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.
The candidates are back on the campaign trail, following the third, and final, debate on Wednesday night.
It’s Friday, October 21—the election is now less than three weeks away. Donald Trump and Hillary Clinton are back on the campaign trail to deliver their final pitch to voters, ahead of Election Day. We’ll bring you the latest updates from the trail, as events unfold. Also see our continuing coverage:
South Africa says it will leave the ICC, ISIS attacks Kirkuk, Trump gets booed, and more from across the United States and around the world.
—South Africa has notified the UN that it is withdrawing from The Hague-based International Criminal Court. A government minister said South Africa didn’t want to carry out ICC arrest warrants against other African leaders—warrants, he said, that would lead to “regime change.” More here
—ISIS, under sustained attack in its last major Iraqi stronghold, Mosul, attacked the city of Kirkuk. At least 19 people are dead in the attacks.
Science says lasting relationships come down to—you guessed it—kindness and generosity.
Every day in June, the most popular wedding month of the year, about 13,000 American couples will say “I do,” committing to a lifelong relationship that will be full of friendship, joy, and love that will carry them forward to their final days on this earth.
Except, of course, it doesn’t work out that way for most people. The majority of marriages fail, either ending in divorce and separation or devolving into bitterness and dysfunction. Of all the people who get married, only three in ten remain in healthy, happy marriages, as psychologist Ty Tashiro points out in his book The Science of Happily Ever After, which was published earlier this year.
Social scientists first started studying marriages by observing them in action in the 1970s in response to a crisis: Married couples were divorcing at unprecedented rates. Worried about the impact these divorces would have on the children of the broken marriages, psychologists decided to cast their scientific net on couples, bringing them into the lab to observe them and determine what the ingredients of a healthy, lasting relationship were. Was each unhappy family unhappy in its own way, as Tolstoy claimed, or did the miserable marriages all share something toxic in common?
Why her vow not to “add a penny to the debt” is an impossible pledge to keep
Hillary Clinton said nothing on Wednesday night that should derail her considerable chances of winning the presidency on November 8. But if she wins, one simple promise she repeated over and over again could come back to haunt her reelection bid in 2020.
“I also will not add a penny to the debt,” Clinton said toward the beginning of her final presidential-debate performance. She made a similar pledge two more times that night, and it’s a line she has used before on the campaign trail. It’s a short-hand reference to the fact that although she has proposed hundreds of billions in new federal spending for infrastructure, paid family leave, education, and other items, she would pay for those investments by raising an equal or greater amount in revenue through higher taxes on the wealthy and corporations.
The House speaker thinks there’s a better way for America—and that his plan will change your life.
Picture the set of the Broadway musical hit, The Book of Mormon. House Speaker Paul Ryan stands on the doorstep of a cozy, nondescript house in a cozy, nondescript suburb. The well-tended yards up and down the street are a sea of red and blue campaign signs crowing “Trump!” and “I’m With Her!” Ryan is wearing a short-sleeve white oxford, black dress slacks, and a black tie. He clutches a slender, white booklet to his chest as he rings the doorbell, wide smile lighting his boyish face. After a few seconds, the door is opened by an impatient-looking blonde woman holding a cell phone to her ear. Before she can say a word, the Speaker of the House takes a deep breath, opens his mouth, and bursts into song.
An interview with Bill O’Reilly Monday night distilled many of the struggles the Late Show host has had in his first year on the job.
Almost 10 years ago, Stephen Colbert appeared on Fox News’ The O’Reilly Factor in character as the Colbert Report host—a pugnacious, egotistical super-pundit who tolerates no criticism. Colbert has frequently acknowledged that O’Reilly was the chief inspiration for his on-screen persona, and it was hilarious to see the imitation go up against the real thing. “What I do, Bill, is I catch the world in the headlights of my justice,” Colbert bragged to a smirking O’Reilly. “I’m not afraid of anything. Well, I might be afraid of you.” The same day, O’Reilly went on Colbert’s show; the combative tension between the two remains genuinely thrilling to watch.
On Monday night O’Reilly went on The Late Show With Stephen Colbert to talk about the state of the Republican Party and Fox News. The conversation was civil, at times energetic, but mostly bland. O’Reilly, clearly far more at ease, pontificated on the state of the Trump campaign while dodging any discussion of some of its biggest controversies. Ultimately, it was a notable reminder of just how much things have changed for Colbert since he cast off his late-night character and joined CBS. To stand out in a crowded landscape, Colbert has pursued even-handedness and empathy, a drastic swerve away from his former public persona. It’s an approach both noble and misguided, but a year into his Late Show run, it’s kept him firmly out of the zeitgeist.
Rarely have presidential nominees declared, without qualification, that it’s a woman’s right to choose.
Even in a presidential campaign that has become so intensely focused on gender, there was something surreal about watching Hillary Clinton’s response to a question about abortion in Wednesday night’s debate.
Here was the first woman nominated by a major party for the United States presidency, standing on the debate stage in “suffragette white,” and talking in no uncertain terms about her strong commitment to protecting a woman’s right to “make the most intimate, most difficult in many cases, decisions about her health care that one can imagine.”
Democrats are expected to support abortion rights, of course, but that support is often couched with carefully hedged language. This is an understandable impulse, given how divisive the issue of abortion remains.
Thais find ways to grieve the only monarch most have ever known, from black pants to body art.
In the waiting room of the Sak Lai tattoo studio in central Bangkok, the owner, who goes by the name Leck New York, showed me his latest design: the numeral “9,” sketched in Thai several times on drafting paper. It’s a popular choice among clients looking to pay tribute to the late King Bhumibol Adulyadej, the ninth monarch of the Chakri dynasty, and a widely revered figure in fractious Thailand. More than 10 clients have been inked with a royal motif at Sak Lai since the 88-year-old king died last week, ending his 70-year reign as the world’s longest-serving monarch. For some, it’s the words “Long Live The King.” Others get a tattoo of Bhumibol’s signature glasses, twisted into a 9. Still other popular choices include a well-known saying that translates to “Let me serve under his Majesty the king in every life.” And some ask for a portrait of Bhumibol.
Trump’s refusal to say he would accept the election results will ensure negative coverage for the final three weeks of the election, and with good reason.
At times during tonight’s debate, Donald Trump seemed controlled, succinct, even prepared.
It didn’t matter. In an instant, he lost the debate and blew his chance of using it to turn around his sinking campaign.
That instant came when Trump refused to say he would respect the outcome of next month’s vote.
Barring some massive unforeseen news, that comment will dominate political conversation in the coming days. By next week, it will be all anyone remembers about tonight. And for good reason. A major party nominee suggesting he won’t concede defeat in a presidential election he has clearly lost was, until Trump came along, unthinkable. Had Al Gore taken that position in 2000, the United States might not be a functioning democracy today. If Trump’s position becomes the new normal--if future candidates refuse to respect the voters’ will--America may not remain one. Democracies require public legitimacy for their survival. When powerful actors withhold that legitimacy, the system crumbles.
“Imagine what would happen if we don’t stand and fight [ISIS],” he said:
If we didn’t do that, you could have allies and friends of ours fall. You could have a massive migration into Europe that destroys Europe, leads to the pure destruction of Europe, ends the European project, and everyone runs for cover and you’ve got the 1930s all over again, with nationalism and fascism and other things breaking out. Of course we have an interest in this, a huge interest in this.