Wednesday, September 30, 2009

The case for mandatory paid sick leave

In the US, many workers, especially part-time and/or low-wage workers, are not eligible for paid sick leave days. Businesses would argue that it's too expensive to provide these days, although they are required to provide a certain number of unpaid days under the Family Medical Leave Act. Unpaid sick days are imperfect. Hourly workers obviously lose income if they take time off work for their own illness, or a family member's illness. This dissuades people from taking time off.

As a CNN Money article argues, the swine flu does provide a certain impetus for policymakers to consider mandating paid time off. If someone is infected but comes to work because they don't want to lose hours, that places everyone at risk for a pandemic. Even without the swine flu, paid days off are good public policy, and many European countries have considerably stronger sick leave laws than the US. Nonetheless, there is pushback from businesses:

Mandated leave
In May, Brewer introduced a sick-leave law modeled on San Francisco's: nine days a year of paid time off for workers at businesses with 10 or more employees, five days for those at smaller businesses. The legislation, which already has 38 of the city's 51 council members as sponsors, would also allow workers to use sick time to care not only for ill children, but also for kids whose schools are closed because of swine flu fears.

"A child can't stay home without a parent staying with them," Warren says. "So if the parent doesn't have paid sick time, the child mostly likely goes to school, and the parent goes to work."

In response, the chambers of commerce from each of New York's five boroughs have banded together to form the 5 Boro Chamber Alliance to fight the paid-leave bill.

Their main concern is what they see as an excessive number of days required, and the inflexibility it would impose on small business owners.

"Government is trying to do something that's well-intentioned, but they have no idea what the effect is on a small business owner," says Jack Friedman, executive vice-president of the Queens Chamber of Commerce. "So our business owners are coming back to us and saying, 'We already offer our employees some sick days -- five sick days, six sick days. And the difference between what we're offering and what the government is requiring us to offer could cost our business tens of thousands of dollars.'"

For many workers, though, even five sick days is an unheard-of benefit. As part of its soon-to-be-released annual Unheard Third survey of 1,212 New Yorkers, the Manhattan-based Community Service Society is estimating that 39% of all workers -- amounting to 1.3 million people citywide -- have no paid leave of any kind. In the leisure and hospitality industries, which include restaurants and food service, only 23% are allotted paid sick leave.

Nationwide, the same trend holds: The proportions of workers without paid leave are higher in lower-wage industries, including food service, nursing care, and retail workers.

"Oftentimes, the folks who are most in contact with the public are the ones who are least likely to have paid sick days and be able to stay home when they're sick," says the National Partnership's Ness.

I think the case hasn't been adequately made that mandated sick days will, in the long run, be a boon to businesses. The main reason is the cost of turnover. It costs a lot to recruit and train a worker. If you have people leaving or being fired because they didn't show up to work because of illness, a business then has to find and train a worker, who will be less productive to start. The cycle repeats.

Consider this cost-benefit analysis by the Institute for Women's Policy Research. For just the state of Illinois, they find that mandated sick days would cause about $589 million in new costs to businesses. However, this amounts to only about $7 per worker newly covered by the policy (i.e. who doesn't already have sick leave benefits) per week.

Additionally, the benefits from reduced turnover would total an estimated $795 million. Additional benefits from lost productivity by sick people on the job and the reduced amount of illness would total $66 million. In other words, a mandated sick leave policy could produce $272 million in savings for all businesses. Similar results would occur in other states.

The key provisions of the law that IWPR proposes are:

1. All workers earn one hour of paid sick time for every 30 hours they work, up to a maximum of 7 paid sick days.
2. Paid sick time may be used for diagnosis or treatment. It may be used by the worker, or they may use it to accompany a family member.
3. Employers may require a doctor's note for any absence over 3 days.
4. Employers who already provide paid sick time at or above the level of the new law would not be required to provide any additional time.

While IWPR's work is necessarily an estimate based on census-level data, it seems that businesses are likely to be missing the big picture. At the worst, they might break even by complying with a well-designed sick leave mandate.

NYT: An Anti-Tax Argument That's Hard to Swallow

Randy Cohen, writing on the Ethicist blog at the New York Times, debunks the argument that taxing sugary soft drinks is unethical (he makes no arguments about whether it's good tax or health policy).

The Issue

Proposals to tax sugary drinks as a way to fight obesity and finance health care reform have found support from medical experts and some interest from President Obama while meeting resistance from the beverage industry in general and the Coca-Cola C.E.O. Muhtar Kent in particular. “I have never seen it work where a government tells people what to eat and what to drink,” he told the Rotary Club of Atlanta last month. “If it worked, the Soviet Union would still be around.” Is this sort of argument so dubious, and does it come from the maker of products so damaging, that Muhtar Kent should be dragged off in handcuffs — or worse?

The Argument

I am an expert on neither tax policy nor nutrition, but it is worth examining a few of the arguments against taxing sugary drinks as examples of the reasoning all of us can encounter when making moral choices or weighing the issues of the day or confronting a bumptious uncle at Thanksgiving.

Muhtar Kent’s assertion is fishy because it confuses a positive and a negative. The various plans under consideration do not tell us what we should drink; they are concerned with what we should not drink — sugary beverages, what critics call “liquid candy.” Urging people not to drive short distances is different from saying they should reach the corner store by hopping. Urging people not to drink cola is different from pressuring them to drink cat pee.

And of course our government does tell people what to eat and has for years. Perhaps “tell” is too coercive a term — no federal food police pound on your door at dinnertime demanding to see your broccoli. But “strongly recommend” is apt. Kent should check out the Department of Agriculture’s food pyramid at the delightfully titled or visit where jackbooted thugs engage in tyrannical meal planning — O.K., there are no jackboots and no thuggery, but there are some tasty menus. (The recipe for cranberry-nut muffins looks delish.)

Our government, as many a nation does, also tells people what to eat in other ways, both directly, by creating menus for public-school cafeterias and military mess halls, and indirectly, influencing our diets through farm policies, tariffs, trade agreements and food regulation.

(Kent’s further assertion, his evocation of the Soviets, is entirely meretricious, deploying the familiar debater’s tactic of deprecating something by linking it to what is widely reviled. The Beatles are bad because Pol Pot liked “Hey, Jude.” Bowling is evil because Satan plays — he’s on a team with John and George.)

It is commonplace for a democracy to concern itself with the nutrition of its citizens. What is rightly and vigorously debated — by, for example, the writer Michael Pollan, the documentary film “Food, Inc.,” the National Cattlemen’s Beef Association or the American Academy Of Pediatrics — is not if government should involve itself in such things, but how. That’s politics in the best sense.

Kevin W. Keane, senior vice president for public affairs of the American Beverage Association, says it is wrongheaded to single out soda: “When it comes to losing weight, all calories count, regardless of the food source.” This is specious, akin to saying that when I have only partial responsibility, I have no responsibility. If I was the triggerman on that bank job, I couldn’t beg for a break because I wasn’t also the lookout and the getaway driver and the caterer. (Are bank robberies catered? Must you pack a lunch? A very healthful lunch?)

Assuredly, many factors affect our weight. But it doesn’t follow that because a policy fails to address all of them, it should not address any. That the feds devote few resources to going after counterfeiters who mint fake quarters doesn’t mean they should decline to pursue those who run off $20 bills.

What’s more, the multiple causes of a problem need not share equal significance. Studies suggest that sugary beverages are a key contributor to obesity. In its analysis, the Center on Budget and Policy Priorities notes that “Americans consume about 250-300 more daily calories today than they did several decades ago, and nearly half of this increase reflects greater consumption of high-sugar soft drinks.” So there’s a case to be made for giving serious consideration to a soda tax even if other steps are not taken.

Such errors of reasoning might be seen as intellectual, not moral, failings, but it is difficult to extend that benefit of the doubt to Americans Against Food Taxes, which describes itself as “a coalition of concerned citizens — responsible individuals, financially strapped families, small and large businesses in communities across the country.” As was reported in The Times, A.A.F.T. looks like a veiled industry organization; calls to a media contact listed on the group’s Web site go to the American Beverage Association. This smells like Astroturf, or corporate lobbyists posing as a grass-roots organization. It is entirely suitable for interested parties to participate in public debate; it is not suitable to conceal who’s doing the debating.

Now, I, too, engaged in some forensic high jinks, I’ll admit. There are no actual proposals out there that call for a guillotine to be erected on the Washington Mall and for Muhtar Kent’s head to be separated from his. But to pose the question as I did is not deceit but a rhetorical device: I assume that readers recognize hyperbole. Of course Kent should not be executed. Most moralists agree that a punishment must be proportional to the transgression (although it’s often hard to agree on the terms). Nor should Kent even be imprisoned. I’d reserve that penalty for those who produce inarguably toxic products — the senior executives of tobacco companies, for instance. But it would be a fine thing if Kent and his cohort were ordered into a class on critical thinking, much as a traffic-court judge can send recalcitrant speeders to driver-improvement school.

Editor: I will note that imposing a federal tax on sugary soft drinks (i.e. non-diet sodas and fruit juices to which sugar or high-fructose corn lobby syrup has been added) will mean that food stamp recipients will no longer be able to buy them with food stamp dollars. This seems reasonable. However, one would need to be cautious in expanding a tax to all unhealthy foods. One should not presume that the poor don't know how to eat well; many of the poor work long hours, which may mean they lack time to prepare meals from scratch. At minimum one would need to modify the food stamp regulations.

For non-US readers, food stamps are a supplemental nutrition assistance program (actually, the program is now called SNAP). The benefits are funded solely by the Federal government. It is administered by the individual states; theoretically, the states don't have any incentive to impose barriers to people getting benefits, since it does end up being free money for the state and its residents.

Monday, September 28, 2009

Why I am clarifying the law on assisted suicide: Keir Starmer, Director of Public Prosecutions in the UK

From the Daily Telegraph:

As you may be aware, today I am publishing my interim guidance on what public interest factors should be considered when deciding whether or not to prosecute the offence of assisted suicide – an act which is itself not a crime. I have been required to do this by the Law Lords following the case involving Debbie Purdy.

Assisting suicide is a subject about which many people have deeply held and sincere views – on both sides of the debate. My guidance will add to this debate.

Let me make it clear: only Parliament may change the criminal law. I am not able to do so and neither is any court. Neither am I able to provide individuals with a guarantee that they will not be prosecuted if they do or do not do certain acts.

In 1961, Parliament decided that committing suicide should not be a crime; but to protect the vulnerable, it also decided that those who assist another to commit suicide should be guilty of an offence. And again let me make it clear: this debate is not about legalising euthanasia. If an individual directly causes the death of another, the appropriate charge is murder or manslaughter.

But even in 1961, Parliament recognised that the ways in which people commit suicide and how others may assist are very varied. In order to bring some consistency to when proceedings should be brought Parliament required the Director of Public Prosecutions to consent to any prosecution.

It has never been the case in this country that every criminal offence for which there is sufficient evidence should be prosecuted. Parliament has given those who prosecute discretion whether to bring criminal proceedings depending on an evaluation of the public interest.

Of course, the criminal law must be upheld and prosecutions must be brought in appropriate cases. But we are proud of the way we temper justice with mercy. The discretion not to prosecute provides essential flexibility to prosecutors. Being able to translate the often blunt words of a criminal statute into a meaningful decision based on the individual facts of a case enables compassion to be shown where appropriate.

So the critical question I have considered is: what are the circumstances in which it is or is not in the public interest to prosecute a person against whom there is enough evidence to support the criminal offence of assisted suicide?

There are many factual circumstances: whether it is the accompanying of a loved one on a flight to Switzerland or what appears to be a suicide pact between an elderly couple in which one of them has survived.

I have already indicated that acting with compassion and assisting someone who had a clear and settled intent to commit suicide would be factors against prosecution. But would it make a difference if a person was under the age of 18? Does it matter if the person who dies was not suffering from a terminal illness or severe degenerative condition, or if they had a mental illness or learning difficulty?

Are any of these factors more worthy of sympathy than a criminal trial?

If you answer “Yes”, you are exercising your discretion whether to prosecute. I think these factors do make a difference, and I will be setting out exactly how later on today.

I am also opening a public consultation on these guidelines and I am keen to hear from all those who want to contribute to the debate.

Response to Leavitt et al and objections to community rating (WSJ)

Michael Leavitt, Al Hubbard and Keith Hennessy, all alums of the Bush administration, have an article on the Wall Street Journal arguing that guaranteed issue and community rating provision in the health reform bills are essentially a redistribution of income from the healthy to the sick. They object, arguing that this redistribution isn't transparent to the public (i.e. healthy folks won't know precisely how much they're subsidizing sicker folks).

On the first point, they are correct: the two insurance reforms they pointed two would result in a redistribution of economic resources from the healthy to the sick. However, they are wrong that this is objectionable.

From the consumer's perspective, an insurance contract means that you incur a small, certain and regular loss (your monthly premiums) in exchange for protection from a large loss that you can't predict (an illness or accident). From the insurer's perspective, they collect and pool claims. Insurers then use this money to pay off claims because when they consider the population in aggregate, they can use statistical methods to predict roughly how many people will be sick or injured. So, the healthy are subsidizing the sick.

The 80-20 rule, which applies to numerous industries, holds that about 20% of the population account for about 80% of the claims due to illness. However, you could easily go from the healthy 80% to the sick 20% without warning and through little or no fault of your own. The current system leaves many of the sick 20% with no easy way, or no way at all, to pay access medical treatment. In other words, the system isn't spreading risk effectively. If you spread their risk to the rest of the population, the increases in premiums will be manageable for the healthy folks. This already happens to a large extent in the employer-sponsored insurance market (mainly for larger employers).

Briefly, community rating means that insurers must charge all enrollees the same price (although they will be allowed to vary prices by age in health reform). Experience rating means that insurers may charge sick people more and healthy people less.

Leavitt et al argue for "wiser" and "more equitable" ways to make the subsidy to the sick explicit and to still get them healthcare - state subsidized high-risk pools and subsidized vouchers for people to buy health insurance. I find it bizarre how the authors can possibly think that either is wise or equitable when neither has really worked. The state high risk pools have low enrollment. They are small and expensive and offer poor coverage. My wife and I witnessed this first hand when we shopped for coverage with Maryland's high risk pool (she ended up getting employed temporarily with a company which offers insurance). There were more exclusions and higher deductibles than many similar individual insurance policies provided to healthy people. In principle, the high-risk pools could be expanded, but if you're segregating the sick people, they would still be more expensive. The insurer who is running the pool might not manage it very well, or might offer substantially poorer terms (higher cost sharing, more exclusions of services). And state subsidies to the pools would be vulnerable to cuts in poor economic times. It's not a workable plan.

Leavitt et al are also correct that some folks will pay more. Right now, I pay $52 a month for individual health insurance. I can get that rate because I'm a young, healthy man. Under health reform, I will have to pay more - and I will be subsidized if necessary, although the subsidies might not be sufficient. However, I will get a lot more. My deductible is $8,000 a month. The Finance Committee, for example, is now proposing that a rating band of 4:1 be used for age. This means that the oldest folks will pay 4 times the youngest folks. That is approximately how much the younger folks will be subsidizing the older folks. This is a little high, but it can, and probably should, be decreased over time as people adjust to the mandate. Other reform bills had no more than a 2:1 rating band. Age is the only factor on which rating is allowed in the current proposals.

If you do not require community rating and guaranteed issue, then all it will take is for one company to offer insurance to people based on their health status. The whole market will eventually have to follow. In the past, the Blue Cross Blue Shield insurers, all of whom were initially nonprofit, all offered community rated products. When for-profit insurers came along and offered experience-rated products, they skimmed off the younger and healthier folks. The Blues were left with the sicker ones and had to raise prices. This set off a spiral. Many of the Blues went for profit (usually under Wellpoint). Many of the remaining nonprofit Blues offer experience rated products just like everyone else. In some states, the nonprofit Blues are the insurer of last resort, meaning that they may offer insurance to people who would otherwise be excluded from the market due to pre-existing conditions. I don't know the specifics, but the Blues would either have to charge more to these people (possibly too much for them to afford insurance) and/or receive subsidies from the state.

The bottom line is that the insurance market is unworkable for people who have pre-existing conditions and can't get insurance through a large employer. Leavitt et al are wrong in that an expansion of the existing ad hoc solutions is workable.

Sunday, September 27, 2009

MSN Money: The machine that's ruining our healthcare

MSN Money has a good article about the use of MRI machines. Conservatives like to point out how the US has so many more MRI machines per capita than other countries, but that's not the whole story. Here's the most relevant first page of the article:

The main question of the national debate on health care has been who should pay for it, but lurking behind it is another one: Why does American health care cost so much in the first place? If you want an answer to that question, there's no better place to start than the proliferation of the gleaming new magnetic resonance imaging machines filling U.S. hospitals.

According to the latest data, the United States has just over one MRI scanner for every 40,000 people. That number that may not sound high, but it means that we have more than three times as many devices per person as you will find in the United Kingdom or France, and almost four times as many as in Canada. Only Japan, an MRI-happy outlier, has more.
Obviously, the MRI is an extremely useful tool, giving doctors an ability to see inside the body and diagnose conditions that would otherwise require them to probe and cut into their patients' bodies. It is also expensive to buy -- at about $2 million -- and expensive to operate. Worse, the machine is used aggressively for tests such as breast-cancer screening and yields a high rate of false positives that lead, in turn, to unnecessary surgeries.

Although MRI scanning has obvious advantages over invasive procedures, its use on the very sick is also not cost-free. When my own father was dying of cancer last year in one of New York's best hospitals, he was subjected over a period of weeks to a battery of scans. While the healthy may think of MRIs as an almost entirely benign procedure, it is not at all the same for a patient whose spine is fractured in several places from bone marrow cancer, who cannot easily lie flat, and who is hallucinating from morphine. My father came down with pneumonia from complications involving sedation for what should have been a harmless scan. In these situations, even noninvasive, seemingly harmless procedures come with risks and difficulties.

The physician and writer Atul Gawande, in an extraordinary article in The New Yorker [Editor: everyone should read this, it's really very good], detailed how doctors with a financial interest in expensive cardiac procedures have driven skyrocketing medical costs in McAllen, Texas.

Gawande demonstrates how the financial interests of doctors push patients into expensive operations of questionable usefulness. As Gawande shows, even for doctors who do not consciously seek to profit from pricy procedures, the emphasis on expensive treatments changes the norms of medical practice. And we can almost certainly add to this that it changes the expectations of patients, who come to believe that more treatment equates with better treatment.

The MRI data are a good proxy for the much more general tendency of U.S. physicians and patients to count on expensive technologies and operations.

In case after case, however, the confidence in this approach to medicine turns out to be misplaced. Whether it is the latest artificial hip, which then needs replacement itself, or an elective full body CT scan that exposes patients to radiation and leads to treatments of uncertain benefit, the reliance on technology leads to medicine that is more expensive without being better.

Editor: The McKinsey Global Institute sheds some additional light on the MRI subject in the US. (McKinsey is a well-known consulting firm.) The authors of their 2007 report, Accounting for the Cost of Health Care in the United States, point out that many MRI machines and CT scanners are acquired by outpatient clinics. These machines are very expensive, and they need a certain level of use to break even. In many other Western countries, they're centralized at hospitals.

However, the McKinsey team finds that higher prices are pervasive throughout the health care system in the US. As a result, since reimbursements are higher, the break-even volume is lower, so physicians can operate the machines (the McKinsey team calls it sub-scale operation, at least relative to the OECD countries). When you gives folks a fancy gadget, they'll use it - and it's well-documented that physicians who own an MRI machine or CT scanner will use it more than physicians who don't own one. That higher use drives total expenses up. Japan actually has more MRI machines per capita, but their reimbursements are significantly less. On a technical note, I've heard one recommendation to have the Centers for Medicare and Medicaid Services generate some formula to alter reimbursements depending on service volume. If a certain service experiences significant volume growth, it gets reimbursed less.

Saturday, September 26, 2009

Smartmoney: Your Health Plan's "Dr. No"

Angie Marek writes a very good article for Smartmoney about utilization review in insurance companies - where the companies basically ration care. Conservatives have made noise about the government using health reform to ration care. Insurance companies do it already.

Smartmoney profiles Dr. Don Liss, a former internist who is now a medical director for Aetna. He basically decides by remote if patients' doctors are over-treating their patients. There are about 1,000 medical directors nationwide, and they get little respect from their former colleagues.

But playing bad cop has earned medical directors their share of enemies over the years. At the height of the HMO era in the early 1990s, they denied coverage so frequently—and hounded doctors so often with scorecards comparing their costs with their peers’—that doctors came to see them as antagonists and tormentors. Some directors testified that they got bonuses if they denied more doctor bills. While insurers say those specific practices have long since stopped, physicians in the field remain frustrated with the system; some refuse even to refer to their counterparts on the insurance side as “doctors.” It doesn’t help that as medicine grows more specialized, many of the doctors evaluating claims have backgrounds in primary care (as is the case with eight out of 12 of the members of Liss’s team). “How do you even argue necessity with insurers,” says prominent Los Angeles orthopedist Ralph Gambardella, “if the only time a joint surgery is truly ‘necessary’ is when you’ve got a bone sticking out of your skin?”

After 12 years with Aetna, Liss has gotten used to being on the front lines of this battle. (Even, occasionally, at home: Liss’s wife is a primary-care doctor.) Over the years, he’s had to say no in various tough calls, involving mental health care, injury rehab and more, though he says all those rulings were medically justified. Recently, Liss says, he traveled to New Jersey to defend Aetna’s decision to stop covering home nursing care for a child. He describes the girl as a “neurologically devastated 6-year-old” who was “cute as a button” and “clearly needs care day and night.” But as Liss told her family and its lawyer, because her seizures had lessened recently, Aetna believed that a parent or nanny—instead of a $150,000-a-year nurse—could handle tasks like feeding the child through the tube in her stomach. The family’s reaction, says Liss, was “businesslike.”

There's a flip side to utilization review. Medicine is extremely complex, and doctors are the ones who help the rest of us navigate the system. Patients usually take doctors at their word. Unfortunately, there are financial pressures on doctors, and a general fascination in American culture with technology. In sociology, the latter phenomenon is known as the technological imperative - if something can be done the old way or with a shiny gadget, you must use the gadget. As a result, doctors often use aggressive, high-technology treatments. This drives up the cost of healthcare.

Of all the medical-cost battlegrounds, none are hotter than the ones centered on technological breakthroughs, which generate headlines and hopes long before they become standard practice. For insurers, keeping up with the advances is no easy task. That’s why Liss makes frequent visits to places like the University of Pennsylvania’s proton-beam radiation center, a new facility with a $140 million price tag. During a two-hour tour with other Aetna brass, Liss got a close look at the center’s cyclotron, a particle accelerator bigger than a football field, and listened to a presentation by a guide who spoke of the machine as a game-changing innovation in cancer care. Indeed, many doctors think proton beams could be ideal for treating tumors near the eye or spine, since they do less damage to surrounding tissue than traditional radiation. Prostate-cancer patients want the treatment too, since it may help them avoid complications like incontinence.

But Liss sees two nagging issues here: For most cancers, the medical community is still debating the effectiveness of proton-beam treatment, and it typically costs four times as much as traditional radiation. Aetna staff are continually churning out bulletins outlining the evidence behind new and controversial treatments like this. So Liss was shocked when, at the end of his grip-and-grin outing, a Penn official said the university hoped to put about half their radiation patients through the center by 2012. “I walked out of there a whiter shade of pale,” Liss recalls. (Stephen Hahn, chairman of radiation oncology at the university, says the center will be “prudent” about which patients get the therapy.) Liss says it’s his job to make sure such big-ticket spending has enough evidence to back it up. “You hope at least on the margins you bring some sanity,” he says.

In other words, utilization review is necessary as one thing that can put the brakes on healthcare spending. We need to do it more transparently, and we need to make sure the insurers are using good data to do it.

Medical directors say they’re the ones who can apply the brakes to runaway spending, by monitoring the relevant science and data to decide what kind of care is the most effective. Indeed, even their critics say medical directors are becoming more important players. “We’re all headed for a health care train wreck if things don’t change,” says Shannon Brownlee, senior fellow at the New America Foundation and author of Overtreated.

Single-payer advocates, like President Obama's family physician, Dr. David Scheiner, accuse the insurers of "screwing it up" by interfering with clinical decision making. They say that Medicare for all would be better, but in fact, Medicare doesn't do utilization review well enough. The Medicare Payment Advisory Commission (MedPAC) often makes recommendations to cut reimbursements for procedures it feels don't add value, but Congress ignores or overrides them.

Going forward, comparative effectiveness research will be a key piece of the puzzle in making transparent which treatments are effective and which aren't. As things stand, the insurers' medical directors may be using internal studies on comparative effectiveness that the public doesn't have access to; for example, Kaiser Permanente, a very well-regarded non-profit insurer and hospital system, is known to have and use a bunch of internal data. Alternatively, medical directors or patients' physicians may be basing their decisions on clinical trials. However, the FDA trials only compare treatments to placebos. They do not generally put treatments or medical devices head to head. Comparative effectiveness research would do that.

The American health system rations care today, mostly by ability to pay. It does so inconsistently and non-transparently. It needs to ration care more, more consistently, by fairer criteria, and more transparently. During the debates on the stimulus bill, which inserted funding for comparative effectiveness research, the Republicans tried to insert amendments prohibiting that research from being used by government insurers (Medicare, Medicaid, the Veterans Administration, and possibly the Indian Health Service) to make coverage decisions. The fact of the matter is that private and public insurers need to use CER as one basis for coverage decisions, although they need to keep in mind that not all patients are the same.

One last word about medical directors. The article notes that consumers often appeal denials to state insurance commissioners. In 2006, the most recent year for which figures are available, about 41% of denials were reversed upon appeal. Appeals are costly and stressful, but there is currently a way to introduce some transparency and oversight into the private system. I do not think that Medicare currently has a similar process. In fact, when the Centers for Medicare and Medicaid services decided not to pay for spinal fusions in Medicare on the basis that they weren't generally an effective treatment, specialty physicians appealed directly to Congress, which reversed that decision. Congress is generally captive to moneyed interests, like specialty physicians. It should not be allowed to micromanage Medicare in this fashion. Additionally, it might be a good idea to subject Medicare to state insurance oversight to give consumers a better, more targeted appeals process.

Friday, September 25, 2009

Washington Independent: Christian Right embraces libertarian conservative ideals, oddly enough

The Christian Right in the U.S. recently held the Values Voter Summit, featuring Mike Huckabee, Mitt Romney, Tim Pawlenty and Mike Pence. The latter is the governor of Texas.

The Washington Independent reports that the conference took a heavily libertarian conservative stance. The Christian Right is reportedly looking to the national debt and the economy as issues for 2010. Romney said that "big government activists" were “substitut[ing] their ideology for the wisdom and good sense of the American people.” Even the moral issues folks at the conference apparently connected their concerns to the economy and government control.

Jesus did not speak directly to the governance of nation states. He claimed his own kingdom was not of this world, and sought to bring about the reign of God on earth. He said that we should treat others as we wish to be treated. He was a member of an indigenous people who suffered oppression at the hands of a really big government. He was tortured and killed at the hands of that government. So, the conservatives may be right to think he would be opposed to big government.

However, the Washington Independent reports that Gov. Perry said "as far as I'm concerned, you can't not legislate morality". And money was the moral issue that Jesus spoke the most about. He was deeply concerned about money, calling it the root of all evil. He said to the rich man, sell all you have. Give the money to the poor. Only then will you enter the kingdom. Jesus did not say anything about homosexuality. As to the family in general, he had only a few choice commands: don't get divorced, and whoever doesn't hate his father and mother has no place as my disciple.

If Jesus were to endorse legislating morality, I have a feeling the values voters would not like what he had to say. I somehow doubt he would come down on the side of the libertarians and their beloved free market economy that doesn't truly serve the needs of the poor. Jesus might well say to Gov. Perry and the values voters, if you don't like the government redistributing your wealth, then you must do it yourselves. Go, sell all you have. Give the money to the poor. Only then will you enter the kingdom.

Thursday, September 10, 2009

The "You lie!!" incident: Rep Wilson is incorrect

The Republicans have long been concerned about undocumented immigrants accessing public benefits. I don't mean to completely dismiss their concerns. There have been cases where undocumented immigrants have been on public benefits.

When the Republicans were in power, they mandated that enrollees in public programs document their citizenship before applying. Readers in other countries may be surprised that many Americans don't have passports, but it's true. More poor Americans don't have passports than others, and passports are a good way to prove your citizenship. People who are homeless or institutionalized, or even people who are just poor, may have severe difficulty producing passports or alternative documents like birth certificates. Working poor people who don't have documents will have to take time off work to get them replaced.

As a result, it's generally agreed that after the Deficit Reduction Act of 2005's citizenship documentation requirements took hold, a lot of citizens ended up being disenrolled from Medicaid and CHIP (the Child Health Insurance Plan), and that very few undocumented aliens were identified. Leighton Ku of the Center on Budget and Policy Priorities explains here.

He also argues that there are a number of automated data systems that can verify citizenship. For example, the Social Security Administration had a lot of data, and many states kept extensive records of birth certificates. These could have been used to verify eligibility for Medicaid and CHIP applicants. However, under the Bush Administration, the Centers for Medicare and Medicaid services issued guidance stating that applicants had to submit paper documents first. The electronic systems were to be used only as a last resort.

President Obama gave a good speech about health reform yesterday. He clearly stated his rationale for why he wanted a public plan. He addressed some misconceptions that some had about the reform plans, one of which was that they would give health insurance to undocumented immigrants. This was incorrect. However, Representative Joe Wilson of South Carolina yelled, "You lie!" at the President when he said that.

Rep. Wilson has since apologized for his intemperate outburst. However I don't believe he admitted to being mistaken about the facts. He is mistaken. The health reform bills do not allow undocumented immigrants to receive health insurance, and there are sufficient existing mechanisms to prohibit this. The Republicans have complained that they were voted down when they tried to insert an amendment requiring citizenship documentation. It's odd that they haven't heeded the lessons learned after the DRA: requiring extensive citizenship documentation hurts citizens and legal immigrants more than undocumented immigrants.

Edit: It seems to me that there undocumented immigrants may be eligible to purchase insurance, but cannot receive subsidies. They are not, as I recally, subject to the mandate. I'm not sure if there's any disagreement, but if they're willing to purchase unsubsidized insurance, they should be allowed to do so.

Center on Budget and Policy Priorities on 2008 poverty and insurance data

Robert Greenstein has comments on the new Census data:

Today’s grim Census Bureau report shows the nation lost substantial ground in 2008 on poverty, median income, and the number of people who are uninsured. Several aspects of the Census report stand out.

The number of people living in poverty jumped by 2.6 million to 39.8 million — the highest since 1960. The poverty rate — the percentage of people living in poverty — also rose, to 13.2 percent, which is its highest level since 1997. Similarly, real median household income fell by $1,860 to $50,303, its lowest level since 1997.

These figures are particularly grim because they come after the disappointing record of the 2001-2007 expansion. Poverty was actually higher — and median income for working-age households lower — at the end of that expansion than during the 2001 recession. Such a dismal record during an expansion has never occurred before, since the nation began collecting these data.

Health Insurance Data
The health insurance figures are instructive. The percentage of uninsured people remained unchanged at 15.4 percent, while the number of uninsured jumped by 682,000 to 46.3 million. The story was not worse because gains in public (that is, government) health insurance programs, especially for children, helped to offset continued declines in employer health coverage.

Consider two figures. First, the number of children without insurance actually fell by 801,000 in 2008, due to expansions in government health insurance programs for children. But the number of workers without coverage rose by 932,000, evidence of the continued erosion of employer-based coverage.

Figures Will Be Worse in 2009
All of these figures almost certainly will look considerably worse next year, since the economy has weakened further in 2009 and unemployment has risen sharply. The number of people in poverty will likely set a 50-year high, while the number of uninsured will likely climb toward the 50 million mark.

Moreover, the expected increases in 2009 in poverty and in the number and percentage of uninsured people would be substantially greater if not for the economic recovery law that the Administration and Congress enacted earlier this year. Just seven provisions of that law — including tax credits for working families, expansions of unemployment insurance and nutrition assistance, and one-time payments to senior citizens, veterans, and people with disabilities — will prevent an estimated 6.2 million Americans, including 2.4 million children, from falling into poverty, according to an analysis the Center issued yesterday.[1] Moreover, these figures understate the poverty-preventing effects of the recovery act because they do not capture other provisions of the law, such as increases in housing, child care services, or the law’s effects on preserving or creating jobs. In addition, the law’s increases in medical assistance are preventing hundreds of thousands more from becoming uninsured.

Finally, today’s disquieting health insurance figures underscore the need for comprehensive health care reform. The decline in job-based health coverage is leaving millions of Americans uninsured or underinsured. As noted above, the new Census data show that last year’s economic decline did not fuel an even greater drop in overall insurance coverage only because of the expansion in coverage by public insurance programs.

Health reform bills that Congress is considering would help to address this problem by covering tens of millions of Americans who lack insurance. They would strengthen employer coverage and Medicaid, offer new health insurance choices for Americans, and prevent insurance companies from denying coverage or charging exorbitant amounts to people with medical conditions. The bills also seek to slow the growth of health care costs, which is essential to expanding coverage and sustaining progress in reducing the ranks of the uninsured over the long run.

End Notes:
[1] The 6.2 million figure is based on an alternative measure of poverty that counts non-cash benefits as income.
# # # #

Coalition on Human Needs' comments on new poverty and uninsurance data in the US

Grim Census Data on Poverty Points to Growing Need Even Before Unemployment Skyrocketed this Year

Uninsured numbers reflect the importance of public health insurance programs
see links to data and analyses below

WASHINGTON, D.C. -- Today's Census Bureau report that the number of Americans living in poverty increased by nearly 2.6 million to 13.2 percent in 2008 is a stark reminder of the toll the recession was already taking on families even before the economic picture worsened this year.

Continuing a long-term trend, the number of people without health insurance grew to 46.3 million, according to the Census data. From 2000 to 2008, the proportion without insurance rose from 13.7 to 15.4 percent. The numbers of uninsured working age adults (18-64 years old) increased from 19.6 percent to 20.3 percent between 2007 and 2008, an increase of more than 1.5 million people. Bucking the trend, the total number of uninsured children dropped from 11 percent to 9.9 percent, because many children are eligible for public insurance programs such as SCHIP and Medicaid that are unavailable to most adults.

"This data shows the enormous importance of public health insurance programs in filling the gaps as more people continue to lose private health insurance," said Deborah Weinstein, executive director of the Coalition on Human Needs, adding that President Obama's call to action on health care reform could not be timelier.

Last year's 39.8 million poor people comprise the highest number of Americans living in poverty since 1960. As bad as that number is, Weinstein pointed out that the overall poverty rate is almost certainly worse today than it was in 2008 when the recession was first getting underway -- the period reflected by the Census data. Unemployment averaged 5.8 percent last year compared with the August rate of 9.7 percent. The Economic Policy Institute estimates that assuming an average unemployment rate of 9.3 percent for 2009, poverty would increase to 14.7 percent. Higher unemployment will hit children disproportionately hard. Their poverty is expected to rise from 19 percent in 2008 to 25 percent this year, which translates into one in four children living in poverty.

In a family of three that means trying to provide children with a roof over their heads, adequate health care and a nutritious diet on an annual income of $17,163. Still worse, the proportion of children living below half the poverty line ($8,600 for a family of three) is rising steeply, from 6.4 percent in 2000 to 8.5 percent in 2008. "If poor children were not hidden from most of us -- if they could look us in the eye -- we would not allow their hardships to continue," said Weinstein.

The huge increase in poverty clearly points out the need for continuing aid to help the unemployed and states struggling to maintain vital services in the face of growing need.

"Without this aid we risk stamping out a fledgling economic recovery before its full impact has been felt by millions of Americans.

"If we invest in health care, education, and rebuilding communities, we will create jobs and renew our economy. Failure to act is a moral wrong, since it causes preventable harm to vulnerable people. Inaction is a practical wrong as well, because consigning tens of millions to poverty, with no protections against sickness and debt, drags our economy down and further delays our recovery."

# # # # # #

For key points about the grim poverty and health insurance trends:

For a first fast look at the national poverty and health insurance data:

You can find national and state poverty, health insurance, and household income data and analyses on the Coalition on Human Needs website, at

Wednesday, September 09, 2009

Senate Finance Committee moves slightly closer to health bill

Smartmoney has the latest story on financing mechanisms that the Senate Finance Committee is proposing. A tax on high-cost plans is on the table; the committee will need to adjust this for region and workforce size and composition (smaller firms and firms with older workers have higher premiums); the proposed adjustment isn't sufficient.

In addition, Sen. Baucus is proposing targeted fees on players in the healthcare industry. The insurers would pay $6 billion a year. Pharmaceutical companies, device makers and clinical laboratory companies would pay $2.3bn, $4bn and $750m a year. The fees would be allocated by market share. This is affordable, frankly. Insurers have low profit margins and might need to worry about the adequacy of their capital.

Monday, September 07, 2009

Reflections on Episcopal and mainline Christian liturgy

There is no way I could ever say this to my choir director's face, so I'll say it semi-anonymously on my blog. I'm an Episcopalian in spite of our church music. I'm not formally trained in music, but I feel our church music is not generally very compelling and that it needs several major improvements for the church to stay attractive and relevant. And this is not just a cosmetic issue.

Yesterday we sung Come Labor On, aka the Protestant Work Ethic Song. The pause after each verse was way too long and the pacing was too slow overall.

And yet, this was tolerable. PWES was in the White people's hymnal and was designed to be played on the organ. What was really intolerable was when we sang Jesu, Jesu to the organ. The midi file from the Oremus hymnal approximates what we sang in church:

From the Oremus Hymnal:
Jesu, Jesu, fill us with your love,
show us how to serve
the neighbors we have from you.

Kneels at the feet of his friends,
silently washes their feet,
master who acts as a slave to them. Refrain

Neighbors are rich and poor,
varied in color and race,
neighbors are near and far away. Refrain

These are the ones we should serve,
these are the ones we should love;
all these are neighbors to us and you. Refrain

Loving puts us on our knees,
serving as though we are slaves;
this is the way we should live with you. Refrain

Kneel at the feet of our friends,
silently washing their feet;
this is the way we should live with you. Refrain

Jesu, Jesu is a Ghanian folk song. The pacing is supposed to be significantly faster than the midi file goes (and in church, we actually went a bit slower than this). The song can easily be sung a capella, or with simple instruments. The original singers very likely clapped to the song and possibly used drums. I've heard it set to Jazz music, which originates with African-Americans, and that was just fine.

The soft, reverent, meditative tone is fine for church music of European origin - but music of African origin is supposed to be sung passionately, as the introduction to Lift Every Voice and Sing (the Black people's hymnal in the Episcopal Church) indicates. In fact, choir directors should think very, very hard before playing any song in LEVAS on the organ (except perhaps for the title song, Lift Every Voice and Sing).

At worst, this is White people butchering Black people's music. This is especially ironic because my church is unusually racially integrated compared to most others. We do not need to expect White choir directors to play LEVAS exactly the way that Black choir directors would, but I think we can definitely expect them to use the appropriate instrument and pacing for the songs. Again, many of the tunes in LEVAS are unsuitable for the organ. Jesu, Jesu is especially poorly suited to be played on the organ.

More generally, passion for our faith is something I think the mainline Christian tradition needs to emphasize more. Our church music doesn't generally allow us to do that. The mood of the music doesn't quite do it. I'm probably not using the exact musical term, but I think musicians will get what I mean. There are many reasons why the mainline, institutional church is losing members, but liturgy is one and it should be relatively easy to fix.

Cesar Chavez

Cesar Chavez, champion of the poor, saw his family’s home and small farm seized by creditors when he was only 10. He spent his youth as a migrant worker, traveling with his family wherever there were crops to harvest. They shared what little they had with those who had less.

Work in the fields meant long hours of backbreaking tasks and exposure to dangerous pesticides, for half the wages other workers in the United States could expect. Workers had no rights and lived at the mercy of employers. This experience of helplessness and poverty engendered in Cesar a profound thirst for justice. From 1952 until his death, he worked ceaselessly to improve the lot of his people.

After ten years of working in voter registration drives and in challenging police and immigration abuse, he turned his attention to the struggle for justice for migrant workers. Using non-violent tactics and sustained by the deep spirituality of his Catholic Mexican roots, he led the United Farm Workers through seemingly impossible situations. Agribusiness sometimes responded with violence. Several union members were killed. Even the Teamsters tried to sabotage what gains his union made. In spite of all odds, he made the plight of migrants known to the rest of the nation, giving a voice to those who had been forgotten.

Always a poor man, Cesar sometimes had to ask for food for his wife and children from the very workers he was trying to organize. He died on April 23, away from home on union business, after an eight-day water-only fast. An estimated 35 thousand people formed his three-mile-long funeral procession. He was buried as a poor man in a simple pine box. He remains in our midst, however, as a patron of all the poor, but especially of immigrant minorities who suffer solely because they will not watch their families starve. In this icon he carries the Constitution of the United States, for whose guarantees he fought, on behalf of all the oppressed.

-Br Robert Lentz, OFM

Selected verses from Come Labor On, aka the Protestant Work Ethic Song.
Midi file and text from the Oremus Hymnal.

Come, labor on.
The enemy is watching night and day,
to sow the tares, to snatch the seed away;
while we in sleep our duty have forgot,
he slumbered not.

Come, labor on.
The toil is pleasant, the reward is sure,
blessed are those who to the end endure;
how full their joy, how deep their rest shall be,
O Lord, with thee.

Washington Post op ed: Unhappy Labor Day

By Harold Meyerson:

Official unemployment hovers just under 10 percent, its highest level since the early 1980s. Add in the partly employed and those who have given up on hunting for jobs because there are so few jobs to be had, and the unemployed and underemployed total 16.8 percent of the labor force -- one out of six American workers.

The problems facing workers predate, and are more profound than, the recession, as three important surveys released last week show. Young workers are unemployed in record numbers -- 25 percent of teenagers, or about 1.6 million, are without work, the highest since 1948, when tracking data by age began. But the lot of employed workers under age 35 is dismal, too, as a survey conducted by Peter Hart Research for the AFL-CIO makes clear. Thirty-one percent are uninsured -- up from 24 percent a decade ago. Just 31 percent say that they make enough money to put some aside, down from 52 percent in 1999. With private-sector unionization at a mere 8 percent, and with Chinese competition dragging down wages and benefits across the United States, the living standards of non-professional young Americans are spiraling lower.

Things don't look any better for older workers. The Pew Research Center found that nearly two out of five Americans over 62 who are still working say that they've delayed their retirement because of the recession, and a stunning 63 percent of workers ages 50 to 61 say that they might have to push back their retirement dates because of economic conditions. Those conditions reflect not just the recession but also the massive shift away from defined-benefit pensions to the 401(k) plans that employers have imposed over the past few decades. Even before the recession, it was clear that Americans reliant on 401(k)s hadn't saved nearly enough to guarantee a secure retirement, and many of those who thought they'd put aside enough saw their savings plunge dramatically with the stock market in the past two years.

In the days when defined-benefit pensions were the norm, older Americans actually retired: From 1950 through the mid-80s, the participation of American seniors in the labor force steadily decreased. Since then, though, it has steadily risen. In European nations, where governmental pensions for seniors are more generous and where a stronger union movement has preserved defined-benefit pensions, seniors' participation in the workforce has continued to decrease. Last year, the New York Times reports, almost a third of Americans in their later 60s were still working. In France, just 4 percent of people that age were either employed or looking for work.

The problems of the old become the problems of the young, of course: When fewer older workers retire, fewer younger workers get hired.

The third of last week's trifecta of troubling economic surveys, put together by the National Employment Law Project and a slew of universities and foundations, interviewed 4,387 low-wage workers in New York, Chicago and Los Angeles in the first half of 2008 -- before the full force of the recession took hold -- and found that 26 percent were illegally paid less than the minimum wage in the preceding week. Of the quarter of respondents who worked extra hours, fully 70 percent not only didn't receive overtime pay but received no pay at all for their additional work.

Gather all these mournful numbers -- the millions of Americans unable to find work, the 70 percent of workers under 35 who are unable to set aside any money, the nearly two out of three Americans approaching retirement age who fear they won't be able to retire, and the sub-nation of low-wage Americans routinely cheated on the job -- and what emerges is a picture of a country in decline. The first nation in human history to create a middle-class majority looks increasingly to be losing it. The economic security that was common, though by no means universal, in this country when the institutions created by the New Deal were strong, often provided by unionized corporations that felt compelled to offer insurance and pensions to their workers, is as dead as the dodo.

The Reaganite ideology of the past 30 years insisted that if Americans were freed from the constraints of government and unions and made responsible for their own economic security, a golden age would come. Sure enough, American businesses have eluded regulation and cast off their unions -- but they've left their workers in the lurch. If we fail to enact universal health care and laws that truly make it possible for workers to form unions again, each of our Labor Days will be grimmer than the last.

Sunday, September 06, 2009

For Profit, Industry Seeks Cancer Drugs

The New York Times has a story on the pharmaceutical industry's renewed focus on cancer drugs. Cancer is a cluster of dozens, perhaps hundreds of diseases, and there probably will be no one treatment to cure all kinds of cancer.

Cancer is also a disease that has immense emotional impact ... which can obscure efforts to develop the most effective cancer treatments. Many drugs extend life for a very limited period of time at great cost:

Cancer drugs have been the biggest category of drugs in terms of sales worldwide since 2006 and in the United States since 2008, according to the market researcher IMS Health.

Such money attracts companies. “Cancer is such an emotional issue that the free market doesn’t work like it does for bicycle wheels and umbrellas,” said Robert L. Erwin, a biotechnology industry executive who heads the Marti Nelson Cancer Foundation, a patient advocacy group. “As long as the health care system will pay the price, the money will flow in that direction.”

But Mr. Erwin and some other experts say that is not always a good thing for patients because it can set the bar too low for drug companies.

“As long as the marketplace does not distinguish between modestly effective drugs and dramatically effective drugs, there won’t be an incentive to shift resources to a greater emphasis on a larger benefit,” said Dr. Neal J. Meropol, an oncologist at the Fox Chase Cancer Center in Philadelphia who has been studying drug prices.

Many executives dispute this, saying they would produce drugs offering bigger gains if they knew how. But they must balance their portfolio of experimental drugs between long shots and some drugs that have a better chance of making it to market and sustaining the enterprise.


With health care costs rising, there is new pressure on companies to be more selective in drugs they develop. Some experts now talk about “financial toxicity” as a side effect of cancer drug treatment, along with nausea and hair loss.

“A question is how the system can tolerate 400 new drugs on the market, all at the same price” of $50,000 a year, said Dr. Lee Newcomer, senior vice president for oncology at United Healthcare, a big insurer.

Such cost pressures, and the fact that only a handful of cancer drugs get to market each year, mean the big investments now being made into cancer drugs are likely to turn sour for many companies.

“It’s the biggest bubble you’ve ever seen,” said Dr. Mark Ratain, an oncologist at the University of Chicago.

Saturday, September 05, 2009

WSJ: John Murtha's Airport and Other Wasteful Earmarks

My political science professor told me how amazed European visitors were at the practice of earmarks: legislators amend bills to insert spending provisions that benefit their own states. Although not all of these earmarks are wasteful, many are. The Wall Street Journal has a piece about some earmarks that are egregiously wasteful:

If you hate the hubbub of crowded airports, you might want to consider flying out of Johnstown, Pa. The airport sees an average of fewer than 30 people per day, there is never a wait for security, you can park for free right outside the gate, and you are almost guaranteed a row to yourself on any flight.

You might wonder how the region ever had the air traffic demand to justify such a facility. It didn't. But it is located in the district of one of Congress's most unapologetic earmarkers: Democrat John Murtha.

In 20 years, Mr. Murtha has successfully doled out more than $150 million of federal payments to what is now being called the airport for no one. I took a trip to southwestern Pennsylvania to explore how this small town received so much money and whether the John Murtha Airport is a legitimate federal investment.

There are many in Johnstown who see the airport as crucial. Johnstown Chamber of Commerce President Bob Layo tells me: "If the airport isn't paying dividends now, it will in the future." But those dividends appear to be a mirage.

There are a total of 18 flights per week, all of which go to Dulles Airport in Washington, D.C. I was visiting the airport from Washington, but because flights cost a pricey $400, I drove. The drive took less than three and a half hours and cost about $35 in gas—not to mention that it was arguably faster than flying. And this isn't a remote area of the state: Murtha airport is less than two hours from the Pittsburgh airport.

The airport has an $8.5 million, taxpayer-funded radar system that has never been used. The runway was paved with reinforced concrete at a cost of more than $17 million. The latest investment was $800,000 from the $787 billion American Recovery and Reinvestment Act to repave half of the secondary runway. (Never mind that the first one is hardly ever in use.)

Airport Director Scott Voelker admitted in an interview that having a never-used unmanned radar system is "dumber than dirt." But he says the airport is necessary and blames its current shortcomings on the economy. "To get more passengers, we need more flights. To get more flights, we need more passengers," he says. Mr. Voelker believes the "economy has dictated to the airlines to cut back on flights." In other words: The airport was not built in response to passenger or airline needs.

The usually barren airport—there were several times during the day I paced the building for 15 minutes and did not see another human being—has a lot of unused advertising space. But you can't miss the large picture of John Murtha among a collage of Lockheed Martin workers at the airport's center. It's a monument to earmarks: "Partnerships Make a World of Difference," the ad reads.

Tickets to fly to Johnstown are expensive, even though every passenger flying out of John Murtha Airport has a $100 subsidy behind the ticket courtesy of the federal Essential Air Service program, which provides support to struggling rural airports. A woman who had just gotten off a flight told me that there were only four people on her plane. "The plane could have held at least 30 passengers," she said.

In addition to the airport, Mr. Murtha's ability to corral federal funds is apparent in the local medical research center (named after his wife), the John P. Murtha Technology Center, the area's thriving defense contracting industry, and numerous other local landmarks. The unemployment rate in Johnstown is currently below the national average of 9.4% thanks to federal largess and the fact that so many have moved away from the area.

Bill Polacek, a local businessman and a member of the airport's board of directors, told me that the citizens of Johnstown need Mr. Murtha's earmarks. "Quite frankly, if he didn't do that, we wouldn't elect him," he said.

I asked Mr. Layo of the Chamber of Commerce if he thinks Mr. Murtha's earmarks should stop now that Johnstown has emerged from the economic crisis it faced two decades ago. "I don't think you're ever finished," he replied. As long as Mr. Murtha is in Congress, they never will be.

Republican Congresspeople briefly outline a Republican vision for healthcare

I recently said that the Republicans had not helped their health reform case by a) not stating precisely what they support and what they oppose and b) by opposing reforms that no person with any reasonable knowledge of health policy would oppose. In a Wall Street Journal op-ed, two Republican Congresspeople, Reps. John Shadegg and Pete Hoekstra, outline a bit more of the party's philosophy.

They agree with the problem of the uninsured (phew!). Basically, they would offer subsidies through the tax system to purchase insurance, would require insurers to disregard pre-existing conditions, and would expand the existing state high risk pools. Briefly, some states operate insurance pools for people who are denied health insurance due to pre-existing conditions. These pools are expensive even after state subsidies, and often offer poor coverage (numerous exclusions, high deductibles and copays). As such, they're not a good solution. Any state subsidies would be vulnerable during budget cuts. It would be far better to place the sick folks in pools with everybody else.

Reps Hoekstra and Shadegg also accuse the Democrats of trying to take over the entire system. That's implausible. Even if a public plan were offered, insurers would adapt to it and care would continue to be delivered by mostly independent doctors. The drug and device industries would be independent of the government. Government action is required to fix many of the flaws that have been developed; Hoekstra and Shadegg will not help their case if they continue to say that the market can take care of everything.

I should perhaps have clarified my previous suggestion: the Republicans need to offer a sensible package of reforms they endorse.

Fluorescent bulbs: a hard sell, but no need to worry about the mercury content

A CNN Money article has an interview with a woman who broke a compact fluorescent light bulb. Worried about the mercury levels, she called state officials. They did some tests and told her to have the room decontaminated by a hazardous waste crew to the tune of $2,000.

That level of reaction was completely unnecessary, as the article describes. While it's true that mercury is unsafe, Consumer Reports finds that CFLs contain very little of it. If you do break one, pick it up with a piece of cardboard and dispose of that. Also, open the window and put the broken bulb outside.

The article also notes that on net, CFLs significantly reduce the amount of mercury in the environment: coal contains mercury and is a main source of energy. In addition, CFLs are a significant money saver for households.

Sadly, some of the anti-government folks are up in arms about a federal mandate that would phase incandescent bulbs out starting in 2012. Europe has such a phase out starting now.

NYT: Low-wage workers often cheated

The New York Times reports about a study showing that low-wage workers in the US are often cheated by employers: they are denied overtime pay and paid less than the minimum wage. The study found that the violates amounted to an average loss of 15% in pay. Additionally, among the 20% of workers who engaged in union organizing activities, 43% said they experienced some form of illegal retaliation like firing or suspension.

You shall not withhold the wages of poor and needy labourers, whether other Israelites or aliens who reside in your land in one of your towns. You shall pay them their wages daily before sunset, because they are poor and their livelihood depends on them; otherwise they might cry to the Lord against you, and you would incur guilt.

Deuteronomy 24:14-15

It's important to note that most employers comply with the law. However, the study reports that some small businesses feel that they are forced to break the law in order to remain competitive. Regarding the passage above, the International Standard Bible's concordance notes that the existence of hired workers in ancient Israel was "precarious", although it was better than being a slave, and notes that protections for their rights had to be implemented in the law.

The shortcomings of the CLASS Act (a long-term care social insurance proposal in the US)

Upon the late Senator Ted Kennedy's death, I briefly mentioned an analysis I did of a proposal that would provide insurance to people needing long-term care. 70% of Americans over age 65 will need some long-term care at some point in their lives. They will need an average of about 2 years, although 20% will need 2-5 years of care, and another 20% will need over 5 years of care. Not all of this 70% will need care in a nursing home. The majority (70+%) of people receive care solely from unpaid caregivers; these are mainly women. Unpaid caregivers incur substantial opportunity costs in helping their relatives, like lost earnings.

The Community Living And Social Supports Act (CLASS Act) is mainly targeted at unpaid caregivers. The Act's benefit would be insufficient by itself to fund a long nursing home or assisted living facility stay. It would play a role similar to Social Security, which is not sufficient to fund retirement by itself for most Americans (albeit most low income folks live solely on Social Security).

However, I strongly suspected that the late Senator was charging too little. The American Academy of Actuaries did an analysis that confirms this. The CLASS Act is structured as an opt-out provision; Sen. Kennedy's office felt that this would lead to much higher participation than a voluntary enrollment program, but AAA believes that only 6% of eligibles would enroll. They also believe that premiums would need to average $125 per month (as opposed to the $65 specified in the Act) for the program to be actuarially sound, and that the premium would need to increase with inflation yearly. The CLASS Act specified that people who enroll should pay the same premium for the rest of their lives; AAA estimates that people would need to pay $160/mo under this structure to achieve actuarial soundness. For the Act to be actuarially sound, its fund would need to be able to pay benefits for 75 years, which is similar to the specifications for Social Security.

With voluntary participation, the Act runs into two problems. One, with low participation, administrative expenses are relatively higher. The Social Security program's administrative expenses are under 1% of premiums collected. The Actuaries estimate that the CLASS Act's administrative expenses would be as high as 7% of premiums collected. Two, there will be adverse selection. People who have good reason to think they may be disabled (for example, who have a chronic disease or a history of disability in old age) will enroll and then collect benefits after the 5-year vesting period. Healthier people and younger people will put off enrollment unless they feel they may need it. The poor are offered the chance to enroll at a significant discount, and they have higher disability rates than average, so they will be more likely to enroll. All these will drive expenses up; the AAA analysis accounts for this effect.

The Democrats have three options regarding the CLASS Act. They can scrap it or make it mandatory. If they insist on continuing it as a voluntary program, they could increase the vesting period to 10 or 15 years (in other words, you must pay premiums for 10-15 years before you can collect any benefits). They can also consider implementing a deductible (in LTC insurance, this is structured as an elimination period, which is a set length of time after you become disabled for which the insurance doesn't pay). It would be possible to start the Act as a voluntary program, and later make it mandatory. The only way to make it a really sound and effective program is to have mandatory participation, which is also applies to regular health insurance.

Shawn Tully of CNN Money argues that the Democrats are interested in the CLASS Act because it has a budget gimmick effect. The US uses a 10-year budget window - expenses and tax collections are anticipated 10 years ahead under current law or a proposed change to the laws. The CLASS Act brings in money over the next 10 years on net, but after that, expenses will increase significantly. For better or worse, like Social Security, the funds collected in taxes are not segregated from general funds. In other words, it looks like the CLASS Act is contributing $58 billion dollars to offset the anticipated costs of health reform; the Democratic House bill is about $250 billion short right now. Tully's opinions on health reform are detestable, but lawmakers would be best advised not to use the CLASS Act as a budget trick. Health reform needs to be paid for, and you also cannot enact a long-term care program that will not be paid for.

Thursday, September 03, 2009

Huffington Post: Michael Steele: Meet Amanda Duzak

Huffington Post has a write up of an incident at Howard University, a historically Black university in Washington DC, where Michael Steele made comments on health reform. A student, Amanda Duzak, said her mother had just died of cancer, showing the need for universal healthcare:

Then came Amanda Duzak, and Steele's evening just got a whole lot worse.

Duzak, a 23 year old Towson University grad, stood up, against the rules and out of turn.

"My mother died of cancer 6 months ago because she could only afford three of her six prescription chemotherapy medications," she projected. "There are 50 million people in this country who could end up like my mom, suffering or dying because they do not have adequate health care. Everyone in this room and everyone in this country should have access to good health care."

The room woke up and other than those glaring from the front, the applause was wall to wall...

At this point, Steele should have emphasized that Republicans were committed to achieving good health care for all. He should have stated what reforms they were amenable to and then reiterated his stance that excessive government involvement would create its own problems. Instead, he said this:

But it's Steele's response that makes this moment both newsworthy and a terrible comment on his character. After saying that he believed in a mature, honest discussion and not in shouting, Steele said, "People are coming to these town meetings and they're like [he then shakes]." He then looked and gestured right at Ms. Duzak and said, "It makes for great TV. You'll probably make it tonight, enjoy it." He then turned his back to her, as the crowd clapped.

Think about what Steele did. He didn't only turn his back and rudely dismiss a young woman whose mother just died of cancer. He used the shameful recent behavior of the right wing town hall screamers -- his own party's base -- to try and turn the crowd against Ms. Duzak.

Damian Smith, a after school counselor and Prince George's County resident, also weighed in about how his aunt is losing her home because of her medical bills. Other people started to shout out as well.

But Steele was worse than non-responsive. He was dismissive and profoundly disrespectful. As Smith said to me afterward, "I couldn't believe he acted that way toward her... toward all of us. He was just mean."

It doesn't help Michael Steele that the existing Republican health reform plan is a non-solution. First, the Patients' Choice Act, sponsored by Rep. Paul Ryan (R-WI), does not institute the market reforms that are absolutely crucial to getting people insured: it does require the use of guaranteed issue, but it does not require community rating, where premiums are set regardless of a person's health status. If I have a chronic illness, an insurer would have to offer me a plan but not to set the premiums at an affordable rate. In fact, the Act actually prohibits states from restricting premiums or cost sharing. Admittedly, states might choose to implement the necessary market reforms, but forbidding them from regulating prices may render the reform meaningless.

Second It also includes measures that could weaken, and perhaps destroy, the employer sponsored insurance market. It would eliminate the tax exclusion for health insurance and give everyone a refundable tax credit. Young people like me, then, will actually get money back if they leave their employer sponsored plan and buy a cheap plan on the individual market. That leaves sicker people in the employer plans. Employers then have to raise the cost, which will drive more people out of their plans. Over the long haul, employer plans could go into a death spiral, and people would not have a viable individual market to go to.

Last, the Act severely weakens Medicaid and offers insufficient subsidies for most people to purchase insurance.

The Republicans need a better plan. For the most part, they are offering good theater but poor governance. Michael Steele also needs to apologize immediately.

Wednesday, September 02, 2009

Prosecuting the CIA: NYT Room for Debate Blog

US Attorney General Eric Holder's decision to appoint a special prosecutor to see if US laws were violated by CIA workers who interrogated detainees is debated on a New York Times blog. None of the opinions listed opposed opening an investigation, but one opinion by Benjamin Wittes, a scholar at the Brookings Institution, caught my eye:

Republicans are calling it a witch hunt. Civil libertarians and human rights activists are calling it a whitewash or, at best, a first step. My best guess is that Attorney General Eric Holder probably acted quite reasonably.

I say best guess, because I don’t know — any more than do all of the people criticizing Holder’s decision — exactly what information led to his move. I am therefore far from sure that I agree that the specific cases he referred to prosecutor John Durham warrant further investigation. Nor is it clear that other incidents that he did not refer to Durham do not warrant inquiry. That said, the broad principles reflected by Holder’s action seem to me correct.

First, Holder is taking heat from the left for not authorizing a general criminal inquest into Bush administration interrogation policies and their development. He is right to refuse. As President Obama has made clear, nobody should face criminal prosecution for following in good faith the law as articulated by the Department of Justice. Nor should lawyers in the department face criminal investigation for interpreting the law, even wrongly, in the absence of evidence that they did not believe their interpretations were reasonable.

But this leaves the question of what should happen to those operatives who acted beyond the exceptionally permissive guidance that the lawyers gave them. Some of these incidents are very ugly. Some detainees even died in custody. And if people acted in violent fashions beyond what the Justice Department authorized and if there is some reason for Holder to be dissatisfied with the manner in which the career prosecutors in the Justice Department previously investigated their cases, it strikes me as appropriate for him to request another look.

The key, it seems to me, is that the investigation should focus only on the specific incidents in which people exceeded the legal guidance they were given. If it spreads beyond those incidents, it risks becoming the witch hunt conservatives are already decrying. By contrast, a failure to resolve those cases credibly risks becoming the whitewash the left has already proclaimed.

It is worth asking, if CIA workers violated human rights and claimed, as a defense, that their orders were legal under the prevailing laws and that they were following those orders, how is this any different from the Nuremburg trials? These workers should have known that what they were doing was wrong and they should have refused. If they did not know, they deserve punishment.

From a pragmatic standpoint, Wittes is absolutely right. Make no mistake, there are people out there who seek to do harm to the West, including the US. Their methods do not fit the conventional warfare for which the laws of war are designed. Nonetheless, they need to be stopped or innocent people will die. From that perspective, CIA officers who acted in good faith and were told they were acting in accordance with the law should not be punished.

The detainees at Guantanamo were being tortured, and their continued indefinite detention is a form of torture. Regardless of whether they were told it was legal, those who participate in torture will answer to a higher court.

The present administration is taking steps to engage with the Muslim world. This is necessary, although it isn't sufficient by itself, to bring us on a path to a more peaceful world. If we stop doing this, if a later, more belligerent administration takes over and undoes this someday, then there will be hell to pay, and the entire country will have to answer to that higher court.