Scientific American on Health Care

I love Scientific American for two reasons. One, it is amazing to see new advances - or theories - in science as they are unfolding. Two, in appropriate situations, they weigh in on policy and politics. When they do, I trust them because, more than anyone else, I feel they are free from ideology and base recommendations on science and data.

In this month's issue, they write about health care and what needs to be done to control costs. Here is what they say about Obamacare and Paul Ryan's plan:

Politicians have acknowledged the crippling cost of medicine, yet their proposals do little to fix these basic flaws. For instance, replacing Medicare benefits with vouchers that individuals can use to buy their own health insurance, as was recently proposed by House Committee on the Budget Chair Paul Ryan, merely shifts more of the financial burden to private citizens. And most of the cost-saving initiatives found in the Affordable Care Act are demonstration projects—not large-scale reforms. The factors that inflate health costs must be addressed widely and directly. Fortunately, promising solutions are beginning to emerge:

What they recommend is not particularly new, but they give these proposals more credibility: reduce fragmentation, phase out fee-for-service, and compare effectiveness of procedures.

Now, if we are really going to compare Obama v. Ryan, we would acknowledge that Obamacare does this stuff, albeit slowly, and Ryan's doesn't at all. But it is good to see the scientific community weighing in. And it is good to see that they support Democratic plans - although they clearly think they need to be more ambitious.

Ryan on Healthcare

Paul Ryan is getting a lot of attention for his budget plan, including his plan for medicare. I think what he is saying needs to be analyzed and responded to. So here is a good quote from WashtingtonStakeout (hat tip Paul Krugman - I didn't actually know this website).

There are three facts about medicare that you simply can’t dispute: 10,000 seniors are retiring everyday with fewer workers going into the workforce to pay for them; healthcare costs are skyrocketing at about four times the rate of inflation, which threatens medicare’s ability to give affordable care; and number three, the non-partisan experts agree that Medicare is going bankrupt. So Medicare’s status quo is bankruptcy and that threatens healthcare not only for current seniors but obviously for future seniors, so I believe a patient-centered healthcare system — reforms that put the patient at the center of the healthcare system, not the government — are the best for people who need healthcare and they’re best for the economy, and they’re the best way to avert a debt crisis.

To start, let's assume that his three facts are true; I don't see anything I disagree with. But even if all the things he says are true, his solution isn't the only option based on those facts.

If Medicare is going bankrupt, then we have a few options. One is to increase funding. Another is to decrease services - either by cutting spending on the government side, or, as Ryan proposes, by making it a voucher program and underfunding it. My main problem with Ryan's plan is how he describes it; he tries to say that by using vouchers, he won't be underfunding services and that markets will magically bring down prices so that services won't be cut. This is stupid. He is cutting costs by cutting services - plain and simple.

A fourth option would be to keep it government-funded but to change incentives and structures to bring down costs. What is driving increased medical costs is in part an aging population and in part unnecessary services driven by our for-profit, fee-for-service system. Obama's health care plan plays with fixes, but only does so as pilots - afraid to change too much too soon. It is a prudent approach, but it means health care costs won't change very soon - instead all we can expect is that it might bend the curve so that future costs are less than we are projecting.

In retrospect, I think maybe he shouldn't have been so prudent. By taking on health care and only expanding coverage and doing modest pilots on cost-control, he left the door open for conservatives like Ryan to talk about cost control and to propose terrible schemes like consumer choice.

Either way though, the point is that Ryan may be right that Medicare is not on solid footing, but his plan is the least fair, least effective and therefore least desirable option out there.

Deja Vu

As you might guess, I have less time to read the news and blog these days. But one place I still check in on is Paul Krugman's blog. When it comes to economics, budget, and spending issues - including health care - he has the most clear writing and the best analysis.

Yet it seems to me he spends a lot of time repeating himself. I don't blame him of course. I think it stems from the fact that he makes obvious points that fail to make any traction. Take a recent post explaining that federal spending as a percent of GDP has increased recently in large part because GDP growth has slowed so much and because spending on the safety net increased to deal with the recession. I swear I have read this at least a few times. (It is also true that much of the budget debt we have is due to Bush policies - and Krugman has made this point as well.)

In another post, Krugman makes the point that the health care plan we have is as conservative as it can be if we want to have something close to universal coverage. I am sure Krugman has made this point before as well.

It is a shame that Krugman, and those making similar points, are not being heard.

Is the Mandate Unconstitutional?

The answer is a resounding no according to David Cole. You should read the whole argument, but let me see if I can summarize correctly.

First, although the people that oppose health reform, and the mandate particularly, seem to do so form a libertarian perspective, there is nothing in the constitution that guarantees the freedom these people want. Instead, their only hope is to appeal to state's rights. In fact, the states themselves clearly have the right to have an individual mandate.

So does state's rights argument work? No. The necessary and proper clause, as it has been interpreted since the New Deal allows Congress to pass such a mandate, as does the interstate commerce clause. The courts have found that the federal government has the ability to regulate individual interactions if they affect bigger interstate interactions. Marijuana laws and laws restricting growing of wheat for individual consumption show that the federal government can regulate people who are not ingaging in the market.

Cole goes on to say that the federal judge that struck down the law did so using jurisprudence that is no longer in use. He therefore thinks the law will be upheld and not by a close vote.

While I am convinced by Cole's argument, I am only moderately reassured. What seems like clear cut legal reasoning, the Supreme Court, especially one as conservative as this one is, is capable of finding arguments for political decisions. My gut is that this decision comes down 5-4, hopefully with Kennedy deciding in favor of the law. Anything more than that is too much to expect.

Book Report: And the Band Played On

And the Band Played On is one of the best books I have ever read. It is a pretty quick and easy read considering how big the book is. At times it is enraging, other times dispiriting, and sometimes really, really sad. Maybe most importantly, the lessons on policy and politics are huge.

I think the first take away is that services cost money. This point is crystal clear in this book. The Reagan administration wanted to cut the size of government based on their belief that government is wasteful and does too much. What happens in reality though is that government is prevented from doing the things it should be doing. Of course, Reagan cared little for the populations originally affected by AIDS - homosexuals and IV drug users (why hemophiliacs were not more sympathetic is surprising), but more importantly, Reagan and his budget office did not see the value in government-run medical research and disease prevention.

The author also makes the point often about how the press largely ignored this issue until it seemed like it might affect straight people as well. With the press ignoring the issue, the Reagan administration was able to get off the hook even when Congress pressed. In fact, at times it seems that the author (a journalist himself) blames the press more than he blames Reagan. And so do I; you expect Reagan to be heartless, but not journalists.

Also, quite a few public officials from that time come off looking really bad. Mayor Ed Koch did nothing to help educate people or otherwise prevent the spread nor did he provide funding for services to care for those that were developing it. Mario Cuomo as governor of New York was no better. Diane Feinstein also looks bad - although not quite as bad as Koch and Cuomo (her main flaw was to oppose closing the bath houses until late). Other public officials actually surprised you and did the right thing. The one that comes to mind is Orin Hatch.

What was most dispiriting was how many people acted in their own interest instead of doing what in retrospect was clearly the right thing to save the most people. Bath house owners fought to stay open and blood banks refused to test their blood.

Parts of the medical community also come off looking bad in the book. Actually, it is more accurate to say that research and academics looked bad, while many general practitioners - the few heroes in this epidemic - fought valiantly to raise awareness and help those that were diagnosed.

The author also shows the big fights inside the gay community over this issue, and it is painful to see those that were sounding the alarm getting viciously attacked. I don't imagine that this was an easy issue in the moment, especially the early days, for those in the gay community. But the real lesson should be that when something like this comes up, we need to do everything we can to look at the issue objectively and if not without emotion, than at least with the right kind of emotion.

Everyone should have been most focused on the lives being lost and the great potential for so many more if action wasn't taken (as happened because action was not taken). Instead people focused on petty concerns (money) and non-petty concerns (gay rights / defending against sexual morality attacks) that still paled compared the health risks.

I will say this again - this is one of the best and most important books I have read. I wish everyone would read it.

Drinking the Sand

"People want leadership, Mr. President, and in the absence of genuine leadership, they'll listen to anyone who steps up to the microphone. They want leadership. They're so thirsty for it they'll crawl through the desert toward a mirage, and when they discover there's no water, they'll drink the sand." - Michael J. Fox as Lewis Rothschild in The American President

I was watching Meet the Press this morning for the first time in a really long time. I was disappointed in two people. First, I was disappointed in Lindsey Graham who did nothing but spout superficial and erroneous talking points. But I was more disappointed with David Gregory who is not living up to the show that Tim Russert ran and was letting Graham get away with it. There was no depth from Graham and no requirement for depth from Gregory.

However, Lindsey Graham did say at least one thing that was true and I have been thinking about for a while. He said Democrats are not talking about the Health Care bill or the Stimulus bill. He is right and he is especially right when it comes to President Obama. I am getting more disappointed in him by the day and mostly because he is not out there fighting for what he believes in.

Democrats passed a health care bill that even got relative support from Ben Stein. It was marginally unpopular when it was passed and seems to be getting more unpopular as time goes on. Democrats seem scared to talk about this bill because it is unpopular and can be considered a big government expansion. The bill will not go away and will not get more popular unless they stick up for it.

The health care bill, although probably more complicated than it needed to be (I'll get to that another time), did things that are important. It expanded care to people without insurance and will prevent people from being excluded due to pre-existing conditions. I believe these things were worth doing and Democrats apparently did also. If they are worth doing, they are worth defending.

As the quote above shows though, if we aren't talking about it, people will listen to whoever is. Right now, only Republicans are talking about it and they have only negative things to say. Democrats feel that a fight over the right size of government is a losing fight. That is ridiculous. We believe that there are things government can and should do and many of these things the public supports.

The same thing goes for the stimulus. Why is Paul Krugman the only one out there defending Keynesian economics? The public perception is that because the stimulus did not stop the job losses, it did not work and therefore Keynesian policies do not work. President Obama is choosing to take the road that the stimulus is working, but slowly. Unfortunately, no one is buying this. Maybe he doesn't need to go as far as Krugman is, but he needs to defend Keynes and maybe needs to acknowledge that the stimulus was too small, not too big. And there are plenty of economists who will defend him.

I disagree with David Brooks, Obama does not need to avoid the debate over the right size of government. He needs to enter it. He and the rest of the party need to stop letting Republicans set the terms of the debate and need to argue for what we believe in. Short of that, we are likely in for a really ugly November.

Ben Stein on Health Care

I have been meaning to write about the health care bill (and the financial reform bill). But I need to do a lot more reading to make sure I understand what it will do. By the way, I completely agree with and understand the criticisms that the health care bill is too large and complex for most people to understand. After all, our government should be transparent and can only be so if its policies are simple and understandable. But as I have seen, it takes a not insignificant time investment to really get my head around it.

In the meantime, for all those conservatives that read this blog - you know who you are, you send me absurd emails about how Obama wants to ruin the country (instead of Bush who did it by accident) - I thought I would share Ben Stein's take on the health care bill. I do this because some of you are very fond of the famous monotone conservative's position on issues. Enjoy.

My First 2010 Prediction

So I have been checking back in at NY Times political map, as well as InTrade and Rasmussen (which does seem somewhat conservative, but also seems pretty accurate). My prediction in the Senate is 53 Democrats and 47 Republicans; Democrats look like they'll win California, Connecticut and Illinois and Republicans will win the other toss-up states and Pennsylvania. The House looks like it will stay Democrat as well - maybe around 235 Democrats. Of course a whole lot can change between now and next November as issues change and candidates rise and fall (see Scott Brown), so take this with a gigantic grain of salt.

In fact, the thing I will be the most interested to track between now and November is the approval of the health care change - as well as the passion for one side or the other. My sense from past experiences is that people tend to forget about issues pretty quickly. With health care, I think much of the dissatisfaction is over how long it took to get passed, how contentious it was, the political procedures used to get it all passed, and a lack of understanding / believing some of the mischaracterization of it. None of these concerns seem to me to be things that voters would hold on to.

While we are talking about voting, I do want to reference one other related thing. Megan McArdle, writing for the Atlantic after health care was passed, wrote this pretty angry, and completely absurd post. She says we are in a different world because elected officials voted for something that many polls show has a minority of voter support. She seems genuinely shocked that politicians could ignore the will of their voters. Unfortunately, Ms. McArdle does not seem to understand the political system that was formed by our Constitution.

Our system is one of representative democracy - not direct democracy. Elected representatives have two, often conflicting, purposes tugging at them. On purpose is to follow the will of the voters; when politicians vote on something, they need to consider how their voters feel, and how strongly they feel it, if they want to get re-elected. But the other, and just as important, purpose is of an elected official in our system is to do the research and learn the issues and make the best decisions on the policies before them.

This means that sometimes an elected official will vote their conscience, or will have a better understanding of the issue than the voters (ahem, death panels), and will therefore vote differently than the majority of their constituents. At other times though, they will realize their voters feel strongly and will choose to vote against their conscience and best evidence (of course sometimes, maybe even most times, their conscience and the voters' preferences are in line). Either way, it is a regular tension and calculation among elected officials. And in fact it was designed that way. So to pretend that this is something new shows either that Megan McArdle does not actually understand the basic nature of our political system or was so mad about health care that she allowed herself to write an unreasonable, and poorly reasoned, post.

The beauty of our system though is that when politicians do vote against their constituents, their constituents have the ability to vote in someone who will vote differently - which in fact is what conservatives are pushing for. If health care is repealed in that way, I will likely be as mad then as she was when health care passed. But I will hopefully be wise enough to understand that it is part of the system, as opposed to a scary new world.

Healthcare Markets

There have been two articles* I have read about market distortions in America's health care market. These distortions, namely the fact that consumers do not ever see or feel the costs of services, prevent cost savings and efficiencies. The arguments are compelling - certainly, the more we see and feel the costs of our care, the better we would be about choosing only the care that is likely to be effective.

However, the more we feel the costs (in other words, the more responsible we are for funding our care), the more likely it is that some people will not be able to afford certain necessary treatments. Maybe the people calling for this are right and that it would be cheaper to have a system where people pay for more of their care, and then have government support for people who cannot afford certain care that is too expensive. I still fear that people would be left out.

Once again we come back to efficiency versus fairness, the two opposing forces in economics. The question here is how inefficient are we (probably an extreme) and how fair are we (still not so fair - yet). Soon I'll have another post that looks more deeply at the health care proposal and how it does deal with the fairness and efficiency concerns.


*A side note - I do not think I am going to renew my subscription to The Atlantic. I get the feeling that they are trying too hard to be provocative and purposefully publishing articles that attempt to contradict "convention wisdom". I do not have a problem with that in general, however the articles that do have that feeling also seem to have a lot of data and arguments that are purposefully misleading - the healthcare article I linked to being one example and their recent marriage articles among other examples.

Obama Health Care Speech

Last night was Obama's speech about health care reform. I did not watch it, but I did read the text here. And here is a link to the GOP response.

It seems like the speech went over well, and I think in general he made all the right points. The only thing that stands out is the claim that we will pay for it with savings and if we cannot, the law will force the government to find the savings somewhere else. Seems to me like he is kicking the can down the road, since I find it unlikely that the savings will pay for the new costs. Although maybe it is smart politics - pass the reform now, then later make the hard choices about cutting programs or increasing taxes.

The Republican responses seem to be all over the map. Their call to start over with a new bill is absurd. Bill Kristol's thinks that this shouldn't be a priority right now - another ridiculous statement. But their concerns over the cost are accurate. We'll just have to see what resonates. In general it seems many want to just kill it, but I think enough want something to happen, which will allow a good bill to pass.

Anyway, for your information, here is the Times' version of fact-checking.

Kruman on Health Care

Krugman has a really good column about health care reform. I would not advise taking it as truth without doing your own research, since Krugman is notoriously partisan and sometimes not very objective. However, it does lay out some good arguments. Check it out.

No Anecdotes Please

The election this fall made it clear that our health-care system needed reform. Costs are escalating much faster than inflation and many people are uninsured. The changes we make will need to be carried out thoughtfully. Unfortunately, I think a lot of the debate will be in the form of articles like this one in the Atlantic, where anecdotes take the place of data that explains bigger picture issues.

In places the article mentions the big issues we'll have to deal with: Do we want everyone to have the same coverage or are we okay if the rich can buy better care? Do we want government making decisions about treatments (or insurance companies - an alternative the author doesn't consider)? How does government control affect innovation in health-care? How much are we willing to pay for care?

Although it mentions these questions, the article doesn't really answer them, and doesn't supplement the anecdote with any data to at least get us closer to the answers. So instead, we get a very superficial article about health-care masquerading as something relevant. In reality though, many people will read it - and many articles like it - and decide how they feel about more / less centralized medicine based on the one anecdote. (I haven't seen Micheal Moore's movie, but I have heard it is similar, although from the other side.)

If you have ever heard Senate debate on policy / legislation issues, you know that they also focus on anecdotes. And so I fear that we will end up with bad policy unless the debate begins to include actual information on the real ways different approaches will affect health-care in general. Will centralized medicine prevent drugs like the one in the story from being made? Will everyone be denied more expensive treatments or just the poor? We need to answer these questions through real data, not emotional stories.

Health Care

I went to an amazing policy breakfast the other day on health care. It was hosted by the Maxwell School and Public Agenda and featured Drew Altman. Because of the breakfast, I am now a huge fan of Public Agenda (a group I knew nothing of before this) and I expect I will be paying more attention to them in the future.

Basically, the breakfast did a great job of highlighting the real differences between McCain and Obama's health care philosophies (and by extension the difference between Republicans and Democrats) - which is different than talking about their plans. Neither are likely to have their actual plans passed, so understanding their philosophies is more important.

Before I get into that though, Drew Altman made three important points that I want to mention. First, he said surveys show that people are more concerned with making health care more affordable - with being able to pay their bills when they receive health coverage. Percent of people with health insurance isn't as big a concern (except how an inability to afford coverage would affect them).

Secondly, he said that what we have seen recently is that as costs are increasing, health plans are charging higher deductibles and providing skimpier coverage. This is likely to continue unless something major changes.

Finally, he talked about what he thought was mostly likely to happen. He thought it somewhat unlikely that there would be an immediate major shift in health care policy. Instead, he predicted small changes that would build on the Children's Health Insurance Program or maybe a bigger program that moved towards universal coverage but would be phased-in if the economy improved.

Now, the major differences between the parties on health care:

Republicans:
-Want to move away from the employer-based system
-Believe a market-based approach can make health care more affordable
-Want less regulation on coverage
-If people have control over their coverage and knowledge of the real costs of their care, they will make better decisions and waste less money (health savings accounts are a move in this direction)

Democrats:
-Want to build on the employer-based system
-Want to move towards universal coverage
-Believe we need to regulate levels of coverage
-Buying health care is extremely complicated and public cannot make decisions about coverage

After hearing this, I think I came down on the side of Democrats. First, I think health coverage is a right not a privilege. Also, while I think we definitely need to do what we can to make health care more affordable, I don't know that I trust the market for this - especially if there is less regulation. Choosing health care coverage is a really complicated decision that involves many factors, some of which the buyer doesn't even know to consider. People will have to make decisions about deductible amounts, choice of doctors, and detailed levels of coverage for treatments. It's not that I think the public is stupid, but that there is naturally information asymmetry that the insurance companies can and do exploit.

Here is where my mind splits though. Above I said I think we need to make health care more affordable. I don't really trust government to be able to do this. The problem is that markets are often more efficient (not always, but often) but definitely not fair. Since so much of health care is about fairness (ie ensuring everyone has adequate coverage), markets cannot be trusted. But without some market pressure, we won't be able to afford to provide coverage for everyone.

I obviously need to do some more thinking about this. I think there is a lot of bad information out there (one-sided pieces like Michael Moore's Sicko for example), and I have not found much good information aside from this breakfast panel. There are some serious questions out there that I haven't heard good answers to yet, like: What are the real strengths and weaknesses of some of Europe's single-payer universal coverage systems? How much do they cost? Why are there extreme variations in costs between states that don't match variations in outcomes?

This is going to be a huge issue no matter who is elected. Costs are rising rapidly and for such an advanced country we have too many people who lack coverage. I will definitely be coming back to this issue. (After all, I didn't even touch on the lack of access to preventative medicine for people without coverage or the overall health of our country.) This is all I've got for now though.

Autism

From the NYTimes:

The research emphasis of the act is appropriate, given how little is still known about the causes and the physiology of autism spectrum disorders, as well as the means by which medical treatments can reduce autism’s severity if applied early enough. Basic questions like whether the frequency of childhood vaccines today contributes to autism are still unresolved.

As parents of a child facing these challenges, we applaud those lawmakers and fellow parents who have done so much to promote this and other initiatives. But research is not enough. We as a nation must also begin to focus seriously on treating those children who are already afflicted. At present, we are failing miserably to do so.

This Opinion piece explains briefly how expensive quality intervention can be (more than $50,000 a year for preschool children), but also how the chances for improvement are increased dramatically with it.

Studies now show that 40 percent to 50 percent of toddlers undergoing intensive Applied Behavior Analysis, one of the best-known methods, can be mainstreamed in regular classrooms without personal aides by the time they reach school age. (The figure is close to zero for children not given special care.) Most of the other 50 percent to 60 percent make notable progress too.

What makes this even more of a no-brainer is that it isn't just the humane thing to do, it also seems to be the efficient thing to do. By investing money up front to help improve the lives of these children, you decrease the long term costs associated with their care for the rest of their life. The authors are right, more funding for research is good, but not enough. Here are our options:

Our options range from mandating that insurance companies cover therapies documented to work, to trumpeting the example of places that do provide coverage in the hope others will follow, to expanding autism Medicaid waivers.