Monday, January 28, 2013

Public Health and the Second Amendment


Why not treat guns like a public health menace you ask? The Second Amendment gives it more status than public health issues is the easy answer.

As I (may) have said; I'm ambivalent about guns. Oddly, I have more of an urge to buy a gun now, and/or train to use a gun given our national "conversation." Sadly, I think what you are finding from me, and maybe others, is a lack of trust that solving a public health issue is the only motive for this conversation. I trust you. Some of the other voices out there, not so much.


Guns And Public Health


Back in the Pleistocene epoch, when you and Mrs. Knabe decided to wed, as part of the condition for being granted a marriage license, you were both required to undergo a blood test to prove you were free of syphilis. In the same epoch, during my training in a public hospital, I was compelled to immediately report suspected case of virulent tuberculosis to the local public health authorities for possible quarantine. In 49 states (the exception being New Hampshire), the law demands the use of a seat belt at all times. Failure to comply results in a fine of varying amounts. These examples illustrate the principle that under certain circumstances  the government may limit individual liberty to protect the public health. While the nature of those circumstances and that interest continue to be the source of ongoing debate, the principle itself is firmly rooted in both law and the ethics.

In 2010, there were >30,000 firearm related deaths in the United States. That number would place gun related deaths as the 12th most common cause of mortality, and the 4th most common preventable cause of death behind those related to smoking, obesity, and motor vehicle accidents, all of which are subject to a wide variety of public health efforts . The majority of gun related deaths are suicides, and as such are powerfully amenable to prevention, since most suicidal patients remain at high risk for very short periods of time, and the absence of an available firearm during these periods would constitute an effective prophylactic.

So why we don't treat gun related deaths as we do every other public health menace?


If  "freedom of the press and freedom from corruption are directly related," then what is wrong with the Citizen's United decision? Seems to me the NY Times and Wall Street Journal are corporations with strong opinions and explicit political opinions. They use their power to attempt to sway voters and legislators. But that honor should be reserved to them? Why can't I form a corporation and do the same thing? Why would you grant that right to the NY Times and Wall Street Journal but not me? Citizen's United was prevented from exercising its First Amendment rights but the NY Times and Wall Street Journal were not similarly prevented. What's the difference?


PS. Love the maps.

Political Corruption And The Size Of Government


From Wikipedia

"Political corruption is the use of power by government officials for illegitimate private gain. Misuse of government power for other purposes, such as repression of political opponents and general police brutality " is not considered political corruption."

So Mayor Emmanuel's efforts to curb gun related violence through the use of  Chicago's financial power to influence the economic decisions of private entities may be misguided, arrogant,  ineffective or some combination of all three, but it is not corrupt.

Even with the current state of campaign financing, the US is relatively free of political corruption, at least compared to the majority of other countries in the world.

World Map Index of perception of corruption

As the map below, combined with the map above, demonstrate, government debt as a percentage of GDP and political corruption appear, with notable exceptions, to be inversely related.

Public debt as a percent of GDP (2010).

There doesn't seem to be much relation between intensity of corruption and the size of government as defined by % GDP.

Unsurprisingly,  freedom of the press and freedom from corruption are directly related.
2010 press freedom index scores


Corruption without Money


Not sure if you think this is an appropriate use of power. I don't

Chicago Mayor Rahm Emanuel, moving to take a lead role in the gun control debate, is turning up the pressure on banks that do business with firearms manufacturers. 
Emanuel is sending letters to two major financial institutions, TD Bank and Bank of America, which offer lines of credit to gun makers suggesting that they stop lending money to the manufacturers if they don’t come out for new gun restrictions.

This corruption is a function of a powerful and intrusive government, not money.


Sunday, January 27, 2013

Money and Politics and Speech


Corruption is the inevitable result of a powerful and intrusive government. The more powerful and more intrusive the greater the corruption there will be. Money isn't the cause of the corruption, it's the means to achieve it. Take away the money and a different way to accomplish the corruption desired will be found.

You ask how the Citizen's United decision helps all of this? Doubt it will frankly. But, as some like to say, it evens the playing field.


Wednesday, January 23, 2013


The gate agent just said the first class cabin could now pre-board. Is that right? Aren't they boarding? Clearly first class is boarding first. But pre-boarding?

Tuesday, January 22, 2013

35 mm Film And the Electronic Medical Record


Do you remember 35 mm cameras? They produced some of the most iconic images of the last century, and their portability, precision, and durability made them the tool of choice for both serious amateurs and professionals alike. But what really made them so powerful was the easy access, quality, and reliability of 35mm film. You could walk into any shop from Boston to Bombay (excuse me, Mumbai nowadays) grab a pack of TriX  or  Kodachrome  and you knew exactly what you were getting. And of course, you took it for granted that the film fit in the damn camera. I have no idea how such a standard between camera manufacturers and film makers was adopted, but I can't imagine it was accomplished by government fiat.

Contrast that with the current chaos of the mad push to an electronic medical record. Four hundred different vendors, each with its own product completely incompatibly with everyone else.  Each with its own mind numbing and illogical learning curve. I used to be able to write an order in a patient's chart in 30 seconds. Now it takes me a minute just to log on. What's more, the EMR is a bonanza for malpractice lawyers because they can  track every interrogation into the chart with regards to exactly when and for how long you entered a particular record. On the good side, to be fair, it does allow for dissemination and rapid retrieval of old records and test results.

So I'm with you on this one. We docs need to do a much better job of making medical information portable and accessible. It would have been much more preferable for a set of universal standards to emerge organically



The Mothers Milk Of Politics


Your post today,  Everyone Plays By The Same Rules might have just as easily come from Mother Jones say, or The Nation  Either way, it nicely highlights both the hypocrisy behind so much of current political discourse, and the consequences of a political system in which nearly unlimited amounts of money are used to buy unlimited amounts of access. So tell me again, as you like to say, how allowing special interests to lavish even more money on the politicians they capture will solve this problem.



Everyone plays by the same rules


"A nation where everyone fets a fair shot, does their fair share, and plays by the same set of rules."
Obama campaign tag line.

Together, we discovered that a free market only thrives when there are rules to ensure competition and fair play." Obama Second Inaugural

WASHINGTON — Just two weeks after pleading guilty in a major federal fraud case, Amgen, the world’s largest biotechnology firm, scored a largely unnoticed coup on Capitol Hill: Lawmakers inserted a paragraph into the “fiscal cliff” bill that did not mention the company by name but strongly favored one of its drugs.
Supporters of the delay, primarily leaders of the Senate Finance Committee who have long benefited from Amgen’s political largess, said it was necessary to allow regulators to prepare properly for the pricing change. 
But critics, including several Congressional aides who were stunned to find the measure in the final bill, pointed out that Amgen had already won a previous two-year delay, and they depicted a second one as an unnecessary giveaway. 


Monday, January 21, 2013

The Mystery of Ezra Klein | The Daily Caller

And I'm glad the ACA is solving the cost problem also. 

The Mystery of Ezra Klein | The Daily Caller

The Education of Ezra Klein (and Barack Obama) continues: In 2007, Young Ezra Klein was full of enthusiasm about the cost-saving potential of electronic record keeping in the health industry.  The failure to rapidly adopt this new technology was nothing less than an indictment of the American Way of Medicine:

I've never read a compelling explanation of why the nation's doctors and hospitals haven't broadly adopted electronic medical records. It's not as if they're allergic to technology. At this point, cardiovascular care employs every strategy but astral projection to keep our [hearts] in rhythm. It's not as if it wouldn't be cheaper and easier for them. …

That all these factors haven't spurred our private providers to incorporate such broadly appreciated technology should be one of our first signs that American medicine is not responding to the incentives we'd expect.

Others, such as Drs. Jerome Groopman and Pamela Hartzband, were skeptical when President Obama made subsidizing electronic medical records a centerpiece of both his stimulus ($19 billion subsidy) and health care reform plans:

Last week, President Barack Obama convened a health-care summit in Washington to identify programs that would improve quality and restrain burgeoning costs. He stated that all his policies would be based on rigorous scientific evidence of benefit. The flagship proposal presented by the president at this gathering was the national adoption of electronic medical records — a computer-based system that would contain every patient's clinical history, laboratory results, and treatments. This, he said, would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.

Following his announcement, we spoke with fellow physicians at the Harvard teaching hospitals, where electronic medical records have been in use for years. All of us were dumbfounded, wondering how such dramatic claims of cost-saving and quality improvement could be true.

Klein, however, remained enthusiastic:

There's an argument that we're eventually going to look back at the stimulus bill's investment in electronic medical records as the most important improvement the Obama administration made to the health-care delivery system — and, if the more optimistic assessments are right, as a crucial piece of infrastructure that allowed us to eventually get costs under control.

Comes now the RAND corporation to tell us that the projected cost-saving benefits of electronic medical records have not materialized. From the NYT's report:

But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.

It turns out that electronic records allow hospitals to easily "upcode" procedures, charging more for them, while removing some of the hassle of ordering expensive tests. As Groopman and Hartzband note, the most common kind of costly medical error is misdiagnosis–and those misdiagnoses are now spread far and wide at the speed of electricity rather than carbon paper. Doctors may also be discovering something Microsoft employees discovered long ago: computers allow the exponential proliferation of bureaucratic paperwork. You don't even need the paper.

It's possible electronic medical records will still pay off, once systems are more widespread, "interoperable," and adapted to the mobile devices like iPads. More training may be necessary. It's also possible that this payoff was actually delayed because Obama's massive subsidy paid doctors to install systems rapidly before figuring out which ones were best. And it's possible there will be no cost-saving payoff at all.  Klein's "Wonkblog" colleague, Sarah Kliff, ends her recent analysis on a decidedly agnostic note:

The larger American health-care system isn't even in a position yet to figure out whether cost savings are possible …

What are we to make, then, of Klein's confident enthusiasm in 2010 and earlier? Did he really believe it? I assume he did (in the sense that he wasn't cynically BSing). But why? Was it a) the result of a continuing process of investigation in which he confronted the best arguments against the idea or b) something some expert (not Groopman!) told him or c) a convenient belief because it plugged a political hole for Democrats, allowing Obama and his supporters to pretend that universal health care coverage was going to be a lot cheaper than people thought (thanks to the cost-saving bonanza of electronic records)?  If a belief satisfies criterion (c), does Klein even really care if it satisfies (a)?

This is the epistemological mystery of Ezra Klein. It's not a mystery for most journalists–they claim to be playing Game (a). If they fall short, that's highly embarrassing for them. It's not a mystery for President Obama–he's a politician who wanted to pass a universal health insurance coverage plan. He's playing Game (c).  If a theory like "green jobs" or "electronic medical record savings" plugs a political hole for him, he's going to go for it (having probably concluded that even if, say, electronic medical record savings turn out not to be real, the country's still better off with greater Obamacare coverage).  Klein poses as a "wonk," indicating he may think he's playing Game (a), but his history on the electronic records issue suggests that if he is he's deluding himself–and his readers.

Hoaxer, self-hoaxer, or just confused? When they are through with Manti Te'o maybe the nation's amateur detectives can turn to Klein.

Counting Full Time Employees - The Daily Beast

Well I sure am glad the ACA solved the access problem. 


Counting Full Time Employees

by Megan McArdle

Employers are planning to cut hours in anticipation of new health care rules. Can the IRS fight back?

This is the year that agencies will be finalizing the rules that tell us what ObamaCare will look like.  Funnily enough, the IRS is one of the most important agencies, because they decide how the penalties . . . er, pardon me, Justice Roberts, the taxes . . . get applied.  

I wrote earlier this week about the rules governing adjunct professors, who thanks to an IRS ruling, are likely to qualify as full-time employees for the purposes of assessing penalties against universities.  In response, universities--the most left-wing employers in the country, except for maybe labor unions--are already planning cutbacks in their adjunct hours.  

If the universities are doing it, you know it must be coming in other sectors; anecdotally, workers in the retail sector are about to get hammered.  Employers are going to be hypervigilant about making sure that employees don't get anywhere near the 30 hour threshhold.  And for employers that use variable shifts, like restaurants (where slow nights see workers sent home early, and very busy nights see them staying hours late) that's going to mean scheduling a lot fewer shifts per worker.  

But the IRS is wiley.  They understand that this is the likely outcome of penalizing employers who do not cover 95% of their full-time-employees (defined as anyone working more than 30 hours a week).  And just as they have written rules making it very difficult to, say, pay your salary to a corporation that pays you nothing, but owns a very attractive house and grocery stash that you are free to use, they are writing rules to make this sort of arbitrage difficult.  Such as declaring that if you try to put people on part time so that you have fewer than 50 full time workers (the threshhold at which the penalty is triggered), they will add up the hours of your part time employees, and count two employees working 20 hours each as one full-time employee.  

Welcome to the regulatory cascade.  You write a rule, and people try to dodge it.  So you write another rule, and they come up with a way to dodge that, so still another rule is needed . . . eventually you are penalizing things very far from the behavior you are trying to regulate.  Think of the folks who want to make Sudafed a prescription drug in order to prevent meth labs from getting a hold of the stuff. Or functionally criminalize the carrying of large amounts of cash.

Undoubtedly, we can look forward to just such a cascade regarding part time employees.  If the shifting is as broad as early reports suggest, there is going to be considerable pressure on the administration to crack down on it, perhaps by broadening the definition of a full time worker.  That will trigger strategic responses from employers, and further rounds of crackdowns from the IRS.

Meanwhile, I don't know what happens to the employees, who are the mouse in this cat-and-mouse game.  As I've noted before, the modern use of scheduling software--so that workers never know more than a week ahead what hours they'll get--is going to make that extra-hard on workers, because the variable shifts make it hard to tack on an extra part-time job.  I'm not sure how some lower-end retail workers are going to survive the cutback.  (Waitstaff, whose hourly wages are a fairly trivial part of their compensation, will presumably just clock out and keep working.)  On the bright side, they will qualify for Medicaid.

Can the IRS prevent this?  I don't know.  The agency has very broad powers, and it's remarkably successful at keeping people from, say, shielding all their assets in a corporation.  But can the agency simply demand that employers use mostly full time employees?  That's pretty broad, even for the IRS--which just highlights how sweeping a change Obamacare really was.  

What's A Sociopath?


In answer to your question yesterday, a reasonable description of the features of the sociopath is listed below. Psychopath and anti social personality disorder are synonymous terms. Even though this "condition" if it can be called such, is listed as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disordersmost psychiatrists do not regard it as a mental illness in the category of say depression or schizophrenia.  Evidence is accumulating that it is an inherent condition of the brain  that is neither caused by environmental factors nor responsive to treatment. Lance Armstrong  is an excellent example. Jerry Sandusky is another.

In general, the best place for sociopaths, when they engage in behavior that harms others (as they almost always do), is far away from the rest of us, in prison.


  • Glibness and Superficial Charm
  • Manipulative and Conning
    They never recognize the rights of others and see their self-serving behaviors as permissible. They appear to be charming, yet are covertly hostile and domineering, seeing their victim as merely an instrument to be used. They may dominate and humiliate their victims.
  • Grandiose Sense of Self
    Feels entitled to certain things as "their right."
  • Pathological Lying
    Has no problem lying coolly and easily and it is almost impossible for them to be truthful on a consistent basis. Can create, and get caught up in, a complex belief about their own powers and abilities. Extremely convincing and even able to pass lie detector tests.
  • Lack of Remorse, Shame or Guilt
    A deep seated rage, which is split off and repressed, is at their core. Does not see others around them as people, but only as targets and opportunities. Instead of friends, they have victims and accomplices who end up as victims. The end always justifies the means and they let nothing stand in their way.
  • Shallow Emotions
    When they show what seems to be warmth, joy, love and compassion it is more feigned than experienced and serves an ulterior motive. Outraged by insignificant matters, yet remaining unmoved and cold by what would upset a normal person. Since they are not genuine, neither are their promises.
  • Incapacity for Love
  • Need for Stimulation
    Living on the edge. Verbal outbursts and physical punishments are normal. Promiscuity and gambling are common.
  • Callousness/Lack of Empathy
    Unable to empathize with the pain of their victims, having only contempt for others' feelings of distress and readily taking advantage of them.
  • Poor Behavioral Controls/Impulsive Nature
    Rage and abuse, alternating with small expressions of love and approval produce an addictive cycle for abuser and abused, as well as creating hopelessness in the victim. Believe they are all-powerful, all-knowing, entitled to every wish, no sense of personal boundaries, no concern for their impact on others.
  • Early Behavior Problems/Juvenile Delinquency
    Usually has a history of behavioral and academic difficulties, yet "gets by" by conning others. Problems in making and keeping friends; aberrant behaviors such as cruelty to people or animals, stealing, etc.
  • Irresponsibility/Unreliability
    Not concerned about wrecking others' lives and dreams. Oblivious or indifferent to the devastation they cause. Does not accept blame themselves, but blames others, even for acts they obviously committed.
  • Promiscuous Sexual Behavior/Infidelity
    Promiscuity, child sexual abuse, rape and sexual acting out of all sorts.
  • Lack of Realistic Life Plan/Parasitic Lifestyle
    Tends to move around a lot or makes all encompassing promises for the future, poor work ethic but exploits others effectively.
  • Criminal or Entrepreneurial Versatility
    Changes their image as needed to avoid prosecution. Changes life story readily.

Other Related Qualities:
  1. Contemptuous of those who seek to understand them
  2. Does not perceive that anything is wrong with them
  3. Authoritarian
  4. Secretive
  5. Paranoid
  6. Only rarely in difficulty with the law, but seeks out situations where their tyrannical behavior will be tolerated, condoned, or admired
  7. Conventional appearance
  8. Goal of enslavement of their victim(s)
  9. Exercises despotic control over every aspect of the victim's life
  10. Has an emotional need to justify their crimes and therefore needs their victim's affirmation (respect, gratitude and love)
  11. Ultimate goal is the creation of a willing victim
  12. Incapable of real human attachment to another
  13. Unable to feel remorse or guilt
  14. Extreme narcissism and grandiose
  15. May state readily that their goal is to rule the world  

Sunday, January 20, 2013

Run The Football, Stop The Run


Some things remain constant. Despite the aerial circus that has become the NFL in our era, controlling the football still wins games. Given how closely matched today's AFC championship contestants are matched, I have now idea how the absurd 91/2 point spread got generated. Wait, I seem to forgetting all the lessons you've been teaching me. The bookies are obviously providing an incentive to bring betters in on the Baltimore side of the wager.

In any event, here are my hardly novel predictions for the statistical determinants of today's contest, in order.

1) Net turnovers (Patriots 1st, Ravens 9th).

2) Net rushing yards (Patriots ranked 3rd, Ravens 5th).

3) Net time of possession. To the degree that  the Ravens can deprive Brady of opportunities to score, their chances of prevailing are excellent.

4) Net negative passing  yards. In other words, the team with more passing yards is likely to be the loser, especially if the score is not close.


Guns And Mental Health


I don't think these two issues have much to do with each other, the current public conversation as you derisively describe it, notwithstanding. The availability and efficacy of mental health care across the country is one issue. Whether or not any change in public policy. access, surveillance, etc would alter the inclination  of certain young white males to engage in indiscriminate public slaughter is quite another, and the two should not be conflated.

Regarding the former, I have no expertise, although for many years I had a close personal connection with someone who did. What I do know is that if you present to my hospital this morning with a heart attack you will receive prompt (the rule is 30 minutes), definitive therapy from a team of highly qualified experts who are literally standing by for such emergencies. If one the other hand, you present in the midst of a psychotic break, suicidal ideation, or any other psychiatric condition that warrants immediate acute care hospitalization  you will likely wait, perhaps strapped to a gurney, in the "psych" section of the ER, for anywhere up to 96 hours until a bed can be found for you. If you are without means, you may wait even longer, given the dramatic decline in public facilities for the inpatient treatment of the mentally ill. On the outpatient side, the state of affairs is are equally problematic, in terms of both availability and efficacy.

But I doubt, I  repeat, that this state of affairs no matter what one thinks of it, has much to do with the nation's failure to attenuate gun violence. Gun availability surely is part of the equation. But I don't believe that's the whole story. Something deeper and harder to define within the American psyche is also at work.

As far as your neighbors' resentment of public funding for children with learning disabilities, the obvious query comes to mind. What do you think their attitude would be if they blessed with, and loved, such a child?


The Gun Issue


I haven't read through the President's proposal in detail, and as such am am not qualified to opine as to what parts of I like and don't like. I do agree with the return of the assault weapons ban and a ban on high capacity magazines. I think such actions might reduce the magnitude of the mass killings that plague us, although I accept the likelihood that such actions will  have a modest effect upon the overall appalling incidence of deaths in which the instrument used is firearm (the most neutral way I can put it). From a public health perspective, most gun related deaths are accidents and suicides; as such they are directly related to gun availability, and the gun of choice is a legally purchased and owned handgun.


Saturday, January 19, 2013



The more we (the nation) have this "conversation," (Lord do I despise that term to describe the back and forth taking place) on gun control the more uncomfortable I am about the impact this will have on those who have or need mental health services. Anti-gun proponents suggest guns are the problem. Pro-gun proponents suggest mental health is the problem. Anti-gun activists are more than willing to add mental health to the effective and smart government regulation and services they propose to create their paradise here on Earth.

Let's prevent the mentally ill from owning guns sounds like such a common-sense proposal. What is mentally ill? Is it someone who has ever been prescribed an anti-depressant? What if that person was a minor when on the anti-depressant? How long does he have to be off the anti-depressant before the scarlet G is removed? What other Constitutional rights should be denied to the person who received anti-depressants? Will every person be required to have a mental examination before purchasing a gun? Who will administer this exam? What will be the appeal process? Will the patient's HIPPA rights be violated? What other rights will be impacted by the result of this exam? If people know being diagnosed with a mental health disorder will lead to restriction in their freedom, will they be more reluctant to seek mental health services?

I live in a community that has experienced a significant increase in spending for special education over the past decade. Some of the kids have physical issues, some mental, some both. The law of the land requires school districts to provide a comparable education to these kids as the kids in the mainstream population. Believe it or not, since we have a state that mandates it is the state's responsibility to educate our kids, I agree kids with special needs should be helped.

But my friends and neighbors are not as charitable. They complain parents move to our district just to participate in our special ed program. All these leaches want is private education for their children at the expense of the community my neighbors complain. These same parents have no issue with large budgets for sports programs, or art programs, somehow those "normal" kids are more deserving of our budget. But the kid with a learning disability, or emotional issue is a parasite, in their view. My friends and neighbors say we need to cut the special ed budget, we need to be tough on these kids. (Tough on these kids?!) These kids have become the scapegoat for a school budget that is overwhelmingly driven by personnel costs.

I see how people react to those who are scapegoated. It's not pretty. Yes Newtown was a tragedy. Yes guns are an issue. Yes mental health is an issue. Can we please tread carefully and not do "something" just to do something. The lives of many will be impacted by ineffective laws, and many of those people impacted will be the weak and in-need people we as a society should be helping, not vilifying.


Friday, January 18, 2013

You Have an Annoying Habit


You have an annoying habit of assuming since I question and criticize the effectiveness of government than I must be against all government. If I ask what are the costs of a program like unemployment benefits (a program I have used, by the way) then I must be against unemployment benefits. If I state there is a cost to providing "free" health care (despite taking advantage of many aspects of the government's mandates and largesse) than I must be against any government involvement in health care. You have a Pavlovian response of invoking Dickensian poverty whenever I mention a year starting with the digits 18.

I want to "throw people out," of what I'm not sure, "leave them to their own devices"; throwing them out of this unknown structure into the great void will lead lead to a degree of suffering you know will occur because you have conjured it out of your imagination in response to a suggestion I have not made.

The answer to ineffective government indeed may be effective government. Alternatively it may be no government. Head Start has been shown to be ineffective. We have three choices: 1) Keep spending money on something that in ineffective 2) Implement the effective solution to whatever the problem is 3) do nothing. If we don't know what 2) is would you prefer to continue ineffective policy 1)? How does that make sense? Does that mean I'm against children?

You are horrified by throwing people out and leaving them to their own devices, but you have expressed multiple times horror how certain current programs are effective now but at a cost of placing a tremendous burden on our children and grandchildren. That is, it's only effective if we allow a giant inter-generational theft. If something is ineffective, at the very least, don't do MORE of it. If you are in a hole, stop digging.

I don't think the answer is to ignore the voices on the ends of the bell curve. Everyone gets one vote. I don't question their patriotism nor do I think it's useful to characterize, or mis-characterize their motives. They have opinions and a right to share them. Like you I think many on the edges need remedial math lessons, but even so, I have no reason to believe the opinions they are sharing are not honestly come by.

I just finished a book called, "The Professor and the Commissions," by Bernard Schwartz. The author was chief counsel for a Congressional inquiry into the six major regulatory agencies in the second Eisenhower administration. He found a bit too much dirt for the comfort of Congress, the Administration and the regulators and was fired about six months after the inquiry began. Schwartz was most troubled by the FCC, which granted television and radio licenses via a process that was highly arbitrary  subject to political influence and at its core unfair and inefficient. Ronald Coase and the Chicago boys love to quote the book, as well as mock the somewhat overwrought tone of the later chapters. To them it's a good example of regulatory capture. That is, the regulators become the pawns of the businesses they regulatie. It's a good example of crony capitalism since friends and relatives enrich themselves at the public trough. LBJ became quite a wealthy man with his manipulation of the FCC. (Maybe someday we'll find out how that other tribune of the people, Harry Reid, amassed a $10 million fortune on a Senator's salary). To the Chicago boys they look at this ineffective government regulation and see restricted consumer choice and higher prices as the result of this policy. Your typical response to this is to dismiss the criticism, and a knee-jerk reaction that they want to eliminate government and let big corporations take over. That's is exactly what they DON'T want or propose.

What did Coase and the Chicago boys recommend? Let the market figure out the best use of the resource with clear rules set by the government. And to a large extent, that is what the FCC has done. Not fully, the FCC still plays a large role, but it has very much attempted to let the market sort out more of the allocation of spectrum, and the result has been greater consumer choice and lower prices. The result has been exactly what the theory predicted. 50 years ago Ronald Coase suggested a more effective FCC and it was Bill Clinton that finally listened. I don't think I've every suggested, even remotely, the elimination of government. I have argued making the government more effective may mean making it less powerful in the allocation of resources, but not less powerful in setting the rules that all play by.

We both want more effective government. But you often conflate my belief that more effective government may mean less arbitrary, less totalitarian for a belief in anarchy.

There. I got that off my chest. Go Pats.


Instability Provides The Potential For Change


Thomas Edsell makes a compelling point about the divergent interests within the democratic coalition and the potential for instability that creates. When David Bois starts suing firefighters on behalf of the state of Rhode island, you know something's up in liberal land   For the Republicans, the potential for instability is equally potent. But I don't see that as a bad thing. The current north/south, urban/rural, religious/secular, white/nonwhite fault lines haven't worked out so well for everyone except the 1%, who seem to do well no matter whose in power. Maybe a shifting coalition or two would shake things up.


Finding Solutions


If there's one thing that the experience of writing this blog has convinced me of, it's that complex problems don't readily lend themselves to simple solutions. The diversity of  American political opinion,of which you and I represent a surprisingly small part, is just too great for that. Someone will always be unhappy, and the people who are most unhappy are those at the extremes of the spectrum. That includes not only the ultra liberal wing of the Democratic party but the Tea party as well. Neither of these groups has the nations's best interest at heart, only their own ideology and the obsessions of their constituents. When a proposal like Simpson Bowles pisses off both sides, that's a sure sign that its just about right as far as I'm concerned.

I don't agree at all that we couldn't make a deal if it were left up to us. I am fact sure that we would compromise. The reality is that as proud members of the 1%, we have much more in common with each other, despite our ideological starting points, than we do with everybody else.

That said, I do not think the answer to fixing the entitlements is to throw them out and leave people to their own devices. To speak plainly, I do not want to live in a country that would generate the degree of suffering such a solution would produce, and I don't believe that you do either, your elegant assertions to the contrary notwithstanding. The answer to ineffective government isn't no government. It's effective government.


Thank God Have a Strong Defender Against the 1% Inhabiting the White House


The Washington Post reports:

Most will come by train, by foot or by bus. More than a few, though, will arrive in inaugural Washington by private plane.
And the region’s biggest airport is looking to roll out the concrete carpet for the high-flying arrivals. Officials at Dulles International may close the airport’s westernmost runway to accommodate hundreds of private planes expected to descend on the region over the next few days. 
After all, those Gulfstreams and Learjets will need a place to park while their passengers are in town for the inaugural festivities.

As a point of comparison, the Post quotes airport officials expecting 300 to 600 arrivals this year, down from the 700 in 2009. That's double the number of arrivals from George Bush's second inauguration.

I don't know if you ever bought the (what I consider nonsense) about the 1%. But if you did, what say you of this?


Tuesday, January 15, 2013

First Rule of Holes: When you are in a hole, stop digging


We have hit a bit of a bump in the road to our liberal paradise in CT recently. First Governor Malloy discovered raising taxes on everyone, not just the wealthy, doesn't mean the budget will be balanced, and today some rather disturbing news on CT state pension obligations.

From a CT Mirror story:

The state employee pension system fell to a 24-year-low this fiscal year as investment losses and more conservative projections for future earnings left the fund with enough assets to cover just 42 percent of its obligations, according to a new report. 
According to the latest actuarial valuation, prepared by Cavanaugh Macdonald Consulting of Kennesaw, Ga., the fund had $9.74 billion in assets and $23 billion in obligations for a funded ratio of 42.3 percent. 
Analysts typically cite a ratio between 70 and 80 percent as fiscally healthy.
There is a table (page 9) from the actuarial valuation report that caught my eye:

Since 2007 the amount the state of CT owes to its pensioners has increased from $18 billion to $23 billion while the amount saved to pay these retirees has been flat. Meaning the ratio saved has fallen from 53.6% to 42.3%. 

Most of corporate America moved away from pensions to 401-K's years ago. They did it to remain competitive. Since there is no competition for government, there was little incentive to do so. Cities like San Bernadino are suffering from their past prolificacy. The unfunded liabilities of the Social Security System, Medicare and Medicaid, the pillars of the New Deal and the Great Society, make CT's finances look sound. 

But not to worry, because according to Nancy Pelosi, 

Well I think as far as Social Security is concerned, this is an insurance initiative, that was very masterfully put together so it's not a poor people's program. It is an insurance program that people pay in, thee and me, we take out. 
Why do Democrats have such veneration for programs that are literally (thanks VP Biden) driving the country bankrupt? And why do Republicans talk the talk and talk the talk and talk the talk and talk the talk?


Don't Mess With Jon Stewart


Paul Krugman should have known better. It's one thing to regularly dismiss entire schools of economists, not to mention millions of concerned citizens (like us), as crackpots and frauds. But taking the Daily Show funnyman to task  for lampooning the trillion dollar coin caper? Big mistake...

Say what you want about Stewart (as I'm sure you will). He has a wonderful way of making the absurd seem, well, absurd. 


"Social Security is an Insurance Program"


There are times when I've given up all hope for you, then you pen something like, "What the Debt Ceiling Debate is Really About," and hope is restored. I'm not the biggest fan of Brooks but I thought the piece you referenced was the issue in a nutshell: Older Americans are quite comfortable taxing their children and grandchildren to provide for their comfort today. They elect politicians who enable that theft.

I also agree, Republicans and Democrats are both guilty of this thievery. What is interesting to me is the only group accused of opposing this inter-generational theft is characterized as the lunatic fringe by people like you. Frankly, I think there is an inner Tea Partier in you trying to get out.

By the way, here is how Nancy Pelosi characterized Social Security on "Face The Nation" last Sunday

Well I think as far as Social Security is concerned, this is an insurance initiative, that was very masterfully put together so it's not a poor people's program. It is an insurance program that people pay in, thee and me, we take out. 
This is just as dangerous as Romney and Ryan's criticism of Obama for reducing Medicare and then standing up as defenders of the status quo.

I'm not sure you and I would compromise if we ran the world, but at least I think we would agree on the facts.


What The Debt Ceiling Debate Is Really About


If the Republicans in the House really want to reign in spending all they have to do is vote to do so. They can cut Medicare (a choice opposed by 70% of Americans) or Social Security (opposed by an equal number). But they won't do that because they know they won't get reelected if they do. The Democrats, perhaps even worse,  are perfectly happy to pretend that there is no problem with the debt at all -just ask my friend on the left Professor Krugman When the debt no longer becomes sustainable, they will squeeze the rich (that's us) or just inflate the debt away.

David Brooks expresses this reality far better than I can

 "Ultimately, we should blame the American voters. The average Medicare couple pays $109,000 into the program and gets $343,000 in benefits out, according to the Urban Institute. This is $234,000 in free money. Many voters have decided they like spending a lot on themselves and pushing costs onto their children and grandchildren. They have decided they like borrowing up to $1 trillion a year for tax credits, disability payments, defense contracts and the rest. They have found that the original Keynesian rationale for these deficits provides a perfect cover for permanent deficit-living. They have made it clear that they will destroy any politician who tries to stop them from cost-shifting in this way.

Most members of Congress are responding efficiently to the popular will. A large number of reactionary Democrats reject any measure to touch Medicare or other entitlement programs. A large number of impotent Republicans talk about reducing the debt, but are incapable of forging a deal that balances tax increases with spending cuts.        

So the debt ceiling nonsense is simply a way for each side to see if they can blame the other when both are collaborating efficiently at giving the American people exactly what they want.


Chicken or Egg


A typical sentiment on the debt ceiling is articulated by Alan Blinder in today's Wall Street Journal, "Only in America is there another law that might, and sometimes does, contradict the budget law: a limit on how much the government may borrow."

Why is the debt ceiling law the ridiculous law? Why isn't the spending law the ridiculous law? Surely when Congress signed and the President signed the budget it was known this would violate the debt ceiling. Why were Congress and the President willing to pass and sign a law they knew would violate another law?

Tell me why the debt ceiling is the bad law, instead of the spending law that violates the debt ceiling law.


Monday, January 14, 2013



The analogy isn't perfect, but the sentiment is good enough. In a 2003 game against the Giants, the 49ers should have been called for pass interference, but weren't. Afterwards, the NFL admitted the officials made a mistake. Steve Mariucci's response, "Bummer." 

Obama and the Dems don't like it there is a debt limit? Bummer.
They don't like it that the debt limit law won't allow for all the spending another law allowed? Bummer.
They object if the debt limit isn't raised, choices will have to be made how to allocate receipts? Bummer.
They don't like it they'll have to negotiate to raise the debt ceiling? Bummer.

Bummer dude. Get over it.


Why playing Chicken With The Country's Fiscal Reputation Is A Bad Idea


This comes not from my friends on the left  but from your friends on the right. Whether screwing around with the debt ceiling is good policy or not, it's likely to be disastrous politics.


Why Belicheck Is One Of the Greats


He was an economics major at Wesleyan.

As such perhaps he understands risk and reward in a way that many of his coaching brethren do not. And it always helps to have one of the all time great QBs on your side of the ball


Dueling Headlines


In my inbox at 12:23 pm:

News from The Hill: Obama demands Congress raise $16.4 trillion debt ceiling

About twenty minutes later:

News from The Hill: White House tells Ryan it won't meet budget deadline

and this summary of the story:

The White House has informed House Budget Committee Chairman Paul Ryan (R-Wis.) that it will miss the legal deadline for sending a budget to Congress. 
Acting Budget Director Jeff Zients told Ryan (R-Wis.) late Friday that the budget will not be delivered by Feb. 4, as required by law, a House aide said. 
“Late Friday evening, Deputy Director Zients confirmed that for the fourth time in five years, the President’s budget will not be submitted in compliance with the law,” the aide said. 
“Zients did not indicate how late the administration will delay its submission, simply noting ‘We will submit it to Congress as soon as possible,’” the aide added


Sunday, January 13, 2013

He Who Shall Not Be Named

Maybe you were limiting yourself to football, but this is the one I was sure would seer your memory.

My burden is remembering the Broncos losses to the Giant,s 49ers and Redskins . These were sins committed by Dan Reeves, as he wasted Elway's talents for a decade. Retribution was exacted by the Broncos Super Bowl victory over Atlanta and Elway's MVP award in that game.

We Remember The Losses


More than the triumphs it seems. My condolences on yesterday's bitterly disappointing result. I share your pain. I remember the Ben Dreith's roughing the passer penalty against Sugar Bear Hamilton like it was yesterday.

Even the infamous tuck rule call 25 years later didn't quite make up for it.

But between our two teams, here is the record that most NFL fans would sacrifice their 1st born for.

Division championships: 27
Conference championships: 13
Superbowl championships: 5

Of course talk to me at 7 o'clock if the Patriots do not prevail in today's contest and I no doubt will be singing a different tune.


Saturday, January 12, 2013

OK. I understand the Broncos wanted to lose. But did they have to take over 4 hours to do it?


Two Manning fumbles. (I'm counting the one that was negated by the Raven's penalty). Two Manning interceptions. Bailey doing his best imitation of toast. Third and seven, a 7-point lead and 90 seconds left on the clock with history's best QB and they run the ball. I don't want to even remember the name of the defender who waved his hands and fell down when Flacco threw the Hail Mary at the end of regulation. I don't want to clutter my mind with his name since surely he won't be on the team next year.

This game reminded me (even going into it) too much of the 1996 Broncos. Elway as QB. Shanahan was coach. Terrell Davis in the backfield. Eddie McCaffrey and Rod Smith wide receivers. Shannon Sharpe at tight end. Steve Atwater safety, Bill Romanowski at LB. That team went 13-3 for the season and only lost due to their own mistakes, sloppiness and ennui. You watched that team and thought, "No one can beat them. They only way they lose is if they don't show up."

It was their year. No one in Denver worried about Jacksonville, that was just a warm up for the Steelers  or the Patriots. And they sleepwalked through the game against Jacksonville, and lost, at home, they lost.

I remember that game too well. I was visiting my Mom in Denver and sat in that room watching the Broncos piss away their season. Periodically she would come in and ask, "How are we doing?" She really couldn't care less about the Broncos, a healthy attitude generally, and one that served her very well that year.

I watched this game with Mrs. Knabe and at times daughter Knabe graced us with her presence. At 28-28 it was clear the Broncos didn't want to win the game. Did they really have to drag it out for four hours? A couple of times I was tempted to shout out, "Mom, we are doing horrible, they obviously have skiing vacations planned for next week."



The Debt Ceiling. Return of the Mayan Apocalypse


Remember when the world ended in 2012, just like the Mayans said? No? Me either. Remember the economic calamity that resulted from the last debt ceiling debate? Remember how the world was going to end if Europe wasn't bailed out? Remember how the economy was certainly heading into a recession, or depression, or how our current recession or depression would get worse if we didn't raise taxes on the millionaires and billionaires making $250,000 per year? Well the sky is falling crowd is on to their new calamity. Return of the Debt Ceiling!

We are already hearing the claims the US Government will "default" if the debt ceiling isn't raised. This is of course a sloppy choice of words. Default refers to an inability to pay the interest on debt and/or make scheduled principal payments. According to the US Treasury annual receipts were $2.4 trillion in fiscal 2012 and interest payments were $359 billion. Defaulting on interest payments would be a choice, not a consequence of a static debt ceiling. There's about $3 trillion of debt maturing in the government's fiscal 2013, and it's a pretty safe assumption the Treasury can roll over that debt, that is, borrow money to pay off the debt due. All of that without increasing debt. So again, default would be a choice, not a necessity. Not raising the debt ceiling would require some difficult (well at least difficult for some) choices about current spending.

In order to avoid the debt ceiling law your buddies on the Left are twisted into pretzels and just plain silly. For instance, this is Ezra Klein's summary of the argument Chris Hayes makes in favor of the trillion dollar coin:

Past periods of great strain in American life have often led to unsettling (at the time) innovations in currency policy. Abraham Lincoln printed greenbacks at a staggering rate during the Civil War. FDR took us off the gold standard during the Great Depression. Perhaps, when we look back, the platinum coin, or scrip, or the 14th Amendment (which I'm told is the preferred option of Senate Democrats) will be seen as another of these necessary innovations that helped the country survive the deep dysfunction taking hold in its political system.

Yea, the trillion dollar coin, that will do it, because this is an existential crisis like the Civil War. These are two of the leading intellectual lights, and I use that term loosely, the left has to offer,

It seems every time we have one of these discussions we can't avoid the hyperbole and distortions. Raise taxes or teachers, or firefighters will be laid off. Your kids won't get that sub-par education they are offered. National parks will close. Traffic lights will stop working. Police will stay home. The Mayan apocalypse.

For a party that makes such a stink about being believers in science and adherents to the truth it sure spends a great deal of time denying reality. Which is this: You want a welfare state that will require federal taxes to increase to about 25-30% of GDP. Right now federal taxes are about 15% of GDP. So to get to your liberal paradise taxes need to be increased 66% to 100% over current levels. State taxes will have to go higher as well. I think the reason you don't put the argument this way is because you know you would be laughed out of office. Instead you phrase it like this: Everyone has a right to free health care. Sandra Fluke should not be denied the right to have me pay for her birth control. I would be thrilled if Sandra felt free to fornicate at will. I do however prefer my taxes not double in order to accomplish that noble goal.

This chicken little act is tiresome. I say bring on the Mayan apocalypse.


Quarterbacks Respond to Adverse Incentives


Four quarterbacks tomorrow. Two immortals who have already met every mark of greatness, including overcoming career threatening injury to return to their former level of excellence and who have done some amazing things with otherwise ordinary teammates at times. Two others who have a won a lot of football games for very good football teams with very good defenses but have never met the mark, or even approached it.

What amazes me about Brady and Manning is not their physical gifts, as substantial as they are. It's that cognitive ability so see what's going on around them with such precision. Combine that with their decision making ability and you have the archetype of what a quarterback should be.

But even they aren't immune to pressure. Tomorrow will be about time. If Ray Lewis, Von Miller, Rod Ninkovich, or  JJ Watt spend enough time on the other side of the line of scrimmagel, it will be a long day for the men they are trying to transform into pretzels.

Good luck to your Broncos today. Hope we get to have out bet next Sunday.


Dealing With Affliction


One of my colleagues came into the emergency room yesterday with a small stroke. When his MRI  suggested that the stroke may have resulted from a blood clot in his heart, I was asked to take a picture with my transesophageal probe. The study instantly revealed the cause of his stroke, a rare, benign  but nevertheless life threatening cardiac tumor. It had to come out, and as soon as soon as he woke up from my test I showed him the pictures and asked him which surgeon he wanted me to call.

As he stared at this god awful piece of crap flopping around in his left atrium like a jellyfish, a big grin spread across his face. He looked like a school boy who has just solved a difficult math problem.  "Interesting" he said, and went back to sleep. He had after all become his own fascinating case. In that moment he dealt with the terror of his situation by removing himself to a familiar comfort zone, the dispassionate doctor presiding over an intellectual problem. He found a way to swallow his spit and go forward. He went to the operating room 3 hours later.

I only wish I had done half as well with my most recent injury. I haven't been the sturdy, stoical fellow I assumed I would always be in such a situation. I've been angry and blaming and self pitying and full of doubt about whether I would resume my former physical self, despite the almost daily evidence of improvement and the steady, patient reassurance of my outstanding physician and physical therapist (I know I know, you're stunned to hear me say anything good in relation to our health care system). In sum, I was far short of the man I thought I would be in my moment of affliction.

You never know until you get there. Sometimes we surprise ourselves. More often, it seems, we disappoint.

My colleague, BTW, had a great result. Woke up after his surgery without difficulty, still grinning.


Friday, January 11, 2013

Is US Health Care Really as Bad as the Headlines?


If you read only the headline, "US Health in International Perspective-Shorter Lives: Poorer Health," you would conclude there's a total failure of our health care providers. However, even a cursory glance at the report reveals there are many more reasons for shorter lives and poorer health in the US than health care. Which makes sense to me. I don't know about you, but it seems to me doctors and nurses are much less incompetent than they are portrayed by your buddies on the Left. (Also makes me wonder why you and your buddies on the Left regard, either implicitly or explicitly, your colleagues as such charlatans).

 Why are Americans so unhealthy asks the Committee on Population? Four answers:

  • Health Systems
  • Health Behaviors
  • Social and Economic Conditions
  • Physical Environments

So according to the the Committee on Population three-fourths of the reason we have shorter lives and poorer health has nothing to do with physician-provided care, but rather with socio-economic conditions, personal behavioral choices and physical environments.

The Committee points out Americans eat more, do more drugs, wear fewer seat belts, drive drunker or drive more often drunk, and use more guns. That doesn't say anything about health care, and it implies nothing, nothing, about the Affordable Care Act will lower health care costs. In fact, our current health care markets and the ACA encourage this behavior since the costs are born by someone else. It gets worse under the ACA since more of the costs are born by others; the marginal cost of obesity, drunk driving and guns injuries will decline. Prices down, consumption up.

The Committee also claims poverty, income inequality and social mobility contribute to shorter lives and poorer health. Not sure how income inequality and social mobility necessarily leads to poor health outcomes, and poverty is a relative concept.

Our automobile-centric lifestyle discourages exercise and contributes to obesity, according to the Committee.

Of course, the committee asserts lack of insurance and limited access to primary care as a reason for our shorter lives and poorer health, but it is interesting to me it cites so many other reasons as significant reasons for the country's poor relative outcomes, reasons that will have nothing to do with health insurance or health care.

I've read some articles questioning the statistical methods of these international comparisons. For instance, these criticisms claim definitions of live births differ across countries and different levels of care for pre-term babies who have higher mortality rates, impacts measurements of life spans and infant mortality. I've never bothered to ascertain the veracity of those claims. But if those claims are true and there are many non-health-care reasons contributing to our health care performance then our obsession with health spending as a percent of GDP is a giant waste of time.


Monday, January 7, 2013

Won't get fooled again


From the NY Times we see again the artificial demand for biofuels created by government subsidies and mandates results in real hardship for the most poor while lining the pockets of the few. Thank God we've learned our lesson and won't do something like that again.


Why I Stopped Reading Krugman


Stephen Williamson periodically engages in flame wars with Paul Krugman; always good for a laugh. This post explains why months ago I just stopped reading Krugman: he is dishonest.

Stephen Williamson: New Monetarist Economics. "Ideology?"


Sunday, January 6, 2013

Reform For All


Thank you providing the correct voting totals for OH and PA and remedying my error. I had searched in vain for them. Shows once again why you are the superior scholar of politics. Nevertheless I don't think those totals negate the argument that gerrymandering disenfranchises voters.

I would embrace any solution that maximizes the influence of every voter. I don't think that citizens living in CT1 (Larson, 8 terms), or CT3 (DeLauro, 12 terms) are well served by the absence of a true contest for those seats.  As far as the majority minority districts created by the Voting Rights Act, it can be argued that packing minorities into such districts actually minimizes the influence of those voters, since no one outside of their districts has to pay any attention to their concerns. That said, race is a place where I will tread very softly, if at all. The experience of being a minority is not one that can be shared.

So reform away. We'd have a very different Congress, maybe one that had an interest in solving our problems.


Political Reform for Me but not for thee?


There are those who believe gerrymandering is the deserved spoils of political victory, but I am not one of them. Nor do I believe "there's no circumstance under which you would see more Democrats in Congress as an improvement," and frankly it's irrelevant. If that's who voters choose, that's who they choose. I get one vote, in my district. What other's do with their vote, in their district, is their business, not mine.

While you are correct there are more Republican representatives in Ohio and Pennsylvania than the proportional votes for the parties you are incorrect there were more votes cast for Democrats in both states. The opposite is true

Ohio votes for US House of Representatives:
Republican 2,620,233
Democrat 2,412,385
Other 109,508

Pennsylvania votes for US House of Representatives
Republican 2,710,070
Democrat 2,693,538
Other 52,722

The sources for each are the Office of the Secretary of State for each state, links above.

But tell me, does your zeal for reform extend to places like Connecticut where 33% of the votes were for Republicans yet zero Republicans were elected to Congress? If it is unfair more Republicans were elected to the House from Ohio and Pennsylvania than the proportional votes received isn't it  unfair in Connecticut also?

Does your zeal for reform extend to this oddly-shaped district:

How about this one? You see this district resulting in politicians enthralled "to an ever smaller and ever more extreme proportion of the voters."?

Both are majority-minority districts. Would you be so eager for reform if the independent commissions that redraw districts resulted in fewer majority-minority districts like IL-2 and MS-2? I won't assume what your answer is, although I suspect many would find it outrageous and racist to suggest redrawing these districts as well.

It seems to me Democrats don't like it that Republicans disagree with them. They blame the "partisanship" and "extremism" on the Tea Party. When it's pointed out more votes are cast for Republicans than Democrats in states like Pennsylvania and Ohio, they respond gerrymandering is the cause of this partisanship and extremism. It is an asymmetric argument since the extremism resulting in Republican gerrymandering is absent in Democratic gerrymandering. 

Like I said, there are those who believe gerrymandering is the deserved spoils of political victory, but I am not one of them. How about you?


Saturday, January 5, 2013

Political Reform


You, as a student of history, know the country's long tradition of political reform far better than I. From the direct election of senators to the right to vote for women to the end of political machines to voting rights for minority Americans, the country has constantly tinkered with the machinery of democracy, not always with salutary results, but mostly for the better. Maybe a little bit of that would help us now. Pennsylvania sent only 5 Democrats (out of 18) and Ohio 4/16 despite more votes cast for Democratic candidates in both states. Here's what the 2012 PA congressional district map looks like:

Compare this map with Iowa, which uses a nonpartisan commission to establish Congressional districts.

Now I can see you rolling your eyes at yet another example of my left wing lunatic fringe do goodism. Gerrymanddering is nearly as old  as the republic itself. Both parties do it every chance they get. There's no circumstance under which you would see more Democrats in Congress as an improvement. But the current arrangement enthralls elected politicians to an ever smaller and ever more extreme proportion of the voters. When representatives are more afraid of "geting primaried" than answering to their constituents, something has gone deeply wrong with the way we are electing them.  

Reform doesn't come from above. One can't wish it into being. One must always be mindful of unintended consequences. But it's hard to imagine that we can't do better than we are doing now.


The breast pump industry is booming, thanks to Obamacare | Wonkblog


This is from The Washington Post's Wonkblog, the same authors who praised the 111th Congress, authors of this law, and disparaged the 1112th Congress for the lack of laws passed. I just look at this law and say, DMUB.


The breast pump industry is booming, thanks to Obamacare

The legislators who drafted Obamacare wrestled with cosmic issues of health and spending, but here's one consequence they didn't foresee: a boom in demand for breast pumps that has left some retailers scrambling to keep up.

Tucked within the Affordable Care Act is a provision requiring insurance companies to cover breast pumps and visits to lactation consultants at no cost to the patient.

Other mandated benefits, including the requirement to pay for contraceptives, drew far more attention and controversy. But when health insurance plans began resetting Jan. 1 under the new terms, it was the breast- pump clause that took off with consumers.

"We're getting a lot of calls from prospective mothers and new mothers," said Bruce Frishman, president of New Hampshire Pharmacy and Medical Equipment, a  supplier based in the District. "We've started stocking a lot more pumps that would be purchased through insurance."

Yummy Mummy, a New York boutique that specializes in breast pumps and accessories, is in the process of acquiring a warehouse and call center to accommodate the increased demand.

"I have three employees taking calls right now," owner Amanda Cole said. "We're still in the stage where we're figuring out how to add fax machines and phone lines. It's all very new to us."

Specialty suppliers like Yummy Mummy stand to benefit from the change if they manage to get on insurers' lists of approved distributors. Women who might have bought a  breast pump at a local retailer are now likely to turn to their insurance plan.

Cole opened her store in 2009 but never thought about working with an insurance company until last year, when she learned of the health law's new requirement. She began to worry that if women got their breast pumps through their insurer, her store would not have any business left.

"I began pounding the pavement to get onto their list of providers," said Cole, who recently signed a contract with Aetna to provide pumps nationwide. "Now that the plan really took effect on January 1st, there's been a marked change."

Insurance companies are figuring out the best way to navigate the federal regulation and provide a benefit that, until now, they had not routinely covered.

The government does not bear the costs of providing breast pumps. Instead, insurers will have to pay for the new benefit, likely with a slight increase to the premiums they charge their members.

Administrators of insurance plans still have questions about how to best implement the rule. No state has ever required insurance companies to cover the benefit, although Louisiana did convene a study panel on the issue in 2002, according to the National Center for State Legislatures.

"This was a medical service that is advantageous for both women and babies, so we thought it should be seriously considered," said Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center, who testified on the subject before the federal panel that set the guidelines.

"Turns out," she said, "that they decided to seriously consider it."

Thirty-one states already require Medicaid, for the low-income, to cover breast pumps.

The health-care law's requirement does not specify whether insurance companies must cover certain brands or types of breast pumps. It directs health plans to pay for "the costs of renting breastfeeding equipment" in conjunction with each birth. The breast pumps available for rental tend to be larger and more durable than those sold commercially, which are not intended for long-term use.

"There are various interpretations from the insurers," said Rachel Mennell, a spokeswoman for Medela, one of the country's largest makers of breast-feeding equipment. "There appear to be more questions than answers from not only the insurers, but moms as well."

UnitedHealthcare, the country's largest health insurer, decided it would cover rentals and purchases. Before the Affordable Care Act, the company had a patchwork of breast pump coverage, with some plans covering the equipment.

"The law states that we must provide rental pumps," said UnitedHealthcare spokesman Matthew Stearns. "These pumps are hospital-grade, and they are larger, harder to clean and more expensive than personalized pumps for women. We are providing women the option of getting a personal pump in lieu of renting the more-expensive pump."

Blue Shield of California will cover only equipment rentals. Before the Affordable Care Act, the company assessed requests on a case-by-case basis,  approving only those claims for the situations in which they were deemed medically necessary.

Health-insurance companies have also begun recruiting lactation consultants to join their networks so they can comply with the mandate to cover lactation support and counseling.

In late July, Aetna sent lactation consultants a letter noting that the company was expanding its "network of international board certified lactation consultants" and inviting providers to join.

Some lactation consultants, however, have declined these entreaties, saying that the reimbursement rates insurance companies have offered are significantly lower than  the amount they charge for a consultation.

"We as a company have decided not to sign up as a preferred provider," said Diana West, of Mahala Mom, a lactation consulting company in Northwest New Jersey.

West's consultations, which tend to run between 90 minutes and two hours, cost about $200 depending on the location. Insurance companies have made reimbursement offers that hover around $80, she said.

"This is a very big obstacle that my industry is really abuzz about," she added.

Consumers, too, are still trying to figure out how to take advantage of the new requirement. Leila Abolfazli is a senior counsel at the National Women's Law Center, one of the groups that advocated for the coverage. She gave birth in October and, as she prepared to return to work from maternity leave, called her insurance carrier in December to ask about obtaining a breast pump.

"They said they do cover it with no co-payment but I had to go through a medical supplier," she said.

Two calls to the recommended medical suppliers were dead ends: One did not have the breast pumps, the other said it had not yet signed a contract with the insurer for the  coverage.  

"Our plans started covering this back in August, and I've gotten birth control without a co-payment with no problem," Abolfazli said. "This seems to have been a bit more difficult to implement."