BJCefola's Podcasts and Stuff

Real Tort Reform

2012-02-18T10:15:00.000-08:00

I don't have time now to do a full write-up of what I think tort reform should look like and why, and to my surprise I discovered I don't need to. I guess I'm not the first person to think that a workers comp style process is applicable to Medical Malpractice. Closer to home, I found that Jack Roberts had written about this very concept back in 2009 in the O (emphasis mine):

Other proposals are more specific to medical malpractice, such as specialized health care courts and safe-harbor practices to protect doctors from liability even if something goes wrong. But maybe it's time to consider a more radical reform, such as a system of no-fault insurance for medical malpractice similar to the workers' compensation system.

Since the adoption of workers' comp laws early in the last century, workers injured on the job are covered without regard to whether the injury was caused by the negligence of the employer, a co-worker, the worker himself or simply bad luck. Injured workers have their medical bills and other out-of-pocket costs covered as well as receiving compensation for loss of income and certain general damages in accordance with an established schedule. In return, they give up the right to bring an individual lawsuit against their employer and with it the hope of winning a lottery-size award or settlement.

Applied to medical malpractice, such a system would compensate any patient whose surgery or other treatment (or lack of treatment) resulted in an adverse result, whether or not the doctor, hospital or nurse was at fault. It could redirect resources currently spent finding fault to compensating patients who have been harmed. And it would recognize that even where medical providers have performed their jobs badly, large jury verdicts are not paid by the wrongdoers but shared by everyone through the insurance system.

To get a sense of how much more efficient workers comp is at delivering benefits than med mal, let's look at Oregon state wide experience:

ALAE are expenses that can be directly attributed to a specific claim. So the cost of a court filing for instance is particular to a claim while the cost of a claims department generally is not. In practice, for these lines ALAE is mainly defense counsel.

What these figures show is that from 2003 to 2010 only half of the med mal premium dollars went to indemnity payments to claimants. The rest was chewed up by defense costs, overhead and profit. In contrast only 13% of the Workers Comp premiums were diverted in this way. The difference is even more striking when you realize med mal claims are much more likely to have a plaintiff's attorney involved than workers comp, and they are paid from indemnity proceeds. So not even half of the med mal premium money actually reaches patients suffering harm.

A lot of ink has been spilled on the extension of a tort cap, but I think all of the above shows that we need to ask a deeper question. Does the way we've structured Medical Malpractice liability make sense? As our experience with Workers Compensation shows, alternate structures exist that have far less costly processes for adjudication.

What Opt-In Does

2012-02-16T18:30:00.000-08:00

Nick Christensen does a write-up on how Metro councilors view Opt-In, a registration-required online survey tool. I think this gets at what this service really does, and what it replaces:

Metro spent $76,000 on Opt In in 2011, generating more than 20,000 responses – about $4.50 per completed survey.

By comparison, said a staff report for Tuesday's work session, Metro spent about $400 per open house attendee during the 2010 roll-out of then-Metro chief operating officer Michael Jordan's growth and policy recommendations; those numbers soar to $2,800 per completed survey at each of those open houses. The agency also spent $35 per attendee at the dozens of stakeholder meetings Jordan attended.

Opt-in is a new way of connecting with citizens, in a way that allows two way communication- both Metro and citizens learn from the interaction. And look at the number of people reached, a recent survey had 4,000 respondents. How many public meetings or open houses have you seen that attracted 4,000 people? How about a meeting where 4,000 people got to get up individually and express their view?

Some councilors expressed concern that their hands would be tied by the surveys. How could they justify a vote that went against "majority opinion?" Even aside from concerns about the opt-in demographics, councilors have a pretty solid excuse: Voters elected them, not a survey.

The people who should be nervous are the interest groups who make up most of the participants at conventional public meetings. They are the people most motivated to attend, and most likely through pooling and coordination to have a representative available to attend a meeting at 9am on a weekday. Most individuals don't have the time or interest for that. That dynamic gives interest groups a dominant role in reflecting "the public", quite independent of how much popular support their positions actually have. As Metro President Tom Hughes said,

"Public hearings are an avenue for getting public input, but they're imperfect at best," Hughes said. "They're usually repetitive, not very helpful and usually the people who show up are the people who are absolutely directly involved – you don't get a sense of what the public wants."

Opt-in offers a potential check on interest groups, it creates an opportunity for a truer test of the popular will. Whether it fulfills that potential depends on participation. If the only people who sign up are the same people who would otherwise be represented by interest groups, nothing changes. So if you're a Metro resident not already signed up, please consider it. Especially if you disagree with me.

Oregon Republicans disappoint

2012-02-13T19:28:00.000-08:00

Right after I write about why Democrats should compromise on the CCO bill, Republicans prove me wrong.

A coalition of 30 Republicans and 1 Democrat in the state House of Representatives blocked approval of Oregon's health insurance exchange this morning, prompting concern that bills are being taken hostage to leverage other votes in the month-long 2012 Legislature...

[A Republican house leader] said questions had arisen in a recent caucus meeting of House Republicans over what commitments existed over federal funding of the program, as well as the potential for a change to the legal status of federal health care reforms, currently under consideration by the U.S Supreme Court.

In contrast to tort reform and the CCO bill, this looks like a straight forward attempt to spike the Health Insurance Exchange. That would put Oregon in league with the other red states that are standing around waiting for a federal exchange to be dropped on them. Thing is, only in the most sheltered, isolated, reality deprived imagination could today's Oregon be conceived of as a red state. Efforts like this ensure it never will be.

CCO Bill and Tort Cap

2012-02-12T18:20:00.000-08:00

The Oregon Legislature is trying to figure out whether or not to include a tort cap in the CCO bill. The stakes are high, as legislators are expecting up to $2.5 billion in federal aid if the CCO bill passes. I don't know the politics well enough to guess what would happen if a CCO bill doesn't pass in this session. Maybe the federal money will still be there next year, maybe not. But since the state already banked savings resulting from CCO's in the current biennium budget, it doesn't really matter. The bill needs to pass.

For that reason I think Democrats need to hold their noses and pass the bill with the tort cap included. While it is true that Republicans are engaging in hostage taking and you risk encouraging such behavior by giving in, there are some mitigating factors.

One of the central purposes of CCO's is to save money by reducing unnecessary or ineffective care. The tort cap may be politically undesirable and only marginally effective, but however slightly it still promotes the goals of the CCO. Tacking this on isn't as irresponsible as would be say, a demand for PERS reform or tax cuts.
Passing the CCO bill with a tort cap does not forestall pursuing more effective tort reform in the next session. Passage of a more comprehensive reform which affected all providers state wide would render the CCO compromise moot. And make no mistake, there is ample reason to pursue tort reform quite apart from CCO's.

Given the money at stake and the relatively small compromise needed, legislators would be grossly negligent if they fail to pass this bill. Jawbone and posture all you want. Call out the fine 15 for committing to the proposition that $20M in annual savings is worth more than $2.5B, a trade that takes 125 years to pay off. But at the end of the day, we need this bill. Get it done.

Honesty in Medicine

2012-02-08T19:06:00.000-08:00

Incidental Economist is another great blog I wholeheartedly recommend. Aaron Carroll calls attention to a study of physician attitudes towards honesty. The punchline, emphasis mine:

They[sic] survey also asked specifically about things subjects had actually done in the last year. That’s where it gets even more depressing. More than 10% of docs had told an adult patient or guardian something that wasn’t true. Almost 20% had – in the last year – not fully disclosed a mistake because they were afraid of being sued. And more than a quarter of physicians had revealed, either intentionally or unintentionally, personal health information of one of their patients to an unauthorized person.

Bear in mind those are physicians voluntarily self-identifying their behavior, in the wild it's probably even more common. I've said it before, but doctors really are not angels.

Hospitals and Data mining

2012-02-06T22:39:00.000-08:00

More reporting from Phil Galewitz. Back in December he described how hospitals were using former drug reps to target physicians to get referrals for "profitable, well-insured patients". The suggestion that doctors could and would prompt patients to get particular procedures at a particular facility at the whim of a sales rep is pretty grotesque, even to someone who has read a lot about health care finance. But at least there is a possibility of responsibility, doctors after all do take an oath to do no harm. What happens when hospitals cut them out and go straight to the patients? And not just ad buys on TV, but specific procedures marketed directly to individuals:

[Provena St. Joseph Medical Center] is one of a growing number of hospitals using their patients' health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether they have children or pets at home.

[...]

While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to – additional tests and procedures, including surgery.

"It's all about downstream revenue," says Patrick Kane, senior vice president of marketing at Cape Cod Healthcare in Massachusetts who used such approaches at Wellmont Health System in Kingsport, Tenn. "The old adage in business is that it’s easier to sell an existing customer new services, rather than find a new customer."

[...]

One of the biggest pluses for hospital executives is that they can track a campaign's financial success by comparing the amount of services used by targeted consumers against those in a control group with the same demographic and economic characteristics, but who are not sent mailings.

When the Henry Ford Health System promoted mammograms last year in mailings to 30,000 women aged 40 or older, more than 5,700 responded -- 304 more than in the control group. The mailings generated $268,000 more in profit than the control group -- a return of more than four to one on the cost of the campaign, says Denise Beaudoin, vice president of customer engagement.

"Some doctors used to be leery about the effectiveness of these marketing campaigns, but not when we can show them data like this," she says.

It's nice to know that while we don't know much about whether one treatment works better than another, we have randomized controlled trials on the effectiveness of their marketing. Great job folks!

Passages I like

2012-02-04T21:33:00.000-08:00

From Cringely:

My kids go to the best public school in Sonoma County. I know that because I chose my house based on that research. But when Cole finishes his math problems in a quarter the time it takes anyone else in the class, his teacher has him insert a wait state by putting his head down on his desk. Conversely, when some other kid never quite gets the problem set finished, ever, well he/she never gets a rest and never masters the material, either.

The current system is unfair to both kids.

The only solution I can see is one teacher per student. And the only way something close to that is going to happen is through technology. And it’s coming.

A followup passage that I don't like but agree with:

My conclusion, then, is that schools serve a limited social and cultural function but our kids mainly learn despite them. My own experience is that I learned a lot about learning from half a dozen teachers in my life, so those relationships are both rare and essential. But are they reliable enough to even justify modern schools? I don’t know. What I do know is that if I want to improve the educational environment for my children in the next year or two, I’ll probably have to come up with my own solutions.

Republicans and Medicare Cuts

2012-02-04T19:23:00.000-08:00

I don't mind saying, John McDonough's blog is worth following.

The claim that Democrats voted to cut Medicare through the ACA has gotten a lot of play. Here in Oregon it came up a lot in the Bonamici-Cornilles race, with Cornilles claiming Bonamici wanted to restrict choices for seniors. Via McDonough, here is an aspect that didn't get a lot of press (emphasis mine):

In the new Republican-controlled House of Representative in 2011, House Budget Chair Paul Ryan (R-WI) advanced a controversial federal budget plan which included a major restructuring of the Medicare program to change the program from largely fee-for-service to premium support/vouchers. This proposal drew widespread praise and condemnation, and mountains of attention.

Less noticed was the part of the Ryan budget plan which repealed most of the ACA, with one huge and unnoticed exception -- the $449 billion in Medicare reductions, documented in the CBO report on the Ryan plan. The Ryan plan was put before the entire House, and nearly every Republican member voted for it; the plan was also put before the Senate and endorsed by all Republican members minus four (one of those four was MA Senator Scott Brown).

So the one part of the ACA that congressional Republicans are on record as supporting are those same Medicare cuts that Republican candidates use to bash Democrats. And Rob Cornilles was as culpable as Bonamici (neither served in Congress for the ACA or its repeal vote) of everything he accused her of. Gee, I wonder how Politifact missed that.

Health Insurance is not Auto Insurance

2012-02-02T17:30:00.000-08:00

John McDonough reviews Mitt Romney's concept of cost control: co-insurance and high deductibles (emphasis mine)

...Mitt Romney's approach to controlling private sector health spending growth is to continue and to accelerate the shift to insurance policies that expose patients to higher and higher levels of cost sharing. This reflects a view, popular among conservative health economists, that health insurance should, as much as possible, resemble auto insurance, where you only get help for catastrophic events.

There is a big problem with equating health insurance and auto insurance. With auto insurance underlying costs tend to correlate with income. Someone working minimum wage probably drives a beater with no collision and minimal liability limits. That policy costs much less than the one for a one-percenter driving a porsche with $1M limits. Cost, and thus premiums correlate with income.

In contrast with health insurance there is no correlation, poorer people do not need less expensive care than richer people. There is no equivalent to a "beater" surgeon, cutting people open in a dirty basement. At least not today...

Senior Tax Deferrals

2012-01-30T19:15:00.000-08:00

There is an op-ed in today's O that demonstrates the difference between a government program and private insurance. The state of Oregon has long had a property tax deferral program to help seniors stay in their homes. Taxes are deferred until a home is sold, with annual interest charges accruing. The program is equivalent to a reverse mortgage with the annual payment fixed at the property tax level. The state acts as the insurer, fronting the deferred taxes to counties and taking risk on the level of repayments.

Unsurprisingly, the program has gotten screwed up because of the recession. Tax repayments are no longer adequate to front the money to counties, and the state has to either find a way to reduce fronted expenses or get into the business of subsidizing senior property taxes.

The legislature opted for the former (emphasis mine),

The Revenue Committee's response to this temporary downturn was to eliminate 5,000 people from program rolls -- by capping enrollment, raising interest rates, changing eligibility rules and excluding anyone with a reverse mortgage. The cruelest response was to apply these changes retroactively to existing program participants.

The result was to disqualify nearly half of the 10,500 families in the program, including many lower-income homeowners -- the very people it was designed to help. Most participants had assumed that once certified for assistance, they could be reasonably secure in their retirement years and safe from the threat of tax defaults.

I don't fault the legislature for refusing to create a subsidy, that money doesn't come out of the air. It comes out of budgets for other priorities like education, healthcare, and social services which have already been slashed. Prioritizing public spending, deciding what should be paid for and what should not is pretty much the legislature's job.

And that shows the difference between public and private insurance: A public insurance program has no guaranty, it exists at the whim of lawmakers. As a program it necessarily competes with other public spending for priority and its benefits and costs can be changed unilaterally with the stroke of a pen. In contrast, private insurance is spelled out by contract and can be changed only with mutual consent. People who buy private insurance don't have to justify its benefit against money for schools or Medicaid or whatever the public thinks is more important.

As participants in the tax deferral program are discovering, that is no small thing.

Reading Now: Since Yesterday

2012-01-26T21:51:00.000-08:00

An op-ed from a few months ago was interesting enough to land Since Yesterday on my reading list. To my surprise the local library branch had a copy, which is now in my hands.

I'm reading it to get a sense of how we've changed since then, and how we have not.

I liked this passage, on FDR's inauguration speech:

You can turn off the radio now. You have heard what you wanted to hear. This man sounds no longer cautious, evasive. For he has seen that a tortured and bewildered people want to throw overboard the old and welcome something new; that they are sick of waiting, they want somebody who will fight this Depression for them and with them; they want leadership, the thrill of bold decisions. And not only in his words but in the challenge of the very accents of his voice he has promised them what they want.

I feel the appeal of these sentiments, but I could also see them leading a nation to a really bad place. Magnificent and terrifying...

Dancing around a problem

2012-01-18T20:53:00.000-08:00

WonkBlog notes a CBO writeup on the failure of some Medicare demonstration projects to reduce spending. The summation (emphasis mine):

Why didn’t the demonstrations reduce costs? Largely because they didn’t reduce the quantity of care delivered. Some programs actually correlated with increased hospital admissions. A few saw reductions. On balance, it was pretty much a wash — and a troublesome sign for the health reform law’s soon-to-launch attempts to curb Medicare spending.

That rang a bell, which led me to dig up this passage from Money-Driven Medicine (emphasis mine):

Critics [of pay for performance] point out that very few of the performance targets address the problems of overtreatment. While CMS is rewarding health care providers to do "more" in the form of tests and procedures that they might overlook, there are few obvious incentives to do less. "Counting how many patients survived bypass surgery is one thing," says one New York City hospital executive. "But how many survived a surgery that they didn't need? That's the important number that you'll never see."

Dr. Stephen Jencks, Medicare's director of quality coordination, concedes that the critics have a point: "I would say we are moving much more slowly on trying to prevent overuse than in trying to fix underuse," he acknowledged at the end of 2004. "If I tell a physician he shouldn't do a surgery he wants to do, I personally would anticipate a lot more resistance than if I told him he should give a medicine he wasn't thinking of giving." Yet if Medicare and other payers don't find ways to locate and discourage unnecessary treatment, pay for performance will only add another layer to health care inflation.

Telling doctors what to do is hard, but it's even harder telling them what not to do. We're going to have to grapple with that in a serious way if we want affordable health care.

Finished Money-Driven Medicine

2012-01-17T21:24:00.000-08:00

Wow, this wasgood.

Incorporatingjournal research, literature and original interviews, Mahar describes themyriad conflicts within the health care industry that drive up spending, andwhy that spending buys so little. Thechapters on for-profit hospitals and ineffective treatment are particularlygood, the latter should be required reading for anyone who utters the phrase"death panel". I like that thebook is rich in sources, most of the articles are as relevant today asthey were in 2006. Here is one favorite:

There is no formal rationing system in the U.S., withits complex mix of private insurance and Medicare and Medicaid coverage, plus41 million uninsured people who pay for their own care or get treated ascharity cases. But in fact, health-care rationing occurs every day in the U.S.,in thousands of big and small decisions, made mostly out of sight of patients,according to rules that often aren't consistently applied.

The people who make these decisions are harrieddoctors, Medicaid functionaries, hospital administrators, insurance workers andnurses. These are the gatekeepers of the American health-care system, the onesforced to say "no" to certain demands for treatment.

"The Big Secret in Health Care: Rationing is Here" Wall Street Journal, 9/12/2003

This book is anexcellent place to start for those interested in understanding health carecosts, I strongly recommend.

Disclosing Drug Payments

2012-01-17T19:15:00.000-08:00

The ACA was derided in part because of its length and complexity. Funny thing is, the more we see of the health care reform the better it looks. Here is one small measure packed into it that means a lot: mandatory disclosure of payments to doctors from drug companies regardless of how it is accounted for. Sales, research, ~~kickbacks~~, whatever. All of it will be subject to public review, so you can judge for yourself how closely your doctor's interests coincide with your own (at least when it comes to prescription drugs). That might not seem like a lot until you realize you can't do that now, efforts of ProPublica not withstanding.

One of many ways the ACA reforms healthcare in America.

Great Quote on leadership

2012-01-16T19:17:00.000-08:00

A great quote from Don Berwick, cited in Money-Driven Medicine (it can also be found here):

"The leader who thinks it is enough to create report cards and contingent rewards misses the biggest and hardest opportunity of leadership itself- to help people discover and celebrate the meaning in their work."

That rings true on so many levels it makes my head dizzy.

More on property tax dilemma

2012-01-13T19:55:00.000-08:00

Portland Tribune has a story covering the mayor of Tigard's annual address. He lays out the situation plainly (emphasis mine),

Many cities and counties across the state are in financial trouble, Dirksen said, and the problem isn’t because of the still struggling economy.

“The problem is caused by a fundamental problem with the way tax revenue is collected in Oregon,” Dirksen said. “Not the overall tax rate, but the process.”

Part of the problem, Dirksen said, is Measure 50, the Oregon law passed in 1997 that limits the rise of a property’s maximum assessed value to no more than 3 percent per year.

But while the state is taxing homes at the same rate each year, the cost of doing business continues to rise.

“Though the assessed value only rises by 3 percent, the municipal costs increase in Tigard by about 4 to 5 percent in order to provide the same level of service as we did the year before,” Dirksen said.

This is the same problem ECONorthwest wrote about, it is why every municipal budget discussion in Oregon amounts to a question of "what will we cut this year". The only way to grow revenue faster then 3% is to either impose new use-based fees or allow development to reset property values to a higher (much higher) value. Remember this when someone tosses around the idea of another historic preservation district.

Retainer Medicine

2012-01-13T18:09:00.000-08:00

I was surprised to see this press release from DCBS, I don't recall any public discussion of how retainer services would be regulated during the last legislative session. The registration asks for a business plan with specifics on how and when prepaid fees would be subject to refund, and a filter-type question on bankruptcy. Some thoughts:

What is to stop doctors from offering contracts that bar refunds under any condition? Conceivably people could be paying up to a year's worth of fees up front.
Who is buying these contracts? Are they well-to-do people who are buying luxury, or is it low income people with cat coverage? The lack of regulatory specifics suggest this is aimed at the former group, but some material suggests the latter. If so the regulations are way too weak, see "predatory lending" for how that story ends.
What protection is there against a doctor blowing all the money up front, or conversely taking on an arbitrarily large number of patients and never being available for appointments?

One could argue that consumers need no more protection from retainer medicine then they do from plumbers or electricians, but there is a big difference. Society teaches us to be skeptical of contractors, from the adage about getting multiple quotes to fear stories about scams and rip-offs. We don't have the same skepticism of doctors, quite the opposite. People are taught they should listen to their doctors and do what they say. That can lead to all kinds of conflict of interest situations even when the financing is at arms length via insurance, how does this work when the money is front and center?

What life looks like without effectiveness research

2012-01-12T18:00:00.000-08:00

Via healthcare economist, a gooznews post on why patient advocacy groups are unlikely to promote comparative effectiveness research even though such concerns are of central interest to patients.

Compare the crying need that gooz describes with the mission of PCORI as described by its Chief Operating Officer:

Q: Can you give an example of how you envision people using the kind of research that PCORI will fund?

A: Let’s say someone is trying to decide if they should have Procedure A versus Procedure B. You give them all this information, but what the patient is saying is, "Well, what’s really important for me is that I’m very afraid of pain. What procedure is going to be the lowest pain option that still gives me the benefits that I need?" Somebody else is going to be very interested in what will give them the longest life. Somebody else may say, "Well, what’s really important to me is whatever procedures I have, I am a working parent and I can’t really afford a lot of time off from work, so what procedure is really going to take care of this condition, but get me back to work as quickly as I can?"

So, then we [at PCORI] are trying to think of the different options that are available to us, not only looking at research that says, "If you do this cardiac procedure versus this cardiac procedure, here's what the outcome is." But now: here’s what the outcome is in terms of pain, here’s what the outcome is in terms of days off from work, here’s what the outcome is in terms of longevity. So then you, as the patient, have the information to make that comparison and make really a tailored decision that meets your needs.

There are a lot of problems in health care, but it isn't like we can't solve them. We just have to learn how to ignore yahoos who get in the way.

Good Quote on legal challenges to Health Care Reform

2012-01-09T19:30:00.000-08:00

The Times ran an op-ed refuting some common arguments against the legality of the individual mandate. I thought this quote was particularly good (emphasis mine).

Opponents of the new mandate complain that if Congress can force us to buy health insurance, it can force us to buy anything. They frequently raise the specter that Congress might require us to buy broccoli in order to make us healthier [...]

That certainly sounds like a stupid law. But our Constitution has no provision banning stupid laws. The protection against stupid laws that our Constitution provides is the political process, which allows us to toss out of office elected officials who enact them. This is better than having unelected judges decide such policy questions, because we cannot toss the judges out if we disagree with them.

Nor are all required purchases stupid. It is not stupid to require us to buy air bags for our cars and pensions for our retirements. Nor would it be stupid to require us to buy life and disability insurance to make sure we have provided for our children. Whether the law should is up to our political process, not judicial second-guessing.

This gets at one of the reasons I find the conduct of congressional Republicans so inexcusable. They claim to be serious about reducing the deficit and managing long term liabilities, but they are utter cowards when it comes to building actual legislation. Their preferred approach is to find a bomb (payroll tax cut, debt limit, federal budget) and threaten to set it off unless Democrats pass their legislation for them. Republicans do none of the hard work of gaining support through compromise, they consign that to "not my problem" status. The thing is, making political choices is exactly their problem, that is what they are supposed to do. If they want deficit reduction then come up with a deficit reduction package that can get the needed votes and pass it. It may or may not be popular, but casting such votes and living with the consequences is the core definition of their job.

I've criticized Occupy protesters for not understanding civics, but at least they have the excuse of being joe-schmoe citizens. What excuse do Republicans in Congress have for not understanding their job description?

H/T White Coat Notes

Green Castle Wins

2012-01-05T17:59:00.000-08:00

Green Castle won their land use appeal against BDS over the zoning decision that shut down the cart pod. Some notable points:

- The Hearing Officer rejected the 1987 neighborhood action plan as mostly irrelevant:

[what should be considered is] the character of the neighborhood as it exists today, not how it may be envisioned in the future by an adopted area plan. For this reason, the Hearings Officer disagrees that the Kerns Neighborhood Action Plan can be a criterion for approval in analyzing whether the proposed food court fits into the residential character of the surrounding neighborhood. Such area plans, however, can constitute some evidence of the existing character of the neighborhood and provide an indication of whether an adjacent residential area will remain residentially zoned over time. Here~ the 1987 Kerns Neighborhood Action Plan, which is admittedly outdated, indicates that the residentially zoned lands near the subject property are likely to remain residentially zoned at least into the near future. Other than that, the area plan is not very helpful in this analysis.

Do you know what your neighborhood action plan is? Do you know who wrote it? Are you comfortable with someone making any decision of consequence based on it? Score one for common sense!

- The officer then goes back to Websters Dictionary(!) to get a working definition of "residential character". Based on that,

it is reasonable to read the concept of"residential character" as used in 33.25S.0S0.B.2 to mean the distinctive quality of the place where people dwell and live. For this reason, the Hearings Officer concludes that for the purposes of complying with 33.25S.0S0.B.2, the "residential character of the * * * R zoned area" cannot be determined solely by looking to the zoned use of the residentially designated buildings in the vicinity of the nonconforming situation. As described more fully below, it is reasonable to examine the residential area's proximity to other uses such as existing commercial uses to determine the "character" of the residential area, and to determine whether the appearance of the proposed change in the nonconforming situation conflicts with that character.

Score TWO for common sense! You can't understand the character of a neighborhood without actually looking at... the neighborhood. The whole neighborhood, warts and arterial traffic and other zoning uses and all.

- Finally, the officer acknowledges that neighborhood opinion should matter:

...the analysis is not as dependent on definitional limits as BDS Staff seems to conclude, but is determined primarily by substantial evidence. Here, the preponderance of substantial evidence strongly supports the Appellant. At the hearing, several parties submitted uncontroverted testimony that the "appearance" of the commercial parking lot before the food carts arrived was very undesirable. Those parties stated that illegal camping, litter, and illegal dumping were occurring and that the parking lot had an unkempt look. In contrast, the parties described the food court, while it was in operation, as clean, well kept and well lit. Their testimony indicated that illegal dumping and camping had ceased, and that the food court generally had a pleasant appearance. The Hearings Officer views this testimony as substantial evidence that the appearance of the food court is considered a benefit or amenity to the surrounding residential area.

And he hits the trifecta!

The appeal finding pretty much refutes everything that made the initial BDS decision so bad. Voices of today should count while those from 1987 should not. Boundary lines that exist only on zoning maps shouldn't be taken to arbitrarily limit what constitutes a neighborhood. Cheers to the Hearings Office and Green Castle!

As the swallows return to Capistrano...

2012-01-05T17:24:00.000-08:00

so Republicans rush to defend ineffective medicine. What is it with these guys? The PPACA funds the Patient Centered Outcomes Research Institute (PCORI) with a $2 per person per year tax on health insurance policies. $2 a year is about half the cost of a latte and about 1/200th of the cost increase in the average annual premium for an individual from 2010 to 2011. That's really not that much to pay to avoid having your (or someone you love's) hip shredded, or to avoid an unnecessary radical mastectomy. Think about it...

Doctors weigh in on PPACA

2012-01-03T18:31:00.000-08:00

Via Health Care Finance News, Deloitte published a study of physician views of PPACA. In case you were confused about who the bad guys in health care are:

So most surgeons think US healthcare is good or excellent while most of everyone else does not, most surgeons think they will make less money because of Obama's reform while most of everyone else does not, and unsurprisingly most surgeons think the Obama reform is a step in the wrong direction while most of everyone else does not.

Maybe I've been reading too much of Maggie Mahar's chapter on Tenet, but I wouldn't trust a surgeon any further then I could throw one.

Suburbs vs. the City

2012-01-02T13:24:00.000-08:00

In commenting on a recent editorial, I tried to highlight what I think is a serious blind spot in popular notions of urban planning and sustainability. In Portland, much thought and effort is directed at "livability." Few of those efforts though are targeted at families, and in fact measures such as the composting program seem intended to push families out. I wanted to put some numbers on migration, so I looked at the 2009 ACS data. I compared figures for the city of Portland to the Portland-Vancouver-Beaverton MSA minus the city of Portland, taking the latter group as an approximation for suburbs.

The data tells an interesting story. Series 1101 gives total households, families, and families with children under 18 split into three subsets: Families with children under 6, families with children both under and over 6, and families with all children 6 or older.
At the outset there is an obvious difference in the number of households reported as "families", unsurprisingly singles tend to be attracted to the city. And at first glance there isn't much difference between city and suburbs when it comes to how many families have kids, 46% vs 49%. The net result is that suburban households are significantly more likely to have children, one third vs less then a quarter in the city.

Things get weird when you get into the age groups. The percentage of households with young children is very close, only half a point separates city and suburb. The difference is concentrated in families with older children:
Now some might construe this as evidence of a shift in preference, that newer parents are more comfortable raising kids in the city and its only a matter of time before the figures for households with older kids come into line. So I looked at 2005 ACS data:

This pattern isn't new. What it speaks to is a transition, that as children age families are more likely to pack up and move out of the city. How many people are we talking about? If Portland had the same share of families with older kids as it has of families with younger kids it would mean an extra 13,355 families. Averaging that over 18 years and it comes out to 742 families per year. That's 742 families who tried living in the city, put up with it for at least 6 years and then decided to do something else and embraced suburban car culture. Each year. That was the status quo.

Now think about the composting program and how the city gave the functional equivalent of a raised middle finger when people asked what they were supposed to do with diapers. How many more families will boogie off to the burbs? The city has a grace period because families are trapped by the rotten housing market but that won't last forever. Eventually families will regain a choice in housing, and no one should be surprised when they act on it.

How sustainable is a vision of the city that drives families out into the suburbs?

Interesting New Years Healthcare Retrospective

2012-01-02T00:07:00.000-08:00

by John McDonough. He touches on the irony of the potential rebirth of provider rate regulation on the 20th anniversary of its execution. He condenses decades of history into a paragraph:

In the late 1980s, reducing the size of the hospital system was an unattainable policy obsession, and in the 1990s, the deregulated market made it happen with stunning efficiency. This is a clear-cut case of "be careful what you wish for, because you just might get it." While the downsizing eliminated excess capacity, it also enabled market consolidation triggering widespread hospital payment and health insurance cost inflation over the last ten years.

I wish Oregon had someone of his caliber and commitment to public engagement writing about healthcare. What could such a person tell us about Kitzhaber, about CCO's or the insurance exchange?

As a followup question, that's the first reference I've seen to a perception in the 80's of excess capacity. What's that about?

Growth Comparison: Medicare vs. Private Insurance

2011-12-31T09:54:00.000-08:00

This piece in the Times gave me an excuse (and a source) to look at growth rates of normalized per enrollee expenditures for Medicare vs. Private Insurance. The author uses the data to make a case against competition:

Despite competition and choice in the private insurance system, Medicare spending has grown more slowly than private insurance premiums for comparable coverage for more than 30 years.

Below is a chart showing the annual change in cost. At first glance it supports the contention that private insurance on average has higher growth rates. The actual annualized rates from 1969 - 2009 are 8.2% for Medicare and 9.5% for private insurance. That makes a big difference over 40 years.

But check out the spike in the late 80's. Up to that point spending growth tracked fairly closely, the annualized growth rates from 1969 - 1986 are within a tenth of a percentage point. Then from 1987 to 1991 private insurance becomes a house on fire. What happened? The answer is that Congress raided Medicare using the newly enacted PPS reform. From the Incidental Economist piece:

Aggregate Medicare hospital payment-to-cost ratios fell every year from 1987-1992 because hospital did not restrain costs as quickly as payments were adjusted (Guterman, Ashby, and Greene 1996). As Medicare margins fell, private pay margins grew over this period. The effects of managed care had not yet been fully felt in the commercial market, leaving private purchasers vulnerable to hospitals’ market power...

Hospitals took back from the private insurer market what they lost from inadequate Medicare payments. Hospitals pushed that as long as they could until employers responded by embracing managed care, initiating the age of HMO's. Getting back to the growth rates, if private insurance had grown at the same rate as Medicare from 87 to 91 the annualized rate over 40 years drops to 8.7%. Still half a point higher then Medicare, but a lot closer then Medicare/single payer advocates like to claim. Especially if you think cost shifting happened in more then just those 5 years.

More important though is that there is no fiat answer to slowing cost inflation. From 1969 to 1986 Medicare and private insurers were equally bad at it, competition or its absence was irrelevant. Once payers started getting tough both systems proved capable of containing costs. PPS made a huge difference to Medicare, and managed care proved effective in private markets (look at 92 - 97).

What it comes down to is that for cost control you don't need any particular system, you just need the backbone to stand up to providers.

More coverage on implants

2011-12-28T17:56:00.000-08:00

in the NY Times. The part they don't mention is that the cost of settling all this crap will ultimately be born by citizens, either directly by patients facing unreimbursed costs or by health insurance payers who will make everyone in the industry whole through higher prices. Not only will we pay for direct damages to remove the implants and defragment people, but we'll pay all the legal bills incurred as doctors, hospitals, manufacturers and insurers try to pin blame on each other. It's too bad no one tested these implants for effectiveness, assuming an average severity of 5K per recipient puts the total liability at 2.5 billion. That would pay for a lot of effectiveness testing...

Coincidentally AP ran a story on the Patient-Centered Outcomes Research Institute (PCORI), created by the Obama health care reform. The mission of that organization is exactly that- testing medical effectiveness. Expect opposition from care providers and whoever will carry water for them. When they say "death panel", think "hip shredder".

Development and Taxes

2011-12-28T17:08:00.000-08:00

Random statistics: The property tax payoff for the SE 28th and Burnside condos. An old greasy spoon Chinese restaurant on the corner of Burnside and 28th was torn down to make way for condos in 2009. How much value did this create?

I'll use a real simple first order approximation and look at property taxes. The figures are online at Portlandmaps.com. The 32 condo units have a 2011 tax totaling $138,997 or an average of $4,344 per unit. That's about 10% more then the average tax paid by the rest of the non tax-exempt property owners on the block, who actually own land! To put those numbers in concrete terms, look at the map:

Now you might think there is something wrong with that block, maybe the land use is particularly ill-conceived and atypical. So I rolled up the taxes on the block south as well. That block had an even lower average tax, a few points below the Burnside block the condos sit on. Here is a total view:

So that little sliver of condos pays almost as much in taxes as the rest of the two blocks combined. To put it another way, the condo development almost doubled the tax revenue coming from the two blocks.

Who benefits from the taxes? Pretty much everyone. It is money for schools, the city, the county, and just about every other local municipal agency. Even the greasy spoon came out better off. And best of all it was accomplished without coercion, but by just staying out of the way and letting change happen. Keep that in mind the next time you hear about a development proposal.

Implants: An object lesson in Ineffectiveness

2011-12-24T10:20:00.000-08:00

Via the NY Times, an Australian study shows how newer models of joint prostheses fail at higher rates then older more established models. The failure rate may not be the worst aspect of the newer style implants. They also pose risks due to breakdown of the metal rubbing on metal, releasing metallic particles into surrounding tissue. Resulting inflammation can make replacement surgery "far more complex and can leave some patients with lasting complications." Some questions:

What drove physicians to use the newer implant style over the old one?
What disclosure was made to patients about the relative risks?
Do we really not keep an implant registry? Getting information second hand from Australia is the best we can do?

Memory and the Future

2011-12-20T18:21:00.000-08:00

This piece by Ryan Aventdisplays a rare sense of humility inadmitting how difficult it is to imagine the future and how our descendantsmight judge us. To participate, considerhow you think about the past, and in particular the decisions made by ourpredecessors. Do you lament or celebratethe widespread adoption of the automobile, or the industrial development thatpolluted so much of our environment, or... anything? Thesad truth is we think little about the past at all, the world is what it is andwe try to make the best of it.

This is part of whatI dislike about preservationism, the idea that we should preserve structures sothat future generations can enjoy them. Who knows what future generations will enjoy or value or need? Think about BDS shuttingdown the Green Castle cart pod in part because a neighborhood planningdocument written in 1987 didn't contemplate food carts. 1987! That's only 24 years ago, yet I have absolutely no idea, interest, oreven desire to know what people back then thought except as a purely historicalconcern. How much less compelling wouldbe the ideas and intentions of people from fifty years ago, or a hundred?

Preservation doesn'tsave the past so much as it foists the present whether people want it ornot. Implicit is the belief that theway things are now is the best that they could ever be, and that any changewould necessarily be for the worse. Itis narcissism writ large.

Medicare and the Development of Rate Setting

2011-12-18T17:06:00.000-08:00

Via IncidentalEconomist and WhiteCoat Notes, I found a pretty good paperon the developments that led to Medicare's Prospective Payment System (PPS) in1982. PPS is the price setting mechanismthat specifies what price hospitals are paid for the services they render. Under PPS they get a per diem rate set by thefederal government. Prior to the adventof PPS Medicare just paid cost- hospitals sent in the bill and Medicare paidit.

The paper describeshow Medicare from inception was beset with massive price inflation, withexpenditures running at 5 times what was expected a mere 8 years after fullimplementation. That inflation quicklyled to cost control efforts, first with Nixon in 1972. Though ineffective at controlling prices,that reform enabled state pricing regulation such as Maryland's all payersystem. Coincidentally, they were thefirst state to seek out pricing regulations and they are the only state thatkept them.

Carter took anotherbite at the apple but whiffed, with hospitals successfully killing his proposalin Congress. Carter's efforts were notfor naught however as the price hospitals paid was a commitment to voluntarycost controls. The voluntary effortshowed modest success for two years, before hospitals fell off the wagon atroughly the same time Reagan came into office. The outcome of this combination was not what you'd expect.

Republicans had hungtheir hats with the hospitals against Carter and been made to look likefools. Their antipathy for governmentspending overruled their hatred of regulation, with some added incentive thatSocial Security was bankrupt (and I mean "we don't know where next month'spayments will come from" bankrupt). This led to a monster Social Security reform bill, part of whichinvolved robbing the Medicare trust and paying for it by using PPS to bringcosts in line with the balance. Mostlegislators didn't even know what a DRG was, to them it was just a SocialSecurity bill.

Some lessons to drawfrom this:

"Single Payer" means absolutely nothing when it comes to reining in prices. What matters is political consensus and the will to enforce it.
Compare how Reagan and Dole reacted to their challenges to say, George W Bush and Tom Delay. The GOP has fallen a long, long way.
That said, cost control reform doesn’t happen without major bipartisan support. 72 and 82 both involved mixed leadership. Carter's efforts failed in large measure because Republicans made hay by standing with the hospitals.
Major reform involves lots of actors with lots of motivations. Republicans put aside their antipathy to regulation when it allowed them to save money.
Successful reform requires provider participation. They won't come to the table unless you hit them with a really big stick first, one big enough that whatever reform you seek looks like pain relief to them. TEFRA served this purpose with PPS.
All reform is temporary. Providers will eventually subvert any cost control regime given enough time, as Medicare's current finances demonstrate.
Finally, crises really are opportunities. The Social Security debacle was the backdrop for PPS and it gave everyone more backbone then they would have had otherwise.

Hospitals are the new Drug Companies

2011-12-17T10:36:00.000-08:00

Good: Regulations aimed at limiting the influenceof drug reps over physician behavior has led to lots of unemployed drug reps.

Bad: Those same drugreps are now being hired by hospitals to influence physician behavior. Some choice quotes (emphasis mine):

"Whilehospitals have always tried to woo doctors to refer patients to them, theinstitutions are growing more direct in their efforts. The hospitals mine data to see which doctors have the most profitable,well-insured patients, and then they assign those doctors to a salesrep. "

"While federallaw prohibits hospitals from paying doctors to admit patients, hospitals paying sales people to influence doctors canget the same results [said a critic]."

Remember, market leverage is what allows hospitals to raise prices. Just one more example of why it is profoundlyunwise to pretend medical providers are angels.

Cumings' Korean War

2011-12-17T06:16:00.000-08:00

I finished reading Bruce Cumings' Korean War this week. This book is a thoughtfulretrospective on what the Korean War means to Korea and the vast misconceptionsthat still define the conflict in the American consciousness. It is not for the faint of heart, Cumingsdoes not shy away from gory detail when he wants to make a point. His views of North Korea are considerablymore sympathetic than pretty much any other American author. That was in fact why I picked up the book,dissidents may be right or wrong but they're almost always interesting. I was not disappointed.

Cumings describes aconflict that anticipates Iraq as much as it does Vietnam. An ignorant and ill-prepared militaryoccupation quickly followed by guerilla warfare, rampant atrocities againstcivilians committed by American troops and the Korean forces they empowered,and driving it all an arrogant belief in the inerrancy of American militarypower. It is tragic that Korea is ourforgotten war, there is a hell of a lot to learn in it.

Happy Ending in Hollywood

2011-12-15T06:18:00.000-08:00

I'm glad Creston Homes found a way around neighborhood opposition to build on the empty lot next to Hollywood Theater. Success came from giving up early on working with the Design Commission and neighbors. The article quotes a project manager with the developer (emphasis mine),

“It had a lot to do with the fact that anyone in the neighborhood could file an appeal of any decision (of the design commission), for a small fee,” he said.

Such appeals, [the project manager] noted, could have derailed the project.

The commission’s design review process also could have been longer, he said. And that would have made a huge difference because city building permit fees increased on July 1. Because the team applied before fees increased, [the project manager] estimates that it saved $56,000. The permit for construction was issued Nov. 17.

Anyone can appeal anything for any reason, at low cost. Even if the appeals are eventually rejected by the Design Commission that can drag out the review process for months. That by itself is enough to kill projects. The net result is a regular review track heavily weighted towards preserving the status quo, even when that means keeping an empty lot at an address with a walk score of 92 in an area targeted for major transit infrastructure. As a city with dreams of growth and density Portland needs to do better.

Conflicts of Interest in Medicine

2011-12-13T19:26:00.000-08:00

Nothing good comes from thinking of doctors as angels. That isn't to say that they are bad, just that they put pants on one leg at a time like anyone else. And when one takes 300K in sponsorship money from a drug company, that means they have a conflict of interest just like it would for anyone else...

The real lesson here though is that your care is ultimately your own responsibility. Finding out whether your doctor's financial interests may conflict with your own, and what to do about it, is up to you.

(H/T White Coat Notes)

Republicans and Ineffective Medicine

2011-12-12T18:22:00.000-08:00

Incidental Economist noted an interesting story from a few years ago by Shannon Brownlee in the Washington Monthly, it is well worth reading in its entirety. The gist of it is that there is very little research on the comparative effectiveness of medical treatments. So when a doctor recommends treatment x, there is a good chance there is no scientific basis for saying that x is a better choice then treatment y. The consequences of this can be horrific:

For example, surgeons long assumed that a radical mastectomy for breast cancer, removing not just the breast but the underlying chest muscle and the lymph nodes under the arm, was the only way to get every last cancer cell. Then a massive, multimillion-dollar clinical trial launched by the NIH in the 1990s found that lumpectomy with radiation was just as effective, not to mention less traumatic for many women. Many patients and doctors also fervently believed that high-dose chemotherapy was a woman's best hope when she had advanced breast cancer. The brutal regimen was used for twenty years before clinical trials finally demonstrated that it was no more effective than standard, far less punishing doses of chemo. During those twenty years, an estimated 9,000 women were killed not by their cancer, but by the high-dose treatment.

You'll need to read the story to understand all the reasons why we do so little research in comparative effectiveness, but one cause stands out because of its intentional character. The first Bush administration created an agency that could deal with this problem, the Agency for Health Care Policy and Research (AHCPR).

Democrats and Republicans alike hoped that the AHCPR's research would help rein in costs by giving doctors better direction, and offering payers—especially Medicare—the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed—and refrain from giving them care that could harm them.

Unfortunately, the agency did its job and released a study on back pain in 1994 that was unfavorable to back surgeons. The surgeons got up in arms and found a champion on capitol hill in the new Speaker of the House, Newt Gingrich. Although he failed in his goal of eliminating the agency, he succeeded in restricting its mission. "Now, the AHCPR would merely be a 'clearinghouse' for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover."

Simply put, Newt worked to keep healthcare stupid. The consequences of that stupidity are obvious: rampant price inflation, unaffordable premiums and increasing numbers of uninsured, and oh yeah, a bunch of guys who were rendered impotent and/or incontinent for no good reason.

You might think that this would be an issue given Newt's front-runner status for the Republican Presidential nomination, and in a different world it would be. But in this world making healthcare stupid isn't exceptional for the Republican party, it is the rule. Just look at the treatment of Don Berwick, Obama's nominee to head the Centers for Medicare and Medicaid Services. He served a year under recess appointment before being filibustered out of office by Senate Republicans. His awful crime? You guessed it, promoting medical effectiveness. I won't even go into IPAB.

All of this leads to a question: What is it about ineffective medicine that so appeals to Republicans?

How the Internet makes the world smaller

2011-12-10T09:28:00.001-08:00

While reading comments on a post on one of the health care blogs I noticed someone named Maggie Mahar. Her comment jumped out as it received a response from the blog author that showed obvious respect. Later while looking for something to read on my next trip I found this, a big book by Maggie Mahar on health care financing. Small world...

Different stick, same horse

2011-12-08T17:40:00.001-08:00

Beating the samehorse as yesterday, here's a WWstory on problems in the Portland rental market. The elephant in the room is that most of theinner east side is reserved for single family housing. Planners have sort of acknowledged theincongruity between their density goals and the infrastructure on hand, but theonly solution they've posed is grannyapartments. They are nuts if theythink that is a solution, if people don't want to live in their mom's basementwhy would they want to live in some other mom's basement? And on the owner side if people can afford tobuy a single family home in the city why would they take on the infrastructurecost and liability of creating a separate unit in exchange for low endrent? Even in this puffpiece they cite $1,200 per month in rent- exactly the high end niche thatis already amply served.

The reality is thatif Portland wants to encourage high population density it needs high densityhousing. What exists on much of the inner east side isn't it.

Followup on Irvington

2011-12-07T21:30:00.000-08:00

The new issue of the Hollywood Star has further reporting on problems between the Irvington Community Association (ICA) and the city over the Historic Preservation District. The story is worth reading in its entirety, but sadly is not available online as far as I can tell. The gist of it is that there are two issues:

The current fee schedule represents a "doubling" of cost per the ICA
The ICA is dissatisfied with what actions trigger review and what do not.

No offense, but buyer beware. By doing what it did the ICA voluntary subjected Irvington to the whims of the city's review process and its expense. There is no exception in the city code that says review will follow exactly what the ICA wants at exactly the price ICA thinks appropriate. That point is obvious, and it should have been obvious to everyone involved last year. But focusing on the ICA misses the real culprit, which is evident in a parallel story about the Buckman neighborhood's pursuit of its own historic register listing.

Per the Buckman story the only way a register listing can be opposed is if a majority of property owners send a notarized letter of opposition. Read that twice- they aren't saying a majority of people who write in, but an absolute majority of all property owners have to send notarized letters opposing the designation to shut it down. That burden is so insurmountable that the state doesn't even include the possibility in its process flow chart. It's a process so slanted to produce an "approval" it would make union organizers blush.

No wonder the Irvington listing passed, there was no way it couldn't. The process doesn't imply real consent, it is designed to provide a fig leaf of consent while passing the listing. I'd expect to see something like that in a history of Jim Crow South, not living in the flesh in my state government.

This brings me back to a quote in the original posting on Portland Architecture,

[an architectural historian and Irvington Preservation Committee member] said the Portland currently counts 5,277 buildings either in historic districts or individual landmarks on the National Register – all of which require design review for exterior alternations.

That list could grow substantially in the future. Citizens are either gathering data for potential historic districts in the Buckman neighborhood and are investigating that option in at least two others. Under national historic standards, [the historian] said 85 percent of buildings in North and Northeast Portland west of 82nd Avenue could qualify as eligible for historic protection.

Much of inner Southeast Portland is basically of the same vintage, so potentially the entire inner east side could be put off limits to development. How does that square with the urban growth boundary, which demands urban infill? How does that square with Oregon's property tax limits, which demand redevelopment in order to sustainably fund city services? How does that square with the premise that the Portland metro population will double in the next 30 years? There is a serious disconnect here...

What we have here is, a failure to communicate...

2011-12-06T17:10:00.001-08:00

Per Incidental Economist, a study on how well parents of overweight children understood their children were overweight... after being told by a doctor that their children were overweight.

This study couldn’t be simpler. The parents of nearly 5000 children who were over the 85th percentile for BMI were asked if they had been told their child was overweight (they were). Know how many said yes? 22%.

Admissions to med school are ultra competitive, with selection based on MCAT scores, GPA and the like. What if the people selected by those criteria absolutely suck at communication with the average American? I see it as just more evidence that we have the wrong people practicing medicine.

Kitzhaber (vs. Occupy?)

2011-12-03T08:40:00.001-08:00

From an address by the governor yesterday to the Oregon Civics Conference (emphasis mine):

That brings me to this whole issue of civic engagement and civic literacy. It is our civic machinery, our structure of government, that gives us the capacity to resolve disputes and work in the interest of the common good. It allows us to achieve our highest aspirations as a society. We take that for granted, but it works only as well as the people who are engaged in it. So that means people have to understand it.

So let me wrap up with a quick story from my own background. I was civically illerate for the first two decades of my life. I was bored to death. I was not interested in politics. I was not interested in government. I was a 21-year-old student, a junior, at Dartmouth College in 1968, when a lot of things were going on — the civil rights movement and the war in Vietnam.

“Martin Luther King was registering black voters in the South, there were sit-ins in restaurants, where they would go into segregated restaurants and sit down at the counter and expect to get arrested. They didn’t oppose the rule of law, but they wanted to highlight a law they felt was unjust. As a result of that, we had the Civil Rights Act, the Voting Rights Act, and ultimately elected Barack Obama president.

In 1969, people were getting drafted to go to Vietnam at the age of 18, but you could not vote until you were 21. So we were essentially being drafted and sent halfway around the world to fight in a war that had murky justifications, at least to us, who had no say in that. Bobby Kennedy was running for president; he was against the war, and he was giving a voice to many voiceless people — the farm workers in California, native Americans on reservations, who were out of the mainstream of American life. That was all going on.

That April (1968), Martin Luther King was assassinated. I can remember right where I was. I was in a physics shop, I remember putting my screwdriver down, listened to the radio and felt profoundly moved. I couldn’t even begin to tell you why. It was just as if the light had gone out. Then when Bobby Kennedy was assassinated on June 6, just after he won the California primary. I think for a lot of people my age, we just decided the country lost something that was a lot more than two individuals. But it was a belief that you could work in the system, work within the structure and change the world and make it better — and we all had a responsibility to do that. That was my moment of political awakening. I ended up doing this for a lot of reasons.

So my message to you is that you really are not powerless. I am speaking more to young people, not to those who teach and guide them. What this country desperately needs is to rebuild a sense of community. There are certain things we have to do together to make us all better. The only tool we have to make that happen is our government structure — and the will of individuals to use that structure. If you drop out, it operates on its own. You are the drivers. Civic literacy gets you there. It is your ticket.

That looks a lot like a rebuttal to the Occupy movement to my eyes:

America has structures for civic engagement but those structures don't run themselves, they are only tools for citizens.
The civil rights movement is a demonstration of how to effectively use those tools. Civil disobediance targeted at specific laws, with the purpose of changing them to create fairer and better laws. With the tools we have, even the most disadvantaged segments of society can affect radical change.
No system is perfect, and sometimes things go bad as when national reform leaders were murdered. We face a choice in those moments, to carry on the work of building a better society or to abandon it and fall into cynicism and disassociation.
Too many people have chosen the latter course in the false belief that it is a means of reform. It is not. Our system of governance is the only one we have, and disassociating from that system won't change it. It just makes the system operate poorly.

Instead of blowing up another park Occupy leaders might want to think about this.

Bartlett on Gingrich

2011-12-01T07:40:00.001-08:00

Bruce Bartlett has a good op-ed in the NY Times on Gingrich's efforts to stupidify congress. What struck me was the ending line:

It is essential that Congress not cripple what is left of its in-house expertise. Gutting the G.A.O. and abolishing the C.B.O. would be acts of nihilism. Any politician recommending such things is unfit for office.

Acts of nihilism are pretty much all Republicans can manage. Consider the attempt to default on America's debt, or the intent to revoke health care reform without an alternative solution. On too many fronts Republican ideas have been proven decisively wrong: Lassez-faire markets and the wall street debacle, climate change and the increasing frequency of catastrophic weather events, trickle down economics and the most unequal society in living memory, the George W Bush administration... Rather then acknowledge failure, Republicans resort to wholesale denials of reality and nihilism. Gingrich isn't exceptional in his need to dumb things down, he is typical of the Republican party.

Finished reading "Broken Branch"

2011-12-01T07:35:00.001-08:00

This book wasn'twhat I wanted. Too much of it was theauthors quoting their own columns in Roll Call. Ugh… I came away knowing not muchmore then I did going in. Newt Gingrichis responsible for a lot of bad things, the level of centralization within thehouse has changed over time.

Ok, why did thehouse trend toward decentralization for most of the 20th century? Why did incoming Democratic freshmen demandmore of a voice, while incoming Republican freshmen gave it up? Why are congressmen less likely to stay in DCand why in an age of ever-present telecommunication does it matter? Why does the south seem to dominate nationalpolitics through whichever party it leans towards?

Questions foranother day (and a different book).

Huh (All Payer Claims Database Edition)

2011-11-28T22:31:00.001-08:00

The MA commission reviewing provider pricing regulation came out with recommendations a few weeks ago. The headline is that this is another step towards pricing regulation, but something else caught my eye. One of their recommendations was to increase price transparency, and included this (emphasis mine),

Access to the All-Payer Claims Database. DHCFP is currently in the process of developing an All-Payer Claims Database (APCD), pursuant to M.G.L. c. 118G §6. The Special Commission recommends that the state make the APCD accessible to consumers, purchasers, providers, insurers, and researchers both for standardized queries and in support of research to analyze price variation consistent with the provisions of the Data Release regulations, 114.5 CMR 22.00 et seq. Such disclosure should carefully guard protected health information (PHI), consistent with the Health Insurance Portability and Accountability Act (HIPAA). In addition, the Special Commission recommends including third-party administrators that process claims for self-insuring employers among the entities required to submit claims data to the APCD, consistent with the filing requirements for insurers serving fully-insured employers and individuals, to the extent it is legally feasible to do so.

Back in February I emailed the Office for Oregon Health Policy and Research to see if citizens would have any access to Oregon's all payer data. The answer was no, due to privacy restrictions. Maybe I'll forward them a copy of the MA report...

More on the concept that we need different doctors

2011-11-28T21:31:00.001-08:00

Via Incidental Economist, more evidence that we'd be better off with different people going into med school. Some folks did a study comparing graduates from Mount Sinai's non traditional HuMed program with those from the regular med school. From the abstract:

Purpose: Students compete aggressively as they prepare for the MCAT and fulfill traditional premedical requirements that have uncertain educational value for medical and scientific careers and limit the scope of their liberal arts and biomedical education. This study assessed the medical school performance of humanities and social science majors who omitted organic chemistry, physics, and calculus, and did not take the MCAT.
...
Conclusions: Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.

Not only was their performance statistically the same, but HuMed grads were more likely to go into cost effective primary care and less likely to do high cost surgical specialties. That isn't a neutral result, it's a win.

Irvington Historic District: Buyers Remorse

2011-11-27T22:00:00.001-08:00

I guess some people didn't know what they were signing up for when Irvington applied for Historic District status. Take a look at the fees applicable. "Minor Projects" like changing the house color or adding exterior lights now costs $1,050, just to pay the city to think about whether or not it will allow the homeowner to proceed. I can understand why people would be upset, but how did they not know what they were signing up for? It's not like the city just created the fee schedule, this is what Irvington residents elected to do to themselves.

I can laugh now, but I'll be downright pissed if they get the fees reduced and I wind up having to subsidize their nonsense.

Paul Starr Op-Ed

2011-11-27T18:03:00.001-08:00

The O linked to a Paul Starr Op-ed today. A lot of it is a digest of Remedy and Reaction, but with some extra musing about the paring of Obama and Romney:

If former Massachusetts Gov. Mitt Romney and President Obama face off in the 2012 presidential campaign, America will witness the singular spectacle of two candidates getting very little love, and plenty of hate, for the same signature achievement: reforming health care.

Both overcame long odds to pass legislation, Romney in Massachusetts, Obama at the national level. Even the specifics of their reform laws are similar: Both include subsidies for private insurance, the establishment of insurance exchanges and a mandate for individuals to maintain a minimum level of coverage. Each man expected to reap credit for his effort. But neither has gotten political mileage out of it; in fact, both may have lost more ground than they picked up.

In another era, we might be celebrating the remarkable fact that both a Democratic president and a leading Republican challenger arrived at fundamentally the same approach to fixing our health-care system. That is not the America we live in now.

Worth reading.

If you wonder whyenactment was delayed until 2014, Starr gave these reasons in R&R:

Delaying enactment reduced the CBO cost, which covers the next 10 calendar years
The decision to give states the responsibility for creating exchanges meant giving them time to enact legislation
IRS said it would be confusing and chaotic tax-wise if programs incepted mid year or inconsistently across states

Dems did not want enrollment occurring in Nov 2012 during election. Medicare Part D blew up in someone's face in 2004(?).

Starr implied that the real problem was Obama's failure to anticipate right wingers' willingness to turn on their own ideas in order to score political points. That's what makes the prospect of a race between Obama and Romney so ironic.

Occupy vs voting

2011-11-25T08:56:00.001-08:00

There are aspects of the Occupy movement I'm sympathetic to: The initial focus on the actual Wall Street and the institutions that inhabited it was brilliant. Just by being there, just by showing that citizens have as much right to Wall Street as Main Street they knocked it's mystique down a peg. But then everyone decided to Occupy Wall Street, and many decided that New York was too far away and it was easier to occupy whatever was close at hand and would gain attention. The movement when downhill from there...

That leads to today's post in the Oregonian. I'd read that protest camps tended to rely on caucuses and consensus rather then voting to make decisions, but I didn't know their contempt for voting ran so deep:

"We are demanding that we stop trying to solve problems in a "vote yes, vote no" format. We are making a statement that they cannot and will not be resolved simply by electing a different puppet into the same political structure..."

How do these people reconcile themselves with the history of struggle and sacrifice aimed at extending voting rights? Do they think that was just a waste of time? Gaining majority support is hard and uncertain, but without it there is no legitimacy. Demagoguery is a poor substitute for democracy.

More Pushback from VT Providers

2011-11-21T10:56:00.001-08:00

We've seen the "good cop" side of Vermont care providers' response to Single Payer, here comes the "bad cop." The good doctor gives a litany of ways providers will react to the cost control regime, none of them good. This kind of reaction is predictable and inevitable, it is why single payer advocates who focus solely on the evils of private insurance are not setting themselves up for success. But two points are worth bearing in mind:

The fact that doctors practicing under the current system are unwilling to practice under a system affordable to the public doesn't mean that reform is unworkable. It just means that different doctors will be needed. Med Schools starting at the application stage need to reconsider what it means for someone to be a good candidate to become a doctor. Why does someone want to practice medicine? Is it to help people, or to get automatic entry into the top 0.1% of the economy? Such questions need to be given priority, especially when you consider how trivial admissions processes are (is it relevant in any meaningful sense whether someone got an "A" or a "B" in a weed-out OChem class?)
Despite all the threats and complaints, the reality is that doctors in countries with single payer plans tend to be happier with their work then doctors now in the U.S. Again, see the point that maybe we need different people with different priorities and motivations practicing medicine.

Why the "industry" means more then insurers

2011-11-19T07:56:00.001-08:00

When Oregon considered creating its Health Insurance Exchange, there were two key issues of dispute.

Would the exchange be an "active purchaser", with the ability to exclude carriers even though they met federal qualifications?
How many board members could be from the "health care industry," where that was broadly construed to mean insurers and providers.

In discussions of the latter issue, it was routine to see questions about why doctors should be excluded or to simply construe "industry" as meaning insurers. Implied was that providers were disinterested parties not at all concerned about money. Here is a headline that puts such thinking in its place:

AMA opposes ‘active purchaser’ model for exchanges

H/T Incidental Economist

Irreconcilable Differences on the Right

2011-11-19T07:32:00.001-08:00

From Kaiser, on why South Carolina isn’t trying to build an exchange:

[South Carolina’s Director of Health and Human Services] argues that the main function of the exchanges is to deliver the federal subsidies. That, according to Keck and other members of the subcommittee he chairs, "is solely a federal concern in which the state has no compelling interest."

From WSJ, claiming federal exchanges can’t offer subsidies:

ObamaCare authorizes premium assistance in state-run exchanges (Section 1311) but not federal ones (Section 1321). In other words, states that refuse to create an exchange can block much of ObamaCare's spending and practically force Congress to reopen the law for revisions.

Who’s lying? Also notice the extortion angle in the WSJ piece- rewrite the health care law or Tea Party states will go to court to deny themselves exchange subsidies. Wow, that will keep people up at night.

Ratemaking vs. Negotiating in Vermont

2011-11-14T20:26:00.001-08:00

Doctors in Vermont have apparently picked up on the concept that they will be providing most of the savings under Single Payer. Unsurprisingly, they're forming bargaining units to "inform the process."

Here is a philosophical question: Does it make sense to pay doctor groups differentially based on how effectively they negotiate? Should the Vermont Medical Society get paid more then HealthFirst because of the skill of their lobbyist?

That question points out a politically incorrect truth. The process of establishing provider payments isn't really a negotiation at all, it is an exercise in rate setting by the state. That rates will likely be influenced by "negotiators" does not contravene this, it will just indicate a clumsy and poorly thought out ratemaking process.

POW: Alex Steffen

2011-11-12T08:15:00.001-08:00

LSE hosted Alex Steffen for a discussion of where the world in general and cities in particular are going. I thought the most interesting take was the concept that what will save us is better data. He talks about how everything from how we drive (mileage meters) to how we use power or water will eventually automatically record data and then give us information- how do we do compared to average? How are we doing compared to yesterday or the year before? To me it is a profound example of tech making what was once arbitrary and irrelevant into something specific and purposeful- changing how we use the gas and break pedal to be more efficient, connecting actions with consequences.

There is a downside though, in that the process of converting data into knowledge is not value free. Someone has to determine what the average is and how it should be calculated, someone determines the scales on which we judge ourselves. For example with utilities is the relevant average per household or per person? For vehicles should they be judged by class (hatchbacks separate from SUV’s) or all together? Those questions establish norms for society, but because of their “back room” nature it is unlikely people will be aware of them or the values embodied in their selection. It’s analogous to what insurers do in developing classification plans, except that if people don’t like the way an insurer classifies them it’s easy enough to find a different insurer. Not so with society…

Notes from Vermont

2011-11-09T17:07:00.000-08:00

The Vermont Legislative Joint Fiscal Office released a report estimating the savings made possible by Single Payer. They estimate it will save between 0.8 and 3.5 billion between 2014 and 2019. To put those numbers in perspective, at the high end it would save more in six years on a per person basis then the much ballyhooed “super committee” is trying to cut in ten.

There’s also plenty of grist to back up my suspicions that people who advocate for Single Payer don’t really know what they’re talking about. The most common narrative advocating Single Payer runs along the line of “If we just get rid of the insurers, there will be tons of money and everyone will be happy.” Helpfully, Vermont breaks out their savings into some detail:

The low estimate shows about a third of savings coming from admin including both the payer (insurance) and provider (doctor) sides. More then half the savings come from clinical reform, which addresses how much doctors get paid, in what manner (capitation vs. fee for service), and improvements to public health and reduced utilization. The location of the "fat" is even more apparent in the high estimate:

So if Single Payer works the way people want it to, more then 75% of savings come from medical reform, not admin. And unsurprisingly, this is really hard. The paper discusses some of the issues confronted just to construct credible estimates. For example,

Each of these [payment reforms] has its own set of difficulties. For example, what is the right price to pay for a medical service? Is it the amount it costs to produce? Is it the amount at which an adequate provider supply is available? Is it the amount someone without insurance would be willing to pay for it (and who – Bill Gates or someone working at a minimum wage job)? Finally, is it the amount we as a society can afford to pay?

Implementing Single Payer involves all kinds of questions about what care should be delivered and what should be paid for it. In my view to answer those questions is to sell the program. How likely are people to buy into single payer if they don't know what they are getting? Instead advocates rely on a false narrative that reinforces a mythical conception of cost-free healthcare, one that ensures that even if the public does buy into single payer they will be unwilling to accept the compromises necessary for it to actually work.

Remedy and Reaction

2011-11-03T22:13:00.001-07:00

I finished reading Paul Starr’s Remedy and Reaction. This is an extraordinarily readable discussion of health insurance. The book is worth getting for the first chapter alone, which summarizes reform efforts from the progressive era through Carter with enough detail to articulate why programs like Medicare succeeded versus the many others that failed.

Starr then devotes chapter length treatments to the Clinton and Obama plans, describing why the Clinton plan ran off the rails and how Obama was determined to avoid the same fate. I couldn’t help but walk away with much more respect for both men for their efforts.

Highly Recommended!

Pushback on rates

2011-10-31T17:02:00.001-07:00

This is interesting. A large health insurer is suing Maine for setting rates below what would be required for a "a fair and reasonable return." The margins in question are

2009 3%
2010 0.5%
2011 1%

For context, Oregon (cited in the article) set rates at negative returns, specifically saying they wanted to take insurer surplus and give it to consumers.

This kind of “taking” looks fair if you don’t think about it. After all, why shouldn’t consumers benefit if insurers have excess capital? The problem in a nutshell is that the excess capital wasn’t paid in by the same people who would be getting it out. People who are policy holders in 2011 are not necessarily the same people who were policy holders in prior years when the surplus was built up. Even more so, there are differences in product mix. If an insurer is making “fat” profits off large group customers, what is the moral reasoning behind taking that money and giving it to small group or individual customers? It subsidizes small business at the expense of large, or even worse subsidizes employers that don’t offer insurance by taking from those that do. Anthem leaves this to section III-A-3 in their brief, but to me it’s their best argument.

I hope the Anthem suit fails because regulators should have maximum flexibility to respond to market place needs. But at the same time the concept of “taking” deserves much more public scrutiny, and for that I’m glad the suit was filed. Scheduled for oral arguments 11/8/2011.

Women and the City

2011-10-29T07:44:00.001-07:00

One of the angles I don’t see covered enough in public discussions of urban living is gender. For instance, the desirability of standing alone in the dark at a bus or train station may change markedly depending on who you ask. I’d expect that to filter down to residential choices, that women faced with income constraints would be more likely to move out until they found affordable housing rather then stay in and accept the trade-off in neighborhood quality.

Here in a roundabout way is empirical evidence. The MTO study didn’t show the educational effects for children its authors were looking for, but it did find significant health benefits for women who moved out of high poverty neighborhoods to those with low poverty. In essence better neighborhoods are healthier neighborhoods for women in a way that doesn’t apply to men.

Worth considering for a region like Portland with specific goals for densification and urbanization.

Blue Shirts Unwanted

2011-10-21T19:53:00.001-07:00

"You're probably used to seeing TSA's signature blue uniforms at the airport…" When I see the signature blue uniforms an announcement goes off in my head.

"Attention! You are now entering a liberty-free zone. What you once understood to be inalienable rights are void. So long as you are here your rights are the equivalent to what they'd be if we lost World War II. Thank you and have a good day."

The prospect of seeing signature blue uniforms more often and in places other then airports is both depressing and unsurprising.

Hospital Pricing Regulation: A History (as of 1997)

2011-10-16T17:27:00.001-07:00

I came across an extremely readable short history of state level hospital pricing regulation. I highly recommend it for getting a broad overview of what was going on in the 70’s, and why it stopped.

The short version is that prices were gamed, particularly by urban and teaching hospitals. It created a situation where everyone, from the insurers to businesses to unions to the states themselves decided they could negotiate lower prices than the official rates.

The author notes the influence of politics on deregulation but suggests it was mostly symbolic, providing a rallying point for existing interests. I think that gives short shrift to the power of ideology. It’s a reverse Lake Woebegone effect- its mathematically impossible for everyone to negotiate costs below average, but everyone in the 80’s suddenly became convinced that’s what they could do. Whatever you call it, the Reagan ethos had an effect.

It’s kind of funny, you wouldn’t guess from the paper’s tone that 14 years later HMO would be a 4 letter word. The paper is actually a sort-of defense of regulation. From the conclusion:

…viewed by the standards of the era in which they were created, and seen in the context of the tools that were available and usable at that time, mandatory hospital rate-setting programs were able to leave an overall legacy of effective intervention. In future years, when the shape and effects of the emerging system are more clear, we may yet come to a greater appreciation of the challenges and accomplishments of this health policy epoch.

I wonder if the author expected we’d be taking another look at this.

History and Heart

2011-10-15T08:26:00.001-07:00

I thought this column on learning from history was trivial, is it possible to engage analytically with the world without referencing history? To do otherwise is an exercise in mythmaking or religion. But he ends with a provocative question: America came out of the Great Depression stronger and more unified, but does anyone think that will happen this time?

Book Review: Ghosts of Cannae

2011-10-14T22:39:00.001-07:00

I finished reading Ghosts of Cannae. Very readable and enjoyable military history of the Second Punic War. Hannibal invaded Italy with enormous success, winning devastating tactical victories at Trasimene and Cannae. But he never translated those victories into strategic success, Rome stood undeterred. In a sense Hannibal was outclassed. Rome was not ruled by any warlord or Greek despot willing to make peace based on a rational calculation of interest. Instead it was already an empire with unmatched manpower and a Senate determined to win at all costs. If that meant sacking their own major cities like Capua then so be it.

Capua is instructive. They accepted Hannibal's offer to break off from Rome on the condition that they didn't need to contribute soldiers. That left Hannibal with the liability of protecting the city but no additional assets to do the job. An impossible situation, one quickly exploited by Rome. Hannibal couldn't win by being a mere warlord, he needed to make the conflict with Rome into a civil war instead of just a foreign invasion. That meant giving dissident latins something to fight for, they needed an ideology or an idea that was worth dying for. Hannibal couldn't just break up Rome, he needed to create an alternative. Instead, Rome created a new Hannibal in the form of Scipio Africanus and the rest is history.

The book references a provocative thesis I hadn't seen before: That the Republic fell because Rome couldn't meet its military challenges without powerful and charismatic generals, and that this was Hannibal's ultimate legacy. This seems a bit off- Rome did quite well isolating and marginalizing Hannibal without a superstar. The only way Scipio is necessary is if you think Rome would have run out of willing soldiers, and there's nothing to support that. How different would things be if Publius Scipio died at Cannae!

Auto Enrollment vs. Mandates

2011-10-08T08:51:00.001-07:00

The Incidental Economist looks at the Republican version of health care reform. One interesting concept picked out is the idea of auto-enrollment:

Mechanisms include “ERs, submission of state tax forms, workplaces, and state dept of motor vehicles offices, such as when people renew their drivers license.” Presumably by using these to boost enrollment other incentives such as the mandate/tax penalty would be unnecessary.

Two thoughts:

What a whopper of hypocrisy to protest the mandate as unconstitutional because “the government can’t force you to buy something”, then propose something like this. Here, the DMV or IRS is actually buying it for you without your consent.
Is there anything stopping a less coercive measure at the state level to supplement the mandate? Make it as easy and mainstream to sign up for the exchange as it is to register to vote.

Good Quote from Robert Gates

2011-10-07T18:44:00.001-07:00

Speaking at the National Constitution Center, he says,

I have worked for eight presidents, and I have known many politicians of both parties over nearly five decades, and I never met one who had a monopoly on revealed truth.
At a time when our country faces deep economic and other challenges at home and a world that just keeps getting more complex and more dangerous, those who think that they alone have the right answers, those who demonize those who think differently, and those who refuse to listen and take other points of view into account—these leaders, in my view, are a danger to the American people and to the future of our republic.

Worth remembering.

Development Matters

2011-09-29T17:14:00.001-07:00

ECONorthwest recently released a report on the long term financial challenges facing municipalities commissioned by the League of Oregon Cities. The headlines are about benefit costs, and how their growth is far out of line with growth in government wages and property tax revenue. But the report touches on something I don’t often see mentioned, the connection between development and property tax revenue.

From the intro discussing property taxes (emphasis mine):

Even though property taxes are not directly tied to personal income, it makes sense that the two go hand in hand. As a city experiences growth in population, and as its residents see their incomes grow, they drive demand for new housing and new businesses. This new construction fuels growth in assessed value, and in property taxes.

If measures 5 and 50 are a problem because they limit growth in property taxes, development is a salve that eases the problem. And note that location matters:

Cities will also experience unequal property tax growth. Cities able to capture new residents and employment growth will experience more property tax growth, whereas cities unable to attract residents and jobs will experience personnel costs that far exceed any growth in property tax revenue.

If it’s easier to develop in Washington County then that’s where development will go, and so will the property tax revenue.

This is why I get ticked when I see people blithely trying to kill development projects or redlining whole neighborhoods, as if there weren’t a cost to their actions. Forestalling such development leaves the city and its residents poorer. Some buildings are worth paying that cost in order to save and some are not. But an honest discussion of costs and benefits is impossible when you miss one entire side of the equation.

PPS looking grim

2011-09-22T18:15:00.001-07:00

Conservatives rail against social security, warning young people not to assume it will be viable when they retire. I feel that way when I look at PPS. Increasingly I think it won't be able to provide an acceptable level of education to my kids. It doesn't mean private school but it does mean I'll treat it like a tool, one of many needed to get the job done.

I wonder how many other parents feel that way? I wonder what we could do on our own if we put our heads together?

Hospital Concentration vs. Insurer Concentration

2011-09-17T09:13:00.001-07:00

Here is a very good post on the Incidental Economist discussing the leverage effects on pricing. The author posits a “sweet spot” in the middle, ie too much concentration on either the insurer side or the provider side will raise prices.

Something missed: Regulation. There is a well established regulatory authority to review insurer pricing and ensure monopoly benefits are passed on to consumers. The regulatory task actually gets easier and more efficient as the number of insurers drops, and when you take it to the extreme you wind up in Vermont with single payer. In contrast there is no established regulatory authority over hospital pricing, that’s still the wild wild west.

That suggests the “sweet spot” curve needs to be tweaked…

Hardware vs. Software

2011-09-09T17:27:00.001-07:00

The NY Times ran a story this week questioning the value of technology in the classroom. They cite in particular a showcase district in Arizona that has been pouring money into tech without creating any observable benefit in test scores.

To me that story highlights a key point: The “software”, that is the teaching practices and processes that rely on tech are critical to effective utilization. As one teacher puts it in their signature file,

“It’s not the stuff that counts — it’s what you do with it that matters.”

The conclusion to draw from that isn’t that tech doesn’t matter, it’s that you need to do more then just buy stuff. You need to think about how to use it, and adapt as you gather experience.

Flashback: The Social Life of Information makes the same point about business processes.

Provider Pricing Regulation takes another step closer to reality

2011-09-05T23:28:00.001-07:00

in Massachusetts. The fate of this proposal deserves as much attention as Vermont’s single payer plan. Both depend on much greater scrutiny and regulation of health care pricing.

POW: Delete

2011-08-27T08:08:00.001-07:00

LSE hosted Viktor Mayer-Schönberger for a podcast discussion of his book, Delete: The Virtue of Forgetting in the Digital Age. I’m a big fan of technology and its ability to shift information through space and time. Mayer-Schönberger describes significant downsides to this ability, and how it conflicts with human cognitive function.

Forgetting isn’t just loss, it is a curating process in which the necessary is separated from that which we don’t want or don’t need to carry forward. Forgetting defines and creates us as much as it destroys. By putting so much of ourselves online we lose control over that process, the cloud forgets nothing. Alternatively we could become luddites and withdraw from technology, but who would want to do that? Mayer-Schönberger suggests an alternative solution: building the ability to forget into cloud systems and making their function a little more human.

Interesting stuff.

A better Groupon

2011-08-18T17:32:00.001-07:00

WW has an article on the frustrations and problems of contracting with Groupon. It got me thinking. How to do it better?

For starters, I’d use a different middleman. Groupon reaches an audience that self selects for cheap eats. Why not reach out to alternative local communities- for instance blog readers? There are all kinds of local interest blogs like Blue Oregon, Portland Transport, Bog Blog, etc. Why not reach out to them?

Offer a theme night, with customers claiming “the Blog” sent them getting an x% discount. The blog gets a reasonable kickback for promotion and generating traffic, the restaurant gets control over how much and when a discount is offered so disruption to existing clients is minimal, and blog fans get to show their support for their favorite bloggers while also getting a discounted meal and (depending on the venue) an opportunity to socialize with fellow fans. If a particular audience proves a poor fit then they’re gone after one night and you never see them again. If an audience fits in and does well then invite them back once in a while What’s not to like?.

S&P Downgrade

2011-08-07T16:53:00.001-07:00

S&P is getting a lot of flak for the downgrade, with suggestions that because they ignored a big math error they were really just playing politics. That criticism misses the point. The downgrade isn’t a consequence of any mathematical formula, it’s a judgment on the behavior of congress (and especially the Tea Party) in last week’s debt ceiling debate. The U.S. very nearly defaulted. The whole purpose of ratings is to warn ahead of time of such an outcome. A post on Actuarial Opinions said it best:

Are you really surprised? AAA debt is supposed to be the ultimate sleep insurance. You park your money there and don’t have to ever worry about it. You don’t have to think about it. It is completely, unquestionably safe. If you didn’t feel that way last weekend, you agree with S&P.

What if…

2011-08-04T18:01:00.001-07:00

There is a lot of feel good talk about how well the recent state legislative session went, with big agreements on health care, education and the budget. I’ve had a fear in the back of my mind though: What if the economy slows down in the second half of 2011, and state revenue fails to meet forecast? That looks increasingly likely.

The question highlights how bipartisanship was possible largely because of an implicit (who knows, maybe explicit) agreement not to pursue fee or tax increases. I don’t see how that arrangement survives if the economy does a double dip. The line between us and Minnesota may not be as wide as we think…

Kudos to DCBS

2011-08-04T17:59:00.001-07:00

DCBS gets some much deserved credit for its robust health insurance rate review process. There are a lot of things DCBS can improve on, but it’s important to recognize they do a lot of things right as well.

An interesting micro debate

2011-07-23T18:50:00.001-07:00

on how progressively health care costs should be spread. This story (especially the comments) presents a debate within one of the major public employee unions over how to bear health care costs. One option was for everyone to pay a fixed percentage of their insurance premium, the other option was for everyone to pay a percentage of income. Obviously, the first option would hit lower paid employees harder as they’d have to pay a higher percent of income, while the second option was more progressive.

Here is what they decided.

Book Review: Taney vs. Lincoln

2011-07-23T11:01:00.001-07:00

I picked this up as a continuation of supreme court/federal history from the Marbury vs. Madison book. This wasn't as interesting. Cliff Sloan's history was a story of exploration and settlement as the court (and Washington DC) found their place in America. This is a story of their decline into irrelevance as they fought a futile campaign to preserve slavery in America. The Dred Scott decision was discarded in the north as soon as it was issued, the Prize cases were important not to America but to the British, and at the start of the war the Federal Government couldn’t even count on the loyalty of surrounding territory in Maryland. The real action in this period happens not in DC but in the nation at large: fighting in Kansas, a revolt against the fugitive slave law in Wisconsin, the south's secession first from the Democratic Party and then from the nation.

Lincoln’s office was a product of the fighting in the country at large, and it is misleading to pose him and Taney in parallel. Their conflict was no more a match between equals then a speeding train hitting a car stalled on the tracks.

Effective Columning

2011-07-09T11:55:00.001-07:00

Reading Lister’s column on Hales got me thinking. What good is it to trash a candidate 10 months before the primary, where the field isn’t even clear yet? Lister lambasts Hales for leaving office midterm 9 years ago, but what will he do if the general comes down to Hales vs Cogen (who would be abandoning the county chairmanship midterm to run…)? Point is, it’s too early to bust on candidates.

So what is a columnist to do? Why not promote the issues that they think this election should be about. Lister mentions the police and firefighters disability fund for instance, only to use it as a mudball. Why not devote a column to telling people what the fund is and what the actuarial projections imply. You don’t need to solve it, just put it out there and try to make people care about it. It seems like a much more effective way to influence the discourse then trying to direct votes that won’t be cast for a long time.

POW: John Mearsheimer

2011-07-08T19:00:00.001-07:00

John Mearsheimer led a discussion promoting his new book, courtesy of the Cato Institute. He discusses why leaders lie, fib, prevaricate and otherwise answer other then truthfully. He describes how lying tends to correlate with trust: Governments lie to their own citizens much more then they lie to each other, and democratic governments lie more often then non-democratic ones. Lying over wars of choice gets particular attention, with contrasting views of Bush and FDR (crafty enough that he didn’t need to lie).

Interesting and timely material.

POW: Michael Scheuer

2011-07-05T17:20:00.001-07:00

Michael Scheuer makes for an interesting lecture, even in a post Bin Laden world. He provides a sharp critique of the American war on terrorism and the “they hate us for our freedoms” meme that I usually only see from Glenn Greenwald. I’m a sucker for grumpy old folks pounding the table about how everyone is wrong, especially when there’s some truth to what they’re saying.

More head scratching on Hollywood Theater

2011-07-04T19:18:00.000-07:00

I travel up and down Sandy a lot, so I routinely go past the Hollywood Theater. I still can’t get over the concept that they think they’re better off with an empty garbage strewn lot for a neighbor rather then an apartment building targeted at young, single, bike/transit oriented people. But I’ll put aside the economics, it isn’t my theater after all. Considering only the aesthetic question of whether an apartment building would “infringe” on the theater’s image, I still think they’re nuts.

Below is a series of pictures from the southwest (the theater sits on a street running diagonal, from the southwest to the northeast). And I’ll assume no one would suggest the proposed building interferes with the view from the northeast, since from that angle the theater is in front.

First I’ll set the floor. The theater is barely visible from either side of Sandy at 3900. On the west side a traffic island with trees almost totally obscures the theater, if you zoom and look closely you can see the billboard.

From the east side, the only portion of the theater visible is the top of the facade tower.

Moving up toward 40th street, the theater comes in to view on the west side. You can also see how much is happening to obscure the view. Trees and street signs everywhere.
Over on the east side of Sandy, the sidewalk is shifted to allow a turning lane. No part of the theater is visible.

On the west side, it's only when you get to 40th that you can see the view and imagine it being adversely affected by the apartments.
Note that on the East side there is no impact on the view at 40th, the facade is almost totally obscured by trees.

Finally, moving on to 41st the west side facade view becomes clear as you'd move past the apartment building.
On the east side you begin getting a view impact once you clear the trees, roughly midway between 40th and 41st.

So to recap, there is no impact to the view anywhere except between 40th and 41st. On the west side the lower half of that block is affected, on the east side it's the upper half. Round up and call it one square block. What is that worth? Then consider the view we have now:

Why is this even a discussion?

Online Education

2011-07-02T08:41:00.001-07:00

I was impressed with this article in Harvard Magazine covering online education. It ties together a number of threads: Disruptive innovation, the unsustainable increases in tuition, the potential impact of dynamic programming tailor learning to the individual. Best line:

When America’s traditional universities arose, knowledge was scarce, which meant that research and teaching had to be coupled tightly. That is no longer the case.

Even sharper is this analysis of the structural problems with traditional universities:

Examining the traditional universities through the lens of innovation, we see that a muddled business model is causing the industry’s ruinous cost increases... A typical state university today, for example, is the equivalent of a three-way merger of the consulting firm McKinsey—focused on diagnosing and solving unstructured problems; the manufacturing operations of Whirlpool—which uses established processes to add value to things that are incomplete or broken; and Northwestern Mutual Life Insurance Company—in which participants exchange things to derive value: fundamentally different and incompatible business models all housed within the same organization.

Good stuff!

Mass AG: Time to regulate Provider Pricing

2011-06-25T07:52:00.001-07:00

I think provider pricing regulation is both inevitable and necessary to controlling growth in health care costs. Step by step, Massachusetts is reaching the same conclusion. Per Incidental Economist, here is state Attorney General putting the idea out in the annual cost analysis (emphasis mine):

The competitive benefits of tiered or limited network products, however, are unlikely to counteract, on their own, the historic price disparities that threaten many health care providers. During this time of market transition, we recommend temporary statutory restrictions on how much prices may vary for comparable services. Statutory restrictions should only be used as a stop-gap to the extent necessary to moderate price distortions until the corrective effects of tiered and limited network products can improve market function. We are not recommending a return to rate setting for hospitals and physician groups. Instead, we recommend a competitive market-based approach balanced with limited government intervention to foster effective market function.

The AG can call it what she likes, she’s not fooling anyone. Whether it’s single payer like Vermont or mandate based private insurance like Mass, all roads lead to regulating provider pricing. All roads, that is, that work.

What I’m listening to

2011-06-18T17:15:00.001-07:00

The podcast interview of Peter Godwin, on Robert Mugabe’s efforts to hold power. Interesting enough that I’d put him on my reading list.

Followup on Massachusetts

2011-06-12T09:17:00.001-07:00

Via Incidental Economist. The difference in substance between the discussions there and here in Oregon is striking.

Worth chewing on: Annual public hearings on health care costs, as opposed to holding hearings on individual insurer filings in isolation. Compare and contrast…

Another dark corner of health care… Residency

2011-06-11T07:29:00.001-07:00

Passages that make you wonder about the people taking 17% of GDP:

I could spend days telling you tales of horror, but one quick instance springs to mind. I had a bad two months at a county hospital because many of the physicians who worked there demanded that I do things that I felt were not only bad ideas, but also borderline unethical. I refused, and also refused to keep my mouth shut about it. When the end of the rotation came around, I sat with the physician who was to evaluate me. He told me I was going to get a crappy evaluation. He asked me why I couldn’t just keep my head down and conform. This guy had literally made a career out of “sticking it to the man”, and was known as an iconoclast; the irony was lost on him. He ended by telling me he felt compelled to try and sabotage my fellowship application. He said this with a straight face.
Even today, ten years later, I shake with anger as I write this.
This kind of thing happened every day. Physicians don’t talk about it, but we all have stories. The system covers up incompetence and punishes independence. We keep a hierarchical structure in place which continually reminds you that someone is on the bottom. And, more than anything else, we fight to defend this system against all encroachment. We all know, deep down inside, that having an underclass of physicians who will do all the crappy work, all night, all weekend, for relatively little money is the only way to hold it all together.
It’s rotten, it’s wrong, and I loathe it.

I’ve said before that doctors are people and subject to the same biases and failings as anyone else. When we turn a blind eye to those failings and put them on a pedestal we shouldn’t be surprised that abusive practices proliferate. The residency system is one manifestation of such practice. Can you think of any other service which systematically exploits recruits like this? I can…

Governments, Insurance and Unfunded Liabilities

2011-06-07T17:08:00.001-07:00

There are a lot of things one can criticize about the private insurance market, but one thing you can’t say is that they have chronic issues with unfunded liabilities. In contrast, you can barely find a story about government pensions or retiree benefits that doesn’t involve funding problems.

Simply put, governments are really bad at managing current commitments to future obligations. They habitually fail to put enough money aside to fund their promises. I suspect a deep sociological root to this, that those with immediate needs or experiencing immediate suffering will always take precedence over future needs which can only be understood now in abstract. Or it could be a cynical political calculation that tomorrow’s voters don’t vote in today’s elections. Regardless, efforts to write insurance through government agencies warrant skepticism.

Ask the question of your elected officials: are you willing to ignore current needs and suffering in order to save enough money to meet future obligations? If not, you shouldn’t be in the insurance business.

All Payer

2011-06-04T09:33:00.001-07:00

I was surprised to see these guys advocating all-payer, I thought it had been tried in Maryland and wasn’t all that great. Turns out I misunderstood what Maryland was doing. Maryland does have an all payer system, in which all patients pay the same price regardless of insurance. The ratemaking however is handled by the state, not the hospitals. Presumably that leads to a less dynamic, static system without incentive to innovate. That’s better then totally unregulated providers, but not as good as if they competed on service or price.

Key question: Hospital pricing is regulated, but what about everything else? Outpatient surgery? Imaging? A lot of money get spent in places that aren’t hospitals.

PHS Case

2011-05-31T18:02:00.001-07:00

An interesting case of PHS brewing. Interesting because there is no structure to be preserved, people are fighting to protect rat habitat!

It’s hard to understand what is going through the heads of local business owners. That section of Hollywood, bordered by Sandy, Halsey, 39th and say 42nd is extremely dense. I don’t think I’ve ever parked on the street to patronize a business there, all the significant shops have on-site parking. So these business owners are saying, gee, it’s really hard to park here and most people get here on foot. And someone wants to build all this housing next door without parking, meaning lots of people walking around. Ergo we should oppose it?

The guy from the theater gets bonus points for the inevitable day when he asks for public money via the arts bond. Maybe if he had a large and ready supply of patrons living next door he wouldn’t need to feed at the public trough.

Rate Review vs. the Legislature

2011-05-28T08:41:00.001-07:00

One thing worth pointing out is the open and democratic nature of the provider pricing regulatory process in MA. Hospitals will push back and rightly so, whatever doctrine emerges will need their support and consent. The right way to get at that is through a legislative process. That may be slow, cumbersome and prone to unwieldy compromises but so is life.

In contrast certain people in Oregon have pushed to twist premium rate reviews into the be-all end-all of healthcare reform. Rate review is a poor forum for the task, it is dominated by technical calculations that few people understand and has no apparatus or experience with assimilating input from all the interests involved. With limited input you are more prone to get unintended consequences.

Case in point, the call to subsidize individual policies at the expense of large group plans. That would in effect penalize companies who offered health coverage to the benefit of those who did not. Obviously, it would encourage companies to drop employee coverage which goes against the stated objectives of reform advocates never mind the politics. It’s an absurd policy on it’s face that would likely not make it out of committee in the legislature. Rate review on the other hand is basically at the discretion of DCBS. It merely takes an ambitious Director to put such an ill-conceived policy into practice.

It makes you wonder, why are reformers so reliant on demagoguery? If it’s good policy bring it through the legislature, make a case for it and make it law. The back door stuff demeans us all.

Cost Control Efforts in MA

2011-05-28T08:30:00.001-07:00

Oregon efforts at health care reform are consumed with regulating insurance in isolation from providers, but eventually people will figure out that the only way to get cheaper health insurance is to get cheaper health care. Massachusetts, which is a good proxy for life under PPACA is addressing the issue head-on:

The governor recently proposed legislation that would allow the insurance commissioner to scrutinize contracts setting the amounts insurers pay hospitals and doctors and reject health insurance premium increases based on excessive fees for providers.
The administration has scheduled four days of hearings starting June 27 on how to control health care costs. Legislators held their own hearing this month and are grappling with whether to support the governor’s bill, a process they have warned could take months.

Developing an effective doctrine for how, what and why providers should be compensated is the central dilemma of health care reform. I wish MA good luck.

Health care reform turns doctors into slaves?

2011-05-15T18:27:00.001-07:00

Rand Paul seems to think so. Histrionics aside, there is a real issue there. The term Rand Paul seems unfamiliar with is 'public servant', i.e. if health care is to be a public good then care providers are going to be more like fire fighters or police officers and less like lawyers. That is a big change, for patients and doctors alike.

Good Government

2011-05-14T07:44:00.001-07:00

25 Good Ideas, per Harvard Kennedy School. Of the bunch I think the Civic Consulting Alliance in Chicago sounds the most interesting, not exactly how I remember Chicago politics.

Vermont Single Payer

2011-05-14T07:23:00.001-07:00

That Vermont is on the cusp of adopting a Single Payer health care system is getting notice across the nation. What gets less notice is the structure of that particular arrangement.

At heart, what has been agreed to is a grand bargain between people and providers. Providers will provide necessary care and people will pay for it, under a mutually agreed rate structure and limitations. That is the key hurdle single payer plans must climb, getting providers to accept pricing regulation. Other aspects of single payer have been done before, taxes and government health care are not new but the provider pricing regulation is unprecedented.

In Oregon proponents of Single Payer generally brush aside cost control with hand-waiving about “negotiating”. They ignore the reality that providers have choices, either to not participate and effectively create a second, smaller and much more expensive private market or to even move out of state. Buy-in from providers is critical, as it is from people with respect to limits (i.e. no “death panel” drama). Without the cost control mechanism single payer is nothing but a new tax plan.

I expect Oregon will learn a lot from Vermont, I hope we learn the right lessons.

Correction: Provider pricing regulation isn't totally unprecedented, but Vermont's plan is significantly tougher and broader.

Things I like: Portland Police Edition

2011-05-07T07:29:00.001-07:00

I was impressed with a recent speech by Portland Police Chief Mike Reese to City Club. A former counselor with Boys and Girls Club with an educational background in psychology and public administration, he seems as suited to run a non-profit as he does a metro police force.

A story in today’s paper suggests his influence on the department, and I like it.

Doctors as Angels?

2011-04-22T16:28:00.001-07:00

I have a lot of respect for Paul Krugman’s writing, but he’s off in lionizing doctors:

The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

In reality, doctors are people. They are subject to the same frailties, vanities, and flaws that every human being suffers from. And at least some people know this and are using it to their advantage:

Novartis persuaded doctors to promote Trileptal, and five other of its blockbuster drugs, for off-label uses through millions in “kickbacks” disguised as speaker fees at continuing medical education programs. The company implemented an aggressive recruitment effort in order to train up to 4,000 physicians to speak at these events. Furthermore, the speakers were not recruited based on professional credentials but rather targeted those based on prescription-writing volume potential. According to whistleblower Jeremy Garrity, “As long as they had a prescription pad and were willing to prescribe our products, they qualified as Novartis speakers.” Once speakers were accepted on the speaker circuit, minimum prescription levels were required by some Novartis managers. According to Garrity, he was required to tell underperformers that they would be removed unless they raised prescriptions to a certain level. The company conducted return-on-investment analysis of its kickback scheme.

Note that physicians faced no consequences for their participation, only the drug company. Is there any other profession that can take bribes in return for robbing the public on a massive scale, get caught and unambiguously exposed, and then walk away without any legal liability? That’s what you get for pretending doctors are angels.

…

On second thought, Wall Street is an obvious example. I guess doctors can be added to the upper class of Greenwald’s two tiers of justice.

20 people in a room saying they want to pay less for health insurance

2011-04-16T15:36:00.001-07:00

It’s a question I posed in a comment on this post, and I’ll repeat it here: What is the point of a public hearing on health insurance rate increases where the only people in the room are the public and the insurer?

Hospital Profits

2011-03-30T17:53:00.001-07:00

I noticed the Lund Report was showing rising profit margins for health insurers in 2010. That’s good news for insureds, as they can expect that to translate into relatively lower rate increases. It also got me wondering about hospital profits, how do their margins compare to insurance? Fortunately, Oregon has easily accessible data on the financials. Here are the 8 largest hospitals and the state wide total:

	Fiscal Year 2009
	Operating Income	Operating Margin	4 Year Avg Operating Margin
Legacy Emanuel Hospital	-2,313,000	-0.4%	0.8%
OHSU Hospital	56,581,768	5.9%	4.7%
Providence Portland Medical Center	13,709,002	2.3%	3.2%
Providence St. Vincent Medical Center	59,341,480	8.4%	8.5%
Rogue Valley Medical Center	26,624,000	7.9%	3.3%
Sacred Heart Medical Center Eugene	-15,026,259	-3.0%	7.0%
Salem Hospital	7,157,704	1.5%	2.9%
St. Charles Medical Center (Bend)	26,762,158	7.1%	5.6%
	172,836,853	3.9%	4.7%

Total Statewide	330,548,996	4.0%	4.2%

Other then Legacy I’m not seeing any angels. And the 3% insurers made in 2010 seems pretty light given that they have capital at risk.

How throwing rocks at insurers hurts reform efforts

2011-03-28T22:37:00.001-07:00

I’ve gotten into arguments with people about why focusing on insurance is a dead end if you want to reform health care. I think it is actually worse than that, not just an absence of good but an actual bad. Why? Because it encourages the belief that the only thing wrong with health care is that insurers won’t pay claims. If people adopt that mindset, why would they ever accept any kind of cost control? For instance…

Here is a pretty good proposal for cost control, through the creation of CCO’s. Those entities would sit between providers and the insurer (the state), and act to coordinate and plan care across disciplines, including oral, behavioral and physical care. They would also promote individual accountability and seek to prevent unnecessary care.

This seems like a cut and dry ACO reform that will save a lot of money for the state. I also think that politically it is dead meat. The CCO concept will be tarred as an HMO, a comparison that is essentially correct. HMO’s were actually even more detested in their day then insurers are now. I don’t see how the public will accept them without a cogent argument* based on costs and benefits. Bashing insurers promotes a view antithetical to that argument, that the only thing that matters is getting care paid for and where the money comes from is irrelevant. It makes it that much harder for cost control efforts like the CCO proposal to succeed.

Maybe I’m wrong about the fate of this proposal, I’d be happy if I was. Time will tell either way.

*I look to the left for this argument because I’m pretty sure there won’t be one coming from the right.

POW: Scorpions (not the band)

2011-03-26T18:09:00.001-07:00

After Words produced a nice interview podcast with Noah Feldman discussing, Scorpions: The Battles and Triumphs of FDR's Great Supreme Court Justices. The story is how FDR nominated four great liberal judges, and the surprising manner in which their careers on the bench played out. It makes for a neat parlor game to pick four comparable contemporaries. I come up with Cass Sunstein, Eliott Spitzer, Hillary Clinton, and Eric Holder. Politics was a very different animal back then…

POW: Robert Fisk

2011-03-14T19:07:00.001-07:00

Here is a very good lecture by Robert Fisk, sponsored by Georgetown’s Center for International and Regional Studies from about a year ago. He discusses how western and US media in particular have become subservient to government authority, and how that perverts public discussion of foreign policy. The themes will be familiar to fans of Glenn Greenwald, but it is more powerful hearing about them from someone inside and “on the ground” among foreign correspondents.

Worth listening to for the story of the soldier from the 82nd airborne 33 minutes in.

People Against Controlling Health Care Costs

2011-03-11T18:20:00.003-08:00

I’ve seen a lot of discussion on the need to control health care costs, but rarely do I see someone take up the other side. It’s odd, no one ever says they are for higher health care costs, yet that has been the dominant policy of the last 20 years.

Here are some people unafraid to state this position openly: Congressional Republicans en masse. As Austin Frankt says,

There really is no cost control solution if something like the IPAB can’t work.

You can follow the fate of it here.