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 Fox host’s insistence that black laborers building the White House were “well-fed and had decent lodgings” fits in a long history of insisting the “peculiar institution” wasn’t so bad.
In her widely lauded speech at the Democratic National Convention on Monday, Michelle Obama reflected on the remarkable fact of her African American family living in the executive mansion. “I wake up every morning in a house that was built by slaves. And I watch my daughters, two beautiful, intelligent, black young women, playing with their dogs on the White House lawn,” she said.
On Tuesday, Fox News host Bill O’Reilly discussed the moment in his Tip of the Day. In a moment first noticed by the liberal press-tracking group Media Matters, O’Reilly said this:
As we mentioned, Talking Points Memo, Michelle Obama referenced slaves building the White House in referring to the evolution of America in a positive way. It was a positive comment. The history behind her remark is fascinating. George Washington selected the site in 1791, and as president laid the cornerstone in 1792. Washington was then running the country out of Philadelphia.
Slaves did participate in the construction of the White House. Records show about 400 payments made to slave masters between 1795 and 1801. In addition, free blacks, whites, and immigrants also worked on the massive building. There were no illegal immigrants at that time. If you could make it here, you could stay here.
In 1800, President John Adams took up residence in what was then called the Executive Mansion. It was only later on they named it the White House. But Adams was in there with Abigail, and they were still hammering nails, the construction was still going on.
Slaves that worked there were well-fed and had decent lodgings provided by the government, which stopped hiring slave labor in 1802. However, the feds did not forbid subcontractors from using slave labor. So, Michelle Obama is essentially correct in citing slaves as builders of the White House, but there were others working as well. Got it all? There will be a quiz.
The billionaire former New York mayor denounced the Republican nominee as a “dangerous demagogue” and a “risky, reckless, and radical choice.”
Michael Bloomberg, a brand-name billionaire far wealthier than Donald Trump, a famously independent voter who derides both the Democratic and Republican parties, endorsed Hillary Clinton on Wednesday and called Trump a “risky, radical and reckless choice” for president.
“Let’s elect a sane, competent person,” he said.
The normally soft-spoken owner of Bloomberg financial-news service excoriated his fellow New Yorker, labeling him a “dangerous demagogue,” a hypocrite, a con, and—slashing at the core of Trump’s self-worth—a horrible businessman.
“Throughout his career,” Bloomberg said in his prime-time address. “Trump has left behind a well-documented record of bankruptcies and thousands of lawsuits and angry shareholders and contractors who feel cheated and disillusioned customers who feel ripped off. Trump says he wants to run the nation like he’s run his business. God help us!”
His call on a foreign government to hack Hillary Clinton’s email account is a complete subversion of GOP ideals.
The first excuse for Donald Trump’s amazing press conference on Wednesday, in which he called on the Russians to hack and publish the 30,000 emails wiped from Hillary Clinton’s home server, was: He was only joking.
That excuse almost immediately dissolved. When Trump was asked by CNN’s Jim Acosta whether he would call on Vladimir Putin to stay out of U.S. elections, the presidential nominee answered that he would not tell Putin what to do. After the conference ended, Trump tweeted out a slightly tidied up request to the Russians to find Clinton’s emails—but to hand them over to the FBI rather than publish them.
The second excuse, produced on Twitter minutes later by Newt Gingrich, is that Trump’s remark, while possibly unfortunate, mattered less than Clinton’s careless handling of classified material on her server. That defense seems likely to have more staying power than the first—about which, more in a minute.
The Republican presidential nominee appeared to suggest he’d recognize Russia’s annexation of the Ukrainian territory in 2014.
Donald Trump’s call on Russia to hack Hillary Clinton’s emails Wednesday resulted in widespread criticism. But his comments on Crimea, coupled with ones he made last week on NATO, are likely to have greater significance if he is elected president in November.
The question came from Mareike Aden, a German reporter, who asked him whether a President Trump would recognize Crimea as Russian and lift sanctions on Moscow imposed after its 2014 annexation of the Ukrainian territory. The candidate’s reply: “Yes. We would be looking at that.”
That response is likely to spread much cheer through Russia—already buoyant about the prospect of a Trump victory in November. But it could spread at least an equal amount of dread in the former Soviet republics. In a matter of two weeks, the man who could become the next American president has not only questioned the utility of NATO, thereby repudiating the post-World War II security consensus, he also has seemingly removed whatever fig leaf of protection from Russia the U.S. offered the post-Soviet republics and Moscow’s former allies in the Eastern bloc.
His first Q&A on the site seemed free-wheeling and open to all, but it was actually obsessively controlled.
Cruising the skies above Ohio (and perhaps looking to take more attention away from the Democratic National Convention), Donald Trump tried a new publicity tactic Wednesday night. Instead of his typical podium-and-flag setup, he opened his MacBook and invited users of Reddit to ask him anything.
AMAs—that’s the popular abbreviation—are a staple of the free-wheeling forum site, which has hosted hundreds of celebrities and slightly less famous people who are willing put out a shingle and take questions from strangers on the internet. Reddit—part old-school forum, part meme-machine, part possible-future-of-human-society—prides itself on its community, which moderates itself and (in theory) highlights the best the internet has to offer. Barack Obama hosted his own AMA back in 2012; so have Bill Gates, Patrick Stewart, and a guy who fought off a bear.
A former NATO general imagines a frightening scenario.
In 2014, shortly after Russia forcefully intervened in Ukraine and admitted Crimea into the Russian Federation, Richard Shirreff stepped down as NATO’s deputy supreme allied commander Europe, one of the highest-ranking positions in the military alliance. The British general proceeded to do something highly unusual. He criticized the government he once served, arguing that Britain’s cuts to defense spending were “one hell of a risk” at a time of renewed Russian aggression. Next, he wrote a startling account of what might follow from the failure of the United Kingdom and many of its NATO allies to, in his view, sufficiently invest in countering the Kremlin militarily. He describes the account as a “work of fiction,” but also a “realistic” and “urgent” warning.
The president took the DNC stage on Wednesday, showing why he will be his one-time rival's best advocate this fall.
Barack Obama needed to bring Democrats together tonight at the DNC. Tim Kaine had a far more difficult task: Hillary Clinton’s vice-presidential pick needed to prove he can be trusted, has the capacity to inspire, and can effectively take on Donald Trump.
In the end, Obama and Kaine both won raucous cheers and applause. At one point during the president’s speech, someone in the crowd cried out: “Four more years!” Another screamed: “I love you!” And despite earlier threats of revolt from Bernie Sanders supporters, Kaine made it through his speech without major incident. He came across as dedicated to the cause, and ready to fight, hitting high notes along the way. In all, the evening showed a party that seemed far more willing to come together than it did when the convention began.
We can all agree that Millennials are the worst. But what is a Millennial? A fight between The New York Times and Slate inspired us to try and figure that out.
We can all agree that Millennials are the worst. But what is a Millennial? A fight between The New York Times and Slate inspired us to try and figure that out.
After the Times ran a column giving employers tips on how to deal with Millennials (for example, they need regular naps) (I didn't read the article; that's from my experience), Slate's Amanda Hess pointed out that the examples the Times used to demonstrate their points weren't actually Millennials. Some of the people quoted in the article were as old as 37, which was considered elderly only 5,000 short years ago.
The age of employees of The Wire, the humble website you are currently reading, varies widely, meaning that we too have in the past wondered where the boundaries for the various generations were drawn. Is a 37-year-old who gets text-message condolences from her friends a Millennial by virtue of her behavior? Or is she some other generation, because she was born super long ago? (Sorry, 37-year-old Rebecca Soffer who is a friend of a friend of mine and who I met once! You're not actually that old!) Since The Wire is committed to Broadening Human Understanding™, I decided to find out where generational boundaries are drawn.
This week, the co-author of Donald Trump’s autobiography said in The New Yorker that if he were writing The Art of the Deal today, it would be a very different book with a very different title: The Sociopath.
To title a person’s life story with that label is a serious accusation, and one worth considering. The stakes are high. Tony Schwartz, the writer of the best-selling book, said that he “genuinely believe[s] that if Trump wins and gets the nuclear codes, there is an excellent possibility it will lead to the end of civilization.” In that light, Schwartz said he feels “deep remorse” at having “put lipstick on a pig.”
That seemed to me to be something of a contradiction to the charge of sociopathy, as pigs have been found to show signs of empathy. If you call a pig by name, it will come and play with you, reciprocating affection like a dog. So which is it, pig or sociopath?
Twelve years after introducing himself to the American public as the son of an immigrant, the president recast himself as a bearer of Scotch-Irish values.
Twelve years ago, Barack Obama introduced himself to America as just a skinny kid with a funny name. He made his story into the American story—a tale of immigrant hopes, of opportunities, of success that could only come true in the United States. That speech launched him to the presidency.
In Philadelphia on Wednesday night, as he tried to anoint his successor and secure his legacy, he returned to his biography to close his appeal. But this time, he pulled out a different strand of the story. He spoke not just of his grandparents in Kansas, whose stories he has told many times before, but of their kin and communities, of their vision and values. They were, he said:
Scotch-Irish mostly, farmers, teachers, ranch hands, pharmacists, oil-rig workers. Hardy, small-town folk. Some were Democrats, but a lot of them, maybe even most of them, were Republicans—Party of Lincoln. My grandparents explained that the folks in these parts, they didn’t like show-offs. They didn’t admire braggarts or bullies. They didn’t respect mean-spiritedness, or folks who were always looking for shortcuts in life. Instead, what they valued were traits like honesty and hard work. Kindness; courtesy; humility; responsibility; helping each other out. That’s what they believed in. True things. Things that last. The things we try to teach our kids.