LOL manuscripts

Came across this passage in Sarah Vowell's latest effort about New England Puritans, The Wordy Shipmates, which reminded me of some of yesterday's posts:

Protestantism's evolution away from hierarchy and authority has enormous consequences for America and the world. On the one hand, the democritization of religion runs parallel to political democritization. The king of England, questioning the pope, inspires English subjects to question the king and his Anglican bishops. Such dissent is backed up by a Bible full of handy Scripture arguing for arguing with one's king. This is the root of self-government in the English-speaking world. On the other hand, Protestantism's shedding away of authority, as evidenced by my mother's proclamation that I needn't go to church or listen to a preacher to achieve salvation, inspires self-reliance -- along with a dangerous disregard for expertise. So the impulse that leads to democracy can also be the downside of democracy -- namely, a suspicion of people who know what they are talking about. It's why in U.S. presidential elections the American people will elect a wisecracking good ol' boy who's fun in a malt shop instead of a serious thinker who actually knows some of the pompous, brainy stuff that might actually get fewer people laid off or killed.

#49

For whatever reason, Tim Wakefield has long been my favorite Red Sox player. Actually, strike that, it makes a lot of sense -- he's been a Red Sox for almost as long as I've been a fan. He'll hopefully appear in the All Star game tomorrow night, and today the Globe ran a nice story about him. I'll never forget his call-up with the Sox in 1995; as Wikipedia notes, "He began the season with a 1.65 ERA and a 14-1 record through 17 games - 6 of which were complete games."

Hey, they are the 100 best & brightest, right?

A Newsweek story reporting that AG Eric Holder might appoint a special prosecutor to look at Bush-era war crimes opines:

Such a decision would roil the country, would likely plunge Washington into a new round of partisan warfare, and could even imperil Obama's domestic priorities, including health care and energy reform.

I think this is totally wrong. First, we've already achieved essentially-maximal partisan warfare, whereby Republicans vote in lock-step against whatever the Democrats try to do. And it is not like the various apparatachiks (no, I can't spell that) to the two parties behave civilly when appearing on TV and radio. So how in the hell would this imperil any of Obama's priorities? Sure, Hannity will have something new to bitch about, but it is not like the inability of the news media to cover more than one story at a time will prevent the US Congress from putting legislation through the sausage grinder.

I suppose one could argue that this could be damaging to Obama's priorities if there's a vast anti-Obama backlash should the AG appoint a prosecutor, which would then give some 'centrist' Senators cover to vote against Obama... BUT they already do that! There are plenty of 'centrists' who are going to require a lot of cajoling (read: legal bribing) before they get on board with various pieces of legislation. And there are plenty of Republican Senators from states Obama carried who haven't even attempted to move left after '08 (e.g. North Carolina, Indiana, Maine). So while the newsmedia may be derailed in their ability to spout uninformed opinions on health care because they are too busy spouting uninformed opinions on Bush's war crimes, I think the Senate is more than capable of multi-tasking and screwing up many pieces of legislation no matter what the AG is doing.

History Lesson

Judge Smails provides some important historical background. To this I'll only add what The Votemaster often says: in politics, a week is a long time.

You wrote: Honestly, I don't think the identity of the Republican nominee matters a whit -- the election will be 100% a referendum on Obama. If we have been attacked by terrorists, he loses. If we haven't been attacked by terrorists and the economy is still in the shitter, he loses. Otherwise, he wins. I agree, in general, with the first sentence --- an incumbent Presidential election is usually a referendum on his policies (1996 might be an exception). The second sentence, however, strikes me as a bit off-center, for two reasons: (1) I think a terrorist attack --- especially one that happens soon (say, in the next 6-12 months) --- would not hurt the Democrats as much as is popularly perceived. My guess would be that another major terrorist attack would demolish what's left of the civil libertarian element in America, on both left and right, rather than demolish the Obama coalition. Besides, he's already strongly in the right-wing of the Democratic party on the issue, and he can't be that far from the center of the Republican party. (I know it hurts liberal ears to hear/say that, but rendition/indefinite dention/state secrets/military tribunals/enhanced interrogation,etc.) That may or may not be bad for America (I would say it is), but I'm pretty sure it's not a disaster for Obama's electoral colation. (2) More importantly, events matter. Presidential elections are hugely contingent, and 4 years is a lifetime in politics. I would say that the 2008 election was a massive historical exception, in the sense that it truly felt like a rematch of the same two basic coalitions from 2004, with changes in public opinion but few intervening events. Go back beyond that, and I can't find an election in my lifetime (except perhaps 1988) that wasn't strongly structured by events that were impossible to see during the first-year of the previous term (where we are now). 1980 election: In summer 1977, the Afghanistan invasion and the Iranian revolution / hostage crisis had not yet happened, nor had the stagflation hit its peak yet. 1984 election: In summer 1981, the economy was still getting worse. The recovery and boom of 1983/1984 were not particularly expected. Nor was the massive re-opening of the arms race. 1988 election: In summer 1985, the crack (non-)epidemic had yet to explode. Same with Challenger. And Iran-Contra. And the Reagan-Congress deals on immigration and tax reform. 1992 election: In summer 1989, the fall of the Soviet union had not happened, Germany was not reunified, we hadn't fought a war in the Middle East, and there was no recession on the horizon. 1996 election: In summer 1993, health care was going to pass, the Democrats would always control Congress, and who the hell thought anyone would ever shut down the government? 2000 election: I never thought in summer 1997 I would see a President impeached in my lifetime. 2004 election: Remember what a big deal Bush's stem cell speech was in August 2001? People were actually talking about that like it would affect the 2004 election. Anyway, my point is not to take on the underlying structure you present: the public perception of the President's handling of the economy, as you point to, is a basically contigent event taht will always be an important factor. Same with the incumbent President's perceived ability to defend the nation and pass his highest-priority policies. But my guess is that at least a few of the main issues of the 2012 election are things we have yet to ponder seriously as possible election issues. I mean, who cares about terrorism and the economy if Pakistan and India start a nuclear war that results in Chinese imperalist invasions in South Asia? And if that sounds far-fetched, go reread the list above.

Gosh it's hot

Back from NY. Judge Smails continues the climate discussion:

Let me press you on your central point: What percentage of your personal salary would you be willing to give up to ensure that none of these three things happened? I'm not willing to cut every American's standard of living by 80% to save New Orleans, and I doubt you are either. So there's clearly a number. That is, after all, the question we're asking here. I don't disagree that it's tough to price these things, but I do agree with Manzi that at some price point it becomes no worth it to save the polar bears. Of course, you correctly point out that there's a brick wall at the end of all this, because of course we can't really price out human extinction. But that again goes to Manzi's point: human extinction due to climate change isn't necessarily coming for hundreds of years. What proportion of your personal wealth are you willing to fork over now such that your great-great-great-great-grandkids may survive? The answer isn't obvious to me, but I know it's not 80% (or whatever).

But here's the problem... we're not talking anything close to 80% (I know the Judge is just throwing out an extreme number). And if everyone had to give up, say, 10% of their salary, then prices for things would drop, and probably more importantly, we wouldn't feel poorer, because one's relative place in the economic ladder wouldn't change. Certainly one can argue about how much various countries are sacrificing, but right now we're the world's worst offenders, so it seems silly to suggest that we do nothing now because later China and India might be worse than us.

Smails counters:

Perhaps that's right --- I don't know enough about economics to understand the deflationary aspects of massive taxation, although I suspect it's not quite the same as everyone literally burning 10% of their cash. We wouldn't be taking the money out of the system. But surely your larger point is correct --- we're not talking 80%, because if that's what it will take, we're probably doomed. But it does raise another key question: is the amount of sacrifice required too demanding for a democratic society? That is, is it possible to put the necessary costs on the public prior to truly impending doom? You watch things like Waxman-Markey develop, and you get scared the answer is no. It's the classic problem of democracies as a form of government --- long-term planning that requires sacrifice is almost impossible.

The last point is perhaps the most crucial. But there have been points in our history where sacrifice was possible, most notably WWII. Another point could have been 9/11, but instead of saying, jeez, mucking about in the Middle East for the past 30 years to protect the oil supply isn't really paying dividends to the country as a whole, we doubled down on that policy and have sunk even more money into that shitstorm. But that wasn't the only option -- we could have, instead, used 9/11 as a stimulus to wean ourselves off Persian Gulf oil. I'll conclude with the words of Matt Yglesias, in writing about the generally-idiotic state of public debate:

My strong sense is that contrarianness reached its apogee in the 1990s when a general sense took over that politics was basically silly and that punditry should be seen as basically akin to the college debate circuit wherein the idea is to construct the most clever possible argument rather than to actually hit on the truth. When this general spirit of the times merged with the elite press’ inexplicable loathing of Al Gore you started getting really bizarre arguments being made with a straight face. People would say that one good thing about George W. Bush was that he was dimwitted, which made him understand leadership. Or that a big problem with Gore was that he was interested in public policy. This attitude brought us thousands of Americans killed in a terrorist attack, thousands more killed in a senseless war, and eventually the collapse of the world economy. But that in turn has at least to a small extent reminded people that it actually does matter what happens and who’s right.

If this is true, we're screwed

Um, so I'm hoping that this is an April Fool's joke, based on the March 31, 11:59pm post time. But if not, oh well, we've had a good run as a species. An example:

On January 12th 2009, the STT run (Standard Turing Test) confirmed behavior indistinguishable from that of a reasonable human being with above-average intelligence and 3.8 GPA (we're still struggling to understand that missing .2; we suspect it points to fundamental flaws in the GPA system rather than CADIE. It's also worth noting that CADIE was never shown any textbooks and reading material for the classes; she was only administered the exams. In fact, during the first morning of testing she pointed out several important theoretical flaws in particle physics and cosmology. On several occasions she asked us whether we were really sure we wanted to do this; it is unclear what exactly she meant by these questions, or even by the word 'this.')

Melting planet

On vacation in upstate NY, but Judge Smails asked my opinion on Waxman-Markey, so here goes:

I fall in with those who think that Waxman-Markey is unfortunately watered down and doesn't get us to where we need to be, but it is better than doing nothing so I grudgingly support it, and I worry about it will look like after it goes through the Senate.

My problem with Manzi is that the economic argument is not the right way to talk about climate change. As Nate Silver pointed out, you can eliminate millions upon millions of people and only have a 5% drop in GDP, if you just take out poor countries. What is the value of having polar bears on the planet? Or any of the thousands of other species that could be wiped out if the climate were to change? Or abandoning New Orleans completely if sea levels keep rising? To me, Manzi is simply being a contrarian while ignoring the dire state that the planet is currently in:

Further, I get the point that indefinite accumulations of CO2 in the atmosphere will eventually become very damaging.

This statement is far too blase. We're already in the curve of the hockey stick and things will only accelerate. This is not an issue of "eventually." You can't price inhabitable conditions on the one planet we have. Sure, you can do the cost-benefit analysis about various means to an end -- for example, figuring out that ethanol from corn is actually a horrible way of trying to make alternative energy. But to come to the conclusion that we should do nothing is just idiotic.

Ice Queen Resignith

Well, now we won't have Sarah Palin to kick around any more. For the various reasons volleyed about for why she is resigning, I'm inclined to just go with the 'bat shit crazy' as a satisfactory explanation. And, of course, a good chunk of the commentary has been focused on 2012. Honestly, I don't think the identity of the Republican nominee matters a whit -- the election will be 100% a referendum on Obama. If we have been attacked by terrorists, he loses. If we haven't been attacked by terrorists and the economy is still in the shitter, he loses. Otherwise, he wins.*

* What if he doesn't pass health care? Honestly, I'm not sure if that is make-or-break for his administration for an election that will be held three and half years from now.

White knight

Judge Smails comes to Kennedy's rescue (kinda):

1) Byrd [will never cast] another vote. People were more optimistic with Kennedy in the last month, but that has faded. 2) The MA special election process can't formally begin (i.e. writs of election issued and campaign period commence) until Kennedy formally retires or dies. This ain't the Supreme Court. 3) The MA legislature could at any time, however, reinstate the governor's power to fill vacancies (stripped in '04), which would help speed things up once Kennedy plays his next card. 4) I think Capuano would make a great Senator, although it's not obvious to me he's a great statewide candidate.

Obviously the Blago incident was a lesson in why it might be bad to give a governor sole discretion in appointing a Senator. But going without one for a length of time ain't great either. Wyoming (I think) had a system where the party of the out-going guy would give a list of three names to the governor and he'd pick one.

Oh, WV has a Democratic governor who can just appoint the successor, so Byrd's seat is a non-issue.

Get over yourself

Now that Al Franken can finally be seated, the Democrats number 58, plus Sanders and Lieberman, independents who caucus with them, giving them the "magical" 60. As many have pointed out, though, it is not as if this means everything progressive folks want is going to now breeze through the Senate. There are plenty of Senators who are going to be a pain in the ass -- I'm looking at you, Nelson -- and depending on the issue, it will be a different coalition of Senators who will be a pain in the ass in the name of "centrism" (i.e. pissing everyone off). Cap and trade, for example, will probably have no problem getting Collins and Snowe from Maine on-board, as least relative to, say, Landrieu. But anyway, a lot of this has been said.

Of course, you cannot vote for a bill if you aren't there, so Ted Kennedy needs to get over himself and his legacy and just frickin' retire. If he were to drop dead tomorrow, it could take months before a replacement arrives, and that is just one more vote that Reid needs to scrounge up, one more Senator who gets to extract his or her pound of flesh from a piece of legislation before it gets through. Kennedy already pissed me off when he suggested, upon his diagnosis, that he really wants his wife to have his Senate seat, as if we live in 17th century Europe and the masses should just accept this decree. Massachusetts has plenty of able-bodied, progressive people in it with legislative experience who would be more than adequate to fill the role (Capuano, perhaps?). So instead of setting ourselves up for the inevitable period when Massachusetts is only represented by a single Senator (you think Kerry is unsufferable now, wait until he's the senior Senator from Massachusetts), Kennedy should take one for the team, announce he's leaving the Senate, and allow the Commonwealth to find a replacement while he continues to serve.

But of course that won't happen, because Kennedy is much more interested in what's best for Kennedy than what's best for Massachusetts.

P.S. The same could probably be said for Robert Byrd, who's 91 and in and out of the hospital, but there's a 100% chance that Kennedy's replacement would be a reliable Democrat, but I have no idea what West Virginia would send.

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.