As regular readers know, I'm deeply skeptical about the polling of complicated issues like health care...but it is interesting to note that, according to CNN [see related: CNN Poll: Support Jumps For Obama & Health Care Bill], support for health care reform is up, especially among Democrats. This may or may not have something to say about the impact of left-wing bloggers and Deaniacs trying to scuttle the bill--i.e., their impact is minimal. Oh, they can raise some money, and eyebrows, but when they call themselves the Democratic party's "base," they're being excessively optimistic. They are, if anything, the wing not the base.
And given the reactionary arguments against a bill that is a massive transfer of wealth--via subsidies--toward the working poor, I'd be reluctant to call these people "progressives" as well--progressivity, strictly defined, being the notion that rich should pay a higher tax rate than the poor.
ps--Obama is up six points in the poll as well, from his previous low of 48% approval to 54%. This is an excellent showing for a President taking on some of the hardest, most controversial issues in American life.
Netroots, meet your allies: For Pete Wehner, master of short-term, right-wing conventional wisdom, the sky is always falling.
And furthermore: Over at Huffpost, Harold Pollack of the University of Chicago, has this on the massive, progressive income transfer to the working poor that this bill represents:
Fully implemented, the bill would provide about $200 billion per year down the income scale in subsidies to poor, near-poor, and working Americans.
$200 billion is a big number. It exceeds the combined total of federal spending on Food Stamps and all nutrition assistance programs, the Earned Income Tax Credit, Head Start, TANF cash payments to single mothers and their children, the Department of Housing and Urban Development*, and the National Institutes of Health.
More than that, this bill codifies the responsibility of the federal government to ensure decent and affordable health coverage is available to every American. The Senate bill does not yet live up to this responsibility in every particular. Still, by almost any measure this is a historic expansion in the humanity and the ambition of American government. Paul Krugman, Jonathan Cohn, Jacob Hacker, Ezra Klein, and Paul Starr disagree about many things. Not about this. Almost everyone I know with expertise in health policy, public health, and the politics of health care believes as I do: we just have to pass this bill.
And while the bill would also provide the insurance companies 30 million new customers, it would saddle them with a strict regulatory regime: they would have to provide coverage regardless of pre-existing conditions and within prescribed community-rating bands (which would fiercely limit their ability to overcharge the middle-aged)--and that is why the insurance companies have been spending tens of millions of dollars in advertising to kill it.
This is not perfect, but it is progress...it is, in fact, the most significant piece of social legislation since the 1960s. Those who oppose it from the left are measuring it against unattainable fantasies; or they are making false charges, claiming that the working poor would be offered "junk" insurance. I find their opposition mind-boggling and myopic; it empowers the Wehners, Boehners and Coburns of the world.
The same poll posted about in "For Democrats, the red flags are flying at full mast", also found this (as reported by the Wall St Journal):
The loosely organized group made of up mostly conservative activists and independent voters that’s come to be known as the Tea Party movement currently boasts higher favorability ratings than either the Democratic or Republican Parties, according to the latest Wall Street Journal/NBC News poll coming out later today.
More than four in 10, 41%, of respondents said they had a very or somewhat favorable view of the Tea Party movement, while 24% said they had a somewhat or very negative view of the group. The Tea Party movement gained notoriety over the summer following a series of protests in Washington, D.C. and other cities over government spending and other U.S. economic policies.
Meanwhile, the Democratic Party, which controls both the White House and Congress, has a 35% positive rating compared with a 45% negative rating.
The Republican Party identifies closest to the Tea Party movement’s ideology, but the group has also caused splits within the GOP. Republicans currently hold a 28% favorability rating compared with a 43% negative one.
John Allen Paulos mounts the defense I've been waiting to see for evidence-based medicine. I particularly like his reductio ad absurdum, argument as it's the anti-Denialism one I've been privately making for weeks:
In his inaugural address, Barack Obama promised to restore science to its “rightful place.” This has partly occurred, as evidenced by this month’s release of 13 new human embryonic stem-cell lines. The recent brouhaha over the guidelines put forth by the government task force on breast-cancer screening, however, illustrates how tricky it can be to deliver on this promise. One big reason is that people may not like or even understand what scientists say, especially when what they say is complex, counterintuitive or ambiguous.
As we now know, the panel of scientists advised that routine screening for asymptomatic women in their 40s was not warranted and that mammograms for women 50 or over should be given biennially rather than annually. The response was furious. Fortunately, both the panel’s concerns and the public’s reaction to its recommendations may be better understood by delving into the murky area between mathematics and psychology.
Much of our discomfort with the panel’s findings stems from a basic intuition: since earlier and more frequent screening increases the likelihood of detecting a possibly fatal cancer, it is always desirable. But is this really so? Consider the technique mathematicians call a reductio ad absurdum, taking a statement to an extreme in order to refute it. Applying it to the contention that more screening is always better leads us to note that if screening catches the breast cancers of some asymptomatic women in their 40s, then it would also catch those of some asymptomatic women in their 30s. But why stop there? Why not monthly mammograms beginning at age 15?
The answer, of course, is that they would cause more harm than good. Alas, it’s not easy to weigh the dangers of breast cancer against the cumulative effects of radiation from dozens of mammograms, the invasiveness of biopsies (some of them minor operations) and the aggressive and debilitating treatment of slow-growing tumors that would never prove fatal.
The exact weight the panel gave to these considerations is unclear, but one factor that was clearly relevant was the problem of frequent false positives when testing for a relatively rare condition. A little vignette with made-up numbers may shed some light. Assume there is a screening test for a certain cancer that is 95 percent accurate; that is, if someone has the cancer, the test will be positive 95 percent of the time. Let’s also assume that if someone doesn’t have the cancer, the test will be positive just 1 percent of the time. Assume further that 0.5 percent — one out of 200 people — actually have this type of cancer. Now imagine that you’ve taken the test and that your doctor somberly intones that you’ve tested positive. Does this mean you’re likely to have the cancer? Surprisingly, the answer is no.
To see why, let’s suppose 100,000 screenings for this cancer are conducted.
Apparently, the pressure from the public, government and especially, shareholders (Wall Street Pay Practices Under Pressure; Now From Shareholders Too) has had an impact. From the NY Times:
With France joining Britain in proposing a steep tax on bank bonuses, Goldman Sachs moved on Thursday to quell the uproar over its resurgent profits and pay.
Bowing to calls for restraint in tough economic times, Goldman said that its most senior executives would forgo cash bonuses this year. Instead, the 30 executives will be paid in the form of long-term stock — an arrangement that means they will not get big year-end paydays, but one that could turn out to be enormously lucrative if Goldman’s share price rises over time.
The move is meant to address concerns that bankers and traders in the past benefited from short-term performance. The shift at Goldman locks up the executives’ rewards for five years and enables Goldman to claw back the bonuses in the event the bank’s business sours.
Goldman did not say how much it would pay the executives, suggesting the bank would continue a practice — widely followed in investment banking — of allocating roughly half its annual revenue for compensation. While their bonuses will be paid in long-term stock, the payouts are likely to be worth many millions of dollars.
It is uncertain if the move, which applies only to a small number of Goldman employees, will be enough to placate critics of Wall Street, including some policy makers in Washington, where Kenneth R. Feinberg, the special master of compensation, will release new pay rulings on Friday.
“We’re starting to see some firms adopt compensation structures and policies that are in the direction of the principles that the president and Feinberg have been articulating, but we have a long way to go,” said Neal Wolin, deputy secretary of the Treasury ...
Peter Atlas always thought Concord-Carlisle Regional High School was open to diversity, but when he put out his casting call for the musical “Falsettos’’ he had doubts about the turnout.
How many teenagers would audition for a show about two homosexual couples, a straight couple, and a 12-year-old boy?
Dozens, he learned. When it came time to cast the seven-member ensemble, Atlas had his pick from among around 50 candidates from across the student body.
“I can’t begin to tell you how proud I am of our administration for supporting this show,’’ said Atlas, a math teacher and sometime theatrical director. “To say I was surprised would be to underestimate them, but I can tell you I was delighted.’’
As Atlas and his cast prepare to open “Falsettos’’ this Friday, they may be making high school theatrical history.
The musical, co-written by Natick native William Finn and James Lapine, won two Tony awards after its 1992 debut. But according to Brad Lohrenz, director of licensing at the agency that handles Finn’s royalties, Concord-Carlisle is the first public high school in the country to produce the show for an outside audience.
“I can’t quite believe that a public high school is doing this,’’ Finn said last week. “It seems either very brave or very stupid to me. But honestly, it’s wonderful that this is being done. It makes me think that high school must be a much more civilized place than it was when I was a student.’’
But it doesn’t surprise the cast members that their school is the one to break new ground in this way. They say they have all grown up in an environment that welcomes diversity of all kinds, including sexual orientation.
“Among most groups here, it’s widely accepted, just another thing that the person is, and not something negative. A characteristic, like having blue eyes,’’ said stage manager Ben Marsh. “There will always be a few jerks who think it’s not OK, but that’s to be expected. This play definitely discourages stereotypes and serves as an information source.’’
“Falsettos’’ tells the story of Marvin, a married man who decides to leave his wife to begin a new life with his male lover, and the effect that decision has on his own family as well as two other couples, one lesbian and one heterosexual.
Representative Louise M. Slaughter, Democrat of New York. At 80, she is co-chairwoman of the Congressional Pro-Choice Caucus — a member of what Nancy Keenan, president of Naral Pro-Choice America, calls “the menopausal militia.”
The militia was working overtime in Washington last week, plotting strategy for the coming debate over President Obama’s proposed health care overhaul. With the Senate set to take up its measure on Monday, a fight over federal funding for abortion is threatening to thwart the bill — a development that has both galvanized the abortion rights movement and forced its leaders to turn inward, raising questions about how to carry their agenda forward in a complex, 21st-century world.
It has been nearly 37 years since Roe v. Wade, the landmark Supreme Court decision that established a right to abortion, and in that time, an entire generation — including Mr. Obama, who was 11 when Roe was decided — has grown up without memories like those Ms. Slaughter says are “seared into my mind.” The result is a generational divide — not because younger women are any less supportive of abortion rights than their elders, but because their frame of reference is different.
“Here is a generation that has never known a time when abortion has been illegal,” said Anna Greenberg, a Democratic pollster who studies attitudes toward abortion. “For many of them, the daily experience is: It’s legal and if you really need one you can probably figure out how to get one. So when we send out e-mail alerts saying, ‘Oh my God, write to your senator,’ it’s hard for young people to have that same sense of urgency.”
Polls over the last two decades have shown that a clear majority of Americans support the right to abortion, and there’s little evidence of a difference between those over 30 and under 30, but the vocabulary of the debate has shifted with the political culture. Ms. Keenan, who is 57, says women like her, who came of age when abortion was illegal, tend to view it in stark political terms — as a right to be defended, like freedom of speech or freedom of religion. But younger people tend to view abortion as a personal issue, and their interests are different.
The 30- to 40-somethings — “middle-school moms and dads,” Ms. Keenan calls them — are more concerned with educating their children about sex, and generally too busy to be bothered with political causes. The 25-and-under crowd, animated by activism, sees a deeper threat in climate change or banning gay marriage or the Darfur genocide than in any rollback of reproductive rights. Naral is running focus groups with these “millennials” to better learn how they think.
“The language and values, if you are older, is around the right to control your own body, reproductive freedom, sexual liberation as empowerment,” said Ms. Greenberg, the pollster. “That is a baby-boom generation way of thinking. If you look at people under 30, that is not their touchstone, it is not wrapped up around feminism and women’s rights.”
The number of food stamp recipients has climbed by about 10 million over the past two years, resulting in a program that now feeds 1 in 8 Americans and nearly 1 in 4 children. Here's the NY Times' analysis:
With food stamp use at record highs and climbing every month, a program once scorned as a failed welfare scheme now helps feed one in eight Americans and one in four children.
It has grown so rapidly in places so diverse that it is becoming nearly as ordinary as the groceries it buys. More than 36 million people use inconspicuous plastic cards for staples like milk, bread and cheese, swiping them at counters in blighted cities and in suburbs pocked with foreclosure signs.
Virtually all have incomes near or below the federal poverty line, but their eclectic ranks testify to the range of people struggling with basic needs. They include single mothers and married couples, the newly jobless and the chronically poor, longtime recipients of welfare checks and workers whose reduced hours or slender wages leave pantries bare.
While the numbers have soared during the recession, the path was cleared in better times when the Bush administration led a campaign to erase the program’s stigma, calling food stamps “nutritional aid” instead of welfare, and made it easier to apply. That bipartisan effort capped an extraordinary reversal from the 1990s, when some conservatives tried to abolish the program, Congress enacted large cuts and bureaucratic hurdles chased many needy people away.
From the ailing resorts of the Florida Keys to Alaskan villages along the Bering Sea, the program is now expanding at a pace of about 20,000 people a day.
There are 239 counties in the United States where at least a quarter of the population receives food stamps, according to an analysis of local data collected by The New York Times.
The counties are as big as the Bronx and Philadelphia and as small as Owsley County in Kentucky, a patch of Appalachian distress where half of the 4,600 residents receive food stamps.
In more than 750 counties, the program helps feed one in three blacks. In more than 800 counties, it helps feed one in three children. In the Mississippi River cities of St. Louis, Memphis and New Orleans, half of the children or more receive food stamps. Even in Peoria, Ill. — Everytown, U.S.A. — nearly 40 percent of children receive aid.
While use is greatest where poverty runs deep, the growth has been especially swift in once-prosperous places hit by the housing bust. There are about 50 small counties and a dozen sizable ones where the rolls have doubled in the last two years. In another 205 counties, they have risen by at least two-thirds. These places with soaring rolls include populous Riverside County, Calif., most of greater Phoenix and Las Vegas, a ring of affluent Atlanta suburbs, and a 150-mile stretch of southwest Florida from Bradenton to the Everglades.
Although the program is growing at a record rate, the federal official who oversees it would like it to grow even faster.
“I think the response of the program has been tremendous,” said Kevin Concannon, an under secretary of agriculture, “but we’re mindful that there are another 15, 16 million who could benefit.”
Nationwide, food stamps reach about two-thirds of those eligible, with rates ranging from an estimated 50 percent in California to 98 percent in Missouri. Mr. Concannon urged lagging states to do more to enroll the needy, citing a recent government report that found a sharp rise in Americans with inconsistent access to adequate food.
“This is the most urgent time for our feeding programs in our lifetime, with the exception of the Depression,” he said. “It’s time for us to face up to the fact that in this country of plenty, there are hungry people.” ...
The uproar over the on-again, off-again guidelines on when women should have mammograms is proof of the blindingly obvious: Health-care reform that actually controls costs -- rather than just pretending to do so -- would be virtually impossible to achieve.
I say "would be" because none of the voluminous reform bills being shuttled around the Capitol on hand trucks even tries to address a central factor that sends costs spiraling out of control, which is that each of us wants the best shot at a long, healthy life that medical science can offer. Just as all politics is local, all health care is personal. Skimping on somebody else's tests and procedures may be worth debating, but don't mess with mine.
Intellectually, it's simple to understand why it might make sense for women -- those who have no special risk factors for breast cancer -- to wait until they're 50, rather than 40, to start getting mammograms. The analysis by the U.S. Preventive Services Task Force, which made the recommendation, looks sound. According to the panel, a whopping 10 percent of mammograms result in false-positive readings that can lead to unjustified worry and unneeded procedures, such as biopsies. In a small number of cases, women are subjected to cancer treatment or even a mastectomy they didn't need.
This harm, the task force reasoned, outweighs the benefits of discovering relatively few cases of fast-growing, life-threatening breast cancer in women in their 40s through annual mammography. It is also true that waiting to begin regular mammograms until a woman reaches 50 -- and reducing the frequency to once every two years, as the task force recommended -- would save a portion of the more than $5 billion spent on mammography in the United States each year.
The problem lies in those relatively few instances when a mammogram does find that a woman in her 40s has a life-threatening tumor, and when early detection saves her life. This scenario may be fairly rare, but it happens. Given the option, many women would rather be safe than sorry -- and safe costs money ....
Each of us should ask ourselves: How much expensive, unnecessary, high-tech testing and treatment am I willing to have our out-of-control health system pay for to save one life, if the life in question might be mine or that of a loved one? The honest answer, I think, is: a whole bunch.
The honest solution is a word that cannot be spoken: rationing. Our system already rations health care based on the individual's ability to pay. Insurance companies ration some tests and procedures based on age, risk factors and what often seems like whim. This ad hoc rationing doesn't work very well, and nothing in any of the reform bills even tries to address the basic consensus that makes spending continue to rise: Put a lid on everybody else's costs, but don't touch mine.
For more young adults, there is no place like home for the holidays, and for the rest of the year, too. Ten percent of adults younger than 35 told the Pew Research Center that they had moved back in with their parents because of the recession.
They also blamed the economy for other lifestyle decisions. Twelve percent had gotten a roommate to share expenses. Fifteen percent said they had postponed getting married, and 14 percent said they had delayed having a baby.
In the Pew study, 13 percent of parents with grown children said one of their adult sons or daughters had moved back home in the past year. According to Pew, of all grown children who lived with their parents, 2 in 10 were full-time students, one-quarter were unemployed and about one-third said they had lived on their own before returning home.
According to the census, 56 percent of men 18 to 24 years old and 48 percent of women were either still under the same roof as their parents or had moved back home.
A smaller share of 16-to-24-year-olds — 46 percent — is currently employed than at any time since the government began collecting that data in 1948.
Meanwhile, the portion of adults 18 to 29 who lived alone declined to 7.3 percent in 2009 from 7.9 percent in 2007, according to the Current Population Survey. A decline that big was recorded only twice before over three decades, in the early 1980s and the early 1990s during or after recessions.
Dr. Nancy makes a compelling case for the scientific method and against knee jerk, pre-judged reactions, on yesterday's Meet The Press:
A few years ago, an independent group that issues guidelines on cancer screening decided to review its recommendations for breast cancer. It had last issued guidelines in 2002, but things had changed — there was new science and researchers had become more sophisticated in analyzing existing data.
So the group, the U.S. Preventive Services Task Force, started what it thought would be a straightforward job: gathering the newest science and asking about the benefits and risks of breast cancer screening, the best time to start and how often women should be screened.
The group ended up recommending that most women forgo routine mammograms in their 40s and test every other year instead of every year.
The response was swift and angry. Professional groups, like the American College of Radiology, advocacy groups, like the American Cancer Society, and politicians said the guidelines would deprive women of a life-saving test. And some said the guidelines were politically motivated to save money.
Panel members have been taken aback by the response. Their work seemed almost mundane, they say, just an effort to gather and evaluate the best possible evidence.
The task force, a 16-member panel of experts appointed by the Department of Health and Human Services, began its work as usual. It went to an academic center, in this case the Evidence-Based Practice Center at the Oregon Health and Science University, and asked for an extensive review of all the relevant papers published on breast cancer screening, including ones used in the last review. At that time, the task force recommended routine screening starting at 40, saying that there were benefits although they became greater as age increased. The Oregon group had done similar reviews for the panel, including a review for the 2002 guidelines.
This time, the panel hoped that it could get missing pieces of the puzzle. New studies allowed scientists to zero in on benefits and harms for women in their 40s and to evaluate with far more certainty not just whether women should be screened but also how often.
The Oregon scientists began by combing the literature. By November 2007, the researchers, led by Dr. Heidi D. Nelson, a professor of medicine, medical informatics and clinical epidemiology at the university, had finished its review and sent its work to 15 outside scientists for review, then sent it to the panel. Finally, the researchers were ready to make their first full presentation to the panel members.
Part of that evidence, which Dr. Nelson’s group included, was new results from a huge study in England of mammograms for women in their 40s. This study, published in 2006, compared 54,000 women offered mammograms starting at age 40 with 107,00 women the same age who were not offered them. Previous studies of women in their 40s had them starting at various times in that decade of their lives and so were less useful.
But the British study saw only a small decline in the breast cancer death rate after 10 years, and it was not statistically significant, meaning it could have occurred by chance. Previous studies also failed to find a statistically significant effect for women in their 40s.
Dr. Nelson’s group did a new analysis combining all the studies. By adding up all the small benefits, the researchers concluded that there was a slight benefit of screening, a statistically significant 15 percent decline in the death rate from breast cancer for women in their 40s.
That means, they said, that 1,900 women ages 40 to 50 must be screened to prevent one death from breast cancer up to 20 years later. At the same time, even with the screening, five deaths would have occurred anyway, probably because many of those cancers grew so fast that no matter how early they were found it was impossible to cure the women. So in the end, 1 out of 6 deaths would have been prevented.
The task force wanted more information. What about the harms of screenings for women in their 40s, it asked?
One harm is excess tests, like biopsies. But there was not much published data.
Dr. Nelson’s group drew upon a National Cancer Institute database of eight million mammograms in the United States telling what sort of mammogram — digital or film — the women got, when they got it, and whether they had follow-up tests. Analyzing those data, she concluded that women in their 40s have about a 10 percent chance of a false positive and a 1 percent chance of having a biopsy each time they have a mammogram. While those risks are small, they gain more significance when weighed against the relatively small risk of cancer for women in their 40s — a risk of 1.5 per of 1,000 women.
The serious harm, panel members said, is overdiagnosis, finding cancers that are better off not being found.
In 2002, when the group last reviewed breast cancer screening studies, the idea of overdiagnosis was not well formed. It has been hard for many people, even scientists, to believe that some cancers start then stop or even regress. But researchers all over the world have been finding overdiagnosis in studies of all sorts of cancers.
Last year, the government spent $50 billion in the last two months of a patients life: more than it spends on the Dept of Education or Homeland Security. Much of this money is wasted in futile attempts to keep the natural, inevitable result at bay. Medicare, for instance, will spend $40,000 on a drug that extends breast cancer victims lives by one month (I wonder how many vaccines $40k would buy?).
How much is too much, when is enough enough, and what should our priorities be -- these are the fundamental, rational questions we need to be asking ourselves if we truly want to reform our health care system. Unfortunately, after weeks like the last one, rational, evidence-based discussion of what's appropriate, for whom and when seems even less likely than before. From 60 Minutes:
The Cost of Dying:
Many Americans spend their last days in an intensive care unit, subjected to uncomfortable machines or surgeries to prolong their lives at enormous cost.
Watch CBS News Videos Online
At Home, At Peace:
Dr. Herb Maurer has made a decision about where he will spend his final days.
Watch CBS News Videos Online
Comfort and Costs:
According to oncologist Letha Mills, whose 70-year-old husband Dr. Herb Maurer is terminally ill with cancer, helping people die at home might increase their comfort and create savings in our healthcare system.
Watch CBS News Videos Online
President Obama’s scramble for a health care overhaul, like his dash across Asia last week, obscures an irony of his first year in office. As he tries to effect his agenda, the politician who campaigned on “the fierce urgency of now” plays for time to demonstrate the benefits of policies that, if they work, will not work quickly.
Mr. Obama, backed by some independent economists, believes that his stimulus plan has helped pull the economy into recovery. But he is at least months away from being able to make that case by pointing to a decline in joblessness.
Mr. Obama returned from Asia to lobby Congress on his health policy goals, and won a significant preliminary victory in the Senate over the weekend. Many changes would not even be in place until 2013 — including such popular provisions as subsidies for buying coverage and prohibitions against insurance companies from denying coverage to people with pre-existing conditions.
His initiative to curb global warming by limiting carbon emissions may raise energy costs long before Americans perceive environmental or economic benefits, if they ever do. The most demonstrable near-term result of his forthcoming Afghanistan strategy will be more troops for an unpopular war.
In Asia, Mr. Obama pushed to “rebalance” the world economy through policy shifts in Beijing that he hoped would benefit Americans via more exports to China. The world’s oldest continuous major civilization showed no sign of a quick pivot.
The president’s challenge is pursuing far-reaching changes in a political and media culture centered on short-term consequences. He has disdained the values of the “24-hour news cycle” and vowed to ignore day-to-day fluctuations in polls, financial markets and cable-TV chatter.
“I’ve got to be looking at the horizon,” Mr. Obama said in a January interview. That becomes harder to afford with an approaching election ...
White House aides bristled at news media reviews suggesting Mr. Obama had failed to secure diplomatic victories in China. “This isn’t an immediate gratification business,” said David Axelrod, the presidential adviser.
But midterm elections arrive in 11 months. For Congressional Democrats — facing politically risky votes on Mr. Obama’s health care, energy, budget and immigration initiatives — the horizon is approaching rapidly.
For their sake and its own, Team Obama is not ignoring that reality.
A White House “jobs summit” will explore near-term steps to accelerate job creation, even though the administration is loath to widen the budget deficit and additional spending may not reduce unemployment rapidly anyway.
To ensure that voters see immediate benefits from health legislation, Democrats have included quick-trigger provisions to bar insurers from putting lifetime caps on benefits and to help expensive-to-cover patients buy insurance through government “high-risk pools.” Weeks before visiting Beijing, Mr. Obama nodded to the anxieties of American workers by imposing tariffs on Chinese tires.
Mr. Obama enjoys thicker political insulation than Democrats in Congress; polls show that voters like him personally, and he does not face re-election until 2012. But he feels the pressures of his strategy, nonetheless.
Before returning to Washington, he took solace in the timelessness of the Great Wall. “It gives you a good perspective on a lot of the day-to-day things,” he mused. “They don’t amount to much in the scope of history.”
As regular A Blue View readers know, I'm reading, and have been greatly effected by, Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives. Here's an interview with the author:
President Obama's vision for making health care in America more effective and efficient collided for the first time last week with the realities and peculiarities of the nation's health-care system.
As the Senate moved toward its first floor vote on the health-care reform bill, two independent expert groups coincidentally released new guidelines for mammograms and Pap tests aimed at improving treatment for two forms of cancer in women.
Although neither set of recommendations was aimed at cutting costs, both were based on the kind of objective analysis of scientific research that the Obama administration has embraced in its bid to make care better and more economical.
But after the recommendations unleashed fierce criticism, controversy and debate, the administration appeared to quickly distance itself from the mammography guidelines to try to prevent the uproar from endangering a domestic priority.
"This tells us an awful lot more about where we are as a country in terms of our relationship to the health-care system and health-care reform than they do provide new information about how often women should get screened," said John Abramson, a clinical instructor at Harvard Medical School and a leading proponent of eliminating unnecessary care. "It's like a Rorschach test of where we are when it comes to the health-care system and health-care reform."
Nancy-Ann DeParle, director of the White House Office for Health Reform, said Saturday that the debate over the guidelines goes to the heart of "the unique doctor-patient relationship in the American health-care system and the desire to preserve that."
"Today many of these decisions are being made by insurance companies and bureaucrats, and we want to make sure those decisions are made by doctors," DeParle said.
The recommendations about mammograms and Pap tests are the latest in a series of guidelines that have been emerging as part of "evidence-based" medicine. The seemingly obvious idea behind the movement is to base medical decisions on the best available scientific evidence, including "comparative effectiveness" studies, instead of relying on tradition, intuition or personal experience.
"One of the things I think you're seeing is the maturation of the concept of evidence-based medicine," said Ned Calonge, chairman of the U.S. Preventive Services Task Force, the federally appointed panel that issued the new mammography guidelines.
Here's a perfect example of Denialism from the Chris Mathews show. Notice how no doctors or scientists are presented, very few scientific/medical objections are raised to the new mammogram recommendation and the few that are, are generally wrong (sorry Bazell, risk reward analysis is science). And while I generally like Congresswoman Debbie Wasserman-Schulz, having been a breast cancer patient does not make you an oncologist and its therefore wildly inappropriate of her to be offering medical advice (especially when she has the power to codify her personal opinions into law):
Now contrast that approach with this one presented on another MSNBC show, one actually hosted by a medical doctor, Dr Nancy Sneiderman. Perhaps not surprisingly, she sets the entire debate between medical professionals and they focus their comments on the science. It's also worth noting how the American Cancer Society rep seems to have an agenda designed to scare people (any chance so it's they keep donating to his group?). Notice how Dr. Nancy and the other expert both strongly object to the misleading way he presents the statistical data.
We need to be seeing more of Dr. Nancy's approach and less of Chris Mathews: the only valid way to rebut the new mammogram & pap smear recommendations is a debate of their scientific & medical merits.
My point about Denialism is that the way the panel's recommendations are generally being rebutted in the media--by talking heads expressing their personal opinions, beliefs & preconceived biases--is not the way to do it. That's not science, that's religion.
Health and Human Services Secretary Kathleen Sebelius did a marvelous job this week of undermining the move toward evidence-based medicine with her hasty and cowardly disavowal of a recommendation from her department's own task force that women under 50 are probably better off not getting routine annual mammograms.
This is an old issue that has not only sharply divided the medical community for more than 20 years, but also taps into deep resentments among women who, over the years, have felt neglected by a male-dominated medical establishment. And there's no doubt that the advisory panel's recommendation came at a politically inconvenient time, just as Congress enters the crucial final phase in a health reform debate in which opponents have successfully stoked fears of medical rationing.
But rather than showing the leadership necessary to lead a grown-up national discussion on how to eliminate unnecessary or wasteful procedures, Sebelius simply disowned the task force and ran for political cover. Just as the hysteria over "death panels" killed any chance that Medicare recipients and their patients might be encouraged to engage in an intelligent conversation about end-of-life care before it becomes an issue, the mammogram brouhaha is likely to set back efforts to dramatically increase research into what really works and what doesn't, and use the results to revamp the way medical care is delivered and paid for.
I should acknowledge that I have no idea who should and should not get routine mammograms. But I know enough about statistics to say that the issue is not settled just because you know of someone in her 40s whose breast cancer was detected by a mammogram and cured. As economists and medical researchers are fond of saying, the plural of anecdote is data.
To make a valid scientific finding of who should be screened and how often, you'd have to take into consideration how big the risk is that women are likely to develop cancer at any particular age; how fast tumors are likely to grow and how likely they are to be cured once they are caught; what is the likelihood that a tumor detected by mammogram might be found some other way; what is the probability that a suspected tumor turns out not to be pre-cancerous, or that doing a biopsy on it will actually increase the chance that it could become dangerous later. You'd also have to weigh the benefits of routine screening -- deaths avoided and years of life extended -- against the medical problems caused by complications that arise from biopsies, along with the mental anguish that goes along with the large number of false positives that crop up on mammographies of women in their 40s.
All that, of course, is exactly what the task force did, based on numerous studies done in different countries using different methodologies. In the end, it found that while some lives might be saved each year, the benefits of annual screening of women in their 40s were outweighed by the costs -- and that's without even getting into the financial costs, which run to several billion dollars a year.
As is often the case in such matters, those raising the most fuss were those with greatest financial interest in mammography (the radiologists and the makers of mammography machines) and the disease groups (in this case, the American Cancer Society), which tend to resist recognizing limits on how much time, money and attention is devoted to their cause.
"How many mothers, sisters, aunts, grandmothers, daughters and friends are we willing to lose to breast cancer while the debate goes on about the limitations of mammography?" Otis Brawley, chief medical officer of the American Cancer Society, asked in an op-ed article in Thursday's Washington Post. Dr. Brawley cleverly didn't answer his own question, but the clear implication of his question was that the only acceptable number should be zero. And it is that very attitude, applied across the board to every patient and every disease, which goes a long way in explaining why ours is the most expensive, and one of the least effective, health-care systems in the industrialized world.
The political argument from the White House was that it was necessary to duck this fight over evidence-based medicine in order to save it. The better approach would have been to see this as one of those teachable moments that could be used to reaffirm the entire rationale for reform. For while debate continues over whether some women may be getting too many mammograms, there is evidence that there are women who, because they lack insurance, are getting too few -- and dying unnecessarily as a result. What health reform is about is correcting that imbalance while devising new mechanisms for improving health outcomes and getting better control over costs.
Put in that context, it would have been perfectly reasonable for Sebelius to have announced that she was delaying implementation of the task force recommendation for a year in order to give it more time to seek a broader consensus among researchers, doctors and patients. That would have made clear that the administration remained committed to a health-care system driven by the best medical evidence but one that is also sensitive to broad public opinion. This is a tough-love message the country, and the Congress, need to hear.
This week, the science of medicine bumped up against the foundations of American medical consumerism: that more is better, that saving a life is worth any sacrifice, that health care is a birthright.
Two new recommendations, calling for delaying the start and reducing the frequency of screening for breast and cervical cancer [see The Next Medical Test Whose Use Will Be Decided By A Popularity Contest], have been met with anger and confusion from some corners, not to mention a measure of political posturing.
The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.
“People are being asked to think differently about risk,” said Sheila M. Rothman, a professor of public health at Columbia University. “The public state of mind right now is that they’re frightened that evidence-based medicine is going to be equated with rationing. They don’t see it in a scientific perspective.”
For decades, the medical establishment, the government and the news media have preached the mantra of early detection, spending untold millions of dollars to spread the word. Now, the hypothesis that screening is vital to health and longevity is being turned on its head, with researchers asserting that mammograms and Pap smears can cause more harm than good for women of certain ages.
On Monday, the United States Preventive Services Task Force, a federally appointed advisory panel, recommended that most women delay the start of routine mammograms until they are 50, rather than 40, as the group suggested in 2002. It also recommended that women receive the test every two years rather than annually, and that physicians not train women to perform breast self-examination.
The task force, whose recommendations are not binding on insurers or physicians, concluded after surveying the latest research that the risks caused by over-diagnosis, anxiety, false-positive test results and excess biopsies outweighed the benefits of screening for women in their 40s. It found that one cancer death is prevented for every 1,904 women ages 40 to 49 who are screened for 10 years, compared with one death for every 1,339 women from 50 to 74, and one death for every 377 women from 60 to 69.
On Friday, the American College of Obstetricians and Gynecologists plans to announce a similar revision to its screening guidelines for cervical cancer [see The Next Medical Test Whose Use Will Be Decided By A Popularity Contest] ...
“A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs and avoids unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman, a professor at the University of New Mexico who directed the process.
The challenge of persuading patients and doctors to accept such standards requires a transformational shift in thinking, particularly when the disease involved is as prevalent, as deadly, and as potentially curable as cancer. How do you convince them that it is in their best interest to play the odds when they have been conditioned for so long to not gamble on health? After all, for the one in 1,904 women in their 40s whose life would be saved by early detection of breast cancer, taking the risk would in retrospect seem a bad choice.
“This represents a broader understanding that the efforts to detect cancer early can be a two-edged sword,” said Dr. H. Gilbert Welch, a professor of medicine at Dartmouth who is among the pioneers of research into the negative effects of early detection. “Yes, it helps some people, but it harms others.”
Dr. Welch said this week’s recommendations could mark a turning point in public acceptance of that notion. “Now we’re trying to negotiate that balance,” he said. “There’s no right answer, but I can tell you that the right answer is not always to start earlier, look harder and look more frequently.”
That concept is proving easier to swallow in the halls of Dartmouth Medical School than in the halls of Congress. Coming as they did at the height of debate over a sweeping health care overhaul, the recommendations have provided fresh ammunition for those who warn that greater government involvement in medical decision-making would lead to rationing of health care. It has not mattered that the breast cancer screening recommendation is only advisory, and that the federal government, the American Cancer Society, and numerous private insurers have said they will not adopt it.
Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas, cited the task force’s screening statistics in a floor speech on Thursday. “One life out of 1,904 to be saved,” Ms. Hutchison said, “but the choice is not going to be yours. It’s going to be someone else that has never met you, that does not know family history.” She added, “This is not the American way of looking at our health care coverage.”
The health care bills in both the House and the Senate would establish commissions to encourage research into the effectiveness of medical tests and procedures, but would not require that the findings be translated into practice or reimbursement policies.
As throughout history, it may take decades for medical culture to catch up to medical science. Dr. Rothman pointed out that it took 20 years for the public to accept the discovery in 1882 that tuberculosis was caused by a bacterium and not by heredity or behavior ...
“It’s going to take time, there’s no doubt about it,” said Louise B. Russell, a research professor at the Rutgers University Institute of Health who has studied whether prevention necessarily saves money (and found it does not always do so). “It’s going to take time in part because too many people in this country have had a health insurer say no, and it’s not for a good reason. So they’re not used to having a group come out and say we ought to do less, and it’s because it’s best for you.”
There's another medical procedure that we'll use a popularity contest to decide how often, and on whom, it is done. At least that's the likely result of this NY Times report:
New guidelines for cervical cancer screening say women should delay their first Pap test until age 21, and be screened less often than recommended in the past.
The advice, from the American College of Obstetricians and Gynecologists, is meant to decrease unnecessary testing and potentially harmful treatment, particularly in teenagers and young women. The group’s previous guidelines had recommended yearly testing for young women, starting within three years of their first sexual intercourse, but no later than age 21.
Arriving on the heels of hotly disputed guidelines calling for less use of mammography, the new recommendations might seem like part of a larger plan to slash cancer screening for women. But the timing was coincidental, said Dr. Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that developed the Pap smear guidelines. The group updates its advice regularly based on new medical information, and Dr. Iglesia said the latest recommendations had been in the works for several years, “long before the Obama health plan came into existence.”
She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding, “There’s no political agenda with regard to these recommendations.”
Dr. Iglesia said the argument for changing Pap screening was more compelling than that for cutting back on mammography — which the obstetricians’ group has staunchly opposed — because there is more potential for harm from the overuse of Pap tests. The reason is that young women are especially prone to develop abnormalities in the cervix that appear to be precancerous, but that will go away if left alone. But when Pap tests find the growths, doctors often remove them, with procedures that can injure the cervix and lead to problems later when a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean.
Still, the new recommendations for Pap tests are likely to feed a political debate in Washington over health care overhaul proposals. The mammogram advice led some Republicans to predict that such recommendations would lead to rationing.
Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in an interview that he would continue to offer Pap smears to sexually active young women. Democratic proposals to involve the government more deeply in the nation’s health care system, he said, would lead the new mammography, Pap smear and other guidelines to be adopted without regard to patient differences, hurting many people.
“These are going to be set in stone,” Mr. Coburn said.
Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer screening, said in an interview: “And this Pap smear guideline is yet another cut back in screening? That is curious.” Mr. Specter, who was treated for Hodgkin’s lymphoma in 2005 and 2008, said Congress was committed to increasing cancer screenings, not limiting them.
Representative Rosa DeLauro, Democrat of Connecticut, said that the new guidelines would have no effect on federal policy and that “Republicans are using these new recommendations as a distraction.”
“Making such arguments, especially at this critical point in the debate, merely clouds the very simple issue that our health reform bill would increase access to care for millions of women across the country,” she said.
There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low incidence that convinces many doctors that it is safe to wait until 21 to screen.
The doctors’ group also felt it was safe to test women less often because cervical cancer grows slowly, so there is time to catch precancerous growths. Cervical cancer is caused by a sexually transmitted virus, human papillomavirus, or HPV, that is practically ubiquitous. Only some people who are exposed to it develop cancer; in most, the immune system fights off the virus. If cancer does develop, it can take 10 to 20 years after exposure to the virus.
The new guidelines say women 30 and older who have three consecutive Pap tests that were normal, and who have no history of seriously abnormal findings, can stretch the interval between screenings to three years.
In addition, women who have a total hysterectomy (which removes the uterus and cervix) for a noncancerous condition, and who had no severe abnormalities on previous Pap tests, can quit having the tests entirely.
The guidelines also say that women can stop having Pap tests between 65 and 70 if they have three or more negative tests in a row and no abnormal test results in the last 10 years.
The changes do not apply to women with certain health problems that could make them more prone to aggressive cervical cancer, including H.I.V. infection or having an organ transplant or other condition that would lead to a suppressed immune system.
It is by no means clear that doctors or patients will follow the new guidelines. Medical groups, including the American Cancer Society, have been suggesting for years that women with repeated normal Pap tests could begin to have the test less frequently, but many have gone on to have them year after year anyway.
Debbie Saslow, director of breast and gynecologic cancer for the American Cancer Society ... said, doctors in this country have been performing 15 million Pap tests a year to look for cervical cancer in women who have no cervix, because they have had hysterectomies.
Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial Sloan-Kettering Cancer Center, said the new guidelines should probably not be applied to all women, because there are some girls who begin having sex at 12 or 13 and may be prone to develop cervical cancer at an early age.
“I’m concerned that whenever you send a message out to the public to do less, the most vulnerable people at highest risk might take the message and not get screened at all,” Dr. Brown said.
Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he heard the advice to delay Pap testing until 21, “My emotional response is ‘Wow, that seems dangerous,’ and yet I know the chances of an adolescent getting cervical cancer are really low.”
I'm in the process of reading the excellent new book by Michael Specter Denialism: How Irrational Thinking Hinders Scientific Progress, Harms the Planet, and Threatens Our Lives and will have more on it later. The reaction to the recent scientific panel's pronouncement no longer recommending mammograms to women under 40, nor self-exams to any woman, as reported by the Wash Post below, is, however, a near perfect proof of Specter's argument: far too many people only support scientific conclusions that suit their preconceived biases while rejecting those that don't.
In 1997, a federal committee of medical experts recommended against routine mammograms for women in their 40s, sparking a political uproar that led to congressional hearings and a unanimous Senate vote challenging the findings.
Now, 12 years later, a similar drama is playing out around a different federal medical panel, which this week recommended against routine mammograms for women younger than 50, saying it is not worth subjecting some patients to unnecessary biopsies, radiation and stress.
The independent panel, the U.S. Preventive Services Task Force, also recommended against teaching women to do regular self-exams and concluded that there is insufficient evidence to recommend that doctors do exams.
The findings underscore a decades-long debate in the medical community about the benefits and risks of routine breast cancer screening for younger women. The conclusions also plunge the nonpartisan, nonpolitical advisory panel into the middle of a strident Washington discussion about health care, which has included allegations from Republicans that the Democrats' proposed reforms would lead to reduced care for patients.
Rep. Frank Pallone Jr. (D-N.J.) announced Tuesday that his House health subcommittee will hold hearings on the mammogram issue next month. Other lawmakers from both parties suggested that the task force had been swayed by insurance companies that stand to save money if fewer screenings are performed.
"We can't allow the insurance industry to continue to drive health-care decisions," said Rep. Debbie Wasserman Schultz (D-Fla.), who said earlier this year that she had undergone treatment for breast cancer.
The recommendations also garnered harsh criticism from powerful medical groups including the American Cancer Society -- which says it will continue to recommend regular mammograms for women older than 40 -- and the Access to Medical Imaging Coalition, which warned that the findings would "turn back the clock on the war on breast cancer."
Many patient advocacy groups and breast cancer experts, however, praised the decision, arguing that politics have too often interfered with science when it comes to mammograms. Maryann Napoli, associate director of the Center for Medical Consumers, said breast cancer screening is frequently "used by politicians as a way to say they are for women," whether or not the underlying policy makes sense.
The Anti-Defamation League, in a report released this week, has asserted that “a current of anti-government hostility has swept across the United States” since President Obama was elected just over a year ago.
Perhaps not surprisingly, the study cites the Tea Party movement and the at times rowdy health care town halls that occurred over the summer as examples of the increasingly anti-government climate. But it also takes aim at one prominent media figure: Glenn Beck.
In general, the report said that those more hostile toward government believe the Obama administration poses a threat to the long-term well-being of the country, with some believing the president wants to import socialism or fascism to America.
“Some of these assertions are motivated by prejudice, but more common is an intense strain of anti-government distrust and anger, colored by a streak of paranoia and belief in conspiracies,” the study found.
And Mr. Beck, the report found, has helped fan that hostility by invoking conspiracy theories and “demonizing” the administration on both his radio program and Fox News television show. In contrast, the A.D.L., a prominent Jewish organization whose mission is to fight anti-Semitism, reported that commentators like Rush Limbaugh and Sean Hannity have sharply criticized Mr. Obama on partisan grounds while dismissing extremists and conspiracy theorists.
Mr. Beck’s broadcasts “play an important role in drawing people further out of the mainstream, making them more receptive to the more extreme notions and conspiracy theories.”
Christopher Balfe, the president of Mr. Beck’s production company, Mercury Radio Arts, said Mr. Beck had no comment on the report at this time.
I love the fact that the first message was not something profound like the ones Samuel Morse and Alexandar Graham Bell transmitted, but something far more prosaic: "login." From NPR (listen to story):
The Internet began with a whimper, not a bang. And not everyone agrees on when that whimper occurred. But 40 years ago Thursday, something called the ARPANET came into existence, and since then, communication hasn't been the same.
Charley Kline's moment in history unfolded inside a large, empty computer lab at the University of California, Los Angeles, at 10:30 p.m. on Oct. 29, 1969.
"I was 21 and a programmer who liked to program all hours of the day and night," Kline says.
Those hours were spent with the SDS Sigma 7 — a computer the size of a one-bedroom apartment.
On the night of Oct. 29, Kline sent an electronic message from the Sigma 7 to another computer at the Stanford Research Institute in Menlo Park.
That transmission would literally transform the way we communicate today. To tell the story of how it happened, you have to start with the context in which it happened.
A communication revolution was taking place — but it was happening over the telephone. Telephones were for communicating, while computers were built to process information — to do things like payroll and number-crunching.
The IBM 1401, a computer system about the size of a two-car garage, could process about as much information as your cell phone — your ratty old cell phone from the 1980s, that is.
On a recent afternoon at the Computer History Museum in Mountain View, Calif., a few old-timers got the IBM 1401 up and running. That computer is one of many in the museum's main exhibit hall — a space the size of four football fields.
But, says Bill Duvall, "It's fair to say that your BlackBerry has more computing power than all of the computers in this room combined."
Duvall was on the receiving end of Kline's first message.
Nearly four years before Duvall and Kline did the Internet equivalent of the moon landing, Bob Taylor was sitting in his office at the Pentagon, where he worked for the Advanced Research Projects Agency, or ARPA.
And he was frustrated.
Taylor had three computer terminals in his office. Each one connected to a different computer in a different part of the country.
"To get in touch with someone in Santa Monica through the computer, I'd sit in front of one terminal, but to do the same thing with someone in Massachusetts, I would have to get up and move over to another terminal," Taylor recalls. "You don't have to look at this very long to realize this is silly. This is stupid. So I decided, OK, I want to build a network that connects all of these."
So Taylor started to collect really smart people — people who could build that network, like Duvall, Len Kleinrock at UCLA and the young Kline.
Taylor also sent word to the biggest technology companies that they could bid on a contract to help build that network.
"IBM refused to bid, as did AT&T," Kline remembers. "They both said, 'Can't be done; it's useless.' They saw the future of computing as bigger and bigger mainframes."
So a smaller company, Bolt, Beranek and Newman, got the contract. It built a device called the IMP, the interface message processor. It was as big as two full-size gym lockers.
Kline explains how it worked: "I would type a character. It would go into my computer. My software would take it, wrap around it all the necessary software to send it to the IMP. The IMP would take it and say, 'Oh, this is supposed to go up to SRI.' "
Think about it like your home Internet router, only 100 times bigger.
A Message For The History Books
It took about a year for Bolt, Beranek and Newman to build several of these IMPs and get them into place at different locations in the country, including at UCLA and SRI.
"At some point, we were ready to test it," Kline says. "It wasn't like we had planned it."
So, late on that October night in 1969, Kline, sitting at the UCLA computer lab, placed a phone call to Duvall at Stanford.
"We didn't walk into a darkened room, turn on the lights, flip the switch and have it work," Duvall says. "This was something that we tried some number of times. ... We were hooked up with a telephone headset, and we were talking to each other."
Kline started to type the historic message — an online communication roughly equivalent to what the Neanderthal is to modern humans.
"We should have prepared a wonderful message," says Kleinrock, who headed UCLA's computer lab then. "Certainly Samuel Morse did, when he prepared 'What hath God wrought,' a beautiful Biblical quotation. Or Alexander Graham Bell: 'Come here, Watson. I need you.' Or Armstrong up in the moon — 'a giant leap for mankind.' These guys were smart. They understood public relations. They had quotes ready for history."
On Oct. 29, Kleinrock says, "All we wanted to do ... was to send a simple login capability from UCLA to SRI. We just wanted to log into the SRI machine from UCLA."
And so the first computer network communication was — well, it was supposed to be the word "login."
"The first thing I typed was an L," Kline says. Over the phone, Duvall told Kline he had gotten it. "I typed the O, and he got the O."
Then Kline typed the G. "And he had a bug and it crashed."
And that was it. The first-ever communication over a computer network was "lo." The ARPANET was born.
About an hour later, at 10:30, they got it to work — and successfully transmitted L-O-G-I-N. Kline scribbled some notes into a logbook and went home to bed.
The question of whether people will follow a government order that they carry health insurance -- an issue that will help determine whether universal health care is a success or costly failure -- will depend on more than the penalty they would pay for refusing, many economists say. This, they say, is the lesson of behavioral economics, a school of thought that holds that people do not necessarily make decisions out of well-reasoned self-interest. It is an approach that has gained a powerful foothold in the Obama White House.
"We're human. And there are lots of other influences that go into what we do," said Kenneth Baer, a spokesman for the Office of Management and Budget. "One of the most important insights of behavioral economics is that we're not all rational maximizers calculating our cost and benefits and doing things like a computer."
As the proposed $900 billion health-care legislation inches toward the finish line, a critical unknown is whether people would comply with a mandate on individuals to carry insurance, one of the Democrats' primary tools to significantly increase the number of Americans who have coverage. The Senate Finance Committee, whose bill has dominated much of the recent debate, set its maximum penalty for noncompliance at $750 per year, at the same time creating subsidies to help low-income Americans buy coverage. In the House, the penalty is based on income, but works out to about the same for a middle-class family.
But many reform supporters say the finance panel's subsidies are too low. And insurers are pushing for larger penalties. If younger, healthier people pay the penalties instead of buying coverage, they warn, it will upset the legislation's balance, resulting in higher premiums for less-healthy people or bigger costs to the government.
That calculation is more complex when seen through the prism of behavioral economics, a hybrid of economics and psychology that has been ascendant for years, never more so than today, with many of its leading practitioners in the White House.
As the behavioral economists see it, compliance will depend not only on the penalties and cost of coverage, but also on the ease of signing up for coverage and whether people can be persuaded that it is a widely accepted social norm. They point to the large number of eligible people who fail to take advantage of Medicaid, food stamps and Pell grants as a sign that perceived inconvenience can keep people from taking steps in their economic interest. By contrast, the Medicare drug benefit program has achieved high enrollment partly because low-income Medicare recipients did not need to apply for subsidies if they already qualified for Medicaid.
"Non-financial things matter. . . . When the choice itself is complicated, it can deter people from making choices," said William J. Congdon of the Brookings Institution. "The small hassles associated with taking up programs -- driving to an office, filling out a form -- have a disproportionate effect in discouraging people."
The record of mandates is mixed, according to research done by Sherry Glied, a Columbia University professor of health policy who has been nominated for a position in the administration. The rates of people buying car insurance, for example, vary among states and do not correlate directly with the size of penalties for going without insurance. Overall, she found, mandates work best when compliance is relatively easy and affordable, when penalties are "stiff but not excessive," and when enforcement is prompt and routine.
From Nate Silver:
Back when I used to do high school debate, there were all sorts of esoteric arguments related to the notion of positive and negative rights. The distinction, to simplify the matter greatly, is that a positive right is something that permits you to act a certain way -- something granted to you -- whereas a negative right is a claim to noninterference -- something that precludes action from being taken against you, either by government or by other people. You'll most commonly hear the distinction in association with libertarianism, as libertarians tend to regard positive rights as impure manifestations of government fiat power, whereas negative rights exist intrinsically outside of government, which in turn has a duty to protect them.
I never found this framing terribly satisfying as a matter of moral philosophy -- there are too many things which fall somewhere in between the two poles. But as a political matter, the distinction is potentially quite interesting.
Take for example the issue of gay marriage. When gay marriage is polled, it is almost always framed as a positive right, as in: "should the government permit Adam and Steve to get married?". I wouldn't necessarily say I find this framing biased -- since gay marriage is only permitted in six out of the 50 states and only came about in those states very recently, it is probably the more natural, plain-English way to ask the question.
But there is a different way to frame the question that is no less fair, and flips the issue on its head. Namely: "should the government be allowed to prohibit Adam and Steve from getting married?". This is closer to the logic embodied by the court decisions in Iowa, California, Massachusetts, and other states. Those courts didn't create gay marriage; they argued, rather, that it was already protected by their respective state constitutions.
And it turns out that if you frame a polling question in this particular way, as Gallup and USA Today did recently, you get a very different set of responses. Take a look at what happens:
When USA Today asks whether gay marriage is a private decision, or rather whether government has the right to pass laws which regulate it, 63 percent say it's a private decision. This contrasts significantly with all other polling on gay marriage. The highest level of support gay marriage has received in the more traditional, positive-rights framing is 49 percent, from a ABC/Washington Post poll in late April. The average support is closer to about 41-42 percent. And indeed, this same survey organization, Gallup, last month released a poll that put the number of Americans approving of gay marriage at 40 percent.
So this USA Today poll is really something quite different -- nearly two-thirds of Americans say that gay marriage is "strictly a private decision" ...
The better argument against my interpretation of this poll is that it's contradicted by other evidence. Namely, last November in California, a state whose highest court had indeed ruled that gay marriage was protected by the state's constitution, some 52 percent of the electorate decided that they knew better, and that Adam and Steve would have to catch the next available flight to Burlington, Vermont.
But even though gay marriage had already become -- however briefly -- the law of the land in California, that wasn't how the debate unfolded on Proposition 8. Instead, look at what Equality California said on its website at the time:Every Californian should have the choice to marry the person they love. It’s a personal and fundamental freedom guaranteed by the California Constitution.Emphasis mine. True, Equality California mentioned that gay marriage had already been established under the state's constitution. The problem is that Proposition 8 wasn't an argument over how to interpret the state constitution -- it was an argument about whether or not to amend the constitution to render interpretation unnecessary.
What if Equality California had instead said this:California's government should not have the right to interfere with the decision of two loving adults to get married. It’s a personal and fundamental freedom protected by the California Constitution.You see the distinction? Equality California was still stuck in the positive rights paradigm. Gay marriage was something given to California by the state Supreme Court in its benevolent wisdom, not an intrinsic (negative) right for which the government had a duty of noninterference.
Would changing these few little words have made a difference last November? Probably not. But advocates for same-sex marriage can do a better job of framing their argument. Generally speaking, appeals to government noninterference are fairly popular; people don't like government telling them what they do and they don't have the right to do. Posit equal treatment under the law as the default -- how dare the government make a law that abridges this right on the basis of something as trivial as sexual orientation.
Whether it's because of this new poll (Support for Legalizing Marijuana Reaches New High Of 44%), this 2003 poll (75% of Americans favored allowing doctors to legally prescribe marijuana to patients) or just Obama honoring a campaign pledge, sanity is creeping into the "War on Drugs" according to the NY Times:
People who use marijuana for medical purposes and those who distribute it to them should not face federal prosecution, provided they act according to state law, the Justice Department said Monday in a directive with far-reaching political and legal implications.
In a memorandum to federal prosecutors in the 14 states that make some allowance for the use of medical marijuana, the department said that it was committed to the “efficient and rational use” of its resources and that prosecuting patients and distributors who are in “clear and unambiguous compliance” with state laws did not meet that standard.
The new stance was hardly an enthusiastic embrace of medical marijuana, or the laws that allow it in some states, but signaled clearly that the Obama administration thought there were more important priorities for prosecutors.
“It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana,” Attorney General Eric H. Holder Jr. said in a statement accompanying the memo, “but we will not tolerate drug traffickers who hide behind claims of compliance with state law to mask activities that are clearly illegal.”
Emphasizing that it would continue to pursue those who use the concept of medical marijuana as a ruse, the department said, “Marijuana distribution in the United States remains the single largest source of revenue for the Mexican cartels,” and pursuing the makers and sellers of illegal drugs, including marijuana, will remain a “core priority.”
The new memo is the latest reversal of Bush administration social policies that had especially rankled liberals. Yet the politics of marijuana cross ideological lines. For instance, in effectively deferring to the states on this particular issue, the Obama administration is taking what could be seen as a states’ rights stance, more commonly associated with conservatives. That was a theme that echoed on many conservative and libertarian Internet sites in the wake of Monday’s announcement ...
Graham Boyd, director of the Drug Law Reform Project at the American Civil Liberties Union, called the Justice Department’s move “an enormous step in the right direction and, no doubt, a great relief to the thousands of Americans who benefit from the medical use of marijuana.”