Greg Sanders

“We are not bound to win, but we are bound to be true.”

Unlike that dark day of January, when for a moment just duplicating the Senate bill or passing a new bill through reconciliation seemed like an unlikely best hope, the strategy that emerged of the House passing the Senate bill and fixing it in reconciliation has brought us to the very brink of victory. My Representative supports it so at this point I’m just making a few donations for the final push.

Speaker Pelosi had been my last hope and according to Carrie Budoff Brown and Glenn Thrush in Politico, my faith was vindicated (article via @brianbeutler). This isn’t to say there’s been no mistakes, or even no unforced errors, but by God they’re trying and that’s all I can ask. I’d been worried by the initial summary of Obama’s summit strategy but it appears my assessment after being calmed by friends was correct and the tactic worked. I have to say, I had been disappointed by some of Obama’s choices, but he has re-earned my faith and based on his actions and speeches like the one below has led me to believe he’s found his footing on domestic issues in a way he hadn’t even back during the campaign.

Here’s the text of his speech via Ezra Klein (video from @ebertchicago). I’ll just quote the excerpt I put in the post title:

I have the great pleasure of having a really nice library at the White House. And I was tooling through some of the writings of some previous Presidents and I came upon this quote by Abraham Lincoln: “I am not bound to win, but I’m bound to be true. I’m not bound to succeed, but I’m bound to live up to what light I have.”

 

Visit msnbc.com for breaking news, world news, and news about the economy

Thank you leaders, that’s all I can ask for.

If you’re looking for where to follow the news tomorrow, Twitter is actually very useful for this purpose I find, my top sources: @brianbeutler, @fivethirtyeight, @jeffreyyoung_hc, @jcohntnr, and @ezraklein are the ones to watch.

[As a final note, I do strongly believe that if we win here, as the President says, good policy is good politics. Dana Milbank does a good job of summarizing why.  Given the economy, we’re likely to take some losses in 2010, but the voters will fight to protect the right to health care once they’ve had the chance to enjoy it.]

CBO as Referee

Peter Suderman has a good piece up in Reason magazine about the CBO. I think he does a great job telling its story and describing the role it is playing in the current health care reform debate.  That said, I do disagree with the subhead describing the CBO as Obama-care’s chief obstacle (see comments).  Suderman was kind enough to respond to my questioning of that point:

But I think it’s a good enough subhead: part of the point of the piece (not the only point!) was that, during the summer, the bill lived and died by the CBO — it exercised a strong pass/fail authority over the bill’s life. And it proved a lot of trouble for Democrats. Indeed, if you look at where the debate’s at today, there’s still a lot of that going on — the sorta-kinda deal they put together last night is contingent upon the CBO’s analysis.

All true. That said, the chief obstacle is the fact that the filibuster has become a de facto 60 vote minimum on everything.  Absent that consideration, the CBO wouldn’t be playing nearly as prominent a role.  Moreover, having the CBO validate the public option as a deficit reducer didn’t bring any “fiscal hawks” around. 

As the title indicates, I think the CBO is best seen as a referee.  The President and Sen. Baucus both wanted to get to 60 votes by emphasizing deficit reduction, the CBO made the call as to whether they played fair while doing so according to its sometime idiosyncratic rules.  As Suderman notes, we do complain some about the calls, generally speaking, liberals argue that the CBO underestimates various saving measures and we have some cases to back us up.  That said, the CBO is also required to be credulous that Congress will implement certain provisions they consistently vote against, so the idiosyncratic bits can cut both ways. However, even if we don’t like some of the calls, playing with a referee is conducive to good policy.  I believe it is vital that we find ways to undermine the pernicious and unprecedented impact of the filibuster, but I think we should celebrate the prominence of actual accounting brought by the CBO even if it sometimes makes our lives hard.  After all, health care reform has gotten further under this set of conditions than it ever has before.

A defense of the fiscal responsibility of the Senate Health bill

Tyler Cowen attacks those of us who support the bill claiming we retreat into the relative.  In short, he doesn’t believe the various automatic cuts will happen and is unsatisfied with our defenses of those cuts.

This fight gets more into political science than economics as such.  The economics of the bill as written are covered by the CBO, the question is whether the politics of the bill are sustainable.

Here’s why I think they are:

1. Assuming no changes to the filibuster as implemented in the 21st century, post-passage it will be possible to defend the fiscal responsibility of the bill with 41 votes rather than the 60 votes otherwise required (or 51 votes and luck of the draw if using reconciliation).
2. People with expensive health plans are elite, but they lack the organizational infrastructure and natural ties held by the doctors and elderly who have blocked automatic Medicare cuts.  Their negotiating clout is undercut by the fact that the group contains natural enemies: union workers and corporate execs.  Further, their numbers will be decreased by many companies choosing to simply avoid the health care excise by giving more taxable income.
3. Democrats, under the prior Democratic president, managed to balance the budget.  The good economic times of the 90s were certainly critical to that happening, but we managed it nonetheless largely due to the revenue raising that helped lose us the Congress.  Why would we do it again after losing the Congress the last time?  I don’t believe in politician fiscal hawks, but I do believe that your average Democratic Representative and Senator faces more elite pressure to do something about the deficit than expand health benefits.  Universal Healthcare does address a core middle class concern, but things like the level of subsidies and the benefits of the bronze plan are going to be lower priority for Democratic leadership than being described by the media as fiscally responsible.  If this wasn’t the case, then why did the Reid bill come it at $856B rather than maxing out the $900B the President suggested.  Liberal bloggers, such as myself, won’t get their in a better world cost reductions but we also won’t get our better world benefits for the poor.
4. This will make it easier to raise the eligibility age for Medicare once universal healthcare is in place.  We can do something sensible like index it to the expected lifespan.  Obviously this will be grandfathered in due to the political clout of the elderly, but those who aren’t that near receiving benefits are a larger group that won’t be as motivated.
5. Some of the bloggers Tyler is critiquing are willing to say that the new mammogram guidelines could well be a good idea and that critics should provide counter arguments based on science.  There may well be strong counterarguments, I’d be curious if the false positive downsides still outweighed the detection upsides if we’re talking African American and/or lower income women, but I need to see that data before I go along with the critique. Furthermore, when it comes to things like mammograms, many people are averse to getting tests in the first place, stopping government encouragement for those under 50 without special risk factors, even if coverage is maintained, should make a difference in usage.  I will concede that this up roar and HHS concessions does bad for us, but the strength of the response on breast cancer is the exception as advocates for breast cancer patients are highly organized and feminist groups are on edge after being backstabbed in the House.  There was not a political response of the same magnitude of recommendations on prostate cancer screens.  Interestingly enough, the American Cancer Society didn’t object to those, so I think their critique on changing mammogram standards should certainly get a fair hearing.  Also, I’ll note the fact that the timing of this release shows the scientific independence of the review process, the timing was awful.

Senate Finance Committee votes 14-9 for universal health care

This healthy margin was more than was required and reflects the support of Republican Sen. Olympia Snowe.  While I’m still a bit dubious of some of Sen. Baucus’ choices, I think he’s earned a pat on the back today.  We haven’t guaranteed Sen. Snowe’s vote for the main bill, but this is a very good symbol and it changes the incentives for voting decisions substantially.  With 60 Democrats plus one Republican that means we can afford to lose a single vote.  If we only had 60 votes than any single Democrat could be a spoiler.  As is, the leadership only has to meet the demands of the second biggest pain in the but, which means there can be a real penalty if you get too greedy.

RIP Sen. Kennedy

I think Fallows summarizes his life well, see Joe Klein for a longer form version:

A flawed man, who started unimpressively in life -- the college problems, the silver-spoon boy senator, everything involved with Chappaquiddick -- but redeemed himself, in the eyes of all but the committed haters, with his bravery and perseverance and commitment to the long haul. And his big, open heart. A powerful, brave, often-wounded animal at last brought down.

Ezra Klein also has a terrific selection of articles written about him.  Kennedy’s cause, aptly summarized by Harold Meyerson, was looking after the downtrodden and as back in 1980, the year I was born, he was already a forceful advocate for providing health care to all.  Sen. Byrd suggested naming the health care bill after him (via Ezra Klein).  It seems logical.  The best way to honor the dead is not pomp or circumstance but to advance the causes the what they consider the cause of their life.  It’s certainly how I’d want to be remembered.  There will be haters, but as Achenbach noted for all of Kennedy’s polarizing qualities the Senator was one of the best at getting compromises.  I heard on NPR tonight the story of how he helped Sheppard through the sanctions on the apartheid regime in South Africa, even overcoming Reagan’s veto.

Random health reform thought

One benefit of electronic records and the like is that we could begin to see the effectiveness of various forms of medical training.  One of the limits on the supply of doctors is that it’s hugely expensive and time intensive to get a degree.  Early work in hospitals practically seems to represent a form of hazing through long hours.  In some specialties, that may well just be necessary.  On the other hand, classically professional organizations often try to limit the incoming supply of people of the same profession to keep both the prestige and the wages up.

This is an area where conservatism is appropriate.  Medicine is an old high and a risk field.  That said, I expect there’s already a fair amount of variety in teaching methods in the U.S. let alone the world.  Monitoring physicians success rates after graduating and seeing how it compares between various programs may indicate what educational methods actually work fairly well.

When wandering hospitals, I’ve seen a fair number of ads for the number of years all their radiologists were trained.  I think it was something like thirteen.  I can accept that such training may be necessary, but it seems more like a lamentable fact rather than something worth crowing over if that’s the case.  I’m more inclined to be impressed by outcomes than inputs.

The fight to get America a decent health insurance system

The conventional wisdom and Nate Silver’s analysis seems to show that a public insurance option isn’t going to make it into the bill.  This is rightfully angering many liberals, but I am of the belief that we can live without it in this round.  Kevin Drum notes that world-wide universal health care tends to come incrementally rather than in one grand bargain.

This isn’t to say that liberals should top fighting for it.  Ezra Klein argues that attempts to compromise with all but a handful of Republicans are futile.  The incentives to cooperate just aren’t there.  It will likely be necessary to give up the public plan to get enough votes in the Senate, but giving it up preemptively will just result in a new set of lies about some other part of the proposal.  However, it’s vital that if we can get the principal of universal health care in place that we take a deal public option or no.  I tend to think, despite bluster, that most of the real liberal fighters understand this and I trust they know

What we need is reform such that insurance is available to all and will not abandon them when they need it most.  This is not the case with the present employer based system although many people don’t find that out until it is too late.  Yglesias has a helpful White House summary of the key reforms necessary to remove the worst dysfunction from the system. 

Ultimately, I think in the long term controlling costs probably will mean providing a system that makes more sense than employer based insurance.  I want a robust public option, if it out competes private and non-profit insurance that’s great, if not than so long as costs are contained I don’t really care.  Moreover, I have no desire to place any sort of cap on spending even under my ideal system, I’m happy to have people buy supplemental insurance or putting all their wealth into buying all the care or medical research they want.  There are exceptions but an aversion to caps is the standard American liberal view, let alone the view of Democrats that are electable outside of liberal enclaves.

Finally, for those of you already on board here’s a bit of catharsis via Yglesias who argues against defensive crouches and for hitting back fearlessly.  The level of aggression here is dang satisfying and probably often a good idea, but I think not showing fear is the key take-away.  I don’t think that’s actually a useful lesson in overall strategy, but it’s quite important in the specific instance of public speaking.

Implications of mental health parity

By a recent law, insurance coverage should treat physical and mental health care in an equal manner.  I think that’s a good idea, but my friend Arwen T. did raise, on the record, a negative consequence.  As someone who has been treated in the past for a phobia she now has trouble getting coverage in the same way someone with a physical pre-existing condition would. 

Due to this vagaries of America’s health care “system” the standard way around that is to find employment with benefits.  But, getting good jobs are always tricky, particularly during a massive recession.  Similarly, severe pre-existing conditions will make finding a job harder.  For those who’ve recently lost jobs with there’s COBRA and depending on the state there may also be programs like I-CHIP.  Both allow methods of buying insurance that go around the employer base system and the denials common with individual accounts.  They aren’t cheap, but being without healthcare can be far more expensive.

On the whole, I think this downside is worth it.  Ultimately insurance needs to cover important needs or it’s a cruel joke.  The logical solution to these sorts of problem is to switch from an employer based system of care to a universal one which somehow the rest of the developed democracies of the world manage to provide.  Moving to universal care won’t eliminate trade-offs, but it does pool risk and make lives better by ensuring access to necessary and effective treatments.  However, while the odds for healthcare are good, we can’t forget about those negatively affected in the interim.

This gets to why the stimulus aid to states matters.  Most states have a hard time running deficits and so reinforce bad times with cuts to that hit healthcare and other vital services.  In addition top insuring funding we also have to make sure the transition goes smoothly.  Arwen’s been waiting a while on her I-CHIP app and I suspect that Illinois, along with most states, may be playing catch-up to deal with the new mandates in coverage.  I suspect some of the insurance companies are also reacting with blanket denials as a first recourse rather than looking at the gradations in pre-existing conditions. That may well change over time, but that’s little consolation in the meantime and healthcare often can’t wait.

This gets to why health care proposals are so careful to make sure people keep their existing coverage.  Transitions can be difficult and people do fall through the cracks. Improving care in the aggregate isn’t that appealing if you are afraid of losing yours.  I think a public option is a good idea, but I want people to switch to it because they think it’s superior coverage or a better deal.

Disturbing local news

Apparently two high school students were planning an attack on Springbrook High School in Silver Spring.  The method would have been explosives, not guns.  That actually makes me hope that they wouldn’t have been that successful at pulling it off as even terrorists with some logistic support can botch that, but thank goodness we didn’t find out.  Saw the news from Andrew Gelman who I didn’t realize was an alumni.  I don’t know too many high school students these days, but back then I had several friends that went there.

I don’t know to what extent small groups launching murderous attacks on society is cyclical or if this is a disturbing, albeit still extremely uncommon, new trend.  One thing I have heard is that sensationalism does feed this phenomenon, so I’m trying to keep this entry low-key and not repeating the name of the students involved.  Also, it is still breaking news, so things might not be as they now seem.

A lot of the common perceptions around school attacks are wrong.  This came up recently in Gary Krist’s review of David Cullen’s Columbine.  It’s fairly widely known that there’s no evidence to support the idea that they were targeting Christians, but the early incorrect information doesn’t end there.

We remember Columbine," Cullen writes, "as a pair of outcast Goths from the Trench Coat Mafia snapping and [then] tearing through their high school hunting down jocks to settle a long-running feud. Almost none of that happened. No Goths, no outcasts, nobody snapping. No targets, no feud, and no Trench Coat Mafia. Most of those elements existed at Columbine -- which is what gave them such currency. They just had nothing to do with the murders."

Far from feckless pariahs, in fact, the two shooters in the Columbine case – [See above regarding names] -- were smart, reasonably popular kids who doled out more bullying than they ever suffered. Their shooting spree was not some precipitous act of revenge against specific tormentors, but more like an elaborately planned theater piece, worked out almost a year in advance, designed to demonstrate their innate superiority by indiscriminately killing as many victims as possible.

It is important that we keep this kind of thing in perspective.  The normal flu for examples kills 30,000+ annually in the U.S.  Driving collisions kill many more than that.   Overreacting to these incidents takes away resources from more pressing needs and can result in mistreatment of those who are outcasts to begin with. 

One recent change that gives me hope is that by law mental healthcare and physical healthcare must be given equal coverage.  Political radicalization is one issue, but I think it’s uncontroversial to say that anyone who would commit the alleged acts is deeply troubled in one form or another.  I don’t believe we have any sort of panacea at the moment for these cases, or for many other mental health challenges.  But I do believe in science and in medicine, as we study and assist all those that need help but don’t strike out violently, we will do great good and should learn more about how to assist the extreme cases.

Gapminder

At work I’ve been fooling around some with Gapminder.  It’s an online datastore house with a neat graphing interface that makes it relatively easy to examine a whole host of data. 

For example, here’s a graph where I plotted rural doctors per hundred people versus rural health expenditures for China’s provinces.  I’m a bit disappoint there’s not an embed option, hopefully the Google Motion Graphs version will be able to handle that. 

Health care innovation!

Many hospital beds have neat features like being able to rise to essentially chair like stature or lay down like a full bed.  The tricky part about this is pillows.  Pillows in an upright bed tend to fall down when the patient leaves the bed and returns or even just adjusts the altitude of the bed.  Patients are also typically not that mobile, and so require the aid of another to sit up and put the pillows back in position.

I think the solution here is to make bed pillows that work like lazy boy pillows.  They could either have cases that wrap around both sides or perhaps can be clipped to the back of the bed.  In either case, it would save a lot of trouble without really requiring new tech.

At this point, I’m fairly mobile and mostly content to leave my pillows at the bottom of the bed, but this issue has annoyed me before.

Slow posting for a week or so

I’m doing some field study of the American health care system and so am going to be posting fewer entries for the next week or so.  Might have some guest author posts, depending on the availability of my fiancee and friends.

I think I had that operation done in… 2002? Summer maybe? The name started with a V.

Ezra Klein provides a compelling parable:

If you walked into a bank and asked to open an account, and they opened a huge ledger book and began paging to your letter in the alphabet, you'd gape for a second, walk out, and call your friends. Or maybe you'd Twitter the experience. It is the 21st Century, after all. What you wouldn't do is use that bank.

But what we'd never allow with our money is constantly endured with our health.

I can personally testify to this.  I’ve spent a lot of time around hospitals this year and have often had to repeat information about what I’ve had done, including stuff that took place at that very hospital.  I found that some of my older records were even lost to the ages because the doctor didn’t retain them.  Particularly in the diagnostic phase, I spent much of my time recounting, with medium fidelity, my health history.  With the assistance of my parents, we have a pretty good file on me, this has got to really suck for those who aren’t good record-keepers or don’t have assistance from one. 

So far I’ve dealt with one of the 20% of the physicians that had extensive electronic records.  Took an extra hour or so the first time I saw him, but every subsequent time has been much faster and I haven’t had to pull open my datebook.

Electronic medical records are part of Obama’s stimulus package.  That makes sense, it will apparently cost about $50k per physician to implement it and that spending will probably be mostly in the U.S.  Happily, we should recoup that investment within two years:

[Duplicate paragraph deleted]

The evidence is clear on this score: Electronic health records not only save money, they save lives. The remarkable achievements of the Veteran's Health Administration are largely the work of VISTA, their electronic health records architecture. Indeed, the Commonwealth Fund found that the savings from EHRs are considerable:

This is basically a classic public goods problem.  The benefits are dispersed, costs are concentrated, and standards are needed.  Happily Obama is actually doing something about it.

Back

Sorry about the period of absence, had and am now increasingly recovering from some major health issues that I’ll be vague on since this is a full public venue.

Anyways so expect a series of dozens of entries in short order to make up for... ha, no. I’m going to try to get back in the daily posting habit sooner rather than later though and might even get a little help with that.

Aww hell

Ezra Klein reacts to the news that Ted Kennedy has a malignant brain tumor:

Kennedy is the most effective, dogged, determined, and skilled liberal legislator in the Senate. He’s one of the few Senators who is genuinely irreplaceable, whose absence would degrade the nation’s social policy, and thus the life chances and economic security of millions of its disadvantaged residents. Without Kennedy, we wouldn’t have the Americans with Disabilities Act, S-CHIP, the Family and Medical Leave Act, or any of a hundred other crucial pieces of legislation.

I concur, Kennedy really is one of our toughest fighters in the Senate, an unabashed liberal but also a deal maker who could get things passed even under the current President. He’s already secured his legacy, but I’m hoping he can stick around for some time to come.

Day in the life

Finally got my doctor’s appointment today. Looks like I’ve got a pinched L2 nerve alright but there may also be something else wrong with me. Anyways, we’re getting more tests and hopefully I’ll have some results by the end of the week.

It’s one of those situations where I do thank God I have healthcare. The costs of my appointments, of my tests, and of standard resulting treatments are all likely to be covered. This is basically what I want for all Americans and based on the experience in France and Germany it should be something we can afford without making a huge number of rationing sacrifices.

I know some of the privileges I enjoy are zero-sum. The fact that I get them means someone else doesn’t have them or has them to a lesser degree. But in many other areas, privileges can be positive sum. Far many more people could live a life that gives them multiple opportunities to pursue their dreams by reducing the amount of attention they need to pay to just scraping by. That’s the kind of world I’d like to build, because it’s one I’m very grateful to have lived in.

Bad politicians, bad!

There are many stupid political policy panders out there. As an example Yglesias notes complaints about the price of gas when ultimately dealing with environmental problems will require higher prices. Far more troubling, as Jason Zengerle is pandering on issues like whether vaccines are linked to autism:

Actually, as the WaPo’s Michael Dobbs points out, the science isn’t inconclusive: numerous studies have found no link between vaccines and autism. But there are plenty of people who don’t let the science get in the way of their suspicions. Having two out of the three presidential remaining presidential candidates fan those suspicions--McCain has made comments similar to Obama’s--doesn’t help matters.

P.S. Which is all the more reason to get behind this ScienceDebate2008 idea.

That sort of thing is a real gaffe and the candidates should be called on it. Ezra Klein notes that Clinton has done it too, although hers was a lower key written response if I’m reading this right.

Some medications aren't overprescribed

Interesting news from an article in the Washington Post:

Warnings from federal regulators four years ago that antidepressants were increasing the risk of suicidal behavior among young people led to a precipitous drop in the use of the drugs. Now a new study has found that the drop coincides with an unprecedented increase in the number of suicides among children...

The trend lines do not prove that suicides rose because of the drop in prescriptions, but Gibbons, Insel and other experts said the international evidence leaves few other plausible explanations. Previous studies have shown that U.S. suicide rates are lower in counties where antidepressant use is higher, and a recent study of 200,000 depressed veterans found that those taking an antidepressant had one-third the risk of suicide of those who were not.

There's some ghoulish calculus here, but all-in-all it seems to say that young people probably have less anti-depressants than they could really use.  I think the conventional wisdom is that we're over-prescribing our kids.  That may be true for some medications, but this is a rather important exception.