RSS FeedAmerica’s Primary Care Shortage
Here’s a snapshot of America’s primary care shortage as measured in 2008. Red designates counties in which there aren’t enough primary care physicians; turquoise designates counties with partial shortages in certain areas; white means no shortage.
H/t Kavita Patel for the New Health Dialogue blog.
Mr. Churchill, the Quotable
Is there no one alive today as quotable as Winston Churchill was? Or does it just seem that way? Anyway, I really like this one:
You can always count on Americans to do the right thing – after they’ve tried everything else.
Obviously, at some point a reputation for aphorism begins to be embellished and the subject is mythologized. Like Yogi Berra, Churchill probably didn’t say a lot of the stuff he said. He just didn’t say it better.
Weekend Birdbrainery: Canny Corvid Nutcrackers
A propos of last week’s birdery post, here is video of Carrion Crows in Japan using cars as nutcrackers:
From David Attenborough’s Life of Birds.
Health Reform Lobbying Chart
Via Igor Volsky, here’s a chart from Roll Call breaking down how much money various healthcare interest groups spent lobbying Congress about health reform from January 2009 through March 2010.
Hospitals seem to have been particularly effective in their efforts. See Volsky for the details.
Pre-Weekend Wordery: The Adjectival Kitchen Sink
Ezra Klein shares this:
A friend of mine used to say that the rhetorical separation between good food and bad food came down to adjectives. Onion omelet? Pass. Caramelized onion omelet? Sure. Chicken? What do you mean, chicken? Roast chicken? Sure. Vegetable salad? Yawn. Spring vegetable salad? I’ll take a look. And it’s easy to go on: Potatoes vs. roast potatoes, fish vs. seared tuna, beans vs. farmers market fava beans.
There are a lot of vegetables (and assorted other non-meat items) that can be prepared in a lot of different ways. But if you’re not interested enough in the dish to explain what’s in it and how it was made, it’s a pretty good signal to potential buyers that it’s not very good. You don’t see menu items labeled “meat” and you shouldn’t see menu items labeled “veggie.” It’s like a large, blinking, sign: “THIS WILL NOT TASTE VERY GOOD.”
No doubt it’s true: adjectives are often helpful. But not always! My complaints about contemporary menu drafting are more often in the opposite direction: way too much quasi-descriptive embellishment.
I’ve come to think the adjective-seared jumble-aya of today’s menus is also a pretty good signal of a dish (or restaurant) to avoid. It’s as if contemporary menus are caught in some kind of rococo arms race, with each item buried deeper in modifying phrases than the last, to the point where it becomes a serious challenge to identify the noun portion of the meal. You know, something like: Applewood hickory-infused rosemary pine nut glaze reduction with lavender herb encoarsened fair trade sea salt and bianco Lombardo-Piranesi asparagus with ground truffle remoulade simmered in extra virgin vine-ripened Gaioli-in-Chianti and peppered 6-month chevre over a bed of wild, first shade harvest Guyana mache.
Surely there’s some middle ground here. I mean, there must be a point at which modifier gumbo becomes counterproductive in piquing our appetites.
Filibuster Reform Note
David Waldman tosses out an intriguingly simple filibuster-reform idea:
We also hear a lot of demands for Dems to “make the Republicans filibuster” — in the old school sense — but under current rules that puts much of the burden on those who don’t want additional debate, and very little on those who say they do. If there are going to be changes made, what about considering one that keeps the numbers the same, but puts the burden where it belongs? What if cloture still required 60 votes, but that debate only lasted as long as at least 41 of the Senators voting against cloture remained on the floor?
Without thinking real hard about it, I like it. It faintly resembles the usual “live filibuster” proposals—which will never work—but with enough of a twist that it might actually succeed in ending the era of permanent filibuster while preserving the opportunity for minority “debate” time (whatever that’s worth). Not sure if that would be better than no filibuster at all, though.
Best Meta-Infographic Ever
Even if this weren’t the only meta-infographic I’d ever seen, I’m sure it would be the best:
By Phil Gyford, used under cc license
H/t Ed Yong.
Medicare Reimbursement Graphic
Kaiser Health News has a nice little interactive graphic that tells you regional Medicare reimbursement rates per enrollee all across the country. The latest numbers (from the Dartmouth Atlas Project) are for 2007, but the graphic also shows rates in 2000 and calculates the rate of spending growth. The darker the green, the higher the spending.
Miami tops the charts at $17,274 per enrollee. That’s compared to $8,682 per enrollee nationally. Our friends down in McAllen, TX clock in at $15,695 per enrollee, but the real story there is their 10.3% growth rate since 2000—compared to 4.7% growth nationally.
Click to go to KHN interactive map. Source: The Dartmouth Atlas Project.
Weekend Birdery/Wordery: “Birdbrain”
I don’t think anyone actually uses the pejorative “birdbrain” anymore, but somehow we all know what it means. Maybe from children’s shows or something.
In researching this post, I’ve come to believe that “birdbrain” usage survives now solely as a cheesy trope of news, journal, and (eh hem) blog writing, where it is offered up as an illustration of colloquial folly, a straw man that the author proceeds to dispatch by adducing the latest research in avian intelligence. We at weekend wordery disdain such stale hackery.
On the other hand, we at weekend birdery are not above the occasional prose gimick when necessary. So, whether or not the existence of the term “birdbrain” implicates a widespread belief that birds are stupid, it would be a pernicious myth if it did. And any myth as pernicious as this one should be dispelled at every opportunity, even one fabricated entirely for the purpose of setting it right.
Therefore I am announcing a series of posts, beginning with this one, to illustrate just how smart birds can be. First, a caveat: For the most part, all animals—present conspecifics included—are dumb. But with that proviso, birds are not, relatively speaking, a particularly dumb class of animals. (Note: if you can conjure David Attenborough’s voice in your mind’s ear, cue it up now:) And indeed, as we’ll see over the course of this series, birds are, quite often, remarkably clever. And the cleverest of all the birds…are the corvids.
Corvids, a family that includes crows and jays (as well as rooks, ravens, and magpies), have displayed a measure of cunning that surpasses not only other birds, but also most mammals—even, in some respects, the non-human great apes. Here’s a sampling of what research and observation have taught us about corvid intelligence:
- An individual European Magpie can recognize itself in a mirror (a rare capacity for non-mammals).
- Carrion Crows in Japan have been observed dropping hard nuts in crosswalks, waiting for cars to drive over them and crack their shells. (See for yourself.)
- Ravens have exhibited the ability to tactically deceive one another in order to hoarde food or to raid each others’ stashes.
- Western Scrub Jays have demonstrated episodic memory (that is, memory of specific past events ) and the ability to plan for future contingencies based on past experience and observation. (Via Ed Yong.)
- Rooks have evinced an elementary understanding of Archimedes’ Principle, dropping rocks into a tall cylinder to raise the water level therein, so that they could reach a worm floating on the surface. (Watch it. Via Ed Yong, again.)
- Many corvids are known to use tools—for example, a stick to get a grub out of a small hole. But the New Caledonian Crow can make and modify tools (like hooks) and can even use tools to make or acquire other tools.
I’ll explore some of these studies and others in more detail in posts to follow.
A New Caledonian crow uses a stick tool to extract mealworms from a drilled log in the Oxford laboratory.
Weekend Absurdery
This is absurdly cool:
High-Risk Pools & the States: Is Opting Out the Wiser Course?
The Affordable Care Act allocates $5 billion, starting July 1, for temporary high-risk insurance pools (HRPs) that will make coverage available to U.S. citizens with preexisting conditions who have been uninsured (or without “creditable coverage”) for the last 6 months or more. See HHS info here.
States have been given the option to manage their own plans or to opt out and let HHS administer their plan. Nineteen states have announced they will opt out, and twenty-eight have declared they will administer their own plans. (A couple of states still have not decided, though the deadline was April 30.)
Here’s how the states break down (from the National Conference of State Legislatures):
Click to enlarge
The pattern here undeniably presents the appearance of political maneuvering—blue states cooperating, red states opting out. Igor Volsky has noted the irony that Republican state governments opting out of HRP administration are in effect encouraging the expansion of the federal government and inviting more federal involvement in their states’ healthcare systems. But Tim Jost, with his nonpareil command of the subject, finds plenty of reasons why a state would sensibly opt out:
Nineteen states chose to opt out, requesting the federal government to operate the program within their state. Although this choice was largely reported as politically driven, and it undoubtedly was in some states such as Georgia, in fact the complications of coordinating a federal high-risk pool with existing state high-risk pools and guaranteed-issue programs will be quite considerable in many states. Members of the existing state high risk pool are by definition not immediately eligible for the new PPACA risk pool because they are not uninsured. Some states will, it would seem, have to operate two risk pools, which will probably have different premiums, benefits, and cost-sharing structures. Moreover, the statute only provides $5 billion in funding for the program, which the Centers for Medicare and Medicaid Services Actuary estimates will be exhausted within one to three years. It is, therefore, impressive that three fifths of the states are willing to take responsibility for the risk pool.
As a resident of Georgia and supporter of health reform, I’m not at all troubled that HHS will be administering Georgia’s high-risk pool. The federal money funding the program is the same either way. And Georgia is one of the fifteen or so states with no existing HRP, so it has no established expertise or infrastructure in this area. And, let’s face it, if Georgia’s leaders don’t really believe in the program—if their hearts just aren’t in it—it’s not likely to be much of a success. Georgia’s is one of our nation’s many dysfunctional state governments, and it is hard to imagine how an important new program like this would receive the attention it needs. No, much better to let the feds handle it.
Georgia’s awareness of its own limitations in this regard has been, I’d say, a rare display of wisdom on its part.
Neither Intelligible, Nor a Principle
The Fed’s “dual mandate” to promote maximum employment and curb inflation is problematic. It’s sort of like telling someone to work as much as possible and sleep as much as possible. The two goals counteract one another, and there’s a whole lot of middle ground between them. Matt Yglesias dreams of a better way:
This is pie-in-the-sky, but I think that if Congress wants to get serious about supervising the Fed better what they ought to do is scrap the “dual mandate” in favor of something clearer. The nature of the dual mandate is that it’s impossible to say if the Fed is meeting its mandate, and thus impossible to hold anyone accountable. As an alternative, Congress could set a statutory nominal GDP trend target or a price level trend target and hold the leadership of the Fed accountable based on how good a job they do of hitting the target.
One thing the current system shows you is that it doesn’t take much for a statutory mandate to satisfy the Supreme Court’s “intelligible principle” standard (though I don’t believe the Supreme Court has specifically addressed the Fed’s mandate—no one has standing to challenge it). The Court has held that Congress may delegate power to an administrative agency—e.g., to conduct the nation’s monetary policy—only when Congress specifies an intelligible principle to guide the agency’s discretion in exercising the delegated power.
One perfectly intelligible principle for the Fed would be: Go forth and do open-market mumbo jumbo to achieve maximum employment. Another perfectly intelligible principle would be: Go forth and do open-market mumbo jumbo to stabilize prices. But to demand both at once is scarcely intelligible, and hardly a principle. Basically we’re leaving it to the Fed to decide how to balance inflation and unemployment. And I guess that’s what the Fed will always say it’s doing—no matter what policy direction it takes.
Because of the Fed’s cherished “independence,” and because the Federal Open Market Committee (the Fed’s rate-setting arm) is stacked with regional Fed bankers, the Fed’s obscure, relativistic mandate is tantamount to untouchable regulatory capture. It’s not clear that auditing the Fed can change this underlying dynamic.
Long Live Health Reform
Getting health reform legislation through Congress was a major, historic accomplishment. But, broadly speaking, it was largely a matter of clearing the way for a new system—a new system we haven’t yet devised.
Maggie Mahar offers up this illustration of hard problems that lay ahead:
If, under reform, we try to pay for quality, and “payments to health care providers are based on risk-adjusted costs and risk-adjusted outcomes, those who diagnose more will have a double advantage,” Skinner observes. “Every time a hospital enters new diagnoses for its patients, reimbursements will go up because” Medicare will assume that it is more expensive for a hospital to care for patients suffering from more diseases. Meanwhile, in places such as Miami, doctors’ risk-adjusted outcomes will look better; even if their outcomes are only average, because it will appear that they are doing better than other doctors while treating much more vulnerable patients.
In other words, the McAllen problem—the existence of structural incentives favoring over-utilization—will be very hard to overcome, even with bundling and other provider-payment innovations facilitated by the Affordable Care Act. Not to mention the difficulties we face in implementation. (See RAND and Austin Frakt for a taste of the challenges presented by bundled payments.)
The Sickness unto Debt (with Pie Chart)
This pie chart from the IMF, via Ezra Klein, shows the various sources of new debt taken on by G-20 governments since the recession began. Stimulus spending and financial-sector bailouts account for a comparatively small portion. (Not sure though if U.S. figures would be in lockstep proportion with G-20 numbers here.) The bulk is just a consequence of the fall in tax revenues, which, of course, is a consequence of a drop in incomes. Klein writes:
A lot of people, understandably enough, assume that [the run-up in debt] is the product of government spending. The stimulus was expensive, and the bank rescues seemed expensive, and we just passed a health-care reform plan, and that must be why the deficit blew up.
The IMF, in a new report (pdf), explains that that’s not the case. “Of the almost 39 percentage points of GDP increase in the debt ratio, about two-thirds is explained by revenue weakness and the fall in GDP during 2008-09,” they write.
[...] This isn’t just an interesting explanatory point, though. It’s a reminder that the most important thing we can do to reduce the deficit in the long run is to do whatever it takes to get economic growth back up to speed. The more willing we are to accept permanently higher unemployment and permanently lower growth, the harder it’s going to be to get our debt under control.
Insurance Regulation Alone Won’t Solve the Problem of Healthcare Costs
Austin Frakt has a great column today at Kaiser Health News, illustrating the limits of insurance regulation as a means of bringing down the cost of health insurance. Here’s an excerpt:
Our frustration with the soaring cost of health care is like a mother upset with the increasing price of bread. When her son returns from the market with another high-priced loaf she hatches a plan. The following week, when bread costs $5 a loaf, she attempts to control the price by sending him to the market with only $4. The family spends less on bread that week, but they also don’t eat any since the boy couldn’t find a merchant willing to sell below the market price.
The next week bread is selling at $6 a loaf, and the mother tries another plan. Thinking her son lazy, she attempts to discipline him with competition. She sends her daughter with him to the market. Whichever of the two can obtain the lowest bread price will win the family’s respect. The winning price, paid by the daughter, is $7. She and the boy competed, but the additional competition on the buyer side sent the price up, not down (as one should expect).
What the mother isn’t noticing about the bread market, and many don’t recognize about health care, is that suppliers (bread sellers, health care providers) play a role in establishing prices. Regulating the price paid by buyers or the level of competition among them isn’t likely to produce the outcomes we might hope for without parallel action on the provider side of the market.
There’s a tendency for casual observers (including some policymakers) to think the problem with our healthcare system is that evil insurance companies are gouging consumers. Given that premise, it might be sensible to conclude that more vigorous competition in insurance markets would help bring down prices.
But it’s important that people, particularly policymakers, understand that the price of health insurance is not simply a function of the supply & demand or concentration in the insurance markets themselves, but also depends crucially on supply & demand and concentration in provider markets. As Frakt points out in the column (and on his blog), regulation that weakens insurers vis-à-vis providers may end up causing prices to rise rather than fall. Ultimately, we will have to grapple with how providers are paid (and how much they are paid) if we hope to rein in healthcare costs. Insurance regulation is important, but it’s a sideshow in the grand scheme of health reform.