Map of life expectancy at birth from Global Education Project.

Wednesday, October 31, 2012

It does make me sad

My grandmother's sister lived in Ventnor, New Jersey, the town next to Atlantic City. As a matter of fact they lived on Ventnor Avenue, with which you are familiar if you have played Monopoly. When I was a kid, we used to visit in the summer. Aunt Mary and Uncle Oby didn't have kids so they shamelessly spoiled us. Uncle Oby was a local macher so he had free passes to all the rides on the Steeplechase Pier. They took us -- me, my siblings and cousins -- to all the shows on the Steel Pier: Herman's Hermits, Dave Clark Five, Wilson Pickett. We'd go to watch the diving horse and walk along the boardwalk scarfing up the salt water taffy, cotton candy, Planters Peanuts (they had a guy in a giant Mr. Peanut costume) and Taylor fried pork roll (basically a Spam competitor but a greasy treat for a kid). It was the greatest!

Atlantic City hasn't been all about the wholesome family entertainment since they sold out to Donald Trump and the Mafia and brought in casino gambling in the '70s. But the Boardwalk and the Steel Pier were still there. Until Monday, that is. The Atlantic City boardwalk has been destroyed, and judging from the pictures, the Steel Pier is history.  At least half of it is gone and I'm guessing they won't rebuild it.

I don't know whether the ocean made it as far as Ventnor Avenue, which is the second avenue paralleling the ocean behind Atlantic Avenue. I don't know whether Aunt Mary and Uncle Oby's house is still standing. Of course they died a long time ago and I haven't been to Atlantic City since I was maybe thirteen. I did visit Avalon, further south on the Jersey Shore, when I was in college. But anyway that whole area is deep in my family lore and my fondest childhood memories.* Now it's gone, just gone. Gone. The governor has said the Jersey shore will never be the same, and I'm sure he is right.

Was this a natural disaster? Partly. But it was also one of the greatest monuments to human folly of my lifetime. Yes of course war is a great folly and we've had plenty of wars that have been even more destructive and killed far more people. But these events will just keep happening, all around the globe. Good luck to us all.

* Don't know what to make of it, but of course Bruce Springsteen's famous ode to Asbury Park is subtitled "Sandy." According to the narrative of the song Sandy was his goodbye girl as he prepared to set out to make his fortune. "For me this boardwalk life's through, you ought to quit this scene too." The Asbury Park boardwalk is gone too, but I expect they'll rebuild that one. Haven't heard what happened to the Stone Pony.

Update:  Friend Steph says the section of the AC Boardwalk with the main attractions is in decent shape. That's good to know. Of course the social and economic decline of the old Atlantic City was only accelerated by casino gambling, not arrested.

Tuesday, October 30, 2012

LBTA- part 3

My power went out last night so I'm blogging on batteries. The power company gives no estimate of when I'll get the juice back, no blame there I'm sure there's just starting to get an idea of what they are facing. The political future just got even more critical, it seems to me.

There is some tragedy here, and a lot of pain and a whole lot more inconvenience and economic cost. But it's also an opportunity, potentially a wake up call. We'll have to do a whole lot differently from now on, from improving Manhattan's defenses against the rising ocean to stringing power lines that can withstand a twig falling on them to moving development away from the coast, and a whole lot more of that mitigation and adaptation. That means a huge amount of public investment.

Most important, of course, we need to stop spewing so much CO2 into the atmosphere.

Electing Mitt Romney, who wants to drastically cut the budget for disaster aid and reduce FEMA to block grants because nobody likes FEMA anyway, and who says he doesn't believe that humans are causing climate change, and who says that the way to create jobs is to cut government spending, will destroy this one chance. Make sure it doesn't happen.

Monday, October 29, 2012

Live blogging the apocalypse -- Part two

So far (8:00 am eastern time) I'm cool. It's getting a bit breezy but not so as to bring down any timber. I've got my 'lectric, just had my morning cup of joe, and . .. whoops, there goes a big gust. The National Weather Service is promising me tropical storm force winds soon enough, so I'm staying home.

I hereby command you to read Joe Romm on this situation. He very much likes the term Frankenstorm. My grandfather was a professor of English literature, who had a wide range of interests from Chaucer to Faulkner. Along the way he wrote about Mary Shelly's Frankenstein. The novel's central metaphor is taken to represent the ways in which scientific and technological advances can unleash unforeseeable consequences. (It's subtitle, in case you didn't know, is The New Prometheus. The Gods punished Prometheus for giving fire to humanity but we're all getting it on the chin for our collective folly in this world.)

Romm explains why this unprecedented event is happening now. What is unprecedented about it? It starts out as the largest hurricane in known history. That means, not the hurricane with the most powerful central winds, but the hurricane with the largest extent of tropical force winds, hundreds of miles in width. It could form as late in the season as it did, and retain its power as a hurricane, because the ocean is much warmer than it has been previously -- some 5 degrees Fahrenheit off the mid-Atlantic coast. At the same time, the disappearance of arctic sea ice and the reduced arctic temperature gradient causes the jet stream to develop deep southerly loops. An unprecedented blocking high off of Greenland and a powerful winter storm with its central low pressure moving into the central U.S. are causing the hurricane to make a highly unusual west turn into New Jersey, where it is colliding with the winter storm to create a hybrid which has never been seen before.

We'll see how extensive the wind damage, including power outages, really turn out to be, and whether Manhattan is inundated by the surge. Meanwhile, I'll be catching up on my reading. I'll let you know what Habermas says about Lifeworld and System. And I'll try to get back to you once the woods start crashing down around me, if the technology holds up well enough.

Sunday, October 28, 2012

Live blogging the apocalypse

I expect to lose electricity some time tomorrow, there's no telling how long the computer battery will last or whether Verizon will be able to get me to your Intertubes anyway. So I might as well get it while I can.

I have a five gallon can of potable water in the kitchen, a bucket in the bathroom for toilet flushing and two big tubs on the porch to scoop more out of. I'm building up the ice supply, have non-perishable food laid in and plenty of candles. The wood rack is full so I don't have to brave the elements. I'll just sit here and listen to the trees crashing down. Should be fun.

My aunt owns a beachfront house in Clinton, CT. No, she's not rich. She's the widow of a preacher, they had a bachelor friend who left the house to them. Fortunately her property is on a bluff about 20 feet above sea level. Her house should be okay but I expect the surge will overtop her seawall and possibly wash out her stairs and take away a chunk of front yard. Anyway she and my mother are going to stay at my cousin's house, well inland. They have a generator. Don't want to think about all the old folks who are going to have to ride it out alone. If you know any such people, check on them please.

What's really annoying about this is that we're getting used to it. I didn't get a generator after last year's serial collapses of civilization because I figured, what's the chance of it happening again? Well I'm a fool. We're all fools, who brought this on ourselves. Maybe we'll wake up.

First thing to do, when you do awake: take a solemn vow never, ever, to vote for any Republican candidate, for any office, under any circumstances. Republican=Koch=death.

Friday, October 26, 2012

We don't give medical advice . . .

. . . but, you might want to know that this pretty good study finds that taking benzodiazapines -- i.e. tranquilizers like Valium -- increases the risk of dementia by about 50%.

Guidelines call for these drugs to be used only on a short-term basis, but they are very widely prescribed, they are addictive, and many people take them for years on end. As a matter of fact many people doctor shop to get excessive benzo prescriptions just as others seek opioids.

This study doesn't absolutely drive the final nail into the coffin. It's difficult to correct for confounding by indication in this situation because symptoms that may foreshadow dementia could also be reasons for prescribing and taking these drugs. However, this study is carefully designed to account for that problem as much as possible, and it adds a more powerful and robust finding to a growing body of evidence.

As far as I'm concerned, dementia is the worst thing that can happen to you. It's also really unfortunate for your family and friends, and for society. Now we actually have a way of avoiding a substantial number of cases, by not taking tranquilizers. This is personal, by the way. My father died after a long, horrific journey with dementia. At one point, when he had a crisis, my mother's doctor gave her a big box of Valium. I'm happy to report that I advised her not to take it, and she threw it away.

Unfortunately, it's very difficult to get from findings such as this to real changes in clinical practice.

Wednesday, October 24, 2012


Indiana senatorial candidate Richard Mourdock has actually done us all a favor by forcing a public discussion about theology. That is a realm that has heretofore been off limits in politics. I'll bet a  lot of people might be interested to know more about the Mormon religion, but we aren't allowed to talk about it. Now we at least get to talk about Christianity.

In order to be a Christian, you absolutely must compartmentalize your thinking, so as to wall off what would be fatal conflicts if the wrong pieces ever came in contact with each other. Think about natural disasters. The reporters will go to a town that has been devastated by a tornado, and the survivors will all be giving thanks to God for protecting them. Of course, the people next door, maybe including your aunt and your cousins, are all dead or maimed. Hmm.

The miners are trapped underground.. A crew of 100 shows up with drilling equipment and works without sleep for five days, and gets them out, except for the guys who died in the initial collapse. Everybody thanks God for saving the miners. Hmm.

Your daughter is raped. Amazingly, even though it's a legitimate rape, the normal means the female body has to "shut all that down" fail in this case, and she's pregnant. God is all powerful, all knowing, and therefore one can only conclude that God intended for that to happen.

As a matter of fact, God knew at the beginning of time that after he got Mary pregnant, king Herod would get wind of it and murder all the babies in town. He intended for that to happen. God knew that Hitler was going to try to murder all the Jews in Europe. He intended for that to happen. God intended for me to lose my hair, for that matter, and he intended for you to get poison ivy. He intended it all. Hmm.

Tuesday, October 23, 2012

If it isn't on TV, it isn't happening

I was almost afraid to look at Climate Progress because I figured Joe Romm would be apoplectic over the "debate" last night. (I put the word in quotation marks because Romneybot 4.1 seemed to agree with Obama on everything except the quality of his rhetoric. But I digress.) Yes, it seems that "foreign policy" consists of vague conversations about the Middle East including whether we will do everything Bibi Netanyahu wants us to, whether we're gonna call China names, and how many navy ships we need for unstated purposes. I know Bob Schieffer is a much more serious person than me, but I would have asked about:

Anthropogenic climate change

Resource depletion

The global threat of communicable diseases including the faltering effort to eradicate polio, drug resistant TB, malaria, and other pathogens

The Mexican drug wars and the deleterious effects generally of the illicit drug trade in much of Latin America. (We, of course, being the consumers. Not that decriminalization could have come up as part of the solution. Sigh.)

The European financial crisis, granted not much for the U.S. to do about it but maybe there's a lesson there for the austerions? (Note that the candidates did manage to work in the U.S.  federal budget deficit as the greatest threat facing our children. Feh.)

The poverty killing children and crushing their lives in sub-Saharan Africa, Afghanistan, Pakistan (no, they can't eat bullets or hellfire missiles), parts of India and elsewhere in the world

International cooperation on science and technology

Russia is looking increasingly authoritarian and crony capitalistic, but is this a problem we need to worry about? Why or why not? How about continued nuclear arms reduction and other measures to achieve mutual reductions in military expenditures and increase security?

Global nuclear arms control, reduction, and eventual de-nuclearization of the planet? Nahhh, that's silly.

We really need to extract our collective heads from our collective posteriors.

Monday, October 22, 2012


The last time I wrote about Lance Armstrong, I was in essence responding to a friend who was a fan, who believed Armstrong was being persecuted. Now, on the one hand, having seen the USADA report, there seems no room for doubt that Armstrong was essentially the ringleader in a continual conspiracy by his team to get away with using banned performance enhancing drugs and autologous blood transfusions. There also can be no doubt that he has been a habitual, remorseless liar throughout his career.

Could there be an "on the other hand"? Well, yes, sorta kinda. The fact is it's a more than fair bet that every elite cyclist in that era broke the rules, or at least the majority of them. The TdF will be very reluctant, I expect, to declare the second place finishers in Armstrong's races the victors. Note that baseball, faced with a similar situation, has not invalidated any records or games from its own era of pervasive PED use. That was just the reality at the time, and it cannot be undone.

That said, every elite athlete's extreme capabilities depend on all sorts of scientifically tested artificial interventions, from diet and training routines finely tuned by biological measurements, to surgery, high altitude training, computer enhanced rehearsal techniques, you name it. The authorities don't necessarily get around to banning some substances until after they've been in use for a while -- the rules can change. So the question is, why exactly are some methods of enhancing performance allowed, while others are banned?

Some people argue that performance enhancing drugs can be harmful to health over the long term, so we don't want to encourage young people to use them. Maybe so, although the evidence in the case of some methods is weak. It is true, for example, that excessive use of EPO over the long term is harmful to cancer or dialysis patients -- you want the right amount of red blood cells, not too many. However, there is no evidence I'm aware of that episodic use by fit young people is dangerous. I haven't heard of cyclists having strokes or heart attacks.

And the fact is, while it's good to exercise and be physically fit, the extreme training routines and competition of elite athletes are actually detrimental in the long term. When they get older, athletes develop osteoarthritis at a very high rate, and of course they may have sequelae of concussions or other injuries, depending on the sport. American football is just starting to make some efforts to reduce this toll but it cannot be eliminated. Heck, we even allow boxing and mixed martial arts -- just participating in those sports is far more dangerous than using steroids or EPO.

So there is something arbitrary about this. Many people have proposed relaxing the rules for professional athletes, perhaps banning only those methods that have good evidence for long-term harm. I'm not taking a strong position here, but the fact is, athletes take physical risks and make physical sacrifices knowingly, all the time. It's in the nature of being an elite athlete. In fact, that's part of what thrills us about them. We know they are courting danger and paying a price.

Yes, the rules are the rules and Armstrong broke them. But as long as the rewards for championships are so great, people will keep looking for a way.

Update: A commenter points out that apparently, there were indeed some deaths of cyclists linked with EPO use back in the 90s. So I erred about that. Apparently the reason it stopped is that they did start monitoring hematocrit levels (i.e. the red blood cell count). So if EPO use were to be allowed, that would certainly have to be strictly enforced.

Thursday, October 18, 2012

Epic take down

Two of my colleagues here at what is actually the World's Greatest University, and my old friend John McDonough at the institution which only pretends to the honor, fillet Mitt Romney like a salmon on health care policy.

Props to NEJM for letting you read it yourself, but I feel I should contribute some value  added so a couple of highlights:

"Though Romney has offered many opinions and comments as a presidential candidate, he has not provided any detailed blueprint of his plans for U.S. health system reform, and his proposals provoke more questions than they provide answers."

That's one of the great things about Romney -- you could cut and paste that statement onto a discussion of just about any of his policy proposals. Anyhow, they do manage to find, after combing through his various statements, five "essential elements of his policy intentions."

  1. Repeal much of the Affordable Care Act, especially the parts having to do with expanding insurance coverage.
  2. Convert Medicare into a "defined contribution," i.e. voucher program.
  3. Make individually purchased insurance tax deductible [hey wait a minute -- I thought he wanted to eliminate tax deductions and simplify the tax code].
  4. Take away states' power to regulate health insurance markets [hey wait a minute, I thought -- oh never mind].
  5. Massively reduce federal spending on all health programs.
Does that sound good? Are you for it?

He says he'll repeal the $716 billion in Medicare savings that are part of the ACA, which he goes around falsely implying that represent a cut in benefits. (It does not.) Sayeth our informants: "Rescinding these savings would advance the insolvency of the Medicare Part A Hospital Insurance Trust Fund from 2024 to 2026 and trigger a $323 increase in premiums for most Medicare beneficiaries . . . "  Does that sound good? Are you for it?

Converting Medicare to a defined contribution program would shift growing costs to beneficiaries starting in 2023.

Turning Medicaid into a block grant and capping the federal contribution would swell the ranks of the uninsured by something on the order of 20 million people and cut benefits for those who were left, along with payments to providers.

He believes that "health care goods and services should be traded in an open market, where competition drives choice, efficiency, quality and price." That would not explain why choice, efficiency, quality and price are best in countries that have the most tightly regulated markets and socialized insurance, and why we, who in fact already have the least regulated market do the worst on those measures.

Finally, "If his proposals for a balanced budget, defense spending hikes, and non-defense spending reductions are achieved, all non-defense programs except Social Security would require cuts averaging 29% in 2016 and 59% in 2022. Included would be Medicare, Medicaid, the National Institutes of Health, Centers for Disease Control and Prevention, the Veterans Health Administration, and every other federal health program."

So all you doctors out there, who want to hold on to your sailboats. Are you for this?

Wednesday, October 17, 2012

Chalk one up for the nanny state

I think you're going to be stuck with the abstract only but that's okay. Here's all you need to know. From 1988 to 2010, data from the National Health and Nutrition Examination Survey (NHANES), show that the average level of "bad cholesterol" (Low Density Lipoprotein, LDL-C ) in U.S. adults declined from 129 (95% CI, 127-130) mg/dL to 116 (95% CI, 114-117) mg/dL (P <.001 for linear trend). 

First of all, I should point out that NHANES is a socialist government plot to obtain information about the health of the American people, presumably so they can nefariously use it to find ways of making us healthier. 

The well-known liberal bias of reality is fully on display here as well. The question is, why did this happen? It's not just because more people are taking statins - the trend was also observed in people who are not. It's obviously not because people are exercising more and losing weight, or generally eating a better diet, because, well, they aren't. Au contraire.

But what did happen, and what appears to be the only plausible explanation (not proved, of course, just a sensible conclusion) is that this results from the purging of trans fats from the American diet. This happened partly because of public information campaigns in conjunction with requirements for nutritional labeling; and partly because of local governments imposing regulations on  fast food restaurants; and in general because CDC and USDA put out so much information about the evils of trans fats that food manufacturers started to brag about taking it out of their products. Check out the potato chip aisle if you haven't already noticed that.

This doesn't just make you healthier, even if you're a Republican. It saves you money on your health insurance and your taxes, because you aren't paying for as many heart attacks and strokes. I remember when regulations on fast food restaurants were happening getting into fights with commenters here (I used to have more of them, including trolls; those were the days) who thought they were being ruthlessly deprived of their personal freedom to eat french fries cooked in trans fats. They seemed unimpressed by the argument that they wouldn't be able to tell the difference but would live longer. Well suck on this, pal: you weren't able to tell the difference, and you're alive.

Tuesday, October 16, 2012

Stayin' Alive

Have I used that title before? Anyhow, I've been remarking lately on the astonishingly unique times in which we live. Here's another contribution to the wonderment from an international group of scholars writing in the Proceedings of the National Academy of Sciences. (Yes, you can read it.)

We just take it for granted, but in the wealthy countries, human life expectancy at birth has increased by about 3 months per year since 1840. This means that until the late 1800s, the human life expectancy everywhere was about the same as that of hunter-gatherers, in other words probably about what it had been since the emergence of anatomically modern humans more than a quarter million years ago. A 30 year old hunter-gatherer has about the same probability of death as a 72 year old Japanese. Life span at birth for a hunter-gatherer is about 31. For Swedes, it was 32 in 1900, and it's 82 today.

We don't know exactly how to explain this -- no doubt it's a combination of everything you can think of -- better nutrition, housing, sanitation, medicine, probably lower rates of violence (at least that's what Stephen Pinker thinks, WWII notwithstanding). But it's absolutely astonishing.

The authors' main point is that our assumptions about senescence -- that genetic patterns that are beneficial at young ages, and particularly in the highest reproductive years, are not necessarily beneficial at older ages, so we just fall apart and die -- can't exactly be true. The reductions in death rates have occurred at all ages, and are actually greater past reproductive age.

Keep in mind, we're talking about Sweden and Japan here -- in the U.S. by the way we haven't done nearly as well, but well enough I suppose. But this has completely revolutionized society, culture, the economy, in ways we scarcely notice. I recently embarked on a new and demanding career at the age of 55, and I have complete confidence that I'll hang in long enough to leave a good legacy of accomplishment. As Tom Lehrer put it, "It is a sobering thought, for example, that when Mozart was my age, he had been dead for two years." But that was no great tragedy in Mozart's day, it was typical.

Will this last? Stay tuned.

Monday, October 15, 2012

A couple of minor issues nobody's talking about . .

. . . in the presidential campaign. Like, none of this is happening.

  1. Anthropogenic global climate change and everything having to do with it.
  2. Resource depletion and unsustainability generally -- water, soil, phosphorous, feeding the world's people
  3. Major public health challenges -- drug resistant pathogens including TB, malaria, MRSA, and other really scary stuff; lack of potable water and sanitation; obesity and type 2 diabetes; others I could name
  4. The real problem with our health care non-system: unsustainable waste and inefficiency. That is also our real fiscal challenge, not discretionary domestic spending
  5. The president acting as judge, jury and executioner and secretly ordering robot planes to blow people up in distant lands, often blowing up people who are innocently attending weddings and funerals.
  6. The outrageous inequality of incomes and the hollowing out of the middle class. And no, raising top marginal tax rates a couple of percent isn't getting at the problem. 
  7. Racism

I'm sure you have a couple of your own. But really, what does any of this matter?

Friday, October 12, 2012

Debate This

Folks on the port-side are feeling pretty good about the Vice Presidential debate last night, just as people to starboard were all excited over the first presidential debate. Me, I care how the election turns out but this debate schtick just frosts my pumpkin.

My idea of a debate is that people marshal facts, logical arguments and, if applicable to the question, values on behalf of a controversial proposition. The winner is the person who makes the most compelling argument. The elements of a compelling argument are:

  1. True facts
  2. Correct logic
  3. Values I happen to agree with
So why did Mitt Romney and Joe Biden "win" their respective debates?

You could go through the transcript of the first presidential debate with a microscope and I doubt you'd find Mitt Romney saying anything factually true or logically correct. I was more inclined to find Joe Biden's arguments, to the extent he actually made any, compelling, but that's not why he "won" his debate.

The fact is the voters they are trying to win over don't have a clue what's true or not or how to decide that, and couldn't tell a logical argument from doubletalk. The winner, in both cases, was the guy with the most impressive swagger, the one who gave the beat down, the guy who swung the biggest stick. And that's what the press coverage says too. Sure, Romney was more full of shit than a port-o-potty but that's irrelevant. Biden was large and in charge although he laughed too much. On the other hand Ryan drank too much water.

This is a totally idiotic way to to choose a president. These "debates" are worthless.

Thursday, October 11, 2012

Separated at birth?

Reason vs. Madness

That would be Barack Obama and WM Romney, arguing for their health care policies side-by-side, which you can read right here in the new NEJM. (And yes, they have kindly invited to masses to read it.)

I hereby assert the privilege of the chair to make the following comments:

Obama provides a coherent, focused, spirited defense of the Affordable Care Act, and proudly claims the label of Obamacare. He also directly, cogently and unabashedly criticizes the claims of his opponent. My conclusion? He didn't write this himself, because he sure as hell never talks this way.

Here's a taste:

My opponent in this election, Mitt Romney, has a radically different vision for the future of our health care system — even if it means running from his past as the architect of health reform in Massachusetts. He would begin by repealing Obamacare on day 1. Your patients would once again be charged excessive copays for preventive care, and millions of Americans would be one illness or injury away from bankruptcy. He would undo the progress we are making toward a more coordinated delivery system. Romney and his running mate, Congressman Paul Ryan, have proposed a budget that could force drastic cuts to investment in medical research, eliminating 1600 National Institutes of Health grants and slowing our progress on scientific and medical breakthroughs. They have pledged to turn Medicaid into a block grant and slash its funding by a third — plunging tens of millions more Americans into the ranks of the uninsured and leaving our hospitals and health care providers to grapple with an increasing burden of uncompensated care. And they are committed to ending Medicare as we know it by turning it into a voucher program, with insurance companies set to make millions while seniors and people with disabilities are forced to pay thousands more every year.

Romney, as usual, is long on rhetoric, short on specifics, and wrong when he does offer any up. He claims the PPACA increases taxes by $1 trillion, which will "hit the middle class hard and drive medical innovation overseas." This is of course utter nonsense. The major revenue sources in the bill are an added tax of 3.8% on unearned income for high-income taxpayers, which I suppose does include people who Romney thinks are the "middle class"; an annual fee paid by insurance providers, which fund the Patient Centered Outcomes Research Institute; and a  40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family, which is not designed to actually raise revenue but to discourage employers from providing such "cadillac" plans. There are various smaller taxes on medical device makers and odds and ends, but the total of new revenues over ten years is $392.1 billion, which is less than 2/5 of $1 trillion. So he's just flat out lying -- in the pages of the New England Journal of Medicine. If his article were peer reviewed, it would have been rejected.

The Act doe raise the Medicare tax by .9%, which makes it more reflective of reality. I kind of wish it didn't do that, since the tax is regressive. However, the poor and middle class will save money as a result of the act, and get affordable health care, more than offsetting anything they have to pay.

Romney repeats the lie about $716 in cuts to Medicare, which I don't think I have to re-debunk here.

Then he says:

If elected President, I will repeal Obamacare and replace it — not with another massive federal bill that purports to solve all our problems from Washington, but with common-sense, patient-centered reforms suited to the challenges we face.
In the health care system that I envision, costs will be brought under control not because a board of bureaucrats decrees it but because everyone — providers, insurers, and patients — has incentives to do it. Families will have the option of keeping their employer-sponsored coverage, but they will also be empowered to enjoy the greater choice, portability, and security of purchasing their own insurance plans. As a result, they will be price-sensitive, quality-conscious, and able to seek out the features they want. Insurers will have to compete for their business. And providers will find themselves operating in a context where cost and price finally matter. Competition among providers and choice among consumers has always been the formula for better quality at lower cost, and it can succeed in health care as well.

If people decide not to take their employer's health insurance, but to go out on their own and try to buy insurance on the non-group market, it will cost them vastly more, and if they have any pre-existing conditions, they won't be covered. They'll also face life-time caps, and the possibility that their policy will be canceled if they get sick -- in other words, all the problems the PPACA was designed to solve. These "competitive markets" Romney talks about have always existed, and they exist today, and they do not have the results he claims they do. He is not proposing anything specifically that would change that. So it's nothing but BS.

Will Obama be able to articulate that in next televised debate? Stay tuned.

Tuesday, October 09, 2012

System and Lifeworld, and electoral democracy

Or republic, or whatever you want to call it. As some readers may know, "system" and "lifeworld" are key terms in the philosophy of Jurgen Habermas. (It's a long story, but his theory of communicative action and in particular his development of speech act theory are important in my own work. Here I will go off on a different application.)

For most people, the forces that create the high-level context of their lives are largely inscrutable. Somehow human society produces the built environment of roads and sidewalks and corner stores; the job market in which they struggle to provide for themselves; the commercial products which are available and affordable or not; war and peace; and the mass media content that is constantly drilling into their brains.

People obviously have various theories about all this. To a large extent, they get those theories from their lifeworlds -- the interacting, communicative environments in which they do have competence and some degree of control. Together with our family, friends, coworkers, and to some extent people with whom we interact in a formal capacity such as teachers and health care providers, we mutually create our lifeworld. If, in our lifeworld, the earth is 6,000 years old and the reason we can't find a job is because rich people pay too much in taxes, well, that's how it is.

But the lifeworld is obviously not autonomous. At the system level, people are working to shape it through what Habermas calls strategic (as opposed to communicative) action. Vast forces contend for influence over our lifeworlds, whether it's Coke or Pepsi or God wants you to vote Republican. Ultimately, the processes that produce an electoral outcome owe only a passing and usually non-dispositive accountability to verifiable reality.

Yes, people's values differ and they decide what is in their own self-interest, so if they don't want gay people to get married they really don't want that. That's a component of their lifeworld, or it isn't, and strategic action has more capacity to mobilize it than to create it. (Although scare tactics are certainly employed. [The passive voice is chosen deliberately.]) A champion of democracy has to accept that voters will act on such feelings, and if you don't like it, that's the price you have to pay for democracy.

But the question of whether further cutting millionaires' taxes, as opposed to spending more on mass transit and public education, will do more to reduce unemployment is what Habermas calls a "first world" criticizable validity claim. It's a claim about intersubjective reality, that has a particular kind of truth which is independent of your values or feelings. The same goes for Saddam Hussein's weapons of mass destruction and the effect of carbon dioxide emissions on the climate. And it turns out that in U.S. politics, right now, such truths don't matter very much. And that's a disaster for us all.

Friday, October 05, 2012

Talking points

A couple of completely meaningless events happened in the past couple of weeks, both of them courtesy of the Bureau of Labor Statistics. Despite being completely meaningless, they are very meaningful, because they force the Romneybot to produce different text outputs.

Last week (IIRC, doesn't matter exactly) the BLS did its routine revision of quarterly employment numbers and concluded that more people are employed today than were employed when Obama took office. Again, this is meaningless. The job market was plummeting like a meteorite when Obama took office. It stabilized after a couple of years and began a slow recovery. I'm not going to argue here about the effect of federal policy on this or who did what to make federal policy what it has been -- that's beside the point. Whatever you may think about that, at some point the number of employed people was going to exceed the number on January 20, 2008.

Today, the BLS announced that the unemployment rate fell to 7.8%. Again, I won't go into how the unemployment rate is calculated, what it really means, or who or what is or is not responsible for the number now being below 8%.

The point is, Romneybot has been outputting the message that there are fewer Americans working today than when Obama took office. Again, a completely meaningless fact but it registers in people's frontal cortices as a failure on the part of Obama. Romneybot can no longer output that text. Similarly, the bot has been outputting that unemployment has been above 8% the whole time Obama has been in office. That output also ceases. Is there some reason why the difference between 8.1 and 7.8 is greater than the difference between, say, 8.5 and 8.2? Okay, it is actually proportionally more, but that's not what people hear -- it's the first digit  that matters. The same reason stuff costs 99 cents, or $99.98. That's a lot cheaper than $1.01, or $100.27.

So while Eric Fehrnstrom figures out how to re-write the stump speech, we should all contemplate the absurdities of our minds. Yes, it's good news for Obama, whether or not it should be and whether or not it means you personally have a job yet. But as I always say, history turns on the arbitrary and the illusory.

Thursday, October 04, 2012

More on scientific fraud

It turns out I'm not just imagining things, it seems there is more of it lately -- or at least it's being caught out more. According to this study, the rate at which scientific papers are retracted has increased ten times since 1975. And contrary to the conventional wisdom, 2/3 of retractions are due to fraud, plagiarism, or duplicate publication, not unintentional error.

The rate went up noticeably after 2005, when Congress flatlined NIH. This is unfortunate but not unsurprising. The dynamic is that a period of increased funding for research increases the supply of Ph.D. students, post-docs and junior faculty who are looking to make it as scientists. When funding gets tight, some of them get desperate. Right now NIH is funding less than 10% of proposals, and if you can't get yours into that very lucky category, you can't have a career.

There's more to it than that, or course. For instance, there is also institutional culture. The report says that 43% of retractions came from just 38 labs. That means thousands of labs and research centers had none. (Mine included, I'm happy to say. Indeed, as far as I know, my entire university remains pure as the Antarctic snow.)

A commitment to stable federal support for research, growing with inflation and GDP, would help a lot. Then we'd have a world in which the number of people who make it onto the first rung of the scientific career ladder is reasonably matched to the number who can look forward to having a decent career, allowing for the appropriate level of attrition and people who just don't cut the mustard. But that's my selfish, parochial point of view. More important, we would continue to make steady progress in basic and clinical sciences with less wasted effort and investment, and maybe some day we'd have effective treatments or prevention for Alzheimer's disease or diabetes or cancer or MS, and people would get the right care that met their particular needs, at lower cost.

Wouldn't that be nice.

Wednesday, October 03, 2012

Am I missing something here?

A tragic and bizarre story has dominated the local news in Connecticut for the past few days. A woman in the affluent town of New Fairfield heard somebody trying to break into her house in the middle of the night, so she called her brother, who lived next door. The brother grabbed his hand gun and came on over, where he found a man dressed all in black, wearing a ski mask, and holding a shiny object in his hand. The brother shot the intruder dead. The intruder turned out to have been his 15 year old son, who was carrying a knife.

Nobody knows what the heck the kid was up to, so yeah, it's weird. The police will not charge the shooter -- self defense, home is your castle, stand your ground and all that.

But what nobody has said, as far as I have discovered, is this:

If you think somebody is trying to break into your house, should you call your brother, and have him come over and shoot the guy? Or should you call the police --  you know, 9-1-1? They work nights, and they'll come over right away. And they're specially trained for this sort of thing.

I know, that's socialism and communism and the NRA will make sure I can never run for public office. But I mean come on! What the hell is wrong with us?

Tuesday, October 02, 2012

Like I always say . . .

. . . we don't really have a federal spending problem or a long-term structural deficit problem in this country. Well yeah, we have a ridiculously bloated military and rich people don't pay enough taxes, but getting past those obvious facts, what we really have is a health care spending problem. Medicaid is the biggest problem for state budgets right now, and Medicare + Medicaid is the long-term problem for the federal budget. Get our health care spending down to that of the rest of the civilized world and everything else is much more tractable.

And, as I have also said, the Affordable Care Act is not the solution, but it's a start -- it gives us  a framework to build on. The Urban Institute agrees with me. The problem is, this won't fit on a bumper sticker. In fact, the prospects of actually getting more than 5% of voters to understand anything about this, or even to want to, are dismal.

Basically, the Act lays down the following foundations:

It restrains growth in Medicare payment to providers, mostly hospitals and nursing homes. Republicans, of course, portray this as "cuts" to Medicare, but it doesn't cut benefits at all. The idea is that the providers will become more efficient, reduce useless and unnecessary services -- and that can indeed happen. There's plenty of room for it and they've already started. (BTW, yesterday a provision kicked in that essentially fines hospitals for excessive short-term readmissions for people with heart failure and some other conditions. We'll see how it goes but they aren't really complaining -- they're already figuring out how to do this.)

It sets up greater competition among insurance companies and makes it easier for consumers to comparison shop through the "exchanges." And it already requires them to return more of their premiums for actual health care and spend less on marketing and profits. Soon, it will eliminate medical underwriting. All this cuts administrative expenses.

It taxes "Cadillac" health plans, correcting one of the perverse incentives resulting from the tax exemption for employer-provided health insurance.

It sets up the Patient Centered Outcomes Research Institute. Even though Medicare isn't allowed to actually use the information for coverage decisions (death panels and all that) one hopes that doctors will use it to deliver care more wisely.

How much will all this save? It remains to be seen, but growth in health care spending has already slowed. And as I say, it's just a start. Like all new legislation, it will require fixing and improving down the road. Hey, maybe we can even add a public option!

But it all depends on the election. Yes, it really matters.

Monday, October 01, 2012

The politics of Nowhere Land

Maybe it's too much to ask that voters, politicians and stenographers journalists have some grasp of history, but it would be so much better if political discourse was rooted in some idea of what the past has been, how we got to where we are, and oh yeah, where we are at.

I've noticed quite a lot of interest among the pointy-headed intellectual set lately in the broad sweep of economic history. The latest nugget is from Brad DeLong, who on the occasion of the death of historian Eric Hobsbawm has reprinted this review from 1995 of the lapsed Communist historian's Age of Extremes. I'm not particularly interested in Hobsbawm's ideologically induced brain damage as I am in the history DeLong reviews. I've come across several other essays on the general subject of what exactly it was that happened from the late 19th through late 20th Century that made our world.

And what a world it is. As DeLong says, it is not clear that people in say, 18th Century France or Virginia were materially any better off than Athenians. But today, Americans are arguably 20 times wealthier than they were in 1900. You can't really quantify it because a whole lot of our stuff didn't even exist then. Take it back to 1850 and you can't even make sense of the question. People spent a good many hours every day hauling water and firewood into the house and hauling out excrement. Bedrooms were unheated. There was no refrigeration, or even canning. You had to either eat produce within a couple of days or somehow preserve it by drying or pickling. If you wanted to communicate with someone in your own town, you had to physically go to their house and, if they weren't home, leave a message.  Agricultural techniques hadn't changed substantially since Roman times. If you wanted to hear music, you needed a village band or to wait for a traveling performer to come through town. Chances are you had never been more than a few miles from the place you were born. If you did move -- say from the east coast to the frontier -- it was a once in a lifetime journey filled with great peril. Now people of modest means fly back and forth from the west to east coast in a few hours, for the sake of a brief vacation or a one-day business meeting.

The political developments of the 19th and particularly the 20th Centuries were possible only in the context of this astonishing material transformation; and they were necessary in order to sustain it. But now many intersecting crises threaten the good life people have come to take for granted and assume must last forever. To take just a few of the most important, we have to begin with the fundamental dependence of the transformation on fossil fuel energy, which is not sustainable. Many other essential resources are being depleted, from water to soil to phosphorus.

That aside, industrial capitalism must grow or contract -- it cannot stand still. One could quite credibly argue that we have enough already, we just need to distribute it properly and turn our energies from creating more and more stuff to contemplating art and cultivating the virtues. But we have no mechanism of organizing society so as to make that happen. But fueling continued growth requires continuing technological innovation. You probably have central heating and indoor plumbing and major appliances and an automobile. The next generation of smartphone isn't gong to get you to spend more than a fraction of what you spent on that stuff. The Chinese and Indians have managed to find a way to grow and more of their people will be able to buy those things, or at least so it seems. But it's not clear they will be made in the U.S.A., and anyway that will top out in due course.

We haven't figured out how to allocate investment without creating both repeated financial crises and gross inequality. The prospect of the whole house of cards collapsing is quite real, though not for the reasons Ron Paul thinks. The threat is not the national debt, but the claim on non-existent assets represented by the immense accumulation of monetary wealth. That's what's driving Europe into depression -- the creditors demand to be paid money lent on bogus collateral, and the ordinary people, who had nothing to do with the whole scam, are being made to pay. This promises a downward spiral of misery with no clear end in sight.

We aren't having any sort of a discussion about the problems we actually face. The marginal tax rate on the wealthy does matter, but even that discussion is happening on nonsensical terms. It's time we all got real, folks.