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.
When President Obama left, I stayed on at the National Security Council in order to serve my country. I lasted eight days.
In 2011, I was hired, straight out of college, to work at the White House and eventually the National Security Council. My job there was to promote and protect the best of what my country stands for. I am a hijab-wearing Muslim woman––I was the only hijabi in the West Wing––and the Obama administration always made me feel welcome and included.
Like most of my fellow American Muslims, I spent much of 2016 watching with consternation as Donald Trump vilified our community. Despite this––or because of it––I thought I should try to stay on the NSC staff during the Trump Administration, in order to give the new president and his aides a more nuanced view of Islam, and of America's Muslim citizens.
Passengers on a domestic flight deplaning in New York were asked to present ID by Customs and Border Protection agents—a likely unenforceable demand that nevertheless diminishes freedom.
American citizens had their introduction to the Trump-era immigration machine Wednesday, when Customs and Border Protection agents met an airliner that had just landed at New York’s JFK airport after a flight from San Francisco. According to passenger accounts, a flight attendant announced that all passengers would have to show their “documents” as they deplaned, and they did. The reason for the search, Homeland Security officials said, was to assist Immigration and Customs Enforcement in a search for a specific immigrant who had received a deportation order after multiple criminal convictions. The target was not on the flight.
After days of research, I can find no legal authority for ICE or CBP to require passengers to show identification on an entirely domestic fight. The ICE authorizing statute, 8 U.S.C. § 1357, provides that agents can conduct warrantless searches of “any person seeking admission to the United States”—if, that is, the officer has “reasonable cause to suspect” that the individual searched may be deportable. CBP’s statute, 19 U.S.C. § 1467, grants search authority “whenever a vessel from a foreign port or place or from a port or place in any Territory or possession of the United States arrives at a port or place in the United States.” CBP regulations, set out at 19 C.F.R. § 162.6, allow agents to search “persons, baggage, and merchandise arriving in the Customs territory of the United States from places outside thereof.”
The president has long toyed with the media, but the stakes are much higher now.
American presidents have often clashed with the press. But for a long time, the chief executive had little choice but to interact with journalists anyway.
This was as much a logistical matter as it was a begrudging commitment to the underpinnings of Democracy: News organizations were the nation’s watchdogs, yes, but also stewards of the complex editorial and technological infrastructure necessary to reach the rest of the people. They had the printing presses, then the steel-latticed radio towers, and, eventually, the satellite TV trucks. The internet changed everything. Now, when Donald Trump wants to say something to the masses, he types a few lines onto his pocket-sized computer-phone and broadcasts it to an audience of 26 million people (and bots) with the tap of a button.
Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments.
First, listen to the story with the happy ending: At 61, the executive was in excellent health. His blood pressure was a bit high, but everything else looked good, and he exercised regularly. Then he had a scare. He went for a brisk post-lunch walk on a cool winter day, and his chest began to hurt. Back inside his office, he sat down, and the pain disappeared as quickly as it had come.
That night, he thought more about it: middle-aged man, high blood pressure, stressful job, chest discomfort. The next day, he went to a local emergency department. Doctors determined that the man had not suffered a heart attack and that the electrical activity of his heart was completely normal. All signs suggested that the executive had stable angina—chest pain that occurs when the heart muscle is getting less blood-borne oxygen than it needs, often because an artery is partially blocked.
John Krakaeur, a neuroscientist at Johns Hopkins Hospital, has been asked to BRAIN Initiative meetings before, and describes it like “Maleficent being invited to Sleeping Beauty’s birthday.” That’s because he and four like-minded friends have become increasingly disenchanted by their colleagues’ obsession with their toys. And in a new paper that’s part philosophical treatise and part shot across the bow, they argue that this technological fetish is leading the field astray. “People think technology + big data + machine learning = science,” says Krakauer. “And it’s not.”
Two years ago, at a retail-marketing conference called “The Internet of Things: Shopping,” a consultant took the stage and predicted that by 2028, half of Americans will have implants that communicate with retailers as they walk down stores’ aisles and inspect various items. By 2054, he added, this would be true of nearly all Americans. The rest of the vision went like this: Based on how long shoppers hold an item, the retailer’s computers would be able to determine whether or not they like it. Other signals from the implant would indicate whether consumers are nervous or cautious when they look at the price of the product they’re holding—an analysis that may prompt the retailer to try to put them at ease with a personalized discount.
You can tell a lot about a person from how they react to something.
That’s why Facebook’s various “Like” buttons are so powerful. Clicking a reaction icon isn’t just a way to register an emotional response, it’s also a way for Facebook to refine its sense of who you are. So when you “Love” a photo of a friend’s baby, and click “Angry” on an article about the New England Patriots winning the Super Bowl, you’re training Facebook to see you a certain way: You are a person who seems to love babies and hate Tom Brady.
The more you click, the more sophisticated Facebook’s idea of who you are becomes. (Remember: Although the reaction choices seem limited now—Like, Love, Haha, Wow, Sad, or Angry—up until around this time last year, there was only a “Like” button.)
The preconditions are present in the U.S. today. Here’s the playbook Donald Trump could use to set the country down a path toward illiberalism.
It’s 2021, and President Donald Trump will shortly be sworn in for his second term. The 45th president has visibly aged over the past four years. He rests heavily on his daughter Ivanka’s arm during his infrequent public appearances.
Fortunately for him, he did not need to campaign hard for reelection. His has been a popular presidency: Big tax cuts, big spending, and big deficits have worked their familiar expansive magic. Wages have grown strongly in the Trump years, especially for men without a college degree, even if rising inflation is beginning to bite into the gains. The president’s supporters credit his restrictive immigration policies and his TrumpWorks infrastructure program.
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Two of the world’s three richest people extol the virtue, and relevance, of optimism in the age of Trump—and predict a comeback for fact-based discourse.
Bill Gates, the world’s richest man, and Warren Buffett, the third richest, are—not entirely coincidentally—two of the most unremittingly optimistic men on the planet. So when I met the two of them in New York recently to talk about the state of humankind, and about the future of American democracy, I had a clear understanding of my mission, which was to pressure-test their sanguinity at every turn.
I tried, and failed, though not completely. Both men appear to doubt some of President Trump’s innovations in rhetoric and policy. Both men have warm feelings about immigrants, and also about facts, and so are predisposed to react skeptically to recent developments in the capital. When I asked whether they believed America needed to be made great again, Buffett nearly jumped out of his chair: “We are great! We are great!” And when I asked about the Trump Administration’s problematic relationship with empiricism, Gates said, “I predict a comeback for the truth.” He went on to say, “To the degree that certain solutions are created not based on facts, I believe these won’t be as successful as those that are based on facts. Democracy is a self-correcting thing.”