Tuesday, June 30, 2009


Judge Smails sends in a quote from a recent column that I also found to be useful:
With no comment on the merits of the article, I thought Michael Kinsley provided a nice practical definition here (in comparison to the relatively useless fear-mongering vs. everything is already rationed debate):
Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

I like it, because it sets up an easy to consider metric while also allowing that some rationing is reasonable (most people expect the President to get modestly better care than themselves).

We all know that health care rationing already occurs to a high degree in this country -- wealthy people can afford better care. Some of this occurs because they actually pay more for a nicer room with no roommate for their hospital stay. But, some of it is more structural -- Boston is a nice city to live in with a lot going on, so lots of people want to live here, so housing is expensive. One of the 'things going on' in Boston is Harvard Medical School, so there are a lot of highly skilled doctors around, so all things being equal, you're better off getting hit by a car here than in Topeka. I can't find a good citation for it, but I've heard time and again that one predictor of cancer survival is how far you travel for treatment -- you're going to get much better treatment, with newer imaging and access to clinical trials, if you happen to be near a major cancer center. So if you live in Nebraska and have little means of traveling far, you're kinda screwed.

PS Back in the States; Ireland was great.

Thursday, June 25, 2009

Fraudulent Costs

I find it amusing that the Google ads have changed based on my overseas IP address. Several have assumed that I'm traveling abroad in search of an abortion. Huh.

Anyway, Judge Smails writes in:
Heard an interesting anti-public option argument today. I like the idea of public-private competition, so don't take this as me on some sort of crusade. I just thought it was a pretty solid argument against the public option:

Private insurance firms work on a profit-system. This allegedly has many good benefits (i.e. competition reduces prices). But it also has at least one bad side effect in the health insurance industry: firms seek to make more profit in part by getting out of paying claims. Indeed, this is a major complaint of many people --- their insurance company fought them over paying out for things they were supposed to pay for. In theory, a public option that had no profit-motive wouldn't worry nearly as much about such things; there would be no profit to be gained by aggressively denying claims.

However, there is a flip-side to this coin. Private firms that aggressively fight paying out claims in order to make more profits are also likely to aggressively fight fraudulent claims, since those claims would also undermine profits. Conversely, a public option that has no profit-motive will have less incentive to fight fraudulent claims. So we should expect that the public option will be burdened with a higher-level of deadweight loss due to fraud. And indeed, Medicare fraud is a serious problem that costs billions of dollars.

Thought it was an interesting argument. It's not a damning argument against the public option idea, but it does raise one legitimate negative that makes sense to me.

This is the first time I've heard of Medicare fraud being a particular problem (who is getting the extra dough? It can't be the patients, so, doctors? hospitals?) but I'll take that as a given for the purposes of this post. There are at least two replies to defend the honor of a public system.

First, even though a public option would be a non-profit, it doesn't follow that it would be less concerned about fraud, any more than any other non-profit doesn't need to keep an eye on the bottom line (assuming that the public option doesn't have access to limitless subsidies, which is an argument for another time, but certainly I'm hoping that it doesn't). Faced with fraud, a private insurer can either recoup the cost by decreasing profits, decreasing care, or trying to limit fraud. The public plan would have only two of those three avenues open, and I don't think it necessarily follows that the tolerate-fraud-decrease-care would be the default position.

Second, I think the main attraction of the public option is the competition aspect of it. Private insurers keep their costs down by denying claims, but raise costs by making a profit. The public option can have higher costs (i.e. giving more care) because it doesn't have a profit motive. So even if the public option were burdened by fraud above and beyond a private plan it could still be competitive.

Looks like Obama is really starting to put some weight behind this. Krugman and Yglesias have made been arguing the point, however, that Obama seems to run to the middle too early. Krugman:
My big fear about Obama has always been not that he doesn’t understand the issues, but that his urge to compromise — his vision of himself as a politician who transcends the old partisan divisions — will lead him to negotiate with himself, and give away far too much. He did that on the stimulus bill, where he offered an inadequate plan in order to win bipartisan support, then got nothing in return — and was forced to reduce the plan further so that Susan Collins could claim her pound of flesh.

Framing effects are important in politics. The public-private competition is supposed to be a compromise between the pristine vision of single-payer and the desire of private insurers not to be put out of business. It creates a situation in which insurers are challenged to prove that single-payer advocates are wrong, rather than simply assert it. But with no single-payer plan in the mix, this gets lost, and the compromise becomes the leftmost anchor of the debate. A single-payer plan couldn’t possibly have passed, but I think having hearings on single-payer and having one committee draft a serious single-payer bill that gets a serious CBO score would have been a useful exercise. In particular, it would have focused the mind on the costs involved in rejecting this option.

Conference summary

Captain Ahab, also traveling abroad at a conference, passes on this quote from David Lodges. Yeah, this is pretty much where I'm at right now:
But the real source of depression, as the conferees gathered for the sherry, and squinted at the little white cardboard lapel badges on which each person's name, and university, were neatly printed, was the paucity and, it must be said, the generally undistinguished quality of their numbers. Within a very short time they had established that none of the stars of the profession was in residence--no one, indeed, whom it would be worth traveling ten miles to meet, let alone the hundreds that many had covered...Long before it was all over they would have sickened of each other's company, exhausted all topics of conversation, used up all congenial seating arrangements at table, and succumbed to the familiar conference syndrome of bad breath, coated tongue and persistent headache, that came from smoking, drinking and talking five times as much as normal.

Sunday, June 21, 2009


Link to our pics, updated as we go along:

Saturday, June 20, 2009

Somerville Named All America City!

Beyond the fact that it offends my grammar sensibilities (shouldn't it be All American?), Somerville shouldn't get too happy because Utica is also an All America City...

Irish Dispatch I

Two notes from day 1 in the Emerald Isle...
1) Pick up the rental car, fortunately at 7am on a Saturday so the roads were empty while we got used to driving on the left, and turn on the radio. First thing we hear... Tom Brady is expecting a baby with Giselle. I should note that we're even in the actual Beyond the Pale section of the country.

2) On Friday the 19th I woke up at 7am, got on a plane at 7pm, arrived in Ireland at 6am local time on the 20th (all the while not sleeping on the plane while confirming that the sun never set during our flight), drove around the country all day, and now it is 8:30 pm local time. But since I've also traveled north ~10 degrees of longitude, and it is the 2nd longest day of the year, 8:30 pm local looks like ~6pm -- i.e. the sun is still hours away from setting. In conclusion, I've been awake for about 33 consecutive hours, and probably won't fall asleep for another few. All things being equal, I actually feel pretty okay.

Oh, third note as well. Maggie, the only regrettable character from Caddyshack, asserts that Lacy Underalls has been plucked more times than the rose of Tralee. I was in Tralee today. First, they have a very nice rose garden. Second, The Rose of Tralee is a title bestowed upon a local girl in a beauty paegant each year. So I got that going for me...

Western Ireland is unbelievable, by the way. Gorgeous. And it was sunny all day!

Thursday, June 18, 2009

Is that for serious?

I like Nate Silver, he's a good blogger who's really good at crunching numbers, and he's on-the-ball when people try to push bad statistics on the public. But this statement, which as far as I can tell was said in all seriousness, is just dumb:
But the Congress is never a popular institution, and with Ted Kennedy ailing and Hillary Clinton heading the State Department, the Democrats are notably lacking the sorts of charismatic leaders who know how to pitch legislation to the public.

Yes, if only Ted Kennedy were showing up on TV more often, then we'd have a health care bill worth voting for...

Free market fail

As you may have noticed, I'm not a huge believer in all the promises of the free market. Don't get me wrong, I believe that competition is a good thing and I don't believe in the ability of governments to engineer away problems, but I think that self-interested, irrational humans won't always arrive at the optimal result (see: Wall Street) and that there are some aspects of society that shouldn't be subject to the free market (like roads and, in my opinion, health care).

Interesting story in the Boston Globe today, noting that Genzyme, the largest biotech company in the commonwealth, recently discovered that a vat of CHO cells used to make a drug was contaminated with a virus. As a result, there won't be enough Cerezyme to treat patients with Gaucher's disease (no, I had never heard of either of them).

Admittedly, this is a few degrees away from the current health care debate, but this is a great example of where the free market fails in delivering health care. I highly doubt that the various private insurers have made sure to have back-up supplies of Cerezyme lest their two or three patients who have Gaucher's disease drop dead before Genzyme gets back up and running -- why would it be in their financial interest to waste money on storing back-ups for a variety of drugs? Or, to put another way, please note that, for the next few months, in the absence of a public health care option, Cerezyme will now be rationed by a private pharmaceutical company to private insurers...

Friday, June 12, 2009

All your amplification needs

In a nicely-timed post, Damn Good Technician just happened to recommend a polymerase for amplification from genomic DNA, KOD polymerase from EMD. I had never heard of this polymerase, but I have recently become quite familiar with the fact that Phusion polymerase (Pfu fused to a dsDNA binding protein) from NEB/Finnzyme really sucks for amplification from gDNA. I know it is the enzyme itself that sucks because (after several rounds of troubleshooting that, naturally, assumed other things were the problem) I compared Phusion to regular old Taq -- Taq did them all, Phusion did none (oddly, Phusion worked on one when the template was a BAC, so I guess there is something about the complexity of the gDNA, or at least the relatively rarity of primer/template complexes that Phusion can't handle).

Since it is a Friday and I am impatient, I'm not going to wait for my KOD to arrive sometime next week, so I'm going to try a few rounds of Taq amplfication and use that as substrate for the Phusion, hoping that once Taq 'gets it started' Phusion can take over from there.

Thursday, June 11, 2009

Health Care: probably solved by the end of this post

Judge Smails continues:
I think we actually agree on most of what is being discussed here. I would quibble with your comments, but I'd rather talk about this:

But health care is not a business, it is a basic human right -- it is promoting the general welfare -- and it is the government's job to take care of everyone in this regard.

I don't know if agree with this or not as a normative statement. But as a positive description of the U.S., it's clearly not true. Health care is a massive business right now, for better and worse. I think it's undeniable that drug innovation in the U.S. is driven in part by the opportunity for capitalistic wealth. And we know lots of people are getting rich in the health care fields right now. It's also true that people are willing to spend hundreds of thousands of dollars (and years of their lives) to become practitioners. Some are purely noble; I think a lot also want to make 300k/year and drive a BMW.

From my seat, however, this is mostly important because it means the politics of health care will be, at least in part, the politics of big business. You seemed aghast earlier today that the AMA would be self-interested and trying to protect it's own. But that seems perfectly natural to me --- I don't seem the AMA as any different than the tobacco lobby or the UAW. To think of people as anything but self-interested (as you seem to think of the bio-tech world) is utterly foreign to me, at least in the world of politics. The doctors are [sic -- aren't?] bad people, they just see their BMW's potentially being traded in for Honda Accords, and they don't like that.

That doesn't make them right. But it does tend to reduce the politics of health care to something like a big version of any kind of politics. However much you (or I) wish we were fighting out the civil rights movement here, we're not. We're fighting over traditional interest-group politics: who gets what and how many zeroes are on the end of the number.

The Judge is right that we do agree quite a bit about this issue. But I think proponents of reform would be unwise to ignore the language of rights and to instead focus entirely on the economics. Surely, the budget picture is how you scare some people into action, but the what-kind-of-society-are-we language is also necessary for building the popular will for reform. And I'm not just saying that as an organizing strategy, but rather because I believe it. By any measure our health care system is bad for all but the most privledged, and I think that's wrong. I'm sure there were economic arguments to be made about various other civil rights issues in the past (as Colbert once joked, segregation was a real boon to the water fountain industry) but the language of dollar signs isn't nearly as powerful -- indeed, I don't think you'll see gays arguing that they should be allowed to be married in state X because there appear to be some economic benefits to states that allow gay marriage.

Relatedly, Ms. McGee furthers by adding more about that New Yorker article I mentioned:
more health testing and more expensive tests, more surgery, does not necessarily equal better health care. In the New Yorker two weeks ago there was an article by a Dr. comparing health care in several different areas of the country, some that have the lowest per capita medicare spending and some that have the highest per capita medicare spending. Guess what, there were no differences in patient outcome or quality of hospital or anything else that functionally matters to people. The thing that was different was in the high cost areas the Drs. are profit-driven, they get trained to do ultrasounds, by an ultrasound machine for their office, and then recommend that their patients get more ultrasounds so they can get billed for it. They also prescribe more home health care visits by home health care aids while telling the home health care agencies that if they pay them 100,000 a year in consulting fees they will send their patients to them.

The low cost areas pool all the $$ earned by all the Drs and then pay all the Drs. a salary. Excess $$ goes to research in comparing and improving treatments, buying equipment, and having a well-trained staff. Another low cost area agreed that all the Drs. would be paid the same fees regardless if the patient was medicare, medicaid, or private insurance. They also had a committee to evaluate patient charts to find out look at poor prevention practices, unnecessary surgery etc.

It seems to me like the biggest innovations are occurring in places where we are trying NOT to let the market/private insurers drive innovations. Its amazing that health costs have sky rocketed over the last decades when people in general have picked up healthier habits, like not smoking. So many of our innovations don't come with rigorous analysis of when to use them and when not to, so if you make a machine that does X, the company that makes that machine is going to find every way that you could possibly use machine X. Then if the Drs. get paid every time they use machine X, GREED will tell them to use it a lot regardless of whether it improves the health of people.
I don't have a problem with people making money -- hell, my former and current advisors have both done very well for themselves in the biotech industry, and I don't begrudge them a cent for it. But they clearly didn't get into biology for the dough, they got into it because they are nerds, and they certainly didn't get into it for the dough while saying they were in it to help people.

I think that's my problem with the AMA -- as an organization representing doctors (rather than, say, pipe fitters) -- is that they'll deny it is about the money and instead spin stories about how it'll harm their patients. Considering the rather exalted station doctors have in our society, and the exalted station they often have in their own minds, I think they should be held to a higher standard (call it the special license plate theory of organized labor or something). Since we'd never tolerate an individual doctor lying to an individual patient (yet we're fine with car dealers just making crap up, in fact, we expect it), I don't see why it is okay for a collection of doctors to lie to a collection of patients.

On Private v. Public

Judge Smails writes in:

It seems to me there are only two reasons to favor a public plan that competes with the private plans. Either:

(A) you think that both public plans and private plans have advantages, and setting them in competition can enhance these advantages; or

(B) you really want a single-payer plan, but you know it's not politically viable, so you think this is a route toward that.

Obviously, (B) is just political strategy. Set that aside.

The problem I see with (A) is not on the merits. Public plans have certain advantages (market share bargaining, for one); private plans have other advantages (a profit motive for innovation in management, for one). In theory, making them compete could get both of them to perform better, and derive the benefits of each type.

The problem is that, if not structured perfectly, we could end up in an equilibrium in which either everyone went to the public plan or everyone went to the private plan. At first glance, that seems like a win: the market let people decide, and the market scored the outcome. But if the market scores for the private plans, then the public plan will undoubtedly be subsidized by tax money to stay afloat. It will be too big (economically and politically) to fail. Which just makes it GM vs. Ford, with all the negative consequences.

And if the public plan wins, then we effectively end up with single-payer, which might be better for any individual, but is a net loss for society because we lose out on the innovation that comes in hand with profit-driven greed, as well as the ability of private plans to keep the public plan in check when it starts doing things that only work in a monopoly (rationing treatment, etc.).

If you really believe that public and private plans offer unqiue advantages, and that putting them in competition yields another advantage, then having one win out over the other is not really a victory for consumers or taxpayers. It's a market failure. Public or private, a monopoly will reduce the long-term benefit of the system.

I'm not sure I agree with all this. First, the supposition that if the private plan wins then the public plan will undoubtedly be subsidized by taxes is misleading in that private plans are currently subsidized by taxes and other indirect costs. Private plans don't cover everyone, so a lot of uninsured people get treated by hospitals, which pay that cost. Likewise, the government is already subsidizing many people's health care, via Medicare & the VA system.

But I really don't agree with the idea that greed leads to innovation, certainly not in health care, and probably not as a general concept. I'm not saying that greed can't or doesn't lead to innovation, but rather that a lot of other motivations do too (and probably lead to better innovation: I mean, just look at the three-card-monty that was Wall Street over the past however many years -- sure, there was a lot of greed-driven "innovation," but it was all crap). I can't imagine that armies of scientists and doctors are suddenly going to leave the bench and bedside, or just stop trying as hard, should there be a public health care option. Speaking both personally and for a lot of scientists who work in various biotech-related fields, we're not in it for the money (if we were, we'd have chosen our careers quite poorly).

Also, Judge Smails seems to imply that the free market of public vs. private will inevitably produce a winner and then we'll be stuck with someone having a monopoly. Not sure I buy this, but I certainly don't buy the notion that only in this scenario will we be rationing care. We already ration care, quite blatantly! I've never had a whole-body PET scan, I've never had my genome sequenced, I've never been tested for all sorts of rare metabolic disorders that could strike a 31 year old male at any minute.

In sum, I don't want a single-payer system. I want to see a public system that can compete against a private system, and in doing so prove itself. If the result of that is a single-payer system then I am fine with the outcome, because only because it resulted from the appropriate experiment. My hypothesis is that health care isn't like buying a new cell phone, and thus standard free-market assumptions do not apply.

We talk about the moral hazard of the government bailing out GM & banks & such, and many of us get upset because we think they should be allowed to fail -- or perhaps better said, they should have been prevented from getting so large that they could fail without ruining many innocent bystanders in the process. But health care is not a business, it is a basic human right -- it is promoting the general welfare -- and it is the government's job to take care of everyone in this regard.

Trickle down costs

From today's New York Times, the American Medical Association comes out against a public option:
But in comments submitted to the Senate Finance Committee, the American Medical Association said: “The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”

The first sentence is a bit weird, as on its face it seems to imply that a public option is actually really good idea for people over than 65, but if that is true, then why isn't it a good idea for those under 65? Of course, the AMA knows that Medicare is popular so they don't want to piss on it, but the statement itself is a bit odd.

But the second sentence is just bizarre, partly because there are two ways to read it. First, a public plan would restrict patient choice of insurers by driving out private insurers. Since most people don't really have a choice of insurers anyway, this doesn't really make any sense -- in other words, I'm insured by whomever Harvard says I'll be insured by, I don't have any say in the matter. The second way of reading the sentence takes the more common usage of "patient choice" meaning "patient choice of doctor." But this doesn't make any sense either -- why would a public plan necessarily lead to decreased physician options? There will be limits if lawmakers write in limits, and there won't be if they don't. But I don't see how a private insurance scheme automatically leads to greater patient choice than a public one.

And, of course, what goes unsaid is why there's a threat of a public plan "driving out private insurers." Perhaps because it is hard for a non-profit to compete with a for-profit, because the non-profit isn't paying executives obscene amounts of money? For example, the CEO of Blue Cross Blue Shield Massachusetts was paid $4.3 million dollars last year. Considering that there are about 3 million people in MA covered by Blue Cross, that's over a dollar per person just to pay the damn CEO (while a dollar doesn't seem like that much, notice how ape-shit people go when there's talk of funding some million dollar program that will cost each state resident pennies).

Peter Orszag, Obama's budget guru, has recently been citing a much-read (and highly-recommended) New Yorker article by Atul Gawande from a few weeks back (who, I now realize, works across the street from me). Essentially, the article looks at health care costs in various places and comes to the conclusion that health care costs more in places where doctors make a lot of money (and that costs have no relation to results -- the Mayo clinic is held up as an example of high quality care delivered at low cost). So when the AMA comes out against a public option, just remember where their bread is buttered.

Tuesday, June 9, 2009

Health Care Wars

Since there are no major celebrity scandals, pirates, multiple-birth mothers, plane crashes, natural disasters, or any of the other things that news organizations would rather cover than actual news, health care is receiving a lot of attention lately, as it appears that Congress might actually attempt to do something about it.

People who report on The White House report that Obama is taking a more active role in lobbying Congress than he did for, say, the stimulus package, in terms of crafting the structure of the legislation. From my perspective, Obama hasn't really used the bully pulpit of the Presidency in terms of directing legislative progress -- we'll see if that changes when it comes to health care. I hope it does.

My basic thought is that we desperately need a public option, as it is the only way we can hope to curtail costs in the long run. The system as currently constituted does not provide the proper incentives for private insurers to actually deliver high quality, low-cost health care to the masses. Essentially the only objection I've heard about the public option is that private insurers won't be able to compete on a cost/quality basis. Um, fine, then they either improve or go out of business (I mean, that's the free market, right?).

Friday, June 5, 2009

Idiot watch: academic edition

In my mind I have the feeling that Greg Mankiw, a professor of economics at Harvard, is an idiot. I'm not sure exactly why I think that, so won't state as fact that he is an idiot, but just know that the thought was already in the back of my mind when I read this 'thought' of his (via Andrew Sullivan), ruminating about a public option for health care:
Would the public plan have access to taxpayer funds unavailable to private plans?

If the answer is yes, then the public plan would not offer honest competition to private plans. The taxpayer subsidies would tilt the playing field in favor of the public plan. In this case, the whole idea of a public option seems to be a disingenuous route toward a single-payer system, which many on the left favor but recognize is a political nonstarter.

But, Greg, it is the private insurers who are currently receiving giant taxpayer subsidies in the form of Medicare. The majority of people who are old -- i.e. the ones who cost by far the most -- are paid for by the gub'ment. So if you want private insurance to compete on an equal playing field, then they too need to take all comers and not drop them when they change jobs or retire.


Tuesday, June 2, 2009

Sweet shirt

The customer reviews for this hideous shirt has taken on a life of its own on Amazon. My favorite review:
Recently, my girlfriend asked me to meet her parents. I was hesitant at first, and declined the offer for a couple of months. Finally, she wore me down and got me to agree. Her parents are rich enough to own Bill Gates, and they insisted that we go to some nice steak restaurant. Despite her objections, I wore this shirt.

The first thing her father noticed on me was this shirt and, upon shaking my hand, he started to call me son. As soon as we sat down, he wrote me a check for 100,000 dollars and told me to call him if I ever needed anything, and her beautiful mother began rubbing my leg in a not unpleasent way.

Half way through the dinner, a man collapsed at the table next to us. I jumped to my feet and assessed the situation. I discovered that he was choking on a rather large piece of steak. Now I have no medical training, but the shirt showed me how to save this man's life. And I did.

So grateful for my actions, the man paid for my dinner and gave me the keys to his new corvette outside. Then the waiters all gave me their tips, winking at me and mouthing "nice shirt."

Later that night, my girlfriend couldn't keep her hands off of me. She wanted me. Being no fool, I kept the shirt on. She said the pleasure was so intense she forgot her own name for a minute. We're getting married next week, and I haven't taken the shirt off since.

Only downside: I turn into a werewolf on full moon nights when I wear the shirt. And I occasionally wake up to Carlos Mencia singing in my bathroom. Be warned.