Monday, August 31, 2009

The ninth circle of hell is reserved for theocrats

The Times lede blog relays allegations of unfathomable theocratic depravity from an essay by Iranian feminist lawyer and journalist Shadi Sadr:
Published reports are available about these types of torture committed against women political prisoners after the 1979 Revolution. The most systematic type of reported rape has been the rape of virgin girls who were sentenced to death by execution because of political reasons. They were raped on the night before execution. These reports have been substantiated by frequent statements from the relatives of women political prisoners. On the day after the execution, authorities returned their daughter’s dead body to them along with a sum considered to be the alimony. Reports state that in order to lose their virginity, girls were forced to enter into a temporary marriage with men who were in charge of their prison. Otherwise it was feared that the executed prisoner would go to heaven because she was a virgin!
Beyond the sexually charged sadism, I would have thought the world's major religions united in agreement that acting with intent to deprive any human soul of heaven would by definition damn the perpetrator. But that's misspoken -- there's nothing 'beyond' such sadism...the sexual aggression in this act is so intense that it makes a mockery of any alleged theological intent.

The strange lies of Dick Cheney

Dick Cheney's extended attack on the Obama Administration in his 8/30 interview with Chris Wallace, focused chiefly on the Justice Dept. investigation into whether some CIA interrogators violated the limits set on interrogation techniques by the depraved torture memos, is full of lies. The repeated master lie, providing the theme and structure of Cheney's attack, is easily debunked. Here are three iterations:
We had the president of the United States, President Obama, tell us a few months ago there wouldn't be any investigation like this, that there would not be any look back at CIA personnel who were carrying out the policies of the prior administration. Now they get a little heat from the left wing of the Democratic Party, and they're reversing course on that.

Instead, they're out there now threatening to disbar the lawyers who gave us the legal opinions, threatening contrary to what the president originally said. They're going to go out and investigate the CIA personnel who carried out those investigations.

But my concern is that the damage that will be done by the President of the United States going back on his word, his promise about investigations of CIA personnel who have carried those policies, is seriously going to undermine the moral, if you will, of our folks out at the agency.
Reality check: when the Obama administration released the torture memos on April 16, both Obama and Holder made it very clear that they intended to rule out prosecuting CIA personnel who relied on Justice Department guidance when carrying out interrogations -- that is, who stayed within the limits imposed by the torture memos. Obama's April 16 statement said:
In releasing these memos, it is our intention to assure those who carried out their duties relying in good faith upon legal advice from the Department of Justice that they will not be subject to prosecution. The men and women of our intelligence community serve courageously on the front lines of a dangerous world. Their accomplishments are unsung and their names unknown, but because of their sacrifices, every single American is safer. We must protect their identities as vigilantly as they protect our security, and we must provide them with the confidence that they can do their jobs.
Holder was more explicit about the boundaries of this forbearance:
"It would be unfair to prosecute dedicated men and women working to protect America for conduct that was sanctioned in advance by the Justice Department," said Attorney General Eric Holder.
Also untrue: that "threatening to disbar" authors of the torture memos for their tortured legal reasoning that authorized the obvious abrogation of U.S. treaty obligations and violations of U.S. law constitutes going back on a promise. Obama indicated early that he would prefer not to prosecute the authors of the memos. The draft report by the Justice Dept.'s Office of Professional Responsibility, completed by May of this year, does not recommend prosecution. The still-unreleased report is, according to the Times, (May 6), "likely to ask state bar associations to consider possible disciplinary action, which could include reprimands or even disbarment, for some of the lawyers involved in writing the legal opinions."

As a corollary lie to the lie that Obama has reversed himself, Cheney added this:
We ask those people [intelligence operatives] to do some very difficult things. Sometimes, that put their own lives at risk. They do so at the direction of the president, and they do so with the -- in this case, we had specific legal authority from the Justice Department. And if they are now going to be subject to being investigated and prosecuted by the next administration, nobody's going to sign up for those kinds of missions.
Again, Holder has directed the investigation at those who exceeded the boundaries imposed by the torture memos.

Cheney also lied regarding the import of the declassified CIA memos assessing the effects of the CIA interrogation program:
But the interesting thing about these is it shows that Khalid Sheikh Mohammed and Abu Zubaydah provided the overwhelming majority of reports on Al Qaeda. That they were, as it says, pivotal in the war against Al Qaeda. That both of them were uncooperative at first, that the application of enhanced interrogation techniques, specifically waterboarding, especially in the case of Khalid Sheikh Mohammed, is what really persuaded him. He needed to cooperate.
As Wallace himself indicated in the phrasing of his question, the CIA reports do not show that "the application of enhanced interrogation what really persuaded him." Here's how Wallace put it:
While they say that the overall program got absolutely crucial information, they do not conclude whether the enhanced interrogation programs worked. They just are kind of agnostic on the issue.
Every news organization that has reported the release of these documents has noted that they provide no information as to what techniques yielded what information. And it's a flat-out lie that Abu Zubaydah was "uncooperative at first." Zubaydah's first interrogator, the FBI's Ali Soufan, has written and testified that Zubaydah gave up reams of precious information in interrogations led by Soufan before the CIA intervened and began its escalating series of abuses and torture techniques. No one has contradicted Soufan's testimony.

There were other lies and distortions and misleading innuendos - e.g., that the torture memos provided direction as to how to keep the interrogation program in compliance with U.S. international treaty obligations, when in fact they simply denied the treaties' authority over the President's "article II" authority to conduct war in any way he sees fit; that the FBI is unfit to play the lead in detainee interrogation; that the Bush Administration did not deliberate in detail over the conduct of the interrogation of key detainees; and that the Obama Administration has not stepped up pilotless drone attacks on suspected Taliban leaders )fro better or worse).

Debunking Cheney's lies and distortions is a potentially limitless exercise -- worthwhile only because his slurs sit like time bombs, ready to detonate into full-scale "stab-in-the-back" paranoia after the next major terrorist attack.

Saturday, August 29, 2009

American exceptionalism, domestic peace edition

Jeffrey Goldberg recounts a joyful day of whale-watching off Cape Cod with Andrew Sullivan and spouse, and concludes:
And no, Andrew and I didn't discuss the Middle East. Provincetown seems very far from the Middle East.
That chimes with a thought I had last week at Antietam and again at Gettysburg, at the end of a five-day progress up the Blue Ridge and through the Shenandoah valley and points North with my wife. Both battlefields are preserved (and signposted) to the extent that you can easily visualize men slaughtering each other at close range -- in the sunken road and across Antietam Creek at Antietam, from Little Round Top to Devil's Den at its foot at Gettysburg, not to say in the vast open space between the armies' respective ridges, Seminary and Cemetery, where Pickett's suicidal charge presaged the killing fields of World War I.

The thought, which I associate most clearly with the bridge over Antietam Creek in the late afternoon of a cloudless summer day, was that there's been no such slaughter on these fields or on any other (Continental) U.S. soil --- with the anomalous, jarring exception of 9/11--since the Civil War ended. Not just the stillness of the moment but the domestic peace of a century and a half overlies those fields, the cemeteries on their peripheries, the bodies beneath a visitor's feet.

That's not to minimize the sacrifice and sufferings of Americans through a steady stream of foreign wars, or at home through segregation and discrimination, multigenerational poverty and inner city street violence. But here I am, 50, and I can count peers I've known who have died on the fingers of one hand. My wife and I have four healthy parents between us, and had seven grandparents who lived into their seventies or later. I don't think I've been to a dozen funerals in my life. Middle class Americans of my age and younger who have not served in the military are privileged like no generation anywhere has ever been privileged.

Provincetown -- and Iowa City, and South Orange, NJ, and Denver, CO -- do seem very far from the Middle East. If you're not deployed there. We should never forget how lucky we are, and what our forebears have accomplished. Or what George W. Bush and Dick Cheney - through their assault on our most basic liberties and Constitutional defenses against dictatorship -- imperiled.

Friday, August 28, 2009

Betsy McCaughey's blunderbuss lands one shot

There's no question that Betsy McCaughey, serial saboteur of meaningful healthcare reform, is a smear artist with no compunction about misrepresenting facts or other people's ideas. Specifically, over the past month she's made a dadaist collage out of the life work of bioethicist and Obama advisor Ezekiel Emanuel, first in the New York Post and today in the Wall Street Journal.

Emanuel has written cogently about the causes of overutilization -- Americans' addiction to unnecessary invasive, expensive procedures; the causal link between runaway healthcare costs and the rising number of uninsured; and criteria for making the hardest choices about allocating truly scarce medical resources, such as in organ donation. McCaughey falsely charges that he "blames the Hippocratic Oath" for U.S. doctors' propensity to prescribe unnecessary treatment (rather than a particular interpretation of that oath); that he wants to ration care generally rather than set criteria for allocating resources in the few situations of true scarcity; and that he falsely maligns the US healthcare system by charging that it's "number one in only one sense: the amount we shell out for health care" -- an absolutely true charge undented by the ratings she cherry-picks as counter-evidence.

Alas, even a demagogue can strike home on occasion, and a prolific academic will usually go on record with some disturbing ideas. McCaughey does flag one troubling strain in Emanuel's thought, and his protestations don't entirely hold water.

The trouble comes in a brief 1996 essay in the Hasting Center Report that questions whether American society can bring to bear on healthcare a "concept of the good" that will provide the broad framework enabling us to "develop a principled mechanism for defining what fragment of the vast universe of technically available, effective medical care services is basic and will be guaranteed socially and what services are discretionary and will not be guaranteed socially." The trouble, Emanuel suggests, is that liberalism resists justifying policy by appeals to the good because to do so "would violate the principle of neutrality and be coercive, imposing one conception of the good on citizens who do not necessarily affirm that conception of the good." He suggests that this "strong principle of neutrality" is a weakness and seems to approve of a "growing agreement between many liberals, communitarians and others" that "the just allocation of health care sources...can be addressed only by invoking a particular concept of the good." He suggests that "there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues." He then defines that emerging consensus concept in a passage out of which McCaughey and others have made much hay:
Substantively, it suggests services that promote the continuation of the polity—those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations—are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic, and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia. A less obvious example is guaranteeing neuropsychological services to ensure children with learning disabilities can read and learn to reason.
In defense of this passage, Emanuel told Jake Tapper that he was merely describing this allegedly emerging consensus, not endorsing it. His presentation of the "consensus" cited above is indeed couched in a disclaimer to this effect:
We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues.
I take Emanuel at his word that he does not advocate failing to guarantee health care to those who lack or have lost the capacity to be active citizens. That parenthetical disclaimer is a pretty weak hedge, though. The whole tenor and structure of the article builds toward presenting the liberal-communitarian convergence on this utilitarian "concept" as a cornerstone of true healthcare reform. Early on, Emanuel suggests (again with a slight distancing gesture):
On this view, the reason the United States has failed to enact universal health coverage is not primarily political or economic; the real reason is ethical--it is a failure to provide a philosophically defensible and practical mechanism to distinguish basic from discretionary health care services.
He then decries as "dangerous" a "moral skepticism" that rejects the possibility of defining a "concept of the good" that can attract consensus. He lauds as "fortunate" the alleged fact that many liberals have abandoned such skepticism and alleges "consensus between communitarians and liberals that policies regarding opportunities, wealth and matters of the common good can only be justified by appeal to a particular conception of the good. " That is the buildup to his presentation (without overstating or defending...) of the possible consensus concept of the good. He concludes:
Clearly, more needs to be done to elucidate what specific health care services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services. Perhaps under this progress in political philosophy we can begin to...discuss the goods and goals of medicine.
True, the "concept of the good" sketched out is just a beginning. But Emanuel plainly regards it as a good beginning, a viable basis for determining what gets covered and what doesn't. And that basis is utilitarian -- guaranteeing only those services that help develop and maintain active, participating citizens.

A "White House official" quoted by Tapper in a prior piece claims that Emanuel in fact ends the article by decrying the "concept of the good" around which the article is built. Here's how the "official" presents it:
After a long review of the pluses and minuses of using various schools of philosophical thought to being able to lead a theory of how to allocate health care, he describes the pluses and minuses of the civic republican/deliberative democracy school of thought,” says the official.

The sentence that follows in Emanuel’s article, the official notes, is: “Clearly, more needs to be done to elucidate what specific services are basic; however, the overlap between liberalism and communitarianism points to a way of introducing the good back into medical ethics and devising a principled way of distinguishing basic from discretionary health care services.”

“By the sentence that follows the one McCaughey quoted,” the official says, “it’s obvious that Zeke sees this as a fault in this approach that needs to be addressed in further discussion.”

On the other hand, the sentence introducing the 'concept of the good' in question asserts, "This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources." And while the conclusion acknowledges that "more needs to be done," it also assets that the emerging consensus "points to a way of introducing the good back into medical ethics."

If the assertion that "more needs to be done" constitutes a critique, it is a pretty flaccid one. If the 'concept of the good' leads to morally objectionable conclusions why not say so, and venture an amendment?

UPDATE: I should have noted that the New York Times' James Rutenberg, in an 8/24 article about McCaughey's smear campaign, addressed Emanuel's stance in this article as follows:

He cited as an example, “not guaranteeing health services to patients with dementia.”

Dr. Emanuel said he was simply describing a consensus held by others, not himself.

But even some colleagues said in interviews that the paper did not go far enough in repudiating the view.

“He doesn’t ever endorse it, nor does he explicitly distance himself from it,” said Thomas H. Murray, president of the Hastings Center. But, Mr. Murray added, “anyone who would attribute this isolated sentence to his convictions, it’s just unfair.”

Dr. Emanuel said he understood some of the criticisms.

“Maybe if I had been a smarter, more careful thinker about how people could interpret it, I would have qualified it and condemned it more robustly,” he said. “In my 1.2, 1.3 million written words, you can’t find another sentence that even comes close to advocating that in my voice. When I advocate, I’m not shy.”

To my eye, 'shy advocacy' of the emerging 'consensus' seems to be exactly what this paper offers.

A final thought: I'm not party to the academic dialogue of which this essay is a part. But if anything in the article seems "abstract," as Emanuel characterized his argument, it's the alleged emerging consensus between "communitarian" and "liberal" philosophers. Are there really opposed camps of philosopher-ethicists who are converging on a "concept of the good" that would fail to guarantee services to those who lack the mental capacity for active citizenship?

Wednesday, August 26, 2009

Goldhill's health care fix: cure worse than disease?

David Goldhill's massive case for a radically "consumer-driven" health care system -- which I've always considered the worst, most Darwinian form of health care delivery -- deserves respect. I still believe that the incentives in a system where we each paid out of pocket for all medical expenses under, say, $50,000 would be even more skewed than those of the current system. But Goldhill's willingness to rethink the entire system of health care delivery raises several crucial and sobering points and claims worth thinking about, e.g.:
  • While current U.S. health care spending may be more wasteful than that of any other developed country, health care inflation in countries with better systems, such as Canada and France, is almost as bad as in the U.S. No current system is controlling costs effectively. (Though Goldhill may overstate the equivalence. From 2000-2005, he claims, U.S. per capita health care spending grew 40% vs. 33% in Canada. That's not an insignificant difference.)
  • The skewed incentives in the U.S. (and presumably other industrialized) systems go beyond those caused by fee-for-service; incentives are distorted primarily by the fact that we the consumers are not the "customers," i.e., the payers to whom the service providers are accountable.
  • Health care is the only industry in which technological improvements lead to higher rather than lower costs.
  • Health care is the only industry in which pricing is almost completely opaque (see Andrew Sullivan's view from your sick bed series, in which several participants have detailed the impossibility of getting pricing information in advance of service).
  • In those few health care markets in which insurance does not kick in -- such as laser eye surgery -- competitive pricing and outcomes information have become a norm.
  • Almost all of us are paying more in our working lifetime, via Medicare taxes, lost wage increases and co-pays, than we would likely spend on health care out of pocket, with catastrophic insurance.
Goldhill envisions a system in which we would each pay modestly for megacatastrophic insurance (covering expenses over, say, $50,000), make mandatory contributions to an HSA for major health care expenses, and pay smaller expenses out of pocket. The government could pay for the poor's catastrophic premiums and HSA contributions at relatively modest cost - less than that of Medicaid. Charity care would "go away." Doctors, hospitals, and specialty care facilities unleashed to compete with hospitals would be accountable to each of us for outcomes and cost.

What's wrong with this picture? I've always assumed that, faced with major surgery, it would be brutal to be forced to choose among competing surgeons based on cost and outcomes data. That's not necessarily so, if transparent data were to become the norm. Nonetheless, I think we'd all be faced with untenable cost-benefit calculations. A quadruple bypass or an operation for early stage prostate cancer may or may not be the best course of action for different patients. Should the prospect of spending $10k or $40k out of pocket tip the balance? Should such decisions be easier for the wealthy than for the middle class? (The poor would presumably be subsidized more heavily.) Not in what I would consider a civilized society.

As a counter-example to Goldhill's portrait of the laser surgery market, consider dental care, for which very few have insurance. The market is opaque and expensive, with no good outcomes data. There's nary a dentist who will not recommend more x-rays than you need. And in America today, poor teeth are a class marker; the poor generally simply don't get dental care.

Goldhill argues that bureaucratic cost controls can't control prices with the efficiency that a competitive market does. That may be true generally, but the proper comparison for health care is not with other consumer markets. The health care market is in some key ways naturally opaque. We'd be better off knowing what different surgeons charged for a prostate cancer operation. But we often can't know what we'll gain by getting the operation-- or what we'd lose (i.e., potentially, our life) if we abstained. Cost should figure into that equation -- if under certain circumstances "watchful waiting" or chemotherapy is as likely to have a good outcome as an operation. No provider should have an incentive for doing the more expensive thing. But cost shouldn't determine the individual's choice.

Saturday, August 22, 2009

Dept. of self-cancelling statements

From the Washington Post re Tom Ridge tell-all:
"When you serve a president, you owe him a high degree of discretion," says Paul Begala, a former Clinton White House aide who has criticized the tenor of his friend Stephanopoulos's book. "Every time a publisher suggested I write a book about my experiences with Clinton, I said, 'I don't want to lie and I don't want to tell the truth.'
A model of discretion, he.

Monday, August 17, 2009

Addington's legacy: we're "one bomb away"

By now, much of the astounding information unearthed by Jane Mayer in The Dark Side has been replayed in media accounts and augmented by the release of documents including the torture memos and the ICRC's report on U.S. treatment of prisoners held in the "black sites."

The book remains indispensable, however, in documenting the extent and means by which David Addington and John Yoo hijacked the Justice Department and for at least two years cowed, silenced or marginalized their colleagues and superiors to ram through binding opinions that authorized the executive branch to abrogate the Geneva Conventions, the Convention Against Torture, the Bill of Rights and the separation of powers stipulated in the Constitution.

To my mind, the most telling passage in the book comes in the account of how Addington and Yoo green-lighted the NSA's violation of the Foreign Service Intelligence Act (FISA) through domestic spying in the Terrorist Surveillance Program. According to Mayer, with reference to the FISA Court:
Addington had been heard to mutter, "We're one bomb away from getting rid of that obnoxious court."
We were one bomb away, and ultimately perhaps remain one bomb away, from getting rid of not only FISA, but perhaps all the civil liberties and Constitutional protections that Americans have enjoyed for 200+ years. This was my constant thought in early 2008 as I listened to the thug's gallery of candidates for the Republican presidential nomination strive to outbid each other in promises to continue torturing those held in US custody and otherwise reaffirm the Bush Administration's twisted concept of the "unitary executive."

It's true that antibodies in the US political system did kick in to a degree -- in the person of Justice Department and Pentagon attorneys including Goldsmith, Comey, and Mora; in multiple reports by the military and later by the Senate detailing the extent of abuse; in Supreme Court decisions; and ultimately at the ballot box.

But taboos and norms, once violated, will be violated again under stress if the violations are not unequivocally repudiated. Which they haven't been.

Monday, August 10, 2009

Telling it like it is

Perhaps it's because we've had to face some stark realities in the past year, but it seems that people in the news have developed a penchant for simple declarative statements these days. To wit:
"My husband is not Secretary of State. I am."
-- Hillary Clinton

“I am not afraid of August. It is a month."
-- Nancy Pelosi

"Newspapers have a future."
-- Bill Keller

"We live in the coldest state in the Union..."
-- Alaska State Senator Lyman Hoffman

"we remember all of AK is BIG/WILD/GOOD"
-- Former Alaska Governor Sarah Palin

Sunday, August 09, 2009

It ain't so, MoDo: Palin never changed

Fecklessly following up an apparent free association about how how journalists "drive the people we write about crazy", Maureen Dowd imagines a prelapsarian Sarah Palin, "serene" and"tough"... "before she became unhinged by fame and her fixation with her reviews":

The same McCain advisers who later turned against Palin were impressed with her at first, when she earned adjectives like unruffled, self-confident, tough-minded and self-assured.

From Bill Ayers to Reverend Wright, “Sarahcuda” was ready to bite, telling rallies, “The heels are on, the gloves are off.”

But by the end, after Tina Fey, Katie Couric and the shopping spree, Palin had lost confidence. She became erratic.

MoDo is maxed out on movies mythologizing magical transformations. From her first appearance on the public stage in Wasilla in the early 90s, Palin has always been a paranoid, vindictive, backstabbing, demagogic, ignorant meglomaniac.

P.S. "the gloves are off" is a dog whistle to torture enthusiasts.

Annals of unpublished letters: NYT flags global payment proposal in Massachusetts

Today the Times editorial board, lauding the "Massachusetts experiment in near universal care," flags the recent proposal to move the state to a "global payment system":
Now the state seems poised to tackle costs — with an approach that is far more ambitious than anything currently being contemplated on Capitol Hill.

A special commission has just recommended that the state try, within five years, to move its entire health care system away from reliance on fee-for-service medicine, in which doctors are paid more for each additional test or procedure they provide.

In its place, the commission wants a system in which groups of doctors and hospitals would receive fixed sums to deliver whatever care a patient needed over the course of a year. The hope is that doctors would be motivated to deliver only the most appropriate care, not needless and excessively costly care, with safeguards to ensure that they do not skimp on quality.

On July 20, a certain frustrated letter writer sent this to the editorial board as well as to the letters editor:
While exhorting Congress to do more in pending healthcare reform legislation to control costs, the Times editorial board might have noted the truly radical core proposal of Massachusetts' Special Commission on the Healthcare Payment System: abandoning fee-for-service in favor a "global payment" system that pays by the patient, rather than by the treatment, and rewards good performance. At the core of this system would be development of Accountable Care Organizations that accept responsibility for the full spectrum of each patient's care.

This proposal goes to the heart of what the editorial board itself has identified as the central driver of healthcare inflation: providers' incentives to prescribe expensive -- and often unnecessary or unproven -- treatments. The reform, if adopted, will not be easy. The Commission envisions a five-year phase in period to develop a global payment system that "will include adjustments for clinical risk, socio-economic status, geography (if appropriate), core access and quality incentive measures, and other factors." But such reform, if adopted, would be truly fundamental.
Footnote: on a quick read, it appears that Medicare Advantage providers are paid by the patient rather than by the procedure -- and have not reduced healthcare costs. Why not? More on this later....

Friday, August 07, 2009

Iran kills 7 lawyers representing detainees: Jerusalem Post

In a particularly brazen assault on the rule of law, the Iranian regime is murdering and executing lawyers representing those jailed during the post-election protests, according to the Jerusalem Post -- beating some to death in prison, hanging others on trumped-up drug charges.
"The government is targeting lawyers - and as a result, many have stopped representing protesters."
How accurate is the Jerusalem Post's reporting on Iran? On July 1, the paper reported that six Mousavi supporters had been hanged in Mashhad. That report seems neither to have been echoed nor denied by other mainstream sources.

The Blackwaters of universal healthcare?

A BusinessWeek cover story claims that the health insurance industry has "already won" the healthcare reform battle. That is, by 1) neutering public plan proposals and 2) reducing mandatory minimum coverage guidelines, the industry has (pardon the expression) ensured that any emerging reform bill, with its coverage mandates and subsidies, will actually boost industry profits.

In a prior post I buried the lede, so excuse a retweet. One subtext of the BizWeek article is a kind of backhanded tribute to the healthcare giants' strength in diversification, through subsidiaries that provide plan administration, data crunching, software, etc. In a way, the article undercuts its central premise -- that the insurance industry will gut "universal" coverage -- by suggesting that giants like UnitedHealth are equipped to survive in almost any payment system. One unspoken possibility the article points toward is that the health insurance industry might complete an already partial transformation from insurer to administrator. Terhune and Epstein note the role in public healthcare of one UnitedHealth subsidiary:

United's AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice's revenue rose 34% last year, to $6 billion, and it has 2.7 million people enrolled. Those numbers should continue rising under reform since congressional Democrats are proposing an expansion of Medicaid to help achieve universal coverage. More of the working poor would qualify for Medicaid, and AmeriChoice can sell itself to states as the leading service provider.

The authors might further have noted that more than half of Americans who get their health plans from their employers are in self-funded plans. These plans are for the most part run by so-called third party adminstrators (TPAs), some of which are owned by the largest health insurers; UnitedHealth owns the third-largest, UMR. I suppose -- and need to read further -- that Medicare Advantage plans amount to another form of plan administration without financial risk. Add in the revenues that conglomerates like United get from data processing subsidiaries -- noted by BizWeek -- and health reform of any kind could ultimately prove to be win-win for the "insurers." Even under a single payer system, American style, they might be lucratively employed as the Blackwaters of healthcare delivery.

Related posts:
MedPAC: Obama's rudder for the healthcare battleship
The Times points another arrow at fee-for-service
Did Obama read Atul Gawande? cont.

Will health insurance giants administer single payer?

According to a BusinessWeek cover story by Chad Terhune and Keith Epstein, health insurers have "already won" -- that is, ensured that healthcare reform will boost, not crimp, their profits:
The industry has already accomplished its main goal of at least curbing, and maybe blocking altogether, any new publicly administered insurance program that could grab market share from the corporations that dominate the business. UnitedHealth has distinguished itself by more deftly and aggressively feeding sophisticated pricing and actuarial data to information-starved congressional staff members. With its rivals, the carrier has also achieved a secondary aim of constraining the new benefits that will become available to tens of millions of people who are currently uninsured. That will make the new customers more lucrative to the industry.
The massive lobbying efforts the article documents are not particularly surprising. Would anyone have expected the industry not to have bombarded Congress with cash and data? The apparent effects, too, are not a surprise to those who have been following the course of House and Senate negotiations. Nonetheless, the summations are sobering:

A fundamental question about the health overhaul is what minimum standards will apply to the coverage all Americans will be required to have. UnitedHealth has been exchanging a high volume of information on the topic with members of the Senate Finance Committee and their staff. Stevens, the former British health aide, regularly scans PowerPoint presentations generated by the committee staff that attempt to calculate the actuarial value of proposed benefit packages. Senators stung by the projected $1 trillion price tag are winnowing down the required coverage levels to cut costs.

This is good news for UnitedHealth, which benefits when patients pick up more of the tab. In late spring, the Finance Committee was assuming a 76% reimbursement rate on average, meaning consumers would be responsible for paying the remaining 24% of their medical bills, in addition to their insurance premiums. Stevens and his UnitedHealth colleagues urged a more industry-friendly ratio. Subsequently the committee reduced the reimbursement figure to 65%, suggesting a 35% contribution by consumers—more in line with what the big insurer wants. The final figures are still being debated.

One unspoken possibility the article points toward is that the health insurance industry might complete an already partial transformation from insurer to administrator. (On the plus side, the health giants' already substantial diversification may be sparing us a death struggle to kill reform altogether.) BizWeek does note the role in public healthcare of one UnitedHealth subsidiary:

United's AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice's revenue rose 34% last year, to $6 billion, and it has 2.7 million people enrolled. Those numbers should continue rising under reform since congressional Democrats are proposing an expansion of Medicaid to help achieve universal coverage. More of the working poor would qualify for Medicaid, and AmeriChoice can sell itself to states as the leading service provider.

The authors might further have noted that more than half of Americans who get their health plans from their employers are in self-funded plans. These plans are for the most part administered by so-called third party adminstrators (TPAs), some of which are owned by the largest health insurers; UnitedHealth owns the third-largest, UMR. Add in the revenues that conglomerates like United get from data processing subsidiaries -- noted by BizWeek -- and health reform of any kind could ultimately prove to be win-win for the "insurers." Even under a single payer system, American style, they might be lucratively employed as the Blackwaters of healthcare delivery.

Related posts:
MedPAC: Obama's rudder for the healthcare battleship
The Times points another arrow at fee-for-service
Did Obama read Atul Gawande? cont.

Life after Life for the last fighting Tommy?

My basic skepticism about individual life after death has held a caveat ever since I read, as a teen, Life After Life by Raymond Moody, a compilation of near-death experiences that held several core elements in common: a sensation of being detached from the suffering body and viewing it calmly from a height; a sense of being called or led toward a light by loved ones or exalted guides; a 'turnaround' moment, where the nearly-dead is given to understand that his or her time isn't yet; and a complete absence of fear of death for the remainder of life. These experiences are often chronicled in literature and are probably the core of received notions of life after death enshrined in scripture and religious belief; they are a true human universal.

Such an experience is relayed in today's Times' account of the funeral of the last living British combat veteran of World War I, Harry Patch, who died at age 111 two weeks ago. A radical skeptic about the the efficacy of war who felt a kinship with soldiers of all nationalities, Mr. Patch, was eulogized in part by his own writing:
A Belgian diplomat read an excerpt from Mr. Patch’s 2007 autobiography, “The Last Fighting Tommy,” in which he described an offensive during the battle at Paschendaele, the bloodiest chapter in the Ypres fighting, when he came across a fellow soldier “ripped from his shoulder to his waist by shrapnel” during a British assault on German lines.

The episode reinforced in Mr. Patch, a devout Christian, the belief that there is a life after death. “When we got to him, he looked at us and said, ‘Shoot me,’ ” he recalled. “He was beyond all human help, and before we could draw a revolver he was dead. And the final word he uttered was ‘Mother!’ It wasn’t a cry of despair, it was a cry of surprise and joy.”
He added, “I’m positive that when he left this world, wherever he went, his mother was there, and from that day, I’ve always remembered that cry, and that death is not the end.”
Such experiences prove nothing, of course. For whatever reason or no reason, we may be wired for acceptance at the end; our biological equipment may include a last-minute endorphin rush, a kind of final compensation for dissolution. For that matter, Mr. Patch's memory of the occurrence, like so many war memories (and memories, period), may not be 100% accurate. But the ubiquity of such experiences, and the unquestioned authority they hold for those who undergo them, at the very least leads one to the brink of mystery.

Thursday, August 06, 2009

Healthcare inflation reaches every nook and cranny

We often read these days that healthcare inflation is holding wages down. Looks like it also cuts into educational programs (as well as doubtless holding teachers' wages down). Here's some news from my hometown of South Orange, NJ (united in a school district with Maplewood):
SOUTH ORANGE, NJ - The school district will pay higher health insurance premiums for its 750 full-time employees starting in January.

The news did not catch the district off-guard. They budgeted a double-digit increase in anticipation that premiums would go up.

But in a decision that affects districts statewide, the 25 percent increase that the School Employees’ Benefits Commission approved July 14 was more than what officials thought it would be.

“This is a kick in the pants,” said school board President Mark Gleason Tuesday.

He said the district had enjoyed a couple of years of moderate increases. This, however, was far different.

“Every year, it takes more and more away from our budget,” Gleason said.

With $112 million budget already set for fiscal 2009, the district will need to find savings or cut spending to make up the projected $400,000 difference between the budgeted rate hike versus what was approved last month.

Every year, the school budgeting in our towns is an exercise in squeezing blood from a stone, a desperate struggle over this cut or that. How timely that this year, healthcare is taking an extra bite.

Tuesday, August 04, 2009

Minorities set us free

Via Andrew Sullivan, Nate Silver's take on the ethnic underpinnnings of the Democratic resurgence:
Consider this remarkable statistic. In 1980, 32 percent of the electorate consisted of white Democrats (or at least white Carter voters) -- likewise, in 2008, 32 percent of the electorate consisted of white Obama voters. But whereas, in 1980, just 9 percent of the electorate were nonwhite Carter voters, 21 percent of the electorate were nonwhite Obama voters last year. Thus, Carter went down to a landslide defeat, whereas Obama defeated John McCain by a healthy margin.
I am struck by the economic implications of this shift in the electorate. The average Democratic voter is probably not poorer relative to the average Republican than in 1980, since Democrats have lost poor white voters and probably gained richer white ones. Nonetheless, the ethnic shift in the U.S. population does give the less well-off more of a voice-- at least if you assume that Democrats can represent the economic interests of the less well-off more effectively than Republicans.

At the height of the Bush era, as income inequality soared, lobbyists and Republicans flaunted their symbiosis, Rovian smear campaigning reached its apotheosis and the Republicans increased their majorities in Congress, it was possible to think that American democracy was being hollowed out by an oligarchy that was cementing its economic gains with a lock on the political process. But it turned out that the country's hardening democratic arteries still ran clear enough --defibrillated by an unpopular and mismanaged war started until false pretenses -- to give the Democrats a fresh shot at rolling back the great wealth shift and the great risk shift of the last 30 years.

As in 1980, democracy performed its core function: give failure its due reward, throw the bums out, and let a fresh crew at least try to do better. Today that means mending the safety net, rebuilding the educational system, and creating more opportunity for those not born into privelege.

Monday, August 03, 2009

An Iranian's forecast that resonates

Steve Clemons of the Washington Note has posted a detailed narrative from a friend inside Iran recounting the July 30 protests marking the 40-day anniversary of the death of Neda Agha Soltan, the young woman shot in the street during the protests of June 20. Lucid and factual, this young woman protestor captures the ebb and flow of cat-and-mouse confrontations throughout the city between the protesters and the riot police and Basij -- while also chronicling the more sympathetic stance of the regular police and army (as opposed to the Revolutionary Guard.

This skilled young writer ends with a vignette that may prove to be worth volumes of well-informed scholarly speculation about the likely outcome of continued resistance to the riged election outcome in Iran:
One mother told a soldier who asked her to go back home "I'm not going anywhere. Don't you know that we brought you guys into power by doing just this: by being out on the streets for nights on end. We brought you to where you are today, and we're going to take you out by being on the streets. I'm not going anywhere."
Those who lived through or have studied the revolution of 1979 know that the toppling of the Shah played out over the course of a year of recurring and escalating protests. While more than half of Iran's population is under 25, the memory of that regime toppling is obviously still very much alive. The resilience of this battered populace that reveres martyrdom and remembers bringing about regime change should not be underestimated.

Sunday, August 02, 2009

Torturers can't be arbiters

Once again, U.S. torture undermines U.S. moral authority. From today's Green Brief:

Picture of the day (Front Page of Keyhan Daily):
(The large red circle says: “Evidence of Mousavi’s Betrayal of Iran Exposed!” while the small red circle says: “Evidence of Inhuman Torture of Detainees by Americans in Bagram Prison [Afghanistan]).
Link above unfortunately is dead. UPDATE: Sully has the screenshot.

Saturday, August 01, 2009

Alienation in Tehran, and abroad

Tehran Bureau has a moving personal essay by a young woman of Iranian descent, living in London but with lots of family and friends in Iran, which she's visited often. Kamin Mohammadi traces through the experience of friends and family, as well as herself, the alienation, or schizophrenia, induced by living under an oppressive regime (or being closely bound to those who do). She ends with the confession of an uncle she had long admired:
as we sipped our teas at Mehrabad Airport, he started to confide in me, much to my embarrassment and no doubt his too, proud man that he is. But confide he did, in that way I have become accustomed to Iranians doing with me, trusted family or old friend yet an outsider who would take their secrets home with me rather than sit and gossip in Tehran.

And what he told me was that on his visit to Europe, he had felt like an alien. Looking, walking and talking just like all the other people, but, after 30 years of Islamic rule, after all the daily compromises he has had to make with his soul, his conscience, his very being in order to survive the regime and even prosper, he felt so different to all the people living as people should — in freedom — that he had felt locked up inside himself, unable to break the mask, unable to relate to anyone or allow himself to be understood.

‘Kamin jan,’ he said to me as I tried to contain his confidences, ‘we here, we look like human beings, but we are aliens. We are not like other people. I realised this in Europe. There is a gulf because they simply cannot understand what we go through every single day of our lives in order to survive this regime.’

The experiences Mohammadi chronicles recall those of eastern Europeans in the latter days of the Soviet empire, forced always in public life to do obeisance to an ideology nearly everyone recognized as bankrupt. State terror comes in many flavors, but the alienation it induces is recognizable across wide cultural gulfs.

Why Khamenei did it

The Financial Times editorial board has an interesting (and unelaborated) take on why Khamenei and cohorts rigged the June 12 election:
Mr Khamenei and his entourage took such a costly risk at the elections because they fear the engagement tactics of Barack Obama. They trust only themselves to negotiate with him.
If that's true, the sequence of unintended consequences has been and will continue to be dizzying.