Fly-Over Country

Red State Update

Know your wingnuts

From the June 30 Glenn Beck show on Fox:

Former CIA operative (and current wingnut) Michael Scheuer says that "The only chance we have as a country right now is" for bin Laden to "detonate a major weapon" inside the United States.  Only then, he says, will our government do what is necessary to prevent bin Laden from . . . detonating a major weapon inside the United States.  Glenn Beck nods appreciatively.

Let's be clear about this.  Scheuer and Beck are expressly hoping for a mass casualty terror strike within the United States because that would further their political agenda.  This batshit insanity now passes for mainstream discourse on the right.  Somebody throw a net on these guys.

Graph of the Day

Holier than who?

Source: New York Times (June 27, 2009)

Moral hazard and health care reform

The debate over health care reform reflects a fundamental ideological disagreement. Liberals think the private market has failed and that government should step in to redress that failure.  Conservatives contend that the real problem is that the government and other third-party payers (insurance companies) are distorting the market: Since someone else is paying for our care, we demand much more care, and the price goes up.  To fix that problem, conservatives say, we need to set up systems that make individuals bear more of the financial responsibility for their care so they demand fewer services.

Malcolm Gladwell summarizes this view:

"Moral hazard" is the term economists use to describe the fact that insurance can change the behavior of the person being insured.  If your office gives you and your co-workers all the free Pepsi you want—if your employer, in effect, offers universal Pepsi insurance—you'll drink more Pepsi than you would have otherwise. . . The savings-and-loan crisis of the nineteen-eighties was created, in large part, by the fact that the federal government insured savings deposits of up to a hundred thousand dollars, and so the newly deregulated S. & L.s made far riskier investments than they would have otherwise. . . Insurance is an attempt to make human life safer and more secure.  But, if those efforts can backfire and produce riskier behavior, providing insurance becomes a much more complicated and problematic endeavor.

In 1968, the economist Mark Pauly argued that moral hazard played an enormous role in medicine, and, as John Nyman writes in his book "The Theory of the Demand for Health Insurance," Pauly's paper has become the "single most influential article in the health economics literature."

. . . What Nyman is saying is that when your insurance company requires that you make a twenty-dollar co-payment for a visit to the doctor, or when your plan includes an annual five-hundred-dollar or thousand-dollar deductible, it's not simply an attempt to get you to pick up a larger share of your health costs.  It is an attempt to make your use of the health-care system more efficient.  Making you responsible for a share of the costs, the argument runs, will reduce moral hazard: you'll no longer grab one of those free Pepsis when you aren't really thirsty.

There's an obvious problem with this:

The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd.  We go to the doctor grudgingly, only because we're sick.  "Moral hazard is overblown," the Princeton economist Uwe Reinhardt says.  "You always hear that the demand for health care is unlimited.  This is just not true.  People who are very well insured, who are very rich, do you see them check into the hospital because it's free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?"

Nor is there any reason to believe that we’d make more efficient choices if we bore more of the financial responsibility.  Unless we were qualified to make medical decisions – and unless we’re doctors we aren’t – we’re as likely to cut back on beneficial treatment as wasteful treatment.  Indeed, our reluctance to spend a little now might cost a lot later.  In fact, this appears to be exactly what happens:

In the late nineteen-seventies, the RAND Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars.  As you might expect, the more that people were asked to chip in for their health care the less care they used.  The problem was that they cut back equally on both frivolous care and useful care.  Poor people in the high-deductible group with hypertension, for instance, didn't do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death. . . The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful.  Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient.  In fact, they are behaviors that could end up saving the health-care system a good deal of money.

This is entirely consistent with the much-discussed article by Dr. Atul Gawande.  Gawande found vast regional disparities in the per capita cost of health care.  For example, the per capita cost in McAllen, Texas is twice as high as the per capita cost in the statistically indistinguishable Texas city of El Paso.  That’s not because the residents of McAllen demand twice as much health care as the residents of El Paso, but because physicians in McAllen prescribe twice as much.  Patients accept this because they have no basis to tell their physicians that they don’t need the third test or the invasive procedure or the monthly follow-ups, but they aren’t in any sense demanding services over and above what patients in El Paso receive.  And if they bore more of the financial responsibility they’d be as likely to decline useful measures as wasteful ones.

Conservatives get health care wrong because their ideological frame is wrong.  If the market is always good and the government is always bad, then it’s inconceivable that we need government to fix a market failure.  Unfortunately, we do have a market failure in health care, and only the government can fix it.  This means that it is essentially impossible to work out a broad bipartisan solution.  If it's a solution then it won’t be bipartisan, and if it's bipartisan then it won’t be a solution.

Graph of the day

This is why Barack Obama should be more aggressive on . . . well, everything, but especially on health care reform.

Thomas Sowell is a crank

Many conservatives consider Thomas Sowell a brilliant guy, and maybe that's true -- in an "A Beautiful Mind" sort of way -- but he's also a crank.  Here is an example:

A quadrupling of the national debt in just one year and accepting a nuclear-armed sponsor of international terrorism such as Iran are not things from which any country is guaranteed to recover. 

Just two nuclear bombs were enough to get Japan to surrender in World War II. It is hard to believe that it would take much more than that for the United States of America to surrender — especially with people in control of both the White House and the Congress who were for turning tail and running in Iraq just a couple of years ago.

Perhaps people who are busy gushing over the Obama cult today might do well to stop and think about what it would mean for their granddaughters to live under sharia law.

The glib pieties in Barack Obama’s televised sermonettes will not stop Iran from becoming a nuclear terrorist nation. Time is running out fast and we will be lucky if it doesn’t happen during the first term of this president. If he gets elected to a second term  — which is quite possible, despite whatever economic disasters he leads us into — our fate as a nation may be sealed.

First a little cleanup on "quadrupling of the national debt in just one year."  When George Bush left office the national debt stood at approximately $10 trillion.  To quadruple that "in just one year" we'd have to run a deficit of $30 trillion in fiscal 2009.  This is not the sort of goofy claim one would expect of a brilliant economist. 

But it's the hyperventiliating about Iran that really caught my eye.  If Iran develops a nuclear bomb or two, Sowell claims, it will blow up a US city or two.  That seems nutty to me, but the really nutty part is Sowell's belief that this would cause us to surrender to Iran and live under Sharia law.  If Obama gets a second term, he warns, our daughters will have to wear burkas.

And he knows this is true because lots of us thought it was a bad idea to keep fighting a disastrous war in Iraq.  I mean, if you don't think we should invade and occupy countries that don't pose any serious threat to us, then obviously you'd let Iran take over the United States.  Right?

Apparently Thomas Sowell thinks "Red Dawn" is a documentary. 

Like shooting fish in a barrel

via videosift.com

Red State Update

A lawyer's thoughts about physician compensation

This roundtable discussion got me wondering whether some of my complaints about the way lawyers are compensated might also apply to doctors.  For example, some of the most valuable time I devote to a client consists of nothing more than thinking about the case, perhaps while gazing out a window or taking a shower (I do some of my best work in the shower.)  But if a client sees "Thinking about the case while taking a shower" on the bill, I'm not going to get paid for that time -- particularly if I'm working for a large corporate client with bean counters paid to flyspeck my bills.  I will only get paid for time that can be described with vigorous action verbs regarding specific deliverables (like a legal brief) or approved actions (like appearing in court).  This is unhelpful, because briefs and court appearances that aren't preceded by thinking will inevitably turn out badly.

Many clients similarly resist being charged for conferences with other lawyers.  They consider this wasteful.  That is stupid, because the second most valuable thing I can do for a client is sound out another lawyer on a thorny issue, particularly if the lawyer has experience on that issue.  Such time can obviate hours of research (which clients also don't want to pay for -- apparently believing that lawyers acquire detailed knowledge of all of the countless potentially applicable statutes, regulations, cases, and other legal sources through some osmotic process).

In a perfect world this would have no effect on the way lawyers practice, but we don't live in a perfect world.  If you believe (as I do) that we'd all be better off if lawyers spent more time thinking, then you ought to oppose a system that refuses to pay them for it.  If the system pays for ill-considered motions but not for thinking, you'll get less thinking and more ill-considered motions.

It appears to me that something similar is happening in the medical practice.  Doctors get paid for office visits, but they don't get paid if they talk to us on the phone.  (This leads to office visits that could have been resolved with a phone call.)  Any time they spend contemplating our care outside an office visit they do for free.  They may refer us to another doctor for specialized care, but they don't get reimbursed for time they spend consulting with one another to improve our care.  If they wish to make real money doctors must spend all their time doing procedures, and the primary care docs who ought to be doing most of the heavy lifting make very little in comparison to the specialists.  These financial incentives shape the care we receive.  This roundtable comment makes that point:

In a recent New Yorker article, Atul Gawande vividly illustrated one of the greatest fiscal threats to American health care: over-utilization. Dr. Gawande and others, including President Obama, have blamed this practice of over-utilization of medical services on physicians and their traditional “fee-for-service” compensation model, which is thought to create a perverse incentive for physicians to do more than is actually needed, since the more care they provide, the more money they get.

In this, they are half right: over-utilization is a driver of cost, and it is in part driven by doctors’ economic incentives. The underlying cause, however, is a bias within the physician compensation system that extravagantly rewards surgical procedures performed compared to “cognitive” services like diagnosis and medical management.

In the E.R., for example, sewing a facial laceration pays far better than accurately diagnosing a heart attack. The same principle applies to any procedure — from angiograms to colonoscopies.

The predictable consequence is that physicians gravitate toward lucrative procedural specialties. They perform more and more procedures, using expensive new technologies, driving costs ever higher.

Meanwhile, office-based primary care doctors struggle. The compensation for an office visit is a tiny fraction of that for the simplest procedures. The family physician must rush from patient to patient just to keep pace with static or diminishing reimbursement. Fewer and fewer medical students are going into primary care.

If we changed the way that lawyers and doctors get paid, lawyers and doctors might end up  being happier, and we could all be better off.

Response from Sen. Blanche Lincoln's office

Today I received an email from Katie Laning Niebaum, Communications Director for Sen. Blanche Lincoln, politely taking issue with my criticism of Sen. Lincoln's position on health care reform:

It is incorrect to portray her as an obstacle to the President’s health care reform objectives.  She has fought for it her entire career in Congress and is communicating regularly with the White House on ways to get it done.

She passed along links to releases here and here outlining Sen. Lincoln's positions on health care reform.

I'm impressed that Sen. Lincoln's communications office would detect a post on an obscure blog like this, let alone respond to it, and I suggested to Ms. Niebaum that she put herself in for a raise.  My concern about Sen. Lincoln's stance on the public option remains, but I appreciate the response -- it's more than I've received from my own Sen. Evan Bayh.  A tip of the hat to Ms. Niebaum.

Our history with Iran and Fred Barnes' ingorance

Here is Stephen Kinzer explaining the impact of our past policies in Iran:

By now, many outsiders can identify the man whose picture is on the right-hand side of this protest sign. He is Mir Hossein Mousavi, the reported loser in this month's presidential election. The elderly gentleman in the other picture is unfamiliar to most non-Iranians. He and his fate, however, lie at the historical root of the protests now shaking Iran.

. . . He does not look like a man whose fate would continue to influence the world decades after his death. But this was Muhammad Mossadeq, the most fervent advocate of democracy ever to emerge in his ancient land.

Above the twinned pictures of Mossadeq and Mousavi on this protest poster are the words "We won't let history repeat itself." Centuries of intervention, humiliation and subjugation at the hand of foreign powers have decisively shaped Iran's collective psyche. The most famous victim of this intervention – and also the most vivid symbol of Iran's long struggle for democracy – is Mossadeq. Whenever Iranians assert their desire to shape their own fate, his image appears.

Iranians began their painful and bloody march toward democracy with the constitutional revolution of 1906. Only after the second world war did they finally manage to consolidate a freely elected government. Mossadeq was prime minister, and became hugely popular for taking up the great cause of the day, nationalisation of Iran's oil industry. That outraged the British, who had "bought" the exclusive right to exploit Iranian oil from a corrupt Shah, and the Americans, who feared that allowing nationalization in Iran would encourage leftists around the world.

In the summer of 1953 the CIA sent the intrepid agent Kermit Roosevelt – grandson of President Theodore Roosevelt, who believed Americans should "walk softly and carry a big stick" – to Tehran with orders to overthrow Mossadeq. He accomplished it in just three weeks.

. . . With this covert operation, the world's proudest democracy put an end to democratic rule in Iran. Mohammad Reza Shah Pahlavi returned to the Peacock Throne and ruled with increasing repression for a quarter-century. His repression produced the explosion of 1979 that brought reactionary mullahs to power. Theirs is the regime that rules Iran today.

. . . Militants in Washington who now want the US to intervene on behalf of Iranian protesters either are unaware of this history or delude themselves into thinking that Iranians have forgotten it.

Here is Fred Barnes on the same subject:

BARNES: And then when you see, you know Obama has used — the most pathetic thing is to say, gee, well, we were involved in 1953 — 1953! This is an extremely young society. You think those demonstrators are thinking, well, we hope the U.S. stays out because they were involved in 1953? That's total nonsense.

POWERS: I think there is a history there.

BARNES: 1953?

POWERS: They do remember the United States meddling.

BARNES: No, they don't.

Like Saxby Chambliss, Barnes has no idea what he's talking about, but that doesn't keep him from pontificating.  He is all the authority he needs.

And speaking of insurance companies . . .

The LA Times recently published a devastating report on three major health insurance companies' refusal to end the practice of rescission.  What's rescission?  Paul Waldman explains:

Here's how it works. As Stupak's committee, investigations by a couple of news organizations and some state insurance commissioners, and lawsuits by policyholders have revealed, many insurance companies routinely take the opportunity of a serious accident or illness by one of their policyholders to launch an investigation to see whether they can drop the policyholder from coverage. They don't do this when you first sign up for your policy -- instead, they cash your premiums every month, waiting until you actually file a major claim. At that point, they begin poring over all your past medical records and every form you ever filled out for them, to see if they can find a reason to claim that you violated the terms of your policy. It doesn't even have to have anything to do with the illness in question -- for instance, the Los Angeles Times cited the case of a nurse in Texas who was booted from her insurance policy "after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne."

. . . Think about this for a moment. Somewhere in America today, a woman is sitting in her doctor's office, experiencing the worst moment of her life, as she learns she has breast cancer. Death is staring her in the face. She's wondering whether she'll be there to raise her children or meet her grandchildren. But there's something she doesn't know as she walks out of the office and begins to plan how to tell her family that she could be dead soon.

What she doesn't know is that because she was just diagnosed with cancer, her insurance company is launching an investigation of her, in the hopes that they can find a mistake on one of the many forms she's filled out over the years. One of their employees is poring through her records, and that employee's job is to see if the company can come up with some rationale, any rationale, for cutting off her coverage, so they won't have to pay for the treatment for her cancer. And of course, once they do drop her, she won't be able to get coverage from any of the other insurance companies. Because she has cancer.

Waldman calls this "evil", and he has a point.  But we don't have to go that far to conclude that it's unacceptable.

When you get sick, your insurer suddenly goes out of the taking-your-money business and enters the paying-for-your-health-care business.  There's no profit in that.  That's why the insurance company executives testified that they're going to keep right on rescinding sick people's coverage.  This is the system that opponents of a public plan are defending.  These are the insurance companies whose profits they are defending.  They should be called to account.

Blanche Lincoln is a centristy centrist

Sen. Blanche Lincoln (D-AR) argues that health care reform shouldn't include a public plan, because that would drive out private competition:

“One of our biggest concerns is that it doesn’t need to be a government plan that usurps that ability to compete in the marketplace, which I’m concerned that a totally government-run option would do,” she said.

Here's digby on the competitive market Sen. Lincoln wishes to preserve in Arkansas:

The Justice Department considers an industry to be “highly concentrated” if one company has 42 percent of the market. In Arkansas — Senator Lincoln should take note — Blue Cross Blue Shield has 75 percent of the market. If you take government self-insurance plans out of the equation, it's higher. The state ranks as the ninth most concentrated in the country. Is it any wonder that insurance premiums have risen five times as fast as wages?

Here's Barack Obama at today's press conference, explaining that a public plan would eliminate private competition only if the insurance companies couldn't offer consumers a better deal:

Why would it drive private insurance out of business? If private insurers say that the marketplace provides the best quality health care; if they tell us that they're offering a good deal, then why is it that the government -- which they say can't run anything -- suddenly is going to drive them out of business? That's not logical.

"Now, the -- I think that there's going to be some healthy debates in Congress about the shape that this takes. I think there can be some legitimate concerns on the part of private insurers that if any public plan is simply being subsidized by taxpayers endlessly that over time they can't compete with the government just printing money, so there are going to be some I think legitimate debates to be had about how this private plan takes shape.

"But just conceptually, the notion that all these insurance companies who say they're giving consumers the best possible deal, if they can't compete against a public plan as one option, with consumers making the decision what's the best deal, that defies logic, which is why I think you've seen in the polling data overwhelming support for a public plan.

I really do not get the stated opposition to the public plan.  According to the critics, it would be so popular that it would drive private insurers out of the market.  Every time I hear this I want to respond, "Wait a minute.  You oppose what you say would be an incredibly popular reform because it would be bad for insurance companies?  Really?  That's your argument?"  In his own polite way, that's what Obama said.  I hope someone in the establishment media is paying attention.  Because people like Blanche Lincoln should be asked to explain why they put insurance companies' interests ahead of the people's interest.

Hodgman roasts Obama

Saxby Chambliss helps me make a point

Sen. Saxby Chambliss went on Hardball the other day to criticize what he sees as Barack Obama's insufficiently assertive response to the Iranian crisis. Chambliss's arguments were measured and respectful and in no way loony or intemperate, but along the way he demonstrated that he doesn't know much about how Iranians actually think:

MATTHEWS: What do you make of the president`s concern that our history over there -- he`s voiced this in the Cairo speech -- that our history over there of getting involved with Kermit Roosevelt and the CIA, overthrowing those elections back in the `50s, getting rid of their democracy when they had one, gives us such a bad reputation in that country that if we go in there now, it`ll look like we`re just trying to grab influence in Iran again to our advantage, to get the oil back, to get the influence back that we had there under the shah?

CHAMBLISS: Well, that election was, what, almost 60 years ago now. The world has changed dramatically since then. And I dare say that you go up to any of those people in Teheran who are protesting in the streets and say, Hey, what about the United States meddling in your election in the `50s, they would shake their heads, like, What in the world are you talking about?

As Reza Aslan points out, however, that's just flat dead wrong:

ASLAN: You know, he mentioned the CIA coup of 1953, which most Americans don't know anything about, but which, I got to tell you, is like the core event, the ur-event of the 20th century as far as Iranians are concerned. It's their revolutionary war, civil war all wrapped up into a single thing. And to hear a president even mention it, let alone acknowledge it in that way, had a huge effect in the cafes in Iran.

It's no sin that Chambliss doesn't know how our history with Iran has affected Iranians' views about us. Aslan is probably right that few of us have any idea how Iranians feel about the 1953 coup -- why would we? The problem is that Chambliss doesn't know that he doesn't know how Iranians think. Without conscious awareness that he's doing it, he fills the gaps in his understanding with his own preconceptions about how Iranians think. This inevitably causes him to presume that the Iranians think pretty much exactly the way he thinks. As a result, he wants to base our policy on what are in fact misconceptions about how Iranians think.

I suppose others fall into the same trap when they think about us, but this tendency has caused us a lot of trouble. For example, it helped us to imagine that Iraqis would be grateful if we invaded and occupied their country. It leads us to imagine that Afghans are as philosophical as we are about the "collateral damage" our operations cause. It encourages us to imagine that all the "good" Muslims will understand we aren't talking about them when we refer to "Islamofascists". It seems to me that if we're going to righteously intervene in others' affairs we ought to be more curious about what the objects of our supposed beneficence actually think about that.

Now if only he'd figure out how to do this with Blue Dog Democrats

More from Dr. Atul Gawande

From his commencement address to the University of Chicago's medical school:

I want to tell you the story of a friend I lost to lung cancer this year. Jerry Sternin was a professor of nutrition at Tufts University, and with his wife, Monique, he’d spent much of his career trying to reduce hunger and starvation in the world. He was for awhile the director of a Save the Children program to reduce malnutrition in poor Vietnamese villages. The usual methods involved bringing in outside experts to analyze the situation followed by food and agriculture techniques from elsewhere.

The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.

So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.

. . . Like the malnourished villagers, we are in trouble. But the public doesn’t know what do about it. The government doesn’t know. The insurance companies don’t know.

They brought in experts who explained that a quarter of our higher costs are from having higher insurance administration costs than other countries and higher physician and nurse pay, too. The vast majority of extra spending, however, is for the tests, procedures, specialist visits, and treatments we order for our patients. More than anything, the evidence shows, we simply do more expensive stuff for patients than any other country in the world.

Fixing this problem can feel dishearteningly complex. Across the country, we have to change skewed incentives that reward quantity over quality, and that reward narrowly specialized individuals, instead of teams that make sure nothing falls between the cracks for patients and resources are not misused. President Obama, I’m pleased to say, committed to making this possible in his reform plan to provide coverage for everyone. But how do we do it?

Well, let us think about this problem the way Jerry Sternin thought about that starving village in Vietnam. Let us look for the positive deviants.

. . . They are the low-cost, high-quality institutions like the Mayo Clinic; the Geisinger Health System in rural Pennsylvania; Intermountain Health Care in Salt Lake City. They are in low-cost, high-quality cities like Seattle, Washington; Durham, North Carolina; and Grand Junction, Colorado. Indeed, you can find positive deviants in pockets of most medical communities that are right now delivering higher value health care than everyone else.

We know too little about these positive deviants. We need an entire nationwide project to understand how they do what they do—how they make it possible to withstand incentives to either overtreat or undertreat—and spread those lessons elsewhere.

I have visited some of these places and met some of these doctors. And one of their lessons is that, although the solutions to our health-cost problems are hard, there are solutions. They lie in producing creative ways to insure we serve our patients more than our revenues. And it seems that we in medicine are the ones who have to make this happen.

Here are some specifics I have observed. First, the positive deviants have found ways to resist the tendency built into every financial incentive in our system to see patients as a revenue stream. These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.

. . . They join with their colleagues to install electronic health records, and look for ways to provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don’t miss their mammograms and pap smears or their cancer follow-up. They think about how to create the local structures and incentives to make better, safer, more appropriate care possible.

Dr. Gawande's wise counsel would do us great good -- if doctors could ignore the incentives built into our current system that lead them to view patients as revenue streams.  But it doesn't seem feasible to assume that doctors will necessarily make the right choices despite the system that rewards them for doing otherwise.    Real reform would eliminate those incentives, or at least constrain providers' ability to act on them.

So by all means let's find the "positive deviants" and publicize the methods they employ, but the hard fact remains that lower costs for us would mean less income for the providers.  We can't rely on mere hope that altruism will compel everyone to do the right thing.  That makes government intervention absolutely essential.  This problem won't solve itself.

The soul of medicine

In the article Dr. Gawande wrote for the New Yorker, he said that "we are witnessing a battle for the soul of American medicine."  His reference to the "soul of American medicine" made me think about the doctors in my own family, who exemplify what I hope the soul of American medicine will turn out to be.  And that reminded me of a newsletter my Dad recently sent me.  He knows that there are medically-related subjects that interest me, and (less often than he should) he passes something along.  Recently he passed along a piece from the Fort Wayne Medicine Quarterly, which (as he expected) I found very interesting.  But long after I'd read the article, the cover of the quarterly newsletter stuck with me.  Maybe the details could be changed or updated, but this image captures what my own upbringing in a family of doctors always struck me as the soul of the profession.

It's about patients, and that's where all our attention should be focused.  That's what I've learned from the docs in my family.

Chart of the day

The New York Times explains where the current budget deficits came from:

The vast bulk of this deficit is George Bush's legacy.  Digging out will be an enormous challenge.

Republicans fear Sotomayor is too Hispanicky

I thought that Senate Republicans would avoid the issue of Sotomayor's race, leaving that to wingnuts like Rush Limbaugh.  I was wrong.  Here's Sen. Lindsey Graham (R-SC):

Graham has been critical of Sotomayor’s 2001 statement in which she suggested that a Latina woman would reach better conclusions than a white male. Her statement prompted conservatives to charge her with racism, an attack that former Speaker Newt Gingrich (R-Ga.) apologized for Wednesday.

Although Graham said he would not use the word racist to describe Sotomayor, he indicated that her past statements raise concerns that, as a Supreme Court justice, she may not treat white males fairly. “Being an average, everyday white guy, that doesn’t exactly make me feel good,” Graham said.

First, if Graham would read the whole speech he'd see that there's no basis for a freakout.  Sotomayor was simply arguing that those who've experienced racial discrimination have a perspective that those in the majority lack.  It is impossible to imagine, for example, an African-American who would have agreed with this absurd statement from the Supreme Court's 1896 upholding "separate but equal" in  Plessy v. Ferguson:

We consider the underlying fallacy of the plaintiff's argument to consist in the assumption that the enforced separation of the two races stamps the colored race with a badge of inferiority. If this be so, it is not by reason of anything found in the act, but solely because the colored race chooses to put that construction upon it.

Instead of fastening on one sentence from a single speech, Sen. Graham might also look to Judge Sotomayor's extensive judicial record to see if, as he fears, a white man can't catch a break from Judge Sotomayor.  If he did, his fears would be relieved:

In sum, in an eleven-year career on the Second Circuit, Judge Sotomayor has participated in roughly 100 panel decisions involving questions of race and has disagreed with her colleagues in those cases (a fair measure of whether she is an outlier) a total of 4 times.  Only one case (Gant) in that entire eleven years actually involved the question whether race discrimination may have occurred.  (In another case (Pappas) she dissented to favor a white bigot.)  She participated in two other panels rejecting district court rulings agreeing with race-based jury-selection claims.  Given that record, it seems absurd to say that Judge Sotomayor allows race to infect her decisionmaking.

But not so absurd that Lindsey Graham won't express his concerns as "an average, everyday white guy".

It's no accident that nearly 90 percent of self-identified Republicans are white.  The party of Lincoln has already given up on the African-American vote, and the ugliness triggered by Sotomayor's nomination has pretty much ended the Hispanic outreach.  As Nate Silver notes, this is steadily driving the GOP deeper and deeper into a hole:

Consider this remarkable statistic. In 1980, 32 percent of the electorate consisted of white Democrats (or at least white Carter voters) -- likewise, in 2008, 32 percent of the electorate consisted of white Obama voters. But whereas, in 1980, just 9 percent of the electorate were nonwhite Carter voters, 21 percent of the electorate were nonwhite Obama voters last year. Thus, Carter went down to a landslide defeat, whereas Obama defeated John McCain by a healthy margin.

In certain ways, I wonder if the GOP isn't paying a price for a strategy adopted years ago -- namely, the Southern Strategy. The Southern Strategy undoubtedly won the GOP many elections over the years, but it was adopted at a time when probably less than 10 percent of the electorate was nonwhite (if minorities were allowed to vote at all), whereas now about a quarter of the electorate is. The steady drumbeat of demographic change, coupled with an inability or unwillingness to adapt to it, has steadily made the Republicans' job harder and harder.

Nevertheless, thet just can't seem to help themselves. As Julian Sanchez observes, "They really have no idea how they sound to anyone else."

Health care cost disparities

A doctor named Atul Gawande has written a great piece for the New Yorker addressing the vast disparities in health care costs here in the United States. When I imagine a place where treatment must be very expensive, I think of the famous Mayo Clinic in Rochester, Minnesota.  As it turns out, though, Mayo's per capita costs are in the lowest 15 percent in the country -- for some of the best health care in the world.  In which places is health care the most expensive then?

The answer, I was surprised to learn, is a place like McAllen, Texas, where per capita health care costs are twice the national average, second only to Miami, Florida (where everything costs more than it does in McAllen).  Indeed, the per capita costs in McAllen are roughly twice the per capita costs in El Paso, a statistically indistinguishable Texas town 800 miles away.  But outcomes aren't any better in McAllen than they are in El Paso.  Doctors in McAllen just prescribe a lot more of everything in McAllen than they do in El Paso.

The overuse of medical care in places like McAllen is a serious problem:

Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.

That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes.

To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.

As Dr. Gawande notes, this is good news in a way: it suggests that we could dramatically reduce health care costs without any reduction in the quality of care.

Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved.

The problem, Gawande argues, is that fee-for-service medicine gives providers every incentive to provide more services than are really necessary.  These incentives are exacerbated when, for example, doctors become owners of the laboratories and other suppliers of the services and treatments they prescribe.  The most expensive piece of equipment in the hospital, Gawande says, is the doctor's pen.

Excerpts really can't do justice to Dr. Gawande's very well written account.  As they say, read the whole thing.

What if there were a terror plot and no one was terrorized?

So, the FBI and the NYPD arrested a group of four pathetic losers who planned to commit acts of terrorism in New York.  I'm glad they're headed for prison, even though it turns out that they're utter incompetents whose aspirational plot wouldn't have gone far enough to get them arrested if the authorities hadn't been stringing them along from the beginning.  What's notable is that, unlike similar schemes that were disrupted during the last eight years, this time no one is freaking out over it.  A dead on post like this one is completely unnecessary.  Maybe we're slowly coming around to this realization:

For any American (at least any American who isn't patroling the streets of Mosul or trying to run down a story in the hills of Afghanistan) to be afraid or anxious about terrorism seems to me as peculiar as being afraid or anxious about being eaten by a shark, or murdered by a serial killer. After all, sharks and serial killers exist, but if I went around obsessing about the possibility of being victimized by either I would be considered cowardly, or paranoid, or both. Now if I were diving for abalone or surfing Mavericks it would be understandable to be a little anxious about sharks. But, when it comes to terrorism, 99.99% of Americans aren't surfing Mavericks -- they're in a shopping mall in Topeka, inside of which (apparently) a good number of them are worried about land sharks.

Maybe it helps that we no longer suffer under a Cheney administration that feels it needs to keep people in a state of fear.

Wanted: Better Democrats

Okay, so you may have heard that Republican partisans are demagoguing Obama's decision to close Guantanamo, claiming this will mean terrorists living next door to you.  This is stupid, of course.  Our prisons already house some seriously dangerous people, including terrorists like the Unabomber, the shoe bomber, and the blind sheikh.  During WWII we housed over 400,000 German and Japanese POWs right here in the good old USA.  The fearmongering on this issue is ludicrous:

So this is it, then, is it?  They’re going to move Osama in next door to you.  Every last one of you, everywhere.  It’s very complicated, involving things like timeshares and wormholes and stem cells, but it’s happening, believe me.  And when it doesn’t happen, we’ll have thought up something even dumber to tell you rubes, believe me.  Maybe next time the Democrats will be grafting al Qaeda heads onto spider bodies and putting them in your baby’s crib.  A winning message for 2012.

Needless to say, though, it's not so ludicrous that Harry Reid isn't quivering in fear of it:

REID: I'm saying that the United States Senate, Democrats and Republicans, do not want terrorists to be released in the United States. That's very clear.

QUESTION: No one's talking about releasing them. We're talking about putting them in prison somewhere in the United States.

REID: Can't put them in prison unless you release them.

QUESTION: Sir, are you going to clarify that a little bit? ...

REID: I can't make it any more clear than the statement I have given to you. We will never allow terrorists to be released in the United States.

It would be easier to keep Republicans from demagoguing this issue if the Democratic Senate Majority Leader didn't repeat their dishonest talking points. But Reid apparently has troubles of his own back in Nevada.  (Hey, here's an idea -- let's have a Senate Majority Leader who doesn't have to tack right to keep his job.  Just a thought.)  In any event, panicked Democrats voted to deny Obama the funds he needs to close Guantanamo until he assures them that they won't have to bunk with Khalid Sheikh Mohammed.  Not exactly profiles in courage.

When Obama disappoints me on issues like his detention policies, I need to remind myself that he's herding cats within his own party.  It doesn't make me feel better, but it is necessary to work within the range of the possible.  And with Democrats like Harry Reid (and Evan Bayh and Ben Nelson and Joe Lieberman), that's not such a big range.

As a follow up on the drone attacks . . .

JCS Chairman Adm. Mike Mullen says our air attacks in Afghanistan aren't working out so well either:

The United States cannot succeed in Afghanistan if the American military keeps killing Afghan civilians, Adm. Mike Mullen, the chairman of the Joint Chiefs of Staff, said on Monday.

In remarks to scholars, national security experts and the media at the Brookings Institution, Admiral Mullen said that the American air strikes that killed an undetermined number of civilians in Afghanistan’s Farah Province two weeks ago had put the U.S. strategy in the country in jeopardy.
“We cannot succeed in Afghanistan or anywhere else, but let’s talk specifically about Afghanistan, by killing Afghan civilians,” Admiral Mullen said, adding that “we can’t keep going through incidents like this and expect the strategy to work.”

In counterinsurgency warfare, the people are the prize.  You can't win them by bombing them.  I'm glad Mullen is worrying about this.