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.
If the president and his aides will tell easily disproven falsehoods about crowd sizes and speeches, what else will they be willing to dissemble about?
One of the many things that is remarkable about the Trump administration is its devotion, even in its first days, to a particular variety of pointless falsehood.
Mendacity among politicians and the spokespeople hired to spin for them runs across eras and aisles, though it is true that some are more honest than others, and Donald Trump was a historically dishonest presidential candidate. But the Trump administration has displayed a commitment to needlessly lying that is confounding to even the most cynical observers of American politics.
In his first official White House briefing, Sean Spicer blasted journalists for “deliberately false reporting,” and made categorical claims about crowd-size at odds with the available evidence.
In his first appearance in the White House briefing room since President Trump’s inauguration, Press Secretary Sean Spicer delivered an indignant statement Saturday night condemning the media’s coverage of the inauguration crowd size, and accusing the press of “deliberately false reporting.”
Standing next to a video screen that showed the crowd from President Trump’s vantage point, Spicer insisted that media outlets had “intentionally framed” their photographs to minimize its size. After attacking journalists for sharing unofficial crowd-size estimates—“no one had numbers,” he said—he proceeded to offer a categorical claim of his own. “This was the largest audience ever to witness an inauguration, period, both in person and around the globe,” he said, visibly outraged. “These attempts to lessen the enthusiasm of the inauguration are shameful and wrong.”
Popular demonstrations can bring change and topple governments. They can also spark retaliation from those in power.
The signs were so clever.
“We shall overcomb.”
“Viva la vulva.”
“I MAKE THE BEST SIGNS I REALLY DO EVERYONE SAYS SO THEY’RE TERRIFIC.”
Someone even made a papier-mâché vagina dentata.
The people were so cheerful and happy to be with one another, forgetting the cold and enjoying what often seemed less like a protest and more like a block party. There were families there, with grandmas in wheelchairs and babies in strollers. They were ecstatic and in disbelief at the number of people. TheWashington Post reported that the organizers put the attendance at up to half a million. They had hoped for less than half that.
It was surreal how similar this all felt, and my Russian friends on social media confirmed it: “Totally Bolotnaya,” one of them wrote. Bolotnaya is the square in the center of Moscow, right across the river from the Kremlin, where on December 10, 2011 around 50,000 people came out to protest fraudulent parliamentary elections. They had expected 3,000 and were stunned by their success. It was cold and gray that day, too, and the feeling of being in that joyous crowd was unforgettable, which is why I remembered it so vividly today. It is the giddiness of watching people vent their political frustrations with a sense of humor and good cheer, and the euphoria of observing people discover that they are not alone, that there are thousands and thousands of people just like them.
Narcissism, disagreeableness, grandiosity—a psychologist investigates how Trump’s extraordinary personality might shape his possible presidency.
In 2006, Donald Trump made plans to purchase the Menie Estate, near Aberdeen, Scotland, aiming to convert the dunes and grassland into a luxury golf resort. He and the estate’s owner, Tom Griffin, sat down to discuss the transaction at the Cock & Bull restaurant. Griffin recalls that Trump was a hard-nosed negotiator, reluctant to give in on even the tiniest details. But, as Michael D’Antonio writes in his recent biography of Trump, Never Enough, Griffin’s most vivid recollection of the evening pertains to the theatrics. It was as if the golden-haired guest sitting across the table were an actor playing a part on the London stage.
“It was Donald Trump playing Donald Trump,” Griffin observed. There was something unreal about it.
The new president’s first actions in office suggest his style from the trail isn’t going away soon.
Inaugurations are America’s modern equivalents of Roman triumphs. Flanked by military and police vehicles, clad in the pomp of tradition, presidents of the United States take their solemn oaths and parade between the classical facades and colonnades lining Pennsylvania Avenue. Crowds of thousands—sometimes millions—of citizens look on. It is meant to be a celebration of the nation in all her stately, martial honor, and of the vir triumphalis who has claimed the status of its moral leader and commander-in-chief. But inauguration is also a transition, not only between presidents, but from the combat of the campaign to the peacetime of governance.
For President Donald Trump, however, that transition has not yet taken place. On Inauguration Day, Trump did not take off the laurel wreath and transform into a governor, but rather extended his fiery campaign. The earliest hours of his presidency suggest that, dogged by unprecedented public disapproval, confronting questions of legitimacy, relying on a base fueled by partisan conflict, and facing extensive grassroots opposition, Trump’s campaign will be indefinite.
Images of today’s marches in Washington, New York, Denver, Chicago, Boston, Los Angeles, Seattle, and from other cities in England, Ghana, France, Canada, Serbia, Australia, Kenya, Germany, India, and many more.
In Washington, DC, today, hundreds of thousands of protesters filled the streets in a demonstration called the Women’s March on DC, while even more marched in cities across the United States and around the world, one day after the inauguration of President Donald J. Trump. Larger-than-expected crowds of women and their allies raised their voices against the new administration, and in support of women's rights, health issues, equality, diversity and inclusion. Below are images of today’s marches in Washington, New York, Denver, Chicago, Boston, Los Angeles, Seattle, and from other cities in England, Ghana, France, Canada, Serbia, Australia, Kenya, Germany, India, and many more.
Driven by opportunism, pragmatism, or fear, many begin to forget that they used to think certain things were unacceptable.
In The Captive Mind, Czeslaw Milosz tells a story about a man who ventures out in the immediate aftermath of the fall of a regime. Papers full of state secrets lie in the streets, their knowledge less important for the moment than that of where to find something to eat. A little boy plays in a bombed-out street, whistling a song about the leader. “The song remains, but the leader of yesterday is already part of an extinct past.”
When authoritarians fall from power, even if they are secretly mourned, they must be publicly forgotten. Yet they remain as traces within the bodies of their people. The muscle memory to salute, to sing their songs, to fear their wrath, can be hard to shake. My years of studying Mussolini and his two-decade long regime have taught me not to underestimate the individual and collective work of disentanglement that comes with the ruler’s fall from power.
A history of the first African American White House—and of what came next
In the waning days of President Barack Obama’s administration, he and his wife, Michelle, hosted a farewell party, the full import of which no one could then grasp. It was late October, Friday the 21st, and the president had spent many of the previous weeks, as he would spend the two subsequent weeks, campaigning for the Democratic presidential nominee, Hillary Clinton. Things were looking up. Polls in the crucial states of Virginia and Pennsylvania showed Clinton with solid advantages. The formidable GOP strongholds of Georgia and Texas were said to be under threat. The moment seemed to buoy Obama. He had been light on his feet in these last few weeks, cracking jokes at the expense of Republican opponents and laughing off hecklers. At a rally in Orlando on October 28, he greeted a student who would be introducing him by dancing toward her and then noting that the song playing over the loudspeakers—the Gap Band’s “Outstanding”—was older than she was.
Most presidents view inaugural addresses as a rare opportunity to appeal beyond “the base.” This was base-only.
For my sins, I have read every U.S. presidential inaugural address ever given, and played a small part in writing one of them—Jimmy Carter’s, delivered 40 years ago today.
The first one I remember hearing, John F. Kennedy’s in 1961, I saw on a fuzzy black-and-white TV from my 7th-grade American history classroom in California. The arctic conditions that day in Washington practically radiated through the TV screen. I remember seeing the revered 87-year-old poet Robert Frost hunch against the wind and squint in the low-sun glare as he tried to read the special inaugural ode he had composed. Then Richard Nixon, just defeated by Kennedy in a hair’s-breadth race, reached across to block the glare with his top hat. Frost waved him off and began reciting from memory one of his best-known poems, “The Gift Outright.” [Update: Other images suggest it could have been VP Lyndon Johnson who was offering Frost the hat. I didn’t really notice at the time; whoever it was, the lasting image was of Frost’s struggling with his script and then beginning to recite.]
The Women’s March on Washington was a protest that also, in its own way, marked a peaceful transition of power.
WASHINGTON, D.C.— In the middle of the National Mall, on the same spot that had, the day before, hosted the revelers who had come out for the inauguration of Donald Trump, a crowd of people protesting the new presidency spontaneously formed themselves into a circle. They grasped hands. They invited others in. “Join our circle!” one woman shouted, merrily, to a small group of passersby. They obliged. The expanse—a small spot of emptiness in a space otherwise teeming with people—got steadily larger, until it spanned nearly 100 feet across. If you happened to be flying directly above the Mall during the early afternoon of January 21, as the Women’s March on Washington was in full swing, you would have seen a throng of people—about half a million of them, according to the most recent estimates—punctuated, in the middle, by an ad-hoc little bullseye.