I found it very odd to see Paul Krugman complaining that "patients are not consumers" as if "consumer" were some sort of horrible, low-status role that should never taint the sacred realm of health care. In my economics classes, "consumer" was not a value judgement; it was a descriptor. A consumer is someone who consumes, just as a producer is someone who produces and a distributor is someone who distributes. So I was a bit befuddled to see an economist arguing that "The idea that all this can be reduced to money -- that doctors are just "providers" selling services to health care "consumers" -- 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." Patients consume health care resources. Providers provide them. And the system through which labor and resources are allocated in our society remains money--an arrangement that I'm pretty sure that Paul Krugman doesn't want to change.
This semantic moralizing takes away from what I do think is the core argument between the partisans of the "Peoples' Budget" and the advocates of Ryan's Medicare voucher plan: whether consumers patients, or a central committee (IPAB) should be in charge of deciding what to do with limited health care resources. Paul Krugman, unsurprisingly, is against putting consumers in control:
"Consumer-based" medicine has been a bust everywhere it has been tried. Medicare Advantage was supposed to save money; it ended up costing substantially more than traditional Medicare. America has the most "consumer-driven" health care system in the advanced world. It also has by far the highest costs yet provides a quality of care no better than far cheaper systems in other countries.
But the fact that Republicans are demanding that we stake our health on a failed approach is only part of what's wrong. As I said earlier, there's something wrong with the whole notion of patients as "consumers" and health care as simply a financial transaction.
Medical care, after all, is an area in which crucial decisions must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge.
Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress or needs action immediately, with no time for discussion, let alone comparison shopping.
The statistics with which he opens are dubious: Medicare Advantage is more expensive because it provides more benefits, and the US isn't even close to being the leader in consumer-driven medicine, if by that you mean cost-sharing and purchasing decisions; in the rich world, that would almost certainly be Switzerland, where consumers patients not only pay heavily out of pocket, but purchase their own insurance, as both Kaiser and Cato will tell you.
But though Krugman may be wrong about how consumer-driven our system is, he's not wrong that this is a core conflict. Nor do I think he's wrong that patients will frequently decide wrong. Where Krugman and I differ is that I don't think that centralized rule making is going to do such a super job either, for two reasons.
The first is that providers and patients are going to fight cuts with every fiber of their being, and they will find it easier to fight on individual procedures than on increasing the size of the health care voucher; the former is not very expensive for any given procedure, while the latter is a large, obvious whack in the pocketbook for taxpayers. Think of how easy it has been for oxygen providers to keep their Medicare reimbursements--and how hard it was to pass a new health care entitlement.
But the second is that while consumers may be stupid, rules are often stupid too. Evidence-based medicine is certainly a good idea, but we are nowhere near being able to generate solid rules that a) cover all major possibilities and b) provide the highest chance of survival for the money. People are incredibly complicated. This makes outcomes hard to measure--and solid guidelines hard to develop. Drugs are the most intensively tested health care treatments we have, with the sort of rigorously controlled, double-blind studies that you need to get significant results. But we don't do nearly as much testing as we should: too little head-to-head testing of various products, and far too little testing that could distinguish sub-populations which benefit most from a given drug. It's common to blame pharmaceutical companies' financial incentives, and that's part of it, which is why I support having the government do more head-to-head testing. But that's far from the only limitation. The biggest limitation is often finding enough patients with a given disease to produce statistically significant results. The more satisfied patients are with their current treatments, the harder it is to test whether those treatments are effective.
But even if we had the kind of data we'd need to develop a comprehensive set of rules, the problem remains: rules are stupid. You need to leave room for individual discretion. And individual discretion on the part of doctors and hospitals is a loophole you could drive a truck through.
Nor do I think the possibility of reducing costs through individual discretion is quite as impossible as Krugman makes things sound. Sure, a lot of decisions are life-or-death last minute things. But a lot of them aren't. They're questions like, "Do we send grandma to a nursing home, or try to keep her in the spare bedroom with the help of a home health-care aide?" Or "I've got stage four breast cancer with bone metastes; should I really mortgage the house to try another round of chemo?"
It's all very well to say that people shouldn't have to make those decisions on the basis of money. But that's all the government is going to do. Sure, there are some procedures that people just shouldn't have (like a lot of back surgery). But a lot of this is value judgements: hip replacements for elderly patients, expensive chemotherapy that may extend life by a few months, more convenient dosing schedules or better side-effect profiles for brand name drugs. Unless we simply rely on across-the-board reimbursement cuts--which would be moronic on every level--the government is mostly not going to be deciding which treatments are effective; it's going to be deciding which treatments are cost-effective. We haven't taken doctors out of the business of selling health care to patients; we've just added a middleman.
Now, maybe you think that the government is smarter than the consumers it's speaking for. But how does the government know what you value most: an extra three months of life when you have cancer, or an extra five years of walking after age 89, or an extra $4,000 right now?
I think that people who favor a central board probably put more faith in technocrats than I do, but also, that they are horrified by the specificity of the choices. They're comfortable making decisions about who lives or who dies when the people in those decisions are just decimal points in an aggregate statistic. But they find it horrifying that anyone--particularly the patient--should have to make that decision about a specific person.
But to me, they're not really that different. All those decimal points are people too. And it's just as heart-rending when they suffer or die.
For decades, the candidate has willfully inflicted pain and humiliation.
Donald J. Trump has a cruel streak. He willfully causes pain and distress to others. And he repeats this public behavior so frequently that it’s fair to call it a character trait. Any single example would be off-putting but forgivable. Being shown many examples across many years should make any decent person recoil in disgust.
Judge for yourself if these examples qualify.
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In national politics, harsh attacks are to be expected. I certainly don’t fault Trump for calling Hillary Clinton dishonest, or wrongheaded, or possessed of bad judgment, even if it’s a jarring departure from the glowing compliments that he used to pay her.
But even in a realm where the harshest critiques are part of the civic process, Trump crossed a line this week when he declared his intention to invite Gennifer Flowers to today’s presidential debate. What kind of man invites a husband’s former mistress to an event to taunt his wife? Trump managed to launch an attack that couldn’t be less relevant to his opponent’s qualifications or more personally cruel. His campaign and his running-mate later said that it was all a big joke. No matter. Whether in earnest or in jest, Trump showed his tendency to humiliate others.
In a unique, home-spun experiment, researchers found that centripetal force could help people pass kidney stones—before they become a serious health-care cost.
East Lansing, Michigan, becomes a ghost town during spring break. Families head south, often to the theme parks in Orlando. A week later, the Midwesterners return sunburned and bereft of disposable income, and, urological surgeon David Wartinger noticed, some also come home with fewer kidney stones.
Wartinger is a professor emeritus at Michigan State, where he has dealt for decades with the scourge of kidney stones, which affect around one in 10 people at some point in life. Most are small, and they pass through us without issue. But many linger in our kidneys and grow, sending hundreds of thousands of people to emergency rooms and costing around $3.8 billion every year in treatment and extraction. The pain of passing a larger stone is often compared to child birth.
There's no good evidence that the invasive policing strategy brought down crime. The real question is what made crime rates climb in the first place. This post is part of a debate series on “Is Stop and Frisk Worth It?," an article featured in the current issue of The Atlantic magazine.
When former NYPD Commissioner Ray Kelly was asked what would happen if stop-and-frisk were curtailed, his response was characteristic of his tenure: “No question about it,” he said “violent crime will go up.” When homicides rose in Chicago, Chicagoans clamored for NYPD-style stop-and-frisk. The same premise is repeated by proponents of stop-and-frisk throughout Daniel Bergner’s illuminating Atlantic article: if you want to reduce crime, you have to be willing to suffer more aggressive policing tactics.
In reality, there’s no good reason to assume that these strategies work to reduce crime. David Greenberg has conducted the most comprehensive analysis of the relationship between the NYPD’s practice of stop-and-frisk and crime levels to date, and he finds “no evidence that misdemeanor arrests reduced levels of homicide, robbery, or aggravated assaults.”
Who will win the debates? Trump’s approach was an important part of his strength in the primaries. But will it work when he faces Clinton onstage?
The most famous story about modern presidential campaigning now has a quaint old-world tone. It’s about the showdown between Richard Nixon and John F. Kennedy in the first debate of their 1960 campaign, which was also the very first nationally televised general-election debate in the United States.
The story is that Kennedy looked great, which is true, and Nixon looked terrible, which is also true—and that this visual difference had an unexpected electoral effect. As Theodore H. White described it in his hugely influential book The Making of the President 1960, which has set the model for campaign coverage ever since, “sample surveys” after the debate found that people who had only heard Kennedy and Nixon talking, over the radio, thought that the debate had been a tie. But those who saw the two men on television were much more likely to think that Kennedy—handsome, tanned, non-sweaty, poised—had won.
Communal living is hardly a departure from tradition—it's a return to how humans have been making their homes for thousands of years.
For most of human history, people were hunter-gatherers. They lived in large camps, depending on one another for food, childcare, and everything else—all without walls, doors, or picket fences. In comparison, the number of people living in most households in today’s developed countries is quite small. According to the Census Bureau, fewer than three people lived in the average American household in 2010. The members of most American households can be counted on one hand, or even, increasingly, one finger: Single-person households only made up about 13 percent of all American households in 1960. Now, that figure is about 28 percent.
Belonging to a relatively small household has become the norm even though it can make daily life more difficult in many ways. Privacy may be nice, but cooking and doing chores become much less time-consuming when shared with an additional person, or even several people. Water, electric, and internet bills also become more bearable when divided among multiple residents. There are social downsides to living alone, too. Many elderly people, young professionals, stay-at-home parents, and single people routinely spend long stretches of time at home alone, no matter how lonely they may feel; more distressingly, many single parents face the catch-22 of working and paying for childcare. Living in smaller numbers can be a drain on money, time, and feelings of community, and the rise of the two-parent dual-earning household only compounds the problems of being time-poor.
A new study of pregnant women finds nausea and vomiting are associated with a reduced risk of miscarriage.
People are always saying the wrong thing to pregnant women.
Expectant mothers hear everything from the obnoxious (“You’re huge!”) to the outright bizarre (“If you eat that Sriracha, your baby will come out bald”).
Then there are the well-meaning—yet utterly unhelpful—superstitions and platitudes: “I can tell from how you’re carrying that it’s a girl.” (No, you can’t.) “At least the terrible sleep you’re getting now is great preparation for all those sleepless nights you’re going to have with baby!” (Bone-splitting exhaustion is not something you need to practice ahead of time.) “But morning sickness means your baby is healthy!”
Actually, there might be something to that last one.
Pregnant women have long been told that feeling miserable every single day for several months may indicate that a developing baby is doing well—especially in the first trimester, when nausea and vomiting are most common. Now, there’s more science to support the idea.
The Republican nominee, stumping for black votes, espouses a policy that’s ineffective, often unconstitutional, and generally unpopular with African Americans.
At a town-hall-style forum hosted by Sean Hannity and airing Wednesday night, Donald Trump was asked what he’d do about black-on-black crime. His answer, reported by NBC’s Alexandra Jaffe, is worth reading in full:
Right, well, one of the things I’d do, Ricardo, is I would do stop-and-frisk. I think you have to. We did it in New York, it worked incredibly well and you have to be proactive, you know, you really help people sort of change their mind automatically, you understand, you have to, in my opinion, I see what’s going on here, I see what’s going on in Chicago, I think stop-and-frisk. In New York City it was so incredible, the way it worked. Now, we had a very good mayor, but New York City was incredible, the way that worked, so I think that could be one step you could do.
The Donald J. Trump Foundation reportedly used $258,000, most of it other people’s money, to settle legal disputes for the Republican nominee.
For people at certain income levels, finding creative ways to avoid taxes is practically a leisure sport. Donald Trump, golf and casino magnate that he is, would never miss out on a leisure sport, would be?
In a new article, The Washington Post’s David Fahrenthold, who’s already collected a series of scoops on the Donald J. Trump Foundation, reports that Trump sometimes had people who owed him money pay his foundation instead—to the tune of at least $2.3 million. That’s legal, provided that the person who would have received the income still pays taxes on the money, which is where things get unclear. A Trump adviser initially denied that Trump had ever directed fees to his foundation, but when presented with evidence that he had a $400,000 fee for appearing on a Comedy Central roast (nice work if you can get it) sent to the foundation, the adviser said Trump had paid taxes on it. But he refused to say whether Trump had paid taxes on the rest of the $2.3 million.
See how your own perception of crime in America stacks up against the reality.
Americans don’t feel safe. More than half worry “a great deal” about crime and violence, the highest rate seen in 15 years. Nearly the same proportion believe shootings will become more common over the next decade. And doesn’t it feel like things are getting worse? Each week offers a new horror—the massacre in Orlando, five dead officers in Dallas, a man bleeding out before the world on Facebook Live. “Crime is out of control, and rapidly getting worse,” Donald Trump tweeted Tuesday. “Not good!”
So let’s try something. In the chart below, click the red dot and trace out your best guess for how the murder rate changed between 1985 and 2014. I’ll show you the rest of the story once you’re done. (Hat tip to the folks at The New York Times, who tried this before with college attendance.)