Monday, April 30, 2012

Outnumbered But Not Outgunned


Wouldn't you rather have the following dramatic heros of the right on your side in a fight?

And last (and least!)

Go ahead, make my day.


George Clooney, Secretary of State


Saturday night was the 97th annual White House Correspondents Dinner, where fortunately for our great Republic, Washington was able to mingle with Zooey-Deschanel, Lindsey Lohan, Rosario Dawson, Elizabeth Banks, Reese Witherspoon and George Clooney. Just so you know, Yahoo news tells us Rosario "flashed way too much cleavage for the conservative affair," (wait a minute, there's such as thing as too much cleavage?) and LiLo wore "a safe-yet-lackluster plunging black dress."

I'm told actors and actresses are people also, but I haven't seen the proof. And they have just as much right to an opinion as everyone else, but we don't encourage politicians to listen the policy opinions of six-year olds so why we would applaud them soliciting opinions with the six-year old's equivalent is beyond me.

I know, I know, we are led to believe no one is listening to what LiLo thinks about Iran or unemployment benefits. But can we be sure? After all, Congress had Steven Colbert testify on immigration policy. And he testified as the character he plays on TV. It would be as if Mike Brady were called to testify on extended families.

The Republicans are just as star struck as the Democrats, but it seems like there is a greater portion of the entertainment industry attending these type of events when the Democrats are in power. Makes sense, Hollywood loves the Dems.


"Here's What Washington Really Does," Robert Samuelson


Robert Samuelson's op-ed, "Here's what Washington really does," in this morning's Washington Post, rang true to me, at least to my amygdala.

He has a line, "The real Washington is in the business of pleasing as many people as possible for as long as possible." which is only one step away from Walter McDougall's comment on Jacksonian Democracy, Jackson rallied "the largest possible number of voters to oppose the smallest and vaguest of enemies."

The beat goes on.

Here’s what Washington really does
The Washington of conventional wisdom and the real Washington are two entirely different places. The Washington of conventional wisdom is overrun by well-paid insiders — lobbyists, lawyers, publicists — who systematically manipulate government policies to benefit corporations and the rich, defying the “will of the people.” The real Washington has government paid for by the rich and well-to-do. Benefits go mainly to the poor and middle class, while politicians of both parties live in fear that they might offend the “will of the people” — voters.

Recently, Ron Haskins of the Brookings Institution, a Washington think tank, testified before the House Budget Committee on the growth of the 10-largest “means tested” federal programs that serve people who qualify by various definitions of poverty. Here’s what Haskins reported: From 1980 to 2011, annual spending on these programs grew from $126 billion to $626 billion (all figures in inflation-adjusted “2011 dollars”); dividing this by the number of people below the government poverty line, spending went from $4,300 per poor person in 1980 to $13,000 in 2011. In 1962, spending per person in poverty was $516.

Haskins’s list includes Medicaid, food stamps (now called the Supplemental Nutrition Assistance Program, or SNAP), the earned-income tax credit (a wage subsidy for some low-income workers), and Pell Grants. There are other, smaller programs dedicated to the poor. A report from the Congressional Research Service estimated the total number at 83; Haskins puts the additional spending on programs below the 10 largest at about $210 billion. The total of all programs for the poor exceeds $800 billion.

To be sure, some spending reflects the effects of the Great Recession. But most doesn’t. As Haskins shows, spending on the poor has increased steadily for decades. Consider food stamps. There are now about 45 million Americans receiving an average of $287 a month in food stamps, up from 26 million in 2007, according to a new Congressional Budget Office report. But the number in 2007, when the economy was healthy, was roughly 50 percent higher than in 2001.

And programs for the poor pale beside middle-class transfers. The giants here are Social Security at $725 billion in 2011 and Medicare at $560 billion. Combine all this spending -- programs for the poor, Social Security and Medicare — and the total is nearly $2.1 trillion. That was about 60 percent of 2011 non-interest federal spending of $3.4 trillion.

You can debate whether all this spending is too much or too little. My point is different: These numbers speak volumes about our politics.

One lesson is that Washington really hasn’t been taken over by monied groups. In a democracy, even the rich are entitled to promote their interests. It’s true that their lobbyists and lawyers sometimes win lucrative tax breaks, subsidies or regulatory preferences. But as the spending numbers show, their influence is exaggerated, especially considering their tax burden. The richest fifth of Americans pay nearly 70 percent of federal taxes (included in this group, the richest 10 percent pay 55 percent), estimates the CBO.

The larger lesson is that, contrary to conventional wisdom, American politics have not become insensitive to the “the people.” In many ways, just the opposite is true. Politicians are too responsive to popular will. The real Washington is in the business of pleasing as many people as possible for as long as possible. There are now vast constituencies dependent on the largesse of the federal government. This is the main cause of huge “structural” budget deficits, meaning that they aren’t simply a hangover from the Great Recession.

There are many sophisticated theories today about why politics have become so polarized and immobilized. Ideologues have captured both parties, it’s said; primary challenges by right- and left-wing zealots doom centrists; cable television and the Internet favor simplistic, highly partisan rhetoric and argument. Political divisions are accentuated; consensus becomes harder. There’s something to these theories, but they also subtly misrepresent and excuse our present paralysis.

More promises were made than can be kept without raising taxes, which — for the most part — were also subject to bipartisan promises against increases. Almost everyone agrees that massive budget deficits pose a long-term economic threat, though no can be precise about how or when the threat might emerge. A central question about our political system is whether, after decades of making more promises to more groups, it can withdraw some promises to minimize the threat.

So far, the answer is “no.” Political leaders don’t lead. They take the path of least resistance, which has been to do little except to find scapegoats — “the rich,” “special interests,” “liberals,” “conservatives” — that arouse their supporters’ angriest antagonisms. It helps explain polarization. This is really what Washington does. It’s a demoralizing commentary on the state of American democracy.

Sunday, April 29, 2012

Throes of Democracy


I think this is a marvelous history of the US. McDougall explores themes in US history which are much richer and deeper than a simple chronological tale.

I was particularly taken by his conclusion on the Age of Jackson. He says there is a "blind men and the elephant quality about Jacksonian scholarship," as one (Schlesinger) looks at the period as "a lower-class protest against monied elites," another (Sellers) sees "Jacksonians as crusaders vainly resisting capitalism," another (Turner updated by Beard) sees "pioneer farmers" as "the core of Jackson's constituency," and another (Meyers) "linked mechanics and farmers by defining Democrats as nostalgic Jeffersonians damning monopolies and corruption in the name of republican virtue." Hofstadter sees Jacksonians as "frustrated capitalists hoping to expand opportunity."  Finally, Fischer "portrayed the democracy as an alliance of the libertarian Scots-Irish and hierarchical Cavalier cultures against the "ordered liberty" upheld by heirs of the Puritans."

McDougall accepts, and rejects, all of these interpretations. It was not a single ideology that united Democrats but "rather moods of the sort that shaped the contemporaneous Romantic era in culture. Americans of many sorts were in one bad mood or another between 1819 and 1850.  They were against many things and sensed that Jackson was, too."

McDougall goes on to list the moods, sometimes resulting in contradictory positions, held by the Democrats and the Whigs. These themes are still resident in the body politic today, almost 200 years later.

Who were the Democrats? Democrats found unbearable "the real or imagined contrast between the myth of equality and the very unequal outcome of free competition in an era of blistering change. "Jackson rallied "the largest possible number of voters to oppose the smallest and vaguest of enemies." For thirty years party leaders "damned corruption, corrupt bargains, conspiracies, "monster" banks, "satanic" mills, monopolies, aristocrats, usurpers, speculators, stockjobbers, abolitionists and meddling self-righteous reformers. Democrats invited any voter with a grievance to assume he had been cheated, thwarted, exploited by powerful men who rigged the game in their favor."

Who were the Whigs? To the Democrats it was a "party of plutocrats, bluenoses, and their dupes." But to the Whigs they were the Party of Clay's "American System," high tariffs and internal improvements. "Whigs looked for the source of society's ills and found it inside individuals whose duty it was to purge their vices and serve the public good."

"Whigs wanted a people as good as their government. Democrats wanted a government as good as the people."

You can see some of the tenets of the current Democratic party in the Jacksonian Democrats. And you can see some of the tenets of the current GOP in the Whigs. But it's almost as if there is a cafeteria of themes, hopes, fears, ideas that remain the same, but the plate each party assembles changes over time.

The book is funny, as all great books are. I love this line, "Andrew Jackson entered the White House in a foul mood. Except for occasional sweet moments of vengeance he stayed angry for eight years."

It's a long book and heavy, literally, heavy. You know me, I love the look, feel and smell of books. But the weight was too much. I finished the first hundred pages or so and decided it was just too much weight to carry around. I'm reading the iBooks edition. I fear I will now be purchasing hardcover editions of books to put on the shelf and the iBooks edition for the actual reading. This means my book budget is about to increase 50%.


The Orphan Master's Son


A John Doe's adventures in North Korea. As powerful as "1984," "A Clockwork Orange," and "Brave New World." Screen shots from the introduction. I was hooked. At the end of part one I was getting slightly fatigued. Part two is a masterpiece.


Saturday, April 28, 2012

An Economist Walks Into A Bar....




Austerity Economics


Obama and his Amen corner keep preaching the danger of austerity economics. You too have expressed fear of austerity more than once. (I still fail to see how increased government spending, but at a lower rate than planned is austerity, but we can save that for later.) The prediction is the economy will tank unless government spending at all levels increases its rate of spending. As proof, Krugman pulls a graph from the St. Louis Fed FRED database.

It was a bit confusing to me since if the proposition is increased levels of government spending lead to better GDP growth, why did the increased rate of spending from 2005 through 2008 lead to a recession and why did the decreased rates of spending since 2009 lead to higher GDP growth?

Here's the same graph, but adding in year over year real GDP growth.

Just from the looks of it the connection between the rate of change in government spending and the rate of change in GDP is difficult to discern. And as you have pointed out in the past, correlation is not causation. 

For grins, I had FRED draw the graph since 1947

The correlation coefficient for these series is 0.18. However, the theory is changes in government spending leads changes in real GDP. Using the one-quarter lead the correlation coefficient falls to 0.07 and a two-quarter lead the correlation falls to 0.01. That is, there is no correlation. Keep in mind, I'm using Krugman's data set choices.

The problem, as you pointed out in your biology lesson, is our brain finds justifications to support our moral beliefs. I'll buy that, up to a point. But I find no problem rejecting the null hypothesis when the correlation coefficient is less than 0.07


Friday, April 27, 2012

EPA's "Little Crude" Comment on Crucifixion



“It was kind of like how the Romans used to conquer little villages in the Mediterranean,” Armendariz said on the video. “They’d go into a little Turkish town somewhere, they’d find the first five guys they saw and they would crucify them. And then you know that town was really easy to manage for the next few years.”

Armendariz said he tried to use the same approach to get companies to obey environmental laws: “You make examples out of people who are not complying with the law,” he said."


Thursday, April 26, 2012

It isn't the Amygdala. Joe Romm is a big fat liar.


I'm surprised you blamed anything but George Bush for the woes of the world, I must be having a salutary impact on you.

But Joe Romm is a big fat liar, irrespective of the amydala's or George Bush's impact on me.



An Obama Re-election strategy: Embrace Constanza


I have a simple plan for Obama to get re-elected. All he has to do is embrace the philosophy of George Constanza in "The Opposite." In that Seinfeld episode George realizes in order to be successful he must do the opposite of what his instinct tells him. As Jerry says, "If every instinct you have is wrong, then the opposite would have to be right."

A Real Clear Markets story today, "Will Unemployment Misbehave Before the Election?" worries unemployment ratios and the employment rates will be negatively impacted by the expiration of unemployment benefits. The story concludes, not too helpfully, that unemployment could increase or fall depending on whether it is increasing or falling.

Let's assume Obama really wants to extend unemployment benefits. If he does that, the incentive, at the margin, will be for beneficiaries to continue looking for work, but stay unemployed. (Calm down. Everything takes place at the margin, and at the margin are those who determine it is better to stay unemployed and collect benefits. This is not the same as what happens to the average or median beneficiary. It does not mean people are stupid and lazy. It means the exact opposite: People are rational wealth maximizers). If that happens, the unemployment rate stays elevated.

Now let's assume Obama does The Opposite. He let's unemployment benefits lapse. At the margin the incentive is for workers to get back in the labor force, unemployment rates go down and Obama is re-elected. He can even make a faux effort to get benefits extended. Let the Republicans shoot it down and get a double benefit: He can tar the Republicans as heartless and claim credit for an improving economy. In this case, since he would have done a Constanza, he would deserve credit for the improving economy.

Yes, it's a brilliant plan. All Obama needs to do is embrace his inner George and recognize "that every decision I've ever made, in my entire life, has been wrong."



Who Pays And What Gets Paid For


We've been confusing the issues for what gets paid for, how that's determined, and who does the paying. Several health care systems that are attractive to me a use a fee for service model, which you endorse.  The Canadians for instance have a singe payer, the government. What gets covered and how much the government will pay for that coverage is negotiated between the government and providers. The quality of the care provided is outstanding by any standard, and superior to ours by many. We have a similar system, called Medicare. The critical difference is that until now there have been few limits on what Medicare will pay for. Inevitably,  lots of care of dubious value is supported, to the benefit of no one but those who provide it.

I share your qualms about IPAB, the law of unintended consequences and the rigidity of bureaucracies that inevitably care more about themselves and their own culture than those they have supposedly been created to serve. And with Congress involved, the potential for meddling in the service of innumerable lobbyists seeking favorable treatment for their drug, procedure, or disease is limitless. IPAB is really just a vehicle for rationing, which I favor. That it's rationing on the sly doesn't bother me in the slightest. A "free market" system also rations based on one's ability to pay, an arrangement that I find indefensible on both moral and public policy grounds. Delayed care is inevitably more expensive and less effective. A middle ground, with basic health care provided for all, and the option for the rich like you and me to buy whatever else we want, would be acceptable. After all, that's the American way.


Wednesday, April 25, 2012

Blame the Amygdala


Named for the Greek word for almond because of its analogous size and shape, the amygdala is located at the base of the brain deep within the temporal lobe. A previously obscure and little studied structure, the amygdala has more recently taken center stage in the neuroscience arena. It appears to function as a way station that links  multiple sensory inputs to a variety of destinations critical to the formation of emotion linked memory. As a consequence of this arrangement, sensory information is frequently reshaped to fit within an emotional response constructed from previous amygdala generated experience. You don't read Paul Krugman or Joe Romm, and I don't listen to any of a variety of conservative icons, without a predictable series of  amygdala driven responses.

The point I was trying to make with Ideological Voter was that none of us (at least not this middle aged man co-writing a blog) come to politics without a set of preconditioned notions about the way we want the world to be. Those notions are the product of our life's experience, temperament etc, but the degree to which they are predetermined is likely much greater than we would care to admit. There is precious little chance that I, the Jewish grandson of  New York socialists, schooled at a bastion of Eastern liberalism, and comfortably ensconced in an academic career, was going to look at politics much differently than I do. I would wager the same predictability applies to most of us.

So just set those primitive responses aside, you might argue, and act rationally That's more easily said than done alas. Evolutionarily speaking, the amygdala is a very old structure designed to perform an essential  function, which is to make us so scared sh-tless by a perceived threat that we will instantly react in whatever way we need to save ourselves. The fallout comes of course when the perception of threat falls to match the reality.


Tuesday, April 24, 2012

Fracking. Joe Romm is a Big Fat Idiot Also


I happened to be driving through an oil field in Utah last week. I turned to my driver, a young lady from Ohio, and asked if the field was being developed with fracking? She didn't know but asked, "Isn't fracking bad?"

We had been talking about the beauty of Utah, the rawness of the countryside we were driving through and how it was a shame some people didn't respect the environment.

I answered her fracking question by saying it was bad if it was done by bad actors that didn't respect the environment. It would be unfair to assert hiking and camping in the desert of Utah was bad because some bad actors didn't respect nature. Similarly it would be unfair to say fracking was bad if some actors didn't exercise proper care.

It's a shame our arguments on important issues, like making sure energy production is done in a responsible manner, is framed by demagogues and liars like Joe Romm at Climate Progress and whoever the right-wing equivalent of Romm is.


One More Time. What's Wrong with Fee for Service?


Your "Corruption in Medicine," takes a bit of license with what I said, and of course I wasn't precisely clear on my point. So I'll try it again.

The main point I was trying to make was a one-size-fits-all medicine doesn't quite make sense to me. As a couple of examples I pointed out face lifts and Lasik seem to do quite well with fee for service. The presumption was if I can easily come up with two examples, there are probably more.

You are correct, when a person has an exigent need for medical services, price shopping probably isn't the best way to go about buying it. But I didn't make that argument, and I'm not making it now. In fact, it supports my argument that different circumstances call for different ways to serve the need.

I do disagree with your assertion that patients "sick, in pain, and scared.. generally do whatever their doctors tell them to do." I have an even higher authority that disagrees with that statement: You. In the previous paragraph you bemoan the patient who didn't listen to you about extra testing. Someone, shall we call him a consumer, just for grins, who listens to multiple opinions and chooses what he thinks best. It seems to me, until doctors have a unanimity of opinion, or are prevented from having a different opinion by law, there will always be consumers seeking out the second opinion. I thought it was recommended patients when purchasing medical services get a second opinion. But if patients are incapable of making a decision, why on earth would we counsel them to get a second opinion? Are you sure you want to stand by the statement that patients "generally do whatever their doctors tell them to do?"

And that is germane to the fee for service argument. The assumption made for preventing fee for service is  consumers are incapable of choosing the appropriate care. But from your example it looks to me like the group incapable of choosing the appropriate care is the medical community. 

So we come back to the same question we've been circling around. If the medical community makes bad decisions, why do you think an unelected medical group, the IPAB, in thrall to Congress and the President will do better than me at making decisions for my care?


Corruption in Medicine


Somehow I missed your  post in praise of fee for service medicine. While I believe there's lots wrong with such a system, I know better than to base my arguments on the basis of either of justice or fairness, at least in the context of our ongoing conversation. If I understand it at all by now, the libertarian world view believes that a free market in health care would best accomplish the essential task of providing the most care to the most people at the best price. I suppose as well, the libertarian may argue  that the failure of the present system to accomplish any of those goals is a reflection of how far it has strayed from free market principles. The libertarian might argue further that the absence of any extant example of free market based health care only strengthens the idea that such an approach would work if we would only try it.

So how about this argument. Fee for service medicine, which rewards health care providers only for doing things to patients, is inherently corrupting. I have seen this in my own professional life with colleagues in practice and with referral sources. I remember vividly the complaint I received from a patient (a lawyer, what else) when I refused to order a routine stress test for him after an angioplasty. His previous doctor ordered one for him twice a year, he reported proudly, so my decision to avoid an unnecessary, costly, and potentially hazardous test must be due to my efforts to limit care. This was a man who was receiving biannual doses of unnecessary radiation at cost of about 5000 bucks a pop, a practice that contradicts every guideline in this area. Why? Because his cardiologist leased a nuclear camera, and had to keep it humming to pay the bills, and line his pockets.

And please do not tell me that in the free market health care system you long for, "consumers" will make rational informed choices. We are not talking about consumers. We are talking about patients. People who are sick, in pain, and scared. Folks in that position generally do whatever their doctors tell them to do.

BTW I'll take your Left Wing Limbaugh as a complement. If only I were that effective. Guess I'll just have to work harder at sharpening my ad hominem attacks.


A Left Wing Rush Limbaugh


Dude, get a grip. My self-described moderate (he describes himself that way so he can label all opponents extreme. In reality its hard to know what his opinion on an issue, unless Nancy Pelosi has spoken) Democrat congressman recently did something I actually agreed with. Go figure! It happens man, broken clock syndrome.

"Loathing?" "European style austerity?" "Economy falling off a cliff?" You've been reading too many talking point memos.

You sound like the left wing version of Rush Limbaugh.


Monday, April 23, 2012

Ideological Voter


The Connecticut state senate is currently considering a bill  SB 243 :AN ACT CONCERNING CERTIFICATES OF MERIT that threatens to undo a vital component of malpractice reform in a state that already has one of the highest average costs per claim in the country. In response to a request from the local chapter of the American College of Cardiology, I dutifully reached out to my local state senator, who happens to be the Republican minority leader in the state senate, to urge him to vote against the bill

Here is a man whose philosophical   leanings on this issue surely dovetail with mine, and whose support in this area I desperately want. And yet, I can barely bring myself to ally with him, given the .loathing I have for so much of what his party represents.

At the national level the paradox remains equally striking. There is no question that a President Romney combined with a Republican controlled Congress would fill my pockets, and that my household is fortunate enough to withstand any mischief they might create otherwise. Assuming that is, that the imposition of European type austerity doesn't send the economy off a cliff.

But I can't do it.



Tuesday, April 17, 2012

What's Wrong with Fee for Service Medicine?


What's wrong with fee for service medicine? If I want to pay for only the medical service I receive what's wrong with that? I want Lasik, I pay a fee, I get Lasik. Seems to work. I want a face lift, I pay a fee, I get a face lift. Seems to work there also. For the record, I've never received Lasik or a face lift.

I've said it before, I have no strong opinion on Accountable Care Organizations, other than it sounds like an HMO, which at least 20 years ago consumers hated. But, so what. You want to buy your health care via a ACO, go ahead. The only thing I would ask you is to allow me the freedom to buy my health care as I see fit.

I really don't understand this compulsive need to "fix the system," with a one size fits all solution. One size fits all doesn't work in any other market, what possible reason do we have to believe it will work in this market?




Obama Proposal Would Rein in Oil Speculation.

Is this guy reading bios of Jimmy Carter and Michael Dukakis?


Sunday, April 15, 2012

Change Is Difficult


“thus the most accessible aspects of the self-system in many late adolescents show superficially incomprehensible falsifications in the person’s view of himself that he is not apt to learn very much in this field unless somebody goes to a great deal of trouble to put him through educative experience. And this kind of experience is fraught with relatively severe anxiety which-as I hope you will grasp by now-people put with only when they can’t help themselves. When the imperative necessity for change is recognized through psychiatric or other experience, then most people are able to withstand some anxiety, though I suppose this varies on the basis of individual past experience. To say that a person is able to stand some anxiety us another way of saying that he is able to observe previously ignored and interpreted experience in such fashion that his formulation of himself and of living can change in a favorable direction. One might suppose then, that anybody who has had considerable anxiety ought to have made wonderful progress. But he joker to that is that overwhelming conviction of necessity is, in other than special circumstances, utterly lacking in people who suffer a great deal of anxiety. In fact they expect to go on indefinitely as they are, and when you attempt to show them what might be done about it, they get still more anxious and know that you are bad medicine and will avoid you.”

I first came across this passage from Harry Stack Sullivan’s Interpersonal Theory of Psychiatry in the summer of 1974. I was 19.  After a disastrous spring  I headed out to Nevada to work on a ranch in the Carson Valley with my college roommate.  Lots of sagebrush in a raw and beautiful semi arid landscape that is still close to my heart. I dug ditch, fixed fence, pushed cows on roundup and became familiar with the terrifying, comforting feel of a 12 gauge shotgun in my hands. On the weekends we went to the family cabin on the shores of Lake Tahoe, hung out with the fabulous Porter Brothers and longed to be older.

That Sullivan’s dictum is difficult to accept does not make it any less true. There is not enough praise for those in our lives who have found the raw guts and resilience to defy it .

BTW I would say his analysis applies equally well to nations as adolescents.


Romneycare and the End of Fee for Service Medicine


An interesting piece in this week's New England Journal of Medicine on the efforts of the Massachusetts medical community to address the issue of cost. Romneycare has done an excellent job of insuring the access issue, as under its aegis more that 98% of the citizens of the Bay State now enjoy some form of health insurance. But the state now finds itself running an unsustainable deficit in support of the policies the law promulgated (sound familiar?) and is beginning to explore the steps necessary to close the gap between what's coming in and what's going out.

The preferred answer is likely to be grounded in the formation of accountable care organizations or ACOs, which we have discussed previously. Once again, this is an innovation transferred directly from Romneycare to Obamacare, and it is the sort of collectivism that I imagine most conservatives simply hate. ACOs among among other things are an extraordinary effective vehicle for  rationing by another name. They also foretell the end of fee-for-service medicine. No longer will docs get rewarded for doing more, but for doing what they can with the resources determined by the number of covered lives the ACO controls.

I greet these developments with ambivalence. On the one hand, I cannot justify the enormous sums paid to physicians during what will surely be seen as a golden age (medically and financially) for medicine in the post WWII era. On the other, I have no doubt that the generous salary I've earned as an academic cardiologist is directly related to the even more lavish earnings of my colleagues in private practice. A third of a heckuva lot is still a lot.


Friday, April 13, 2012

Yes and No


No you say to wasteful government spending, and provide several thoughtful examples of questionable use of the taxpayers money. Let me add a few to the list. No to crop subsidies for big agribusiness or drilling gifts to big oil. No to bigger and bigger weapons systems that don't do a better job that what we have now and that even our generals don't want. No to the gulag of federal prisons required to house the largest proportion of nonviolent offenders incarcerated in the world.

But I have a few yeses to add as well. Yes to public protection for health and the environment (CDC, FDA and EPA and food inspection). Yes to worker protection (OSHA, mine safety). Yes to support for biomedical and mental health research (NIH and NIMH). Yes to the Park Service. And yes to the preservation of opportunity that you and had. I borrowed half the money for college from a program called FISL or Federally Insured Student Loan- 7% interest deferred until I finished med school. Kids (and parents!) would kill for terms like those today.

I did my taxes with Turbotax this year -an amazing invention. Gives you an idea of just how byzantine the tax code has become. Wish I were in your happy position, as the IRS will making a substantial withdrawal from my bank account on Tuesday. 


Thursday, April 12, 2012

Before You Raise One Extra Cent of New Taxes, Tell Me Where You are Going to Spend It.


Before we raise any new taxes on anyone, I want to know where that money is going. If it's going to fund Solyndra-like failures, I say no. If it's going to the Ex-Im Bank, a wholly-owned subsidiary of Boeing and GE, I say no. If it's going to the useless medical procedures you pointed out in your "Bring on the Death Panels 2," I say no. If it's going to more middle-class welfare like social security, medicare, home interest deductions, I say no. If it's going to high-speed rail, the Post Office, Amtrak, Pell Grants, Fannie Mae, Freddie Mac and Obamacare, I say no no no no no no and no.

I make this remark with respect to Obama's high-profile Buffet Rule, the rule that would result in another worksheet in the 1040 instruction book, which over time, like the Alternative Minimum Tax, would turn into a tax that causes migraines to fill out. (I do my own taxes, with the help of Turbo Tax. Even with the help of Turbo Tax, the complexity of Form 1040 is infuriating).

Obama wants to tax rich people more so he can "make investments." In what? High speed rail. Clean energy. Again, no thank you.

And he wants to tax rich people because it's "fair." Bah humbug. Richard Burkhauser et al have a report, "A Second Opinion on the Economic Health of the American Middle Class," that puts a hurt on the idea the middle class have suffered severe harm since 2000. Burkhauser is polite, but in essence says, liar liar pants on fire to those studies Obama quotes to justify his rape and pillage of resources so he can build a clean energy eononomy on high-speed rails.

Ugh. Note to self. Impose a cooling off period on yourself after doing your taxes. And I even got a refund! Imagine my mood if I had to cut a check to those robber barons in Washington DC.



Monday, April 9, 2012

Justice Persian Style


My mate and I took in this year's Oscar winning foreign film, A Separation, at the local cinema this weekend. It's an extraordinary exposition of lives in catastrophic intersection portrayed with a skill that makes great movie making look easy. There's lots of pain and tragedy as loss piles upon loss and the participants crash into one another, literally and emotionally, like a car wreck in slow motion.

But what intrigued me most was the way that justice is represented throughout the film, both as a process and an idea. The film opens with a divorce hearing as the the married couple at the center of the drama make their case before a magistrate in a bare room the size of a storage closet. Just the three of them, without lawyers. The magistrate acts as  interrogator, law interpreter, and judge. The couple talk to both him and each other as they present their arguments. Finally as the opening scene ends the magistrate makes his ruling over the vociferous objections of the losing side and that's that.

As the story unfolds several more of these hearings (I have no idea what they are actually called in Iran), involving both both civil and criminal matters, take place with  the same direct, continuous, often acrimonious exchange among the participants and the intimate involvement of the magistrate, who inserts himself frequenctly on behalf of one side of the other. Occasionally the proceedings are delayed for evidence gathering but the wait is minimal. A rough but accurate version of the truth emerges, and matters get settled in a way that seems just. Money doesn't have anything to do with the outcome, even though rich and poor are adversaries throughout.

I  hope these observations don't come off as some paen to the legal system of a fanatical regime that I consider deeply corrupt and inhumane by any standard. I'm sure that lots of Iranian citizens have experienced a very different sort of justice from a regime so efficient at suppressing its opponents. Still, there was something striking about watching a process in which high priced lawyers had nothing to do with the outcome.


Bring On The Death Panels 2


I was asked to perform a diagnostic procedure on a demented 93 year old this week. The procedure requires passing a long black tube into the patent's throat and using the the ultrasound it generates to produce produce pictures the heart with exquisite clarity. 

It's not terribly dangerous and the patients are asleep during the test  but it's still an invasive procedure with a potential for harm, and it retails for about $3500.

I was asked to study this man because he has a disease called critical aortic stenosis, which over time is uniformly fatal. The big blob in the middle of the picture below with the narrow dotted slit in the middle is one such typically narrowed valve.

Until recently the only treatment for this problem was to replace the valve surgically but now 2 companies have designed valves that can be implanted without surgery , "transcutaneously"

Given that aortic stenosis is mostly a disease of the elderly, and the number of older folks across the industrialized world is increasing exponentially, the number of eligible patients, and the profits they may bring (at about 50K per valve) is hard to overstate. As the technology advances these valves have great potential to relieve suffering and extend life. But I already had performed a viability study in our patient that demonstrated that he would not benefit from valve replacement of any kind. Never mind that he could not remember either my name or his own.

But the the hospital is desperate to push the technology so we can "get a leg up" on our competitors, and his cardiologist wants it done. What will happen next is anybody's guess

This is what makes me crazy about the 17%-of-the-economy that I live in


Monday, April 2, 2012

Obamacare Alternatives


I am hardly wedded to Obamacare, although it certainly seemed better to me then the current alternative. We do agree on the issues, and I'll wager that we can also agree that the goal of any system is to provide the best care to the most people at the least cost. The alternatives, in my highly prejudicial order of preference are (drum roll please...).

1) A nationalized system-this is the UK model. The chief advantage is an ironclad lid on cost. The UK provides pretty good care by the usual broad measures, such as infant mortality, life expectancy etc. The Brits are not crazy about it. I am strongly opposed as a direct result of my experience within the US version of same, which is the VA health care system. I was an advanced trainee at a flagship VA in Boston.  Patients there were treated with an indifference bordering on contempt. Doctors were answerable only to the bureaucracy. Necessary care was denied routinely for the flimsiest of reasons, and the vets were lied to to justify it. By the time I finished I became an expert at getting my patients out of the VA and into one of the fancy teaching hospitals downtown. When your bete noir writes about the virtues of the VA system, my response is, "Come get your health care there. I want to see how long you would put up with it."

2) Single payer-this is the Canadian model, given reasonable marks by those who participate in it. The system delivers high quality care by any measure and frees docs from the torment of engaging in mortal combat with payers on a daily basis. Care is rationed as a function of the total amount of money put into the system (somewhere around $4000 per capita compared to nearly double that in the US). Medicine is an elite profession there just like here, but docs make a middle class living. No orthopedic surgeons making a million a year. There are waits for some kinds of treatment, so if you have a teenage soccer player who needs a timely ACL repair to get back on the field (as 3 of my daughter's high school teammates did) you may have to pay for that out of pocket. I am strongly enamored of such a system, especially since it means that you would take me out to dinner on a regular basis, since I would no longer be able to afford it.

3) Mixed models-the best example seems to be Switzerland, which requires everyone to buy health insurance (there's  that nasty mandate again ) from a consortium of private insurers.Per capital expenditure is significantly higher ($4800) than everywhere but here. Patients have skin in the game through a series of deductibles that vary with the fanciness of the policy they buy, just like car insurance here. Insurers are only allowed to make a profit on more lavish plans. Participants are required to pay up to 8% of their income for insurance, after which the government subsidizes the cost. Indices of health care are among the highest in the world, and Swiss doctors always know exactly what time it is.

4) The Ryan Wyden alternative, or vouchers with premium support. This plan, which is actually just a vague idea at present may have some merit, but the chief criticism launched against it is that it shifts costs on to patients and does little to control total expenditures. I am intrgued but skeptical.

Finally, you are right that the independent payment advisory board (IPAB) brings with it great potiential for unintented consequences. But letting insurance companies screw patients out of care they paid for is not an acceptable alternative.


Sunday, April 1, 2012

Why is ACA the Answer?


Why is the ACA the answer to the issues you pointed out in "Bring on the Death Panels," and "Cognitive Dissonance?" Maybe we've come full circle on this merry-go-round argument.

We are in broad agreement on major issues: The US citizenry demands health care for free. Politicians are happy to oblige by borrowing from our children.  Health care costs have been on an unsustainable path, so they won't be sustained. The end will be violent, bloody and painful, like Greece, or we'll exhaust all options before doing the right thing.

But tell me again, why is the ACA the right thing? Forget about the Constitutionality for a second. What about the ACA will fix the problems you have identified? It seems to me it makes it worse. It taxes, or penalizes the young and healthy in order to subsidize care for the old and infirm. Frankly, I don't know why the young are so meek about it. If your answer is IPAB, isn't that Palin's Death Panel?

I think both political parties are equally culpable in this wealth transfer from our children to ourselves and they are doing it for one simple reason: old people elect them to do so.

You are absolutely correct, we ration now. But from my perspective, most everything is rationed. A person or household has a budget constraint and rations his/their purchases based on that constraint. Except when it comes to health care. It's not rationed because we as a country have deluded ourselves into believing that because we paid taxes for the past forty years we deserve unlimited care for the next twenty, as if it really were an insurance or annuity plan. If you call a dog's tail a leg, the dog still only has four legs. And if you call a wealth transfer scheme an insurance program it's still a wealth transfer scheme.

You and I both know Medicare must end as we know it. With ACA, the IPAB and other mechanisms will impose rationing from without. With Ryan's plan the rationing will come from the individual. I believe the former will be arbitrary and driven by the politics of shouting. For example, the Catholic Church forced to violate its conscience or give up its good works. I believe the latter will have a better chance of encouraging new services and delivery mechanisms. So yes, I want to end Medicare as we know it. But that's going to happen anyway.

The ACA is not dead yet. Far from it. And I'm not convinced the Supreme Court will rule it, or the mandate unconstitutional. Yogi Berra is quoted as saying, "When you come to a fork in the road, take it." Lawyers are kind of like that. When they come to a fork in the road, they make a new road. We'll see what the Court does. In some ways I'd prefer chaos. Strike down the mandate, keep all else. Congress would be forced to act. After it exhausted all other options.


Bring On The Death Panels


I'm on service this week-a time honored exercise in which I, as the attending physician, listen to trainees and students present cases that we have been asked to see in consultation or who have been admitted to the ward cardiology service for poor folks with Medicaid or no health insurance at all. I visit each patient, make sure the trainees don't do anything foolish, try to do a little teaching, and philosophize in the style that you have so graciously tolerated in these pages. With the current health care argument before SCOTUS front and center this week, its been a challenge to keep my frustration with the present state of affairs out of the conversation. The trainees have to listen to whatever I say and pretend to be interested, so I try to make sure I don't bore them.

With the accumulation of gray hair, among other elements of inevitable decline, I no longer believe that the most important contribution I make in this ritual is the medical stuff. "This is the thigh bone, this is the leg bone, this is the knee that joins them", that kind of thing. My young charges, who are all plenty smart, can, and will, learn that from books or someone else. I am much more interested in getting them to be comfortable with the inevitable uncertainty that accompanies  medical decision making, and to see the larger consequences of their decisions. What is the benefit  of dialysis (30K/year) or an implantable defibrillator (50K) or any other of the myriad fantastical treatments that the medical industrial complex dishes up year after year to a demented bed ridden 85 year old? Is more treatment always the answer? Who benefits really?

A terrific op-ed this week from our favorite leftist newspaper reprises the dismal statistics:  1/3 of Medicare expenditures take place within the last 6 months of life, and a 1/3 of that takes place within the last month. Since when did it become a requirement that the dying be poked, probed and  inserted with every possible catheter like Ahab lashed to the mast in search of unobtainable immortality?  How is it that our culture decide that death is an option, like leather interior or extra leg room?

Eventually, as you like to say, this will end because it must. We ration now and we will ration
more in the future. Its just a question whether we will do so with any interest in fairness.