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.
Three Atlantic staffers discuss “The Winds of Winter,” the tenth and final episode of the sixth season.
Every week for the sixth season of Game of Thrones, Christopher Orr, Spencer Kornhaber, and Lenika Cruz discussed new episodes of the HBO drama. Because no screeners were made available to critics in advance this year, we'll be posting our thoughts in installments.
It happened gradually—and until the U.S. figures out how to treat the problem, it will only get worse.
It’s 2020, four years from now. The campaign is under way to succeed the president, who is retiring after a single wretched term. Voters are angrier than ever—at politicians, at compromisers, at the establishment. Congress and the White House seem incapable of working together on anything, even when their interests align. With lawmaking at a standstill, the president’s use of executive orders and regulatory discretion has reached a level that Congress views as dictatorial—not that Congress can do anything about it, except file lawsuits that the divided Supreme Court, its three vacancies unfilled, has been unable to resolve.
On Capitol Hill, Speaker Paul Ryan resigned after proving unable to pass a budget, or much else. The House burned through two more speakers and one “acting” speaker, a job invented following four speakerless months. The Senate, meanwhile, is tied in knots by wannabe presidents and aspiring talk-show hosts, who use the chamber as a social-media platform to build their brands by obstructing—well, everything. The Defense Department is among hundreds of agencies that have not been reauthorized, the government has shut down three times, and, yes, it finally happened: The United States briefly defaulted on the national debt, precipitating a market collapse and an economic downturn. No one wanted that outcome, but no one was able to prevent it.
Millions of men in the prime of their lives are missing from the labor force. Could a big U.S. housing construction project bring them back?
Something is rotten in the U.S. economy. Poor men without a college degree are disappearing from the labor force. The share of prime-age men (ages 25-54) who are neither working nor looking for work has doubled since the 1970s.
The U.S.’s labor participation rate for this group of men is lower than every country in the OECD except for Israel (an outlier, because of the high number of non-working Orthodox Jewish men) and Italy (an economic omnishambles). Today, one in six prime-age men in America are either unemployed or out of the workforce altogether—about 10 million men.
So, this is the 10-million-man question: Where did all these guys go?
According to a report from White House economists released last week, non-working prime-age men skew young, are less likely to be parents, are disproportionately black and less educated, and are concentrated in the South.
The U.S. Supreme Court strikes down two Texas abortion-clinic restrictions in a 5-3 decision.
The U.S. Supreme Court struck down a series of restrictions on Texas abortion clinics Monday, turning back one of the most significant challenges to abortion rights in a generation.
“We conclude that neither of these provisions offers medical benefits sufficient to justify the burdens upon access that each imposes,” Justice Stephen Breyer wrote for a five-justice majority in Whole Woman’s Health v. Hellerstadt. “Each places a substantial obstacle in the path of women seeking a previability abortion, each constitutes an undue burden on abortion access, and each violates the Federal Constitution.”
Justice Anthony Kennedy, who became the Court’s swing vote on abortion cases after the retirement of Justice Sandra Day O’Connor in 2005, joined with the Court’s liberal wing.
Critics claim British voters were unqualified to decide such a complicated issue. But democracy itself isn’t the problem.
It’s easy, in retrospect, to characterize David Cameron’s decision to hold a referendum on Britain’s EU membership as a colossal blunder, at least from the prime minister’s perspective. The idea was reportedly conceived at a pizza restaurant at Chicago O’Hare airport, an inauspicious place to hatch plans of international consequence. Cameron, by many accounts, promised to stage the vote not because he believed in it, or took it especially seriously, or felt the public was demanding it, but because he wanted to appease right-wing “euroskeptics” in his party ahead of the 2015 election. It worked. Cameron won that election, and soon found himself campaigning for Britain to remain in the European Union. Then a majority of Britons voted to do just the opposite. A disgraced David Cameron now finds himself without a job and his country temporarily without its bearings, in a jolted world. Blunders don’t get much bigger.
On swallowing “sorry”s and replacing them with simple “thank you”s.
There are many things I envy about Tami Taylor, the famously empathetic yet take-no-shit matriarch of Friday Night Lights: her perfect hair, her prodigious wine intake, her ability to always say the right thing. But while watching the show, one thing that really grabbed me was her capacity for casual gratitude.
Casual gratitude is a term I just made up, to distinguish it from the more serious, mindful, let-me-sit-down-and-count-my-blessings practice of gratitude, or the formal gratitude of, say, a thank you note, or a life debt. As the Taylors flurried around their Texas kitchen and the local high school, Tami was always quick to recognize others for the small favors they did for her with a “thank you” or “I appreciate it.” And it’s how she says it. She doesn’t make a big deal out of it, just thanks people casually, but with grace and sincerity, and then she moves on. A simple thank you for a simple kindness.
It’s not because they’re inherently harsher leaders than men, but because they often respond to sexism by trying to distance themselves from other women.
There are two dominant cultural ideas about the role women play in helping other women advance at work, and they are seemingly at odds: the Righteous Woman and the Queen Bee.
The Righteous Woman is an ideal, a belief that women have a distinct moral obligation to have one another’s backs. This kind of sentiment is best typified by Madeleine Albright’s now famous quote, “There is a special place in hell for women who don’t help each other!” The basic idea is that since all women experience sexism, they should be more attuned to the gendered barriers that other women face. In turn, this heightened awareness should lead women to foster alliances and actively support one another. If women don’t help each other, this is an even worse form of betrayal than those committed by men. And hence, the special place in hell reserved for those women.
The spacecraft Juno was designed to make it all the way to Jupiter, then orbit the planet without getting destroyed in the process
Jupiter is not to be trifled with.
The gargantuan planet is a gas giant, a term that makes it sound far gentler than it actually is. In fact, Jupiter is severe and volatile.
Its famous Great Red Spot is a violent anticyclone three times the size of Earth that has been raging for at least 400 years. The radiation around Jupiter is a menace, 1 million times more intense than radiation belts that surround Earth. The Jovian magnetosphere, which powers its radiation belts and produces brilliant permanent auroras around the planet’s poles, is the largest structure in our solar system. “Northern Lights on steroids,” as Randy Gladstone, a planetary scientist who focuses on airglow, once put it to NASA. “They're hundreds of times more energetic than auroras on Earth.”
Girls who start to develop at young ages—as more and more of them are—are at risk for a host of physical and psychological problems.
“I wanted to call the book The New Normal, but everyone around me said no, you can’t!” said Louise Greenspan, a pediatric endocrinologist and co-author of a book that ended up being called The New Puberty: How to Navigate Early Development in Today’s Girls, on Sunday at Spotlight Health, a conference co-hosted by the Aspen Institute and The Atlantic. “It may be average, but it’s not okay.”
Greenspan is also a co-author of a longitudinal study that looked at around 1,200 girls ages six to eight, and followed them for seven years, from 2004 to 2011, to see when puberty began for them. While puberty in girls is often measured using the onset of their first menstrual period, the first sign is actually breast development—it’s just that first period is easier to measure, because people typically remember it. For breast development, a doctor really has to do an in-person exam. (Puberty onset in boys hasn’t been well-studied, but it doesn’t seem to be following these same patterns.)