue Ste. Catherine with an open air concert space, which is featuring a free Kings of Leon Concert and 150 booths selling beer and booze. I mean it is absolutely bugfucking insane. I hung out with it for a while then it was just too much.

Believe me, Boston would never try this for opening night of baseball or football. You'd have a guaranteed riot with overturned and torched cars, serial sexual assaults, and mass tazerings and rubber bullets. Here, it's loud for sure, but non-violent. They can do it. We can't.

American Exceptionalism

What I could say of the conference is multiple and various, but one important theme is that the Europeans and Canadians here think we're completely nucking futz. To whit . . .

I attended a talk yesterday in which the investigator reported on surveying cancer patients about out of pocket costs. How much could they pay, how much did they pay, how was it affecting them financially and emotionally, yadda yadda yadda. As you might expect, the answers are not so much, more than they had, and disastrously. (Average cost: $600/mo. Top cost: tens of thousands of dollars a month. Average education: grade 12.)

A guy from Germany or the Netherlands or someplace -- you know, one of those totalitarian dungeons -- said basically WTF? In my country, in all of Europe, nobody who has cancer pays a penny. The speaker was nonplussed. What, you don't even have a copay? No no, the guy said. We might have a conversation over whether it's still worth it if the person is going to die anyway, but of course they don't have to pay. Why should they? They have cancer for heaven's sake!

Makes sense to me. Back in the U -- S-- S-- A one thing the confluence of government shutdown and opening of health insurance exchanges has accomplished is that it has forced the corporate media, against their will, to explain what's going on. Err, okay, the idea is that if you don't have health insurance and you haven't been able to get it because you couldn't afford it or you are disqualified by your diagnosis of pinky spasm, now you can get online and find good, cheap health insurance. Therefore you and your children and grandchildren are no longer free. Or something. Meanwhile people are having their regular doctor appointments and the doctor is telling Granny, no, there isn't any death panel and your Medicare is just the same as ever, except now your prescription drug coverage is better. Even if the doctor is a teabagger, what else is he gonna say? There isn't anything else.

So as far as I can tell this can't end well for Ted Cruz. But I don't prognosticate. We'll see.

The Great Sunny and Warm North

That's Montreal today and prognosticated to be so all week. I'll be here through Wednesday for the International Conference on Communication in Healthcare. I'll let y'all know whatever great stuff happens here (I'm speaking twice so it can't be all bad), but meanwhile I just have my superficial impressions of the city to share.

As you may have heard, they are all kinds of uppity about their effete effeminate language. It's illegal to have signs in English. You're allowed to put English under the French, in smaller print, but for the most part they don't even bother to do that. You'll mostly hear French on the street, but everybody is able to speak English. Of course I'm in the hotel and the staff is so perfectly bilingual its painful.

Rue Ste. Catherine is a major commercial boulevard. You can get any kind of cuisine you want here -- pizza is very popular, the usual burgers, there's an arepa place, Middle Eastern, Greek, pan-Asian, sushi, you name it. Well, one kind of food that I have not seen on offer is French. You can't get that here. The sidewalks are wide and the vehicle traffic on the light side, but the restaurants are 100% indoors. Sidewalk cafes is not a happening thing.

Rather like Basel, the high end and low end businesses are all mixed up here. Fancy watches, high priced clothing, right next to lap dances. There are also a lot of slackers, idle young adults, in some cases openly panhandling for beer and drugs. Lots of tobacco smoking. An ethnic potpourri. Quite stimulating. Now I'm off to the opening session.

Obsolescence

Tom Lehrer claimed that he gave up his public career and went back to laboring in anonymity as a math teacher because satire became obsolete when Henry Kissinger won the Nobel Peace Prize. I don't know if he meant it, but blogging about public health and health care seems kind of obsolete these days when the field is completely dominated by insane liars. I don't know what I can possibly contribute to this "discussion."

Kurt Eichenwald takes on the psychopathic Republican party in Vanity Fair, but I mean really, what's the use? A few tens of thousands of people will read it, most of whom are already pretty much tethered to reality, while 100 million will either get The Crazy mainlined by Faux News or, at best, be told by Chuck Todd that there is a dispute between people who are trying to stop Obamacare from destroying the economy and putting a government bureaucrat in every doctor's examining room; and people who are determined to have it take effect anyway just because.

The Republicans in congress are apparently determined to smash the U.S. economy and political system to rubble, half the people are cheering them on, and the corporate media are just transmitting the pictures. What is really weird is that the Camber of Commerce and most of the business establishment, which face disaster at the hands of the very monster they created, aren't trying to stop it. The vast majority of capitalists have everything to lose and nothing to gain from these nutjobs, but they still seem to think of them as their own tools and they can't stand to lose them. They will live to regret this very, very deeply.

For myself, I'm not sure what the future holds. I won't have a career, or even a job, if there isn't any federal funding for health services research. That's kind of sad since I've worked so long and hard to get to this point and I like to think that I'm starting to make a contribution in the public interest. But if the people don't want to pay for it, because government and knowledge are both equally evil, I guess I'll just have to figure out something else. It's on you, Chuck.

Jeopardy!

I keep sending these in to Alex Trebek, but for some reason they never use them. Remember, your answer must be in the form of a question.


Category: National Monuments
       Clue:  Nobody, it's an above-ground mausoleum

Answer: Who's buried in Grant's tomb?

Category: National origins
       Clue: Obviously!

Answer: Is the Pope Argentinian?

Category: Prominent Journalists
       Clue: Chuck Todd

Answer: Who?

Category: Metaphysics
       Clue: Metabolizing and reproducing entity

Answer: What is the meaning of life?

Category: Clerical Vestments
       Clue: Skirt for an Archbishop

Answer: What is Tutu?

Category: Existentialism
       Clue: Shit

Answer: What happens?

Category: Grammar
       Clue: Objective Case

Answer: Are you talking to me?

As you can tell, I didn't sleep much last night. I'm gradually getting back to normal, but it's taking a while.

Still sick . . .

though getting better. I'll outsource to Jonathan Chait. It's long -- and I know the Intertubes has made it impossible for anyone to concentrate on a single essay for more than 35 seconds -- but it's a good explanation of what's going on with the Republican Doomsday Machine over the Affordable Care Act.

Said lengthiness is also the problem that has been a burr under my saddle for as long as I've been in this racket. It is just impossible to explain to people -- by which I mean not only your local parking lot attendant, steamfitter or divorce lawyer but also those people who style themselves journalists -- how the market for health care and health insurance works and what exactly we need to do to fix it. I just can't make it short and simple and also true. Especially with the entire population irretrievably lost in delusional faith in a non-existent entity called the "Free Market."

Anyway, we're at a hinge of history now folks. Chait may be a bit less optimistic than I, but I'm not in the prediction game.

Something you really, really don't want . . .

. . . is norovirus. At least I think that's what happened to me yesterday. Anyway, whatever it was, same basic idea. The diarrhea started at 3:00 am, and obviously, as I got out of bed and hit the light switch, there was a power outage. It was raining and darker than a black hole, so I spent the night groping my way back and forth from bed to toilet. By morning I managed to get downstairs to continue the performance from the sofa, but I was so weak and tired I could barely get off it to meet the recurrent necessity.

The good news about this is that it doesn't last long. The diarrhea subsided by evening and I even made it in to work today, because I had to, even though I still feel like crap. I'll have to eat something but the very idea of food is still repulsive. The other good news -- and as far as I'm concerned it is good news -- is that there is absolutely no medical treatment that can do the slightest good.* You just have to live through it, then it's over.

The reason that's good news is a) there's no way on earth I could have gotten to a doctor even if somebody would have seen me on a Sunday, and I wouldn't want to be thinking "Damn, if only." Second, it didn't cost anybody anything. If it's over in a day anyway, then okay sure if I had a $10 pill in the cabinet I could have popped that would have stopped it, that would have been worth it. Beyond that, not really.

Lesson: Wash you hands! Wash your vegetables! Keep you kitchen clean! I probably got it from restaurant food or just touching something that was contaminated -- norovirus is very contagious and there are plenty of ways to catch it without eating tainted food. But anything you can do to improve your chances I will strongly endorse.

*Frail elderly, very young and immunocompromised people can be seriously injured or killed, by dehydration Parents of young children should keep Pedialite or similar rehydration fluid in the house, just in case. Sugary drinks, however, are not a good idea.

It's going to happen, might as well hunker down

The Shrill One, here embracing the appellation, figures the Republicans have gone so far around the bend that yes, they will shut down the government and might just refuse to raise the debt limit. I'm holding off on investing my 2013 IRA contribution, because they might just knock us back into 1932.

There's more than enough blame to go around for the collapse of our hallowed republic, but let me single out the the worst offender and no, it's not the Koch brothers or the Club for Growth or Rush Limbaugh or even Fox News. It's CBS, ABC, NBC, CNN, NPR and the rest of the corporate media gang of idiots. Fox News and the Vulgar Pigboy know what they're doing, they do it on purpose, and they're just evil. They know they're lying all the time and they know how they're pushing the buttons and pulling the strings of their deluded followers. The others, however, pretend to be journalists and pretend to be providing some sort of a public service.

No and no. The coverage I see and hear consists of one or another Republican member of Congress declaring that "Obamacare" is the worst legislation of the past 50 years, that it will destroy the economy and our liberty and cost billions of jobs and raise the cost of health care." Then they have Harry Reid saying "no, we aren't going to defund it." That's the debate the people hear, in its entirety. And as Chuck Todd said yesterday, it's not his job to tell people the truth.

Polls show that the majority of people oppose the Affordable Care Act, and an even larger majority don't know what it does. I know damn well that isn't my fault, but I can't get 100 million people to read this blog.

I'll tell you what though. Roger Ailes and Rupert Murdoch and even the Koch brothers don't actually want economic collapse. I'm counting on them to make Rand Paul an offer he can't refuse.

Ripoff!

I think you can only read the abstract (I have a magic cookie on my 'puter that dissolves paywalls), but the new JAMA has a brief review of the evidence about anti-oxidant vitamin supplements. These are the main ingredients in your typical multi-vitamin -- beta carotene/vitamin A, Vitamin C, Vitamin E -- you know, the classics. These have long been touted as promoting health and longevity, on the theory that oxidizing free radicals in the body cause cell damage. If you enter the term "antioxidant supplement" or similar into your favorite search engine, you'll get pages of ads.

Here's the bottom line, folks. The higher the study quality, the worse these look. In fact, taking Vitamin E, beta carotene and Vitamin A supplements is associated with higher all-cause mortality. Vitamin C and selenium (a mineral not a vitamin but also touted as an antioxidant) don't do anything, except cost you money. In other words, the people who are selling these, including big corporations that advertise heavily on TV, major retail chains including CVS and Walmart, and many more, are lying, stealing, and murdering people. And it's perfectly legal.

It is true that eating foods that are high in these substances is generally good for you. That would be your fruits and veggies. So do that instead. Don't buy any of this garbage.

Not exactly fraud

Obviously the cause of science, and therefore the cause of humanity, is harmed when scientists make up results or misrepresent their findings in a scientific paper. I get outraged about it, but it probably isn't all that common.

Even so, false beliefs often persist for a long time. Steven A. Greenberg, in BMJ, tells us how this can happen. This is an excellent and important piece of work which gores some very powerful, oxen, so I recommend it even though it may be somewhat heavy going.

To translate it into English, what Greenberg did was to study all the papers addressing a claim or hypothesis that an uncommon muscle disease called inclusion body myositis is caused by or at least includes in its pathogensis abnormal accumulation of beta amyloid protein, which is famous for being associated with Alzheimer's disease. (It really is found in the brains of people with Alzheimer's, but any causal relationship is unknown.)

He found a small number of original research papers that support the hypothesis, and at least as many that do not. However, in a nutshell, the negative papers were almost never cited in subsequent published research, whereas the positive papers received many citations. Furthermore, the positive papers were discussed in review articles that got even more citations, whereas the negative papers were not, further amplifying the strength of the belief.

It gets worse. Papers that either did not contain data supporting the hypothesis -- perhaps presenting it only as a hypothesis, or offering a data-free discussion -- are frequently cited attached to text claiming the hypothesis has been supported. And worse than that, papers which are not relevant to the hypothesis at all, or which even tend to undermine it, are frequently cited as supporting it. Abstracts -- which receive very limited peer review and contain only very limited presentation of methods -- are often cited as if they are peer reviewed articles. And titles of papers that do not contain original experimental data imply that they do.

Furthermore, proposals to the National Institutes of Health reflect all of these biases and falsehoods, and many of them have been funded. Yet it is not at all clear that this line of inquiry has any prospect of explaining the disease or benefiting patients.

This probably happens partly because of actually dishonesty, and partly because of carelessness. There is also a well-known bias on the part of journal editors against publishing negative findings. But the citation network also tends to grow with a powerful bias toward confirmation for reasons inherent to the research enterprise. When a finding is negative, there is nothing more to say about the subject. The investigators will not continue down that road, and they are unlikely to cite their own paper in the future because they won't be working on the problem any longer. But positive findings generate further funding, further research, self-citation, and citation by others seeking funding for related work. They make fodder for interesting review articles that tell a coherent story, whereas nobody is going to write a review article asserting merely that X does not cause Y.

Yes, these false pathways have to come to an end sooner or later, but it can take much too long.

Most outrageous scientific fraud evahh?

Probably not but it's right up there. Introducing Bruce Murdoch, professor at the University of Queensland, founding head of the Centre for Neurogenic Communication Disorders, and for nearly a decade dean of the UQ School of Health and Rehabilitation Sciences, author of nearly 400 peer reviewed journal articles and 13 books. Murdoch caused a sensation back in 2012 when he presented findings that transcranial magnetic stimulation -- basically applying powerful magnetic fields to the brain -- caused people with advanced Parkinson's disease to regain the ability to speak.

This  historic, miraculous breakthrough was then published in the European Journal of Neurology. Here's the funny part though, you'll really find this amusing. He never did the study. He made the whole thing up.

You've probably heard, and it's generally true, that most cases of research fraud are all about the intense, cutthroat competition for faculty appointments and promotions. We're turning out many more PhDs then will ever have a decent academic job (yes, I count myself lucky), and the competition for research funding also grows ever more brutal, so young people sometimes get desperate. Clearly, this explanation does not apply hear, as it also did not apply to Marc Hauser.

What is going on here? I'm not entirely sure but my guess is that the egotism and ambition that help drive people to the top ranks of academia are ultimately not satisfied by the very narrow circle of fame that pertains. That all the investigators in the field of neurogenic communication disorders have heard of you only slakes your hunger for admiration. When you go to those conferences, you still have to fly economy class, carry your own luggage, and make a 15 minute presentation on the same stage with assistant professors and post-docs. Your students only pretend to worship you because they want a recommendation or a toehold appointment as a lecturer. But if you can do something really astonishing, that will get your name on the television or even an appearance on a talk show, now you'll really be a celebrity, everybody will know you're the really big deal you already know you are.

In discussing other cases, I've pointed out the immense swath of destruction cut by this behavior. His students and post-docs will have trouble finding employment. The university may not be able to find alternative placement for some of them. His collaborators are disgraced. Funding that could have gone to productive research has been squandered. The very limited space in a top journal has been stolen from a legitimate study, and scientists the world over deceived. Some may have initiated work of their own which turns out to be a total waste. Thousands of people around the world have been given false hope.

Just sick.

The Gray Tsunami

You may recall recent findings that the rate of dementia among people 65 and older has been falling in England and Wales, and this is likely true here as well. It's basically because people are generally healthier. But . . .

It's very strange how the general reaction seems to have been, "Oh well then, what have we been so worried about?" News that isn't quite as bad as you thought it was going to be is still bad news. And the fact is that the prevalence of dementia still rises with age, and we're still going to have a lot more people living with dementia in coming years. The estimate here of tripling by 2050 might be too high, but 2 1/2 times as many is still a whole lot.

Now the IOM raises the alarm about cancer, another disease that is strongly associated with increasing age and which costs a whole hell of a lot of money to treat. Here's a good example of why medical advances can drive medical costs: there aren't any effective treatments for dementia, so it's actually relatively cheap. Many people do ultimately need custodial care and that can bankrupt families and strains Medicaid budgets, but Medicare is going to have to pay for all this cancer care and new therapies can cost $100,000 and up. Even though the benefit is generally small, our laws and our cultural consensus say that we still have to pay for them.

IOM also argues that advances in the field are so rapid that many physicians and treatment centers aren't keeping up; and that we'll have a growing shortage of relevant experts. It's hard to predict how this will play out. Advances in what are called medical informatics may make it easier for providers to select the right treatment protocols and deliver the latest, proven technologies. Basically, they won't have to know everything, the computer will tell them. (They will have to ask it the right questions.) Treatments that are really curative may end up saving some money in the long run, or cheaper treatments may emerge, but I'm not going to bet on that.

We can save money by all the means I talk about here -- not overdiagnosing and overtreating, not using useless treatments and tests, not overpaying for specialty care. At least we can in principle, it's proving to be very difficult politically because all that waste is somebody's income. But even if we manage to do that, medical costs will continue to increase. We're a wealthy society, we can afford it, but it means young and healthy people will have to pay for the care of old and sick people. That's a granite hard fact of life. Are we prepared to do it?

Update: And right on cue, This lands in my in-box. (I swear, it was after I put up this post.)

PLAINSBORO, N.J. – Promising targeted therapies and immunotherapies for melanoma, used in combinations so advanced they have outpaced the nation’s regulators, offer hope of survival to patients suffering from a cancer once seen as a “hopeless” malignancy, according to experts convened by The American Journal of Managed Care. A. Mark Fendrick, MD, co-editor-in-chief of AJMC, led the discussion with the following experts:

• Jeffrey Weber, MD, PhD, senior member, H. Lee Moffitt Cancer Center and director, Donald A. Adam Comprehensive Melanoma Research Center.
• Antoni Ribas, MD, PhD, Jonsson Comprehensive Cancer Center, UCLA.  
• Jennifer Malin, MD, PhD, manager and medical director of oncology, WellPoint.

 “Melanoma has gone from being regarded by many oncologists in the community as an impossible-to-treat and hopeless malignancy to a disease that one might argue is the poster child for new targeted and immunologic therapies,” Dr. Weber said.
However, these drug combinations are not cheap, and the panelists warned that there is only so much that cancer patients, their employers and those who fund government health plans will be willing to pay. Already, Dr. Ribas warned, some melanoma patients lack access to cutting edge drugs like ipilimumab, depending on where they seek treatment and whether they have appropriate insurance coverage.

Is Our Journalists Learning?

Maybe so. David D. Kirkpatrick, in the NYT, has abandoned the practice of stenography to point out that three congressional Republicans, visiting Egypt, don't know their sphincters from the Sphinx. Michelle Bachmann, Louis Gohmert and Steve King all think that the Muslim Brotherhood committed the 9/11 attack -- really! Kirkpatrick, in gross violation of journalistic norms and traditions, points out that isn't true, and in fact the Muslim Brotherhood renounced violence decades ago and strongly condemns al Qaeda and all terrorist tactics.

Then there is this:

Representative Louie Gohmert of Texas, appearing with her and Representative Steve King of Iowa, compared the leader of the military takeover, Gen. Abdul-Fattah el-Sisi, to George Washington. Mr. Gohmert overlooked the new government’s mass shootings of hundreds of mostly unarmed protesters, its sweeping roundup of thousands of political opponents and its suspension of all legal protection against arbitrary arrest or other police abuse; instead, he commended General Sisi and the appointed civilian leaders for creating a government where the rule of law was “king.”

This appears on the same day that Paul Krugman's column decries conservatives' general lack of acquaintance with reality, e.g. Rand Paul insisting that government employment has exploded under Obama, global warming denialism, and so forth.

Alas, the New York Times is largely irrelevant. The TV news will never point out when a politician  is lying, in fact they tend to absorb conservative falsehoods as verities. We are in very grave danger with these deluded lunatics running congress, and a corporate media that treat them respectfully while decrying "partisanship" on both sides. You bet I'm partisan when the other side is crazy, but if Alan Grayson says something to that effect, he isn't to be taken seriously.

So it's tough to go on blogging into the wind. Oh well, might as well keep on as not.

 

I'm just befuddled

I think Barack Obama must have a brain tumor. What in the Alpha Quadrant would make him utterly determined, against overwhelming public opinion, the international consensus, and the most basic common sense, to blow up stuff and people in Syria?

Since I stated my own, entirely correct opinion about this proposal a few days ago, I've pretty much found that just about everybody with one neuron to rub against another agrees with me. Mr. Obama's bit supporters are the same people who brought us Iraq and waterboarding, being against which is the reason B. Hussein Obama is now president. And yet here's John Kerry -- Winter Soldier John Fucking Kerry -- going on about Munich and appeasement.

I'm happy to be able to break it to you John -- Assad is not going to conquer Europe, or even the part of Syria he's already lost. And nobody is proposing to give him Czechoslovakia, or even a parking spot. What we are proposing is not to blow up some Syrians on top of the ones who are already being blown up for the purpose of "sending a message" that he should stick to blowing people up rather than gassing them. This is idiotic. And by the way if you're worried about chemical weapons falling into the hands of people who might use them against U.S. interests, or otherwise beyond the current conflict in Syria, the best way to make that happen is to make the Assad regime collapse. Somebody should probably explain that to president John McCain.

What is most bizarre about this is how counterproductive it is when Obama should be using all his bandwidth to promote the Affordable Care Act and explain it to people as it rolls out just three weeks from now. He's stepping all over his own lines with this insanity and meanwhile destroying the credibility with the world community that he has won back after the disasters of the predecessor regime. And oh yeah, he's just compounding the political damage from the Snowden revelations.

And why? What exactly is the affirmative goal? He claims it's to defend the "international norm" against use of chemical weapons but a) the U.S. hasn't been bothering to defend said international norm for the past 50 years or so -- in fact the U.S. used chemical weapons in Vietnam, assisted Saddam Hussein in using chemical weapons, used white phosphorus in Fallujah (yep) and held massive stockpiles of nerve gas until recently.

Syria is not a party to the international convention against chemical weapons use, and the Geneva convention is silent on use within sovereign borders. In other words, the Assad regime did not in fact violate any treaties or international law by this action. You might like it less than you like shooting people and blowing them up, for some reason, but personally, I don't think it matters.

If Obama hadn't been threatening military action, he probably could have gotten a Security Council resolution of condemnation, or at least statements from the European Community and the Arab League. He would have had leverage to get the Russians to temper their support for Assad, but now he's just pissed them off and destroyed any hope of organizing a negotiated solution to the Syrian tragedy. He's made the Iraqi government more hostile and he's greeted the new Iranian government's very obvious and likely sincere diplomatic overtures with a punch in the mouth.

If he goes ahead and does this without congressional authorization, there will be a resolution of impeachment in the House and it might even pass. Then we'll be screwing around with that for the next six months while we hit the debt limit and the continuing resolution for government spending authority expires. It's time to lay in the canned goods, folks.

If it's not a brain tumor, what is it? Somebody please explain. 

Update: Juan Cole has a hypothesis, although it's not very convincing to me. Basically, the U.S. strategy in Syria has been to try to build up a secular fighting force that can beat out the Islamists on the battlefield. That will take a loooonnnnnggg time. The attack in Ghouta, according to Cole, was a response to this incipient force (which is being trained in Jordan) making advances in the Damascus suburbs. The idea is that Obama wants to make Assad fight "fair," (whatever that means) so the strategy has time to develop. Maybe so but is there any reason not to explain that publicly? Then we could have a meaningful discussion.

Just thought folks might like to see these

A pair of fawns came into my front yard a couple of weeks back. They've been hanging around the area together, but I haven't seen their mother, which is a bit odd. Anyway they seem to be doing okay. Some of these behaviors were a bit surprising to me - a lot of self-grooming. Most people live in cities now, so this sort of thing probably seems special if you do. It's nothing out here.

Incentives

A multitude of cogitators, writing in JAMA Internal Medicine, have computed the annual cost of hospital-acquired infections in the U.S. They use the term "healthcare associated infections" but they actually limit the analysis to certain of the most important infections caused by hospital care. They come up with an annual cost of $9.8 billion per year, not counting the pain, suffering and death of the victims.

Okay, that's a bummer. But here's what is, to me, the interesting part. As the authors point out, we've been making some progress on reducing this problem, but it's been slow. Here's the rather dry money quote:

However, despite the availability of solutions, the strong ethical case for improvement, and the intuitive argument that saving lives ought to save money, large-scale progress against HAIs has been slow. Only recently have health care organizations begun to achieve successes and overcome doubts about the scalability of pilot studies and vanguard institutions. Along with leadership of patient safety professionals, an important driver of progress is the move by payers to deny reimbursement for health care related to preventable harm.^10- 11 By placing the costs of HAIs with hospitals, this shift has accentuated the fiscal case for prevention.

Let me translate this into lay language. Until very recently, hospitals made money  by making people sick. That average $45,814 cost of a central line bloodstream infection? That's what the hospitals were paid when one of them happened. The more central line infections, the more revenue. This is a particularly meaningful issue for me because a major teaching hospital of Harvard University (as my surgeon's card bragged) botched what should have been minor surgery on yours truly, and then tried sending me a bill for $25,000 back in 1991. That's on top of what my insurance had paid them. I refused to pay it, they sicked a collection agency on me, I told the collection agency what happened, and the collection agency guy actually called me up to apologize and said they would drop the matter. Most people, however, pay up, plus they probably had already made a profit off of the insurance.

If you think this is insane, you're sane. However, the new reimbursement policies are by no means universal. And they don't go far enough. If your auto mechanic screws up, he is responsible. So should your doctor.