Joementum Strikes Again

With headlines of health reform, blue dogs, and pork barrel politics abound, this week’s Politics as Unusual will feature my favorite U.S. Senator from the insurance capital of the free world. As we look forward to reconciliation days to come, let’s take a look back, way back, past Christmas Eve votes, 1 am clotures, Nebraska purchases, and prayers for the speedy death of the President pro tempore:

Policy Versus Politics, Revisited

This fall, I wrote about policy versus politics in the context of Ted Kennedy’s body of work. Health care events of the past few weeks have reaffirmed many of my conclusions. From the left flank, many prominent bloggers and pundits have taken vastly different stances on whether the current Senate health care bill is worth supporting. Let’s take a look at a one sample question from a 20-question back and forth on the current bill among Nate Silver from FiveThirtyEight, Markos Moulitsas from Daily Kos, and Jon Walker from Firedoglake. You can read all twenty questions here.

After reading all 20 questions and responses, along with other arguments all over the Web, it becomes clear that this is largely a politics versus policy debate. For an additional example from the politics camp, here’s ex-Hollywood producer turned left-wing blogger Jane Hamsher with her own ten reasons to defeat the bill. Her main conclusion is as follows:

The Senate bill isn’t a “starter home,” it’s a sink hole. It needs to die so something else can take its place. It doesn’t matter whether people are on the right or the left — once they understand the con job that’s about to be foisted on them, they agree. That’s why Harry Reid and President Obama are trying to jam it through as fast as they can, before people get wise. So email the list to your friends and family, tweet it and spread the word.

In the policy camp, here’s an example with health care wonk Ezra Klein answering one of Hamsher’s claims (his full 10 answers to Hamsher can be viewed here):

5) Paid for by taxes on the middle class insurance plan you have right now through your employer, causing them to cut back benefits and increase co-pays.

“You” probably don’t have these plans, which are tilted towards the rich, not the middle class. Your plan probably doesn’t cost more than $23,000 a year. And if it does, the only part that gets taxed is the part in excess of $23,000 a year. The average family health-care plan costs about $13,500 — almost a full $10,000 less than the plans this policy taxes. If we don’t manage to slow the growth in health-care costs, this policy will, over time, hit plans that are less generous. But economists consider the excise tax, which functions as a tax on insurers who let premiums grow too quickly, one of the most effective cost-control mechanisms in the bill.

There’s an equity aspect here, too: The problem with the excise tax is that it doesn’t go far enough. All plans should be fully taxable. This policy begins to chip at the edges of one of the most regressive elements of our system: Health benefits, which are mostly given to better-off workers, are protected from taxes, while income isn’t. A worker at Wal-Mart with no health benefits sees his entire paycheck taxed. If that worker goes to buy insurance on his own, the money he uses to buy it is taxed. A worker at Goldman Sachs with a $40,000 health-care plan is getting $40,000 of his paycheck tax-free. It’s wildly regressive, and not something that liberals should support.

Of course, the main reason for political opposition to the bill from the left is associated with the demise of the public option. While the public option would have been a small step forward in providing more competition in certain markets, its merits were largely overemphasized for political reasons. According to the Congressional Budget Office (CBO), the public option passed by the House of Representatives would have covered approximately 6 million or 2% of the 282 million Americans under the 65 years old. The CBO also estimated that this version of the public option would have had higher premiums for consumers, since it would likely have had severe adverse selection, attracting sicker patients on average. A single payer or robust public option would have obviously done more to control costs, but those options were never serious policy options even if President Obama had had the backroom negotiation skills of Lyndon Johnson. In whole, the proposed Medicare expansion would have covered even fewer people than the public option passed by the House.

For many on the left, this was, of course, never about the policy implications of the public option. Rather, the whole debate has been largely about the politics of the public option and what it meant for left-wing morale. After being steamrolled from 2003 to 2007 by a GOP trifecta, the left understandably wanted revenge. The public option was seen as a first step toward the eventual goal of single payer. While the public option would have been a good addition for policy wonks who care about cost control, in reality it was a very small part of the overall bill and the lack of a public option does not necessarily do anything more to preclude future moves toward single payer. (Admittedly, however, the Medicare expansion was perhaps more of a legitimate move toward single payer. Perhaps this should have been the goal of the left from the beginning?)

More importantly, the debate over the public option largely misses the point. The public option, Medicare expansion, and anything else up to and including single payer do not necessarily by themselves do anything to control costs in the long run. Yes, in the short run, they likely do eliminate some excess administrative costs. However, in the long run they do nothing to control runaway increases in costs that, subsides or not, will end up bankrupting the public, the government, or both. Coverage reforms by definition only involve what individuals are covered or not covered by what type of insurance; nothing more, nothing less. Real cost reforms go beyond this to reforming how care is paid for.

Unfortunately, Washington has historically viewed payment reform in the context of payment cuts. This of course leads to limiting of payments but does little to control costs. Real reform that actually bends the proverbial cost curve involves changing incentives and how providers are paid in ways that encourage collaboration, cost control, risk sharing, and sensible evidenced-based rationing. Yes, despite what Sarah Palin may be tweeting, the United States already rations care, largely by socioeconomic status, age, existence of a preexisting condition, and different knowledge levels about how to navigate the insurance appeal process. Rationing by evidence-based effective care and paying for quality instead of quantity are two needed long-term solutions. The Senate and House bills tiptoe in this direction with various demonstration projects. While at first glance, this is too little and too slow, respected health care writer, clinician, and wonk, Dr. Atul Gawande, takes the opposite viewpoint in his latest New Yorker article about how the Senate bill would potentially contain costs.

Another aspect of reform that largely has been forgotten in the political battles over the public option is access, which goes far beyond coverage. Simply insuring individuals does not ensure that there are a sufficient number of providers to care for these newly insured. This is especially true in many rural areas where there is already a severe shortage of primary care providers. Again, here, the Senate and House bills move in the right direction (e.g., payment incentives for primary care and general surgeons who practice in underserved areas), but probably don’t go quite far enough.

Senate vs. House vs. Status Quo

After digesting all of this from a policy standpoint, I would give the Senate and House bills and the status quo the following scores:

Senate:
Coverage: A-
Access: C+
Cost Control: C
Overall: B-

House:
Coverage: A-
Access: C+
Cost Control: C+
Overall: B/B-

Status Quo:
Coverage: C-
Access: D
Cost Control: D+
Overall: D+

Compared to the current system, the bills that have passed each house of Congress achieve much improvement over the status quo, and there is little overall difference between the House and Senate bills.  Both bills will achieve monumental improvements over the status quo in the area of coverage, adding more than 30 million individuals to the ranks of the insured.  Both bills will make more modest gains in the areas of access and cost control. With that said, thousand of lives could be affected at the margins, and it is important for policy wonks and politicos alike to continue to put pressure on Congress to produce the best bill out of conference. However, considering previous attempts at health care reform over the past 60 years, the current political environment, and the arcane Senate filibuster rules, it is outright naive to assume anything better than a “B/B-” was achievable in the first place. Considering the status quo, those who demand that the current bills be killed in favor of the status quo and the faint hope of a better bill are clearly deciding to put politics over policy. Such political calculations matter little to the estimated 45,000 Americans who die each year due to lack of insurance coverage.

Any views expressed here do not necessarily represent the views of any organizations that the author is in any way affiliated with.

A Review of A Bomb in Every Issue

A Bomb in Every Issue: How the Short, Unruly Life of Ramparts Magazine Changed America

by Peter Richardson, 247 Pages, The New Press, $25.95.

After struggling for the right superlative for Ramparts – Was it the most important magazine of its day? The most representative of the New Left? – I settled on one that wasn’t subject to debate: Ramparts was my favorite magazine – ever.  If we were to name the most significant magazine of the twentieth century American Left, it would be hard to deny The Nation, which has lasted the entire hundred years. Yet a couple of others arguably burned more brightly, although far more briefly.  The Masses, which ran from 1911-1917, comes to mind – and Ramparts, which spanned 1962-1975.

Ramparts didn’t just report news; it made news. It was a politically radical magazine with style. If you thought left wing politics ought to be hip, Ramparts was probably what you read.  And if it, indeed, had a bomb in every issue, as its nemesis Time Magazine once said of it, then we might say that Peter Richardson’s zippy new biography of the magazine has a firecracker on every page.

Ramparts was on quite a different course, however, when Edward Keating started it as a liberal Catholic magazine the year Pope John XXIII set about to renew the Church in the Second Vatican Council.  The first issue contained a symposium on author J.D. Salinger, but soon the magazine published Thomas Merton, the Trappist monk author of a widely-read autobiography, “The Seven Storey Mountain,” who was then in the process of engaging with Martin Luther King and the civil rights movement.  And then came an article by the magazine’s future editor, Robert Scheer, examining New York archbishop Francis Cardinal Spellman’s enthusiastic support for the Vietnam War.  Ramparts was, Scheer said, “The only place willing to publish it.”  Warren Hinckle, a recent student newspaper editor at the (Jesuit) University of San Francisco who was also rising to power at the magazine, explained the transition from there: “It was the idea of the church being wrong: If the church was wrong, then the government wasn’t far behind. If the government was wrong, then hell, all bets were off. Why should you believe anybody?”
National notoriety followed with the publication of an interview with German playwright Rolf Hochhuth, whose new play, The Deputy, prompted international furor with a portrayal of a Pope Pius XII generally indifferent to the fate of the Jews under the Nazis.  Or more precisely, the notoriety came when the San Francisco based magazine held a press conference at the Waldorf Astoria Hotel in New York City in defense of the play’s right to be performed on Broadway. The event typified the qualities that Hinckle – a figure about San Francisco to this day – brought to the magazine – brilliant promotion (Bloody Marys served at the press conference) and a flagrant disregard for budget.

Jessica Mitford, the author of “The American Way of Death” who loaned her name to the magazine masthead, described Hinckle and Scheer as “brilliant young bandits doing an extraordinary job,” but bemoaned their “ruthless handling of people.” This would include the ouster of founder Keating who had “found himself in the eye of a hurricane,” in the eyes of Ramparts art director Dugald Stermer, when Ramparts “became a national force. I don’t think any of us had that in mind when we started out.”  Keating himself said, “They threw me out like an old shoe.” The “bandits” were brilliant enough, though, to maintain connections with such Keating finds as Eldridge Cleaver, recently released from prison and on his way to fame with the Black Panther Party.

Until its final demise (it survived one bankruptcy), the magazine would play a signal role in the blowing apart of prior conventional wisdom that “the Sixties” are rightly or wrongly identified with.

Ramparts would never be accused of carrying concealed weapons – oftentimes the bomb in the issue was right on the cover: The December 1967 issue showed four hands holding the burning draft cards of Hinckle, Scheer, and two other staffers.  They later told a New York grand jury that those were their draft cards, but not their extremities – the photographer had used hired hands.  (No one was indicted.)  The April 1969 cover featured a young boy holding a Vietnamese National Liberation Front flag with the caption: “Alienation is when your country is at war and you want the other side to win.” And if irony was your style, there was all-American artist Norman Rockwell’s May 1967 cover drawing of Bertrand Russell for an issue highlighting the British philosopher’s withering critique of American foreign policy.

In its customary budget-be-damned style, the magazine sent ten reporters to cover the 1968 Democratic Convention in Chicago where they produced a daily Ramparts Wall Poster. Contributors of the day included Tom Hayden, who would be indicted for conspiracy to disrupt the convention and stand trial as part of the Chicago Eight; Adam Hochschild, future founder of Mother Jones magazine; Paul Krassner, editor of the intermittent and infamous The Realist magazine; past Students for a Democratic Society president Carl Oglesby, author of the seminal but now largely forgotten book, “Containment and Change;” and Richard Rothstein, future New York Times education writer. Pete Hamill and Hunter Thompson were also in the wings.

In 1970, David Horowitz – before his abrupt about-face denunciation of his New Left days and long career as a leading intellectual figure of the New Right – emerged as the new editor when a staff collective ousted Scheer (who remains a working journalist of the left to this day.)  Hinckle had already left to found the short-lived Scanlan’s Monthly that famously paired Hunter Thompson with cartoonist Ralph Steadman and sent them off to the Kentucky Derby to drink mint juleps and report the decadence they found. The magazine lost the impish touch of the Hinckle/Scheer days, but its politics remained largely unchanged.

Ramparts published Che Guevara’s Bolivia diary and Robert Kennedy’s final interview. It exposed the Central Intelligence Agency funding of the National Student Association and gave early attention to New Orleans District Attorney Jim Garrison’s investigations of the JFK assassination. Sports psychologist Harry Edwards’ article about the use of steroids was decades ahead of the curve. It interviewed Huey Newton and John Lennon, and published Susan Sontag, Noam Chomsky, Howard Zinn, Kurt Vonnegut, and Seymour Hersh. When the stories themselves weren’t enough, Keating, Scheer, and Stanley Scheinbaum, another magazine affiliate, all ran antiwar campaigns in the 1966 Democratic congressional primaries. None won, but each shocked the local establishment with how many votes a newcomer could get by advocating withdrawal from Vietnam.

By the time its finances finally brought it down, Ramparts had touched upon – and usually in a memorable way – the lion’s share of the issues that dominated the remainder of the century.

Tiger Sets off Balloon Girls and Sarah Palin

Washington—December 10. Tiger Woods broke his extended silence today to deny any romantic involvement with Sarah Palin. “No, Sarah Palin is not one of my mistresses,” he told reporters. “She’s not even one of my pinup girls, although she does have a great body. Wow, have you seen that braless pic where she’s painting her walls?  All right, I did have that one taped in my country club locker, but the dog ate it.”

Asked about alleged text messages to the former Alaska governor, Woods spoke emphatically . “No, no, no.  I didn’t tell her she’s ‘hot.’ I said it’s hot in Florida. I said I could use some of that seaside view of Russia right now. I wasn’t interested in her romantically, and my intentions were purely honorable and political in nature.  Why couldn’t she release a copy of her birth certificate? I said. I figure as long as she’s a birther, let me see hers. How do I know she’s not a Russian?”

In Ohio, meanwhile, eyewitnesses reported seeing 14 to 17 former Woods mistresses spill out of an errant UFO-like helium balloon when it crash-landed and sustained a tear in the fabric. The young women were not immediately available for comment because they were busy scrambling through a nearby cornfield, reading their text messages.

Elsewhere, Libyan president Moammar Gadhafi admitted to reporters that all of his famed female bodyguards were Tiger Woods’ girlfriends. “These brave Libyan women withstood the colonialist-imperialist hegemony of American infiltration, of ruthless penetration into our glorious purity. Death to golf!”

A spokeswoman for the Dallas Cowboys Cheerleaders, meanwhile, could not be reached for comment because she was also busy reading text messages. NFL officials say they are still investigating why the Cowboys cheerleaders have “for months been cheerleading golf tournaments instead of football games and disappearing into the club house afterwards.”

“This is highly unusual and most irregular,” said one official who asked not to be identified. “Normally, football cheerleaders cheer-lead football games, not PGA tours. I have to wonder what they’re thinking. Well—to be honest, we don’t get the pick of Rhodes Scholars. Most of our pom-pom girls think ‘foreplay’ is a golf term.”

Friends of Tiger Woods identify Carrie Prejean, the former Miss California and anti-gay marriage activist, as one of the golfer’s minor conquests. Asked for comment, Prejean said opposite sex marriage is a holy sacrament and that she had believed Woods when he’d told her he was single. “Duh, I think music is the universal language,” she said, “and my hope is for world peace. My ambition when I graduate from community college is to help the hungry children of the world.”

Woods refused to comment on the alleged relationship, but did respond to rumors about a liaison with U.S. Secretary to the United Nations Susan Rice. “Hey, Susan is undeniably babe-alicious, and I mean hot,” Woods said in a news conference. “But she’s way out of my league. She’s beautiful but too cerebral for me. Her brain is to the UN what my golf swing is to the PGA tour. Wow, I tried, though. I swung and I missed, if you’ll pardon the baseball metaphor.

“But I categorically deny having anything to do with the Sisterhood of the Traveling Pants. That was a nasty rumor started by Angelina Jolie. She’s always jealous, that little so-and-so, just because I jilted her. First she tells Brad all about me, hoping the guy would beat me to a pulp, but it didn’t happen. So she makes up this nonsense about me bonging everybody in the Sisterhood of the Traveling Pants. Didn’t happen. Except for Amber Tamblyn and America Ferrera. They’re just so hot. Come on, give me a break—what sporting man could resist?”

Lost in Translation: Electronic Records and Health Reform

A typical day at work will invariably find me hunched over a piece of paper, staring at a jumble of illegible loops and lines, trying to figure out what on earth five loops and a squiggle is supposed to convey to the reader.

No, I am not a handwriting analyst, a historian of ancient writing, or a translator of foreign languages. I am a medical student, simply trying to read the paper progress note of another physician or resident in attempt to figure out what happened to my patient during his visit two months ago. This frustration contrasts to a recent gig at a VA hospital whose medical records and charts are completely computerized; a model system where I was able to breezily click through the past medical history of my patients. As an incoming medical professional in an already digitized world, I am constantly disgusted at the inefficiencies and difficulties that arise from using paper charts.

How Common are EHR’s?

Electronic medical record is one of the current buzz words in the health care field. A recent study published in the New England Journal of Medicine this past spring found that only 1.5% of hospitals have a comprehensive-electronic record system present in all units . Other recent studies have found that a small percentage of physicians’ practices currently utilize electronic health record (EHR) system or CPOE (computerized provider order entry) at all practice locations, leaving a larger majority of our hospitals and health care providers to sift through endless piles of paper every day to learn about their patients.

Costs and Benefits

Those who doubt the inherent benefits of comprehensive EHR implementation put forth the financial objection that estimates over hundreds of thousands of dollars for many physician practices to implement and maintain such a system. However, some studies show that the costs to the health care system created by the problems using paper charts have the potential to outweigh the costs of an EHR in the long-run. More importantly, even if ultimately shown to be cost neutral, effective use of electronic health records have been shown to improve quality and save lives. Many of these quality gains are realized with robust systems that include evidence-based decision support tools to providers.

The Scary Truth

The old joke of physicians having illegible handwriting holds true in my experience: for the majority of physician providers, their writing is difficult to read at best. At worst, it is plain illegible. This creates a multitude of problems in our health care system that is a huge detriment to the efficiency, safety, and the economics and structure of the health care system. The most obvious and feared complications of simple bad handwriting are huge mistakes that can needlessly cost a life.

In its landmark report, to Err is Human, the Institute of Medicine estimated that up to 98,000 lives are lost every year from medical errors.  Not surprisingly, one study found that approximately 90% of  inpatient medication errors occur at either the ordering or transcribing stage.  I see nearly every day how easy it can be to make a mistake with a life-or-death magnitude simply by misinterpreting the wrong word or number from a chart leading to a dangerous drug reaction or an incorrect treatment. Even if I finally correctly translate all of the scribbled notes in the paper chart, it will have taken me five times as long to treat my patient, increasing the time it takes to treat the patient and increasing the chance of an adverse outcome. Talk about inefficiency in health care!

Aside from the danger and inefficiency, medical errors due to paper charts can wreak havoc on many other players in the health care system by causing a high number of lawsuits. When a physician is sued due to a medical error, it drives up the cost of the already sky-high malpractice insurance that all physicians have to pay. While it may seem to the general public that all doctors are rich and live to play golf, many have high debts from school, don’t make the big bucks, and work horrendous hours. Add high malpractice insurance, and this causes financial difficulty for physicians in certain specialties that can cause shortages of some primary care doctors such as obstetricians.

Alternatively, physicians might be forced to cherry pick their patients, only accepting Medicare and private insurance patients, causing uninsured and Medicaid patients to use the ER as their only health care venue, thus shifting the burden of cost to taxpayer’s wallets in the form of hidden hospital fees to compensate for many cases of avoidable uncompensated care. Many critics of EHR within medical field fail to realize that in improving the efficiency and safety of medical records translates far down the line to many aspects of the health care system. Indeed, in a time of health care reform, the transition of paper charts to electronic medical records will play a large role in improving the health care system.

Reason for Hope?

Through the ARRA EHR stimulus, part of the larger stimulus bill, Congress recently set aside $19 billion dollars, or the equivalent of over $40,000 per physician in a practice, to assist in implementing electronic health records (EHR) that meet meaningful use definitions (e.g., CPOE). This is a huge step forward in the attempt to computerize medical records across the country.

As a health care professional, I am excited to see the dedication to the improvement in health care of the current administration and frankly shocked at those who refusal to consider any reform to this health care system that is so obviously inefficient, expensive, and backward compared to any other developed industrialized nation. An entire overhaul of our health care system is required, in which EHR are only one part. However, the same critics of implementing EHR because it is “too expensive” are focused on the short term in all areas of health care reform, battling reform not because they have a better idea, but because they have no idea. I challenge any EHR or health care reform naysayer to step into my shoes for a day to read handwritten patient notes in a paper chart and to make a life or death decision based on an illegible scrawl. Our patients deserve better.

Secret New Weapon: Serena Sends Taliban Running for Hills

Inserting myself into one of the remotest regions of Afghanistan—and embedding myself with no one in particular except a sheep farmer named Tirkluckless—I interview him. I do this mainly because he can talk, unlike his sheep. The intelligence he provides me, however, is stunning. As a bandit in A Fistful of Dollars once stated, “In these parts, a man’s life can depend upon a mere scrap of information.”

“You seem pretty calm, Tirk,” I say. “The Taliban are howling at the door, and not a NATO soldier within 50 miles, yet you calmly tiptoe around the sheep dip without a care in the world. What’s that all about?”

“Did ye not know, oh infidel? The American drones circle above like eagles—I can certainly hear them, as they interfere with the bah-bah-ing of my sheep and therefore I cannot sleep when I’m trying to count my sheep. Anyway, there are not only drones but the CIA has also secretly inserted Serena Williams into the foothills of the Forbidden Mountains.”

“What? Serena Williams? Come on.”

“Indeed, it is true, oh unbelieving one. She has been sighted on several occasions, cursing the wolves and frightening them to death. She even outruns them and eats them for breakfast.”

“If this is true, Kirk, it’s still incredible. She makes the Special Forces look like girl scouts.”

“It’s Tirk, not Kirk. My full name is Tirkluckless. How many times must I remind you of that, oh clueless Trekkie nerd? Be careful or I shall smite you. I come from a rough neighborhood. Last week, down near the capital, I was watching a full-scale battle between NATO forces and Taliban insurgents, and a ladies’ tennis match broke out.”

“Good heavens, that is a rough neighborhood. I take it Serena was there?”

“Yes, she was. She is a one-woman Special Forces, to be sure. Already she has crushed many a Taliban with her powerful thighs and decapitated others by hurling tennis rackets with superhuman agility and accuracy. Still others she curses to death with unimaginable slurs calculated to defeat their manhood. Yes, oh beardless one, the mountain villagers sing folk songs about her. They call her the Wild Woman With Huge Haunches and Thighs That May Crush a Man into Ragged Pieces. Oh—I’m getting excited; I had better to stop now.”

“Uhm—no, please, go on. I’m sure you can control yourself.”

“She is also veddy beautiful, you know, and she’s having breasts like mangos!”

“I seem to recall that line from A Passage to India.”

“What, those Shiva-worshipping heathen?”

“Now, now, I think the Serena-lust is getting the better of you.”

“Well, there are always my sheep with which to—“

“Ahem. You were saying?”

“You must understand this is a lonely place, sahib. Indeed, before you there was ne’er a white man to be seen in these hills since the days of W.C. Fields in the 1930s. He had lost his corkscrew, you may recall, and was forced to survive on food and water.”

“Such a contingency would be unfortunate, yes.”

“The word in the hills is that Osama bin Laden watches ladies’ tennis on satellite TV and he shivers with fright as we speak. I have seen a sneak preview of a new video he will release, denouncing women in sport—and women in general, of course. He promises to hack off the arms of any female who dares to bare her arms, let alone use them to hurl tennis rackets at him.”

“How do you feel about this?”

“Well, he’s not all hell and brimstone, actually. He has a heart. He says the point is negotiable and that if the USA will call off Serena, he will settle for a ladies’ tennis referee position at the US Open.”

“He really is scared.”

“He said the officiating call was in error; there was no foot fault and therefore as punishment the referee’s tongue must be removed and Serena’s fine must be canceled.”

“A man of mercy, I see.”

“Praised be to the heavens, Serena shall return home and I shall return to my sheep in peace. If we run out of wolves and Taliban, she might develop a taste for lamb.”