Rationing

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.

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.

Yglesias:

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.

Pics

Link to our pics, updated as we go along:

Ireland

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!

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...

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.

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.

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?).

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.

Idiot.

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.

2 months down...

... and 4 to go in baseball this year. The end of May finds the Sox half a game behind the Yankees in the now-the-universe-is-back-in-order AL east (know your place, Toronto). The Sox are on pace for ~92 wins so on balance there's no need for any one way trips off the Tobin Bridge.

The Good
The Red Sox bullpen has been as good as advertised, with an AL-best 2.96 ERA. Ramon Ramirez, the counterpart in the Coco Crisp trade, has been nearly unhittable, and Manny Delcarmen has become reliable, although Tito has mostly avoided using him in pressure situations. Okajima continues to be effective with his smoke and mirrors, and his countryman Saito has, after a rocky start, settled in nicely to the backup closer role (distinct from the set-up role, which is mostly Okajima and Ramirez). Papelbon has gotten the job done at closer with only a single blown save and an ERA of 2.45, although his peripheral stats haven't been as good as in the past: fewer strikeouts, more guys on base, more pitches per AB. So that's five guys in the pen with ERAs below 3.00, plus a sixth if you count the new guy, Daniel Bard, who really brings the heat. Masterson does a fine job as the swing guy, capable of starting if need be, or pitching multiple innings out of the pen. To call him the long man/mop up guy would really do him a disservice, it is much more a credit to his rubber arm, and he is more than capable of pitching the 8th inning in a one-run game.

The Okay
The Red Sox lineup has its share of hits and misses so far this year. They are third in the AL in OPS and fifth in runs scored, so it isn't like they are anemic, but there is the walking corpse that is David Ortiz, he of the lone home run and 0.185 batting average. There have been no reports of any health issues, so who knows what's wrong with him. The guy most-expected to be a corpse this year, Jason Varitek, has been nicely non-rotting, with 10 HRs and an OPS of 0.849 (last year was 0.672). The meat of the order has been mostly as advertised, with Youkilis continuing to put up MVP-type numbers, his 1.150 OPS behind only Joe Mauer in the AL; Jason Bay with 15 HRs, good for third; Mike Lowell coming back nicely from hip surgery. Pedroia's power numbers are down from last year, but he's still hitting for average and a lot of doubles. Drew has been good, with an 'eh' attached to it, because that's what he does -- he has yet to have a really hot streak. Ellsbury was, appropriately, moved out of leadoff spot for today's game. He's a good ballplayer but he doesn't get on base enough to justify hitting at the top (yeah, he's hitting 0.300, but an OBP of 0.330 is below-average for a leadoff hitter). The SS hole is exactly that, a hole -- Green and Lugo have put up OPS of 0.783 and 0.714, respectively, which I guess classifies as "not horrible" but no better than that.

The Ugly
It'd be a bit simplistic to say the starting pitching has sucked for the Red Sox, only because the defense has largely sucked too, and the two are non-separable. Beckett's top line numbers aren't great, but he had a spectacular May, so the arrow is pointing in the right direction. Lester finally had a good outing today, let's hope it keeps up -- otherwise, he has more or less sucked. Wakefield has been, as always, steady, and he pitched some real gems when the Sox needed it most, coming on nights after the pen was severely taxed. DiceK continues to make me want to blow my brains out, taking forever when he pitches, nibbling, putting a ton of guys on base, same old same old. Of course, last year he was very lucky (low BABIP) and this year he has been very unlucky (high BABIP) and the results show it. Brad Penny has been exactly what you'd expect out of a fifth starter -- with him, the question is do the Sox keep him when Smoltz and/or Buchholz are ready? The former has looked good in several rehab assignments, while the latter has been lights-out in AAA all year.

In sum
The Sox are chugging along with no major needs that can be addressed. That's a good position to be in come June. If Ortiz turns it around then so much the better, although it is not clear to me, or to anyone really, what they do with him if he doesn't. Green and Lugo are a real problem at SS, mostly because of their atrocious defense, but I don't know if Jed Lowrie is the solution (at least he can field okay). I still think they are the favorite to win the AL East.

100% accurate

Coach Dale passes this along:

Good advice?

In the course of emailing a student worrying about her grade for the semester, I wrote something that I think is actually pretty good:

That said, to paraphrase Lyndon Johnson when describing the value of the vice-presidency, GPA is worth a warm bucket of [spit]. I know it is something one worries about when in college, because it is the only barometer one has at the time, but really, it is a very poor predictor of future success. In whatever career you decide to pursue, people will judge you based on the interactions you have with them -- within 5 minutes of meeting you, people of importance will know if you are an idiot or not -- and that judgment is really all that matters. I'm not saying don't try hard to get good grades, but I am saying that it is far more important that you understand the material and, in a broader, why-am-I-in-college-sense, figure out what really gets you intellectually excited. People who don't like their jobs don't feel that way because their job is mentally hard, but rather because it doesn't engage their brain. Likewise, people who do like their jobs don't feel that way because it is as easy as high school, but rather because they're not staring at the clock every day waiting for it to hit quitting time.

Judge Smails continues on medical ethics:

I think I agree with most of what you said about the medical ethics issue. For me, some things your post made me think about: (1) Are we dealing with a born child or a fetus? From the current legal standpoint, a fetus shouldn't really qualify for any protection from society against idiotic parents. So I think that means i agree with you: once we accept that people can abort babies for any reason (including "I don't feel like being pregnant anymore"), then I don't think there's a legal line to be drawn about aborting babies because you don't like their eye color. Similarly, if people want to have "natural" babies, even one's with down's syndrome, it's hard to say no, given that we think they should be able to abort. Of course, this means we have to accept as legit people who want to give their child pre-natal care via prayer only. I think. I think it's much harder with already-born babies, especially when you get to cases in which treatments have possible fatal side effects and "not doing anything" involves no chance of death. So you're taking risks to increase quality of life. I don't know how to think about this. Even worse is when you're dealing with an almost certain possibility of death whether you treat or not, but treating involves horrific pain. Would I get my daughter a bone marrow transplant if it gave her a 5% chance to live and otherwise she dies? I probably would. Could I stomach the government requiring that people do that? No. (2) If we forget the law, and just ask "Given the pro-choice world, what would I counsel my sister to do?" I think the decision largely rests on a cold calculation based on invasivness, probability of disease, and quality of life. I concur with you that in the case of horrific childhood diseases that always result in severe handicap and early death, when the parents know they are carriers, it makes sense to test --- and possibly abort. But that's the easy case. The hard case is when you're just fishing for non-fatal handicaps that don't always severely diminish quality of life, like DS. I don't think you can dismiss the miscarriage rate until you're actually sitting there talking about your own future child. Especially when the miscarriage rate is higher than the probability of having the disease. You're right that technology may wash away this problem soon, but then again, many readers of your blog might be making these decisions later this year. For me, I would personally find it almost impossible to counsel someone to abort a baby simply because it had down's syndrome. In fact, I think I can safely say that I look down upon people who do so. I wouldn't look down on someone who aborted a baby with Angelman's syndrome or something horrific like that, but I'd have a hard time telling them to do it. But that largely has to do with one's opinions of abortion, pro-choice or not. And, of course, I think some cases are just beyond the pale, even though they are highly realistic: If someone told me they were aborting a baby because they wanted the other gender, I'd probably have to stop being friends with the person. (3) What about government action to "force" treatment? To me, this is the most interesting question. We can think of all sorts of things that, if we eliminated them from society, it would just be more efficient. Even dumb things: closest to my heart is left-handedness. If we could just get rid of all the lefties, there'd be a significant economic gain via the synchronization of education and the reduction of highway fatalities. We'll probably be able to eradicate "gay" as well. And from an economic standpoint, there's little reason not to. Still, it's very scary to me to think about the government makign these decisions. It seems inconsistent to say "you can kill the fetus, but if you choose not to kill the fetus, you have to get it this treatment." On the other hand, we require vaccinations to go to the public schools, so why not.

First, a minor point: I ignored the 1% miscarriage risk of amnio only in the context of a 25% chance of a Batten Disease child. Unless you're specifically worried about something, like Batten Disease, Tay Sachs, or you're high risk for something like Downs, the benefits probably don't outweigh the costs. Now, in the context of Down Syndrome, which I believe is one of the more common positive results from an amnio, I do think one's socioeconomic status legitimately plays a role in one's decision to abort. Certainly it helps to be well-off with a strong network of family to help out, and I can't say I'd look down on someone who was worse off if she chose to abort a DS baby.

As for the vaccinations, a very interesting point, but I think there is a difference. From an epidemiology standpoint, there's very little difference to having only some people vaccinated and having no one vaccinated. In other words, one person's refusal to be vaccinated can have a direct negative consequence on the next guy (especially if the next guy is very young or very old) -- it is a bad idea to have anyone in the population carrying the disease, even if for them it isn't lethal, it might be for someone else.

Morning TV

Since I'm driving into work these days, and since I really hate sitting in traffic (how do people do this every day of their lives?), I'm attempting to hang out at home in the mornings until the traffic dies down and then leave for work at about 9am. Likewise I work a little later into the evening, for the same reason. Because of this, and because I know a guy who will be on later in the show, I currently have the Today Show on the teevee. How do people watch this? Today's big story is some girl & mother that were apparently kidnapped in Pennsylvania. So what does the Today Show think will be a good thing to do? Put on the father and ex-husband of the two! And then ask him how he is feeling!

On a side note, I haven't cut my hair in quite some time, to the point where its length would just be described in centimeters instead of millimeters. The wife (Mrs. Disconfirmed?) is a fan of this development, but now that I've seen Matt Lauer and his apparent buzz cut...

But I will say this... the Today Show might be more watchable than Sportscenter, which used to be half an hour long and, you know, gave highlights of sporting events, in much the same way that MTV used to play music videos. Two years ago I turned on Sportscenter while on vacation and they were earnestly debating which of two atheletes was more now.

The answer is D

Coach Dale sends along this link to a poll, asking how many millions are in a trillion.  Go read the comments.  Really.  You will laugh, a lot, at the numberical idiocy.

Funny Balls

I like this picture, which ran alongside a "News & Views" in Nature Reviews Cancer this month.  If (and I emphasize the if) this picture has any relation to the story that it is next to, then the light blue ball with a "black" (green) eye is "mutant FGFR3" while the smirking purple ball is "phage-displayed inhibitory antibody."  Presumably the light ball is angry because he is no longer causing cancer in mouse xenograft models.

Judge Smails writes in:

I agree with you that anyone who withholds medical care from a child is doing something seriously wrong. And while I generally think that any radical ideology --- not just religious ones --- can produce these kinds of mentalities, i think there's a much more interesting question in all this. Namely, how much discretion should parents have in the medical treatment/non-treatment of their children? I experienced this first hand when [my wife] was pregnant with [my child]. We were at one of the first checkups and the doctors asked us if we wanted to have the test done for down's syndrome. I asked if it was invasive and they said yes (it's an amnio test that has something like a 1% of complications or miscarriage). So I then asked what good could come from finding out if the baby had down's syndrome. They hemmed and hawed until I determined that what we were really talking about was abortion. I told them that I thought aborting a DS child was disgusting, and that we would pass. They then threw in the (more reasonable) possibility that we might just like to know ahead of time, such that we could prepare ourselves mentally for a DS child. But to me it was a no-brainer, I'm not taking a 1% chance of miscarriage just so I can be better prepared for some unlikely outcome like that. We politely declined. But here's the thing: what if something could be done? What if, 10 years from now, they can "fix" down's syndrome pre-natally? That might change things for me. On the other hand, I'd still be queasy about doing a test with a 1% miscarriage rate, just on the miniscule chance that the baby has DS. I'd feel even more queasy about looking down on parents who chose not to have the test and ended up with DS child, and even more queasy about a government regulation that required you to get the test.

This is a topic I've been thinking about quite a bit lately, both as part of the on-going health care debate and as part of the genetics class I taught this past semester, in which each student had to research a genetic disease. Does the severity of the disease, at some point, compel the government to step in? Does a government that is paying for the health care have a right to step in? I think we'd all agree that, in terms of children, the rights of parents are not infinite, and the rights -- or perhaps, obligations -- of government are not zero. In the near future, it will be feasible for people of even modest means to get a genetic profile -- maybe not an entire profile, but certainly sequenced for known disease-causing alleles that could be passed on to an offspring.

Let's say that both parents learn that they are carriers for the recessive gene for Batten Disease, a truly horrific juvenille-onset neurodegenerative disorder. The affected are blind by age 10, start showing mental decline by age 15, and are dead by age 25. So what options to these parents have? First is to do pre-implantation testing -- take eggs from mom (hardly a simple or cheap proceedure) and sperm from dad (dads always have it easier), fertilize in vitro, screen out embryos that received a disease gene from both parents (1/4 of them) and then implant some of the good embryos into mom. This would be quite an expensive and laborious proceedure, and I don't really see the cost coming down any time soon.

The other, much cheaper option for these parents would be to get pregnant the usual way and then test the fetus -- and just for the purpose of clarity, I'm going to ignore the slight increase in miscarriage, because I'm more interested in the ehtical debate rather than limitations of current medical technology. There's a 1/4 chance the fetus would test positive for Batten Disease. If there's a positive, have the baby, or have an abortion? I'd opt for an abortion. Perhaps this is another way of saying that I don't see much of a difference between a newly-fertilized egg in a tube and a 3 month-old fetus.

But the waters get murkier when we're talking about less "in-your-face" diseases. Hemophilia? Increased risk of skin cancer at age 60? Attached ear lobe? At some point even the most science-minded, cold-hearted of us will say no, you probably should not have an abortion to avoid a child who cannot roll his tongue. Of course, when I say that, it is not because I've suddenly become squeemish about abortion -- being pro-choice and all -- but rather that the cost of an abortion (risk to the mother, financial cost, etc.) are not outweighed by selecting one genetic variant over another.

I do not think the government should play the role of arbiter and prevent this woman from having an abortion, just as I do not think the government should enforce the abortion of a Batten Disease child -- actually, my logic runs in the reverse: because I think the government should not enforce the Batten abortion, it then follows that the government should not prevent the tongue-roll abortion, no matter how silly I regard the latter.

I suppose this is the cost of a free society, namely that others around you are going to draw lines at wildly different places than you do. One approach would be to say that's fine, you make your decisions and I'll make mine. The second approach would be to villify those who draw their line far away from your line and attempt to use the power of government to make your line the legal standard. I obviously put "reproductive issues" in the first basket, but I also put a heckuva lot of things in the second basket: through the last century -- voting rights for women, civil rights for blacks, environmental regulations for industry, marriage rights for gays. I'll ponder my apparent ideological inconsistency and let you know if I come up with anything.

Perhaps when it is all said and done I'll provide some of my thoughts on the American health care system, as least as I've experienced it over the past 10 days, but in the meantime one story I've been following (and things like this crop up every now and again) centers on some religious nut who killed her child by refusing medical care. Pharyngula has the whole story, and concludes with this jeremiad:

These are cases of religion gone pathological, of belief so absurd and so deep that it denies truth and has overt negative consequences. Moderate Christian believers will read about this and dismiss it as irrelevant to their faith; sure, they'd pray, but they'd also get their children in to legitimate doctors who would give them effective treatment. I have to say something that is heartfelt, and is also meant to offend. I do not absolve you mealy-mouthed moderates, I do not regard your beliefs as harmless. If Colleen Hauser or Leilani Neumann were in your church, you'd tell them to get medical care, but you'd also validate their belief in prayers. You would provide the soothing background muzak that says prayer is good, prayer is virtuous, prayer will connect you to the great lord who can do anything, prayer will give you solace in your time of worry. You would not raise your voice to say that prayer is useless, prayer is self-defeating, that while prayer might make you feel better while your child is suffering, that is no virtue. You pray yourselves. You think it is a noble and generous act for your representatives to prowl the corridors of hospitals, preying on the desperation of the sick. You abase yourselves before false hopes, and sacrifice human dignity on an altar built from the bones of the dead. You would spread the poison, piously excusing yourselves because you only want to administer sub-lethal doses.

Mighty chondria

Rachael Alexander won the Preakness today, not quite the impressive win that she had in the Kentucky Oaks, but she was running against better horses this time around, and she led wire to wire. As a reminder, a female horse is a 'filly' when she's 4 years old or younger and a 'mare' from then on, while a male 4 years old or younger is a 'colt' and then becomes a 'stallion' assuming his balls are still intact (and known as a gelding if they're not). When horses breed, 'sire' is the father and 'dam' is the mother.

The reason I was thinking about this is that it is rare for fillies to race, and even more rare for them to win big races going up against colts, because in general, colts are bigger, faster, and stronger. But from a horse breeding perspective, which is where a lot of the money comes from, I'd think that there should be huge demand for a fast filly: all mitochondria are maternally inherited, and mitochondria play a major role in energy production.

Certainly, there are benefits to having your breeding driven largely by males -- there's a much higher throughput if your impregnating rather than being impregnated. But having a proven dam passing on her mitochondria could give a substantial boost.