Category Archives: Healthcare

The view from the bubble

They say we’re entitled to our own opinions, but not our own facts. Except, of course, if we’re Paul Krugman:

When it comes to Barack Obama, I’ve always been out of sync. Back in 2008, when many liberals were wildly enthusiastic about his candidacy and his press was strongly favorable, I was skeptical. I worried that he was naive, that his talk about transcending the political divide was a dangerous illusion given the unyielding extremism of the modern American right. Furthermore, it seemed clear to me that, far from being the transformational figure his supporters imagined, he was rather conventional-minded: Even before taking office, he showed signs of paying far too much attention to what some of us would later take to calling Very Serious People, people who regarded cutting budget deficits and a willingness to slash Social Security as the very essence of political virtue.

And I wasn’t wrong. Obama was indeed naive: He faced scorched-earth Republican opposition from Day One, and it took him years to start dealing with that opposition realistically. Furthermore, he came perilously close to doing terrible things to the U.S. safety net in pursuit of a budget Grand Bargain; we were saved from significant cuts to Social Security and a rise in the Medicare age only by Republican greed, the GOP’s unwillingness to make even token concessions.

But now the shoe is on the other foot: Obama faces trash talk left, right and center – literally – and doesn’t deserve it. Despite bitter opposition, despite having come close to self-inflicted disaster, Obama has emerged as one of the most consequential and, yes, successful presidents in American history. His health reform is imperfect but still a huge step forward – and it’s working better than anyone expected. Financial reform fell far short of what should have happened, but it’s much more effective than you’d think. Economic management has been half-crippled by Republican obstruction, but has nonetheless been much better than in other advanced countries. And environmental policy is starting to look like it could be a major legacy.

As usual, his screed is filled with cherry picked statistics, unsupported claims, and plenty of vitriol for those who don’t agree with him. He uses these weapons, such as they are, to paint a picture of Barack Obama as a consequential and successful president. While I certainly won’t argue with consequential (there have certainly been consequences for electing Obama), the bar Krugman sets for success is convenient for his case but meaningless to Americans outside the elite bubble.

How does Krugman address this?

Yes, Obama has a low approval rating compared with earlier presidents. But there are a number of reasons to believe that presidential approval doesn’t mean the same thing that it used to: There is much more party-sorting (in which Republicans never, ever have a good word for a Democratic president, and vice versa), the public is negative on politicians in general, and so on. Obviously the midterm election hasn’t happened yet, but in a year when Republicans have a huge structural advantage – Democrats are defending a disproportionate number of Senate seats in deep-red states – most analyses suggest that control of the Senate is in doubt, with Democrats doing considerably better than they were supposed to. This isn’t what you’d expect to see if a failing president were dragging his party down.

More important, however, polls – or even elections – are not the measure of a president. High office shouldn’t be about putting points on the electoral scoreboard, it should be about changing the country for the better. Has Obama done that? Do his achievements look likely to endure? The answer to both questions is yes.

Krugman’s point about changing the country for the better is an interesting one. It inevitably leads to the question of better for whom. We the people, pesky knaves who base our opinions on the reality we face every day, have been rejecting the claim that Obama has been successful in poll after poll for years.

That rejection is not hard to understand. Jobs are still hard to come by. Our hours have been cut. Our benefits have been slashed. Our savings haven’t earned interest in half a decade. We see more and more people on the streets, not just in big cities but in suburban towns. We know we might be one job loss away from joining them. We see a generation graduating from college into a hopeless economic situation. We know our children might be next. Worst of all, we’ve had to listen to the media trumpet recovery and economic good news while our situations are still terrible.

Instead of acknowledging the reality faced by the people, Krugman moves to silence and marginalize us. Our opinions are due to partisanship and being down on politicians in general. With a wave of a hand, he rewrites our stories to fit his narrative. This leaves room to for Krugman to explain Obama’s successes using only his preferences and priorities for reference. Inside the bubble, he matters and we don’t.

Ebola: A Consequence Of Austerity?

Kevin Drum, today, on how “slashing” funding for the NIH has resulted in us not having an Ebola vaccine:

What’s more, even without a vaccine we’d probably be better prepared to react to the Ebola outbreak if we hadn’t spent the past decade steadily slashing funding for public health emergencies. The chart on the right, from Scientific American, tells the story.

There are consequences for budget cuts. Right now we’re living through one of them.

Hey, my fellow Libertarians… We won! We trimmed government to the point where it could be strangled in a bathtub. Taxes are low. Regulation is minimal. Government spending is back at pre-WWI levels. We did it, and now we’re going to have to live without the nanny that we slaughtered. [sadface]

Oh, wait. No, that didn’t happen.

Government has grown by 59% in inflation-adjusted dollars since 1999. It’s grown from 17.6% of GDP to over 21% in the same time.

Clearly, we’re not at a loss for a vaccine because government wasn’t spending money. And whether you’re on the Left, the Right, or even a Libertarian, one can make quite a strong argument that research into cures or treatments for epidemic-level diseases may be a “public good”. It is quite true that shareholders for pharmaceutical companies find a lot more value in helping middle-aged men get erections than staving off the next extinction-level-event*. This sort of pure healthcare research is exactly the sort of thing that the market doesn’t do well, and has such widespread benefit to society overall to be worth it.

So. If we can agree that government’s spending a lot more money in inflation-adjusted dollars, and we can agree that both sides of the aisle view this sort of research as a true public good, worthy of public investment, why is its budget getting slashed?

Simple: science spending doesn’t buy votes.

The truth is that the government has plenty of money. They spend plenty of money. Even beyond this, a lack of money has never been a barrier to them spending money, whether they have to borrow it, or print it, or have the fed print it so they can borrow it from themselves. If something is important to politicians, they’ll find a way to funnel money to it.

In fact, the problem is similar to that of many government programs. They’ll find money for sexy new things like rail line extensions, but suddenly are broke when it comes to maintaining the lines they already have. Oh, and the lack of maintenance mentioned in that story cost more lives than Ebola has in the US.

Apparently the war in Iraq was worth $1T. The stimulus was worth $787B. Obamacare (Apr ’14 CBO estimates) will cost $1.383T over the 2015-2024 period.

Compare that to the NIH, which costs ~$30B/year.

It’s not a question of spending. It’s a question of priorities. Incremental scientific advancements to third-world diseases are important, and worthy of funding. But very few politicians will get credit for voting for that funding, so they let the NIH wither on the vine while they spend money on “important” things. That is the libertarian critique: the NIH could have been fully funded if the government wasn’t distracted–as they always are–by anything shiny.

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Facts Are Stubborn Things, Mr. Reid

Every individual who has told the press that they have had a bad experience with ObamaCare is either lying or are too stupid to know how to use the Internet. This is the latest line by Senate Majority Leader Harry Reid (D-NV), anyway. Perhaps it’s these kinds of accusations that gave one Colorado woman the presence of mind to record her phone call with the “Connect for Health Colorado” navigator due to her own problems with the website.

Rebecca Ryan of Fort Collins has a preexisting condition but until recently, she was covered by a different government healthcare plan called “Cover Colorado.” The reason for changing her plan? As it turns Cover Colorado did not meet the requirements of ObamaCare and some 14,000 plans were canceled as a result. Rebecca liked her healthcare plan but wasn’t able to keep it. Sen. Reid wants Americans to believe Rebecca is lying about this “horror story” but this is only the beginning of Rebecca’s experience so far with ObamaCare.

As it turned out, Rebecca could save $15 a month with the new plan with one little caveat: she would lose her doctor whom she has received care from for the last 9 years. If, however; Rebecca wants to keep seeing this doctor she can do so if she is willing to pay an additional $140 a month:

Rebecca: So, the lowest monthly premium is, um, way higher than I was paying before and I thought this was supposed to be lower.

Rep: Now this could be way higher if it’s a doctor, if you have a doctor that’s (??) in there. So, often, if you have a doctor that you work with, you can be picking plans that are higher, if that doctor is a more specialized doctor.

Rebecca: She’s just a general family doctor. She’s not specialized.

A few minutes later, Rebecca was looking for dental coverage but was having some trouble with the website. The navigator explained that she needed to remove the filters Rebecca had in place for her doctor (stupid citizen!):

Rebecca: Do I have to go through the whole filter thing again?

Rep: Is your doctor listed when you hit ‘Find a Dental Plan’?

Rebecca: I don’t know why she would be. She’s not a dentist.

Rep: But she was put in as a provider? (pause)

Rebecca: Ok, my hospital was listed too, so I removed them both [as search filters]. However, what if I want to keep her? I’ve been with her a long time, and I don’t want a different doctor.

Rep: If you want to keep her then you’re looking to pay the 515 dollars a month.

Rebecca: So they’re going to penalize me because I want to keep my doctor?

Rep: Yes.

There you have it Mr. Reid. One individual whose experience is that 1. she lost the healthcare plan she liked, 2. can keep her doctor if she wants to pay a higher price, and 3. had some difficulty with the website (I’ll leave it to the readers and you to decide if its the fault of Rebecca or the website).

And lest you believe, Mr. Reid; that Rebecca, the original reporter on this story, or I have taken this call out of context, please feel free to listen to the entire 24 minute conversation in the player below.

You see Mr. Reid, no amount of smearing of the groups which oppose ObamaCare, no amount of calling people liars, and no amount of repeating “billionaire Koch brothers” can change the objective fact that some people are now worse off than before ObamaCare. Perhaps many others will also record these phone calls to expose your lies. I’m quite confident that Rebecca Ryan of Fort Collins, Colorado is but one person being hurt by this boondoggle.

I Want My — I Want My — I Want My DNA

Today the FDA dropped a big m-fing hammer on 23andme, a service that will allow you some insight into your own genome. They offer, along with the ability to get a raw report about the specific genes they track, some level of analysis of your genome. They can use your data to look for specific known genetic markers of inherited conditions, and giving you advance warning that you may be at elevated risk of certain problems. In addition, by trying to build a large database of genetic data, they are vastly accelerating the degree to which future genetic markers can be understood for analysis.

This, according to the FDA, is data used for diagnostic and prevention purposes, and therefore makes 23andme a “Medical Device”. Suffice to say that medical devices must to be FDA approved, according to the law, and 23andme hasn’t completed all the hoops necessary to allow me to spit in a cup and send it to a lab. So they can’t sell their kits any longer.

This puts some people, like my wife and myself, in a bit of a strange position.

As many of you know, our 4yo son is autistic. We’ve been through quite a bit to potentially understand the causes of his autism. Without getting too deep into the matter (there are many possible causes, each with its own camp of die-hard adherent believers, all of whom hate each other*), one of the avenues we’ve been traveling down is testing for various types of biomedical dysregulation. As a result, we’ve found that he has a genetic mutation common in a lot of autistic individuals related to what is called the “methylation pathway”. This is a biologic process related to brain activity and development, so the fact that it’s short-circuited gives some indication of where things can be helped**.

So my wife and I are taking this as a chance to better understand more about our own genetic profiles, and with the added benefit of determining more clearly where my son’s genetic mutations have come from***. So we both did the “spit in a tube” thing last week, and our samples are happily on their way to 23andme.

Now, I’m smart enough to know that genetics is NOT an exact science. That getting a report that there might be elevated risk for X doesn’t mean I have X****. I’m not going to use the information to make rash decisions about my medical care.

But it’s a start. It’s information that I don’t have today. It’s information that may be of immeasurable benefit to me in the near term and down the road, if it reveals something real. And it’s information that the FDA doesn’t trust me to have.

“Trust” is the term there. The FDA doesn’t trust us mere citizens. It doesn’t believe we’re capable of making decisions that affect our very lives. The 23andme genetic information isn’t perfect, but they believe that if we can’t get perfect information, we’re better off with no information. This information, of course, is getting better. One of the possible advantages of a widening circle of people partaking in 23andme research is that they can improve their ability to analyze a sample, looking for correlations years from now based on the sample I just gave. Part of the reason I wanted to do this was based upon expected future benefit in addition to learning about the aspects of my genetic that already relate to known markers.

So, our saliva is on the way. With the FDA’s recent proclamation, does that mean that 23andme will complete the testing on our samples? Or will the brakes be put on before they’re allowed to run the test? Will this action end up killing the company, so that even if I *do* get my results today there will never be any future research to make the findings more valuable to me?

So thanks a lot, FDA. You’re making me wonder if I’ll ever get the information I absolutely want and paid for. You’re making the future value of that investment lower, by putting into question the future of 23andme and the amount of data they have access to to analyze. And by doing so, you’re probably putting the brakes on the speed at which future genetic breakthroughs will manifest by artificially culling the data set. Nobody will know how many people will die in the future as a result of slower progress in the growing field of genetic research, but they won’t thank you, nor will I, for protecting me from this information today.

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